jwraider

OK I'm go to make the title obsolete and say yes it was as this patients LOC changes dramatically about 15 mins after arriving at the ED. She was sitting up and conversing normally with no memory of the event. Initial dispatch @ 1am: 39 yo female unresponsive by the river at 601.... yadda yadda (The potential causes were going crazy in my mind!) In reality PT is in a nice RV/mobile home thing in a vacation park in bed with her husband standing there. (Pucker factor went way down!) The PT is "shaking"... looks like shivering. No major movements of the body just tremors all over. Her eyes are also moving rapidly and randomly in small movements. Seizure? Well for some reason I do a sternal rub and ask "Mam can you hear me?" and her eyes stop jerking around and stare right at me until I move away. I ask the husband about her medical history and he says (no joke): "She ate 15 packets of taco bell hot sauce for dinner". I reiterate the MEDICAL part of the question and get: "Thyroid problems and they think some medication of hers caused fluid to build up in her brain last year". He denies any history of seizures, stroke. but does say she has been feeling "sick" for a few days. He denies substance abuse and everything else I came up with. Vitals: (And yes I got these during the possible "seizure") GCS 9 (eyes wide open[4], no verbal noise at all[1], withdraws from pain [4]) HR 100 Sinus Tach no ectopy BP 166/88 RR 12 Sp02 100% on 02 (BLS on scene already had her on a NRB) BGL 96 (PT withdraws from pain during the stick, during the "seizure") Pupils reactive, same size, right size Skin PWD So I don't know what the heck is going on because on one side I have no history of seizures, she can look at me, no incontinence, no oral trauma, not hot/warm/cold, no magic wand... So maybe this is a stroke, poison/OD, or some metabolic thing to do with her thyroid and the cerebral edema. On the otherside she really looks like she is having a seizure and eventually wakes right up in the ED. So thankfully despite my lack of recognition I'm able to move the call quickly and get her into the ambulance and moving. This is where I notice her body is still "tremoring" but now her eyes have stopped going crazy and she is even moving her head alittle to respond to me. Eventually the tremoring/shivering stops (she didn't feel cold but I turned the heat on so maybe that had an effect). Still she counts as a GCS of maybe 11 if you say her head movement counts as normal motor/sensory. So like I said at the ED I go back into her room and she has no memory of the event or me and is conversing totally normal without any complaints. The MD initially thought some kind of ingestion or a bleed. But the common perception after she woke up was a seizure. What do you guys think? Did I really blow it and let a seizure go on (or repeat seizures) for close to 10 minutes? That's the amount of time it took before her eyes were no longer rapidly moving. I'm very frustrated by this call feel free to offer criticism I want to be better next time.

This is my guess: increased intercranial pressure because of irregular breathing. Maybe this ? Encephalitis MD started treating with antibiotics and was doing a lumbar puncture when I left.

Those are some good differentials but not exactly what the Doctors were thinking initially atleast with their assessment and treatments. I'll post what those were later. Remember seizure activity was never confirmed but can't be ruled out either.

