kevkei

Apparently you haven't read and dn't completely understand the EMT AOCP document and that EMT's won't be limited to administering only ASA, Nitro, Glucagon, Ventolin, or Epi. They have been adjusting the AOCP to allow EMT's to administer medications via almost every route- PO, IM, IV, SQ, SL, Neb, Inhaled, etc. Though true they will be limited to administering these specific medications (to be expanded in the future) on standing orders by their medical director, there is more to the skill set. This allows the EMT to be a true ALS assistant and they can administer what I ask them to in the event I am busy doing something else, eg Epi 1:10,000 IVP, Atropine, etc.

Letterman, Hmmmm, apparently you aren't familiar with the Alberta Occupational Compatency Profile (AOCP) and how we are leaps and bounds ahead of the NOCP document. The following exerpt is taken from page 148 ALBERTA COLEGE of PARAMEDICS CONTINUING COMPETENCY PROFILE EMERGENCY MEDICAL TECHNOLOGIST-PARAMEDIC (EMT-P) and can be viewed online. Major Competency Area: I Patient Management Skills Priority: Two Competency: I-18 I-18 Perform Pericardiocentesis A Paramedic will: I-18-1 Demonstrate knowledge of indication for pericardiocentesis: • Relieve cardiac tamponade; • Trauma • Infection • Neoplastic disease • Myocardial rupture. I-18-2 Demonstrate knowledge and ability to perform pericardiocentesis: • Subxiphoid approach; • Beck’s triad. I-18-3 Demonstrate knowledge of contraindications and complications of pericardiocentesis: • Cardiac dysrhythmias; • Puncture or laceration of the cardiac chambers; • Puncture or laceration of the coronary arteries; • Hemorrhage from myocardial or coronary artery puncture. Any questions?

Here's an interesting statistic I have found working with our local Mental Health Crisis Team. Less than 1% of people that claim to be suicidal will successfully act on it. The vast majority are attention seekers.

Chest tube baby, It's the only definitive treatment as you need the negative pressure involved. Needle thoracostomy only buys you time, it's a bridge to getting a chest tube.

Nope. It's not.

Try the Imitrex nasal spray, get the best of both worlds. Faster onsed (than PO) less undesired and adverse side effects (IM)

With the proper training, why not? We can do surgical crics when the ship hits the fanny, we can do a needle decompression, so why not do it right the first time. Not to mention that a needle is only partially effective in a pneumothorax but does nothing for a hemo(pneumo)thorax. We decide to needle a chest, they will be getting a chest tube whether we were right on our clinical assessment or not. As a side note, how about pericardialcentesis too? It's within our scope of practice to do it here.

I agree, especially "to see studies showing that field administered analgesia actually impacts the surgical decision process in reality before I would be 100% for or against field analgesia in acute abdominal pain." But in the interim, shouldn't there be a middle ground to try to make the patient comfortable? I don't think it is unrealistic to help take the edge off all the while them being able to aggrevate the pain at will. Not to mention, looking at maybe a shorter acting analgesic like Fentanyl as opposed to morphine? Here is an iteresting read, albeit it isn't published material but provides good argument. [web:a49a176380]http://www.ahcpr.gov/clinic/ptsafety/chap37a.htm[/web:a49a176380]

So now why do they want us to with hold meds in ABD pain too? This seems just as bad an idea. Clinically it has been proven you can give analgesia and still assess their abdomen, so why should we have to allow a patient to suffer?

I agree with Ridryder, he is in fact, the one that is dumb. He doesn't need to assess the patient, all he needs to do is draw some blood and do a cardiac workup and look at your initial 12 lead and compare it to their serial 12 leads or any previous ones he has had done. To allow your patient to stay in pain is barbaric and unprofessional. I would suggest that if you took the patient with pain 10/10 to be pain free with dynamic ST changes, you did an excellent job. I would suggest you talk to your medical director or another physician and even a cardiologist and get their opinion. I would be surprised to hear that anyone would agree with the doc that told you this. By the way, where is he located to make sure I never see him?

Angingal equivalent: "no specific specific chest pain or discomfort, but the patient presents with sudden or decompensated ventricular failure (dyspnea) or ventricular arrhythmias (palpitations, presyncope or syncope)." ACLS- Principles and Practice. AHA 2003. pp 397 "The concept of chest pain (anginal) "equivalents" Many patients with ACS present with signs and symptoms that have been termed ischemic equivalents or anginal equivalents. It is important to note that these patients are not having atypical chest pain as described above. These are patients who seldom offer complaints of "pain" in the chest, below the sternum, or elsewhere, and the healthcare provider may not be able to elicit a report of such pain. Instead patients may present with a symptom or sign that reflects the effects of the ischemia on left ventricular function or electrical stability. Patients with anginal equivalents are experiencing an ACS. They require the same assessment, treatment, and decision making as any other patient with STEMI or UA/NSTEMI. Note that this phenomenon os ischemic equivalents occurs much more frequently in patients having UA/NSTEMI than in patients having STEMI. Diabetic patients and the elderly are most likely to present with these symptoms. With advancing age, the elderly are more likely to present with diaphoresis. Some of the more common chest pain equivalent symptoms experienced by these ACS patients are shortness of breath on exertion, weakness, fatigue, palpitation, and lightheadedness or near syncope with exercise. The most common signs of anginal equivalents are acute pulmonary edema or pulmonary congestion, cardiomegaly, and a third heart sound. Ventricular arrhythmias can cause symptoms in these patients. Ventricular extrasystoles, nonsustained VT and symptomatic VT or VF have been documented. Ventricular ectopy that increases with activity (most will supress at increased sinus rates) is suspicious for ischemia. Atrial fibrillation is uncommonly an ischemic presentation." ACLS for Experienced Providers. AHA 2003 pp 50.

