systemet

As a rabid socialist, and foreigner, I don't see why it can't be. The US has the world's largest economy, and some of the world's lowest tax rates. Increase the tax rates slightly = free college = less of a class system = more intergenerational social mobility = less angry poor people + adapting to providing knowledge-based services in a rapidly changing global economy where a grade 10 education doesn't cut it any more. I felt like this too. Even medic was too short. I took some university sciences after, and felt like I was learning a lot of things that I should have been taught in medic school. I think this becomes a chicken-and-the-egg argument though. Right now, when some EMT-B programs are a couple of nights a week for four weeks, there's a surplus of qualified people that drives the labour cost down. If the program becomes longer / more challenging, it will reduce the number of qualified applicants, resulting in greater pay. In the same note, where's the incentive for the employer's to increase pay now in the hope that the training will become longer. I think it has to go the other way. Increase the education, then the pay will follow. To some extent, I agree with you. There are definitely a lot of people out there who choose to act in a very professional manner with the current educational standards. But, I think in most careers / professions, where you have a bachelor's level preparation, you see more professional behaviour. Now perhaps I'm being an idealist, as I've seen less than professional behaviour from physicians, lawyers and professors, and perhaps I'm confusing cause and effect -- perhaps people predisposed to more professional behaviour are also those predisposed to enter more academically rigorous programs? I guess part of my point, that perhaps could have been stated better, was more that, right now, EMS isn't a profession. There are individual EMTs and paramedics that exhibit qualities of professionalism, and operate at a high professional standard. But I wouldn't say that we can elevate ourselves to the status of profession, and have it mean anything more than professional realtor, or professional hairdresser, without getting at least a baccalaureate behind the paramedic. And 100 hours for an EMT is a travesty. [This is not to knock EMTs in the current system, I was one, and to some extent I am one, just with a wider scope, more education, etc. Most of us took the best training available at the time we went through school. But the educational standards should be raise, and aren't doing any of us any favours.]

It's hard isn't it --- the most likely explanation for all aberrant behaviour usually falls under "psych". But at the same time, we can't just sit back, and say, hey this is a behavioural issue for fear of missing something serious. I was leaning towards some sort of complex partial, i.e. psychomotor seizure. I'm not sure how reasonable an idea that was. DartmouthDave brought up an excellent point with a potential anticholinergic toxidrome. These patients present like human ping-pong balls, and are often shaking, delirious, and actively clutching at things in air that others can't see. Thanks for the post.

I think arguing against gay marriage on the basis of homosexual couples being unable to procreate is similar to arguing that an impotent man or a woman who has had a hysterectomy shouldn't be allowed to marry. Marriage and procreation have become increasingly removed from each other as more people have children before marrying, or never marry. I also don't think that a gay couple marrying lessens my marriage in any way. If anything has cheapened the institution of marriage in the last couple of generations it's been the staggering increase in the divorce rate amongst heterosexual couples. That being said, I'm also grateful we (I assume), mostly live in societies where it's now acceptable to end a marriage if it's become destructive.

