Ace844

Ditto to the above....

"ptemt," I can't speak for my service as to how many they palce as a whole as I have no involvement in their QA/QI process..... But, perhaps this will help some, of all the BLS airways I have placed in my carreer , 90% have been NPA's. in the last 6 mos....I have placed none in the pre-hospital environment... YMMV, Hope this helps, Ace

"Dust Devil," I agree wholeheartedly with you. The only problem with that is in my practice area, if you follow what you suggested, this can quickly lead to an express trip to the unemployment line. Alas, I have been accused of a few things in my time, but not conforming, and worrying about making waves aren't two of them... !! LOL thanx... It used to be here that if you were good at what you do, and treated patients well, etc... You were left alone, now it seems like the incompetent people are chasing the competent ones out or trying to get them fired..... Out here, Ace844

"DD", Si is Suicidal Ideation. The transport was a non-emergent transfer, so no lights no sirens, and the family ended up leaving just before us and met us at the facility. Hope this helps, Ace844

Hi All, I encountered this situation recently during a shift I worked. It got me to thinking so I figured, I'd post this poll and see what you all thought. So I was working a BLS OT shift doing transfers and we got a call from a hospital based EMH service (located in an ER) to transport a patient to another Local ER for Med clearance, then admission to their psych Rx floor. The partner I was working with claims he had 1 1/2 years exp. (though I had never worked with him before).So we go into the Hosp. get report and go through the paperwork, ensure the sect 12 is valid, etc... The patient is a 15yo Male who is experiencing SI/ and requesting detox as well. The paperwork reveals that this patient was brought to the EMH in Pd custody and that he had assaulted the EMS crew who had gone to his house to txp, at the request of PD/Family. His Mom, Dad, and girlfriend are with him and will follow us toi the other facility. After gettin through all of the billing etc. I ask the staff whether the patient has been searched for weapons, etc..., and whether there were any issues which we should be aware of??? The staff says that the patient has been cooperative, and searched by their security/police while there and is fine, and that there should be no issues and that restraints wouldn't be needed. SO partner then looks right at me and says in front of the staff, " What did you ask them that for?? We don't search our patient's....!?!??!" We package the patient who is cooperative, I ask him in front of family if he has any weapons, lighter, etc.. or other items on him, he'd like to provide or get rid of now... The staff is sending me incredulous looks along with my partner, the patient says no, the family agrees, and says they will take his belongings and meet us there , and that he has nothing. We package the patient and have an uneventful transport until we reach the next hospital. When we arrive there the patient's family meets us and the patient asks me, "Will they search me again here?" I say, " yes, more than likely they will," He looks right at me then turns to his girlfriend and says, "well then can you hold this stuff for me???!!!" He reaches into his pocket, and pulls out, a knife, a needle, a razor blade, marijuana, and a small "baggie of a white powdery substance." He then tries to give it to her.....WTF?!?!?!...right....Any how, this got me to wondering how many others out there search or have their Psych patient's serched by PD or others prior to transport...?????? Out here, Ace844

"ptemt," Could you be abit more specific as to what you mean when you asked, "Please share your experiences as to how often you use an OPA or NPA"? Did you mean in one's career? Of all the airway's one has placed?? thanks, Ace844

"edogs334", The only thing I think that should be clarified in your post is this. The fact of whether a medic does "all 911 shifts here" or works a "dedicated shift" exclusively, and or does one transfer and one 911 shift depends on alot of factors. 1.) The comapny you work for 2.) shifts available 3.) experience 4.) Whether you have an "in", there are more and each company is different. I know some medics who have never seen the inside of an ambulance before who have walked on a job and gotten 2 "dedicated" 911 24's, and I know medics who have had 15 years and they do both 911-transfer..YMMV... As far as Boston EMS, yes they are special, They don't feel they need accrediation or any of that other stuff, because their program speaks for itsself...besides the NE is the Mecca for medicine....LOL..Yes, they do believe this...Hope this helps, Ace844

Thanks for confirming the info I posted , and welcome to the board... Ace844

Perhaps they don't have alot of confidence in the general population of EMS providers clinical ability in your area. Most docs I have spoken with state that if you present your patient in a thorough, concise, professional manner be clear about the what/why of the intervention you are asking for...then you aren't likely to be denied. Being known as a professional with sound clinical judgement also enhances your chances that they will give you the go ahead and or do Med con. the way "Dustdevil" states he has it...It should be noted that this is my experience in my practice environment..YMMV.... Ace844

