Ridryder 911

So let's say you do transport the child.. and now what is the ER supposed to do? They cannot treat the patient until the mom gets there. She (mother) stated there is no medical reason for transport? .. Then why are you even there. She wants the child transported she has two options Transport the child herself or go with the child. The child is not enough distress that immediate care needs to be performed. R/r 911

So from what I can understand it is basically a- well check. No, I would not transport the child unless the mother wanted to go. The hospital is not going to treat the child without her as well there is no emergency. Sorry, it has nothing to do with her being illegal or not, rather practicality. R/r 911

Sure it was the IV?.. .. Back when I used paddles, I used to see them convert just by placing the cold paddles on them... even before I could shock them .. dang! R/r 911

Okay, if you do not have a AED or monitor you cannot assess for V-fib, so if you can't assess you start CPR. The reason for "no-airway, etc. is vigorous movement and as well as intubating can vagal the patient down (slow down a pulse rate, etc.) so one has to be very cautious on true hypothermic patient on the type of care. I suggest you read the special considerations from American Heart Association Health Care Providers book and that portion of ACLS and the new edition of PHTLS as well. It may be more advanced, but will give you some insight of current treatment and why. The main point on truly of hypothermic patients .. "their not dead, until they are warm and dead".... R/r 911

Ditto from what others have said and described. As a first responder, you may feel the need to "do more", in reality even with the additional education many of us, there is nothing more we could had done either. We are all first responders no matter what education level, license, etc when we are off duty.. Again, thank-you.. in case no one told you out there. R/r 911

With that in mind, I have enclosed the MEND's assessment checklist. The Advanced Stroke Life Support is attempting to promote such repeated criteria. It is more simplistic and informative than the Cincinnati and other stroke scales. The author was one of the authors of the Cincinnati scale and described it was never intended to be a indicator for determination of CVA, rather for epidemiology research. This exam does a mini-neuro and with the course one can learn more about the site of stroke and more assessment of SAH vs. NIS. For the full detailed assessment checklist : http://www.asls.net/forms/MEND%20Prehospital%20Checklist.pdf Initially a modified Cincinnati is performed, it is determined then if rapid transport is needed. The MENDS is performed enroute. Each one is done in order & repeated enroute. ED's can adapt to this as well. ASLS has a course for ED's, Stroke Centers, ICU, etc.. R/r 911

I agree with Mike, it is all dependent upon the situation. As well, who cares which is really done first or simultaneously. Insertion of an IV is more commonly an intervention, rather than treatment as Mike described, as well as a XII lead is part of an assessment tool. I personally attempt to obtain these basics simultaneously, I rather not administer NTG without a XII lead, checking of course origin of site of potential AMI. There is more than one medic on the scene, simultaneous things can occur. R/r 911

I believe this says it all....." The victim seeks economic and noneconomic damages.".... R/r 911

NTG is not contraindicated in right sided AMI's as many attempt to claim. Now, with that said, it would be illogical to administer it to a patient and potentially cause a hypotensive event and thus increasing oxygen demand and potentially increasing infarct size. I personally rather obtain a XII lead prior to any NTG administration, to prevent administration to a right sided or inferior wall AMI. It does not take long to obtain, and by the time ASA therapy begins, my ECG should be accomplished. Usually, (not always) one might see lower blood pressures associated with inferior wall, but not necessarily so. I personally still withhold NTG in such cases. In non-right side AMI, I prefer to keep them slightly normotensive ot slightly hypotensive (the old CCU nurse in me) and have no problems administering NTG with systolic pressures > 90 mm/hg. I have found a slight bolus (250 ml) or so actually increases preload in some right sided AMI and will actually decrease their pain. The old saying, if NTG and Morphine is making the pain worse, give some fluid and check to see if you have a right sided AMI. R/r 911

Well, I guess firefighter523 can not read. I posted the national guidelines and indications for lowering blood pressures in the field, which did not include ICP or resuscitation. We quit attempting to significantly lower pressures in the field over 10 years ago, as well as brain reuscitation measures are not reducing of hypertension, since we do not know their normal pressure state and the inability to lower it slowly. Rather emphasis have been to promote more brain perfussion. Even in the ED setting, they are recommending the BP be lowered at a slow rate and then closely monitored. I highly suggest looking at ASLS and Brain Trauma web sites for obtaining information on current treatment and modalities, as well as the discussion of NOT lowering pressure in the field setting, especially the use of nitrates. R/r 911

Wow what a lot of rhetoric rubbish. Sorry, when many of us first joined this site it was primary volunteers and 90 day EMT's that did not know tidal volume from acetylcholine. Guess what ? The numbers increased because we have policed this area with promotion of professional pride, education, and the recommendation of use of grammar and spelling, so we at least can come across as a professional. If you want to know why people leave EMS, then I refer you to check other previous posts and sections. Dumbing down courses or watering them down was in direct correlation to volunteers. If you would like I will cite the scientific finding(s) ... i.e. the Montana Study, Nebraska Study, Vermont Education review; the 1994 NHTSA EMT Curriculum Revision...The same reason(s) The National Scope of Practice became diluted and finally failed. So please check your facts first, it was not because "holes" or job openings as you stated. R/r 911

