EMS49393

I'm going to attempt to answer your question. The vessels relax because calcium channel blockers slow the rate that calcium flows through the vessel walls. I would assume that because blood flow is increased in the vessels, so is the chance of further back up of fluid in the lungs and/or extremities. Calcium channel blockers are listed with cautions for patients that have vessel diseases and congestive heart failure. I believe the mechanism of action for these drugs increases the demand on the already ailing vasculature. I'm not entirely sure I'm answering your question correctly. I thought about it for several hours before I felt I had an acceptable answer. I'd be really interested to have one of our site Physicians offer up their explanation. I'm interested to know if any of my education actually paid off.

I couldn't find a turtle, so I used the cute rubber ducky. Rubber ducky, you're the one. You make bath time lots of fun! [web:d7e978bf76]http://www.sesameworkshop.org/sesamestreet/bio/images/muppet_hdr_ernie.gif[/web:d7e978bf76] When I was a kid we had our choice of TV channels we were allowed to watch. We could watch PBS or PBS. Needless to say there are many lines from Sesame Street and Read All About It I know from heart. And, every time I get to watch "How It's Made" on the Science Channel I am fondly reminded of all the times I got to watch things being made on Picture Picture (Mr. Rodgers). I didn't get out much as a kid. I now return you to your regularly scheduled argument, already in progress.

It's a darn good thing I keep my PDR close by me. Let me clean up what I stated about diltiazem. Contraindications: hypotension, cardiogenic shock, second or third degree AV block, sick sinus syndrome except in presence of a functioning ventricular pacemaker. Acute MI, pulmonary congestion. IV diltiazem with IV beta blockers. Atrial fibrillation of atrial flutter associated with an accessory pathway bypass tract (WPW, PR syndrome). Ventricular tachycardia. Use of lyoJect in newborns. Lactation. Special considerations: CHF. Hepatic disease. Effects of coadministration of diltiazem and beta blocks is unpredictable. Safety and effectiveness in children has not been determined. Half-life may be increased in geratic patients. If you consider pulmonary congestion and pulmonary edema to be two entirely separate things in the field, than I retract my statement of contraindication and offer it to be a part of special considerations. Pulmonary edema was listed as a contraindication with the protocols for my last service. Personally, I wouldn't administer diltiazem to any patient that presents with pulmonary congestion and/or edema in the field. My xray machine on my ambulance has been down for some time, and instead of debating what is causing the pulmonary edema, I'd opt to use the alternative which would be amiodarone. As I have said before, I weigh risks of interventions with benefits. Although I'm an aggressive assessor, I am cautious with any interventions. There is no such thing as a "benign" intervention on my ambulance.

Oh my GOD!! Duck and cover. :duckie: The search function is your friend. This debate has been argued and locked several times. Paid. We have standards that must be followed as conditions for retaining our employment. The volunteer system can't inforce any standards because you give away for free and can make your mortgage without it. Piss poor standards, piss poor patient care. Your money theory is :bs: . I have to work two jobs to pay my bills, and I don't have that many bills. Before I went PRN and dropped my benefits I made $7.07/hr as a PARAMEDIC. Oh, and I'm looking for a well constructed paragraph that is easy to read and understand. That is my passion.

We can as well. Strange how I can't have morphine without consult for chest pain but I can access a central line or infusion port if I have to. I'll probably never understand these protocols. As far as accessing those devices, I really hate to do it. Ambulances are gross, and regardless of how sterile I hope I can make the field, it will never be anything more than really aseptic. Some of our ER nurses feel the exact same way about the ER environment. Not to say I haven't done it and wouldn't do it again if my patient really needed a medication or fluid. I just spend an extra ten seconds making sure the benefits of access outweigh the risks.