Hi All, I have a question somewhat on the subject of this thread...so please forgive me for digressing just a bit. Does anyone's service and or practice environment allow them to start a Vasopressin infuison in sepsis/DKA as well???? just curious.. out here, Ace844

My kind oif med. Director....This Md needs to spread the love...AROUND THE COUNTRY!!! We could certainly use more of those here!! Ace

Hi All, I will try to give you a further idea of the "Boston EMS is the best attitude" about which I had previously posted about. As I posted recently in the "General News" section of these forums Boston EMS was sending 5 crews south to help with the post Kartina/Rita clean up and SAR effort. At the same time Boston police worked out a feal with DHS/FEMA in which they would send LEO teams south as well. As a condition of this they demanded that they would do the following: send 1 team of 6 officers and 1 Boston EMS emt or medic. to be rotated back weekly. They stated that only a "Boston EMS personnel" were qualified and would be able to provide care for the BPD LEO's....in any situation....this is just a small glimpse at the pandemic institutional attitude at BEMS here... out here, Ace844

"Dustsevil," By living in the city limits I do mean that you must live in one of the communities I aforementioned. They are all considered "Boston". No you cannot live in Cambridge/Brookline. That being said there are soem Boston EMS employees who have worked there for along time who were hired in a time when there was no residency requirement, and they were "Grand fathered" so that they donnot have to live in town. Also there was a breif period in the late 80's where it was an on again/off again policy...so it truely depends on DOH and which union contract you were hired under. As far as I can remember there has been a staedy streak which Menino has made even more strick requiring all boston Public safety personnel to live in the city since the early 90's.....Yes cost of living is high here and 48K is not alot. Although it should be mentioned that most privates here pay alot less than 48k, so living here on less is tough, but doable...Certainly you won't be living near the common, or on Newbury ST...Think nice 3 decker in Mattapan... and living right next door to your local friendly crack dealer. He in his Escalade, and you in your Hyandai!!!!! :wink: :shock: :idea: :idea: :!: :arrow: As for shifts they do 8's, 10's, 12's 13's and occasionally 16's but those are rare, and shift length depends on assignment/bid...It should be noted they never allow employees to do 24's...period.. Hope this helps, Ace844

"Joey-pocket" Mass uses Paramedics/Intermediates/Basics.... As far as the 911 stuff well it depends on where you live. There are alot of privates which do have 911 contracts here, but getting a 911 shift is a different matter all together. There are also alot of municipalities which are either fire or third service based as well, it's about a 60/40 mix. To be honest at the BLS level in Mass you will have a hard time finding what you are looking for. Most municipalities have gone to ALS only contracts as their primary response with BLS as back up/or coverage for 2nd and 3rd calls in the system where the dedicated Als EA is busy. There are exceptions though. At the end of thew day it all boils down to, experience, the place you are working, and whether they have an open shift in their 911 systems for you or not.....I could tell you alot more, but with out details, frankly I can't be more specific. So I would suggest taking this either to PM or that you post more info...like where you plan to live, and what you expect/your experience....etc... Hope this helps, Ace844

They are a third service agency which is a branch of the Boston Public Health/Hospitals Dept. They are the primary provider of 911 service for Boston ( meaning: Boston, Roxbury, West Roxbury, Hyde Park, Charlestown, Dorcester, Jamica Plain, Mattapan, East Boston) When they get "overwhelmed" and or need additional ALS units, their dispatcher calls and requests resources from the various privates in the metro area. also, please see my previous posts... Hope this helps, Ace844

