systemet

I don't know if I count as an "old" medic. I graduated 11 years ago, but I had nifedipine on the truck when I was a new grad. I don't miss it. I never had the need to use it, and heard of too many situations where it was given inappropriately. Nowadays if I wanted to decrease MAP, I could use IV NTG, but I can't think of too many situations where I'd want to.

I'm also from outside of the US, in a country with stricter gun control laws. I don't understand why this is a bad time to talk about gun control or the mental health system, or violence in society in general. Isn't this the perfect time? Wouldn't it be more disrespectful to the dead or the grieving not to have difficult discussions in the aftermath of something as horrific as this? Unfortunately I don't think there's a good answer here. Personally, I don't understand why a basic bedrock of US culture is the right to walk into a department store and purchase an assault rifle. But, as an intelligent individual, I also know that it's possible to commit similar acts with a handgun, e.g. Dunblane, 1996. Or that a single-shot rifle, legal with little more than a driver's licence in my country, could be modified to full-auto, or used in just as deadly a manner with single, aimed shots. If I was an American citizen, something like this might make me support a federal ban on assault weapons, but as a rational human being, I can't believe that that would be sufficient to prevent it from happening again. Approaching this from the mental health angle presents the issues that ERDoc has already eloquently described. A fair percentage of society has simple depression. A large number of people have major depression, and a fairly large number of people have schizophrenia or bipolar disorder, many of whom are poorly medicated. Yet the overwhelming majority of these people don't go around shooting up schools. If being restricted from purchasing an AR-15 at Walmart is an unacceptable infringement on your liberty, I can't understand how allowing the random detention and arrest of the mentally ill is going to be considered acceptable. Everyone's an expert after these events happens. Every second-rate news anchor can postulate a host of reasons why Anders Behring Breivik should have been arrested before he shot up Utoya, or how people should have predicted what Klebold and Harris were going to do. But these shocking events, by their nature, are unpredictable. The violence in society issue is even more problematic. I'm not convinced that this is a solely US problem, either. But its hard to identify the root causes, and produce a reasonable plan to address it. This whole event is utterly tragic. No one would think badly of any of the responders if they descended into a spiral of alcohol and depression -- yet we have a ton of 6-7 year old children who survived and witnessed these events. How will they recover? Where will they be in 20 years? As an aside, I share Jake's fear of the random armed stranger sitting next to me. I trust my cops to (mostly) not do stupid and thoughtless things with firearms. But the average citizen? They scare me. I'm not convinced that the widespread availability of firearms prevents crime, and wonder if rather it acts as a multiplier?

Here's an interesting video from youtube, where they've compressed 5 minutes of VF into 15 seconds. Note how the right ventricle becomes distended as pressures in the arterial and venous system equilibriates, and blood returns to the RV without ejection into the pulmonary circulation. One of the proposed mechanisms behind "5 mins of CPR before defibrillation" in unwitnessed arrests was that the physical dilation of the RV displaces the interventricular septum into the LV, and prevents effective contraction. The evidence to support CPR first remains shaky. What's missing here, is the feeling of how the myocardium actually "thickens' and "hardens" during a prolonged arrest. It's a marked difference, sometimes referred to as "stoney heart".

I would always choose patient care, if the rules are directing you away from it. I'm not suggestiing you suggest titrating oxygen therapy in an MI if your local protocols clearly state that they want 100% FiO2; or that you decide not to C-spine someone presenting without deficits with a series of anterior abdominal stab wounds, if they clearly state they want these patients in c-spine. Just that if you're presented with a situation where there's a clear disagreement between some SOP and good patient care that you go for patient care. A decent employer should be looking for attitude and personal attributes as a very high priority. If they're looking to retain people for 10 years + and they're a quality system, they can train someone inexperienced and mentor them. But if you come in day one with no critical thinking skills and a terrible attitude, it's not going to be worth their time, even if you bring a lot of experience. At least, that's how I see it --- to be clear, I've never had any HR responsibilities. A good service should get enough people applying for a position that they can afford to be picky. That being said, a lot of employers in EMS aren't good employers. A lot of them expect to lose 50% or more of their new hires over a 5-10 year period. A lot of regions don't have a lot of paramedics, and might have trouble getting more than 5 candidates for 20 spots, so you never know. Good luck.

