Eydawn

Oy, hombre nueva- Why do you want to be a hosemonkey? If you like paramedicine, why go fire? (Yes, I know... worms... can... open...) But seriously, I want to hear where you're coming from. And what fire department are you singing the praises of? On what basis do you call them the "historically best"? Just curious... All the best, Wendy CO EMT-B RN-ADN Student

Here's a question: Would it be harmful, in any way, to move for the diphenhydramine prior to the benzos if this were a partial complex seizure? If you're truly approaching this from the perspective of a potential prehospital call, will you really be immediately jumping to dystonic reaction as your exclusive (or primary) differential diagnosis, and if so, would it be wiser to prioritize benzodiazepenes with regard to the neurologic symptoms you're seeing? (I don't know the answer to this; I'm curious as to what the OP's take and the smarter folks' brains want to do with regard to this question.) Wendy CO EMT-B RN-ADN Student

I agree with either cops take/watch the kiddos/(or dogs!) or we load everybody up and off we go! What language were they speaking, just out of curiosity? (Wondering about linguistic differences) It all depends on your situation. If you're in the middle of nowhere? Kids come with the guardian unless the cops are right there to help. If the cops can be right there, and dad won't freak out about leaving kids with someone they don't know? Wait for the cops... Wendy CO EMT-B RN-ADN Student

Depends on the scene. If your patient won't calm down because they need to know, tell them what you know... if you're not sure how they'll react, focus the care and interaction on them and tell them once everyone's stabilized/transported will be a better time to figure out what's really happening. If I myself had in fact triaged and determined someone's child was a code black, and they knew it but needed confirmation from me, I wouldn't withhold that information. I would, however, make sure they were safely on the stretcher, in the ambulance, and stable enough for me to take the time to tell them. Not an easy question! Great place to ask it! Bring us more, young padawan... this is the place to stretch those mental wings and pick stuff apart. Wendy CO EMT-B RN-ADN Student

What is PI? And I have no idea- I say what Mike says, contact your State EMS office. Be prepared with documentation and details. Wendy CO EMT-B RN-ADN Student

I hope they revoke his licensure/certification. This is a classic case of not knowing your boundaries and not understanding the system. Actually, this behaviour sounds similar to a fellow I knew once... *shudder*... Gak. Wendy CO EMT-B

Hi folks. At my paid gig on a hospital floor, recently, due to shortages of our more popular PCA drugs and patients with weird narc sensitivities/allergies, we've started having some post-surgical orthopedic patients come up on ketamine PCAs. Most of these patients have been elective back or knee surgeries (haven't had any hips yet on it). In my anecdotal, population size <12 study, I'm beginning to think this is a really, really shitty idea. What do y'all think of ketamine as a PCA? Specifically looking to our higher level folks here that understand all the pharm ramifications... thoughts? I think it doesn't seem to provide the level of analgesia that we expect from a PCA. I also think that it makes many of my patients nuttier than squirrel poo. I'm talking hallucinations, self injurious behavior (leaping out of bed, pulling catheters/IV's/dressings), crazypants to the point of needing benzo sedation and/or 1:1 observation (expensive, harder to staff, takes away from having staff on the floor). Dissociative anaesthesia, in "push your little button" form seems to just not be working out that well. What say you on risk/benefit between ketamine PCA and something like a local block (on-q balls) that can be dialed back slowly? Wendy CO EMT-B RN-ADN Student

I agree with "figure out what you really want to do and then pick it" to a degree. I'm an EMT. Was an EMT long before becoming a CNA. Worked as a personal care provider for several years, started nursing school, tested for my CNA, and now work on a hospital floor that I really hope hires me as an RN when I graduate. I'm still planning to get my paramedic. My EMT experience has made nursing school harder and easier. Easier, in that the patient care aspect was not so scary, harder, in that I wanted to do things in ways that were foreign to my instructors. Plus having a knowledge base really pissed some of them off. *Sighs* I want to get my paramedic so I can work prehospital; however, I love that the RN degree will allow me to work in so many varied care areas. One floor is not like another- each has its own challenges and requires different things of the provider's brain. The advantage of hospital based medicine is you get to see more resolution, more progress, what happens "after you hit the doors" so to speak. Stabilization and transport, while fast paced (sometimes) and exciting (sometimes) only hold so much interest... the "rest of the story" is pretty darn important IMHO. So why do I still want to get mine? EMS still has my heart. I love the setting, and all the different presentations you get exposed to... Also, it's going to be a lot easier to take maternity leave (eventually, not pregnant yet, nobody get excited OK?) as an RN than it would be as a paramedic. Just something to consider if you haven't had your own tiny hoomans yet. So where am I going with this? None of us can answer for you which route you should take. Lord knows mine was circuitous enough... you really do need to pick one, evaluate how it fits into your life goals, and then go for it. If you discover, enroute, that it isn't what you really want, then change. Best of luck to you! Wendy CO EMT-B RN-ADN Student