Hi All, I'll try to post some more info to help clear this up some for you. This is how the Boston EMS hiring/Academy/street EMS system works. 1st you stand a good chance of getting hired if you have/complete the following: a 7 year clean driving record, no criminal history, 3 interviews, a written, and a practical, then a final "grilling" interview by the "management", live in the city ( You have 6 months to move into the city, after date of hire, then the dept. aggressively investagates you to be sure that you actually do live in the city limits) and will stay there, and a strong dose of area knowledge. Regardless of your level of cert. you will first be hired as a EMT-B as I previously posted. They have some Medic-(PA's, RN's, etc... about the only exception thus far has been their medical director, and he doesn't "run calls" all that often) that first started as basics, then waited untill a medic slot and "medic academy" were being run, then moved to an ALS shift. The process works something like this. A bunch of the written test questions are which streets to take in certain areas to get to a certain facility the quickest and without their provision of a map. If you don't know the city that well, you lose points in that. These types of questions are also repeated in the oral interview portions as well. Then you go to their training program ( about 3-6 mos. and essentially a rerun of your EMT-B with PHTLS, etc...)you need to maintain an 80 or better. The cadre also has to decide if they like you and would like to work with you. If you make it through their "academy" then you go to 3rd ride training shift for 3 mos., where they do their best to wash you out, make you feel unwelcome, and let you know if you meet their standards. It is at this point which they decide "how many trainees they'll keep", and start forcing those who aren't connected know or someone out. Once some Paramedic slots open up, they will run an open internal promotion application process where you do essential the same stuff you did as part of their "Basic-training academy" except ALS. Both are essentially repeats of the core Basic/medic class we all would have already completed with some extras thrown in. The dept does this so that everyone there is trained to do it the correct "Boston EMS way." After all of the above you have 6 months probation before you get Union membership and or a secure job slot. They work 2 basics together for a BLS truck on which you may only do BLS skills regardless of your level of cert. On their Paramedic trucks it's 2 medics together. Having said that it can be a good place to work if you like 5, 8 hr shifts a week and once your done with their classes and are out of "probation", it's not a bad place to work. Also they are part of the Boston Police and Patrolmens union, so once you've been there awhile it'll take the management some serious effort to fire you, in that respect you'll have alittle job security. If my memory is correct they run the following BLS: 10-14 BLS ambulances per shift. ALS: 7-10 ambulances per shift. 2 supervisors in Suburbans per shift. their pay starts at about $18/horu and maxes at about 28/hr for a maxed out senior Medic. I hope this helps clear up some of the confusion... Ace844

"medic001918@joeydisasteroid", Boston EMS no longer utilizes those who are certified at the Intermediate level. There was a breif period in the 80's where they did, but this is no longer. I replied previously on this subject in the Help wanted section and you can read more here:: http://www.emtcity.com/phpBB2/viewtopic.php?t=1430. You first need to get hired. No matter your level of cert. You will need to work as a Basic for them for approx 1-1/2 years before being eligible to internally apply for a medic shift. It should be noted that I know people that had to work BLS there for 4 years and some times even longer before medic slots opened up and H@H ran another medic class... But until then here is the place for all your official Boston EMS info. WWW.BOSTONEMS.COM Hope this helps, any other questions fee free to post them, ACE844

Hi All, Just want to thank "Rid, Buddah, Flight, and others," who have taken the time to restate the main point of the discussion here which I think the point trying to be made ends up being.... 1.) Never assume anything 2.) Assess, treat life threats, reassess, find underlying causes, treat, assess, reassess, etc.. ad nauseaum... 3.) For those having trouble understanding this please reread the posts, educate yourself, ask questions... out here, Ace844

