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I had a scenario the past week involving an exacerbation of emphysema which I decided to treat with Nebulized Ventolin through the CPAP mask along with Solumedrol. My instructor decided to introduce a new onset of Angina with Ishemic changes in leads II, III and aVF. He asked me how I would treat the new onset of symptoms to which I replied I would administer 2.5mg of Morphine SIVP. He challeneged me to consider the administration of ASA and Nitro which would require me to remove the CPAP device.. I stood behind my decision to keep the CPAP device on my patient as the COPD exacerbation was the primary complaint, and there's also a risk to the patient in removing the mask once it is applied, and the angina is secondary and can be relived by the morphine. Just curious as to what some other opinions of this would be? Administration*

Some suggestions I could add, that I ponder quite frequently, are in regards to the practical evaluation which I believe shouldn't be given as mark or percentage. The evaluation should instead focus on whether learning took place in the reflection after the scenario. This creates a proactive and positive learning environment and takes away from a lot of the communication and learning barriers experienced so frequently in EMS education. Another concept I've become quite facinated with is called the "pygmalion effect" which I think all preceptors should have knowledge of as it gives credence to the positive and encouraging preceptors who always seem to produce the best trainee's.

Sorry, link didn't copy right:

I think it's great that we're able to go into such detail on the pharmacology and chemical structure of the drugs that we're administering. Just learning about the types of receptors in school now and reading about it in practical application really helps things click and fall into place! As for keeping up with knowledge and re-learning a lot of the things that have been forgotten over the years, I stumbled across a series of medical videos on youtube which are completely free and break down everything into detail step by step, and it didn't feel right to not pass it along to those other than my classmates. Here's the link, his name is Dr. Najeeb and he's been teaching Medical school students for 25 years. http://www.youtube.com/user/DoctorNajeeb?feature=CAQQwRs%3D

I've heard that a lot of people are having trouble with the Braun Introcan Safety caths since they made the switch... I'm glad that we are learning with them instead of having to transition to them after using the Protect IVs.

We had a similar scenario presented to us in class, (where patient is deteriorating despite 02, salbutamol and ipratropiumand) and had a similar discussion to whether we would give the nebs followed by epinephrine 0.5mg SQ. My suggestion, like yours rock, was to give the nebs, then initiate CPAP. My instructor, however said that he considered it just splinting the symptoms instead of treating them, and that once you've initiated CPAP you have to continue that treatment at the hospital. He also mentioned that CPAP creates air-trapping in asthmatic patients which is why it would be a "last resort" treatment. After discussing this case with my instructor for quite a while, we came to the consensus that if the patient is not responding to the nebs, 0.5mg epi is definitely the right treatment.

I'm currently taking my ACP after working two years as an EMT.

welcome

I was considering pre-eclampsia progressing to HELLP/DIC and possible hemorrhage of the liver. Internal hemorrhgage with clotting disorder would explain the low bp and if the patient progressed to decompensated shock would also account for the bradycardia. Yeah, no nausea/vommitting or signs of internal hemorrhage, but I still think that it's a post partum disorder since she has a clean history other than her cholecystectomy 1 year ago..

Hmm.. So I'm now leaning towards Post-Partum eclampsia, which can develop anywhere from 24 hrs to 6 weeks after the baby is delivered. In severe cases of eclampsia, especially when untreated, can lead to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). HELLP syndrome presents with RUQ pain/tenderness, fatigue/malaise, nausea/vomitting and can cause DIC (which could explain her cold extremities). It can lead to liver hemorrhage and renal failure if left untreated. Explains abdominal pain, low BP, and cold peripherals.

I'd like to know what she was prescribed for her depression, when the prescrition was issued, dosage, how many pills are remaining, when did she last take it? I'd like to gain more information on her recent mental state from the husband.. Has there been a history of depression? Has it gotten progressively worse? Associated anxiety or suicidal ideation? I'm leaning towards a possible tricyclic anti-depressant overdose. Having hypotension accompanied with bradycardia causes me to think that we need to know more about this medication. Tricyclic anti-depressant OD's have been known to cause an ileus of the small bowel which would explain the RUQ abdominal pain. Last bowel movement was 8 hours ago, but prolonged use of tricyclics can still cause ischemia progressing to necrosis. Are bowel sounds present? Any ECG abnormalities on the 12-lead indicating OD? As for tx: If QRS >.10 and evidence of cyclic OD 1mEq/kg of sodium bicarb while bolusing normal saline to pressure of 100 mmHg

