WelshMedic

This is a primary ventilation problem that needs adressing emergently because this child is obviously starting to struggle. He is currently compensating, but will shortly be decompensating without adequate treatment. I'd also like to know how his ABG's are, by the way. My proposal: arterial line (primarily for the ABG's but also monitoring) parenteral beta2-adrenergic agonists (as long as the HR can take it) parenteral corticosteroids If all else fails, intubation and mechanical ventilation with low tidal volumes and a lengthened expiratory time to prevent barotrauma. Sedation with ketamine should be considered because of it's positive effect on bronchodilation (morphine should not be considered due to histamine release). Magnesium can be considered due to it's effect on the smooth muscle, but this will more likely be considered at the facility. WM

I'll give you an internship here in the Netherlands. It's a long way, but certainly worth the journey. Let me know if you are interested. WM

My god, an american that has an understanding of european politics....well done my friend!! Now, onto the order of the day: why has the country that benefited the most from EU investment now just rejected it's treaty? A bit ungrateful, don't you think? WM

Man, you seriously need a no-send policy for this sort of stuff. It is tragic that such a nice person is addicted to her pain medication. It is, however, not an EMS problem. WM

Anthony, The way I learned was anterior/posterior for pacing and anterior for defibrillaton. I've never really questioned it, to be honest but I wil do some googling of my own this week. WM

Anthony, You want cardioversion, you got it! This is an actual case, a call I did about 3 weeks ago. Male 39y/o, collapsed after sexual intercourse with his wife. Now lying naked and supine in the bathroom between the toilet and shower cubicle (boy, I so never wat to be in that position myself...) Presentation: Pale, clammy, anxious (I'm going to die...), low BP, no pulses in extremities present. Is Alert en orientated. Complaining of extreme chest pain and dizziness (!). I pride myself on having that sixth sense in diagnosing my patients - I was already convinced this was a right sided barn door MI........my I was wrong.... We gave the patient the usual: o2, IV and made a 12 lead. I found this: . It was a wide-complex tachycardia (Vtach) with a ventricular response of 270bpm! I subsequently gave him amiodarone, but without much effect. He went down to around 230 and then just went right back up again. By this time his BP was 75/36 and he was just getting worse. So I decided to cardiovert him. It was the first time in my career that I had a reason to do so. First I administered a low dose of Versed (2.5mg) because of his hypotension. We use the LP12 so I then placed the ECG in synchronized mode. For those of you who don't know how this works, it just means that the monitor seeks out the R-wave and marks it. When the shock is delivered, it is then delivered at this point thus reducing the risk of VF. Look for the markers I'm talking about on this video: . The patient is then instructed that it may feel uncomfortable (understatement..). Once I did this I selected 150j on the defibrillator and pressed until the shock was given. That's also the difference between cardioversion end defibrillation, because it waits for the R-wave it does not fire instantaneously. The patient converted back into sinus rhythm almost immediately, but did have transient ST elevations in his ECG - this is also a common phenomenon amongst these patients:See here. Almost immediately he felt a lot better, had no more chest pain and just wanted to sleep. So would I, by the way, after having a HR of almost 300 for more than half an hour and getting Versed on top of it. We delivered him to the local CCU for evaluation. When I was cleaning the truck out in the parking lot I came across the patient's brother. He said: "Oh, I was so worried about him. You see, I have Wolf-Parkinson White and have had an ablation last year. Could this have anything to do with it?" My reply: "Errr, go upstairs and tell them about it as quick as you like." Well that's my story about cardioversion....I hope you enjoyed it. WM

Riblett, You probably be better off PM'ing one of the german members here. I know that there are least two active on the forum. I am in Germany's neighbour, Holland, so I can't really be that specific about Germany. However, I do know that the only qualifications that are transferable are the ones gained in the EU (European Union). Don't forget, also, that a lot of German EMS is fire-based. You would have to buy into that too. The exception to this rule is southern Germany (Bavaria in particular) where organizations like the Red Cross and Maltezer Cross are responsible for EMS. The major disadvantage is that this system is physician led. ALS is provided by "Notartzen" in fly-cars, the role of the " Rettungsassistent" is limited. WM