This is really fast for a 35 year old. I'm surprised that it's narrow and there's not some sort of rate-dependent bundle-branch block. I'd also be suspicious of any illicit drug use, or the presence of a concealed accessory pathway -- otherwise this guy's got an impressive AV node. I think I'd get the 12-lead first if he's "stable"-ish. although the information provided didn't give us much. Differentials: AVNT, AVRT, atrial tach, a.fib, I see where craig's coming from the cardioversion, and it's not a bad idea --- this is scenarioland, I bet the guy has WPW -- , but I think I'd go the vagals/adenosine (12mg) route, and see what we see. If he decompensates we can re-evaluate cardioversion,

Sure, the ST elevation on the monitor makes the one patient an MI, providing its not suspicious for one of the common imitators like LVH, LBBB (w/o Sgarbossa criteria), pericarditis, BER, etc. The point was more that your second chest pain patient with a nondiagnostic MI isn't a NSTEMI until you have positive enzymes. Point-of-care testing being fairly rare in EMS, and the available devices often quite slow, it just seems unlikely that you'd know this. It's also some really bad luck to have two people in the same room suddenly develop coronary occlusions. I realise that this is the point where someone's probably going to mention something else extremely rare like "Broken Heart Syndrome"/Takotsubo cardiomyopathy, but this is really reaching. I get this, but this additional information now changes this again, doesn't it? I mean, previously it was a 30 minute ETA for backup. If there's now no available resources, then isn't that backup ETA becoming an hour+? As ridiculous as this interview question is --- I think it's quite unfair that they asked this --- I'm almost starting to like it, because the idea seems to be to see whether the candidate has critical thinking skills. If we allow the initial premises to stand, that somehow we have one patient we 12-lead, and has a STEMI, a second patient develops some sort of anginal symptoms, we then decide to 12-lead them, find something nondiagnostic, then decide to POC test them, work out both are having MIs, and only then find out that our backup truck is 30 minutes + (shouldn't we have called that when we found the first STEMI?). Another major flaw with the initial story, is that we're told this patient has sudden onset chest pain, but we have enough necrosis for markers to be positive, implying the process has been going on for a few hours. Possible, I guess, but again very unlikely. If you don't have a backup truck coming in a reasonable time period, both get ASA, call FD or PD for lift-assist. I *know* FD has someone who can help in an urban environment, it's not like they're busy. One patient can go down on the stair stretcher, one on the chair. I'd put the monitor on the STEMI, as they probably have a higher risk of sudden arrhythmic death. As for oxygen -- is anyone complaing of dyspnea, and does anyone have SpO2 < 95%? If so, they should probably get it. If both, then lets give it to the STEMI. . Maybe you can have a calm first responder drive, so your partner can assist in the back, and along the way you get some lines, and consider some NTG, while you transport to an appropriate facility, which, if you're urban, probably should be somewhere with an available cathlab. In this situation several of the rules come into direct conflict. Sitting on scene for 30 mins + for the next backup unit means delaying transport of a time-critical patient, etc. I would argue that the rules were designed with the aim of providing a framework for the delivery of optimal and safe patient care, that they certainly weren't designed with this particular set of circumstances in mind, can't be expected to apply to every possible situation, and that some of the rules need to be modified to provide the best and safest possible care. Off-topic, I love to find reasons to break rules. I think a lot of us do. It's probably not best to tell the interviewers this. [Obviously, the rules should only be broken when they actually violate the laws of common sense and good patient care.] I hope they would want to see that you understand the intent behind the rules, and why they're in place, and that you can logically work your way through a complex situation. I would hope that they are trying to see whether you can "think outside of the box", without being a complete cowboy, and that you're only going to disregard these rules when its necessary for patient care. Of course, this is EMS. So they could just be looking for someone who has completely crushed any sense of independent thought, and will blindly follow the protocol books and mid-90's phone book size mass of SOPs. But, if they're interviewing like that, it might not be the greatest place to work anyway. Just wanted to add, I've read through what I've written, and I realised it may sound a little pushy / aggressive. I'm not better than anyone else here, and am sure I would have had a hard time with a question like this on an interview. Good luck in the future.

