wrmedic82

Thanks for all your comments. They were about what I expected. I will need to fill in further on some details of the call. Prior to leaving the scene: I did contact a Supervisor /FTO(whom was in the truck) When I was told that the parents can sign on behalf of the patient. From the way it was told to me according to him that there was some type of exception to the rule that I was never aware of. The willingness of the supervisor to condone this action lead me to believe that this was acceptable. (not saying I agreed with it). The only form of online direction we have is base station physicians at the emergency rooms. Due to policies we have to direct disagreements to the supervisor. Most communication in our system to med control is via email, and voice mail. The next day I approached the medical records manager concerning this matter to see if I could get a deeper explanation. He told me about what everyone here has said. Needless to say medical control ( EPAB in our system) was promptly advised of the incident and is currently under audit. There really isn't a good reason as to why we didn't get a BGL. For that I will admit fault, and agree it should have been done. Thanks again everyone for your comments they are much appreciated Patient also had Hx of Hepatitis C. Patient was being seen for psychiatric problems from what Ive been told. No known alcohol abuse specified onscene by therapist, and family onscene. And I agree that he should have been transported, or at least given enough time to return to his baseline mental status and base txp based on the request of the patient.

If you double click on the strip it gets bigger.

The patient's iris and pupils were going side to side in a rapid manner. Kinda cartoon like. But this was a new finding because his eyes were not doing this inside the office building.

Agreed

We responded to a call at a therapist office for a 35/m who had a seizure. Upon our arrival at the patient's side. The patient was found sitting in a chair receiving supplemental oxygen via NC 2 L/min from our firefighter first responders. The patients parents were onscene when we arrived, and did not want their son transported to the emergency room. I personally advised the mother about the needs, risks, and benefits of going to the hospital. Mom didnt budge. Meanwhile the patient is still comming around but still obviously post ictle( not answering all questions appropriatelu). Vital signs were HR 90, RR 20, BP 130/80, SpO2 97% eyes were initially 3mm PEARL, unknown AO status as my partner who was running the show didnt care to find out .PHx seizures, brain bleed secondary to a seizure, cirrhosis of the liver. We did not obtain blood glucose. Parents state that they will call the patient's neurologist to get his opinion. Mom goes into the therapists office and makes a phone call. Shortly after mom returns, and says the neurologist said no that the patient did not need to be transported. No verification was done on my partners end ( as he was running the call) Parents did not have a medical power of attorney with them. My partner had the parents signs AMA, and released the patient to the care of the parents. While we were assisting the patient into the parents car, I noticed that the patients pupils were pinging, and patient began to exhibit lethargy. Now a couple things didn't set right with me, and I want to see if maybe Im being too hypercritical or if Im right to not feel right about this. 1.If the patient is an adult, normally AOx4 confirmed by parents, and is confused due to seizure. Can patient be legally turned over to parents in the absence of medical POA?? 2. If parents talk to patient's physician concerning txp, is it prudent for the medic onscene to make contact with the physician? 3. With the lack of medical POA, unconfirmed request by patient's physician, and the patient obviously confused. Would you have made transport decision for the patient on the side of the family's request or the side of the patient. The responses I got from the medic I was working with was that the decision was on the side of the patient, and that the parents can sign on behalf of the patient, and hold up legally. (not sure I agree with that, but I dont know) What would ya'll do? What insight do ya'll have to offer?

Just incase you are thinking about going the fire route. Just a word of advice. I would start with a 911 EMS service first and gain as much experience and knowledge as possible as a medic. Get a couple hundred calls under your belt, then make the transition. You will benefit alot more by doing this as your focus will be on EMS vs EMS/Fire which may make somethings obscure or it may not. But thats just my opinion. I know some great firefighters who practice medicine very well, and are very knowledgeable. Im still working my way there through EMTP school hopefully to be done at the end of this year. This is just my opinion. As far as pay goes. More pay is great. However I hate to say it but most the money to be made is in fire departments. They seem to be the go-getters when it comes to grants and other means of funding.

