EMS49393

My service uses electronic PCR documentation. I couldn't tell you what type of "tablet" we use, although it says "walkabout" when it's started. I'd have to check what program we use. We have an IT staff, so I rarely pay attention to anything but doing my PCR and downloading my tablet. I will say this... I hate them. Hate may not be a strong enough word. I detest them. We have them mounted in front of a vent, and several of them freeze up when sitting in front of the air conditioner. They're unreliable, hard for patients and facilities to sign their name to, and they shut themselves down for no apparent reason. They tend to erase entire reports, which has been a constant problem. They have not held up to the rigors of the 80,000+ runs a year in our busy urban system. They are so difficult for patients/family/staff to sign on, that we went to paper signature sheets to complete our billing. I guess medicare got a little tired of trying to decipher a signature that looks like a bad drawing made with an etch-a-sketch on crack. The benefits of electronic documentation... you have to sign in to actually write a PCR. I like the idea that my patient information is protected from other providers that really do not need access to my charts. I'm a big advocate of patient privacy. Your new toy might be fine for your rural system. We don't have toughbooks, but I have used them with the last fire department I worked for, and they were impressive. Hopefully your staff will take care of these computers. I don't really understand why it's so hard to take care of your equipment. The more stuff you break, the more you slim a potential raise. Let us know how they are working out for your service after a few months of use. I'd be interested to know how they hold up.

I'm bored, it's early, for some reason I'm awake (that really ticks me off), so I'll play. It's not as if I have anything better to do, seeing as how I can't get back to sleep, secondary to the amazing, yet obnoxious sounds being produced by my other half. It's like a bloody concert in here. On my person: - Sunglasses. Belt (one of those fly basketweave leather numbers issued by my company): - work alpha pager, when we receive a call, the information is transmitted via radio and pager. It's also used to transmit vital, and often not so vital information. They use them to page out road closings, weather alerts, open shifts, and of course who just had a baby. :roll: - my handy little retractable key chain thingy that has my fob and a universal station key on it. In my trousers (hehe, I said in my trousers :twisted: ): - right rear pocket: a small checkcard wallet with checkcard, drivers license, small amount of cash, cert cards, insurance card, and frequent coffee club card. - trauma shears at the small of my back - right front pocket: narc keys, my keys, cell phone, extra hair tie. I can't stand having my hair down and in the way when I'm at work. - right cargo pocket: nothing, hate this pocket, have even cut off the little snap flap things that hold in a pair of shears, they were completely useless. - left cargo pocket: nothing, hate that pocket too. - left front pocket: couple pairs of gloves - left rear pocket: nothing I carry one or two pens in my shirt. I carry my steth. I refuse to use the cheap pass around steths, I have a problem putting those dirty things in my ears. I've had the same Littman cardiology III for the past ten years or so, never lost it. I cavi-wipe my steth after each patient contact. I had those antimicrobial diaphragms for a while, but they turned out to be a giganitic pain in the arse. I have a workbag I toss in the truck. I have a different truck, different partner every shift. - I keep my mapbook, which has all the major city running streets highlighted and extra block number notations in it. - I carry extra narc adminstration records (in case their isn't any in the narc box). - A small plastic clipboard with signature sheets on it, signatures are required for every call, and the ePCR tablet is difficult for a lot of people to sign on. - Incident reports, believe it or not, I'm in trouble quite a bit. - Drug guide, a good one. - The book I'm currently reading. - Cavi-wipes. - A large bottle of water, or diet ginger ale, depends on the season. Our trucks have ice chests in an outside compartment, and we are able to get ice and bottled water at work during the warm months. I might toss a bottle of poweraid in my bag if I know the temp is going to be high. - I have a separate little small bag in my workbag that has my Zune in it. My personal safety glasses. It also has my mini halogen flashlight in it. I work mostly days now, so I have no real use for it anymore. - I have another little bag that I call my "ah sh*t" kit. It has several nasal canula capnography, and ETT capnography sets. A couple packs of pedi-trodes and pedi SPO2 stickies. I have a set up to bag in albuterol put together. (Ever try to put one of those things together when you really need it?) I'm about the only medic at my service that utilizes capnography on a pretty regular basis. The capnography stuff is often neglected when stocking supply cabinets or truck cabinets. This way, I always have my own regardless of what truck I'm assigned. - In one little side compartment I carry my pocket calendar, little notepad, field guide, black sharpie, highlighter, and a bunch of toss away company issued pens. "Go ahead and keep that pen, sir. (Especially since you snotted/bled/vomited all over it.)" - In the other little side compartment, I have hand sanitizer and hand lotion. I have to keep these delicate hands in good condition. - In the small front pouch, I have goodies. Gum, granola bars, pumpkin seeds, sugar-free drink mix singles, teabags, my handy little splenda tablet dispenser, an apple. I refuse to be a slave to fast-fatfood. I also keep some Excedrin Migraine and Advil in this compartment. I also have one of those hospital-issued big cups with the lid, covered plastic straw, and ounce markings. I keep that in the truck, and refill my ice when I get to the hospitals. I have some pretty bad OCD, and I'm a creature of habit. I have to have my cleaning stuff since I'm always wiping things down in the unit. I have to have hand sanitizer, a lot of things we touch are just gross. I have to have a book, I find comfort in silence. I have to have granola bars, because McDonalds is not an option. I have to have my sugar-free drinking options, because empty calories are not an option. Surprisingly, none of that makes me strange or difficult to work with. The fact that I give every patient 110% is what makes me difficult to work with. I'm set in my ways, and I am thorough, which drives a lot of these "me" generation EMT's crazy.

