Kaisu

congrats on good work! Welcome to the wonderful world of paramedicine.

Are you a student? Is this site your way of doing your homework?

I don't wanna brag Dust, but I made my F.Y. money years ago and retired. I am not wealthy, but I don't have to work another day in my life if I didn't want to. I work my heart out and would be deeply offended if someone suggested that I am not a professional. I am doing this because I love it. I guess that makes me a volly.

CHFer with full lungs gets O2, IV, monitor, CPAP (if you have it), NTG, lasix, morphine, methylprednisolone, RSI, intubation CHFer with peripheral edema gets O2, IV, monitor ACS symptoms gets O2, IV, monitor, ASA, NTG, Morphine (possibly), Metoprolol (possibly), etc. All of these treatments are dependent on the presentation of the patient and your local protocols. For example, your right heart ACS patient often presents with hypotension and bradycardia. This patient would NOT get NTG. You will need to be VERY cautious fixing this patient's rate because you don't want to increase the work load of the heart. If they are stable, I don't play with fire. If they are unstable, then I need to go to work. If they have an adequate rate and they are non-perfusing hyptotensive, then you need to think about vasoconstrictors, and nitro is the opposite. My general strategy for dealing with symptomatic cardiac is fix the rate, then fix the tank, finally the pump. I dont know if I am helping you. Maybe some of the others with more experience can chime in here.

Right sided heart failure presents as body edema. This is not an emergent threat to life or limb. While these patients need drying out, it is best for them to do it slowly. Hospital care and home medications is what these folks get. So my answer to your question is - in the absence of ACS, no - no nitrates. (PS - the main cause of right sided heart failure is left sided heart failure. One of the few times you see isolated right heart failure is in cor pulmonale - the emphysema patient that gets pulmonary hypertension from blown blebs.... )

distonic reaction to phenergan?

hahahahahahah.... stop it - you are killing me... hahahahhahahhahahhahhahhahahah

Shigella enteritis?

I want to thank all of you for taking the time to respond. Your answers are thoughtful, insightful, and compassionate and demonstrate the wide variety of experience available to those of us lucky enough to find this resource. I don’t know what I would do without all of you. I want to respond to some of the points that you all bring up. For those of you who tell me to “get out” – I can certainly understand this. Please remember that I generally post only when the excrement hits the ventilation device. You are getting the worst part of the picture. One of the few good things about this incident is that whereas before, I was an outsider and felt very alone, this call had my fellow paramedics rallying around. I had not had this kind of support demonstrated so universally before. That notwithstanding, there is no doubt that this system leaves much to be desired. Initially, a big part of my desire to stay here was the idea that maybe I could be a force for positive change. While not totally discounting that possibility, now my primary motivation is the fact that this place has a lot of lessons to teach me. They will be painful and sometimes overwhelming, but hey – I got you guys right? There is a new hospital opening in this town in less than a year. It is currently under construction and is owned by EMSC. A lot of us are holding out hope for this. Perhaps the town will attract more and better providers with a brand new state of the art facility. The lessons I have learned – 1 – I will never again let anyone in my rig overrule my treatment strategy for flash pulmonary edema. The presentation, symptoms and protocols have been seared into my soul. Remember when I had the problem with the sharps? I am now the goto girl for proper sharp handling in both theory and in practice. I have been researching flash pulmonary edema and I know way more about it now than before this call. 2 – NO ONE draws up drugs from my box without showing me the vial first and then showing me the vial after. I don’t care if it’s the Dustdevil himself in there with me – they are showing me that stuff. (PS Dust – you honor me with your remark about hiring me. It means a lot to me.) 3 – A bad tube is a bad tube no matter who places it and no matter who thinks it is a good one. When I see it again, if I have to, I will rip it out myself and replace it. I am 6 feet tall and I lift weights. Those wusses can take it up with me after the patient lives. For those of you who are concerned about my silence in the face of a lot of this. I want to refer you to the responder who says it is hard to believe that a whole ER staff will not recognize a bad tube. This place has been one shock after another. There is SOP here that made me stand back in disbelief. Sometimes I feel like I am practicing in bizarro world. This is a big reason I come to this board. It is a reality check. I also call on my instructors in Wisconsin. Between the people here on this board, the people I trust and respect in Wisconsin and the experienced medics at my service, I get a lot of input. When I was about ¾ of the way through EMTB, my instructor said he would trust any one of us with him or his family in a medical emergency. I thought he was out of his mind. I couldn’t believe that anyone would let me on an ambulance with what they gave me in EMTB class. After I graduated medic school, they said – Congrats paramedic Kaisu. I thought they were out of their minds. When they threw me onto this rig after a two week orientation and no field experience whatsoever, I thought they were out of their minds AND I was scared s**tless. I am in no position to get forceful about my opinions and beliefs about a lot of things – EXCEPT the stuff I have directly experienced and KNOW in my head, my heart and my gut. Flash pulmonary edema, having someone else draw up my drugs, and speaking up when I see a bad tube are all things that I will have no trouble getting obnoxious about in the future. Finally, thank you Doczilla for pointing out the fact that this patient was doomed. She really was. I can handle deaths without a problem when I know everything that could have been done was done. You reminded me that had everything gone picture perfect, this patient would still have died. There is a part of my mind that will always wonder. I will honor her and her memory by never forgetting the lessons she taught me with her death. Once again, thank you all both for the wonderful PMs and for your responses, your willingness to share and to educate.