So this was not my patient. The PT came in by ambulance code 3 return while I was writing my PCR. I'm going to present it though as if you were on scene with the PT and were running the call as a 1:1 Paramedic without access to all the good stuff the hospital has (except medical control I guess but that's me so it wont get you too far!) Also I'm very busy this week so I will present the entire case and everyone can just give us their entire call/impression and I will come back and try to answer questions. Dispatch: 1 y/o Seizures General: 10 mins to local ED, pediatric hospital available via helicopter only. 2pm on 75 degree sunny day. Crew: You plus 1 EMT and an ALS engine company that arrives just after you. You go on scene and you're at an apartment building in a low income area. Moms boyfriend meets you at the door and says "yeah, he's been shaking and he's not acting right". As you enter the living room mom is frantic and in tears, you see a 2 month old infant on the couch in a diaper only crying. Mother states: "I took him to the ER this morning because he had a seizure but they sent me home with tylenol and said he was fine!" She denies any Hx , Allergies , meds previous to today. She now says "He's been shaking and he won't stop crying". When asked what shaking means she says "more like twitching his arms and legs and his eyes won't close!" Your PT is a 2month old who appears to be the right size (weight) is acting inappropriate for age (staring straight up, not tracking) and also crying and cannot be soothed. You see his belly going up and down and his color looks good but he feels hot. Mom says he has had a fever. So what do you do right now? You're now either still in the house (because you're somewhat brave) or in the ambulance. You're hooking the PT up to the monitor and taking a closer look. Mom and Boyfriend will no longer be able to provide much info except to deny pertinent negatives/positives (no vomiting, coughing, diarrhea, ate normally up until this morning, plenty of wet diapers until this morning, no trauma, no exposure to disease/sickness) LOC - Altered, eyes are open but the PT is is just crying and staring up. No response to mother. A- Airway is intact B- Irregular, "wet" sounding lungs in all fields C- Brachial @ 180, regular. Sinus Tach Skin - normal color, hot, not wet SP02 100% Room air Sugar: 157 You tell the engine medic that the baby is breathing irregularly. He asks "How do you know that?" You say: "I can't tell the pattern but the speed keeps changing and ...." The baby is now apneic. Only change to above vitals: Baby is now not crying Baby is not breathing (Pulse and skin do not change) So what do you do right now? 30 seconds later the baby is breathing again, you're not sure if what you did caused that but it's breathing (so you can start breathing again now FYI). You're now Code 3 to the hospital (local? helicopter?). let's just say you're awesome and you get an IV right away. You're 5 minutes out and call in a report and sit back and try and collect your thoughts and you notice more as you do your detailed physical exam or focused exam just like national registry taught us! The PTs eyes are bulging out. He looks like he's very interested in whatever is happening on the ceiling but they are obviously way larger and protruding say "like bug eyes". His head looks otherwise normal (right size, fontanels seem almost closed but aren't bulging). All other physical features seem to be WNL. The PT is apneic again just prior to arrival. So what do you do right now? This spell lasts about 30 seconds again. As you walk into the ED bay the Doctor is there to meet you (yay!) and asks: "So what do we have?" So what do you do right now? Hope this is interesting and thought provoking I don't have the diagnosis. I know what the initial treatments and assessments were and that the baby was quickly transferred out to a children's hospital. I'll check back and add this info later I'm interested to know how you guys would handle this call and what you think is wrong with the baby. My line of thinking is it's easy to get technical and complicated here but what if you were really on this call?? How would you approach it in a simple manner so you could react and get the right stuff done and still understand what physiological dangers existed.

Is there more information? I find it hard to believe some evil firefighters are going out of their way to pass a law so they are not part of an EMS system at all. There must be something else going on that is causing this side effect which definetely should not take place. No medical oversight is WRONG. I wouldn't want to practice on my own in a million years with just a paramedic license or EMT cert. It's nice knowing that as long as I use sound judgement and common sense while following what the Medical Director wants us to do we are generally safe from litigation etc. Out here firefighters have started a new medic school in order to improve the quality of paramedics coming out of school. Before you laugh too hard consider that there alot of new medics coming from schools such as NCTI that run 5-6 programs a year and require an EMT cert and no other pre-reqs. Something needs to be done to improve education and training in EMS and in my example the FD is trying to do that. I'm one of the few who was involved in EMS first and fire second. I've been blown away by how much better FDs train than EMS personel. Once you're hired at a private EMS company you just need to maintain you certs outside of the company. I don't know any privates around here who spend time on a daily or weekly basis training on actual patient care.

#1 With that BP did she have a radial pulse? Since you said they felt an irregular pulse I'm guessing they did find one. Whether she had one all along or she got excited and her heart went faster when everyone arrived who knows. If not this would be a much more serious case it sounds like EMS showed up and found an OK BP to go along with a normal LOC. With this kind of call all the answers you can get are in the initial assessment... LOC.. ABCs and skin signs... For me an elderly patient with a recent infection and a low BP is probably septic despite how hot their skin may or may not be. That's my best guess for you and first thing I'd rule out. I might do orthostatics if it was safe but otherwise Sp02, 02, monitor, blood sugar check (can add to an infection differential), and of course IV with fluids to keep her BP above 90 sys along with further questioning.

JEMS recently had a great article on Cardiocerebral Resuscitation. It was great for me at least because my county has already implemented a protocol around it that made little sense before reading the article. If you're wondering what CCR is it's basically CPR without ventilations early in the code. This practice is based on evidence that shows positive pressure ventilations actually decrease blood flow and the effectiveness of CPR. JEMS: Cardiocerebral Resuscitation Here is our sample protocol for initial resuscitation: Sample Protocol "passive insufflation" is an OPA with a NRB. Notice how many compressions are done before any interventions other than defibrillation. There is no ventilations until an ALS airway is inserted several minutes into the code. Basically this technique (from what I can gather) is intended to increase perfusion and prolong the life of the brain and heart so that the problem can be solved quickly (defib / meds) and improve the PTs chances of a meaningful survival. The article is also suggesting different approaches for cardiac arrest and respiratory arrest. What do you guys think? Anyone run a code with this yet? I'm a newbie and awaiting my first code and will be running this protocol on top of that (yikes!).