I find visualizing the cords, ausculation of lung sounds, verifying there are no sounds over the epigastrium, and utilizing waveform capnography to be my preferred methods of confirming my tube placement. My service still carries those little colormetric changing devices, however I refuse to use them. Likewise, there are more medics than not that refuse to use capnography at my service. We don't even carry those esophageal bulbs or baams, as our CQI manager deems they are relatively useless when you have other, more reliable means of confirming your tube placement. Waveform capnography does one very, very important thing for me that no little colormetric device can do. It shows me ROSC. When I work a code, check for pulses, swear I feel pulses, and look up at my EtCO2 reading to see it is suddenly 80, I know I have achieved ROSC. I then slowly bag down to get and keep a reading of 35-45. It's also nice and easy to point to the monitor and tell the ride along fireman that I get stuck with to "keep that little number between 35 and 45." Those guys get a little excited when they get ahold of that BVM. Capnography does one thing for my rear end that I appreciate greatly. It proves my tube. In the rare instances I bring in a patient that is intubated, I hit my print button on the monitor before and after my patient is transferred to the hospital bed. I'll be darned if I get called into the CQI office and told that the doctor said my tube was no good. CYA, we have the technology to cover our keisters. When I had the privilege of RSI and a two hour ride to the hospital, capnography became one of my most important tools with a decompensating respiratory patient. I have put down the overly tired breather and have seen EtCO2 readings in the high 90's with these patients. RSI is not something I ever enjoyed doing, and I took great care to make sure it was in the absolute best interest of my patient before I elected to preform that extremely dangerous intervention. With documentation of waveform capnography, I was very easily able to prove to our physicians exactly how sick my patient was pre-intubation. It's one thing to tell the receiving facility what you had, it's another thing entirely to prove what you had. I'm not ashamed to admit capnography is one of my favorite assessment tools. It falls in line right behind my eyes, hands, and ears. I prefer it far and away over the "pulse ox." I'll use them both, but I can tell a great deal more about my patients ventilatory status with waveform capnography. I consider it an invaluable tool, and I hope that more providers take the time to learn and use this resource. (I do not feel I hijacked this thread, rather I added how valuable capnography is to a paramedic when they are faced with proving their findings to a physician.)

