buddha

To reiterate from the above post: Use atropine cautiously in the presence of acute coronary ischemia or MI. An atropine-mediated increase in heart rate may worsen ischemia or increase infarct size.

Must be a US/Canada thing. First, I NEVER suggested that diagnosis should be done by 3 lead - or by basics. Accepted standards, meaning AHA Guidelines. Refer to the Acute Coronary Syndromes Algorithm. Follow the algorithm from initial ECG to the high risk stratification box "ST elevation or new or presumably new LBBB: strongly suspicious for injury (ST-elevation MI)". From here, the algorithm indicates ST elevation greater than 1 mm in two or more contiguous leads and goes on to point out that greter than 90% of patients with ischemic type chest pain and ST segment elevation will develop new Q waves or positive serum markers.

Increased myocardial workload causes increased myocardial oxygen demand. If myocardium is already starved for oxygenat a rate of 40, do you really want to give atropine and increase the rate to 100 or would you like to pace at a rate just high enough to balance the patient's need for perfusion against killing off myocardium??

I can't quote the author of the study, but literature that came with our M-series indicated somewhere around 11% higher conversion rate with Anterior/Posterior pad placement vs. Sternal/Apex. This study may even be referred to in the AHA science guidelines. The label on the Zoll combi-pads even says they need to be A/P for pacing. The 12 lead would have been the key for my treatment of this patient. Had it shown inferior AMI, fluid therapy definitely would have been my first goal and pacing would have been the second line. I would not give atropine to a confirmed MI - impossible to regulate the effect of the drug in a given patient. At least you can control the effect of a pacer, and bad effects go away with the flip of a switch. I believe the AHA guidelines recommend pacing before atropine in the presence of AMI. Once inferior AMI was ruled out, I would have been quite comfortable giving atropine.

Sorry mobey, but you need to attend a few more classes. According to accepted standards, ST elevation greater than 1 mm in two or more contiguous leads = STEMI, pure and simple. The ST elevation will normalize within 24 hours post MI, and often you are left with a pathologic Q wave that indicates an old infarct. Our regional chest pain protocol relies on this criteria to determine patient destination. In short, a 12 lead is performed on all chest pain patients (or any other patient suspicious for AMI). The 12 lead gets sent to the hospital for MD review. Patients without ST elevation or presumed new onset LBBB go to the local facility. Protocol dictates that those patients with ST elevation greater than 1 mm (in 2 contiguous leads) or new LBBB go directly to the nearest cath lab. Our 12 leads must be good enough for the cardiologists, because we often wheel these patients right into a lab. ST Depression = ischemia.

I hope you at least have some women up there, FarNorth...

I agree that the job is about much more than money, but our families like to eat and we deserve at least a comfortable lifestyle...

Most of the medics in this area are in the $10 - $12/hr range, which is pretty sad. These poor souls have to work 60 hour weeks to earn decent money at the end of the year. One local branch of a national company has medics making less than $10/hour, when another branch just 2 hours away is starting medics at$15. Why do you suppose this is?? I know a lot of moonlighters/weekend warriors who work part time in EMS, and since they have better paying "day jobs", they are happy to come in for just a few hours a week and don't really care how much they make. This is screwing the folks who are trying to earn a living in EMS, because employers can find lots of people to work part time, and good business practices dictate that minimizing labor costs improve the bottom line. For the record, my company does well by me - I have no complaints personally - but this appears to be the exception rather than the norm in the northeast.

This ain't north Texas, Toto. Good for you if you can get agencies to put 2 medics and 1 emt on every ambulance, but this is definitely not the case everywhere else. Many agencies apparently can't afford to pay 1 medic decent wages - let alone 2 in the same bus. Not everyone has a bottomless well of municipal money to work with, and in case you hadn't noticed, Medicaid doesn't pay very well. I've worked a lot of calls over a lot of years with just myself and a driver, and occasionally a firefighter/first respondere or 2 - we've done quite well for our community, and our records reflect that. Now, to bring this thread back to the original question - ambulances ran for a lot of years in NY with Certified First Responders in charge. Was it ideal? No. Would it be better to send no ambulance at all than to send one staffed with a CFR, if that is the highest level you have available? No.

To provide a historical perspective for many of you not old enough to remember these things, allow me to expound. In the state of New York, there was absolutely NO minimum level of care for ambulances until Article 30 was amended to require that a minimum of 1 CFR be in attendance on each ambulance call (1997). Prior to 1997, many ambulances ran with basic or advanced first aid, and the state requiring at least one person on the crew to be at least an EMT was seen as blasphemy in many areas. At the time, the NYSDOH CFR curriculum had grown well past the definition of CFR in the rest of the free world. The NYSCFR program had grown to about 90 hours, since many rural areas had no staff available. Our CFR's did immobilization, vital, O2, extrication, and many other things. Up until the year 2000, it was not at all uncommon to see ambulances staffed with 1 CFR and a fireman who drove. Article 30 was subsequently amended again and as of January 1, 2000, all ambulances in New York State were required to have a minimum of 1 EMT-B in attendance with the patient. Again, there was a huge outcry from the rural areas who felt this would destroy the system. NYS also at that time adopted a waiver process to assist agencies who could not meet the staffing requirement, and some ambulances ran up through 2002 with a CFR as the lead. Here we are today, and believe it or not, as long as the patient attendant is at least an EMT-B - there is no statutory training requirement for the remaining crew member(s). Many times, my 2 person crew consists of myself and a driver who has First Aid/CPR. If I need an extra pair of hands, I commandeer a CFR. Up until last year when a law was passed LIMITING CFR training to a maximum of 51 hours, NYSDOH CFR's were still being trained as if they were staffing ambulances. Given a choice, I'd much rather have a CFR trained partner than FA/CPR, but that's just not the way the world works here. On a side note, I find it hard to believe that any service would pay for two medics and an EMT to ride one bus, but I guess you can always dream...

Heck, I wish I could do them all... The person below me finally got that really nasty rash cleared up.

How about the boss's daughter?? The person below me was a bi-curious female in high school.

Only once, and for clarification purposes, it was IN the ambulance. The person below me, enjoyed the experience...

That's not it!!!! My fantasies are much more bizarre than that. The person below me is thinking about how badly they want to grow up to be just like their hero, Buddha.

Too many of you are ASSUMING that the patient's seizures are secondary to acute hypoglycemia. Has anyone who's posted here actually ever given glucagon?? It doesn't work instantly. I have given glucagon for acute hypoglycemia and it has taken upwards of 10 minutes to show marked improvement. How many of you would like to watch a patient continue to seize for 10 minutes while you are waiting to see if your theory is correct?? Again - break the seizure with your benzo of choice, open and clear the airway, do a BG, and treat if needed. Simple.