Eydawn

Colorado you cannot e-prescribe narcotics. All of our narc scrips for discharging patients are printed on special paper and have to be pen/ink signed by the provider instead of electronically signed. Isn't that fun when the provider forgets to sign it... lol. Many of our other scrips are e-prescribed to the patient's pharmacy of choice. We are also seeing a lot of chronic pain visits be admitted and procedural treatments tried... sometimes it helps, sometimes we just end up giving a ton of PO meds with IVP for "breakthrough" and then eventually tossing the person out again... my floor is where they bring a lot of the chronic pain folks. It sucks, because it's so hard to fix. Wendy CO EMT-B RN-ADN

Right... but in patients with unrecognized underlying mental illness, even small doses of ketamine can produce dissociative effects, no? Like any tool, it has benefits and dangers. I just don't buy the "magic K is the way to go!" line that some seem to have... I've just not seen it work the way it's supposed to... Wendy CO EMT-B RN-ADN

I think I've made my views on Ketamine pretty clear... We've used it as a continuous infusion to treat refractory pain (think: chronic regional pain syndrome, opioid intolerance for postoperative patients) and often give concurrent benzos. My personal experience with it as a nurse has been that it turns my patients into fruit loops who need safety partners to keep them from hopping out of the bed/pulling out IV's/swinging at folks. I find that the dissociative effects really cause more harm than the analgesic effects provide benefit, and I really don't think a busy ER or busy nursing floor is a good environment for it. As far as the large bone fracture and benzo use, absolutely some valium has been a godsend... most of my folks with displaced femur/humerus fractures have been in so much pain that IV opiates alone haven't touched it, but you add in the valium (and then oral cyclobenzaprine if they're not immediately headed for the OR) and things get a lot more tolerable. Wendy CO EMT-B RN-ADN

All I got for a migraine at urgent care once was a shot of toradol and a shot of phenergan in the ass. Felt like I was sitting on golf balls. Learned I don't tolerate Macrobid... would have really appreciated not finding out that way! ~_~ The combo did work, no narcs required... On this note, how often do you ER types prescribe narcs for pain of unknown etiology? My chest pain ER visit comes to mind, and they tossed me out with a scrip for 30 vicodin, which I said I didn't want, and when they made me take it with me anyway I promptly deposited it in the shred box up on my home floor when I went to retrieve my stuff from my locker. Was that wierd, or par for the course? Wendy CO EMT-B RN-ADN

I share the concern with this. We have one doctor I refer to as the "candyman" because his patients are all on large amounts of narcotics. Combo #1: Soma (carisoprodol) PO 350mg Q6H, 8mg Dilaudid PO Q4h, Nucynta (Tapentadol) ER 40mg BID, 5mg oxycodone Q6H PRN for "breakthrough" and IVP dilaudid 2mg Q2h for "breakthrough" Combo #2: Morphine ER 40mg PO BID, 15mg roxicodone IR Q4H PRN, Valium 10mg Q8H and of course, dilaudid PCA... high dose settings. Combo #3: Opana 30mg ER PO BID, Morphine 20mg ER PO BID, 10 mg morphine IR PO Q6H PRN, Lyrica 300 mg TID All of these had me shaking my head... just try to be more than 10 minutes off from the "due" time too... what's even scarier is the folks that I know STILL had pain, despite all these combos, who were not sedated in the slightest. Holy shit, batman. I did have to get into it with a PA who was mad about the patient "not being on their home medications" and my very pointed comment was that their sedation level contraindicated resuming some of those medications right now... OMG, they're nodding off/desatting as we're sitting here talking about this, ain't no way I'm adding in more sedation... I have noticed that there's a distinct behavioral difference in some folks. Some folks are driven by the pain medication schedule and become abusive when it is deviated from; others are adamant about it, but understanding of interruptions and much more reliable in pain self reporting. Even if they do never get below a 7/10. Good resouce, Mike! Thanks for posting it. Wendy CO EMT-B RN-ADN

Here's the thing... statins are linked to musculoskeletal injury. Oddly enough, I work on an ortho floor, and guess how many of my non-gross-traumatic-yet-non-elective surgery patients appear to be taking a statin? Yes, statins have some data backing decreased mortality.... but like all medications are not without serious potential for side effect. It'll be interesting to see how this goes. Wendy CO EMT-B RN-ADN

Uh oh. I don't know what the berries are... when I snap a pic and run it thru Google what do I get? Grab a sample in a baggie, look into kiddo's mouth to see if he's all berrylicious and hightail it to the ER. Also ask the brother if he ate any of the goddamn things... What's our updated vitals? Wendy CO EMT-B RN-ADN