I think a lot of this is lifestyle. In North America cars are cheap, gas is cheap, and fast food is cheap. It's harder to cycle or walk, or live without a car in most North American cities, compared to most European cities. So there's this tendency to drive everywhere. Same thing with the fast food / eating out culture. There pretty much is no healthy fast food. There's very little healthy to be found in a gas station at 0300, although there are less bad choices to be had. I think with exercise, the trick is finding a way to fit it in to your routine. I cycle or run to work, which gives me about 15 km of running and about 35 km of cycling a week, give or take a bit. It takes me about as long as taking public transport would, as I can avoid traffic congestion using trails, (plus it's not very far) so it doesn't really impact on when I get home. So there's a couple of hours of cardio every week that I don't have to justify to my wife. I'm fortunate enough to live fairly close to where I work, in a very safe city, with a good trail system. I also think it helps not to have exercise as an end in itself, but to be participating in some sort of sport or activity that provides motivation to do cardio / strength training. For me that's been hiking / climbing / mountaineering at one point, and more recently martial arts. It's a lot easier to train when the motivation is preventing that guy at the gym who's 235 of solid muscle from ripping your head off For me, at least, just training to lift more weight, or lose body fat, as an end in itself, is a little boring. I lift weights at home, I have a chin up bar, a few resistance bands, a swiss ball, a yoga mat and about 100 kg of weights, and 12,16,24,28 kg kettlebells. This saves me from the time and inertia of going to a commercial gym, keeps my wife a little happier, and keeps me around the house if I'm needed. It's enough for my goals, although there's some days when I'd like to be able to go down to the gym and do some heavier barbell squats or deadlifts. I've also found that especially if I'm doing lower rep training with longer rest periods, I can often do a set, prepare some food for dinner in my rest period, do another set, etc. deal with some of the laundry and so on. So my rest time becomes productive. I also like yoga videos. I've downloaded a few, and it just gives me a nice easier workout for when I have some sort of nagging injury, or I'm tired. For me, it seems to help when my back hurts.

On the upside, you're young, so even if you smoke like a chimney, you only have so many pack-years behind you. Your cancer risk is greatly diminished at +5 years after you quit. You're also not obese, even if you're sedentary, so that helps with both cancer and CV risks. I chose to quit smoking after lighting up outside the ambulance bay of a cancer hospital. I realised how terrible I'd feel if my patient's family saw me doing that, and just how stupid I was being. I'm not trying to preach. For me, personally, it was the tipping point. BMI is the weight (kg) / height (m) squared. So take your weight in kg (lbs / 2.02), and divide it by your height (m) two times. Or just go here: http://www.nhlbisupport.com/bmi/ (imperial units) http://www.nhlbisupport.com/bmi/bmi-m.htm (metric) I'm 6'2 (1.88), 195lbs (88kg), and I just squeak under the border of overweight (>25), with a BMI of 24.9. One of the problems with the body mass index as a measure, is that it doesn't measure body composition. Someone could be 6'2, and a 220lb pro hockey player, and in fantastic shape, and score a BMI of 28.8 (overweight, almost obese, which starts at 30), while have 8% body fat. There's no doubt that a pro hockey player is going to be in fantastic shape, and no where near obesity, but the BMI doesn't account for this. Unfortunately, this is probably of little comfort, as despite the inability for BMI to account for differences in body composition, it remains a powerful predictor of mortality. Here's a really awesome study looking at the association between BMI and mortality (and it's free). What I found interesting was the amount of mortality in the underweight cohorts --- it was a lot higher than I thought. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2662372/?tool=pubmed The perception of obesity / being overweight is also quite cultural as well. When I was in North America, and was fairly overweight, at 220lbs (100kg -- BMI 28.3, not the pro hockey player!), this was considered pretty average. I was tall, but not a particularly large guy. A women who had a similar BMI to me, would definitely have been considered overweight, if not obese, but the local values were that a man should be fairly large, that this is "manly". Now I'd be considered very "skinny", despite being close to overweight on the BMI scale. Yet put me in a Scandinavian country, and I'd be considered relatively big. I think in North America, and surely on other continents and in other countries, societies that have a high prevalence of overweight and obese people have sort of "reset" their perception of what normal is. It doesn't help as well, that the concept of "working out", is often focused on going to the gym, and lifting weights like a bodybuilder, and "cardio" is often relegated to a short, slow session on the treatmill or eliptical. For preventing heart disease / cancer, or for increasing longevity this is completely backwards.

Just wanted to add this: http://front.moveon.org/two-lesbians-raised-a-baby-and-this-is-what-they-got/#.TtbsJO1dtsB.facebook

What would be even better, is to get a decent trainer to teach you how to deadlift, or teach yourself very carefully. There's a not so great image here: http://www.exrx.net/WeightExercises/ErectorSpinae/BBDeadlift.html I'm sure if you look around, you'll find better examples. The deadlift is much more functional, it's a very similar movement to lifting the stretcher, it builds great grip strength and requires you to stabilise the upper body with the core, engage the entire posterior chain, and move at the hips, knees, lower back, and to a lesser extent ankles. As opposed to a leg press machine, or a smith rack, where you're not engaing the stabilisers much, and practicing a movement pattern that doesn't really occur in real life very often. The leg press is an ok start, but you'd get much better strength development and transfer from a deadlift.