I'm sorry about your mom. She (and you) are in my thoughts and prayers.

The call came in at 4:00am. I was on duty at the quiet, rural station where we are assigned after serving at the busy, high call volume station. The theory is that we get to rest up a bit. I had run one 5 1/2 hour transfer earlier in the shift. The call was dispatched as female diabetic, difficulty breathing. We were given the wrong cross streets, so it took about 15 minutes to get on scene as opposed to 6 - 8 had we had correct dispatch information. We arrive just in front of the fire department. They are first response and normally get there before us. They go into the house with the monitor and first in bag, my green as grass EMT and I follow with the gurney. We have trouble getting into the house. The driveway is blocked with 2 vehicles and we have to drag the gurney with two wheels on the concrete and the other two in the air. The house is clean and well ordered. There is a male, approximately 35 years of age directing us into the front room. I ask him to locate car keys and move the pickup to enable us to move the patient out if need be. Our patient is sitting on the couch. She looks exhausted. She is soaking wet, clammy and with very weak radial pulses. The patient is speaking in one word sentences. Initially appearing obtunded, fire gets an SNL mask and A/A treatment going immediately. The high flow O2 helps and the patient is more responsive. The patient has a BP of 115/80, heart rate of 125 and respirations of 28, labored, with retractions and accessory muscle use. Fire is starting an IV. We have a 15 - 20 minute ETA to the regional hospital and I think we should have done the IV en route, but until they transfer care to me or get in the ambulance, they are in charge of the scene. I am tapping my foot. I want to get moving RIGHT NOW. The patient's son, (the 35ish man mentioned earlier) cannot find the truck keys. I ask the FD to pick the patient up and lift her on my gurney. They do and my partner and I fly her out of the house and into the ambulance, second set of wheels in the air not withstanding. The patient is 61 years old, looks much younger and has a history of hypertension and type 2 diabetes. She has no cardiac history or history of CHF but I can hear rales in all 4 lung fields. She is wet and full. The FD medic jumps on board. He is a 15 year medic and knows the patient personally. I instruct my EMT to go in hot and I put the patient on the heart monitor. She is sinus tach at 130, BP is 113/77 and respirations are 26. Unable to obtain an O2 Sat. BGL is 235. The FD medic wants my drug box keys. When we got in the ambulance, he took the attendant seat at the head of the patient, I am beside her on the bench. I toss him the keys and he pulls out 125 mg of methylprednisolone and draws it up. I am getting a history. It is slow going but she tells me that she has been feeling badly since 10:00pm when she had nausea and vomitted. The medic passes me the Solu-Medrol and I push it. He patches to the hospital and tells them to have respiratory ready. We have no CPAP in the ambulance. I want to start the CHF protocol with nitro. The fire department medic says NO - he doesnt want to tank her BP. He has 15 years, I have 2 1/2 months. While technically I am in charge because we are in the ambulance, he has not transferred care to me. I think that as we have a nice patent line in her AC and as her systolic is well over 100 we should do it, but I do not push the issue. Meanwhile, I can now hear rales without my scope. My patient is sagging in the gurney. l reach over and pick up her upper body, supporting her in a tripod and assessing her mental status. The FD medic goes rooting in my airway bag for the tubes and the scopes. We should have pushed lasix and morphine too. l don't think of the lasix and while the thought of morphine did go through my brain, I figured if he says no to nitro he will say no to morphine too - PLUS our medical director makes us patch for morphine even in chest pain. It tends to discourage use of the drug when you are told no 90% of the time that you ask for it. I am watching this patient waiting for her to go down enough so that we can tube her. We have no RSI protocols. (No CPAP - No RSI - I told you this is the wild wild west.) The medics here get around this problem with nasal intubations. I have never done one, never learned to do one, and am not about to start now. We get to the hospital and take the patient directly into critical care room 1 where a team is waiting. Doc asks for BiPap but respiratory is not there. (Later the fire medic, who has known this patient for 18 years, is upset because the hospital did not take action on his request.) The fire medic is giving report. l leave the room for a few minutes to deal with paper work. When I get back, they have knocked her down. (RSI'd her). The ED doc is digging in her mouth with the scope. When I went to school, we learned to intubate in the OR. The anestheologists get upset if the cosmetic surgery patient wakes up with busted teeth and broken lips. This does not seem to be a consideration with the ER docs. He pushes in the tube and they put a colormetric device on the end. Seems to me that as we carry capnographers in the ambulance they would have one in the ED, but they don't. I don't see a color change. Someone listens and says the tube in. The patient begins to brady down. I can see her stomach start to inflate. Now the patient goes into complete heart block. I say "that tube is not in". My EMT cautions me to "shut up - they will kick you out of here". Patient goes into non-perfusing ventricular rhythm. I say "the tube is not in". No one listens - Doc commences chest compressions and they shock her. - She goes into coarse Vfib. Her stomach keeps getting bigger. Doc's chest compressions are ineffective. I offer to take over. He gives me a look and then moves. I step over to the patient and the ED tech literally pushes my hands aside and commences equally ineffective chest compressions. 3 rounds of drugs, two shocks later and my patient is in fine Vfib. Out comes the sodium bicarb and I leave the room. I go to the pharmacy to replenish the SoluMedrol, 3cc syringe and the needle. Then I open my drug box. We carry 2 SoluMedrol and there are 2 in the box. 20 hours earlier when I had checked out the drug box, I hadn't noticed extra SoluMedrol. What the F*** did I push? I inventoried the entire box. Nothing was missing. How did the extra SoluMedrol get in there? I called my supervisor. He didn't seem concerned about the drug discrepancy. He just wanted to know if I followed CHF protocol. I cried all the way home. We all failed this patient. I will get another chance with another patient, but this lady doesn't get another chance. When I talked about it to my medic co-workers, one told me that I better get used to the hospital killing my patients. Another told me that she turns over the patient with report and leaves because she would just as soon not know. Thank you for listening. I appreciate any comments you may have.