I love it! She's beautiful. And you're looking nice and mountain-man-grizzled... ;-) (The beard works for ya!) You can tell she loves you... totally bonded to you. I'm glad she's able to help keep you quiet/calm at night... that's awesome. Nothing better than a dog snuggle. Wendy CO EMT-B RN-ADN

Readtheshirt- I'm dying laughing over that one. Tickled my funny!!! Chicksdigmedics69 Iamthebari-lift Sceneissafe247 Wendy CO EMT-B RN-ADN

What kind of medications do the parents take? Can we see all medication bottles in the house? With that temperature and the resps, I'm really thinking he got into a bottle of aspirin... ugh. How responsive is the kiddo with assessment questions? What's his orientaiton level? Breath sounds? Let's get a line in and be ready to support respirations with how fast he's breathing... Wendy CO EMT-B RN-ADN

You know, this occurs to me... there's so much research out about trying to change the culture of education in medicine. Just because folks get chewed on and folks think because they got chewed on as a student/intern/resident they're cool to dish the same at the next generation doesn't mean it's OK. It is not professional. It is not productive. It is not to be encouraged or accepted. Regardless of which level of provider is addressing another level, I might add. If I do something stupid, I fully expect my savvy CNA to call me on it, but with respect, as I would treat them with respect in the same situation. I know some doctors will behave unprofessionally towards colleagues or students; we don't tolerate it at my place of employment. The one diva MD we do have usually only does it when they're sleep deprived, and they come in the following morning bearing lots of apology and humility. It should go without saying that we don't tolerate it from any other level of provider, either. Nobody's trying to hang a nurse out to dry without understanding the whole situation; given the limited information and the fact that we're analyzing it from the outside, we are identifying things which we pretty much all agree on as unprofessional. That's what we do here on this forum. We seek input and discuss issues to become better providers. we identify that which is acceptable and that which is not in order to promote professional practice. Wendy CO EMT-B RN-ADN

Hey Mobes! Glad to hear from someone who's experienced it. I don't doubt there's a deep psych connection. At all. What I found intolerable was being patronized. Dismissed as a stressed out histrionic female. Fuck that doc... this is not all in my head. It has been a rough year. I'm definitely working on the mental stuff. But if there wasn't a vessel wall issue it wouldn't manifest this way in the first place. Looking at the cyclical nature of this problem my history makes so much more sense now. And yes.... it's shown up more in times of high stress. I think cumulatively I've finally landed in the mess... and I am trying to get better at self care. I'd kill for a massage, but I can't swing it financially currently. See: student loans, new mortgage and sole breadwinner. I will say that having the energy to get through a work shift has reduced some overt anxiety pretty significantly. Nightmares... yea, that's been on tap. Had a good recurring one before I started the amlodipine about being coded at work. (It was one of my precognitive type dreams and I actually experienced the day in the dream... that was really eerie.) Other nightmares too. That is also starting to improve. So... yea I agree with you... and it's a work in progress. Like most illnesses it has both physical and psychological components. Thanks for the feedback!! --Wendy

I see how this is going to go. ;-) What ethnicity is the child? Who else is home? Is my scene safe? What are the child's respirations? Can I hear breath sounds walking in, without a stethoscope? What are my baseline vitals, including BP, RR, temp (if I can get one), SaO2? What are my breath sounds, depth and quality of respirations? Where is the child in the home? Wendy CO EMT-B RN-ADN Nota Bene: man, you know I'm stuck and bored when my post count rockets...