A few quick points as I have to rush: * Sounds like your patient R on T'd, and went into VF. This is fairly common in STEMIs. I once had back to back calls when this happened. One patient was an right/inf/post MI that a rehab hospital had given 3xNTG to, and presented to me w/ 68/30 as an initial BP before coding within minutes. Another was an inferior MI with no right changes, normotensive, who I gave a single NTG to, and watched code 5 minutes later, complete with hypoxic seizure. Post-resus 12 showed right sided changes. Possibly post-defibrillation stunning, but probably not. * I wouldn't give NTG here, especially in the absence of CP and in the immediate post-resus period. Tread gently here. Almost all badness improves with a couple of minutes of doing nothing, including most post-resuscitation arhythmias. There's no evidence that NTG improves long term outcomes in acute MI. * You describe inferior STE and anterior STD, this sounds suspicious for inferoposterior wall MI (?R waves in V1-V4, with significant STD). This suggests a right coronary occlusion, which suggests RVMI. Was the STE in lead III > lead II? Were you able to get right-leads? Did you have time for a post-resus 12? * I wouldn't attribute the lack of pain post-defib to intoxication. I had (yet another) patient with a STEMI code on me, and post-resus @+5 minutes her complaint was "I feel kind of cold, what happened?" * It sounds like a challenging call with an emotionally charged scene and an intoxicated patient. You got them to go to the hospital, and dealt with the arrest, and you learned some stuff for next time. Good job.

I'm not American, so I'm not sure how qualified I am to talk about your core values. But I don't think I find these incidents particularly damning. I'm not saying that they're in any way justified or acceptable, just that they fall within the spectrum of criminal behaviour that we've learned to expect. I just don't find them that remarkable. Unloading pepper spray in a crowded store is an antisocial, dangerous and egotistical act. So is stepping over a dead man, being helped by bystanders. But these are not particularly unusual. In the first instance, you can look at any number of instances of people being killed by gun, knife or blunt trauma as the result of a personal insult, or for a trivial monetary gain (e.g. a pair of sneakers, an iPhone). These are arguably much worse. In the second, you can look at the general neglect of the homeless, or children of poor families in many societies. It's perhaps true that this might be a particular problem in the US. But I think part of that is just that you guys have a lot of handguns, both legal and illegal, you have a lot of poor people, and a greater wealth disparity than other first world nations. That's not to judge from a distance, it's just factual. I think it's a problem in most societies that people feel less connected. I'm only 33, so I can't claim to have great insight into the communty sensibilities of generations past. But I think that we feel less responsibility and less empathy for people around us than was common in the time of my grandparents.(Of course, they were watching German bombs fall out of the sky and kill random people around them, so perhaps their situations were relatively unique compared to the experiences of most people in the US). I think societies are becoming more materialistic, and more consumer-oriented. We're not smart enough as a species (nor perhaps as individuals), not to want what's being sold to us, and in some cases we're willing to go to extremes to get it. It's always tempting to thing that things are better in the past (what's that? Historical fallacy? I forget the fancy name), but I think we have been conditioned to spend and purchase. That doesn't remove us of our basic responsibility not to act as ****heads, but I think it explains some of our behaviour. This might be a particular problem in the US, but I doubt that it's unique. I think that similar factors are at play in other societies. There's maybe just a little less violence and poverty in other first world nations. It seems like a lot of them are moving in a similar direction. It feels like sometimes what happens in the US is something of a warning of what's to come in societies elsewhere. I think some of this can be explained by stress reactions. If the shoppers see people tending to the unresponsive man, they may feel relieved of responsibility. This is the old idea that the larger the group of people witnessing an event, the greater the influence of herd behaviour, and the less likely one individual is to act independently (with the caveat that when an individual chooses to act, sometimes it causes the herd to follow). I think we've all probably been on scenes where people are doing stuff that's just crazy, like the wife of 20 years washing the dishes while her husband lies in arrest on the floor in the living room. I think they're getting harder for the average person. The financial crisis hasn't helped anyone. It may get worse yet, depending on what happens with the euro, and how the Chinese choose to intervene (from what little I understand). It's clear that over the last 30 years the earnings of the middle 25-75% have fallen in real value, and the richer percentiles have become richer relative to the poorer percentiles. The right wing counterargument seems to be that the poor deserve to be poor, and the rich rich, by basis of their individual merits. It's interesting to see political activism in the US. Obviously there was a strong antiwar movement during Vietnam, but this was before my time. There's been episodic protests at the G8 events. But it's never seemed that there's been the same political consciousness that's been present in other countries. I think a lot of people have believed the argument that "we're all middle class now", and they're only just beginning to realise that maybe that's not true -- or that even if it is, the middle 50% have taken a bit hit over the last few decades.

