Bieber

Thanks for the great and well thought out response, Systemet! I'll throw in my two cents on your final point, and hopefully one of our docs can correct me if I am mistaken. According to the AHA, the risk is about the same for electrical cardioversion as chemical cardioversion in non-anticoagulated patients IF there is a conversion from atrial fibrillation to a sinus rhythm. The primary issue (to my understanding) is when you get the atria effectively pumping again, in which case if there is a thrombus that has formed in the left atrial appendage, it may become dislodged as opposed to simple rate control where the patient remains in atrial fibrillation without rapid ventricular rate. However all forms of rate control carry the risk of converting atrial fibrillation into a sinus rhythm, as ERDoc pointed out. Also from the AHA, another little useful tidbit:

Doc, what's the best way to achieve rate control WITHOUT conversion to a sinus rhythm? I've been trying to find that out to no avail.

So would I. So what would be the tipping point for you? True hemodynamic instability? Or is evidence of cardiac ischemia enough to cardiovert? Anybody got any numbers to the incidence of thromboembolic events with cardioversion in non-anticoagulated patients who receive cardioversion?

I'm talking about ischemia resulting from inadequate coronary artery perfusion pressure secondary to tachycardia (as opposed to coronary artery occlusion).

I agree, although we will have adequate pain management and sedation available to us by standing order when our new protocols come out and they take diltiazem away (Versed, Ativan, fentanyl and morphine). To everyone, with that in mind, would you consider ischemic chest pain sufficiently "unstable" to cardiovert in the absence of hemodynamic instability and without the option of diltiazem? What if the patient had been in atrial fibrillation for an unknown duration and wasn't currently anticoagulated? Another thing I've considered (although we won't have it by standing order) is to call for amiodarone. Have you used it for atrial fibrillation before? Thoughts on its use for atrial fibrillation?

Hey everyone, So, right now, our protocols state that for stable patients with atrial fibrillation with rapid ventricular rate to administer diltiazem, reserving electrical cardioversion for patients who are unstable. Our new protocols, however, have withdrawn diltiazem from our formulary and only indicate treatment for unstable patients, but I'm having a little bit of trouble with this. It's probably just me, but in my mind I have always considered patients who are maintaining a good pressure "stable" even if they're symptomatic, but I think the AHA considers symptoms such as chest pain/dyspnea/etc signs of instability. I guess my question is, would you consider a patient with an adequate blood pressure who is complaining of chest pain and is in atrial fibrillation with RVR stable or unstable? Would you cardiovert them or give diltiazem? What if you only had the option of cardioversion? Thanks.

After thinking about it, I realized what is probably the single biggest lie I have ever heard in EMS. It has come in multiple different forms from several different people; regardless, the real lie is always in the first two words and made by those who would hold us back and keep us down rather than uplift and advance us: "Paramedics/EMT's can't..."

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-Oxygen is beneficial to uncomplicated MI's. -Diuretics should be given to acute CHF exacerbations (without labs to confirm a true fluid overload state, as oppose to incorrect fluid distribution). -Pain management for abdominal pain is bad. Same for multi-systems trauma. -Code blues should be transported. -Narcan should be given to unconscious patients regardless of respiratory status. -Some patients are too critical for pain management. -Every patient should get a little bit of oxygen. -Spinal immobilization is beneficial to patients with spinal fractures. -Some medications and procedures "need" to be by physician order only. -Intubation and PPV is beneficial to non-hypoxic code blues. -The time saved by emergency traffic is clinically beneficial. -Morphine is beneficial to CHF. I'm sure there's more, but there's a little bit. And I'm not just talking about the procedures or treatments themselves, but the misunderstanding of the pathophysiology behind them that we were taught (or lack thereof).

Greatest embarrassment? Hmm... I'll have to think about that one; there's so many to choose from. Most recent one, the other day on a diabetic patient we were giving some oral glutose and my partner smeared some on her lips and I told her to "lick it off your lips". I didn't think it sounded as funny (or as dirty) as everyone else did, apparently! I'll come back to this with a better one.

Ah. Do you protocols allow you to wait for them to show up on things like fractures or other conditions where pain management is indicated or are you expected to load and go? Just out of curiosity.

Haha... we still rock the Planos as our medboxes. I'd like to get like the Pelican 1600, but I don't think we're going to be switching what we've got right now anytime soon.

Damn man, that would blow. How far away is the nearest ALS unit? I assume you guys get mutual aid from the nearest ALS service?

Fair? Maybe, maybe not. But the employer sets the standards, and I won't knock a service for expecting more than the minimum. The pre-employment tests and the training at my service when I went through it sucked. Like, hardcore sucked. It essentially consisted of some papers explaining navigation and charting, driving around a parking lot (no real driving training on the streets), half an hour messing around with a stretcher and stairchair, and three days of ridealongs before I was thrown onto the streets. I got hired on as an EMT and never had to take the paramedic test after I got certified. We're revamping our hiring and on boarding process and implementing a formal FTO program, and even now they've made some changes that have drastically improved the orientation process, but for me and everyone that came before me, it was pretty much learn as you go. Along with the fact that we don't recognize prior EMS work or advanced education here, it's made for a system that pretty much demanded nothing more a "pulse and a patch"--which hopefully is on its way out.

No... pain meds...? I weep.