"sharon.simmons", Just FYI, the benzo's which you are most likely to be given for your "Seizures" when they occur, DO NOT Rely on glucose to wither reah an effective PK, or be metabolized. Here's the ifo for those drugs... 1.) Valium::"Pharmacokinetic information of diazepam following rectal administration was obtained from studies conducted in healthy adult subjects. No pharmacokinetic studies were conducted in pediatric patients. Therefore, information from the literature is used to define pharmacokinetic labeling in the pediatric population.Diazepam rectal gel is well absorbed following rectal administration, reaching peak plasma concentrations in 1.5 hours. The absolute bioavailability of diazepam rectal gel relative to diazepam injectable solution is 90%. The volume of distribution of diazepam rectal gel is calculated to be approximately 1 L/kg. The mean elimination half-life of diazepam and desmethyldiazepam following administration of a 15 mg dose of diazepam rectal gel was found to be about 46 hours (CV=43%) and 71 hours (CV=37%), respectively. Both diazepam and its major active metabolite desmethyldiazepam bind extensively to plasma proteins (95-98%). Metabolism and Elimination: It has been reported in the literature that diazepam is extensively metabolized to one major active metabolite (desmethyldiazepam) and two minor active metabolites, 3-hydroxydiazepam (temazepam) and 3-hydroxy-N-diazepam (oxazepam) in plasma. At therapeutic doses, desmethyldiazepam is found in plasma at concentrations equivalent to those of diazepam while oxazepam and temazepam are not usually detectable. The metabolism of diazepam is primarily hepatic and involves demethylation (involving primarily CYP2C19 and CYP3A4) and 3-hydroxylation (involving primarily CYP3A4), followed by glucuronidation. The marked inter-individual variability in the clearance of diazepam reported in the literature is probably attributable to variability of CYP2CI9 (which is known to exhibit genetic polymorphism; about 3-5% of Caucasians have little or no activity and are “poor metabolizersâ€) and CYP3A4. No inhibition was demonstrated in the presence of inhibitors selective for CYP2A6, CYP2C9, CYP2D6, CYP2EI, or CYP1A2, indicating that these enzymes are not significantly involved in metabolism of diazepam." 2.) Versed::"Midazolam's activity is primarily due to the parent drug. Elimination of the parent drug takes place via hepatic metabolism of midazolam to hydroxylated metabolites that are conjugated and excreted in the urine. Six single-dose pharmacokinetic studies involving healthy adults yield pharmacokinetic parameters for midazolam in the following ranges: volume of distribution (Vd), 1.0 to 3.1 L/kg; elimination half-life, 1.8 to 6.4 hours (mean approximately 3 hours); total clearance (Cl), 0.25 to 0.54 L/hr/kg. In a parallel group study, there was no difference in the clearance, in subjects administered 0.15 mg/kg (n=4) and 0.30 mg/kg (n=4) IV doses indicating linear kinetics. The clearance was successively reduced by approximately 30% at doses of 0.45 mg/kg (n=4) and 0.6 mg/kg (n=5) indicating non-linear kinetics in this dose range. Absorption: The absolute bioavailability of the intramuscular route was greater than 90% in a crossover study in which healthy subjects (n=17) were administered a 7.5 mg IV or IM dose. The mean peak concentration (C max ) and time to peak (T max ) following the IM dose was 90 ng/mL (20% CV) and 0.5 hour (50% CV). C max for the 1-hydroxy metabolite following the IM dose was 8 ng/mL (T max =1.0 hour). Following IM administration, C max for midazolam and its 1-hydroxy metabolite were approximately one-half of those achieved after intravenous injection. Distribution: The volume of distribution (Vd) determined from six single-dose pharmacokinetic studies involving healthy adults ranged from 1.0 to 3.1 L/kg. Female gender, old age, and obesity are associated with increased values of midazolam Vd. In humans, midazolam has been shown to cross the placenta and enter into fetal circulation and has been detected in human milk and CSF (see Special Populations ). In adults and pediatric patients older than 1 year, midazolam is approximately 97% bound to plasma protein, principally albumin. Metabolism: In vitro studies with human liver microsomes indicate that the biotransformation of midazolam is mediated by cytochrome P450 3A4. This cytochrome also appears to be present in gastrointestinal tract mucosa as well as liver. Sixty to seventy percent of the biotransformation products is 1-hydroxy-midazolam (also termed alpha-hydroxy-midazolam) while 4-hydroxy-midazolam constitutes 5% or less. Small amounts of a dihydroxy derivative have also been detected but not quantified. The principal urinary excretion products are glucuronide conjugates of the hydroxylated derivatives. Drugs that inhibit the activity of cytochrome P450 3A4 may inhibit midazolam clearance and elevate steady-state midazolam concentrations. Studies of the intravenous administration of 1-hydroxy-midazolam in humans suggest that 1-hydroxy-midazolam is at least as potent as the parent compound and may contribute to the net pharmacologic activity of midazolam. In vitro studies have demonstrated that the affinities of 1- and 4-hydroxy-midazolam for the benzodiazepine receptor are approximately 20% and 7%, respectively, relative to midazolam. Excretion: Clearance of midazolam is reduced in association with old age, congestive heart failure, liver disease (cirrhosis) or conditions which diminish cardiac output and hepatic blood flow. The principal urinary excretion product is 1-hydroxy-midazolam in the form of a glucuronide conjugate; smaller amounts of the glucuronide conjugates of 4-hydroxy- and dihydroxy-midazolam are detected as well. The amount of midazolam excreted unchanged in the urine after a single IV dose is less than 0.5% (n=5). Following a single IV infusion in 5 healthy volunteers, 45% to 57% of the dose was excreted in the urine as 1-hydroxymethyl midazolam conjugate. " 3.)Ativan::"Injectable lorazepam is readily absorbed when given intramuscularly. Peak plasma concentrations occur approximately 60 to 90 minutes following administration and appear to be dose-related (e.g., a 2.0 mg dose provides a level of approximately 20 ng/ml and a 4.0 mg dose approximately 40 ng/ml in plasma). The mean half-life or lorazepam is about 16 hours when given intravenously or intramuscularly. Lorazepam is rapidly conjugated at the 3-hydroxyl group into its major metabolite, lorazepam glucuronide, which is then excreted in the urine. Lorazepam glucuronide has no demonstrable CNS activity in animals. When 5 mg of intravenous lorazepam was administered to volunteers once a day for four consecutive days, a steady state of free lorazepam was achieved by the second day (approximately 52 ng/ml of plasma three hours after the first dose and approximately 62 ng/ml three hours after each subsequent dose, one day apart). At clinically relevant concentrations, lorazepam is bound 85% to plasma proteins." My short answer to this long response is thus. It is dangerous/Fatal for the provider/practioner to assume ANYTHING.. The other part of this is if we miss another cause or assume just one it could kill and or seriously/permenantly cause harm to a patient. Are you willing to accept this happening to you or a soemone you care for...I'm willijng to bet not!!!! Hope this helps, Ace844