* Discuss it further with your partner and try and change his mind * Stress the importance of the deep clean for protecting the safety of yourself, your partner, other crews and the patient. * Inform your partner that you will do the deep clean yourself, this one time, but in the future you expect them to help. * Keep an eye on their behaviour in future instances to make sure that they're not violating other company policies. * Report it to management if it becomes part of a trend of unprofessional behaviour, but only after addressing your concerns with your coworker. * Identify to the interviewer that, because this is a relatively minor breach that you can compensate for by yourself, you don't think it needs to generate a formal complaint to management, as you realise that they're very busy, and that you don't want to waste their time with trivial matters. Emphasise that were this issue of a more serious nature, e.g. reckless driving, improper patient care, theft, suspected use of alcohol or narcotics on shift, you would report it immediately. I think that most of the time they want to see that you're a reasonable person. You're going to do your best to get along with people, but your not going to drop your own high personal standards. That you attempt to address minor issues with your colleagues yourself without running immediately to management and burdening, but at the same time, that you won't attempt to cover up a more serious issue. Any time the person's behaviour is described as unreasonable, you're going to mention that you'd try to change that behaviour. What an odd scenario. It's quite unlikely, although I'm sure someone here has probably seen something like this happen at some point. You now have two patients, a duty to act to both of them, and extremely limited resources. Your decisions are whether you attempt to transport them both yourself, wait for backup, or call rotary wing (presumably "backup" includes rotary wing and they're more than 30 minutes?). You can't leave either, otherwise it becomes abandonment. There's no information about the treatment plan for the identified STEMI (I find it odd that we already know the wife is a NSTEMI, which presumes we've assessed her, done a 12-lead, and done some sort of point-of-care testing and got back a positive troponin, all of which takes time). I'd suggest that the reasonable thing would be to call for backup, and begin treating both. If you have extra hands available, you could attempt moving towards the incoming unit, depending on where it's coming from, and how long it takes to package.

This is the original 1988, ISIS-2 study. Streptokinase (the most widely-used thrombolytic at the time), versus ASA, versus ASA + Streptokinase, versus placebo. http://www.ncbi.nlm.nih.gov/pubmed/2903874 Either streptokinase alone, or ASA alone, reduced the 5-week mortality by 25%. Given together, there was an even greater reduction. From this, and later studies, came our current treatment options. As chbare said ASA is absolutely vital.

Sorry man. All the best.

I've been caught by hypothermia before, as well. Especially if you're used to working in cold climates, when you have someone in a relatively warm environment, it's easy for hypothermia to slip down your list of differentials. Surface temperature depends more on peripheral blood flow than on core temperature. [i don't have a source for this, but I'm pretty sure I could find one]. The human hand is a very insensitive device for measuring temperature. I think someone suggested on another thread recently, that if you pour three big bowls of water, one from the cold water tap, one lukewarm, and one that's fairly hot to the touch, place you hands in the hot bowl and the cold bowl for a minute or so, then plunge both into the lukewarm bowl, you get the sensation of warmth in one hand, and cold in the other, despite them both being exposed to the same temperature. We often respond more to changes, and differences, than to absolute values. If you've not been given appropriate equipment to take a core temperature, then obviously it's hard to know what it is. Often we lack any equipment for taking a temperature, or the equipment we have is horribly inaccurate, or only works in a narrow range. If you don't have the ability to do a core temp, then the nurse giving you a hard time about not identifying the hypothermia might as well be complaining that you didn't know his T4 level was low, or that he's hypophosphatemic or something. Even here, if you know this patient is hypothermic, you're limited in what you're going to be able to do about it. You're pretty much restricted to preventing further heat loss at that point, and now know that you need to be fairly gentle in moving/handling them, and that your drugs may not work until the patient warms. It sounds like this guy was still compensating fairly well, despite the hypothermia. He's not that altered, he's not particularly brady, and while you can be very hypothermic without Osborne waves, etc., he doesn't have any ECG changes. I wouldn't feel too bad.

I think the idea of low-dose dopamine has acting via dopaminergic effects has been debunked about 10 years ago. As I recall, it was determined that at low doses we were seeing greater urine output due to an increase in MAP and renal perfusion pressure that was due to beta-adrenoceptor activation, versus any specific renovascular effects through the DA receptors.

Good question. I'm ashamed to admit I hadn't considered this scenario. It also may be a question that's a little above my paygrade and better asked of someone like ERDoc, or someone with an anesthesia background. As I understand it, ketamine is a negative inotrope, and also causes smooth muscle relaxation, in isolated cardiac and vessel preparations. Usually we see vasoconstriction, and increases in contractility and heart rate due to increased sympathetic outflow. It seems reasonable that these would be absent in someone with autonomic dysreflexia, but I think we're probably simplifying the situation a little, as both the action of ketamine and the different degrees of spinal cord injury are probably more complex than I'm making them out to be. How significant a drop in blood pressure would occur, and how much bronchodilation would remain without increased sympathetic activation, I honestly don't know. Sorry for the slow (and waffling) response, I've been travelling a little. (Edit: Just wanted to add that as we're talking about intubating people with spinal cord injuries, succinylcholine can cause life-threatening hyperkalemia in patients with pre-existing spinal cord injury).