I agree with administering diltiazem. Your patient most definitely sounded like a rate problem. I'm interested in knowing how the patient felt once he finally converted to a controlled rate. Keep in mind that pulmonary edema is a contraindication for diltiazem. If you are blessed with the option of diltiazem and amiodarone on your ambulance, you may want to consider the amiodarone. From your description of the patient presentation, it seemed that his pulmonary edema was slight, and more than likely a result of that uncontrolled rate. Personally, I have had a much higher success rate with diltiazem then with amiodarone. Now, young grasshopper, I do not advocate electricity without sedation with any patient that is alert enough to talk to me. However, for your testing purposes, I will tell you that any tachycardiac heart rate with associated symptoms requires cardioversion, regardless of how alert they describe the patient in the scenario. If they have any Chest pain, Hypovolemia, Altered level of consciousness, Pulmonary edema (shortness of breath), or Syncope, you are to cardiovert in your testing scenario with national registry. This is one of those registry questions that just sucks. We all know the right answer, and people get this question wrong because they aren't following the actual textbook criteria (like any patient is kind enough to follow the textbook in presentation). Just a tip. The mnemonic brought up in my class for cardioversion is CHAPS, see above. I rarely give out mnemonics, I don't like them, but I know how people often rely on them, and I'm in a good mood tonight. Look at the whole picture when you assess your patient. He was having chest pain, he was short of breath, sudden onset with a history of a-fib, and the clue that his a-fib had never been that bad. I would have asked him if he had chest discomfort like this before. If so, what was his diagnosis? He may have had symptomatic a-fib and had to undergo a chemical cardioversion before. I'll bring up a quickie about a chest pain patient I had a few years ago. He complained of severe acute chest pain and shortness of breath. I performed a 12-lead and it showed SVT somewhere in the 200's, and it was regular, so I wasn't so concerned with a-fib. The machine had it's little useless interpretation thing turned on, and it spit out ACUTE MI SUSPECTED. I knew I wasn't going to be able to see what was going on unless I slowed down that rate. He did not convert with vagal maneuvers, he did convert with the first dose of 12 mg Adenocard. No MI, just too damn much coffee and cigarettes. Along with the uncontrolled rate, the chest pain and shortness of breath went away. Sometimes you really have to slow that rate down and proceed with treatments for the other symptoms if they are still present after conversion. It's all a learning experience. Although I really don't like my job on the ambulance, I love my job in the ER. I soak up anything the doctors and nurses are willing to teach me. I hope you continue your desire to learn and become a truly great paramedic. Good luck, and my cardiology PM door is always open.

Sounds like most metropolitan areas, including my own. I read the Channel 7 article on Denver EMS, and I feel the same pain those paramedics feel every time I clock in at work.

Perhaps you don't think your patients are seriously ill because you lack the educational foundation to properly assess and treat those patients. Hum... :-k Last year I moved back to a big, busy city. For the three years between big, busy cities, I worked rural in Missouri. I got to sit on my ass for several shifts without turning a wheel, except to go to the grocery store or maybe rent a few movies. I had transport times of a little over an hour to the closest hospital at that station. My calls averaged 3 hours, sometimes more depending on how many interventions I performed during the trip. I worked at another station that was 120 miles, one way, to the hospital. Calls averaged 5-6 hours. Again, I'd sit for shifts on end waiting for that one call. I had another paramedic "assigned" to me at one of my jobs. He went to a crap paramedic class, passed by the skin of his teeth, somehow passed the registry (everyone passes in Memphis), and couldn't find his way around a patient with a map and a flashlight. In the best interest of the patients, he was assigned to me. Imagine an hour long transport and not only do you have no idea what is wrong with your patient, you have no idea how to treat them other than a little O2 and an IV. Imagine having to duck your head up through that little cubby hole to ask the educated provider what you should do. Imagine being so scared on a call, you actually refuse to be a paramedic, and decide it's best if you drive this one. Most of those patients didn't call unless they were seriously ill. I'd say 95% of my calls in both of those systems were outrageously serious. We're talking about rural people that work and pay bills. They'll wait until they are damn near dead to call an ambulance. We also had a large Amish population, well you can imagine how often they call an ambulance. Best part about those jobs, I got paid. Don't tell me rural systems deserve volunteers. If anything, those people deserve educated and paid providers. It's a whole lot easier to be a nimrod in a big urban system. You can always blame your short transport for your inability to properly care for a patient. Believe me, I see it every shift I work in the ambulance, and more often then not when I'm working the ER.

