paramedicmike

Literature is mixed at best. For everything one can find in support of it, and there is some that seems to show evidence in support of NTG use in ACS, there is other evidence that shows no clear benefit. I found these as a nice review of the literature. They're pretty current with updates completed last year. Sources are cited. Relief of Chest Pain with Nitroglycerin - Is it Predictive of Coronary Artery Disease or Cardiac Chest pain? Nitroglycerin Use in the Initial Management of Ischemic Chest Pain From Acute Myocardial Infarction As Off Label has noted there is a demonstrated benefit to NTG in certain circumstances. What's not clear, and more to the point of the OP, is if there is any benefit to it's use prehospitally in ACS. Going back to the original questions asked by the OP specifically regarding therapeutic value. Pain relief can indeed be therapeutic (barring any additional or unintentional side effects from the meds). However, given how the rest of the conversation has progressed so far I'm not convinced that pain relief is the kind of therapeutic value being chased by OP. Also as OP has directly asked, "Does it increase prehospital survival rates like ASA?" The evidence doesn't clearly support this. There is some evidence to suggest it might (in an exceptionally small number of people over 48 hours if used early enough). But there is nothing out there that clearly states "NTG use in prehospital ACS treatments saves lives". If there was we wouldn't be having this discussion. OP wouldn't be having the discussion with his/her medical director and governing body. If there was evidence we'd be doing it with every ACS patient we encountered. Disappointing as that may be for all of us who have dedicated ourselves to doing the right thing, or what we thought was the right thing, for our patients we work with what the literature shows us: There is no evidence it saves lives in the field. When what we do every day is an effort to save people's lives that idea can be a bitter pill to swallow (or let dissolve under your tongue). I'm still intrigued by the idea of a RCT on prehospital NTG use and outcomes.

I prefer to base my practice on evidence based medicine whenever possible. Anecdote and experience do not equate to data. If you have evidence that shows a clear and statistically significant benefit to preshopital nitroglycerin I'd be happy to consider it. I'm sure your medical director, as well as your governing body, would be happy to consider it among all the other evidence they review when putting your treatment guidelines together. As it stands, the current available evidence doesn't meet that. That being said: No. Not every prehospital provider should be able to give NTG. It is not a benign medication. It can have some serious consequences if not used appropriately or if used by people who don't know what they're doing or why. No. I don't think NTG should be given more importance prehospitally. Not until a RCT demonstrates clear benefit to doing so. No. I don't think the evidence supports a clear increase in survival rates in this microcosm of prehospital emergency care. What's more I would caution against falling into a line of thinking that just because logically something *should* work means that it actually works in practice. This could be a good chance to make a name for yourself. Put that first year anatomy class to good use. Put together a RCT for the use of prehospital NTG and present it to your medical director. Get your local IRB on board. Then, when all is said and done get your study published. Who knows? You may change the practice of medicine for thousands of providers around the world.

Does it increase prehospital survival rates? What does the research show? Go do some reading. I think you'll be surprised. Your argument is that it does. Based on what research? What you learned in anatomy and physiology? You're upset about something. The best I can tell from your posts so far is that it sounds like you're upset that your professional governing body and your medical director (you know, the folks who do research on these topics to develop evidence based treatment guidelines for the purpose of actually helping patients and not hurting them) are limiting field interventions within a subset of patients. Perhaps a sit down with your medical director to review some of the literature would be more productive for you.

That would've been good information to lead with. Making your intentions clear from the get go might have helped with faster, more direct answers. Presumably your organization has insurance to cover this sort of thing. Insurance companies tend to have lawyers who will have an opinion on how to approach this so as to reduce their liability. You may also consider approaching the medical director for your local EMS agency or hospital emergency department to discuss with them. If this is a school or school district organization the school district likely has rules/policies in place to address the very questions you're asking. If this is not a school or school district organization asking your local school district on policies they use/follow may provide a guideline on which to base your group's practice. I can appreciate your position. Unfortunately, there are too many variables at play including local ordinance and even state law that would limit the ability of anyone here to answer the questions you need answered.