Thank you all for the advice. I ended up talking to the instructor one on one to get a better idea of what kind of boundries we should establish. The end result was actually quite positive, we now see eye-to-eye and in the end I was told that it would be beneficial for me to continue to start these discussions in class, as long as we don't get too off topic of course. I'd like to comment a bit on the new day and age of adult education as I see it. I understand that a lot of services out there have a whole "eat your young" mentality and "you have to put x amount of years in before you can even have an opinion!" I see it quite a bit in EMS, and I think it is holding us back as a profession. Being a student, you make a lot of sacrafices. You have to take time off work, move away from friends and family and it's not cheap. As students, we have certain expectations going into school that we will be treated a certain way and have a certain amount of freedom in the classroom. However, we are the product of our instructors and our school. Our instructors are the ones with the power and have an obligation towards evaluating us to a certain level. I definitely do not want to border on arrogance, but I want my instructors to help me build confidence when warranted. Having said that, there's also a fine line between confidence and arrogance. If a student is to receive too much hype, praise and flattery, it's a slippery slope that can easily carry them over the border into arrogance. It is not only toxic, it can be deadly. I've tried to make it my goal not to allow myself to get overconfident, especially now that I'm an ACP student, because that's when practitioners will miss a step, lose their focus and potentially hurt somebody. A balance is definitely required in an instructor between fostering learning and being critical towards bad attitudes and bad habits so they don't manifest throughout their career. I liked that quote Dwayne, I think in this day and age we must really pick and choose who we want to learn from, and if it's not a proactive relationship then there's no harm in ending it.

I understand where you're coming from, and I have also worked with some terrible providers whos skills are no where near what they should be.. However, I have also worked with some excellent providers who have been working as EMTs for years and have kept up their knowledge base and skills and I don't think that we should throw the baby out with the bathwater. Just because they took their training in 1976 doesn't mean that their designations should be demoted. That was all that was available at the time. If a more indepth and challenging course was available at that time, I'm sure a lot of them would have been willing to take it. Look at the RN program for example. It used to be a diploma program and they have now switched the course to a full degree. This doesn't mean we should demote the RNs who took the diploma to LPNs just because they took a 2 year program and not a 4 year one. I agree that the oldschool "scoop and scoot" providers who have no interest in advancing their training or competency are holding us back as a profession, but that doesn't mean their title should be demoted to an EMR status "just because." We should have all providers do skill testing along with an annual knowledge exam to advance our profession and the problem will be corrected.

Hello everybody, It's been a while since I've posted. Unfortunately, I have adopted the habit of only accessing this site when looking for advice or information, which many of us do. However, since I am now an ACP student, I am going to put in the effort to post scenarios, interesting encounters, and EMS topics. After spending the summer in the Northern part of the province working as a wilderness guide and first aid attendant I was worried that my knowledge base wouldn't be where it should be when returning to school last week. Fortunately, the first two weeks are "Advanced Care Preparation" and are basically a review of our BLS skills, which if we are entering the ACP level we should all be profecient in anyways. So far things have been going quite well. We have a great class, some good teachers, others, not so good..But so far I havn't felt the need to study too extensively. We have scenario testing tomorrow, which I've been told the instructors try and make you feel as though you have a long ways to go and challenge you on controversial topics. One topic which came up today was in regards to pain management. Local protocols state that if patient cannot self-administer Nitrous because of billateral wrist or hand fractures than Nitrous is contraindicated. I spoke up and said that just because they are unable to grip the mouth piece or mask doesn't mean they don't qualify for pain management. My instuctor disagreed along with several other classmates. I responded with the solution that you could fasten the piece to an uninjured part of their hand or wrist so they can still self-regulate the Nitrous PRN. Still, we were unable to see eye-to-eye. I have a suspicion that if I were to do this in a scenario tomorrow, that I would fail if the instructor, or any other instructors sharing this viewpoint were evaluating me. It's only been a week, and already I'm already running into situations where I'm voicing my opinion then instead of engaging in a discussion about the subject, it's being dismissed or overruled. My hope is that ACP would be a forum in which we could have those collaborative discussions in class, because that is how I learn, but if I am just being an annoyance to the teacher, I'm wondering if I should just hold my tongue and just try and focus on getting my work completed.. I really am trying to find a balance between how much I should stand up for what I believe in, and what I believe is to the greatest benefit to the patient, or to save that for practicum or when I have completed the program. As for workload, I have heard that this program becomes very intense and almost unmanageable at times. I don't want to be one of those people who are always studying and are always tense and on edge, but I also want to be able to gain as much knowledge and wisdom from the program as possible.. I am in the process of getting a tutor through the school I'm in, but I'm a bit nervous that it won't be enough.. I would love to hear some of your personal strategies and methods from when you attended ACP school!