Okay, let's stop with the unscientific facts and potential dangerous treatments. This was supposed to be tricks of the trade, not wives tales such as using drinks with caffeine and scaring people. As well as Azcep describes some as physiologically impossible if not dangerous. Stress induced asthma as per stress with fright can cause a sudden catecholomine response releasing histamine, and can actually increase bronchospasm. Also caffeine is NOT recommended for those that have a history of asthma, as well. Underlying previous administerd medications along with caffeine can cause an increase in ventricular rate, over stimulation, etc. thus causing further complications and the possibility of preventing further treatments that could had been administered. Let's keep it real folks, unless you have solid literature or respectable citations, let's not give unfounded medical advice. We attempt to make sure that treatments are in concurrent with most medical standards. R/r 911

Some of the controversy is the determination and differential of SAH and AIS. I just became an Instructor for Advanced Stroke Life Support. Part of the curriculum is to NOT lower blood pressure in the field setting. I believe the cautionary approach is some of the difficulties in differentiating between such. However; with improved history and neuro assessment, this should improve field determination. I do wonder on the effects of rapidly lowering the BP versus of maintaining MAP and attempting to decrease ICP? Of course with mortality being of 50% and morbidity of 25%, a need of aggressive treatment needs to be discussed, in which I have seen very little. In fact, treatment modalities have actually shifted opposite direction in the past few years. Not attempting to hijack a thread, I thought I would add the ASLS thoughts on ASIS patients and the thoughts of HTN : According to Stroke 200334:1056: Hypertension & AIS ASA Guidelines Based on ANECDOTE In the text of article, guideline authors state: > Little scientific basis or proven benefit to lower BP in ASIS patients In general. do not lower BP : the 5 exceptions include > Aortic dissection, acute renal failure >Acute pulmonary edema, acute myocardial infarction >Hypertensive encephalopathy (which is very rare) No data to define BP values that mandate emergency Rx Yet they further state: Consensus based on level V (anecdotal evidence) treat if SBP is >220 or DBP is >120Recall that patient outcomes worse if the BP is decreased in first 24 hours of AIS. In hospital settings after diagnosing on type of cerebral injury is made, then a more appropriate determination of HTN can be made. Of course one wants to reduce the chance and increasing ICP, but making sure as in the case of AIS injuries of not excessive lowering the BP damaging the penumbra. If considering t-PA and have met then sustained BP> 185/110. It is mentioned that meds such as Nicardine and Labetalol may be considered, and I won't go into detail, since this is ED tx and off the topic. I hate SAH bleeds, and those that massive tend to ruin my day and rain on my parade. Since we have an encapsulated bleeding inside the skull squeezing the brain there is very little we can do. Unfortunately, they will not let me carry my Black and Decker, and although I have seen anecdotal success in osmodiuresis (Mannitol) and diuretic therapy, with maintaining decreased CO[sub:f512c098c8]2[/sub:f512c098c8] work, I am aware of the controversy and dangers that has been presented with that treatment regime. The last therapy I was informed of, was the focus of brain resuscitation measures of maintaining brain perfusion including fluids and potential blood, which is contradictory to what some have been taught. R/r 911

Why would a full time Law Enforcement agency be doing EMS, as well as paying per call? With that many calls a full time EMS could exist, with proper billing know how. EMS does not need to be in Law Enforcement agencies, we have a hard time attempting to justify it to be in the Fire Service. Discussing the amount of money is irrelevant. Dependent on cost of living, benefits, is essential in determining. I know of Paramedics making $32K a year and would be considered good money, and in some areas making >$75k and be considered average income. It is all dependent on your region. R/r 911

Well, I won't give my costs since it was before a lot of you were born.. and the average salary was $2.10hr and gas was 40 cents a gallon. The college I did graduate from now costs $73.00 credit hour and Basic is 6 hours, and Paramedic degree is 63 credit hours. Additional costs for books, lab fees, etc. Ironically, most assume attending the Vo-Tech or business school here is cheaper, which it is not and then they don't have the degree in return. R/r 911

Ditto to what Doc said. There is no absolutes in medicine, that is why it is part science and part art. R/r 911

I still wear Hai Karate, does that count?.. (now, I am showing my age) R/r 911

That is true, however; they are paying a high dollar base rate. Whenever a nurse hears "Baylor Plan" one usually knows this is a no benefit package etc.. Rather the money will be the perk and at a high rate. Baylor plan used to be called the .. "Grand Week-End".. meaning, you work the week end you get a grand! (This was the amount 10 yrs ago) When comparing 24 hours and getting paid for 40 hours at a $25-30/hr is not bad pay check. The reason I am describing and emphasizing such, I would not call it or advertise it as a Baylor Plan, rather a routine shift on week ends and week day shifts. Personal used to the name Baylor Plan may be expecting higher pay..without the benefits. Good luck in your services dilemma R/r 911

LOL !... Maybe we ought to have some tape, with pre-printed outline and lines on it, then tear here... I am sure there would be someone to buy it! R/r 911 (p.s. if anyone does this, AK & I get a portion of the profits!)