Not necessarily possible. We don't know if that person was part of the initial responding crew, or if they were interfering with patient care. Law enforcement, if they're even available, can't remove them without a valid reason. In a legal context, sure. From a conduct & competency perspective, I think the situation is better if the treatment provided was indicated and that the person performing it was sufficiently trained / skilled. Given the information on how close the trauma center was, and that a physician had directed them to transport, it sounds like their actions were probably inappropriate. There's just not a lot of information here to go on. No one is taking that position. What is being said, is that there's a difference between someone who is adequately trained in an out-of-scope procedure, performing it in an appropriate manner, in a situation where it's clearly indicated, and some random guy who decides to do something they read about in a book once. Suturing and pericardialcentesis are two completely different beasts. Suturing is almost never a life-saving procedure. The scope of practice defines what you're not allowed to do. This is a tautology. I think that in this situation it's most likely that the patient died from the initial injuries, possibly compounded by a transport delay. If an autopsy shows that unskilled pericardialcentesis contributed, then there's additional problems here. I would want to know more before voting to yank this guy's license, though. Mistakes get made in medicine, even at the highest level. You clearly see this as an arrogant provider doing something rash to impress their colleagues. If that's shown to be the case, it would influence my opinion as well. The guy is already civilly and likely criminally liable here. Given the limited information here, they probably deserve to have some form of sanction and remediation. I'm just not convinced that taking away their livelihood fixes anything. But presumably the states that perform pericardialcentesis still train this during medic school, right? I think a move towards standaridisation, while painful in the short term, is probably a good thing. Edit : trying to get rid of the blue colour in my responses Edit2: gave up.

Cool! I have one of those!

I have a little bit of a different take on this. (1) This calls sounds like a nightmare. Any scene where one of the responding crew is a relative of the patient and they are acutely sick has all sort of potential to become a massive cluster. In an ideal world there would be enough people on scene to remove any patient care responsibilities from that person, and have someone take over their role. Even with them still present on scene, with no patient care responsibilities, it's going to add an additional dynamic to an already difficult and stressful situation. (2) I'd like to know more about why he felt the pericardialcentesis was indicated, before I judge him too harshly. I realise that from a legal perspective, that if you perform outside of your scope of practice, you're done. But from a peer-review or professional conduct perspective I'd like to know first: * Did he believe that the percardialcentesis was a lifesaving measure that needed to be performed in the field? * Was this belief reasonable given the available information? * Had he had the necessary training to perform this intervention in a competent manner? Scope of practice is designed to protect the patient from poorly-trained or untrained providers. If he was adequately trained to perform the procedure and it was indicated, as ArticKat pointed out, it's a very different scenario to just being a cowboy. Perhaps the violation of the scope of practice was in the patient's best interest? This also speaks a little to the particular silliness in many regions, including the US and Canada, of having multiple scopes of practice and training standards within the same country. (3) I'd like to know more about the airway management medications used. Given what we know about trauma care it seems unlikely that a field RSI (presumably in this case, it was some form of non-RSI approach with sedation?) would be justified if they're close to the ER. I think it's really difficult to judge someone without full knowledge of the situation. I'm also particularly sensitive to the difficulties of dealing with a acutely sick patient who is known to a crew member. If there isn't a pattern of behaviour that indicates a consistent lack of judgment, I think nonrenewal is very heavy handed for a first offence. I doubt a physician would be treated as harshly in a comparable situation, and don't see why we should be some continually willing to throw away paramedics instead of remediating them just because the training time and cost of training one is cheaper. edit: formatting of bullet points.

STEM?

