EMS49393

I have to admit, I'm the Queen of the diluted medication. Anything that can cause tissue necrosis and doesn't have to be pushed fast I try to dilute. Currently, my service only carries two such medications that I routinely dilute before IVP adminstration. D50W and promethazine. I like to dilute D50W down to 10%. Diabetics are notorious for having poor peripheral vascular access. I find it damn near impossible to push 50% dextrose though a 22 gauge catheter, which is often the only port in the storm. Rather than risk extravasation, I simply dilute it with a 60 ml syringe and a bag of saline. In those cases, I'll often give 12 mg, enough to wake them up for the trip to the ER. It seems to me that a sudden rise in blood glucose level from 20 mg/dL to 250 mg/dL would be considerably hard on the body. I prefer to see a steady rise to a comfortable 90-100 mg/dL. If the patient requires more dextrose to maintain glucose levels en route then I will administer more dextrose accordingly. I HATE to get refusals on diabetics. I think that a hypoglycemic episode, one that renders a patient unconscious, or close to unconscious, indicates a need for evaluation by a physician. That episode can be directly related to patient non-compliance, but it can also be related to improper medication dosing, improper patient education, etc. You'd be amazed at how many fragile diabetics I run on that have never seen an endocrinologist or even a nutrionist. Some of these patients have no idea how to manage their diabetes. I take great care to pass that information along in my report to the ER nurses. I'm pretty dedicated to the proper care of the diabetic patient. I do considerable extra reading on the disease and I'm determined to be the first in three generations to completely ward off this disease.

Thiamine, also known as vitamin B-1 is an essential vitamin, required for life functions. As stated, it does convert food to energy. It is also necessary for brain and nervous system function. Any patient can be at risk for thiamine deficiency. Greatest risk goes to the mal-nourished and immuno-compromised population. It is safe to assume that any patient that isn't eating properly (alcoholics, homeless population, drug users, and frequent flier diabetics) can be thiamine deficient. You must also remember that alcohol itself destroys thiamine. A thiamine deficiency can result in a condition called Wernicke's encephalopathy and as it progresses, the patient develops Korsakoff's psychosis, which is irreversible. It can also result in other neurological disorders secondary to the vitamin being essential to proper brain function. The idea of giving thiamine with D50W is to prevent neurological injury/insult when there is not enough thiamine to convert the dextrose to energy. Thiamine is one of the common ingredients found in the "banana bag" given to the ETOH patient in the ER setting. Some of the recent research I have found states that thiamine can be giving within 24 hours of dextrose administration. All other research I've found on the topic states that thiamine should be given before adminstration of dextrose. I NEVER say that a drug is benign, however there is only one contraindication to administration of thiamine, and that is hypersensitivity to the drug. In the case of this drug, the benefits far outweigh any risks in most settings. I have just scratched the surface with my post. If you use google, you'll find research documents which have a wealth of information about this subject.

I don't spank my child because he raises hell and screams at the top of his lungs because he can't focus. I remove him from the stimulation. Don't get me wrong, if Matty hears me tell him not to do something, looks at me knowing he will be in trouble if he disobeys me, and willingly does it anyway without regard to the consequences, than he will suffer the consequences. I will apply the hand of learning to the seat of knowledge. I just refuse to punish him for his illness, and after all this time, I can tell when it's him or his illness acting out. I want to send out the message of what is right and what is wrong. I also need to temper that with teaching him to be understanding of other people and their differences. I would be a hypocrite to teach him to be understanding to other people with disabilities if I punish him for his. I'm not perfect, and I'm not wonder-woman. My kid is a royal handful. I'm lucky to have the support of his grandparents and of his new step-father. My mother is a stay-at-home grandma, only working weekends. She has been a psychiatric nurse for nearly as long as I've been alive. Her early recognition of his problems and determination to create a happy child that isn't a zombie has been instrumental in his continued success. She is the real hero in Matty's life. I'll pass the very kind PM off to her.