I don't see the problem with the Q&A as listed above. It seems pretty straight forward. In that light I'll have to ask what, exactly, are you wondering?

I get the suspicion OP is trolling for support in a lawsuit. If not a lawsuit there is some as yet unknown gain being pursued. Why are you asking, OP? What's your purpose for asking? If you have specific questions about an event you either experienced or encountered personally then your best bet is to engage in conversation with the participants involved the actions you're referencing. We are unable to address a specific event that carries more variables than could easily be discussed in this type of format.

It's a tough spot to be in, for sure. It's never fun when your body decides it no longer wants to keep up. You've got a few options. Several options include going back to school. Some sort of leadership role that would require you to maintain your training yet reduce your street time may be an option. EMS education is another option. Is there some sort of EMS liason or ALS coordinator within your local hospital/health system? That might be another option. Otherwise, please seriously consider going back to school. Yeah. I know. It's expensive. Yes, you can afford to do it provided you budget carefully and take advantage of the financial tools available to help you succeed. Nursing school is one option. PA school is another. (Coincidentally, PA is the route I chose.) Even MD/DO school are options. Any of these educational options would build on your street experience. That same experience would serve as a foundation for additional learning. It sounds like if you maintain your current pace you won't have much choice but to stop working the street due to physical constraints imposed by years of what really is physically demanding work. That you're thinking ahead is a good thing. Don't rule anything out.

Welcome.

Good questions. What should you bring? You should bring a pen, pad of paper, pocket calculator, stethoscope, cash for food in case you don't make it back to the station to eat the lunch you'll have brought with you, study material, an open mind, an abundance of patience. How do you make a good impression? Show up early, be eager to get involved with anything (e.g. checking the ambulance, cleaning, house chores), know when it's appropriate to ask questions (generally after you're transferred care and not in front of the patient or family) and when to keep your mouth shut, say "please" and "thank you" (not kidding). How do you get the guys to like you? You don't. You're not there for them to like you. They're not there for you to like them. You're there to learn. They've agreed to teach. That being said you don't want them to report back to your instructors that you're a jerk. Be respectful of them. Be polite. Be professional. Before the start of your shift talk with them and ask what their expectations are of you. Let them know what you'd like to do during the shift. If you happen to get along well then that's a bonus.

Woah. Wow. If you said anything I totally missed it. Good luck on your interviews.

You still in Baltimore area? Where are you interviewing?

Emergency button on the radio is the local SOS.

So the Coast Guard sent you to EMT school. Was this part of your job while in the military? If so, doesn't Texas have some sort of process for military vets who hold valid NR certifications to gain a state certification? It sounds insane that Texas would play this kind of game. It also sounds like your initial certifying "state" was the Coast Guard where you don't need any specific state certification if you have NR. If they refuse to play ball can you obtain certification in a neighboring state then apply for reciprocity? Failing that start asking why they're discriminating against a military veteran.

Welcome. All the best with your pending exams.

This commentary appeared in the Washington Post today. The author is arguing that we should forgo the scene safety premise to our job and, in certain situations, enter a hot zone to provide care. Thoughts?

Please read your text carefully. Please think very carefully about what you've written. An educated opinion formulated by years of experience is worth much more than that of someone who is brand new to the game. You're right. It's your life. That being said please consider the well seasoned experience from people who have been doing this much longer than you. Pace yourself or you'll burn yourself out. And burned out is not a good place to be.

If that's really what your instructors told you at the beginning of your class then it raises a lot of questions. EMT class is not rocket surgery. While the duration of the class (condensed classes over 2-4 weeks versus classes spread out over a few months) can affect the time you will spend studying and preparing making it your priority over everything else is neither healthy nor productive. You're young. Perhaps your naivete is more influential than you know. I recognize that your limited experience may affect they way you look at and view events in life. If any student elects to make their studies their priority in deference to everything else that is certainly their choice. However, understand that there are consequences to that decision. Nobody can be turned on to a particular topic all the time. My hope is that you recognize that early and avoid the burnout that inevitably comes with the attitude advocated by your instructors.