I just wanted to address a couple of things here, as well: I think right general idea, but wrong nomenclature. You're treating a disease state that's already declared itself, versus trying to pre-empt something that might happen. Also, the steroids are unlikely to be contraindicated in any severe asthma exacerbation. It's more a matter or prioritising interventions if you're working with a small crew. In an ideal environment, with lots of hands, steroids should go in at t=0. Most of the time, it just doesn't work out that way. Might increase the chance of succesful first-shock defibrillation, although the data supporting that is from the days of monophasic defibrillators. As for benefiting resucitation, there's no evidence that epinephrine does much beyond improving the success of initial defibrillation and raising arterial and thus coronary perfusion pressure during CPR. There's no evidence supporting a benefit of epinephrine on long-term survival / neurological outcome, and there's growing concern that historical use of epinephrine may even have been detrimental. So, probably not. We can't show that the epinephrine we currently give is much better than walking into the patients kitchen, finding a jar of peanut butter and smearing them with it. A few thoughts: * "Analogue" is usually reserved for the description of similar organic compounds, i.e. compounds build on a carbon backbone. It makes some sense to say that dopamine is an analogue of epinephrine, but we don't usually say the same thing when discussing inorganics, e.g. H2S and water. * Few pharmaceuticals have really been "targeted". Most have been used traditionally, believed to have a beneficial effect, e.g. morphine, ASA, digoxin, or used for years before their pharmacology was really unravelled, e.g. penicillin. Some really aren't understood now, but continue to be used because they work, e.g. lithium in bipolar disorder. Even today, most new pharamaceuticals are designed by taking a structure that's known to have an effect, and developing 10's of thousands of similar looking molecules, and seeing if they have a beneficial effect ("combinatorial design" and "high throughput screening). It's appeaing to see science as this process where the disease is identified, understood at the molecular level, and then some enterprising pharmaceutical chemist designs an agent to target the aberrant process responsible. More often what happens is an agent has been used historically, potentially has a benefit, and is seeing widespread use. Researchers later identify what systems it affects, and then look at whether those systems are involved in the disease pathogenesis. We're starting to see some movement towards targeted design, but the entire multibillion dollar pharmaceutical industry only licences about 2 novel-clinical entities per year. The vast majority of new drugs are modifications on an existing structure that's proposed to have better pharmacokinetics, or less off-target activity. No. More because ketamine stimulates sympathetic outflow, so it tends to cause tachycardia, hypertension and bronchodilation, at least if the sympathetic nervous system isn't completely exhausted, or the effector tissues unresponsive, e.g. some sepsis patients, a few other conditions. So, if you're going to intubate with something, an agent that might have an added bronchodilator effect is a good idea.

Chbare is a really smart guy, and may well have simplified this to help explain a complex phenomenon. I just want to point out quickly that there's no cAMP receptor on the cross-bridges, and that most of the effects of cAMP are mediated via another regulatory molecule called protein kinase A (aka cAMP dependent protein kinase). Depending on whose textbook you read, PKA may inhibit another enzyme called MLCK, ultimately resulting in a decreased number of active cross-bridges available for cycling. Some doubt has been cast on whether this is physiologically relevant, but PKA also affects Ca2+ handling in the smooth muscle cell, which may be more important. To complicate things further, there's a fair amount of cross-talk between cAMP/PKA-mediated pathways and cGMP/PKG mediated pathways. This isn't fully understood yet. I think that this is entirely accurate, and likely the most important part of the message for most of us. While Chbare's knowledge in this area likely outstrips mine, I also agree. For glucagon to be useful, there have to be enough glucagon receptors expressed in the bronchial smooth muscle, with enough cAMP elevation and PKA activation to achieve a measurable incremental benefit beyond beta-agonists, with the doses available prehospitally. I can't claim an extensive knowledge of the literature, but a quick search revealed one small study that compared 0.03mg/kg (i.e. ~ 1.5-3mg) glucaon IV versus saline in patients with asthma exacerbation (PEFR < 350 L/min), and showed no improvement with glucagon. This study was likely underpowered to find a small difference, and dealt with a fairly homogenous group including a lot of lower acuity patients, but suggests that the bronchodilatory effects of glucagon are pretty weak. Wilber ST, Wilson JE, Blanda M, Gerson LW, Meerbaum SO, Janas G. The bronchodilator effect of intravenous glucagon in asthma exacerbation: a randomized, controlled trial.Ann Emerg Med. 2000 Nov;36(5):427-31.

