tcripp

Interesting rhythm strip. On your initial, I would have called it v-tach with pulses or even v-flutter - I do not see torsades (TDP). The patient appears to be stable (his blood pressure is currently holding) so I'd have some one apply the pads while I went for the drugs. Now, going with what I think I know instead of doing any further research, I'd be pulling out and administering 150mg of Amiodarone over 10 minutes. I'd also be preparing my valium/versed if I need to cardiovert. (Brief memory from school actually taught us, whichever we can get to quickest (drugs/electricity), use because the patient will not stay this way for long.) Now...what is interesting that I didn't see coming was the 12-lead ekg interpretation of "A-Flutter". So...hmmm...go with my initial instinct or with the monintor's interpretation? Or, just use electricty and call it good? Thanks, fiz for the brain stumper...

HNNEE = Head Neck Nose Eyes Ears Interesting predicament. Before I respond, I'd like to give you a little background on me. You see, I started as volunteer in 2004 (both at an ECA and EMT-Basic level) as a first responder for several groups. It was always an expectation that there are certain rules that are followed to be able to run as a first responder. That included the fact that if you were the primary care giver, then you completed the reports and turned them in in a timely manner. I don't ever remember being given a free ride just because I was not paid. It sounds like you already have an established policy that "it's okay because we can't get anyone else to do it". You need to change that and soon. So, my two cents are as follows: Bring everyone together and let them know what is missing in their "performance". You can do this without beating them in to submission. You need to set the expectation up front. Otherwise, they don't see the reason for doing it. Give a class on effective report writing and give them scenarios so that they can practice. If they are only running a few calls now and then, do this practice at your meetings to keep them refreshed. Remember, report writing is a skill just as is taking a blood pressure. Maybe have them rotate as QA/QI and have them read each other's reports. This will give a better understanding of exactly what is missing. As soon as you see information is lacking, have them do addendums. Hold them to the standard you expect. The more you come back to them, the more they will get it right the first time. Don't be afraid that they will all quit because you are asking them to do what they've agreed to do. It just may be that they need the prompting. Toni AKA finally, a paid paramedic!

This is probably the best advice. If not donuts, then brownies or cookies. It's always a GREAT way to break the ice.

Was having a conversation this morning with a paramedic peer when he asked a question to which I didn't understand the question. Am posting to see if my ALS counterparts can give me some direction. (A question from a test reads, verbatim, "Is it okay to attempt OTI after sedation if the patient appears flaccid?") In regards to rapid sequence intubation (RSI), can one opt to not give the neruomuscular blocker if your patient is "flaccid" after giving the sedation. He called the procedure PAI (pharmacy assisted intubation), but I haven't (as of yet) been able to find a good place on the internet to get a better understanding of just why you would want to do this...and when...and the outcomes if you were to choose this route? Of course, my answer to him was more along the lines that our protocols are "guidelines" and we can do what is best for the patient, especially if we can justify why we wouldn't give a particular drug in any treatment plan. But, since I have yet to RSI - I have no experience to pull from. Help?

My sentiments, exactly.

Interesting. I must be alone in my thought process. While I will encourage someone to go POV so that they have a vehicle for the return trip, I haven't minded having a rider. Flip side is...I haven't had "that rider" yet that would give me cause to rethink this personal policy.

I may just start doing the same...

Great input from everyone. Since this isn't a scenario game, per se, I can't tell you how things would have changed based on your interventions. What I can tell you is what I chose to do. I opted for a trip to the local facility for stabilization. That means that my treatment included BVM w/ 12 lpm O2 and diesel for 12 minutes. I am solo in the back, so I didn't get the opportunity to listed to lung sounds again during that time. However, by the time we arrived at the ED, his ETCO2 was 35 and his SPO2 was above 92. Don't remember the number off the top of my head. Upon arrival, the ED sat him fully upright and gave him a neb treatment via NRB prior to my departure. The follow up I received was they eventually intubated him and flew him to a more appropriate facility 1.5 hours away (by ground). Heard that his ABG was 162...and that he is now home and doing well. The one thing I didn't do that you've all pretty much said you would do...12-lead. Dang it!!! (lol...that's why I like this venue) Wait til I post the one with elderly patient with a nose bleed and NO other symptoms who's EKG shows STEMI. Wow...

Same for the great state of Texas. It has to be DCd or locked...

Just a little follow up on this scenario. I sat through a case review with about a dozen paramedics and 6-9 BLS/ILS providers. It was very interesting to see as we went around the table how each medic would have handled that call. First guy...RSI and intubate. Next guy...BVM w/ O2. Next guy...nasal intubation. It's refreshing to know that we don't have a recipe book for patient care...but rather an arsenal of different ways to accomplish the same task. Although he'd be a candidate for it, I'd have to say he was too tired to use the CPAP.

The hardest part will be overcoming the lack of experience. Be sure to draw on characteristics required for the job that you obtained elsewhere and then you can use your clinicals for the patient contact. In addition, if your area has opportunities for volunteer, take full advantage. That, too, will help build up your resume. Good luck to you!

I'd highly recommend you take a new cover letter and resume with you when you go in. That way they don't have to "search" for it while you are there. As Ruffems said, you never know when they'll do an interview on the spot.