I fully agree with you. I tend to write a book when I chart. But you would be surprised

I will pass on the hug thing however you can send that pizza to 551 E. Berry St, FT Worth, TX 76110

Back in the day when I used to volunteer we used Motorola Minator 4 pagers which were tone activated, and allowed dispatch to talk directly to all volunteers via the radio. It would give an annoying chirp so you couldnt ignore it if your tone was sounded. It worked great for our purposes however we didnt run very many calls (maybe 400 a year). Where I work now we do that in a day (the EMS organization not me personally) so it wouldnt be ideal. Check what your communication centers capabilities are before cutting the check.

5

Our system uses 1 toughbook per truck. We utilize Visinet for routing, tracking, and to gain information from dispatch about each call we run. For documentation we have Lifenet ePCR from physiocontrol. (same guys that make Lifepak) Pros Visinet: Gives a quicker idea of the location of a call vs using a Mapsco Map. You can track your own movements for more precise routing (depending on who is navigating its not completely idiot proof) You can have it talk you to the call like a personal GPS. Cons Visinet: Keeping a connection sometimes is a pain in the @%& Pros Lifenet: Ensures that all pertinent info (demographics, MOI, NOI, ect) is entered to keep from accidental omission of information. The chart will not allow you to finalize a chart unless information that is deemed by the software as critical items are filled in. (example: signatures, demographics, meds, allergies, PHx ect.) Also you can set it up to fax the chart from your truck provided you truck has a built in gateway. Cons Lifenet: It crashes daily and may make you want to throw your toughbook every now and then.

:lol: :lol: :lol:

I don't know I would try to dilute with water. Reason being a lot of your corrosives are water reactive. With any chemical I would contact poison control before any interventions are started. I have some data from one program(s) I use on HAZMAT scenes. This maybe useful. Reactivity Documentation CAUSTIC SODA, SOLUTION LYE mixed with WATER Summary [C] Exothermic reaction. May generate heat and/or cause pressurization. [D3] Combination liberates gaseous products, at least one of which is toxic. May cause pressurization. [D5] Combination liberates combustion-enhancing gas (e.g., oxygen). May cause pressurization. [D6] Exothermic, generation of toxic and corrosive fumes. [D7] Generation of corrosive liquid. May produce the following gases: Corrosive Fumes Ammonia Oxygen Details CAUSTIC SODA, SOLUTION Belongs to the following reactive group(s): Bases Water is a reactive group. Reactivity Predictions (for each pair of reactive groups) Bases mixed with Water Hazard Predictions [C] Exothermic reaction. May generate heat and/or cause pressurization. [D3] Combination liberates gaseous products, at least one of which is toxic. May cause pressurization. [D5] Combination liberates combustion-enhancing gas (e.g., oxygen). May cause pressurization. [D6] Exothermic, generation of toxic and corrosive fumes. [D7] Generation of corrosive liquid. Potential Gas Byproducts Ammonia (NH3) Oxygen (O2) Corrosive Fumes (CorrosiveFumes) Acetaldehyde Ammonia resinifies (oxidizes, hardens and turns yellow or brown) on long exposure to air. The compound is very soluble in water. It reacts exothermically with water to evolve gaseous ammonia. [Hawley]. Lithium Amide is flammable and reacts with water or moist air to generate a dangerous amount of heat [Chem Reviews 12:61. 1933]. Lithium amide reacts vigorously with water to generate gaseous NH3. In experiments at Argonne National Laboratory, in which it was mixed with water and stirred at room conditions, about 23 percent of the theoretical yield of NH3 evolved as a gas in the first 0.6 minutes [brown, D. F., et al. (2000) Development of the Table of Initial Isolation and Protective Action Distances for the 2000 Emergency Response Guidebook, ANL-DIS-00-1, Argonne National Laboratory, Argonne IL]. Magnesium Diamide may spontaneously ignite upon exposure to air. Soluble in water. Reacts violently with water to form caustic ammonia/ammonium hydroxide and heat. Potassium Peroxide reacts exothermically with water (or moisture in the air) to give oxygen and a caustic solution, potassium hydroxide [NFPA 491M] . Sodium Methylate ignites in moist air [Wischmeyer 1966]. The compound with moist air, autoignition is possible; strong reducing agent; reacts with light metals forming H2 gas, with fire and explosion hazards; reacts violently with water to form methanol and sodium hydroxide, and with acids, causing hazard of methanol ignition [Handling Chemicals Safely 1980 p. 850]. Sodium Superoxide reacts with moisture and carbon dioxide in the air. Reacts vigorously with water to give oxygen and sodium hydroxide.