I think it's probably accurate that epinephrine's effect is "little more than sympathomimetic", but if you've been trying to deliver beta-agonist by nebuliser in someone you're having a difficult time ventilating, there may have been very poor absorption. If you go to an intravenous route, you will probably get more beta agonist into the bronchial smooth muscle. I don't know if it matters whether it's epinephrine or ventolin. Epinephrine obviously comes with some pressor effects, that might be dose-limiting. Then again, it might help with venous return a little. IV ventolin has a reputation, deservedly or undeservedly, for causing cardiac irritability. I doubt there's any decent research comparing the two, but I haven't looked. Aminophylline used to be an option in some regions, but it's got a pretty narrow therapeutic index with lots of toxicity issues. If you have a status asthmaticus who's sick enough to have a respiratory arrest, you're likely going to be working a full arrest very soon. It's also going to be quite challenging to generate high enough airway pressures to ventilate them with a bag valve mask without an ETT, and even if you can, you're going to be diverting a lot of air into the stomach, and potentially setting yourself up for aspiration. I agree with others that we should try to avoid intubating asthmatics, but I think once the patient has a respiratory arrest, it's time to drop the tube. Preferably a little before. I think here: * 0.1mg epinephrine 1:10,000 IVP * laryngoscopy, with a lidospray at the ready, and a single quick attempt at intubation if you have a decent view. * Repeated 0.1mg 1:10,000 IVP until you have an epi or ventolin drip ready. * Ketamine if you need something to facilitate intubation, or if you bring the saturation up to the point that it's necessary. Second line of attack * 2g mag sulphate over 5 minutes. [This is a little fast, but the patient's pre-code]. * MDI ventolin / atrovent [probably not going to do much if the patient is very bronchoconstricted] Third line * Steroids. They'll help later, if there is a later. Not unless it's fungal. I think you're ok to give the steroids here -- but if there's a suspected pneumonia / sepsis component, some additional fluid is in order, and other issues may be present. Hope this helps.

* Your textbook is probably referring to routine hyperventilation in all patients with signs and symptoms of a closed head injury. This has not been the standard of care for about 20 years. * Cushing's triad is a set of signs of a closed head injury, not a clinical entity in itself. * Hyperventilation is still recommended in suspected herniation, the signs of which include Cushing's traid, aniscoria, and posturing. The physiologic basis behind hyperventilation as a treatment is that it causes vasoconstriction of cerebral vesses, which decreases cerebral blood flow. This will decrease the rate of extravasation of fluid through an injured vessel. This was thought to have minimal consequences and was used routinely. The down-side to hyperventilation is that in the absence of herniation, it's better to allow the cerebral circulation to do what it does best. Artificially restricting cerebral blood flow in patients without herniation has been demonstrated to worsen outcomes. Instead the focus should be on maintaining an appropriate MAP, minimising stimulation and unnecessary instrumentation, preventing hypoglycemia, maintaining normoxia and eucapnia, and preventing recurrent seizure activity. [Also worth noting, that the effect of hyperventilation is quite transient.] * In addition, careful hyperventilation to a PETCO2 of 30 mmHg should be distinguished from autoPEEPing the patient to a BP of 0/0, and it should be recognised that PETCO2 has some limitations as an estimate of PaCO2.

Here's a decent page that discuss the pharmacology of nitrous oxide in more detail that an typical EMT program: http://www.frca.co.uk/article.aspx?articleid=100358 A few highlights (that you may well be informed about already), are that nitrous oxide is too weak to be an anesthetic in most people (MAC = 105%), but has CNS depressant and myocardial depressant effects at higher concentrations, e.g. MAC around 80%. It may also exacerbate increases in ICP, and can diffuse into air-filled spaces, hence the concerns about use in COPD and suspected bowell obstruction. You're giving 50% N20, which is going to produce a MAC of around 42-44% in most non-intubated patients (due to humidification of the N20/02 mix as it passes through the respiratory tract). So, why are EMTs told to instruct the patient in self-administering the medication? Probably a combination of (1) Some patients become dysphoric when taking N20 - "they don't like getting high" - so this way they can stop if it gets to be too much, (2) If your patient starts to become anesthetised, they'll drop the mask from their face, and hopefully breath in enough room air to dilute the alveolar N20 concentrations. Now likely (2) is only going to happen if there's something else causing CNS depression, e.g. alcohol intoxication, benzodiazepines, evolving head injury, or there's some form of equipment failure causing a higher concentration of N20 to be delivered (i.e. the tank wasn't inverted properly, the ambient temperature is too cold, etc., or the patient is unusually susceptible to the cardiac depressant effect, e.g. overdose of vasoactive meds, hypovolemia from occult injuries. But this provides an extra safeguard. Could you simply hold the mask to their face to deliver the medication? Of course. But you would have to be alert to a potential decrease in LOC, you're going to be completely tied up doing a mask seal, which may require devoting one crew member to that task, and if you do this as an EMT, you're probably going outside of your regions accepted scope of practice, and might be vulnerable to civil litigation, or to a complaint from one of your peers. In the not-particular-common scenario of bilateral wrist fractures without other associated major injuries, you could try tying the device to the forearm. I think if you wave your arm around your face a little, you'll see quickly how difficult it would be to provide enough pressure to produce a mask seal on yourself with a device tied to a broken limb. Imagine trying to maintain that while partially sedated from the N20. It may not be a practical real life solution, and a better answer might be to simply call for ALS. As an ALS provider there are generally more effective medication options in most situations. If your local standards are anything like mine were, I would expect an instructor to fail an EMT being evaluated at the EMT level for holding an entonox mask to someone's face. This would be independent of whether they thought they would particularly like to drink a beer with that student. At an ALS level, it's hard to imagine too many situations where this would be the best option, and i think I'd avoid ever giving a scenario like that to cover a fairly unlikely event. [A situation where opiates or another agent wouldn't be a better option]. If your instructor would fail you on a scenario because you disagreed with them in class then you have an extremely poor instructor, and should consider looking for another program, immediately. Before wasting any more money. I don't want to cause offence, but educated people realise that you can disagree about someone on a given topic without it reflecting some deep flaw in either person's character. You can discuss a situation, and disagree without having to dislike each other, or take it personally.