All I can say is that I sure am glad that I'm taking my ACP now. I honestly do not know how they will pull this off... I'm thinking it will most likely be offered as online modules and in-service training which will be added towards the providers annual con-ed points. It also seems as though they will be expecting the health regions to provide practical training grounds to evaluate the newly added NOCPs. I think it's very unfair that they would demote or "freeze" any providers licence level because of ScoP's lack of foresight and lack of transparency.

This has been the first scenario I've been involved in so far with the city and I have to say I sure did learn a lot from it. That modification to add the nasal at 10-15lpm with a bvm/PEEP valve to create the same effect as CPAP was great. I'll be starting up ACP school in August and I'm going to really try and get involved in more scenarios and begin posting my own. I sure hope that there are more scenarios like this one in the future that we can all learn something from and challenge each other with. As for the rhythm, i've seen runs of both PSVT and V-tach in the field which both converted themselves back to NSR. I personally thought it resembled SVT but I may be mistaken. What do you guys think?

I agree with pulmonary edema and administration of Nitro along with CPAP. Nitro will also be helpful for treating the patient's HTN.

I'm considering that the acute onset of SOB is primary a cardiovascular problem which has exasperated the patients COPD causing pulmonary edema, decreased air entry and wheezes. Nobody has mentioned the episode of paroxysmal supraventricular tachycardia the patient experienced which may be caused by a congenital heart defect such as Wolff-Parkinson-White syndrome. What also makes me think cardiac is because the patient's blood pressure is hypertensive which could indicate left ventricular dysfunction. I agree with the application of CPAP as long as we're sure we've ruled out spontaneous pneumothorax. However, I agree that giving a bronchodialator to TX the wheezes beforehand would be the best option. If the patient does not improve post nebulized albuterol and CPAP, incubation is definitely indicated.

Thanks Dwayne, I'll be sure to check it out. The blog I had been following for the past couple years has recently been taken down, so it will be nice to get a new perspective.

Lupus!

I thought his most bizzare "suggestion" was while the patient was in cardiac arrest he yells out "we need a catheter inserted, stat!" I do believe that he just gave the anticonvulsants, inserted the combitube and requested and stepped aside for the code drugs..I'll try and get ahold of the Emergency Response Co-ordinator to follow up on whether an outcome has been reached and let you know.

To be clear, although it remains an interesting concept, and I am facinated by the placebo effect, I have not yet given the "morphine patch" as a treatment; however, it was told to me by a co-worker who states it does give his patients relief of their pain if you truly believe that it will help them.

My favourite method of pain control is a "morphine patch" aka alcohol swab and opsite

Well, the point I was trying to make was that the cardiac arrest should have been led by the health care professional trained to the highest level, which in this case would have been one of the Advanced scope R.N's that the E.R. was staffed by. EMTAs/ICPs do not have ACLS training but ACPs do, so misrepresenting himself did infact misrepresent his qualifications since the nurses associated the title "Paramedic" with having the advanced skills and training. Sure, all of the levels have "Paramedic" in the title, but unless you are willing to explain the scope of Primary, Intermediate, and Advanced care paramedic to the nurses, it is more skillful to understate your qualifications than to overstate them.

Last year we had an incident which clearly illustrates the reasons why EMTs/PCPs EMT-A's/ICPs must not refer to themselves as "Paramedics" or "Medics." We had a single BLS unit covering three reserves in Northern Saskatchewan with no backup for an hour and a half where there was an EMS service (also the nearest hospital) with EMT-As/ICP's in the neighbouring province, Manitoba. We were on a transfer to the hospital and had just dropped off our patient when dispatch informs us that there had been a MCI of 8 patients. 3 of which were critical. Being an hour and a half away, the RCMP and nurses had to respond to the scene and bring the patient's to the clinic where they would attempt to stabalize then mede-vac them to Manitoba. We request a unit from Manitoba to respond with us and proceed to the local clinic where a 19 y/o female patient is suffering from a head-injury, in junctional escape rhythm and currently seizing. We get there and the Manitoba "EMT-A/ICP" introduces himself as a Paramedic. At this point, not knowing what level this particular individual actually can provide, he steps in and takes control and begins calling drugs from the nurses (which arn't in his scope to give) and asks for a combitube..I question his choice in a combitube and why he isn't going for the intubation equipment and he responds that "this way is better" and proceeds to secure the airway device. The girl ended up dieing and I ended up taking down the providers name and reporting him to the emergency response co-ordinator who filed a report to the college of paramedics for misrepresentation and malpractice. As far as I've been told, his file is still under investigation. Bottom line is that if a provider misrepresents him/herself, it provides unrealistic expectations of what skills can be done. In this case, the nurses heard "Paramedic" and associated him with the skills and care level they believed ACP's could perform. It's not right, and this behaviour has to be stopped.