ok on a spigmomanometer the numbers are only even. My question is how did they get 115/75 being optimal when both numbers are odd. I thought I was clear when I asked..my bad

When a patient tells you their norm, provided they know their norm, its something to keep in hindsight. You always treat the patient based on chief complaint, and clinical presentation. A patient may have their normal BP and still be dehydrated if that is their clinical presentation, or it may be elevated in some circumstances. Common sense wont hurt much either (unless common sense lies to you frequently) . Another thing to consider is protocols. In our system if someone has a systolic below 90,according to hypotension protocols they get a initial 250ml fluid bolus, then give 20cc/kg (standard) to maintain a systolic at or above 90. Just curious and don't take this as sarcasm but when did BP have odd numbers vs even numbers. I am not much for monitors as Ive seen them be drastically off too many times. funny case and point was watching the monitors BP cuff take a pressure while not being attached to the patient or anyone for that matter. I am sure routine calibration would fix that. I just like sticking to old reliable spigmomanometer and stethoscope

I guess you can call vital signs WNL if you compare them to what is written in literature. However like others have said vital signs are relative to the patient. Its not a bad idea to ask the patient what thier norms are.

With a patient with a PE, wouldn't the SpO2 be low?? Case and point I'm going to make is I had a patient who was later confirmed to have 4 PE's have a SpO2 of 64 and ETCO2 56. As far as the other stuff there is nothing for us to determine PaO2, PaCO2, ect. So how does that effect our treatment. And yes a patient in DKA can have ETCO2 in the single digits due to tachypnea, but lets say the proverbial paramedic not thinking tries to get the patient to slow respirations. If he is successful in doing so then ETCO2 would significantly rise. Again I go back to patient assessment prior to treatment. If you have access to recent lab work...awesome. This is often not the case. So me personally I would see how the patient presents (i.e anxiety, DKA, sepsis) and go from there. That is where we definitely agree.

I hate to disagree with you there bud, but you actually blow off all your CO2 and have an over abundance of O2 when a person hyperventilates. That is why you will see when you place the person on SpO2 and ETCO2 monitors that the person's SpO2 will be 100% and their ETCO2 will be 19 or lower.Thus making the patient alkalotic, not acidotic. Its again important to evaluate the patient, because if they are hyperventilating secondary acidosis( Example DKA ), we do not want to coach the patient into slowing their respiration. Worst comes to worst, the person passes out, and resumes normal breathing. Or they continue to breath fast to compensate.

Report it....Its every individuals responsibility to maintain their own cert. If the guy is not responsible about keeping his cert up, what else is he not being responsible about ? Besides most states will allow credit for online CE's, as well as count card classes for CE credit. So he has no excuses other than not doing it. Hell soon ACLS will be online with no need to take a formal class. (sad but true).