Are you doing this in situations where the opinion(s) of the class is being asked for? Or are you just randomly interjecting while the instructor is trying to teach? I don't mean to be rude here, but a possible explanation for your feeling that you're being dismissed is that your instructor may have a lot of information to cover, and little time allowed for discussion. This is particularly likely if you're reviewing BLS skills, that you'd assume people would have some understanding/mastery of before entering a paramedic program. As to having your opinions "overruled", I'm not sure what you mean? The instructor can tell you that they disagree with a treatment plan you propose, and suggest an alternative. They can tell you that you misunderstand the pharmacology of an agent, or the physiology of an organ system, but I'm not sure how they overrule you? You should be having these collaborative discussions, but your instructor should be planning time for them. Spontaneous discussion in a classroom setting can be fanastically productive. It can also be a complete waste of time if it strays off topic or wanders into pointless "war stories", e.g. "15 years ago I saw a guy with cocaine induced chest pain given propanolol, so I think it's a good idea". My suggestion is, if you think that you are annoying your instructor, ask them. "Hi, I got the feeling i was pissing you off when I asked a question the other day? Was I? Because I can stop, Would you prefer I ask questions some other time? Are we ok? Cool". There's also a point where you've got to look at how many other people are in the class and whether your question is relevant for them. Or whether it's important in the bigger picture, e.g. "Why does epinephrine cause vascular smooth muscle to contract, but bronchial smooth muscle to relax?" might be an interesting question in terms of physiology, but in terms of the depths of understanding required in most paramedic programs, might not be worth spending an hour discussing. You always have to be an advocate for the patient. But you don't have to expect everyone to agree with you. And you're not enrolled in this program to teach it. The fact that you disagree with an instructor may not be important for the rest of the class to know. The instructor may be wrong. You may be wrong. If the disagreement affects an important area of patient care, it might be in your interest to approach the instructor at another time and ask them what their thought process is. But you're not responsible for the learning of other students in the class. I think you should accept that if you are in a decent program, even if you're a strong student, you should be studying a lot. I think you also need to expect to be tense and stressed if you have a full-time program and any sort of work or family commitments outside of it. Getting knowledge and wisdom is about making sure you understand why you do something (i.e. pharmacology/physiology/pathophysiology/medicine) and when you should do it, versus just what's next in the algorithm. There's also a huge trap with paramedic school of finding something interesting, for example, organophosphate/nerve agent poisoning and devoting weeks of study time to trying to understand it in depth. This would be great if you were sitting around on an ambulance outside a Tokyo subway station a few years back, but generally represents a poor investment of time for return. In my opinion, the bedrock of the program is the physiology/pathophysiology and pharmacology. Understand these, and a lot of the other things fall into place. Try your best to relate what you learn in classroom to situations in the ambulance, and imagine how this knowledge will transfer over before you hit practicum. Realise that psychomotor skills, e.g. intubation, are less important than the background knowledge required to know when they're indicated. Accept that your instructors won't always know the right answer, and that they may give you inaccurate information despite the best of intentions. These people are your peers, not some god-like authority. Do your best to keep some sort of social life outside of class and EMS, but accept that it's probably going to take a big hit for a while.