Hugs are the BEST coin of payment as far as satisfaction goes at my job. A hug says more than any words! It means I did well and made a difference for that person. Love it. As far as accepting thanks, the truth is that not everyone does what we do, or is capable of doing what we do. Does that mean we need a big head about it? Nah. But it is OK to accept the thanks. It may be "just our job" to us, but it's a foreign, scary world to many others. Wendy CO EMT-B

Got a couple funnies... One from oh, about 2 days ago, from my SAR team... our response truck looks like an ambulance, 'cept the box on the back is FULL of stuff (we blew out the stock suspension and had to upgrade it was so heavy!) Eeewww... poor truck... poor deer... The other one is my husband, in his Acura Integra, took out a small airborne duck. Didn't realize the duck was inside the bumper cover, fused to the radiator, until he came out to the garage the next day in 100 degree weather and could smell it... popped the hood and OH MY... Oh yeah. And then we tried SO HARD not to run over all these frogs on the road coming out of a national campsite... it was like real life frogger! No joke! And we missed all except the biggest one... could hear him pop as we hit with the driver's front tire... eeeeeewwww.... Wendy CO EMT-B RN-ADN Student

I think it was appropriate. Climbers love what they do. Just lost a friend myself, down in Peru... just found out 2 days ago that they were overdue and later the same day found out their bodies had been found. Gil Weiss, was his name. He started nursing school with me, did the first 2 semesters, and decided it wasn't for him... Who was the FDNY person and where did they fall? News article? I'm curious as to who the crew was who did the recovery.... Wendy CO EMT-B RN-ADN Student

That's different when you're talking about a rural trauma patient. As they didn't show a mean transport time, and only on scene time, we can only begin to guess how long they had in the ambulance en route to the hospital. When you're driving for 45 minutes, and not in stop and go city traffic, it's a different environment... Also, I wonder how they classified trauma patients? Anyone with any sort of traumatic injury? Trauma alerts? Not enough meat there to satisfy this gal... Wendy CO EMT-B RN-ADN Student

Mods, I respectfully beg that the thread be allowed to continue, as thrutheashes has their answer and there is a good nugget to pursue here that I do not feel needs its own thread... Wendy CO EMT-B RN-ADN Student A 12 lead provides pertinent diagnostic information in a time-sensitive condition. IV access does no such thing. You can't kill someone by screwing up a 12 lead... and time is tissue. If your patient is critical enough, you will be starting that IV. In those non-critical, more stable patients, I don't see a need to hurry up and wait on an IV... especially since they must be dc'd within 48-96 hours (depending on your system). The earlier you start it before it needs to be used, the earlier it gets pulled and the patient gets stuck again for a different access site. I respectfully offer that a hospital room, with the resources at hand and good lighting, on a non-moving bed and with extra hands/eyes to assist with the IV start is a more controlled environment than the back of the most progressive ambulance... especially if said ambulance is moving. What is making the field starts messier? I don't know. I'm not there. But I have a pretty good guess... I'm guessing that to minimize scene/transport times, most interventions are being performed in a moving vehicle. EMS still emphasizes "load and go" over "stay and play" regardless of the type of patient... leading to lots of things being done in a moving vehicle. No, the anticipated need for IV access isn't enough UNLESS that is the expected standard for your particular area and it really does improve the patient's care as soon as they come into the hospital... in many areas, there's no reason to start an IV in the field. Scotty's post shows that they've moved to that model, and I very strongly agree with it. Wendy CO EMT-B RN-ADN Student