Figured I'd just throw this out there and see if any of our higher level providers have ever played with this one before. Thoughts on it? Experiences with patients? I'll give the nutshell version of what happened with me... end of July I worked a night shift after moving all day and ended up with some pretty significant chest pain and took myself down to my own ER. (Damn, I hate when that happens...) EKG had non-specific changes, ER doc decided I wasn't dying after we did a 12-lead and an echo and tossed me out with a scrip for vicodin. "Must be musculoskeletal." Ok, cool. Not really, but hey, it's all good. I wasn't dying. That's what I needed to know. Over the next few months I had a lot of palpitations, chest pressure and fatigue. I'm talking ass kicking, feel like I'm dying, can hardly get through a workday fatigue. Did a 2 week king of hearts monitor- some PVC's, PAC's, brady to 48's and tachy to 130's but not consistent or really diagnostic. Chest pressure/pain and that sense of impending doom suck, by the by... apparently, according to my coworkers, I turn grey when it happens... Go to see first cardiologist. "D'aww! Poor little stressed out new grad. It's just stress. Here's a scrip for propanolol PRN for the palpitations. We'll schedule you for a stress test. We just need reassurance." No, asshat, I need to know what's wrong with me... but thanks... Helped to push a car. Had crushing chest pain. Freaked out a friend from my SAR team who used to be a pacer/defib device rep. He calls a cardiologist friend to get me in for a second evaluation. Stress echo normal. Second cardiologist decides that it sounds like a vasospasm issue (oddly, exactly what my boss and charge nurse had said the day after everything started), started me on 2.5mg amlodipine QD, and I've been 90% good to go since. I've had 4-5 episodes of angina now, lasting less than 30 seconds (but holy shit, it hurts) and a few runs of tachycardia in the 140s that self resolves within 4-5 minutes. Someone way smarter than me knew the name for this particular condition, but oddly my cardiologist hasn't used it specifically... just calls it "vasospasm issues." Doing some research, seems that Prinzmetal's is often cyclical, and it surely would explain some of the episodes of syncope/chest pressure/chest pain that I've had in the past... So! Anyone have Prinzmetal's other than me? Any thoughts from our doc type folks on the random episodes of angina and the tachycardia? I'm 90% back to normal and I'll sure as heck take it over what I was dealing with.... but I'm curious as to folks' thoughts and ponderances... --Wendy

What's my setting- school, playground, home, etc? Age and gender of child? Let's start there.... Wendy CO EMT-B RN-ADN

Yeah, I was busy and missed this... lol. Me and mine were OK in Wellington.... I ended up staying down in Loveland as a lot of our nurses got isolated and couldn't get to the hospital. So I stayed down to stay available, and crashed at a friend's place. It was a blast. Oddly enough, I had a dream about flooding last night... but it was nice warm clear water and my husband fell asleep driving a boat... totally weird stuff. --Wendy

Yeah... mutual respect and communication is important. Hugely important. Perhaps the MOST important thing that contributes to patient safety and accurate care... I'm a newer nurse, but the docs I work with know me and know that I'm keeping good eyes on their patients. When I ask a question or suggest a treatment route, it's a back and forth discussion with my impression, their big picture, and a treatment decision moving forward... Do I ask dumb questions sometimes? Oh hell yes. I have blonde moments, just like anyone else. Fortunately, the providers I work with just laugh, educate me, and we all move forward. I would never berate or belittle someone. Asking if they're qualified to be who they are and where they went to school is an ad hominem lateral violence tactic and it is not excusable. Asking what their treatment decision rationale was and if they were aware of XYZ is appropriate, and can even be done intensely "Did you realize this, this and that? Did you consider this before you attempted that?" while still remaining professional and appropriate. If you got so scared or freaked out that you feel like all you can do is scream at the person "are you a moron?" you need a time out before you attempt to discuss it with them. Also, if your nursing student sees you chew on a doc, it wasn't in private. It was just not in front of a patient/family, which is only *marginally* better. Students are students- not to be exposed to the bullshit and dirty laundry. Trust me, I know all about certain areas or care teams doing certain things. I know about the "this doc trumps that doc and therefore his/her PA overrides this other doc's order" game. At the end of the day, raised hackles and peevish behavior do nothing but create an environment where the patient is at greater risk of harm. What about the next time that resident is working the delivery/resus? Will he be distracted, wondering if this nurse is going to jump him? Will he be less aggressive and miss nuances? Lots to consider here. We can mess each other up psychologically and affect care pretty badly if we're not careful. We already have enough emotional trauma to deal with.... why add to it when there are other alternatives? Wendy CO EMT-B

Welcome back, Squint. Keep on keeping on! So glad to see you back around. Tell us about the pup! I love me a good dog.... pictures?? Wendy CO EMT-B RN-ADN

After doing some reading, it sounds like trauma can be a cause of chyluria if lymph vessels are transected/constricted or there's bladder trauma allowing entrance of lymphatic fluid... (unless my sleep deprived self is not understanding the anatomy at play here). Doc, have you seen chyluria in a trauma scenario before? Because I'm going to take a large guess that this patient didn't have filariasis, unless that's more prevalent in the chilly north than I realize... Wendy CO EMT-B RN-ADN

Hey Cheeky, Really, gotta figure out what kind of EDS you have... a lot of people do great with it. Hang in there! Always a bit of a shocker to discover you've got something you never knew you had (but boy, once the pieces start to fall into place, some of your past experiences can start to make sense once you know..) Chin up! Let us know how it all goes. Wendy CO EMT-B RN-ADN