Check out www.dt4EMS.net He is a Paramedic that is a member of this site, that offers self defense classes and courses designed for scene safety in EMS. I highly recommend that you visit his site and maybe have your state EMS offer his courses at local conferences etc.. Good luck! R/r 911

The only difference though, is the Baylor plan in nursing (as named for the Baylor Hospital in Dallas) is you work week-ends at time and a half or double time pay rate, not straight pay. Remember, unlike EMS most people (including nursing) will offer week-end differential and any thing that is over shift time (day) at a shift differential (evening & night shift diff rate) so yes, most nurses get week-end pay and anything past the daytime shift as added shift differential, when you see them on the week-ends. I have worked the Baylor plan @ Baylor and was paid healthy, the only down fall was they did not withhold taxes.. but, I can live with that :wink: .. I would be sure that you are not screwing your self, working all the week-ends. Sounds like management needs to re-evaluate the pay structure or personnel roster. Usually, most people rather work part time on week-ends. We work a modified Kelly shift of 24 on 24 off for three shifts, then 4 days off straight (10 work days a month). We get paid the full 24 + overtime anything over 40 hours. This means usually at least 8 to 16 hours per pay period. Our PDO is based at 0,10 hr per working hour or basically 1 24 hr shift per pay period, so one accumulates PDO easy enough, the more you work the more days you will have off. We cap it off at little over 180 hours. Most have plenty in reserve. The problem is when taking off, you immediately loose all over time for that week. This is a Federal benefit to employers, and one has to be sure to take time during the lower hour rate to keep from loosing money. R/r 911

Your question is very valid and I am not making light of it. Sometimes, you have to just wonder about the ole heart. It does what it wants to do, you will find out as many cardiologist describe it can be very unpredictable and who knows why? As discussed, sometimes when the intrinsic rate falls below, usually the next firing mechanism will pick up. However; not all the time and the heart will re-set itself. Like I describe as "re-booting" in computers. I believe it is all dependent upon the cardiac tissue of automaticity to detect if another pacemaker needs to fire or a clearing of the system and resetting itself is necessary. This of course can be dependent upon the fluctuation of depolarizing and as well as on how much is needed to regain firing on the absolute period. R/r 911

http://www.jems.com/Columnists/Werfel/articles/278341/ I thought this was an interesting finding Paul Werfel discussed in his article in JEMS. Apparently, the verbal point may be a precursor or indicator on how well a student might score. Interesting finding as well that mathematics score was not as necessary in this testing, that might be needed in other health care professions and other interesting findings. I have asked in the past of those institutions that require pre or entrance examination(s) now I am enquiring if you have seen a correlation between the two as well or even have performed a comparison? As instructors and professors, is this something we should explore as a valid screening tool or at least placement tool? Maybe a hint on points of emphasis or lateral courses to increase the grade or pass of certification examinations. Discussion? R/r 911

I agree that there is alternative ways on treating this scenario. Not saying one way or another is better or clear cut. Personally, I have seen many cases of accidental or even intentional overdosing, (the cause is immaterial), with such I have seen Morphine and most opioid products respond very well to Narcan and relatively usually in small doses (0.4mg-<2mg). My objective is simple though, to see if it responds and to only titrated my treatment to correspond to respiratory and maintaining them hemodynamically stable. Really, the only danger would be those two main objectives. Even in the ED setting our treatment is conservative, and we rarely intubate if we know the cause and are able to improve the respiratory drive and LOC enough so the patient can control their airway. Continuous monitoring of course, as well we are not attempting to reverse suddenly as to cause those potential side effects of sudden withdrawal. Extubation and the problems of associated with intubation should be heavily considered before attempting. Usually, we allow the medication to wear off with time. Again, like ERDoc discussed everyone can armchair quarterback. As well, each of us might have treated differently given the situation. R/r 911

Not to be knit picky, but truthfully EMT's do not have a "scope of practice", with that saying there are general guidelines for each level of practice. No, I doubt there should be any limitations on assessment and knowledge, but there is practicality and appropriateness. The same as a ER physician can order and perform several tests to rule out and diagnose long term illnesses that would not be appropriate to start long term treatment. Rather the physician can make an initial assessment and diagnosis to refer. I probably assess more in detail than others. Yet, I know when it is appropriate and warranted. Checking the cranial nerves on a CVA and not knowing or being able to report and understand and then possibly treat those findings worthwhile? Again, my suggestion is to keep it practical and use good common sense that it is applicable to that situation, not causing delay and attempting to go past your level of license or certification. R/r 911