Had a pt with a temp of 106.9 this weekend (taken in the ED). He was ALOC, hypotensive and tachycardic. I used the AC, fluids and cold packs with no changes. At the ED they got a 2nd bag of NS, more cool packs fanned him and other similair things. Several hours later his temp was 96.X (they over shot!) I think rapid changes would be bad yet you can't leave someone at 106 for very long. Watching this patient makes me think it is a more delicate science than forcing a temperature quickly.

I think a few people nailed what I was getting at... The comment about AMR striving to give each ambulance a call per hour will have a big impact here. The current company strives to meet a 9 min response time 98% of the time. The contract is being bid at 90% and AMR probably doesn't meet 98% anywhere. So there will be less shifts available and some full timers will either be forced into part-time bidding for random shifts or let go. The trick is our union is the same union AMR employees have. They HAVE to side with AMR. It really feels like our unions priorities are 1) AMR 2) our employees. It's amazing the misinformation that goes around even in the public meetings with the county officials.

I know not everyone has an Iphone but many of the people I work with have one and I'm going to develop an app to make our lives easier when dealing with medications (and possibly more someday). I think most of us have the app "Epocrates" and it can be used among other things to look up a patients medication. My experience is that this app loads way too slowly and it takes too long to narrow down the medication and is even impossible to figure out what the medication does sometimes. It's mostly useless on a scene call. I want to create a medication lookup and management application for paramedics that is reliable, efficient and useful during an actual call. It will help us understand medications we don't recognize and manage those patients with 25 medications. My app would load quickly and have an easy to see interface for searching medications. They would be listed with their class or mechanism for quick reference (Atenolol - Beta Blocker) and could then be tapped and added to a current patient list. You could then look at the list and see every med the patient is on with the class. Each medication could also be looked at in detail. I'm looking for opinions so that I know it's worth my time to build and share this with everyone and of course for improvements on my idea. Thanks! Future ideas: PDF viewer and manager - Many counties are starting to put their protocols online in PDF format. This would easily display a pocket gudie of your protocols in your phone. PT info and vitals recording - Hopefully Zoll or someone comes out with a monitor that allows for blue tooth connection. ECGs should be readable by other devices (like your phone) and transmitted as well from them.

I just found out the same guy invented LLR position that named FACE sheets ... FACE sheets (what the hell does that stand for anyway?)

Congrats being a new medic as well it's great to get the first few shifts under your belt and start having fun with things rather tha n try and impress a prceptor. So enjoy and try not to kill anyone! =)

Seems like there may be a big difference between AMR's west and east divisions. It's nice to hear people kept their jobs. Where I am the current company is doing a very good job overall but AMR pays more so the employees are focused on that I think.

I have GERD and when I'm having a hard time laying down (regurgitation and reflux) the left side feels the best. I assumed it was basic gravity helping out. So maybe this position helps keep things down. If I recall correctly left lateral recumbent position is a PT on their left side, with their right leg drawn up. Reason #4501 I heard was with the lungs and left main stem bronchus being at an angle. I'm trying to remember why. Maybe the answer is: D "all of the above" This link almost makes it sound bad It's late maybe I'll find the answer tomorrow or it will come back to me but I think it has to do with pulmonary function and the factors you listed.

Just wondering if anyone cares to speak about any experience they have when AMR takes over a new county? Are the current EMTs and Paramedics often retained? The contract is up for bid where I work and AMR is the only competitor. Currently our company upholds a 98% compliance with response times. AMR as I understand it averages around 95% and in this bid has committed to providing less hours for employees (which I think means less ambulances). To me these two things add up to if AMR takes over some of the workforce has to go even though our union (which happens to represent employees from both companies which blows) says no one will lose their job that qualifies for AMR employment. Does AMR does shift full time people to part time in order to avoid firing them but match their operational goals? This isn't intended to bash AMR but more understand how things work in these situations. It is what it is....