Man, I sure know what you're going through with training and working a full-time job. I had to do that for several years when I was in college. Then I get out of college and my damn employer expects me to show up for PALS, PHTLS, ACLS, CPR and my paramedic refresher. I work full-time and this guy thinks I have the extra 50 hours or so a year to spend in training. Not to mention the crapola they come up with during the year that they make spend time on training. That EZ-IO thing, new c-collars, there is two hours of my life I ain't never getting back. Oh, and there is my other employer, the hospital. They expect I'm going to spend another 20 or so hours a year in training there as well. When do these ridiculous demands ever end? :roll: :roll: :roll: :roll: :roll: :roll: :roll: :roll: :roll: Seriously, I doubt you'll get much sympathy on this forum. A good number of us put ourselves through college while working full-time. Two hundred hours of additional education is child's play. Think about those patients you volunteers vow to protect and save. Do they deserve mediocre care because you are volunteers and extra education is just too much to ask, or do they deserve the best you can give them because you care enough to give it away for free. Unfortunately, this type of post reinforces my general statement of truth about volunteering. You get what you pay for. Good luck, and hopefully your area will realize how valuable professional emergency medical services would be in your community.

You probably did fine. If you didn't pass this time, more than likely you did over think the questions. The best course of action is to simplify, simplify, simplify for that test. I will give the registry just a tiny bit of credit, even though it pains me to do so. You really have to have a good grip on reading comprehension to do well on the exam. Those questions need to be read slowly, digested, and finally answered. Some of the smartest folks I know failed the first time because they breezed through the exam without paying much attention to words such as: NOT, BUT, OR, etc. My best advice, read each word in the question. Generally you can knock off one or two answers as incorrect straight away. After you are left with two reasonable choices, read the question again, and choose your answer. Listen to your gut instinct, and don't second guess yourself. Studies have shown that students that change their test answers will generally have been correct the first time. Now, relax. Enjoy your weekend. Get your passing results, and head off to college for your paramedic degree. :wink:

Just wait until you have to take the national registry paramedic exam. I'll give you some advice on that one... think like a basic, 80% of the questions are basic life support answers. If you happen to be in a really fantastic paramedic program and come out super smart, stop at the local McD's and let them talk to you for a few minutes. You'll need the IQ drain to be able to pass that incredibly easy exam. Well, enough about my feelings on the retarded national registry. I'm sure you did fine. Enjoy your weekend!

What does this paramedic do when he has a patient that may have a head injury, CVA, or cardiac tamponade? Those are just three instances when a provider should be able to accurately asculate both a systolic and diastolic blood pressure. Personally, I have never had much difficulty obtaining an accurate blood pressure, so I can not put myself in the shoes of the author. Perhaps the more experienced forum members can explain another way of determining cerebral perfusion pressure when you don't have the luxury of being able to obtain an accurate blood pressure. Incidently, my paramedic instructor used to make us take blood pressures in class with Motley Crue (at blood curdling volume) in the background. He was very insistent that we be able to obtain a blood pressure even in a noisy arena. I'd had the same Littmann Cardiology III stethoscope for eight years or so and I used it during class. The ear pieces are soft and conform to the shape of my ears very well and act to block out most outside noise. In terms of assessing patients, it was a good investment.

I must be lucky. I rarely have problems with doctors. I occasionally get blown off by a nurse every once in a while, but I take into consideration the caliber of medic they see during a shift. Honestly, I believe my co-workers have the problems they have because they constantly display incompetence. We have very few medics that run 12-leads when indicated. We have very few medics that bring in patients with IV's when they are indicated. We even have medics that bring in alerted mental status patients without checking a blood glucose. I try to put my self in the nurses position. "You were treating this patient for forty minutes and you don't even have a blood glucose, IV, any ECG?" My fellow paramedics in this area argue with me over the value of an immediate 12-lead on a patient with chest pain or cardiac like symptoms. They'll tell me it takes too long. They tell me they don't need one. They give NTG out like candy, no ECG, no IV in place. I actually had one medic argue with me today about how low the incident of RVI actually is, therefore to run a 12-lead before you start treating the patient is wrong. I argue that you can not treat until you assess. Call me crazy. I have a lot of approachable ER doctors and nurses. If I have a question, it doesn't take me long to find a doctor I'm comfortable with and ask them. When I call a report to the nurses, they are pretty confident that what I'm saying is what is going on. They give me a lot of respect on the radio. Incidently, my absolute favorite clinical rotation in paramedic school was my physician mentorship. I got to spend 24 hours in the ER with a doctor that wanted to teach the student that wanted to learn. What I learned from him is invaluable. He was patient, witty, kind, and respectful. I wish I could do another physician mentorship. I've often stated that I feel a paramedic may be able to understand the bigger picture better if they had the chance to really see it from the ER doctors view. I also believe that a program like that may strengthen our relationships with the doctors. It really boils down to respect. I would never call out a nurse, doctor, or other paramedic in front of anyone. I would wait to be alone with them, and present my inquiry at that time. You have to give respect to get respect.