I could roll with your questions, but I doubt I could give any explanation justice. So, my gift to you is a link. I can think of no other document I've seen that explains capnography any better than this document. Bob Page has done a fantastic job putting out these downloads to further the education of any EMS provider. Riding the Waves You can find this and other documents at Edutainment If you have any questions, feel free to PM me. I'm well versed in this particular program.

The service I currently work for has a large fleet. We have several of the new Chevy chassis with an Excellance box mounted. We also have several of the older Fords with the same box style. Our Chevys have a larger cabin than our Fords. The big guys prefer the Chevy to the Ford for that reason. Plenty of leg room. I'm just over five feet tall, so leg room is never an issue for me. My issue with the Chevy chassis is it's height. The ambulances we have that are Chevys are roughly 8 inches taller in the rear than the Ford ambulances. Eight inches is no big deal if you're 6'2". It's a very big deal when you can't see over the top of the floor of the box. (Well, almost.) It's difficult for me to load a patient when I have to lift them up to my neck level. Our breakdown rate is just as bad with the Chevy as with the Ford. Our mechanics are telling us that these small chassis simply can't handle the weight of the box and the equipment, subsequently, we have a lot of transmission issues. On a side note, one of our new Chevy units was involved in a bad accident a few weeks ago. It was a t-bone type collision, to the passenger side. The paramedic was trapped, and had to be cut out of the passenger side of the unit. He walked away sore, with no broken bones, and returned to work about a week later. When looking at the pictures of the damage to the chassis of that truck, there isn't a doubt in anyones mind that our paramedic would have been seriously injured, or killed, had he been in a Ford chassis that day. Unfortunately, there isn't a large run on appropriate vehicles to mount an ambulance box to at this time. You have the choice between the Chevy, which is affordable, to the International and Freightliner chassis, which few services can afford. It's a same that they can't afford those large chassis. I see those big boxes as being life-savers in a collision. If you have a picture of the Chevy your service is using, I'd love to see it. It sounds like it's vastly different from our Chevy chassis.

I started donating blood in high school as well. I never had any ill effects from it. I donated until I turned 23 and wasn't allowed to donate any more secondary to anemia. Since I was 25, I have been on the receiving end of 15 separate blood transfusions totalling over 40 units. My most recent transfusion was last October. In three instances, I had severe enough GI bleeding, I got to spend a week or more in the ICU. Needless to say, I appreciate anyone willing to donate blood. I consider blood and organ donors the "real" life-savers. Thank you for your gift.

Ha ha ha ha (best evil laugh) I went through Bob Page's PARAMEDIC program. Envy me, it makes me happy to see that there are actually people out there that care about a paramedic having a proper education, instead of 1000 hours of mnemonics and war stories. I can say, with near 100% certainty, that we left the mnemonics to the inferior paramedic programs in the area. If we were given a mnemonic as a memory aide, I have long since forgot it.

In my city, everybody thinks "free clinic" when they hear ER.

I haven't seen them yet, but I look forward to the day when they become available. I work with more than a few paramedics that have no idea the Grandview requires a different handle than our disposable fibreoptic blades. Let me roll my eyes for you, :roll: can't risk you hurting your eyeballs and being deprived of your posts. If you worked where I worked, you wouldn't wonder why I have stock in Excedrin Migraine.

Actually, I can almost tolerate crappy pay and hours. I absolutely HATE stupidity. I really hate a paramedic that quotes a textbook when he is arguing with me. The current classes are a joke, the exit exams are a joke. There is no challenge in becoming an EMT or paramedic. Factor in some crooked fire departments and state agencies, you have an even higher number of inadequately educated people performing extremely invasive interventions in the back of an ambulance. The only patient I don't feel sorry for anymore is the dead patient. You can be an idiot and not hurt a dead person. In our own little community here, the very young bright stars are all off furthering their education in colleges across the world. Crappy pay, crappy hours, crappy education, they all contribute pushing out the ones that could make this a better profession. I really believe the incredibly boring classes have a lot more to do with driving away the smarter students than any other factor. It's only my opinion, based on how bored I was during my EMS classes, and how it played a huge role in the fact that I will not remain a paramedic.