I'm going to shoot for the 3rd as well. Gotta see if I can get shift traded around for it! Wendy CO EMT-B RN-ADN

Is it possible that the acute epigastric pain could have been a traumatic renal injury? I'd be leaning towards rhabdo spillage myself... was the milky UOP the same amount per hour as the previous UOP? Or did it increase? Wendy CO EMT-B RN-ADN

Howdy kid. Welcome. As another former homeschooled femlae who got into EMS early, I think we have a lot of common ground. I have some questions for you. 1: How much mainstream socialization do you have? I mean, hanging with folks in the normal school system/community, not a homeschool community. Trust me, there is a HUGE difference. There's a lot of interpersonal stuff you're going to have to play some serious mental catch-up on if you haven't had much mainstream exposure. 2: Don't automatically discount nursing school just because your ma got treated like shit. Nursing school is like that. PA programs can be like that. Paramedic school can be like that. Trust me... I was treated pretty badly in nursing school because I am a strong, intelligent personality and was at a different place than some of my peers. I say that with a lot of humility- I am not the best new grad nurse on the planet, nor was I the best nursing student there ever has been... like any new provider, I make mistakes and learn from them. BUT, my instructors didn't always know what to do with me (and often felt threatened by me.) It was pretty miserable at points. Does that mean nursing school was a mistake? No... it's absolutely a good career for me. So just take that into account as you're looking at what you want to do. 3: How old will you be when you get your GED/AA? If it's under 17, do yourself a favor and spend a couple years at a college taking classes. You won't be behind, and your brain has some growing to do still. Be kind to yourself and let yourself be a college student for a little bit. You'd be surprised at how much learning you'll get that has nothing to do with academia. Where am I coming from with all of this? I started as a first responder in a Venture Crew when I was 16 or 17. I got to do ER shadows and ambulance ride-alongs. I got my EMT when I was 18, and have mostly worked wilderness/community event setting with my EMT license. I have worked as a care provider for the developmentally disabled, an assisted living night shift manager and medication tech (QMAP), a hospital CNA, and now a post-surgical RN. Ask many of the fine folks here on the City... I came along the EMTCity scene when I was about 19, and I was a precocious young'n... much like yourself. (I'm still a young'n, don't get me wrong- I'm only 27.) I can safely say that I am very glad that I did not get my RN when I was younger, and that I did not end up being a super young paramedic. I am a much better provider now than I would have been, because I have a lot more depth to my critical thinking and a lot more intuitive knowledge from my experiences working with people (not just medically speaking, either.) I look back on my third rider days as a 17 year old and realize that perhaps it might not have been the safest thing for me to be doing. They were fun, I learned a lot... but it was a lot of liability for a department to take on. As I have gotten older, I have realized there is value in age. I think it is the nature of the beast that you can't truly appreciate this as much when you are younger. That doesn't mean that age automatically means something; age is subjective. However, Mobey has a point. If I had encountered some of the situations in my life at a younger age, I might not have been able to cope as well or bring as much to the table... hence his reluctance to allow a 15 year old on an ambulance. Does that mean his perceptions 100% apply to you and your specific situation? No... but he does have a point. Good luck to you, and welcome to the City! Whatever path you pick, please stick around here... there is so much of value to be learned (from reading old threads and participating in new discussions.) Wendy CO EMT-B RN-ADN

I have a question for all of our good folks out here in EMTCity land. As many of y'all may know, I live in Colorado. The sky decided to wreck some rather nice parts of my state with fairly large amounts of water. I am on a local SAR team. Here's my question... for resources that come in from other areas, do you feel that it is inappropriate, during down time, for those people to discuss their lives back home with local responders? The specific behavior in question was folks describing having to burn sick days to deploy as federal resources, with some of them with less-than-thrilled employers and having had the experience before of not getting paid for several months for previous disaster deployments by the Dear Old Fed. I found it to be normal discussion and banter. Someone else with whom I've had this discussion finds the idea of this kind of behavior to be intolerable, and states that if you're going to gripe about anything you're not cut out for search and rescue. Assume, for this scenario, that we're referring to a multi-day mission and the folks in question were on a rest day/standby with literally nothing productive to do on this given day. What are your personal experiences? Do you think this kind of chatter (things we can all relate to) is unprofessional given the context? Wendy CO EMT-B RN-ADN Edit: Capitalization mistake.

Scuba- she's actually married to a friend of mine! Born that way... and she's FANTASTIC. ;-) You'd never know she only had one hand till you go to shake her hand... she's a lefty. Wendy CO EMT-B RN-ADN