Ha ha... We've debated before, and I think I've lost / exposed my ignorance on a few occasions! Note to self: tniuqs knows a lot about ventilators, blood gases, and lots of other stuff.

So what you're saying is that sometimes the experts disagree, so we should be skeptical of all opinions, even those considered "expert opinions", and we should all develop an ability to independently and critically appraise the literature? You're suggesting that expert opinion is only slightly more valuable than the personal anecdote of non-experts? I agree. Welcome to a basic cornerstone of science - rational skepticism. You'll also notice that this is why even published and peer reviewed case reports and case series are generally regarded as better quality data than expert opinion. This is also part of the foundations of evidence-based medicine. However, if you're suggesting some sort of radical scientific relativism, for example, that because one can find the odd researcher who opposes climate change, versus the overwhelming majority that do, that each opinion is equally valid, or that your uneducated opinion should be considered to be as valid, then you're straying dangerously into UFO-abduction land. Just because there is disagreement about an issue doesn't mean that both sides of the argument are equally valid, or supported by the available data. As to when scientists believe "life begins", I'm not sure that this is a scientific question, but is probably a religious and /or legal / ethical one. A sperm cell is as alive as a cardiomyocyte, algae, plankton, or a pneumococcus. When people talk about "life beginning", they're usually about to discuss reproductive medicine. Drilling for oil is dangerous. So is breathing. When we start asking the question "What is the acceptable risk for drilling for oil?" we're asking a moral question. One for the polticians. When we ask "Do our current drilling practices exceed a previously determined level of acceptable risk", then we starting to ask a question that can lead to hypothesis generation and application of the scientific method. Are you sure? Go to: http://www.pubmed.com/ Then the question becomes, how do we evaluate the available data? Is defining the argument in terms of the number of articles available the best way to form our question? Or should we try and evaluate the quality of the research performed in each individual article and compare them against each other. If only someone had developed a systematic method for reviewing all the available data, and comparing it to each other. If only there was some sort of consortium that regularly published meta-analyses of the available data... Oh. Wait. It's here: http://www.thecochra...le/CD000560.pdf Cochrane reviews. They're new They've been around forever since 1993, but they're good. Plain language summary (for those of us with common sense, who don't want to read the sciencey bits because they're beneath us.): P L A I N L A N G U A G E S U M M A R Y Psychological debriefing for preventing post traumatic stress disorder (PTSD) This review concerns the efficacy of single session psychological “debriefing” in reducing psychological distress and preventing the development of post traumatic stress disorder (PTSD) after traumatic events. Psychological debriefing is either equivalent to, or worse than, control or educational interventions in preventing or reducing the severity of PTSD, depression, anxiety and general psychological morbidity. There is some suggestion that it may increase the risk of PTSD and depression. The routine use of single session debriefing given to non selected trauma victims is not supported. No evidence has been found that this procedure is effective. Let's see: * You're not educated in the subject area, ergo, you probably don't know what you're talking about. Why should we value your personal uneducated opinion over the opinion of a psychologist or psychiatrist? Or Bledsoe, for that matter. * The academic's theories are formulated based upon the results of peer-reviewed, published data. They are empirical in nature, and they talk not solely to their personal experience, but to the experience of thousands of research participants. They are subject to review in the presence of new data, and are routinely presented and defended at international conferences. I'm not saying that there's not an element of chance here, that you could be right. I'm just saying that you haven't provided any basis for us to believe that your personal opinion is scientific. Future research might support your position (whatever it actually is). But that still doesn't mean that any of us should necessarily value your opinion as highly as the opinion of an expert. And it certainly doesn't mean that instead of interpreting the available peer-reviewed research, we should all just get on the phone and give you a call to tell us the answer! Otherwise that science thing would be so much easier. For example, instead of spending all that money at CERN, we could just ask you, hey, what's going on with those neutrinos? http://www.bbc.co.uk...onment-15830844