Personally, I found paramedic to be less than challenging, so I can only imagine how bored some basic students get during class. I don't really remember much of my basic class, but I'm fairly certain I had several good naps during that class. One particular type of student that does stick out in my mind is the volunteer fire-monkey that thinks he's going to get his big career fire department break because he took an EMT class. He can usually be found in the back of the classroom, with some t-shirt that proclaims how special he his, or a button-down shirt with every possible 8 hour fire class patch he could find on it. Follow the sound of the hero stories, they'll lead you right to his desk. Increase the educational standards of the EMS provider, and see how many of these less than stellar students drop quicker than a dead fly. Simultaneously, you should see the respect level of the actual provider increase. I can't believe they still wonder why our brightest students move on to become nurses and doctors.

Seems to me, you wouldn't need a goofy looking, probably useless device like a Howland Lock, if you used correct technique during intubation. For the larger of the populous, and they are growing (pun) in number, I prefer a grandveiw blade.

My most humble apologies for being "counterproductive." I have sent a PM to the administrator requesting he remove all of my posts and delete my username in full. Congratulations on running off yet another member.

Seems to me, you, yourself stated that you felt this rhythm would not be ventricular in nature, thus being a "narrow-complex" tachycardia, as the wide-complex tachycardia would be ventricular. Also, you need not be so snotty in your reply. I presented my case for forum members to learn by. I had every intention of posting the ECG's surrounding this patient as well. I'll refrain, since by your opinion I have nothing to offer the scenario presented.

I can tell you all about the Indiana EMT-basic/advanced. I've seen a lot of worthless certifications in my life, but that has to take the cake. I worked for a company that had contracts in Indiana. To fulfill the ALS end of the bargain, they put these advanced people on trucks, thereby letting the public think they were getting a bonifide paramedic unit. If I remember correctly, the advanced could start an IV, and put a patient on a cardiac monitor. They could push no drugs, and could barely interpret a lead II strip. I believe combitube was their airway, which was also a basic airway at the time. I never really understood the reasoning behind this level until years later when I became a little more focused on politics. See an ambulance, think everything is okay. I welcome corrections from anyone that still lives in Indiana. I'm curious if this is still going on there.

Last year I had a patient with a complaint of sudden onset chest pain and shortness of breath. 12-lead showed patient to be in a narrow complex tachycardia at 303 bpm. It also had the header of "acute MI suspected." Fortunately, I'm able to interpret a 12-lead in a rapid fashion, thanks to the greatest multi-lead instructor in the world. No delta wave, so I was not concerned with WPW. In gathering a history, patient states he drinks "a lot" of coffee, and smokes even more cigarettes. This had happened to him before, and he was treated at the ER, however he can't tell me what treatment he received. I established an IV rapidly, and went with a trial of Adenosine. I converted him on the first dose of 12 mg. He had relief of of all symptoms after conversion. From that I made the differential diagnosis of PSVT. His post conversion 12-lead showed no evidence of STEMI. I transported him, uneventfully, to the ER. I'm pretty sure I have both the pre and post conversion ECG's and I'll post them when I find them. I'm currently at work. With a 12-lead, a provider should be able to determine if a tachycardia is ventricular in nature. I was taught, unless there is evidence of WPW on the 12-lead, adenosine is the appropriate treatment in narrow complex tachycardia. It slows conduction through the AV node and hopefully slows the rate down enough to determine what the underlying rhythm is. I was also taught to try hard not to have to electrocute someone that was conscious and talking to me. Now, I could have been taught incorrectly, but I doubt it. My paramedic cardiology didactic was over 400 hours in length, and that was after a thorough A&P course. Bob Page taught all 400 hours of my cardiology, and I doubt he would steer me wrong. I'm always willing to learn, and I welcome any valid correction to what I was taught. I promise I won't run to Bob. (Well, I sort of promise. )

Sometimes, I just don't know what to say. :roll: Perhaps I should reconsider becoming a CPA.