Cool guys I'm glad to see some support for the 12 lead backed with some reasons. In doing some research what is interesting is that there are many many articles stating that an abnormal EKG with a CVA puts the patient at a high risk for mortality in the coming months. Here is a report with some hard #s: http://linkinghub.elsevier.com/retrieve/pi...022510X05001206 It also shows the high degree of cardiac problems found in CVA patients. Here is an article: http://www.elements4health.com/stroke-pati...f-fatality.html Looks like a small percentage of patients are actually having an MI and their long term health is also a big concern. But all the same checking a sugar and doing a 12 lead helps ground us in other possible causes of the patient’s condition and avoid tunnel vision that may harm the patient. Also the data shows how likely a CVA patient is to be having cardiac issues at the same time. For me that makes it almost as cut and dry as doing a 12 lead for anyone with chest pain. a 12 lead should not significantly delay transport This gets me back to my original question. To me it means medics and EMTs should be adept at doing a 12 lead (individually and as a team) quickly before leaving the scene. It's an important assessment but it can't delay the transport more than a moment or so. (Anthony I've had that call where the patient was complaining of CP but was also ALOC with facial droop.... yay for $20 an hour for making very important decisions. I used to make $33 hour loading software onto computers but I digress....)

Hello, Our CVA protocol states "Obtain 12 lead EKG if available". I'm wondering if yours said the same would you try and obtain one for every CVA patient? What are the reasons you would or would not obtain one? I think it's an interesting choice to possibly find a cardiac problem while delaying the PT from receiving care for the CVA at the hospital. Personally I think there should be an indication for it like seeing AFIB on the ECG or the PT having a complaint that prompts it (weakness, dizziness, cp, SOB). I'm not sure what the odds are of a PT having both a STEMI and a CVA at the same time but it seems like if they are presenting with an obvious CVA/TIA transporting early and avoiding an EKG seems the best choice. What do you think?

I have one now and I never thought of it that way until crotchity posted so thanks for stoking that fire for no reason. We need to find a better way of testing and interviewing to ensure both fairness and competency. I'm sorry if you failed the test because your background didn't provide you the education you needed to pass it. I know that for countless people this is due to discrimination and lack of opportunity. This is tragic but the problem isn't going to be solved during by EMS/FIRE and hiring placement tests it needs to be solved in our schools and our culture at large. I understand that the debate on this topic is actually doing that so for that reason it is a good thing this has come up. The more we look at the problem and the more we work towards a solution the better for everyone. I'll contradict myself somewhat and acknowledge the opportunity needs to be there in EMS/FIRE. Meaning people need to know that if they do well the job is there waiting for them. Otherwise why try? Who would work hard knowing if they show up for a job they would be passed on because of skin color? Access to public service positions need to be fair and I applaud those trying to do so. I still think their should be requirements for the job that set high standards. The problem is the methods being used! In order to ensure that opportunity I just mentioned for minorities they are making the majority feel like the opportunity is being taken away. For example I know that if I go to a chief’s interview for a big city department the questions will be general and vague: "tell us about a time you had a disagreement with someone". This is discouraging to me and makes me wonder why I've been working so hard to go to school and gain relevant experience to the position? Because I'm white I don't make for a "diverse" workforce so why test for a job where I can't stand out based on who I am and what I've accomplished? The goal should be to attract and hire the best workforce that can do the best job. Personally I believe that workforce would be diverse because human talent is spread across all types of people and the more diverse we get the more talent we find. I get what they are doing seems like it's a good idea. In fact while I'm trying to come up with my own it was the first thing that came to mind that made things fair! First it was strip the requirements for the job because not everyone has an equal opportunity to gain those. Now it's make sure not to test or interview anyone at a level that requires specific skills. So should public service departments drop their standards to champion for equal employment opportunities or bite the bullet and set the bar high even if everyone does not have a chance of reaching that bar?

Awesome thanks... the over the ear method sounds likea great idea. What do you mean by wiggle the catheter?

I'm no longer a student but I wanted to ask the veterans how they proceed and are successful in starting an IV in a persons EJ vein. Any special positioning? How do you hold tension? What angle do you insert at? Do you tamponade? How do you know you're in? I had my first on my own the other night and the PT had JVD so it was as big as a finger (hard to miss). But I've noticed it's hard to hold tension and things start moving around on me. I want to find a better way to approach this that is still safe (no poking myself). -I try to lay the PT flat or with the head down if possible. -I've been holding tension to the sides of the start site with my other hand using my index and thumb in a c shape. -My angle is similar to an AC or slightly distal to one. -I haven't had to hold tamponade yet (little back flow) -It seems like it's hard to be 100% certain you are in. Is a good flash and no obvious infiltration good enough? Anyone have another method of confirmation at this site? Thanks for your advice and experience!