The neat thing with this paper, was they seemed to show that the fetal cells were able to integrate into the myocardium, and couple electrically without causing arrhythmias. A problem with a lot of the research in this area, including a lot of the clinical trials with humans, is they haven't (to my knowledge) been able to show that the stem cells actually do this. There's a fair risk of the stem cells forming tumors, as they divide quite rapidly (de-differentiation to a stem cell-like state is part of tumorigenesis). It's also been shown in some studies that the benefit from stem cell treatments appears to be a result of signalling molecules secreted by the cells, rather than new functional cardiomyocytes forming. Then, when they have had limited success in introducing cells into the myocardium, there tends to be a risk that they form ectopic units. Obviously the potential benefits to these sort of therapies are immense. It's a shame that so much of the research has been held back by a prohibition on federal funds being used for stem cell research in the US. And that, even now, pro-life groups are trying to pass laws that would prevent the use of any fetal-derived material in biomedical research.

In that case, I suggest that we do almost nothing and go to the hospital aggressively address the hyperglycemia pinkness and Kussmaul's respirations with large IV doses of NPH Insulin to rapidly return the bG to 60-100 mg/dl 4-10 mmol/L 5 horses / washing machine less pink and Kussmaully. Regarding the hypotension weak radial pulses (them spymanomanomometers are machines too), I think we should give about 1-2 L of saline while considering baseline renal function and the potential need for bicarbonate, and being careful not to overresuscitate a bucket of NaCl -- it's salty like blood -- go hard or go home. We should consider the potential for hypokalemia and rebound ketosis with overaggressive insulin administration starting quadrilateral 10 gauge IVs, and the risk of hyperchloremic acidosis or hypervolemia with overaggressive fluid administration wearing a ball cap. I'm now going to go to the hospital and tape over every piece of medical equipment I can find, so that they don't end up treating the machine instead of the patient.

Your eyes can get us a creatinine, K+, Mag and Phosphorous? Do they get us a serum osmolarity?

Link to the paper (not sure if you need university access). http://circres.ahajournals.org/content/early/2011/11/11/CIRCRESAHA.111.249037

I'm with ak as well. What this person did was stupid and unprofessional and they deserve to get in a lot of trouble. However, if there wasn't demonstrated malicious intent, or a history of previous discipline, I don't see how you can fire. If you have a half-way decent employer then firing should be their last resort option after a step discipline process. You don't want to fire a guy who has a spot-free record for ten years because of a single instance of poor judgment. What you do want to do, is prevent a pattern of poor judgment from developing and being unchecked.