I don't need a kit or O2. I have a cell phone and I know the number to 911. When I'm off work, I'm OFF work. Unless, of course, it's someone I love or someone that owes me money.

We have those electronic BP cuffs on our monitors as well. I never use them. They are generally far from accurate, and if you're rolling down the road, they either time out for motion or give you a reading such as the one you stated above. I have two perfectly good ears, a perfectly good littman, and a perfectly good wall mounted BP cuff in my ambulance. Hearing is believing, especially when I'm engaged in the act of administering NTG, or an inotrope. For as much as I love the technology of being able to get a diagnostic 12/15 lead ECG and capnography, I equally hate the pulse ox and electronic blood pressure cuffs.

Masimo is a thorn in my ambulance. My last service had lifepaks with all nelcor probes. I rarely had any trouble obtaining a pulse ox. My current service has the lifepak with the two hundred and fifty-five foot cord attached to a rigid probe that states it's for pediatric use. Flame me all you care to. Honestly, I rarely use the pulse ox anymore because it's a peice of garbage. I get tired of positioning, repositioning, and internally cursing masimo. I rely on visual assessment of the patient, lung sounds, and capnography. I do my best with substandard equipment. Go ahead and have at, I've got pretty thick skin.

I do the same thing the local ER nurses do with patients they can't obtain an acurate pulse ox on, I use a disposable sticky pediatic probe. It's small enough to fit nice and snug on the earlobe. I feel that the lifepak 12 has the worst pulse ox in the free world. I like the ease of use of the lifepak, but unfortunately, they have fallen from grace at my service. We are testing other monitors as I type. If I can't obtain any type of reasonable pulse ox on a patient, or they are altered mental status (unresponsive, postictal, etc) I'll opt to use capnography in conjunction with the pulse ox. If the pulse ox is way off, I document equipment failure and move on. I also like my capnography on patients I give narcotic pain medications to. I like to trend ventilation on these patients, particular the elderly patients.

Cha-ching, as a paid professional paramedic, I suddenly became more valuable, especially in a place like Fulton County, KY, where they no longer have any responders. Another one bites the dust (no pun intended)... good riddance!

When I first became an EMT-A, we had thumpers on our ambulances. I think I put it together a total of five times. Back then, we didn't have the luxury of working the code and calling the Doc for a termination. Now, we're talking about 15 years ago, not nearly as long as some here have worked, but long enough to know the difference between ACLS then, and ACLS now. I've recerted ACLS several times. The first few times, it was challenging. The megacode was something the paramedic feared, and you felt like you ran a race when you completed it. The last ACLS class I attended was so easy a caveman could have passed it. Here is irony, back when ACLS meant something, you couldn't terminate a code if your own life depended on it. Today, with the paramedic puppy mills putting all their little pups out there with some half-arsed, ridiculously easy ACLS class, a good number of services are able to call med control to terminate. Including mine. Funnily enough, I'm the only paramedic at my service that works a code, calls med control, and gets orders for termination. I hear other medics running that stuff in to the ER all the time. I just shake my head and hope that a deaf family of four with a vision impaired father doesn't pull out in front of this speeding ambulance and meet an untimely death. An untimely death over a person that is dead. Ugh, it gets me fired up. A side note about the thumper. I would recert my CPR every year with the same rat pack I worked with. We were rebels, not to mention bored senseless (thank God when it changed to a 2 year card), and we were known to create disturbances in class to keep us entertained. Our favorite antic for years was to mimic the sound of the thumper, quietly, under our breath. At least we knew how to have a good time.