Introduction In recent years, more studies have demonstrated the importance of lead aVR during the analysis of the 12-lead electrocardiogram (ECG) in patients with acute coronary syndrome (ACS). These studies have indicated that lead aVR is a strong predictor of left main coronary artery (LMCA) occlusion when used in isolation[1] or in conjunction with other leads.[2] Studies have indicated that the presence of simultaneous ST-segment elevation (STE) in leads aVR + aVL[3] or the presence of STE in aVR that exceeds the amount of STE in lead V1[4,5] is highly specific for LMCA occlusion in patients with ACS. Other studies have discussed STE in lead aVR in less specific terms, simply citing that this finding is indicative of either LMCA occlusion or left anterior artery occlusion,[6,7] or indicative of either LMCA occlusion or triple-vessel disease.[8] The magnitude of STE in lead aVR that is considered significant is inconsistent among these articles; some articles have evaluated any STE in aVR, whereas others have focused on STE greater than 1 mm. This difference may account for the varying specificities for LMCA involvement. Regardless, the literature continues to show with increasing consistency that STE in lead aVR in patients with ACS is associated with more ominous coronary occlusions. Patients with LMCA occlusions, left anterior artery occlusions, or triple-vessel occlusions have a worse prognosis, requiring more aggressive immediate therapy and often bypass surgery. Emergency physicians who find ECG predictors of any of these 3 conditions in their patients with ACS (whether ST-segment elevation myocardial infarction [sTEMI] or non-STE ACS) would be prudent to mobilize resources for rapid invasive therapy. Additionally, because many of these patients will require coronary artery bypass grafting, it certainly seems advisable to withhold clopidogrel.[4] Below is a summary of one more study that adds to the literature indicating that STE in lead aVR predicts more pronounced coronary occlusions and a worse prognosis. Admission ST-Segment Elevation in Lead aVR as the Factor Improving Complex Risk Stratification in Acute Coronary Syndromes Szymanski FM, Grabowski M, Filipiak KJ, Karpinski G, Opolski G Am J Emerg Med. 2008;26:408-412 Summary Szymanski and colleagues evaluated the association of STE in lead aVR with mortality. The investigators assessed 205 consecutive patients with non-STEMI ACS for STE in lead aVR of at least 0.5 mm. Patients were divided into 3 risk groups on the basis of their Thrombolysis in Myocardial Infarction (TIMI) risk score,[9] a validated ACS scoring system that is used to gauge 14-day risk for adverse outcome in patients admitted with ACS. Low-risk patients had 0-2 points; intermediate-risk patients had 3-4 points; and high-risk patients had 5-7 points on the TIMI scale. STE in lead aVR was found in 114 patients. The researchers found that the presence of STE in aVR was a strong and independent predictor of 30-day mortality (odds ratio, 7.8). During this 30-day period, 18 patients (8.8%) died. Of those who died, 16 of 18 (88.9%) had STE in aVR vs 98 of 187 (52.4%) of the survivors who had STE in aVR. Mortality also increased with the severity of STE in aVR. Mortality was 2 of 91 (2.2%) for patients without STE in aVR, 8 of 74 (10.8%) for patients with STE of 0.5 mm, 4 of 29 (13.8%) for patients with STE of 1 mm, 2 of 9 (22.2%) for patients with STE of 1.5-2.5 mm, and 2 of 4 (50%) for patients with STE of ≥ 3 mm. The increases in mortality were statistically significant. Viewpoint When considering the TIMI risk stratification scores, the researchers discovered that patients with STE in aVR, when compared with patients without STE in aVR, had higher death rates in the low-risk (18.5% vs 0%) and intermediate-risk groups (15.5% vs 2.6%). The study authors concluded that STE in lead aVR in patients with ACS was a good predictor of short-term mortality and could be used synergistically with TIMI scores for early stratification of risk. The takeaway point is simple: When patients with ACS, including non-STE ACS, demonstrate STE in lead aVR, the aggressiveness of early management must be increased. These patients have more complex coronary lesions and will likely benefit from earlier invasive therapy. Abstract This study aimed to analyze the prognostic value of the presence of ST elevation in lead aVR [aVR(+)] in initial standard electrocardiogram (ECG) performed on admission in combination with clinical variables and Thrombolysis in Myocardial Infarction (TIMI) risk score for unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). In 205 consecutive patients with UA/NSTEMI, we retrospectively evaluated admission ECG for aVR(+) of more than 0.5 mm. With the use of multivariate analysis, admission aVR(+) was found to be a strong and independent predictor of 30-day mortality. Mortality also increased with the severity of aVR(+): 2.2%, 10.8%, 13.8%, 22.2%, 50% (P value for trend <.0001). In prespecified low-risk groups by clinical factors, those with aVR(+) had higher death rates than those without aVR(+): 16.1% vs 2.2% (P = .04), 13.9% vs 1.1% (P = .001), 12.4% vs 1.1% (P = .002), 9.6% vs 1.2% (P = .02), and 6.7% vs 0% (P = .05) for patients with negative troponin, heart rate of 110 beats per minute or less, systolic blood pressure greater than 90 mm Hg, Killip I class on admission, and age 70 years or younger, respectively. Patients with aVR(+) compared to patients without aVR(+) had higher death rates in the low- and intermediate-risk groups by TIMI risk score. Our findings suggest that aVR(+) has significant prognostic value in patients with UA/NSTEMI and may provide an additional prognostic value to the conventional cardiovascular risk factor, particularly in patients in the low-risk and intermediate-risk groups.