Honestly, if my partner wants to stage on any of these events, we wait. I might ask them why, as none of those four situations, as given, indicate a need to stage for me. There's a possibility for (2) if the situation isn't under control per staff at the school. But unless there's extra information suggesting trouble, I wouldn't automatically stage in any of those situations - especially not (4)!. The presence of the FD is a non-issue. It becomes a problem if they decide to charge in, and declare the scene safe, especially if it's a shooting / domestic / scene with high potential for resumption of violence. If I'm filmed by a news camera, fine. I'm not a cop, I'm not equipped or trained to deal with violent situations, and I'm following a departmental policy for staging, and they should be out defending it, as should my union and my coworkers. If there's a delayed police response, this is an issue that PD and council have to take responsibility for. This sort of scenario has happened in most major cities, and staging policies have survived it. We're not law enforcement.

Ideally, once you've identified the need to stage, you're staging until the cops clear the scene, no matter how long this takes. And this isn't unique to the rural environment. Cops in the city get busy. A call for PD to clear the scene on an OD might wait some time. I've easily staged 30 mins or more on some of these calls in the city. Even when there is actual violence taking place, the cops often do their own version of staging, gathering 3 or 4 cruisers in a parking lot a few minutes from the event and then go in en masse. Sometimes it's safer for them to wait until they can have 3 or 4 sets of eyes instead of trying to be Rambo. Having parked next to them, I can confirm that this takes some time. Plus, once they do go in, calling back and clearing in EMS is often a relatively low priority. They could be, but it's probably not that likely. You're presenting the situation here where there's no indication of violence, and the house is in a "shady" area, but not known to be a violent location. It makes me wonder why you'd be staging here, in this specific situation. Regardless, I think that as long as you're not staging as an attempt to avoid doing work, then it's ok. If the PD are rocking and can't get bodies on scene quickly enough, then that's not your fault. ------------------------- I will say that these situations can get very complicated very fast. For example, I once worked in a rural community, where there were a lot of drugs, violence and social problems. Often our nearest police were as much as 45 minutes away, and often they were busy. So we'd be placed in a situation where we'd be 15 minutes away from a violent call, and we'd be looking at waiting up to an hour for PD. Add in that we lack radio or cellphone coverage for about half our service area, and you start to have a problem really fast. You end up with: (1) Stage at the station, drink a cup of coffee, and hope the patient doesn't come to you, because they probably won't be happy. (2) Go drive the ambulance down a dark road, and park there until the cops call that it's clear. (3) Go do the call. And options (1) and (2) come with the added risk that the patient's family and friends may come find you in the days or weeks following. This was a far from ideal situation, where we ended up often driving by the call, refusing to enter the residence, but telling bystanders to drag the patient out. Then we'd drive a distance away, park, and start assessing the patient. I can't recommend this as a best (or even remotely safe) practice, and we had some dangerous situations occur. But I understand that sometimes there are no good answers. Similar issues occur in urban environments too. What happens if your co-responding fire truck decides to ignore the staging on a shooting call, because they've just been watching Ladder 49, gets on scene, declares it safe and now has two victims needing transport. Do you respond? Or if management decides that a private company providing unarmed and poorly-trained security guards has the authority to declare a scene safe. Or dispatch is trying to encourage you to go in because they have an agitated caller on the line. Or you have a supervisor who decided that staging didn't apply to them, and now they want help. There's a lot of shades of grey, and very few clear answers. But I do think that we should encourage each other to voice our concerns, and when anyone wants to stage, that should be accepted and supported, much as Dwayne and Happiness have said.

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Well, I can't argue with that. I think EMT training needs a real overhaul. Our EMT programs should be a year or two. It would go a long way towards professionalising EMS.

There's no way they'll get that much in Canada, although they probably deserve a fair amount of compensation.

I read this recently, and really enjoyed it: http://www.amazon.com/Post-American-World-Release-2-0/dp/039308180X/ref=sr_1_1?ie=UTF8&qid=1321527962&sr=8-1 It's a book called "The Post American World" by Fareed Zakaria. It starts with the idea that American economic and political dominance is declining, and that while the US is probably going to remain the dominant economy for the next 50 years, there's going to be a lot of new players, that will collectively have larger economies. It looks a lot at India, Brazil, China, etc. and ask what are the consequences of this going to be? I liked it. I'm quite left-wing, especially by US standards, so I wouldn't be surprised if the book slants towards the left, as most of us tend to read things that reinforce our own cultural biases. I have a friend who teaches International Relations at the University level, and he looked down on me a little for reading it, as it "written by a journalist, not a specialist in the field". I kind of argued to him that this was fine for me, because I have no polsci / economics background. I don't know your personal politics, but even if they skew to the right, I don't think that this book would be annoyingly dogmatic.