What if that baby was born and had an initial APGAR of 4? Where would the green fireman be then? I'm betting he'd be out on the porch sucking his thumb asking for his blankie. The paramedic would begin aggressive rescusitation efforts. I'm glad the brand new fireman got to witness the wonderful miracle that is a healthy birth. What I'm not jazzed up about is the fact that the article completely contradicted itself. It's no secret that I do not play nice in the sandbox with the firemen. It's actually the big reason I have switched from a north city car to a south city car. I really do not play well with firemen paramedics that only endure being a paramedic so they can maintain their fire captain level. You want to be a fireman, grab yourself a pint of ice cream, and pull up a recliner. You want to be a paramedic, punch in, check off the ambulance, and pound the pavement the entire shift. I'm lucky to see the inside of any of our crappy EMS substations during my shift. I work for a living. I get to listen to my friends in combo departments b*tch non-stop about having to ride the "gut bucket" for 4 years before they can transfer to fire side. The knew going into the academy they would be required to pass some inadequate cookbook medic class and ride on the ambulance for 4 years. They have no interest in being a medical professional, and frankly, they give those of us that care about our profession a really crappy name. We are not all out there to do the same job. I'm out there to provide the absolute best prehospital care I can. I spend countless hours in education. I attend seminars, I have called hospitals to get classes not offered where I work. I even started working for an ER PRN in the hopes of learning more. I'm a professional, and I'm very dedicated to my title. I'm also dedicated to do my part to abolish the piss poor image EMS currently has. That we're equal on the trucks bit... not so much. My partner is not my equal. They are my technician, and I am the clinician. The do nothing invasive, nor do they perform any assessments outside of a rapid trauma assessment during an MCI. My service mandates that all patients are to be attended at the paramedic level, so I can't even "BLS" a call. Is a CNA equal to an RN? Is an LPN equal to an MD? Well then how is a basic equal to a paramedic? I'll see your 120 hours of night school and raise you 2 full years of college, and I'm not even finished. Go ahead and call me arrogant gaelic, I assure you, it will not be the first or last time that word is used to describe me.

The last service I worked for had the machine interpretation turned off on all the lifepaks. They taught 12 and 15 lead interpretation and held quarterly competencies. It was also required that the paramedic attach the ECG to a form and give the interpretation to complete documentation on the call. The service I currently work for states a 12 lead needs to be performed for any patient that may be a "cardiac patient" or has chest pain. It does not require the provider to be able to interpret the ECG, and the machine readings are provided (and more often than not, incorrect). We are required to attempt to send this 12-lead to the receiving hospital, however only a few hospitals actually have the capability to receive the ECG. There is no training on the 12-lead, no competencies, and we are only required to know if the ECG is "bad." Now, call me simple, but I would think a provider would have a hard time knowing if an ECG is "bad" when they have no idea what they are looking at. I know, way too logic for most services. My advice to new students and new paramedics... Know the heart. Know the ECG. Know to treat your patient, not your monitor. If your school doesn't teach the ECG in such a way that you are sure you know what you're looking at no matter what patient you have, your school sucks. Get a refund. Take the initiative to ask other providers, as our OP has done. Take the initiative to listen and act on our suggestions. Good luck OP, and if you need any more help in your quest for learning, let us know.

Ah, gee whizz. I hate hearing a student ask questions about memorizing ECG strips. It means one thing to me, that they were not prepared for their cardiology class. I would wager my paycheck that a student that passes a college level A&P course will come out of cardiology completely understanding what they see on any ECG strip. It's often not the fault of the student. Some people are so eager to learn, they take any class they can and take their instructors word for gospel. There are plenty of instructors that do not require any knowledge of even basic A&P, let alone tell a student the class they want to take would be so much easier if they had that course first. Shame on those instructors. There is no trick for memorizing ECG strips, unless you're just interested in learning the text book generated strips to pass a test. The best way to understand the ECG, is to understand the heart first. If you were required to translate a novel written in German without having a foundation in the German language through education, you would surely fail at that endeavor. It is the same with the human body. You have to understand how it works before you can translate it, and in turn initiate appropriate treatments. There are a lot of knowledgeable paramedics, college graduates, nurses, and even physicians here that will be more than happy to help you with cardiology. I would be more than happy to help you, but I think you'll find that you will gain much more from any tutoring you receive if you take some time to build your foundation.