I think you need to decide what you want to do. You've identified at least 3 careers (RN, EMT-P, PA), which require substantial education, and have very different working conditons, educational routes, and pay. You also need to consider very carefully any advice you receive about "Just do the RN, then bridge to EMT-P" in the context of where you want to work. In some places, moving from being an RN to a paramedic might be a 2-3 year process, with perhaps the only prior credit being for an A&P course. In other places, it might be a case of taking ACLS, finding a job with a transport company and sending a couple of hundred dollars for a prehospital RN licence. Think about the educational time. Many RN programs are a four-year Bachelor's degree. For PA, you could be looking at anything from 2-5 years depending on the program. There may be varying degrees of advanced credit given for each. Your BScN or paramedic diploma / degree may only count for so much of the pre-req. With the number of years training you're looking at, might it not be better to consider doing an MD? Being a paramedic can be extremely rewarding. It can also be very stressful. There's a lot of back injuries, little lateral movement, and few opportunities in most systems to do anything that isn't shift-work and direct patient care. The RN has a lot more options for lateral movement, also has further educational options, e.g. Nurse-anesthesia, NP, etc. It typically pays better, and often has more flexibility regarding shift work, and is usually much more portable when it comes to moving location. Don't be seduced by the scope of practice in EMS. It's not there because paramedics are inherrently better educated than other fields, just because there is no higher level of care readily available, and it's perceived that the risk of acting is outweighed by the risk of not acting (whether this is actually always the case is another discussion). Sure, you have some independence, but your treatment options are limited by what's placed on the ambulance, and you're often restricted in when you're allowed to exercise your judgement. An RN may have less "autonomy", but often they're also responsible for a large number of patients, some of whom are incredibly sick, often get to use a lot of technology, and have huge responsibility (a fact that many medics miss). It's also worth considering that what you want to do now, and what you want from a career, may be very different in 10, 15. 20 years. Running around lifting people on stretchers, doing night shifts,and being in a stressful environment might not be what you want anymore when you're 55. Or have a family and kids. It's not that you can't educate yourself further, or move on to other things, but this becomes much harder to do when you have more financial responsibilities. All the best.

I think the main thrust of the post was about milliequivalents<->mmol conversion, and has already been answered in detail. I just wanted to add that the expression of solution concentrations as percentages is a little different. A 1% solution is by definition 1g in 100ml. It has nothing to do with millequivalents or molarity / molality. So a 0.9% sodium chloride solution, is 0.9g of sodium chloride with water added to a final volume of 100 ml. You could do the math and convert this to a molarity, in which case you have 154 mmol of Na+, and 154 mmol of chloride. But, this is particular to 0.9% NaCl. If you were to make 0.9% dextrose, for example, you'd have a different molarity. [(9g / 100ml ) / (58.44 g/mol)] * (1000ml / 1L) * ( 1000 mmol / 1 mol) = 154 mmol/L (Here 58.44 g/mol is the molar mass of sodium chloride. Use something with another molar mass, e.g. CaCl2, and the answer will be different).

I haven't read Dubin's book in a long time. I bought an earlier edition of it (mid 90s) when I was an EMT, and it was helpful then. At that time it didn't include much information about 12-lead. Dubin's book is very easy to read, and has a "programmed learning" concept behind it, that's quite neat. Put simply, he leaves blanks on various pages, that you're supposed to fill in yourself as you learn the material, so each time you turn the page, you're forced to actively read. It has some funny illustrations, and is written in a pretty quirky, accessible style. I'd mail you my old copy, but I gave it away to someone else a few years back. Pros: Easy reading, doesn't require a deep understanding of cardiology / physiology Cons: Not a ton of information on 12-lead, not particularly academic Thaler: This book seems to be more aimed at medical students, takes a little more time to explain the physiology, and is written in a more conventional style (no programmed learning). It's not particularly academic (= some funny pictures), but covers much more material than Dubin. It's a more comprehensive introduction. PM me and I might be able to point you in the direction of an electronic copy. I would recommend Thaler over Dubin, if your interest is anything beyond basic 3-lead interpretation. Other books you might want to consider: "The ECG Brain" by Ken Grauer ---> Ken posts on some EMS forums, and has produced a few good books that are a decent read for paramedics. I have a Kindle copy of this and love it. "ECGs for the Emergency Physician" by Amal Mattu. Someone (possibly here?) turned me on to this a while back. It's mostly test 12-leads with a very short history vignette, that you're asked to interpret. There's actually a part 1, and a part 2 as separate books. Worth reading -- and really, given how little we can do in the ambulance, reading some of the same ECG book the ED docs do can't hurt.