Anyone familiar with the term "anginal equivelants?"

Ain't that the truth! Don't get me started on that.

Ace, this Para-God complex is just that, a complex if it exists. It isn't limited to just Paramedics and it isn't just limited to EMS. You can have a Copa-God, Nursea-God, Doctor (they are god), Lawyera-God, Plumbera-God, etc. Anytime someone thinks they are the epitome of what they do. I don't think your examples of these crews reflects this. I just think they were just plain dumb, not Para-God like. Are these crews acting like this the result of a complex, a poorly run system, poor training, or combination? I guess I should just never get sick in your area. Where are you by the way?

Wsa that a nearly clever attempt at a personal slight????

Your statement here is the basis of what we do and what should come first, which is what is in the best interest of the patient. I was just pointing out that based on your comment I quoted earlier seemed to be a case of the pot calling the kettle black. Based on your examples, you were correct and it appears that the ALS crews acted wrong. This doesn't seem to be a Para-god complex but rather stupidity, being lazy, or a combination of both. And Dust, to answer your question, I agree with your statement in that a spade is a spade regardless of the number on the card be it a deuce or an ace (meaning that it is personality driven, not skill level or scope related, it follows the individual.) How does one change their personality just by going to Paramedic school? I don't see it.

This is an example of a BLS Para-God, where they think they know more than a responding Medic. Based on what? I've had EMT's argue with me because they "knew" more than me but their perception is out in right field because what they thought they knew was actually wrong. Just because they think they know more doesn't mean they do. This is the perception again of "BLS saves ALS" and is just as bad, if not worse than an ALS crew or provider demeaning a BLS crew or provider.

I agree with this but I never said you can prove they aren't in pain. As for being discretionary, it is your opinion of the differential diagnosis vs. the working diagnosis. I've seen too many students want to go with O2, ASA, NTG and Morph just because someone said "I have chest pain" not clueing in to the fact that it is clearly not cardiac. The same holds true to pain in general. Do those people in pain require narcotic (opioid) analgesia or would there be a better choice such as nitrous oxide, Tylenol or Toridol? I just don't like the idea or practice that if the patient says "I have 10/10 pain" a person responds with an automatic 2.5 of MS or 100 mcg of Fentanyl.

All things equal, if time and the patients condition will allow, I like to take them out to the unit. I find that it is my "office", I can let in only who I want, I know where everything is, I can control the temperature and lighting, and if I need to leave in a hurry, you are two steps away.

So then do you give analgesia to every patient that you have complaining of pain? To look at someone that is pink, warm and dry, in no obvious visible distress, BP 110/60, HR 64 and resps of 16, you can say there is no pain-o-meter? If someone presents with "severe" pain that clinically looks like the presentation above, I doubt their pain is as severe as they make it to be. You have to be able to form a clinical picture from the global presentation of history, chief complaint and clinical signs and symptoms. Treating pain has to be discretionary, just as is the case with giving ASA, decompressing a chest, intubating, etc. There is no black and white. DustDevil- someone that presents to be cardiac chest pain gets MONA (regardless of 12 lead presentation) until cleared by troponins.

I agree. Hypoglycemic seizures that I have seen are short lived, not a generalized, status seizure. In addition, giving glucagon to a hypoglycemic patient that is in a true status epilepticus will probably be ineffective. By that point, if they are hypoglycemic secondary to the seizure, they have likely used up any glycogen stores they have. Since glucagon causes glycogenolysis, you would need metabolic replacement through D10,25,50W.

What was the substance that was taken? I'd assume it was a narcotic or other controlled substance? If it is a substance abuse problem, it is a significant issue. Theft is theft and is just the beginning of a large snowball effect going from bad to worse.

So in a silent MI, do you propose we do cardiac bloodwork on every patient that enters an ER? Doing a 12 lead may only have evidence shown in 40% of infarcts. It happens that when someone comes in complaining of generalized weakness for a day or two, they "just don't feel right", etc. Is it a viral illness, is it an electorlyte imbalance, is it a hypochondriac? A silent MI often is someone with no "atypical chestpain" complaints or without any infarct imposters. I'd think the main reason the mortality rate is so high is a combination of misdiagnosis or a delayed diagnosis.

PEPP was created and is geared towards prehospital care, where PALS is more for in hospital. I think PEPP is a simplified version of PALS. If you can understand PALS and apply it to EMS, I like it better. If you can't, I have found that PEPP is better for those people. Personally, I like to keep up to date on both as it helps to have a more well rounded approach.

Did anyone else ever get the "Fraggle Rock Blues"? The feeling that you got that meant it was back to school tomorrow because it was on on Sunday nights? And what about when Wayne Gretzky and the Edmonton Oilers dominated the NHL for most of the decade?