All I noticed was the statement "firefighter delivers baby" used in same article with the statement "We recognize paramedics, nurses and doctors don't deliver babies, moms do" (oh and firemen do too). Delivering a baby, so easy even a fireman can do it. :roll:

Don't beat yourself or your medic up over missing this fracture. It is possible for a person to suffer cervical spine fractures and be able to function. Chances are the fracture was not displaced, as it did not seem to affect the spinal nerves. The geriatric population is special in so many unique ways. If your patient had some severe kyphosis, you might not be able to tell if there is any displacement or step-offs on assessment. As we know, and hopefully are taught, elderly caucasian/asian women are at a great risk for bone density issues, such as osteoporosis. Honestly, given the information you presented, it seems you and your medic should not think you missed something. Take it as a learning experience. I know of a fantastic paramedic that had a similar experience, except his patient was a lot younger. Thirties year old male, moderate speed MVC, no restraints, ambulatory at scene and signed a refusal of care. His wife called 911 several hours later when the patient complained that he couldn't feel his legs. He had a cervical spine fracture went from non-displaced to greatly displaced. That medic beat himself up over that call for years. Good medic, good assessment, even the trauma doctor told him that this was just one of those "freak incidents" that rarely happen. Honestly, you are only the second person in my 15 years in this field that I've heard this type of story from. For that I tell you, it sounds like one of those "freak incidents that rarely happen." I hope some of the older providers chime in on this post. I'm interested to know how many times something like this has happened to other providers.

I've used SOAP and CHART for narratives. I probably follow the SOAP note a little more than the CHART method. I document the patient's complaint, including what they actually tell me in quotations. Example, Patient states "I have pain all over and I can't walk." I then add any other subjective information. Patient describes pain as aching. She states she has not taken anything for her pain, and is unable to rest comfortably. I document carefully any statement the patient makes regarding their present need for an ambulance. I also document any pertinent negatives. Patient denies shortness of breath, dizziness, nausea, vomiting, etc. I then move on to my findings, or the objective assessment. Patient appears to be in moderate discomfort. No evidence of recent trauma. Pupils are equal, round, reactive to light. Mucus membranes are pink and moist. Neck is supple, no JVD, no carotid bruits on auscultation. Lung sounds are clear and equal bilaterally. Abdomen is soft, non-tender, no muscle guarding, no masses. I document a complete head to toe assessment. I work in a very busy urban system with short transport times, and there have been occasions where I am unable to perform a full physical assessment because I have life-threatening airway or circulation issues I have to address. I've run some shootings recently and my total patient contact time has been under 15 minutes on several of those calls. The A in the SOAP note stands for assessment. By the time I arrive to A, I've pretty well covered my assessment. I will throw in any pertinent medical history, medication use, or allergies. My big ticket documentation item with regard to medications would be blood thinners. I feel it's important to note that a patient is taking blood thinners especially when they fall down and strike their head. I document any substance abuse history the patient will admit to. Again, alcoholics have a higher risk of IC bleeds when they kiss concrete with their heads. Cocaine use leads to a multitude of cardiac pathologies, etc. P is the plan. I document what I've done, and I document if my treatments were successful or not successful. I like to end my narrative with stating that patient care was transferred to Jane Doe, RN at Big City ER. Even as a basic I found narratives to come incredibly easy for me. I was actually responsible for training basics in IFT documentation. I've had a next to nothing kick back rate on my PCRs for the past 11 years. I make every attempt to pen a cohesive story of my patient and the call. I refuse to use ANY abbreviations. They change too often for me to even want to get wrapped up in trying to figure out if an abbreviation is approved. It makes more sense to me to write out every word. No confusion in Q/A and no confusion in billing. Everyone has to develop their own style of documentation. I won't bore you with any documentation cliches. I will say this, never write a narrative you wouldn't be able to decipher 20 years down the road.