Imagine an 8 year old child that has so many thoughts running through their mind they can't formulate answers to simple questions. Imagine this child repeating over and over again how they can't concentrate. I would hate to feel that helpless which is why my family and I have done everything we can to educate ourselves in ways to help my son through his illness. My son has a severe form of ADHD. He is fairly well controlled with medication, but he has bad days. He was placed in a private school last winter because he was too disruptive during class. He was in a classroom with 30 other second-graders and one teacher. He would spend considerable time during the evening hours upset about his behavior. His on-going excuse was something like this: Some of the kids are stupid, and the teacher has to repeat things over and over again. It's boring, I'm bored, I already know this stuff. He'd apologize for making disruptions, he'd say that he gets bored, and he can't concentrate well when he's bored. When he went into the private school, placement assessments were preformed, and he was subsequently placed in 3rd grade English/reading, and 4th grade math. The class size is roughly 7:1. There are several six graders that are in his math class. He never calls them stupid, in fact, he is willing to help these children understand. He is better stimulated and therefore better behaved. Don't get me wrong, that kid can and does get out of control. We solve that by removing him from the situation. Now, that does eliminate some activities, like flying, but we have found that removing him and discussing the problem works for him. He generally returns, apologizes, and continues on with the activity. He is an avid lover of the outdoors, wildlife, and sports. Up until last fall, he was playing football, baseball, and swimming. During football last fall it was decided that the game involved too much "rough-housing" which altered his behavior. He agreed that football wasn't his type of sport, and has placed more emphasis on his baseball playing. He's been playing baseball more than half his life, and was chosen along with one other player to represent his team in the little league all-star game, which they won. It burns my ass when a parent blames their children's "disorders" for their behavior. It leads me to believe they haven't put forth the effort to educate themselves in appropriate ways to deal with their children's behavior. I saw the news story on this women last night, and several of her statements struck me as strange. This woman took four children on a plane, when she knows two of her children have disabilities. Wouldn't driving have made more sense? After all, you can't remove a disruptive kid mid-flight. Not only that, but she stated she was left stranded with no money, and her mother had to pay to fly them by another airline. Who travels with no money and a bunch of kids? How did she plan on feeding these kids? What if her flight would have been cancelled and she would have had a stay-over? My son is a smart, funny, and good little boy. I never blame his illness for his behavior. I won't let him play victim either. When he is wrong, he knows he is wrong. He knows the meaning of the word consequence, in both its positive and negative form.

Five percent of the time I like the news people. This fell in the 95% of the time that I hate them. I wouldn't have reacted the same way, but I would have reacted in a similar way. I would have utilized police to take care of the greedy little camera douches, and I would have loaded that patient up into the ambulance to protect his privacy. There is no reason they need to be filming and making assumptions about the patient and EMS. That patient deserves privacy, regardless of how often he is intoxicated and found down. In my opinion, that entire thing looked like nothing but a set-up. I wouldn't doubt if the camera people paid off the patient and staged the entire call. I hope someone figures out that those people staged the call. The tables will quickly turn from them "demanding an apology" to them being in trouble for taking police, fire, and EMS out of service for a bogus call. :roll:

Wow. I can't even reply to that, mostly because it's incredibly difficult to read a post that does not have proper paragraphs, punctuation, etc. Get back to me when you graduate from college.

"Steve" What college did you attend and did you graduate? You seem to have a really poor opinion of those of us that went to college. Just asking. Do the nurses you work with know you berate them publicly on this forum? Just asking. I work in a service with a parapuppy mill. They are the worst paramedics I have ever encountered. They are positively stumped when a patient presents in a fashion inconsistent with their protocol book. If they just a good foundation in science, they might actually be able to treat the patient that does not conform to their cookbook. If they were able to form a coherent run report, they might spend less time in litigation, or the CQI office. We might get better reimbursement from insurance companies as well. If only... I also work in an ER. Actually, I work in the ER more than I work on the ambulance because I like being around people that I can hold an intelligent conversation with. I respect our nurses. Our physicians respect our nurses. We often have the IV established, labs drawn, and the ECG performed before the physician even sees the patient. I don't know where you work, but our Doctors appreciate a quick 12-lead handed to them just before they go in to assess the patient. If I'm correct, and I often am, I'd say that you never set foot within the doors of a college. I'd say that the providers that have gone to college hurt your feelings when they are able to hold a discussion about patient care that is over your head. I'd say you like that "C" provider because they have no chance of overshadowing you and making you look like a buffoon. I also call BS on your statements about the ER. Most emergency room nurses have protocols, just as we do, for initiating treatment on the patient. I doubt your nurses (that probably out-number your physicians 5-1) stand around twiddling their thumbs waiting for the doctor to tell them that it is okay to perform a 12-lead, or start an IV. Especially with the new door to balloon time window for the acute STEMI patient, to name one acute life-threatening emergency. What are you afraid of? The educated provider? The trend is going to change, hopefully in my lifetime, and we will all have to have a college degree. Personally, I can't wait. I look forward to the day when I can go to work and be proud instead of being embarrassed.