I meant "Oh look, I've got IV stuff and time, I guess I should start an IV because (we can bill for it) (they might need it later) (the ER nurse will yell at me if I don't)" for the "just because we think we should." I do mean to state that even if you know the patient will need IV access, if you won't be using it, there is no reason for you to initiate it unless you have the time and you know the hospital system likes your IVs. How do you know this patient will *need* IV access? Are you sure? Are you positive they will be admitted, and need IV therapy instead of orals for medications? Can you justify your field start, as opposed to an in hospital, more controlled environment? I'm going to tell you, I trust our EMS system's IVs, but I pull IV's every day as part of my current gig, and the ones that have the most complications (bent catheters, shear, infiltration) have been almost without exception field starts. That may be just my area, but I doubt it. So, if you will not be the person pulling the lab draw, or initiating fluid or medication therapy, I am saying yes, you should possibly hold off depending on the overall status of the patient and the way you interface with your hospital systems. If they expect you to draw lab samples in the field, or expect to have that patient ready for draws/meds, then yes, you should start it. If that's not the expectation, why are you starting it? Wendy CO EMT-B RN-ADN Student

Not every patient transported by EMS to the ER will need IV therapy. Starting an IV prehospitally is not always appropriate IMHO. Starting an IV just because you can, or because you think you should, is not a great idea. I started several superfluous IV's on patients who really didn't need them. Pissed me off. It's not withholding treatment if they don't need it in the first place... with the risks associated with IV insertion and IV therapy are not small... The instances in in which it's acceptable to insert one prehospitally, IMHO, are chest pain patients, possible stroke, respiratory, and fever (possible sepsis). Stubbed toe? Busted arm? Unless you need to deliver IV pain meds, it could wait... Wendy CO EMT-B

*Sighs* sent him a FB message. Last post on FB was 16 hours ago. Hopefully he's just incommunicado for a bit. Mental illness is le suck... hopefully he gets some help. Been trying to encourage that off and on... If you're reading, bro, hope you are OK and get some help. You don't have to slog this alone. --Wendy

Of course you don't blindly neglect something that is right in front of you... we have the ability to advise dispatch of circumstances that arise, thereby placing the "walk up" or "drowning child" into our duty to act. This puts me in mind of the thread where we discussed an interfaclity transport of a critical patient on 'pressors and came across an MVA in the middle of the boonies and there's nobody around, what do you do... the honest answer is you do the best you can based on the judgement call you make given the circumstances you find yourself confronted with. That's what we do, every day, except sometimes the circumstances can be atypical or extreme. The patient you are already treating comes first; if you have that 6th cardiac patient roll up to your hospital, you don't abandon the folks you're working on, you just pull in more resources. That's the beauty of a hospital, you have more resources at your disposal. In the field, you don't necessarily have that luxury. You can end up in a damned if you do, damned if you don't situation, but those are the exception. In general, in non-rural areas, with good expectation of a reasonably fast second unit to respond to the witnessed MVA, your priority should be on responding to the "known" patient (as much as a patient can be "known" through dispatch...) because that is your contractual obligation. In the hairier, more rare situations? It's up to you, your dispatcher, and the best you can do. If you're the only provider in a hefty time-to-response radius, I would think your obligations may differ. Arckticat?? Remote guys? What's your take? Wendy CO EMT-B RN-ADN Student

Did you miss that it's given with a BOLUS OF D50?? Sugar... to go into the cells and take K+ with it... leaving person normoglycemic (or slightly hypo which is then corrected) Just sayin'... Wendy CO EMT-B RN-ADN Student

I might disagree... I've seen insulin/D50 used in hyperkalemic patients who were not DKA. And it is true that DKA patients are often given D5.45 with 20meq of K+ as their maintenance fluid (at least in my limited exposure) to prevent this and treat the systemic hypokalemia, along with Q4-6 lab draws to closely monitor potassium level (as well as being on continuous telemetry monitoring). In someone with a crush injury, how is introducing Ca+ going to be more beneficial than just getting the serum K+ level down? Wendy CO EMT-B RN-ADN Student

Hm. Diverticulitis, perhaps? Triggered by eating certain foods, causes distress, mild shocky-symptoms, and quick resolution because she has good general health? Also, perhaps she has a vagal response during her funky bowel flare, causing the decreased MAP and "whited out/blurry" vision? Which resolves once she's done sitting on the pot? Odd! Wendy CO EMT-B RN-ADN Student