Joe, first things first. Go back and proof your applications/resumes for grammatical and spelling errors. In this note, I see three or four at first glance. If an agency/facility is receiving several apps for the same job, their first cut may be the simple "attention to detail" eliminator. It is never a bad idea to have others review your work before sending it in. To answer your question about making a personal appearance, yes it is okay to go the HR office. However, I would not go after work in another services uniform. Be sure that you are clean and dressed as if you are going to an interview. Toni

In the service where I work, which is rural, the vast majority of our interfacility transferes are to a higher level of care. Most of these patients are transported with IVs, meds, vents, or other ALS interventions. With that being said, the paramedic takes those calls 100% of the time. The only time a basic or intermediate takes an IFT is a return to a nursing home or residence (usually for hospice). In the past year, I think we've had two of those during my shifts. Of course, I work for a 911 service . Agreeing with Dwayne and Richard's posts...I guess it depends on what you want to do in your profession.

I stand corrected. Class "B" uniform.

I'm going to skip over reading the other posts since this is obviously a hot topic but I would like to ask you this. Are you saying that my polo shirt which is nicely embroidered with reflective print on the back that we wear at night isn't appropriate? (We wear class As during the day and then a polo at night...on a 48 hour shift.) What about the crew member who does wear a uniform who fails to keep the "whites white" or is seemingly unfamiliar with an iron. Also, you talk about the 300 lb medics. What about those who are of appropriate weight whose uniform is either too tight or too large because of recent weight loss or weight gain. I suggest we look at the big picture of what professionalism should look like rather than the style of shirt. I'll take a crisp t-shirt over a desheveled "class A" wearer...any day.

Thanks, Dwayne for the feedback. I was really anticipating someone saying, "Enough already!" Also, I am also hoping those participating won't just look to the simple, "Let's fly the patient." Whether or not it's accurate, I'll pull the card, "Air not available for whatever reason." Now, to your questions. General condition of the pt? (I'm willing to bet there is an ashtray and smokes somewhere near the bed) "No bueno" comes to mind. He is lying in a right lateral recumbant position in bed with his head elevated by one pillow. When asked his name/age, he gives inappropriate information. Patient does not appear to be in distress, but rather is tired. He pretty much will do whatever you ask. Oddly enough, you don't see any asthrays/smokes nor does the room have an aroma of such. You do note that it's very, very stuffy. When was the last time that he self-medicated with his prescribed meds? He is compliant with his meds. What makes your appropriate facility more appropriate than the nearest facility? Best to say that the local community hospital just isn't set up for critical patients. They are good for stabilization, but if you go that route, they will be transferred at a later time. Does he use CPAP when he sleeps? Other times? No. Os at home? Times and delivery rate? See above post regarding concentrator. No lung sounds other than just a little air movement? No audible wheezing, crackles, rhonci, rales. You hear short bursts of air in his lungs in all fields on auscultation.Thanks for playing!

What was the patient's original reason for calling? His wife said that he was having difficulty breathing. Were there signs of cyanosis? Yes. Was the patient on supplemental O2, if so,what was the rate/delivery device? He was on an oxygen concentrator at 2 lpm. The last time he was having difficulty breathing, he pushed it to 5 lpm and then lost consciousness upon arrival to the ED.

Good catch. Yes, you have cpap as well.

Ready for another? Based on the post regarding mag sulfate, I thought I'd post another "what would you do?" scenario. For the record, these have been patients of mine. As a new paramedic, I know how and why I chose to treat my patient but I like seeing how and why others choose their course of treatment(s). That is one of the reasons I provide very specific tool box items. This avenue helps me to learn and grow (through experiences of others). I hope it does the same for you. You are called out for a 55yom, COPD, at a private residence (ground floor apartment). You arrive to find your patient lying in bed, with very shallow respirations. Auscultation does not reveal wheezing and you do hear some semblance of air passing through the lungs, but with very short/shallow breaths. Your first set of vitals are BP 116/73; RR 32; HR 118; SPO2 51%; ETCO2 31. Your patient is alert and talking to you, but is very tired - there is no accessory muscle use. You are 10 min away from the closest facility and you are 1.5 hours away from the closest appropriate facility by ground. History includes COPD and anxiety (PTSD - post traumatic stress disorder) / meds include predinisone, a rescue inhaler and nexium / no known drug allergies. Items in your tool box include albuterol ipratropium bromide xoponex epi 1:1000 methylprednisolone magnesium sulfate lidocaine BVM RSI / Intubate What is your course of treatment and transportation? What would you do?

While I've not had the opportunity yet to use this drug, we do have it as an option in our SOCs for patients in severe bronchospasm / extremis. We are a rural service and if we need to drive to a higher level of care, it would be beneficial to get this drug on board early. (Depending on where we are in county and traffic in the big city, our drive can be 1 - 1.5 hours.) I did have a respiratory failure patient not too long ago, but opted to drive to the closest facility for stabilization and then the patient was flown out from there. Otherwise, that would have been my first admin of this drug.

In some areas, we also have guidelines instead of protocols...and I like the guidelines better.

Okay...I'm lost. Isn't a paramedic = ALS? If so, how can you have ALS experience in order to attend a school to become a paramedic? No sarcasm here...

Think maybe you could come work here? I don't like the cold...at all! High today...70... One recommendation of what not to do...don't wipe down the inside with baby oil. It'll put on a shine, but it collects all kinds of grime. No...not me, but one of my partners. Ugh! Don't we all have to be a little crazy to be in this biz?

Yes, washed outside. If it's raining or freezing, it's not really worth the effort. However, since we are in central Texas and don't see to much of either of those (it's supposed to be 80 today), it's really not much of an issue. While I'm clean and go the extra step...I know I'm not as anal as others. And, those are the ones I want as my partner!