Silly Rabbit, KED's are for kids... 8) :idea: Ace

"Buddah," I understand and know how and where RVMI shows ST elevation on a 3 and multilead printout/monitor, but thanks for the refresher. I still stand by my earlier post on why i would be VERY CAUTIOUS about giving a patient with clinically significant Right sided failure with an acute presentation NTG for the reasons posted. This is why usually if a hospital gives "nitrates" in a situation similar to this they use Nitroprusside as the agent of choice, for 3 reasons. 1.) It's easy to titrate to desired effect 2.)It's short acting 3.) It has the same therepeutic benefits as Tardil/NTG .... As always your protocols, med availability, and practice environment, as well as Milage may vary... Out here, Ace844

Hi All, For those that are interested in a synopsis of the latest literature reviews and synopsis and treatments of status seizure as of 3/05 then please check out these links... http://www.cochrane.org/reviews/en/ab001905.html http://www.emedicine.com/emerg/topic554.htm Hope this helps, Ace844

Hi All, Hmmm... an IO for D50, eh!??!!??! :shock: Just curious, "1EMT-P", does this mean that the golden rule in medicine, 1st do no harm, doesn't apply to your EMS practice :?: :?: :?: :idea: :roll: :? :arrow: Ace

"Buddah," With all due respect IMHLO it is essential to assess and consider the possibility that this episdoe of CHF and clinically symptomatic Right sided Heart failure wasn't caused by a RV MI, if you give NTG to a patient who has this you will take away what little "pre-load" that they have keeping them alive, their BP will bottom out and they may possibly soon after arrest on you....just some food for thought... Hope this helps, Ace844

You obviously need glasses or to reread my posts as I wrote in my post the following; . So to further alleviate the need to "reeducate you" or as you so gallantly wrote, Perhaps you should read what "USAF" posted and make sure you are addressing the correct person before attcking another. Also, since you asked here's a place and some links where you can educate your self on ....http://www.mentalhealth.com/drug/p30-a04.html where it states clearly But I'll leave you to go and take the time to read the rest yourself. the next link will educate you on Versed it's; http://web1.caryacademy.org/chemistry/rush...harmacology.htm As for Versed's uses in seizure treatment well you can read a quick article here: http://my.webmd.com/content/article/108/109032.htm Now of further note to your attacks/objections to these posts I noticed that you had nothing to say in the thread "Nasal atomizers as posted by various other posters in this forum ( here's the liink in case your "unable to find it, www.emtcity.com/phpBB2/viewtopic.php?t=373&postdays=0&postorder=asc&start=0 Now I'm curious as to whay you posted no issue there over the use of nasal atomized "Versed" in seizures...hmmm food for thought or is hypocracy your only weapon as wit surely isn't in your reportoire!! :idea: :!: :roll: :twisted: :shock: Out here, Ace844