Not a big patch guy, personally. Although I did submit my own designs when the state was accepting submissions for new state patches (didn't get picked). I'd rather have a nice polo with my name and certification level stitched into it and a company logo on the breast over our current button ups with the service patch on one shoulder and state patch on the right. I feel like such a goober in those. Also, Chris, nice display! Definitely a lot of history there.

Are you going to be working with the Memphis Fire Department or another service? We've been working with MFD lately (along with Wake County and Medstar) as we develope our FTO program, so I have a little bit of knowledge about them, and there might be someone here on the forums who've worked for your service who could answer some of your questions. Also, yeah, things that would have been good to ask during the interview process.

Recovery position, protect airway, compressions if indicated, call 911. That is pretty much what I would recommend doing as a lay person. As far as splinting, I would just offer to assist the patient to manually hold their injured limb, but they'll know what's most comfortable and what hurts and they'll probably do a good enough job maintaining that position of comfort themselves No offense, man, but I think you're over thinking this. As a lay person, the most important things you can bring to the scene of an illness or injury is a knowledge of how to do CPR and a cell phone--off duty, I wouldn't do much more myself (maybe get a name, DOB, and history). Addendum: I recommend not doing any real in depth splinting with any materials on hand because A, the EMS crew may want to resplint it themselves, and B, because the EMS crew may want to give pain management before they do any splinting/manipulation. I had an open radial/ulnar fracture this week and the patient was supporting the limb just fine on his own and I didn't even touch it until I got some fentanyl on board.

Now that I think about it sometimes we do bring the monitor instead of the box. Just depends I guess. Haven't had a field birth yet. Wow, that's a lot of stuff. Do you feel like its appropriate or would you change it if you could?

Thanks for all the replies so far! Dennis, what is in your "jump bag"? Also, slightly off topic, you said you need the stretcher 95% of the time, do you mean you transport 95% of all patients or that you have to move patients to the ambulance via stretcher 95% of the time? Do you have a policy that all patients should be moved to the ambulance via stretcher? Harris, having those meds on your monitor is pretty ingenuous, do you also have IV supplies in it? Do you carry different sizes of BP cuffs on the monitor as well or did you have to sacrifice those for the drugs? With regards to the O2 bag, we have one of those too, but I rarely use it because fire is usually on scene before we are and they have their own O2 bag (plus we have a D cylinder on the foot of the cot), and because I very rarely place people on oxygen unless it's a difficulty breathing complaint. Bern, could you describe what all you carry in your knapsack? Kiwi, wow, that's a ton of weight to lug around. I'll refer you to my next question, which is for everyone... To everyone who brings additional equipment beyond the monitor in on calls, how often do you find yourselves using equipment out of your medboxes/knapsacks/medbags/first in bags/O2 bags? Do you feel like you get a lot of use out of them or that it's mostly there "just in case"? If you could design your own setup for your equipment, what would it be?

Does it weigh as much as an ambulance too? =)

Okay, pretty sure no one else has made this topic before, but I'm just curious, what do you take in with you on calls? I know this is a broad question, so I've divided it into certain categories and answered for myself. Unknown Medical - Monitor Abdominal Pain - Monitor Chest Pain/Cardiac Call - Monitor, medbox (contains bandages, IV supplies, all meds). Difficulty Breathing - Monitor, medbox, O2 bag (if fire isn't already on scene, which they usually are). Cardiac Arrest - Monitor, medbox, IO bag, O2 bag (if fire isn't on scene yet, which they usually are). Diabetic Emergency - Medbox Fall - Monitor, I'll send someone for the board/collar if needed. OB - OB kit, medbox. Minor Trauma- Medbox, or nothing if they're close to the truck. Major Trauma/MVC - Nothing--I go to assess and then send someone for the board/collar or whatever else as needed. Hospital Transfer/Nursing Home - Stretcher, other equipment per call info. Psych - Medbox or nothing. If it's a large complex and we'll be doing a lot of walking, I'll usually bring the cot with me, otherwise I tend to leave it in the truck until I know we'll need it. Do you bring everything in on every call? Why or why not? Do you bring the stretcher in on every call? Have you ever been burned for not taking everything in or not taking a certain piece of equipment in? Did patient care actually suffer from not having a certain piece of equipment on scene immediately, or was it merely an inconvenience? P.S. The list above is not all-inclusive, if anyone thinks of something I missed, let me know!

I wear gloves if I plan on touching something wet that isn't my own. Skin to skin contact I'm not worried about (generally). And I wash and/or sanitize my hands between patients. As far as catching shit from patients, I'm conscious of the risks but I don't tend to worry about it. Keep yourself safe and the risks are lowered as much as they reasonably can be. I'd hate to catch something serious, TB, meningitis, etc, but I know that the risks are low and fretting over all the possibilities is a shitty way to live.

I was just on scene the other day where we were asked to knock on the door of a suspect's house to try and get him to come out because he had supposedly cut his hand after breaking some other relation's window to try and get inside and wasn't answering to PD when they banged on his door (the cop thought he might answer for us). I turned around and saw PD had gone across the street inside the victim's house. Guy could have come out with a gun or a knife or whatever and started going to town on us. Bad move on PD's part, worse move on ours. Shouldn't have done it, no excuse for why I did--won't do it again in the future. The point is, violence against us is largely preventable. It's when we get too comfortable or let our guard down that we start asking for violence. We can blame everyone else in the world for why we ended up in a bad situation, but at the end of the day, the only person accountable for our own safety is us--and we're the ones who have to suffer the consequences of failing to ensure our safety, whatever the means.