YES!!!!!!!

you talk about evidence based medicine and yet there is not a shred of documented proof that ACLS drugs have better outcomes, or even work at all in patients in cardiac arrests. Don't get me wrong Im not advocating against giving vasopressin, epi, or atropine. But I find your comment somewhat hypocritical. Some things to look at http://content.nejm.org/cgi/content/extract/340/22/1763 http://www.annals.org/cgi/content/full/129/6/501 http://www.ncbi.nlm.nih.gov/pubmed/7023292 http://www.eboncall.org/CATs/81.html http://www.ncbi.nlm.nih.gov/pubmed/15642869 However I did dig up a couple articles about checking for pulses being ineffective. To each their own. Im not against checking pulses during CPR nor do I think that stopping to check for a pulse during CPR really has a true negative outcome. Thats my story and Im sticking to it. http://emcrit.org/1-resus/007-adult.resus.htm http://www.merck.com/mmpe/sec06/ch064/ch064d.html

This is our protocol Eclampsia 1. Magnesium Sulfate infusion 2 Grams no faster than 1Gram/min. Mix 4cc of 50% Magnesium Sulfate and 100cc Normal Saline in a Volutrol (60 gtts set) and infuse wide open rate. May repeat once if seizure is still present. Monitor patellar reflexes for Magnesium toxicity and discontinue if they appear. a. Bend the patient’s leg to a 90° angle and tap on the patellar reflex. If the patient’s reflex causes the leg to continually bounce, discontinue the Magnesium Sulfate infusion.

In this case scenario, I don't know if I can truly fault the firefighters. If I was dispatched on the same call, with no indication of a potential for violence from dispatch. All you know is that its a medical call on a elderly. Not expecting to be met by a group of teenagers who want to start trouble. I might have done the same thing and made scene. Its easy to say Ah Ha fire just had a wake up call. And they may have. But we all do it. And do we stage on every call? HELL NO WE DON'T!!!! I will say a couple things en light of this article. 1. extra emphasis on scene size up. Its easy to size up the patient. But what about the surroundings? If you were on scene in stead of fire ( because they are notorious for bullet proof t-shirts and bunker gear) faced with the same scenario, and saw a group of possibly angry teens walking into your general direction, would you step out of the vehicle? God I hope not, but this happens more often than its published in the media. The second thing I would like to emphasize is don't be afraid to back out. Its kinda common sense if the scene is not safe to stage until PD secures the scene. I don't feel the need to beat that further into the ground, not saying its not important. It is not abandonment if your safety is compromised due to bystanders, family members, etc. Ask any experienced incident commander, and they will tell you that the scene is dynamic and always changing. If the scene becomes unsafe for you and your partner there is no shame in backing out for your safety. I'm not sure how much time fire had before they realized "holy crap we are on the receiving end of a beating." But lets say they had 60 seconds before they got jumped. If they saw it coming or if you saw it coming wouldnt you do something to protect yourself by getting out of the situation?? Ask yourself, if you were dispatched P3 Sick Person 123 Anyplace Dr, Anyplace, TX USA 12345 75/f conscious, breathing, CC ABD pain. Would you stage??? And yes I pulled that call out of random because this is common call we all run on. Would you stage based on this information alone? Got something brown on your nose there bub

Here is a link that supports what Im talking about. http://lowfatcooking.about.com/od/healthan...onstickpans.htm