You can't reliably, and it's not that important. It's going to be difficult to distinguish between paced beats, any atrial-initiated complexes that conduct across the AV node, and complexes initiating in the ventricles. That being said: - if the WCT is irregular, then it's more likely to be originating in the fibrillating ventricles, and may just be AF. - The rightward axis, precordial concordance, etc. points towards VT, but isn't 100% sensitive or specific, i.e. in some cases it's there, but it's not VT, in other cases it's not there but it is VT. - AHA says the morphology criteria for VT are too cumbersome to use routinely in emergency situations and recommends against it for MDs. Most of these have better specificity for VT than sensitivity, i.e. if you see criteria for VT, there's a good chance it is, but the absence of these criteria doesn't mean much. - Other signs of VT that aren't as applicable here are: * AV-dissociation (seen on the ECG as buried P waves, or by auscultating heart sounds and hearing an S1 and S2 that don't match; Here unfortunately we have AV dissociation even if the rhythm is supraventricular, because we have a.fib), * Jugular venous "cannon" waves, which occur when the atrial are contracting against a contracted ventricle (but this is already underlying AF, so we're not seeing that here). * Capture beats (occasional atrial-origin beats that conduct across the AV node and appear right before the next VT complex, and have a normal QRS morphology, or a QRS that resembles the morphology of previous supraventricular beats.) * Fusion beats, where an atrial depolarisation and ventricular depolarisation meet. (Again, not going to see this here, because of the AF). If you're lucky, you might get a nice clear regular VT, that looks nothing like either the paced rhythm or the normal QRS complexes, but even here there's a possibility that you have AV-conducted depolarisations with a rate-dependent bundle branch block. So you're pretty much out of luck there too. And it's unlikely that you're going to be able to identify WPW from the ECG if there's AF. You might be able to see it, but then again, you might not. Especially if the QRS is wide / abnormal to start with. It means the delta waves have to be a little more blatant before your eye picks them out.

No offense intended, but are you saying that 48 hours on the ambulance is a long-time when training as an EMT?

* How to draw up meds. They'll enjoy playing with the syringes and needles, and it's nice to have a set of hands that can help with an RSI, or even just draw up some pain control. I'm not suggesting they should be calculating dopamine drips, but they can take the fentanyl or morphine from the vial and put it into the syringe. * Prep'ing for intubation. Chances are they'll never have to do it, but it's nice if you're elbow deep in the airway, decide to use a smaller tube / drop it on the floor, etc. and they can pass it to you. * Sequence of drugs in a code, how to assemble and give preloads. * 12-lead placement. It's really nice if someone else can do this sometimes. * The point behind ETCO2, so they also know how to point out that the tube is no longer where it should be. * Give them an idea of how an IO works, so they don't get terrified on the first ped code you run ALS. * Sim.run, or scenario a few potential critical calls, e.g. cardiac arrest, airway burns / stridor, severe anaphylaxis / life-threatening asthma, crashing CHFer. * See how sharp their triage skills are. If you're the only paramedic, it might be nice to know that you can run with a critical and not have the scene fall apart, if you have to. * Review basic skills, make sure they know how to bag an ET tube if they don't have a lot of experience doing it. Make sure they know to be careful with it and not extubate the patient. I would suggest that as important as what you teach is how you teach it. Especially if any of these guys have more time in the field that you. If you can emphasise that it's a team-based approach, and that they're contribution is equally valid, you'll have a better team. Try and develop a culture of constructive call review / critique, see if you can get them thinking like a paramedic. Do some con/ed. Just some suggestions.