Maryland utilises the EMT-I as an actual cookbook ALS provider. I remember seeing a book, many, many years ago that was a flip guide for the CRT (the old EMT-I). It actually had statements such as this... "If you see this rhythm, push a brown box, and then a purple box." I wish I were kidding. The current Maryland EMT-I is about a 400 hour class. Baltimore City uses them to staff ALS units. It's quick, it's cheap, and the public has no idea they are receiving inferior care. There is no national registry exam until you reach paramedic level in Maryland. It's very easy to buy a state exam if you are the right person. In Arkansas, we have a few people that are classified an EMT-I. Generally, they are a basic that might have once been an EMT-I, but functions only as a basic. The biggest cause for a person being labeled an EMT-I here, is a paramedic that was deemed incompetent and is now only allowed to perform ALS skills under the direct supervision of another paramedic, and they are not allowed to be the sole provider in the back of any ambulance. I will keep my opinion of the classification of the EMT-I to myself. Mark the date.

Wow, and people think I inspire arguments. I'm just curious why you would ask a question on a forum, only to make a valiant attempt to debunk it and try to prove everyone (that took time out of their day) wrong? I completely agree with Dust's explanation on the preferred route of administration of NTG. The very thin membrane and immense vasculature makes a sublingual administration of NTG not only work better, but work faster. I won't go into what degree I have, since it only serves to make people think I am arrogant because I chose to obtain an education. Personally, I prefer to put my NTG on a pump and titrate to effect, especially when dealing with a RVI. I can start off small, hopefully offer some relief, and have better control over the medication.

Why not contact Bob Page and get some feedback from him? I can tell you, because I took his multi-leads medic program, that his book has over 300 12-lead ECG's in it. Perhaps he can give you any required permission you might need to use his work, or be able to send you additional resources. I have a collection of my own 12-leads. I will dig through my folders and scan in what I have. In the meantime, here is some catching eye-candy for you: [web:fd508c7531]http://i84.photobucket.com/albums/k30/emskaren/MySTEMI_1.jpg[/web:fd508c7531] Yes, he was my patient. Yes, he was having the grand-mother of all AMI's. Yes, he lived, and enjoys his new stents.

Dust is spot on with his description of the PUM. How do I know? I currently work for a PUM. I thought I'd try it, heck I've tried many of the various forms of EMS. My favorite? Hospital-based. They required far more education than any other type of service. As I was departing, there was talk of JCAHO putting their hands into any EMS that was hospital-based. I see that as a great step. Safety, education, and appropriate patient care are paramount with a great EMS system. It's just so hard to find.