Crotchety - I personally like your style. As far as being called a paragod... I was on ride time when I went to pick up a kid at a gym. Once the patient was on the gurney, I took my time positioning myself at the end to make sure I preserved good lift mechanics. An EMT (quite rudely) pushed me aside and picked up the patient. I turned to thank him (after all - he did help). He bluntly inquired - "and who are you?". I offered my hand and said "Hi - I'm Kaisu. I'm a medic student". He ignored my hand and said - "Oh great - another paragod". I thought he was kidding. I smiled and said "Paragoddess if you don't mind". He snarled and said "Step on my toes lady and you will find out just how human you are" and walked away. :shock: That was my introduction to insecure a**h***s who call you a paragod even tho they dont know a thing about you. It happens.

I find the most important thing is to remain rigorously honest with myself. This means acknowledging when I am out of my depth or realizing when I handled a call, patient or situation less than ideally. (which is every time - I mean, when can you NOT do better?) I believe that cocky, arrogant a**holes are almost always overcompensating for personal weaknesses and/or covering up fear. PS. you will not become like that because cocky, arrogant a**holes do not hold themselves up to the type of scrutiny you are subjecting yourself to. Good luck

LOL... I am going to repent of my evil ways.. cause those are really bad....

I would read the material before each lecture. Then I would take detailed notes during the lecture. After the lecture, I would transcribe my notes into my notebook computer, with pictures from the WEB. I had the material down cold after this. For memorization (drugs) I would make flash cards and drill drill drill. This required a lot of time and commitment, but I ended with a 4.0. 8) Good luck to you.

I graduated from paramedic school in May of this year. I did nothing related to EMS until I started a brand new job at the end of September. I did no time as an EMT and went directly to paramedic school. All my ride time was in a dual paramedic system - with me as a student, that meant there was 3 paramedics on board. I went into a system that runs 1 EMT/1 Paramedic per rig in a brand new state several thousand miles away in a system and a city that I have NO familiarity with. I was scared s***less. While I would not recommend this approach to anyone, it has been 2 months plus and I am feeling pretty good about the job and my ability to cope. I went to a good school and I was determined to do my very best. I am sure luck had something to do with it. My first calls were either cardiac (which I am very comfortable with) or BS. While I am still hesitant about that MVA with multiple casualties, I am confident that I will do what I am supposed to do when I am supposed to do it. By the way, after EVERY call, I think of at least 2 or 3 things I could have done better and whenever there is something I don't understand, I ask someone. I will continue learning every day, and when that stops, I will find something else to do. Good luck to you. PS - the people on this site were absolutely invaluable. They gave me straight answers that I could trust in those very difficult early days.