I would be leery of using Beta-agonists due to their cardiac effects... even just looking at crush injury/compartment syndrome type stuff, unless you know the full medical history you could possibly cause more harm than good in my opinion. Without knowing what the actual potassium value is, it seems more prudent to provide supportive care until those values can be known and then to use insulin/D-50 to treat a known hyperkalemia. What criteria were you going to use for justifying intervention? What's the odds for potential harm from the hyperkalemia vs. beta agonist effects? I guess the advantage would be reducing hyperkalemia if you had an extended transport time; however, I would want the receiving facility to be on board with it... especially in terms of crush injuries that will be going to OR expeditiously... Kiwi- what do the protocols say, other than NZ "has capacity" for it? It's all well and good to say "oh yea, we do that here" but I want to know the details!! Wendy CO EMT-B RN-ADN Student

I don't believe in minimum ages for EMS (although I am loathe to go younger than 14 for First Responders- there's only so much babysitting one can do when one is trying to treat a patient.) A lot depends on the individual in question. Remember, many of you would not have known I was in my 20's based on my writing... I seem to remember some folks insisting I had to be in my thirties... I do think in general, it is not a good idea to have 16 year olds on an ambulance, but there is a huge difference between age 16 and age 18, and 18 and about 23-ish. I'll take a very mature, open to direction 17 year old working with me over a 19 year old hot shot who's convinced they know everything. I think it takes getting a little older to realize exactly what you don't know, but there are advantages to being younger as well (physical stamina, energy, quick mental processing). Therefore, I think minimum ages are irrelevant. It all depends on the person. The self motivated, intelligent, willing to learn 19 year old paramedic will provide good patient care, whereas the hot shot will screw up or get moved along in some other fashion, or will grow up and become a better provider for it. Case in point-- recent Century Ride in my state... I was at the finish line, and we got SWAMPED with patients. I had two brand new, just passed their test First Responders aged 16 and 17 with me. A little direction here, a little oversight/cross checking there, and those two literally saved the bacon, as there were so many patients that it would have been impossible for me to treat all of them. Would I work with them again? Absolutely. Would I trust that they knew what they were doing? Trust but verify- provide guidance and teaching, and soon they'll really be rock stars. I've also worked with 17-18 year olds in the past who were so gung ho on "being the medic" that they provided treatment that made absolutely no sense and I had to step in and take over for them before they REALLY screwed up... like I said, it all depends on the person. (Those gung ho idiots are all now fully grown and responsible citizens, and some of them actually went into EMS and seem to be doing pretty well for themselves... so they just needed a little seasoning...) Wendy CO EMT-B RN-ADN Student

http://www.cdphe.state.co.us/em/certificationeducation/certification/index.html For initial certification in the State of Colorado, NREMT certification is required along with a CBI or FBI background/fingerprint check. For recertification, continuing education is sufficient. I let my NREMT lapse long ago. Frickin' racket, that... Wendy CO EMT-B RN-ADN Student

Active shooter scene? 10 minutes before being dispatched? 30 minutes after report of scene, they were in to transport? Not the primary agency for the area of response? Excuse me, but what's the problem here? Not everyone operates on the same frequencies... it took dispatch pulling together and realizing they needed multiagency EMS all hands available. Not to say that process couldn't have been sped up a bit, but knowing Aurora as I do, I'm not surprised and I actually don't see that it was a great failing... sounds like dispatch had a hell of a time and not all dispatchers were talking to each other. The after-action analysis always shows places where you could have done better. The politics in Aurora with regard to EMS service is incredibly messed up. I think they did a killer job despite the fustercluck. Wendy CO EMT-B RN-ADN Student

If I'm out in the field: "Hi, my name is Wendy, I'm one of the EMTs that will be treating you. What's going on?" Or some such. Sometimes it's "Wow! Bet you hit the pothole that the five riders before you did, am I right? Let me see that helmet..." (Lord, that was an interesting bicycle race standby...) If I'm on the hospital floor: "Hi, my name is Wendy, I'll be one your CNA's today. How's it going/how you doing? How's your pain?" If I'm settling someone in right after they come up from the PACU (recovery room), I do have a few pat lines... "This here is the call button and TV remote. See the bald red guy on the large button in the middle? Push on the bald red guy if you need help. Or any of the orange crosses on the bedrails. Hear that loud beep? I just turned on the "don't get up without the nurse" alarm... if you get up without calling, bells and whistles go off and folks come running. Please call first!" My other one is after I dc IV's... "See this? It's called Coban. I'm wrapping it around your arm. If you start bleeding through it, put pressure on it. If your fingers start to go numb, please take it off. Basically, if something isn't right, please do SOMETHING!" (Usually we dc IV's immediately prior to discharge) Wendy CO EMT-B RN-ADN Student