I haven’t taken the time yet to respond to this post for one simple reason, I’m at work. I work a rather busy station. It takes time for me to craft a response to this rather insightful post. It would be fair to say I do much more paramedic bashing at work then basic bashing. I expect a lot from a paramedic. I expect them to perform a comprehensive, detailed assessment of not only their patient, but the scene around them. I expect them to be confident, knowledgeable, and in control. I expect them to be able to calm a family and/or bystanders when working a critical patient. I expect them to be honest when dealing with patients, family, and co-workers. I expect them to clean up their own messes, both physical, and emotional. I expect them be in charge of their own education, and not blame anyone when they wait until the month before recertification to take a refresher class. I expect that they know what is right, and they do what is right. I expect a paramedic to be an educated CLINICIAN. I expect an EMT-B to not confront patients, bystanders, or myself in a manner that may be seen as hostile. I expect them to recognize from my body language, and orders, that a patient is having a life-threatening emergency. I shouldn’t have to tell anyone that CPR needs to be performed, that quick patches need to be applied, that I need things set up quickly, completely, and correctly. I expect them to safely transport the patient, any family member, and myself safely, at all times. I expect a basic to be a safe TECHNICIAN. The differences between basics and paramedics should never be likened to that of fruits. There is a great deal of difference between the two, and you do not necessarily need to be a basic before you can be a great paramedic. The same things you learn in that first aid course, are repeated in your paramedic courses, only in greater detail. Along with first aid, we are taught advanced anatomy and physiology, pharmacology, advanced medical terminology, better assessment tools, and how to interpret them. We are educated, or at least we should be educated. My friends that are basics, not everything in EMS that is bad is your fault. There is a great deal of accountability that must be made on the part of the paramedic. Most choose to go to inferior medic-mills. Some choose a degreed program complete with a variety of required collegiate level course. In all honesty, I am a great fan of the basic, only because I detest the medic-mill. I would much rather be in total charge of patient care, than to have an a medic with me that can’t tell the difference between a pink patient and a blue patient. I had the opportunity to work as a double paramedic truck last year. My partner went through a paramedic puppy mill. He had no confidence, no tact, and lousy skills. The most important thing he lacked was a good education, and it was reflected in his patient care. There was one particular instance where he had worked a shift with an EMT, and I had not yet arrived to relieve that EMT. The ended up on a cardiac call, and this man could not start an IV. The skill was not his downfall. His downfall was his lack of education, followed by his lack of confidence because of his poor education. I met them about 40 minutes from the ER. I went on the truck, assessed the patient, and took charge of the call. That should NEVER happen to a paramedic that is allowed to function on his own. Currently I work with a basic. She is golden, and I’d work with her over most paramedics any day. She drives safely. She anticipates my needs with little direction. She knows her limitations. She is a technician. She knows she is more than allowed to ask questions, when it is appropriate. She does not undermine me or confront me. She never asks me why she can’t just give a drug, because she knows my answer. No drug pushing allowed on my truck unless you can tell me what the medication is, how it affects the body, what the contraindications are, the five rights, etc. If you can’t talk me into it, there is no giving it. She knows she doesn’t have the required education to answer my questions. Unfortunately, neither do many of the paramedics I work with. So, how do we fix this problem? Do we continue on the path to sure destruction, as we have been for years? Or, do we take it upon ourselves to say enough is enough. There needs to be education, appropriate testing, and licensure. Do away with paramedic puppy mills, and require a paramedic to obtain a degree before they are eligible to test for their license. Require them to obtain a four year baccalaureate education before they are allowed to function independently on an ambulance. Education, good education, is the key to the success of this profession. I am treated the same as the medic from the mill, despite years in college and a piece of paper that says I spent years in college. People do not see a paramedic that has taken A&P, microbiology, English Composition, psychology, statistical methods. They just see a paramedic. I find when I run on a patient that has been treated by a paramedic before, I spend the first five minutes undoing all the damage that paramedic did. I hear how horrible, inconsiderate, mean, and stupid paramedics are. Occasionally, very occasionally, I hear how one shines. If you want to do a job, do it well. If you’re a janitor, take it upon yourself to know what solution clears the most grime the fastest. If you’re a physician, know what to do to help your patient, and keep them from deteriorating and/or dying, or to ease the suffering when they are dying. I don’t care if you’re an EMT-B, but you better know your limitations and stop tossing one ridiculous reason after another about why you should be able to administer a drug. If you want to be a paramedic, choose your education wisely. No excuses, you are an adult, and this is your life. Excuses are for people that need a reason to do nothing. Everyone likes to get something for free, but consider how much it is really worth. You may find out, in time, that the free paramedic “education” that took you six months to complete is really worth what you paid for it.

Woody Woodpecker.

"The machine that goes PING!" It's so hard to narrow down one line from Monty Python as they are my single most favourite comedy troupe.

We have several uniform standards as well in my organisation. Our "formal" uniform is a light blue flying cross button up shirt, complete with all that BS brass, that I find not only ugly, but dangerous. The casual shirt is a navy golf shirt. Pants are either EMS or BDU style. I personally wear the EMS pants, not because I like the pockets, but because they look a little more refined. Our officers wear white shirts, either style. I wore my favourite uniform while working critical care ground transport. We had scrubs. Functional, easy to don and doff, easy to clean. I can see how they wouldn't be practical in an EMS setting. We are required by policy to have one clean uniform at our base station at all times while at work. There is no excuse to get contaminated and not change. Besides, other peoples cooties are just plain gross.