MSDeltaFlt

Also, the EtCO2 waveform is one of the two field confirmations of ETT placement. The other one being direct visualization. This is all mute if your monitor cannot print off the waveform. It cannot be confirmed if you cannot prove it with documentation. Page 17 of the "Riding The Wave" link above shows pretty much what the proper waveform looks like. To me that is more important than just the number itself. EtCO2 has about a +/- 5 torr margin of error to ABG's PaCO2; usually minus, but not every time. It is also dependent on cardiac output. If they're dead, they're not going to have that much of a cardiac output if any at all. You need to keep that in mind when looking at the waveform. I'll let Vent work her magic from here.

Not enough information. Need VS, breath sounds (Rales? Rhonchi?), and quality of respirations. Tracheal tugging? Other assessory muscle use?

I use the DCHART method going by body systems on "A" covering Head, Neck, Chest, Abd, Pelvis, Back, Ext in that order on each and every pt stating pertinent positives AND pertinent negatives. Even the refusals.

It can also be used, I believe, for symptomatic A-Fib with RVR. However, it's contraindicated for Dig Toxicity. Since we can't check Dig levels prehospital, you won't be able to give it at all if they take Dig. Know an ER MD who swears by it.

In my career I've only handled 3 different epi's 1:100 (Racemic) 1:1000 (multi-dose) 1:10,000 (bristo-jet)

As far as inline nebs go, PM me your email and I'll send you to pics I've got for inline nebs that are cheap as all get out and very simple to set up. Vent knows what I'm talking about. I've tried put them in this post, but it just won't work. That or I'm not holding my mouth right. As far as handling the pt goes, it sounds like you were stuck on "B". He was too air hungry from hypoxia and his CO2 was through the roof so much that you weren't going to get him to anything compliant. The pt was behind the 8 ball before 911 was dialed. You did everything you could. Holler back and I'll hook you up.

I think you miss my point. Everybody wanted her to go the hospital except her. If she can answer all those questions I mentioned appropriately, then you need informed consent to treat and transport. Until then, you can't touch her. It doesn't matter what everybody else says. You get the refusal, explain to everybody there, even her Dr on the phone, that you can't touch her, and to please call you back if anything changes. Also, the operative phrase was not what you highlighted. It was just before. it said "according to my assessment". Plus something else you missed the point on. Why was the crew called in the first place? Grandma kept losing weight. What's the most common symptom a geriatric shows when sick? Altered LOC. When you have an ALOC, you can't refuse, because you're not in your right mind. With respect.

I believe this would be pretty much the same regardless of the state you live in, so here it goes: I would explain to her, her family, Dr, etc, that if she didn't answer these questions correctly then, according to my assessment, I would be forced to deem her a danger to herself and transport her to the hospital as any normal and competent person would want me to do as a patient advocate. 1. What's your name? 2. Where are you? 3. What day/month/yadda is it? 4. Why are you here? Then I would advise her of what might happen if we leave, and have her repeat the possible consequences. If she could do any of that, then you can't touch her. My humble thoughts.

You were bagging around 12 times per minute. Once every 6-8seconds is 16-20 times per minute. Were you wrong? No. You were doing what you were trained to do. Was the RT wrong? No. She probably had ABG's to tell her what the pt needed. Now I love having students in the middle of everything. They get so much hands on experience, and you get to teach them all the way through it. However, Vent's right. That RT was probably pulled between 2-3 areas at least. She's been there, and so have I. At times, it ain't fun. Nurses complain about the miles they walk in a shift. They can't touch what RT does in a shift. Does being on a vent matter? Kind of. The ABG's, CXR matter. The vent will help you on "how" to bag the pt. If the vent is ventilating fast with high pressures, then you're going to bag fast and possibly squeeze harder than you normally would. If the pt is assisting the vent, then you'll have to assist the pt with your bagging. You'll have to bag "with" the pt. If they're on a lot of PEEP, then you'll need to put a PEEP valve on the AMBU bag. You don't want to bag too slow. Remember swimming underwater and you almost didn't make it back up in time? The pt will be feeling the same thing if you bag too slow. You also don't want to bag too fast. Ever blow up too many balloons at one time? The pt will be feeling the same thing if you bag too fast. Simply put, bag as you've been taught until someone, who has more information about the situation than you, instructs you to bag differently. But make sure they have emperical data to back it up. You did good.

As an AMLS instructor, let me give you the basic "gist" of the class. AMLS will teach you to assess, come up with field Dx with differentials, and properly treat your pt without lab values, SpO2, EtCO2, Accu chk, ECG, or CT's... all in 10 min or less. They will show you some hands on assessment tests that physicians are taught. It is an excellent course. I love it.

Paramedics "waste" too much time on scene. -Some do. The good ones don't. Paramedics all think there god and treat EMT's like $hit. - Again, some do. The good ones don't. We don't do enough cardiac arrests to warrant a Paramedic. -True ACLS/PALS/NRP/PHTLS is code prevention. That's where a medic shines in my honest opinion. 2 good EMT's are as good/better than 1 Paramedic. -Not in code prevention. See above. Paramedics waste valuable time starting I.V's on traumas when they should be transporting. -Not the good ones. They get them enroute. Paramedics lose their BLS skills and we(EMT"s) end up picking up the slack. -A good medic has strong basic skills. Hope this helps.