It's a procedure just like any other. The crux of the matter is knowing when and why to do it. That topic has been fairly comprehensively covered here. I have done it a number of times, it's not difficult at all. One of the issues we encountered initially is that the standard needle just isn't long enough sometimes, that's why we also carry vetinary needles. WM

He would have sustained such a severe injury that there would have been an issue of kidney failure, this is caused by a build up of toxins during and after the injury. Usually dialysis is temporary in these cases. WM

I think he may have metastases in the brain causing the seizures, but then again I've had the benefit of reading all the previous posts..... WM

Quite agree with the above: I also give an NSAID for kidney stones. IN our case it's diclofenac. A similar product to ketorolac, I guess. WM

We always gear up for the worst case scenario, however small the incident.

Hi, Without wanting to label your problem "PTSD". I do think that the fact you are having flashbacks to an incident that happened so long ago does not bode well. I would urge you to seek out professional help as soon as possible. This will not go away without help. Oh, and it's not a sign of weakness: I have been down the same road and have come out the other side a better practitioner for it. WM

:shock: :shock: :shock: That, my friend, has a very different meaning in the British version of the english language. Still, you're the lucky one...... WM

I take my words back. You are a well=balanced, enthousiastic student that approached this correctly. Your preceptor was, however, an a$$hole. There are some everywhere, unfortunately. WM

Riblett, I agree wholeheartedly with the sentiment on EMS eating it's young, we are there to nuture our young, securing our future as a profession. However there seems to be a tendency within our younger generation to scream and shout and throw their toys out of the pram when they don't get their way. Why did you immediately call your coordinator? Wouldn't it have been more prudent to try and talk to your colleague about this? If you'd not got the right answers then you could have called. We have to need to be able to trust one another in this job, I don't want a partner that will rat on me every time we disagree. WM

Oops, sorry! I hear that Canadians are like Americans....only nicer! wm

Let me just put you in the picture here..... it's a Dutch commercial for a health insurance company. The setup is a Dutch couple on a cycling holiday in Finland. I gave a presentation in Pennsylvania some weeks ago and ended by showing this film. In order to do so, I asked the insurance company for permission first. Their contact told me that they wanted to set the film in Holland, but knew that our national governing body for EMS wouldn't buy it. I now know what I pay my licence to practice fees for...... Kaisu - the Swedish is Dutch, and never call a Dutchman German! How would you like to be called Canadian? WM

Dwayne, Congratulations from this side of the pond as well. If you are as good a provider for your patients as you are a contributor here, they will be priviledged to have you at their bedside. Just remember, your paramedic badge is just like your driver's license: the real learning starts here. Congratulations and good luck. WM (PS- when are you starting the nursing degree to get a "proper" job? Nah, just kidding ya....)

This does, however, raise an issue that I have come across in the past. ER staff are generally spoilt in terms of an EMS patient. A lot of the work is often, rightly so, initated in the field. On the odd occasion that this is not the case they do tend to scratch their head and say: " What now?" WM

Just a quick question vandellen, who do you work for now? I know the Philly area quite well and was just curious. Send me a PM if you don't to identify yourself any further. WM

Just think about this for a second: Let's all refuse to treat a pt with a deadly transmissible disease. In fact, if the risk is so great then why don't we just refuse these people admission into hospital. That way we can make huge savings in our healthcare budgets - well, let's face it, these pt groups usually cost the most. And we'd protect the lives of thousands of healthcare workers Let's get real here folks. We live in a civilized society, and with that comes a duty of care to all. The risk of transmission of HEP/HIV is minimal when good practice is used. What are we talking about? The transport of one sick, infected individual where contact is minimized? Put yourself in the shoes of a hematology nurse, or a transfusion technician, or a phlebotomist, or even a surgeon for that matter. And yet I've yet to hear the same conversation from any of these professions. Why is that, I wonder? WM

A very elegantly put post, Dwayne. I do think that we're going round in circles on this subject. However, it would be disingenuous of me not to state my position.... I'm with you all the way, Dwayne. WM

ALL RN's, All ALS, all of the time.....and all of them transport. WM

That is such a good point, I think. It's also a huge compliment to you. He sees you first as a mother and then as a medic. That's called getting your priorities right! Don't let this get you down. He will learn as he gets older. WM