I think it's a fantastic idea, if it's used properly. A study was done several years ago that found the average response time when a vehicle used lights and sirens was often less than 30 seconds longer than the same type of vehicle responding cold. I just don't buy into the idea that "our response time could mean the difference between life or property if we don't turn all our toys on." That theory has been debunked. I will look for the study while I'm convalescing today. The idea is to preserve life. It would be fantastic to be able to preserve both life and property, all the time, however in a lot of instances, it's just not feasible. Don't get me wrong, a house suffering damage from a dumpster fire next to the building sucks, but putting hundreds of people at risk racing like gangbusters to the fire is just plain ridiculous. In that instance, life before property. We already put the greater public at risk every time we turn on our lights and sirens. The drivers often don't know which way to go when we run up behind them. They can and have caused accidents with their indecision. Likewise, emergency vehicles have caused accidents while responding. It saving a dumpster or some siding on a house really worth killing three people? From what I've read in both news reports and on another forum for firefighters, I like this Chief Clack. I'm hoping he'll pull the Baltimore City Fire Department out of the pit of hell it has been in for so many years.

One paramedic at a time. This thread has done its job if it has convinced at least one paramedic how important a solid educational foundation really is. Good luck in college, we know you'll be brilliant!

=D> You are my new hero.

You have got to be kidding me. I didn't learn more about being a paramedic than one of the six-month wonders? Oh, let me count the ways... 1. I can do most medication math in my head, without a calculator, accurately, including the mg/kg/min math. A large number of my colleagues can't even figure out the correct dosage of sodium bicarb. Some of them do not even know the dosages of simple medications such as albuterol, Atrovent, lidocaine, etc. They have to rely on calculation tapes, and field guides. Yes, Virginia, there is a need for mathematics. 2. I have no problem understanding what is happening to my patient way down to the cellular level. I understand what capnography means in relationship to how my patient presents. I can recite acid-base balance as it relates to the human being in my sleep. I know and understand the nervous system, parasympathetic/sympathetic, alpha/beta, etc. I know the names and locations of the spinal vertebrae and I know what symptoms a patient will present with when there is a fracture with spinal cord involvement. The six-month paramedic students open the protocol book to the page describing the patients chief complaint and follow the list. 3. I know what certain drugs, either alone, or in combination with other drugs will do to the body. 4. I am able to explain the cardiovascular system, in great detail, including the electrical impulses in the heart. I am able to read a 12 or 15 lead ECG in my sleep, and I know what electrical impulse correlates to what is shown or missing on the ECG. Most of my colleagues are still arguing that a 12-lead in the field "takes to much time, whaaaaaaa." They fail to see the value of a baseline 12-lead and subsequent 12-leads as interventions are performed. 5. I have NEVER been turned down for orders by online medical control. I can carry an intelligent conversation with nurses and doctors regarding my patients. I have NEVER had a nurse or doctor call my supervisor because I didn't treat my patient appropriately. Many of my fellow paramedics have had numerous, documented phone calls. Two paramedics within the past six months have been demoted back to basic and one has been fired. Don't YOU tell me how useless my college education is. You don't even have one to compare. Don't YOU tell me I have no personal life because I went to college. I get the impression that you are a tiny bit jealous of those of us that did attend college in an attempt to raise our profession just a small bit up the food chain. Do you know what employees at my hospital do without a college degree? They are janitors and cafeteria workers. You know what the people do that have a college degree? They are nurses, doctors, physical therapists, psychologists, social workers, etc. They are health care PROFESSIONALS. Incidently, I got married last weekend, but of course, I have no personal life. :roll:

Require all paramedics to hold a degree in paramedicine. All those that don't want to go to college to become a paramedic can go be firefighters. I'd be willing to argue that recruitment and retention would improve if educational standards improve. Who knows how many educated people shy away from wanting to be a paramedic because the profession isn't respected, the pay is horrible, and the hours are even worse. Seriously, I went to college, I became a paramedic. Now I'm turning my attention to nursing because I am flat out sick and tired of being associated with twits that think they don't need any college level classes because "they're boring." All the educated paramedics once employed by my service have moved on. Most are nurses, a few are doctors. My service has been unable to retain these paramedics, mostly because they opted to establish six month paramedic wonder class to deal with the shortage of paramedics. Now they are even more short-handed, and most of what is left is the lowest common denominator of provider. Every single day I am faced with several paramedics that really could have used that English Composition class because their charting is atrocious. They could have really used college level anatomy and physiology because they have no idea how the body or any disease processes function. They could have really used some college psychology and sociology because they have no idea how to deal with patients that have mental illnesses, patients involved in crime, patients in differing economic areas. They could have used some college mathematics when they are unable to calculate a drug correctly and subsequently injure or kill a patient. You don't want to go to college, fine. Be a tradesman. Be a plummer, an HVAC tech, whatever gets your motor churning. You don't want to go to college, fine, just get out of this profession. I'm tired of the non-college educated people dragging this profession down. Oh, and you can have my soapbox, I'm finished with it.

Dickheadery!! I will just have to use that the next time I have to precept some six month wonder parapup that thinks they know everything there is to know about everything and has never set foot in a college classroom. Amen! =D>

The difference is the pulse pressure. The systolic reading indicates one end of the cardiac cycle, while the diastolic reading is the opposite end of the cycle. The pulse pressure can be measured by subtracting the diastolic from the systolic, i.e. 198/0 = 198 pulse pressure. Pulse pressure is defined as the amount of force the heart creates during each contraction. High pulse pressures are hard on the heart. It can cause left ventricular hypertrophy and damage to arteries from the force. I have had patients, usually cardiac patients, with pulse pressures in the 100's myself. The few times I have seen this, my patients were generally in pretty bad condition. I hope this information was helpful to you.

Actually, morphine given IV does not reach peak effectiveness for 20 minutes. Fentanyl reaches peak effectiveness in seconds. Morphine does little in the way of vasodilation in the coronary arteries. However, it does produce hypotension rather quickly, and for a patient that may already having pressure problems, may not be the ideal choice for pain control. Fentanyl does not have the same effect on blood pressure. It is now thought that the main function of the narcotic analgesic is to reduce anxiety, thereby further reducing demand on the possibly compromised myocardium. Any narcotic analgesic could service this purpose. I really have no idea why people seem so timid about fentanyl. I had a parapup with me for a long time that was scared to death of fentanyl. Personally, I'm fond of it. It's amazingly effect for the fractured hip patient that required moving out of a tight back room. It's fast, it's potent, and has minimal side effects, especially when compared to morphine. I also like the ability to truly titrate to pain relief. My last service had standing orders for fentanyl. We could push 50-100 mcg, titrated to relief, with a max of 200 mcg without consult. I often started with 10 mcg on elderly patients. I've reached fantastic pain control with less than 50 mcg on several elderly patients. Fentanyl is so fast a provider can start with 10 mcg and slowly increase the dose until the patient is pain free. Morphine is so slow it often takes a huge dose to make a minimal dent in pain, and before you know it, your patient is hypotensive. Fentanyl is not a big, bad, misunderstood drug. It's a welcome addition to the analgesic cache on the ambulance. Hopefully your service has a protocol roll-out for new drugs, and you are taught enough about the drug to feel more comfortable about using it. In case your service just tosses random drugs in your box and hopes you know all about them, then they suck.