We have a ton of ambulance transfer requests where I live, not unlike most of you. In my state there is a sheet that lists what is considered medical necessity and what isn't. If a pt does not meet medical necessity, I will inform everyone involved that I am not refusing to transport the pt, but I cannot bill their insurance. That would constitute insurance fraud of some sort. Someone's paying for it: EMS, hospital, pt, or family, but not their insurance, and I will not falsify the report. Humbly.

-Chuck Norris can slam revolving doors. -The Big Bang was actually Chuck Norris roundhouse kicking God in the face. -Chuck Norris has counted to infinity. Twice. -Chuck Norris can hit you so hard that he can actually alter your DNA. Decades from now your descendants will occasionally clutch their heads and yell "What The Hell was That?" I got a million of 'em.

-Chuck Norris once shot a German plane down with his finger, by yelling, "Bang!"

Why? Because he wills it so.

That's nothin'. This one time, at band camp, I saw a medic write a GCS=1

To answer your question, firedoc, it depends. Once an EMT, always an EMT? I believe you have to answer two questions first. 1) Do you romanticize the career, or 2) do you answer your calling? If you do romanticize the career, you will soon find out that the honeymoon is over. EMS is not always fun, at times very UN-fun. Very rewarding as you well know, but no fanfare or tickertape parades; just a pat on the back or a firm handshake from your partner saying, "Good job. See you tomorrow. Drive safe." is all we can count on when we make the "big saves". There's no romance in this career. It is a definite calling. When you do answer your calling, in whatever career you choose, it is the best damn job in the world. That's where the longevity comes from. My humble opinion.

Unfortunately it usually does in my experiece of observing. But it depends on the crew makeup (emotional/maturity/psychologically) and the overall mood of the base/shift. Louis Grizzard once said, "Naked is when you ain't got no clothes on. 'Neked' is when you ain't got no clothes on and you're up to somethin'." There is a service I work part time and a crew (who no longer work there) were walked in on and they were "neked". Hence why they no longer work there. But there are others, my full time base, where the crews are very comfortable with each other, and their families know that their family members are safe with the crews. My 0.02.

jwraider, Having COPD Exacerbation and CHF at the same time is not that uncommon. Give a neb, or don't give a neb; it really boils down to the breath sounds. Not the audible sounds. You must put your stethescope on the patient and actually LISTEN. Listen to all lung fields: front, back and side. Listen for Rales. Where do you hear them? Where do they stop? Are there any Wheeze? Where? Musical wheeze? Coarse wheeze? Do you hear any Rhonchi? Where? How about any air exchange? Do you hear any? Or do you hear nothing but the crappy breath sounds forementioned? If they're full of fluid, I'm not going to give a neb. Giving a neb in fluid filled lungs is an excersize in futility IMHO. Hope this helps.

EMTgirl, you had a middle-aged man with new onset midsternal pressure and back pain, borderline BP, and bradycardia. Regardless of what the 12 Lead said, I wouldn't give NTG without a line. If I couldn't get a line in the arm, I'd go EJ. I'd go EJ in a heartbeat regardless of what the protocols said. I do this because my med controls know me and trust me, and they expect me to do what the pt needs. I'm just that aggressive. Regardless of the situation, a middle aged man is not supposed to have a HR that damn low and having pressure in his chest. That is just not supposed to happen. So I would get aggressive on that alone; even more aggressive with what I believe your 12 Lead said to boot. Some may agree. Some may not agree. Those are just my thoughts. With respect.

The phrase I use in dealing with any psych pt is not PC, but it helps me to better grasp the situation: "When faced with a crazy person, you have to ask yourself 2 questions: Are they crazy 'cuz they're sick, or are they crazy 'cuz they're crazy?" This woman is "crazy" (for lack of a better phrase) because she is sick from a chemical imbalance in her head. She has a chronic condition that requires treatment. And, since she is a proven danger to herself and/or to others, she does not have the right to refuse said treatment. It sounds as if the events you told us are relatively recent. She needs to be institutionalized until this episode is under control. Ending her career now might be a little premature. It might need to be tabled, but not ignored.

With gas being over the $3/gl, I do the speed limit. Don't need to sticker my car.

Sorry for the late post. Been out of town a while. Depending on the state (if I'm thinking properly), you can really make an ER RN's life a living hell if he/she's being a bit nasty. I've informed several that if they pushed the issue, every single pt I would bring in would be fully packaged on LSB with at least 2 IV's and on a CM - acting as a proper patient advocate... and I know how to document on my chart. Ensuring that every single pt would be brought back in the ER. After hearing that, a couple of particularly bitchy nurses got REAL quiet REAL quick. Also, you do not have to give a RN a bedside report where I come from. You only have to give report to someone of equal or higher training. Could be the ER doc. The RN must be informed of the pt. Simple. Give bedside report to med control, and INFORM the RN that there is a pt that requires their assessment. They have absolutely no say so in the matter. This may differ from state to state so I may be way off and do not mean to offend. Just FYI.

We are kind of thrown to the wolves upon graduation, aren't we?

It's a bit more complicated than that as is stated above.