My younger daughter is the proud product of this university system. She lives in Toronto and has her head so far up her ass its scary. I love her to death but her pronouncements on issues have me staring blankly in disbelief. Needless to say, her friends all sympathize with her for having a mother that is so reactionary as to be "intellectually abusive". By this they mean someone who pops holes into their touchy feely fantasies about how the world is. I am "disrespectful" and hopelessly out of touch with what is going on.

Dear Walter I hope you can help me here. The other day, I set off for work leaving my husband in the house watching the TV as usual. I hadn't driven more than a mile down the road when the engine conked out and the car shuddered to a halt. I walked back home to get my husband's help. When I got home I couldn't believe my eyes. He was in our bedroom with the neighbor's daughter. I am 32, my husband is 34, and the neighbor's daughter is 22. We have been married for ten years. When I confronted him, he broke down and admitted that they had been having an affair for the past six months. I told him to stop or I would leave him. He was let go from his job six months ago and he says he has been feeling increasingly depressed and worthless. I love him very much, but ever since I gave him the ultimatum he has become increasingly distant. He won 't go to counseling and I'm afraid I can't get through to him anymore. Can you please help? Sincerely, Sheila ****************************** Dear Sheila: A car stalling after being driven a short distance can be caused by a variety of faults with the engine. Start by checking that there is no debris in the fuel line. If it is clear, check the vacuum pipes and hoses on the intake manifold and also check all earth wires. If none of these approaches solves the problem, it could be that the fuel pump itself is faulty, causing low delivery pressure to the injectors. I hope this helps, Walter

happy birthday to yooooooooouuuuu happy birthday to yooooooooooouuuuuuuuuu happy birthday dear ruffems....... happy birthday to yooooooooooou.

I am thankful for you Teri.. and all the others on this site who are so generous with advice, support and the occasional well deserved a&& kicking. I hope all of you have a wonderful thanksgiving - stay safe!

I like the soft stretcher a lot. Case in point - dislocated hip patient lying on his bed in a position of comfort in a tiny trailer house with more curves and tight spots than a holliwood starlet. The man is 74 years old and in a lot of pain. The last thing I want to do is maneuver him onto a long board or stair chair. The gurney will not fit. Carrying him out in a blanket will cause a lot of uncontrolled movement. The soft stretcher worked like a charm. We slid the stretcher under the sheet the patient was laying on and carried him out. (4 mg of morphine was administered before moving him) The passageways in the house were too small to allow more than one person on each end of the stretcher to fit through so the light weight of the stretcher was a big plus too.

This girl ALWAYS says what she thinks... no hidden agendas. It gets her in trouble a lot. I like dealing with an individual that is upfront. Nothing sneaks up behind your back cause she lets you know upfront EXACTLY where she is coming from. She never goes behind your back to a supervisor. If she has a beef, she lets you know upfront and if she does go to a supervisor, she makes sure you know it and can be there with her if you want. This makes her head and shoulders above the sneaky ones.

Amen to that.... our winter gear should be showing up around March....

As a single use device at about 100$ a pop, with medicare reimbursing resuscitation at a grand ole rate of about 600$, the odds of this showing up on an ambulance near you are about nil.

I don't want to hijack this thread, but I do need to respond. I will digress.. but I'm old, and a grandma so humor me. When I first started at this job, I went out to my car and there was a homeless woman sleeping in it. I was mad at first, but as she slowly awoke, I looked around my car. This woman had been very careful to not mess up anything that I had in the car. She just needed a place to sleep. As she came awake, I was taken with her demeanor. She was very childlike - a survivor but an innocent. I took her for breakfast - I was eating anyway, and I can't enjoy a meal if someone in my path is hungry. I took her to a shelter - no way - they only took in men. I called another shelter - got the bureaucratic run around. Long story short, I got the lady housed. The people at the station (and I had just started with them) thought I was crazy. Now that they know me, they know that I have a need to feed those that are hungry. My partner is a young and very idealistic person. Her cynicism is a defensive mechanism to the environment. This is an insular, redneck, hard scrabble town. For a hundred years they have been a "gateway" to Vegas and a stopover for the flotsam and jetsam of society. Those that make a living here have eked it out of the desert. I am showing people that it takes a lot more strength to remain open to those in need than to ignore them. Everyone - sooner or later - is in a position where they need someone. A famous south American writer said that when a people (and this can be an individual or a country) comes out of oppression, they become either oppressors themselves or they become liberators. I know a lot about suicide and suicidal impulses. In the ambulance, I am in charge of patient care. No one will respond to a patient with less than professionalism and on my watch they had better display compassion too. Do not judge a young person feeling her way in a difficult environment. Her heart is in the right place. Her actions are always professional. I am showing her that there is another way to be. (I hope - that's what I'm here for). I love you guys on this site. If it wasn't for all of you here, some of us would not know that there are other and better ways to be than just what is at our own little corner of the world.'