Wow, I wish I were only responsible for myself. However, my employer feels that I am in charge of not only myself, but my patient, and partner. He states that I am the paramedic on the ambulance, therefore, anything that goes wrong is ultimately my responsibility. OP, I meant you no disrespect. I now understand your position and have decided the news article you cited is accountable for their incorrect usage of the word in question. My humble apologies. As my Father tells me often, I can't correct the English of the entire world, sometimes I should let it go.

Yes, I did answer your question. Read my explanation a little better. I gave you the number I am responsible for. I also gave you the number of people in my service area. I apologize that I left out how many paramedics we have working at any given time. That would be roughly 12, give or take a transfer dedicated BLS truck. I just don't agree with being "responsible" for XXX,XXX number of people, because I'm not. I have just a few people at any given time to watch over. As I said, one call at a time. There is nothing I can do about the other XXX,XXX number of people in my service area when I am already dedicated to a patient. With that being said, I don't even worry about those other people, especially when I am already charged with my own patient. Not only that, but I often get the left-over EMT's that no one wants and I spend more than 75% of my day making sure they don't screw up through out the day. By the way, I take great offense to being told that I fail to understand the definition of an elementary word. As a result, I have taken it upon myself to actually look up the definition of the word. Responsible: adjective, anglo-french 1643. 1 a: liable to be called on to answer b (1): liable to be called to account as the primary cause, motive, or agent <a committee responsible for the job> (2): being the cause or explanation <mechanical defects were responsible for the accident> c: liable to legal review or in case of fault to penalties 2 a: able to answer for one's conduct and obligations : trustworthy b: able to choose for oneself between right and wrong 3: marked by or involving responsibility or accountability <responsible financial policies> <a responsible job> 4: politically answerable; especially : required to submit to the electorate if defeated by the legislature —used especially of the British cabinet From Merriam-Webster

I hate to burst your bubble, but the current EMT-B curriculum is a joke. As has been stated numerous times on this site, it is little more than glorified first aid. Boy scouts are probably better trained to handle emergencies than the average EMT-B. Frequently I have basics with me that tell me they don't want to embark on paramedic school without "getting their feet wet" as a basic. Seriously, if you work EMS in a paramedic service you get to lift patients, carry equipment, and drive. Sometimes you might get lucky and get to splint or bandage, but that's rare. My service requires that I attend every call, even transfers, so my basics don't get to do much in the way of patient care. It's almost ridiculous that basic is a requirement to paramedic. I can find a much better use for that 120 hours. English composition, college math, A&P are far better ways to spend that time. Any good paramedic course is going to repeat the core content of a basic course anyway. If your paramedic school doesn't bother to refresh you on this content during your class, they suck. It's been shown time and time again that basics who do not go on to paramedic school almost immediately often have SEVERAL bad habits that have to be broken. I'd much rather have a student that is enthusiastic about learning than one that thinks they know everything already, or seems utterly bored with the entire educational process. A side note... I do not discriminate against the basic alone. I also feel that intermediate courses are a waste of time, as is any paramedic program that does not require any pre-requisite college level English, science, and math.

I was lucky enough to see George Carlin perform some 14 or 15 years ago in the DC area. Roughly 3 minutes into his show I wished I'd had on some adult diapers. He was not only funny, he was brilliant. There only two comedians I like, and he was certainly one of them. His wit and talent will be missed.

Hummm, a person can't "try out" being a doctor, accountant, teacher, etc. without spending a while in college. Why should people be able to "try out" our profession? My father is a CPA (certified public accountant) and he spent four years in college, followed by one of the most difficult professional exams. He did all of this before he was able to be employed as a CPA. Sure a person can take a less demanding regular accounting track, and they'll likely have the same opportunities and pay as the current EMT-B, slim and poorly. My husband and I came from college paramedic programs. We are taken much more seriously in our jobs than the graduate of a six-month paramedic puppy mill. We have an easier time assessing and treating patients because we were required to take A&P. We are able to write complete and coherent reports because we were required to take English Composition. We have no trouble with med math because we were required to take college level mathematics. See the trend here? It's time we face facts. Education is the goose that will lay our professional golden egg.