Anyone work for a private company with a mandatory downtime policy that is not staffed by union employees? Recently I pulled into a facility to take part in a CCT call and an AMR crew was there getting ready to sleep in their rig. We talked to them and they said they were taking mandatory downtime after having worked the past 16 hours (so the call rolled to us). That's great and all but my crew had been working for 23 of the past 25 hours. We then continued to work about 43 hours of the 48 hour shift. The 5 hours time off was used doing station chores and eating with 2-3 30 min to 45 min naps. I'm trying to find some examples and resources to approach my company with. I don't want to create a fight so I'm hoping there are some positive examples out there. Our problem is a new 48 hour shift has been created and management is slow to realize it was a bad idea and come up with ways to alleviate the stress placed on the unit. I'm the only paramedic working it and the rest of the time the car is straight BLS with EMT's who don't have much to stand on seeing as the local JC put's out 50 brand new EMT"s every semester. Thanks for your time! here are a few articles I found: EMS responder article on fatigue Fatigue Management Patients put at risk due to paramedic fatigue Long Hours - near bottom

Hey guys, I'm starting in a new county which will be my third so far and I'm starting to notice a trend that many EMS systems handle trauma very differently. For example my internship was in a busy urban county where the trauma center accepted all ranges of trauma patients most coming from "paramedic opinion" no questions asked. It was a teaching hospital so maybe they liked the business. Outside of a broken toe this is where trauma went for the county. I work currently in a second county that is urban and rural and spells out 4 categories for activations including physiological, anatomical, mechanism and co-morbid factors. They want detailed reports and reasons for coming in and the only catch all is "significant blunt force trauma" if you want to activate someone on sound paramedic judgement. The non trauma hospitals tend to freak a bit when anything trauma comes in yet complain about losing business when a non activation trauma bypasses them. The trauma center decides on whether or not to activate based on the radio report and this can be hit or miss. My point being the non trauma hospitals are trying to avoid dealing with trauma and the trauma center is trying not to over triage... The county seems to be aiming at perfect triage and controlling activations very closesly. So now the third county only lists physiological and anatomical factors as straight activations and requires MD contact for everything else. Their theory is mechanism is a poor indicator of a patient needing a trauma team and that if a significant mechanism is present the patient should have a physiological or anatomical problem (they are the common ones such as hypotension or penetrating trauma etc). They also claim that the trauma center would be over worked if anything more than these two categories was showing up at their door step. They don't apparently trust paramedics to bring them what they want. Which of these systems do you feel is the most progressive? Which system do you like and what type do you work in? What do you think about the third system would that help you or hinder you in making decisions? And for the title of the thread.... Do you feel a patient should activated based on mechanism only? For example a death of someone in the same car. My thoughts are it's interesting how all three systems actually work fairly well where they are. It looks like the second two are starting to aim at bringing non critical trauma patients to outlying facilities and transferring them in as needed. I had no idea this issue was still so underdeveloped. I guess EMS is a newer profession but seeing as these counties operate so differently when they all follow the same ACLS protocols is interesting. I think mechanism is a decent indicator but needs something to go with it. For example this weekend I activated an elderly man who fell from a leaning over position onto his face while petting a cat (age 87, on coumadin, bleeding did not stop on forehead or in mouth). I did not activate a mother and son (40 and 5) who were in a 40 mph roll over as they came out unscathed. I wonder what paramedics could do to gain more confidence from trauma physicians and become more of an asset to the system. This is similar to STEMI patients. The cardiologists are the experts by far but I'm wondering if the same is true for trauma. Reason being we see the actual scene and gain a feel for potential injury something a trauma physician will see but a handful of times in his career. I think paramedics should be given the resource of seeing the results of their patients hospital stay and there should be better recording equipment and data handling methods so trauma physicians can see the incident. I have a feeling these two things would help tremendously.

The page is not loading but than ks for the link anyways. I'm going to spend some time studying this and taking 12 leads further. Here is a nice article: http://ems12lead.blogspot.com/2008/10/prob...-elevation.html

Thanks for this I got to review a rarely used protocol we have. For symptomatic uncontrolled afib we can give a bolus of NS and then move to cardioversion if the PT has a BP under 80 and other severe symptoms (CP, ALOC). I think when deciding on how to treat this guy the NS is a no brainer (nitro dropped his pressure and preload afib did the rest) but cardioversion is a tougher choice. For me it depends on how this guy will end up presenting at the hospital and what they will do. I highly doubt they'll jump to amiodarone they would go with a CCB most likely or cardio version. (For me Amiodarone has some scary side effects and shouldn't be tossed around outside of an arrest or VT with a pulse). So if his BP continued to fall and or he developed ALOC I think I would cardiovert. Thanks again.