Lack of unity is only a part of the problem. Unionization may or may not help EMS. There are currently plenty of examples of unionized EMS providers (IAFF members as part of a larger fire-based department... another problem that I'll touch on shortly). Are they really faring much better? There are examples to support both the yes and no answers to that question. EMS faces many problems. We suffer an identity crisis in that we are health care providers stuck in a public safety mindset. We are stuck in a public safety based delivery system. There is an historical component that explains our current model. We are beyond the time, however, of moving forward out of public safety and into proper health care. As we are health care providers we need to present ourselves as such. We need to be more completely integrated into the delivery of emergency medical care as part of the wider health care system within the US. We need to change our education model to put us more in line with health care education producing health care providers. This leads into my next point; please consider the educational embarrassment that is EMS education. In many places it is still true that it takes more training time to obtain a license to cut hair than it does to become an EMT. National Registry is attempting to address some of the education issues by requiring credentialing of paramedic training programs. Unfortunately, not every State requires NR either for initial certification or maintenance of certification (MOC). So forcing a change by mandating educational program credentialing isn't going to address the entire problem. Continuing with the education theme we need to change the mindset among many EMS providers that "a degree won't help me start an IV any better" and similar nonsense. People don't like to admit this but earning a degree is important. To be taken seriously we need formal degree awarding educational programs. Making that change to degree awarding dedicated EMS programs will help change the mindset that we're simply a bunch of yokel techs joyriding through town with lights and sirens on. Lastly, for this post anyway, we as an industry need to stop giving away services for free. Yes, the history of volly EMS is well entrenched in many places. Unfortunately, when a service is provided for free there is no value placed on the delivery of that service. EMS providers should be paid for the services they provide. Unity? Yes. We do need it. From a union? Perhaps not. Examples of unionized EMSers show mixed results at best. A better option would be a reliable national organization that effectively advocated for EMS as an industry. An organization that could advocate and affect change in education, industry identity while promoting health care ownership. Unfortunately, I don't think that organization exists.

Welcome. Interview questions depend on the person with whom you're meeting. I've had everything from general get to know you type questions to ethical scenarios. Some places will talk practice other places will assume you know what you're doing and not touch on it. Some places will mandate a written test, physical fitness test and/or background check. Others won't. Not terribly helpful but there's not a good way to answer your question. Hope the interview goes well.

Welcome.

Oh good. Another PA-C. That's a good thing.

Hello, Bjorn. My condolences to you regarding the death of your father. From what you have written it sounds like your father suffered an out of hospital cardiac arrest. There are many causes that can contribute to this. Unfortunately, it is impossible for me or anyone else here to speculate as to the cause. Should your father have been intubated is another question that cannot be definitively answered. Current evidence is mixed with some studies suggesting that intubating cardiac arrest victims leads to worse outcomes. The hard part here is that you did not have any airway management equipment with you. You were doing CPR in the back of a moving truck. Approximately 90% of out of hospital cardiac arrests in the US die. As you didn't share what country you're posting from I don't know the numbers that are relevant for you. Many times, however, despite your best efforts, things end badly. In this case you were unable to revive your father From what you've posted you did everything you could to try to help him. Take comfort in knowing that you did everything you could to help him.

Welcome.

Welcome. EMT interview for a job? Or EMT interview to get into an EMT class? If for a class then it'll probably be some questions to try and figure out who you are and if you'd fit/do well in the program. If for a job it will vary wildly. Some places do a sit down interview along with a written test and fitness test. Some places will simply ask if you have a certification and when you can start. Preparing for an interview is like preparing for a test. Get a good night sleep before hand. Eat a good breakfast that day. Brush your teeth before going in. Or at least check and make sure you don't have part of your breakfast between your teeth. Dress well for the interview. This means no random uniform pieces. Business attire is appropriate unless they tell you otherwise. The biggest thing is to relax. You're interviewing them just like they're interviewing you. Be ready with questions to ask them. All the best.

Glad to hear you're safe, Bernhard. Thanks for the update.