No tools, I see enough of those when the fire department shows up. Seriously, I carry a radio, pager, shears, fob, narc keys (all required by my employer) and my ears (I don't trust anyones funky ear germs). I just don't have a need for all that crapola, and frankly I'm getting old enough where that stuff just gets in the way of the stuff I carry that I actually use.

What does membership to NAEMT or registering with NREMT have to do with the advancement of EMS? Education is the answer, not meaningless memberships and poorly written, incredibly easy exams. Requiring a two year degree and establishing a reputable and appropriate licensing exam would be a fantastic start.

Three. Myself, my partner, and my patient. Occasionally I'm responsible for two to four patients during transport, however that is rare. Sorry, I didn't quite agree with other responses. I can only do one call at a time. I'm not responsible for any other patient, call, or event that is occurring while I'm already involved in a call. I am responsible for making sure the mystery meat EMT I'm stuck with doesn't do something stupid. I am responsible for making sure I stay alive and unhurt. I am not responsible for any fire department personnel. I used to worry about them getting injured during a call, however, they are going to do what they want to do regardless of how unsafe I feel they are when they execute their ideas. Therefore, I gave up feeling responsible for them, after all, they have their own captain to babysit them. Now, if you're wondering how many people are in my service area, the answer would be roughly 500,000, give or take daily births and deaths. Guinness, K.

At one time in my life, when I had no life, I was a volunteer. One day I grew up and realized that I would never be a part of the good 'ole boy system. I also found out that I could earn a meager living doing the job I love to do, and I would take a lot less crap from my boss than I ever did from the line officers. Now I work, come home and enjoy hobbies outside of work. Volunteer systems do not have any regulated accountability. If I don't show up for my shift at work, I get a nice page. If I happened to be in the ICU or dead, I'm forgiven. If I ignore that page, I can look forward to receiving my final paycheck with my company. Miss a call night at the volly house, and they might yank my gear. I can assure you that I won't miss that second rate, ill-fitting canary crapola. I really won't miss it because I have no desire to fight fire anyway. I'm a paramedic, not a hose dragger. I will finish this with the statement I know all you volly types just love... You all are heroes, man! :roll: Now hurry up and run out the door like you just got paged for the big one.

Timmy, are you sure you are only 18? I ask this not only because you are able to construct a well planned paragraph, but also because you seem too incredibly bright compared to most 18 year old people I meet. As a matter of fact, I can think of only one person under 25 that I actually enjoy holding a conversation with, and he happens to be 18. Two people, I'll include my eight year old, he's fabulous to converse with. I digress... You are correct young sir. It is possible to attend a class for three weeks and be thrust onto an emergency ambulance as a primary provider of emergency care. This happens in often in volunteer systems, and occasionally in paid systems. But wait, it gets better. You could, after three weeks, be thrown onto an ambulance with a driver that took a 56 hour long first responder class. Do I want either of them working on my family or myself? Not a chance. It is also possible in this great country, to attend a six month paramedic class, with minimal required A&P (usually a picture book written for third graders), and be thrust upon an emergency ambulance with the same guy that spent three whole weeks in class. Again, just hand me a refusal and I'll glady sign. Other countries require a degree to work on an ambulance and provide care to a patient when they are at their sickest and most vulnerable state. It's a real shame that truly educated providers are so hard to find in this country. Volunteer versus paid is really a lame argument when you consider how low our standards are for EMS personnel. Passionate people would step back and see this argument as a way to burn energy that can be spent working on more important projects, namely, education. It's time to raise the bar. If we increase educational demands, we will really see who is passionate. The passionate ones will be the paramedics that cared enough to spend four years of their lives in college, and they have the signed diploma to show for it. By the way, original poster, I printed off your post and handed it, along with a red marker, to my eight year old son. He had a field day playing "find the error." Thanks for providing ten minutes of cheap entertainment to my son.