MrSpykes

My partner is a Paramedic student, she just finished class. she took the NR practical that her class offered and failed the IV station and static cardiology. She took the retest offered that day and passed the IV station but failed static cardiology again. She study and then about a month later she went to Wisconsin and took the static cardiology again and failed. She thought she was unable to test again until she went to the 48 hours of remediation. The NR rep wasn't 100% sure but thought she could so he let her test again and she passed. Does anyone have an idea of wether her pass will be valid or not. The state rep sent it in to NR with a note that said he was unsure but let her retest anyway. Just curious as to what you all thought might happen with this. I had never heard of anything like this. Thanks

I think it might be very useful to look at individual statistics here for 12-lead interpretation. See if it is just a handful of medics calling the bogus MIs or if its everybody calling one occasionally. Obviously everyone isn't going to be batting 100%. In the system I worked in about a year ago they had a QA team for just cath lab alerts and they checked everyones percentages on STEMI recognition. Maybe your system needs to enact a similar setup. They should setup some sort of committee to make a protocol for reviewing these cases and decide on a standard line. Over three months review each EMS PCI activation. Review the initial 12 lead that was done in the field and all serial 12 leads after that, prehospital and in hospital, review the PCR and the hospital charts. Figure out all the medics percentages on recognition and those below the standard line go to remediation with the medical director, or cath lab, or a cardiologist. I agree with always erring on the side of the patient. I would rather the PCI team get woken up for nothing as opposed to sleeping through something.

Here protocols for "Acute Pulmonary Edema" are NTG and CPAP. If the lung sounds and Hx are present we have Albuterol and Atrovent.

Well Lets start with how unresponsive is she any rxn to a sternal rub? How is her breathing? rate? quality? Lung sounds? What are her skin conditions like? Grab a set of vitals(including pulse, BP, resp, Pulse-ox), start a line, get a sugar, put her on monitor. Look through the ECF's paper work looking at Hx, Meds, Allergies. See if there is any recent lab values on her.

Yeah I don't see anything of concern here. The "varying amplitude" of the QRS is because of the wavy baseline. The QRS appears to actually measure out to be the same size and there seems to be a lot of artifact. I think The notching is just because of the artifact or some electrical interference.

Yeah I forgot to mention that the trade of was we got CPAP on our trucks. And our protocols here for "Acute Pulmonary Edema" before the first of the year was for NTG. We could give up to a triple shot depending on BP then the Lasix and Morphine were only after Online Medical Control gave the orders. Now we don't use the Lasix or morphine. Its CPAP and NTG. Which I have seen CPAP and NTG work really well for patients. And I agree that in the city our transports are probably not long enough to need the Lasix. However in the county transport times can be 30min to 45 min and if your CPAP has a mechanical failure it would be a nice back up. Or if your gonna have an extended scene time. Although we can give morphine or another sedative after contacting medical control if the patient isn't tolerating the mask or feel of the CPAP. I wasn't disagreeing with Lasix going by the way side but I don't think that it should be taken away because of the fact that one system had faulty protocols, ad because the medics in that system had a poor educational expeirence.

Glucometer, syringes, 1L Normal saline w/ Macrodrip set, torniquets, tegaderm, tape, IV caths; 14g x3 16gx5 18gx5 20gx5 22x5 24x5, alcohol preps, ammonia inhalants, 2x2s, 10ml 10 saline flush vials, adenocard, albuterol, Amiodarone, ASA, Atropine, CaCl, D50, Cardizem, Benadryl, Dopamine, Epi 1;10,000, Epi 1;1,000, Romazicon, Glucagon, Oral Glucose, Lidocaine, Mag Sulfate, Narcan, Nitro Spray, Phenergan, Sodium Bicarb, and Vassopressin. Up until Jan. 1, 2007 we carried Lasix, but after a new Dr. started in the ER it was removed due to a paper he wrote on the prehospital use of Lasix. He stated that paramedics had a difficult time telling CHF, sepsis, and pnuemonia apart in the field. He also stated that our system didn't have long enough transport times to warrant the use of prehospital Lasix. The protocols of the system he researched for his paper ststed that to give Lasix prehospital the patient had to have Rales and difficulty breathing. Nothing else was needed but those two factors to push Lasix on a pt. Personally, I think that his paper is skewed by the protocols of the system that was studied. And maybe a group of medics that need some remedial training for the assesment of CHF, sepsis and pnuemonia. I think this might be a case of poor education.

I like to use the blue ones but if I need a line and i just got a pressure i will use the cuff. I like to tie one of the blue ones on the center pole. Its easy to grab there when you need.

I would have probably called online medical control as soon as we got the patient and informed him that we had a pt in hospice care but the DNR was incomplete. I would explain that it was just missing the doctors signature and asked him what our course of action should be if the patient does infact code. Just to be on the safe side. I want to to honor the patients wishes but I also need to do what is legally correct. I feel you handled the situation correctly. Everyhting worked out in the end he got to die peacfully at home with his family.

I agree with Shane. This was probably not anything significant but still better safe than sorry. Some other problems that could manifest with these symptoms that i thought of while reading this was a pulmonary embolus or a sickle cell crisis. Although someone 21yo would probably know if they had sickle cell anemia at this stage in her life. Another thought is just maybe some plain old pleuritic chest pain. What did her lungs sound like. A lot of times you can hear some junk or crackle like noise right over where the pain is/was if it is pleuritic chest pain. Routine ALS is the route I would have went too. Its too difficult to rule out anything cardiac with this patient.

What about a pregnancy test? Also, when does she take her Attenolol, morning or at night? If its in the morning, do her headaches feel better after she takes it. She just simply has a headache. She needs to just wake up every morning, take her shower, drink a cup of coffee and if after an hour she still has a headache take a couple Excedrin and get over it!

Ahhh. How do we truly know that no one else knows of this magical morphine that just appeared. I mean come on, how do we know that management didn't put it there as a test to see who would find it and what would happen. For all we know its managements way of seeing how honorable and trustworthy we are. What happened to the last set of medics that quit working here 9 mos. ago. I bet they all got fired for stealing drugs when they found 4 vials of expired morphine in a narc box. Our managers our waiting for one of us to steal this morphine and go shoot up. This is crazy! Everyone is out to get us! :shock:

I guess I would find my partner tell him what was found and ask him if he has any ideas about how it got there and who put it in there. Keep it between the two of us for now and watch it for a couple of days and see what happens. I would record the serial numbers and check it every day to see if they change. If they don't change take one or two out and store them somewhere safe at the station for a day and see if anyone says anything about them being missing. If no one does leave them there. Outta sight outta mind, right? Maybe give some to the headache lady in that one thread. Just kidding.

Ummm. I am not wonderful with the inhospital stuff but i will give it ago with my small knowledge base. Lets start with labs hows about some blood cultures, CBC, and ABG. And CT the head and chest. Thats all I can think of.

I am thinking may be something positional in the way she sleeps, maybe she is pinching a nerve or something. Does the headache get better or go away after she gets up and out of bed, like after an hour or so. Does her headache improve after a hot shower? Does she have any congested sinuses. Is her nose runny or is she stuffy? Maybe they are sinus headaches. Or maybe she is building a tolerance to the Atenolol and needs her dosage up'ed. I don't even know if you can build a tolerance to Atenolol but I figured its worth a shot. Are her pulses and blood pressures equal in both arms? Upon palpation of the ABD do you find anything? Do we know how high her BP was before the Meds and for how long? I am thinking it could be a dissecting aortic aneurysm?