Asysin2leads

I blame it on a lack of fundamentals. The Wal-Mart/McDonald's attitude towards EMS has boiled Anatomy and Physiology down to being able to pick the right letters on a multiple choice test. No matter how chaotic the scene, its pretty obvious if the tube is in the esophagus or the trachea, if you know what you're looking at. A diagram in Brady's is a far cry from something looked at upside down, in the dark, with loads of secretions.

John Cleese, from "How to Irritate People": "A friend of mine was demonstrated something at a party. He stood in the middle of the room, and said very loudly 'The problem with women is that they take everything personally.' Three women then responded 'Well, I don't!!!' " Lighten up, its all in good fun.

Fuck it, call for two more ALS buses, treat the 20 year old, 4 year old, and 3 year old. Let the guy from the RV die. He's old and he shouldn't have let his friend drive. Lose certification, go home, sleep soundly, apply for job at Denny's.

I really don't see a problem with an EMT sitting in on an ACLS class, nor would I imagine an instructor would either, if the EMT agreed that they would not be privy to anymore rights or privelages than if they had not taken the class, and they did not needlessly bog down the pace of the class with questions that could be answered by a higher trained provider. Education is a good thing. However, ACLS is a pretty nuts and bolts class. It really doesn't delve that much into the understanding behind why we do what we do (as it is assumed the person taking the class already knows that), and since you really won't be able to use the procedures in your scope of practice, it won't really matter. Then again, I took PHTLS when I was an EMT-B and got to practice a few intubations on dummies. Not that it ever helped me, but it was really fun.

Oh s--t, mediccjh, that's too funny. I refuse to answer on the grounds I may incriminate myself. Thanks for the feedback, all.

This is a follow up post to "Call from hell...", the two fit together nicely. Today, dispatched for a cardiac, arrived to find 56 year old male sitting in wheelchair at work (works as a security guard) AOx3 reporting "trouble with his heart" that he knew was occuring because he had gotten sweaty. Had a cardiac history, was previously treated for a rapid heartbeat, but could not elaborate. Pt. in no obvious distress, more annoyed that he was being embarassed at work. Was coming rushing into work today when he felt dizzy, lightheaded, and started sweating. Sitting down made him feel better, however, he still felt "not right". Reported mild discomfort in chest and left arm, 2/10, did not take anything for relief. Negative nausea, vomiting, negative headache, still dizzy Skin is cool, pulse is rapid, weak, blood pressure 160/120, HR 150, lungs clear bilaterally, SP02 98% on room air 100% on NRB. EKG shows borderline SVT/Sinus Tachycardia, around 150, 12l lead showed borderline ST elevations V2, V3, V4. History of NIDDM, HTN, takes antihypertensives, glucophage, compliant. No allergies. PE: pupils equal, reactive, negative cyanosis, negative JVD, trachea midline, negative accessory muscle use, equal chest expansion, lungs clear bilaterally, abdomen soft, non-tender, negative incontinence, PMS present x 4 in extremities, negative edema. I had the weirdest sense of deja vu, another diabetic presenting with a borderline SVT but in no obvious distress. I was on my guard like Macauly Culkin at a Michael Jackson sleepover. Administered 02, 10 lpm via NRB, established IV 20 gauge on a knuckle vein, the only site available, trust me, I searched high and low for a better one, but he was a diabetic, obese, and had nothing for periphery. I elected to treat for an MI, giving 162 of ASA and 400 mcg S/L of NTG, no relief. Heartrate had then increased to 176. I really felt deja vu. Administered 6, 12, and 12 of adenosine, patient reported he could feel it working, but there was no change in the rate. Heartrate had now increased to 180. Pressure was stable, 140/120. Pt. reported increased discomfort in the chest, now at 5/10, then 7/10. Elected to treat for possible continued ischemia and repeated NTG administration x 2. Had my partner contact telemetry for diltiazem and repeats of the nitroglycerin, and morphine. I closely monitored the blood pressure to make sure he did not go hypotensive due to the NTG, he maintained at 140/120. Granted orders for diltiazem, 25 mgs, denied morphine or repeats of NTG. Administered the diltiazem, and within seconds his rate was down to 76. He reported immediate relief, so much so that he didn't even really want to go to the hospital. We convinced him it was really advisable. As I listened to him talk to his wife on his cell and complain he had to go to the hospital, I knew I had done the right thing, and in a way, felt redeemed. Of course, no good deed goes unpunished, and I had a later telephone Q&A session with the telemetry physician about "exactly what protocol I was working in". NTG, ASA, and morphine fall under our chest pain protocol, while adenosine and diltiazem fall under our SVT protocol. I got a nice lecture about not "jumping back and forth." The attending physician at the hospital did not have a problem with the NTG administration or treating for an MI, so my question is this, do you think I was out of line to think outside of the box and try and treat both the SVT and ischemia with the evidence presented? Is there an absolute contraindication for morphine and diltiazem? I know ACLS suggests treating with a beta blocker after Morphine, Oxygen, Nitroglycerin, and aspirin, if needed, what about a calcium channel blocker? Was there a medical reason for raking me over the coals for actually thinking about my treatment and not just cookbooking, or was the doc just mad that I was not being a good little soldier?

Look, I agree, its not fire bashing, especially for me, its just that some people have such a lack of a life that they write stuff like the above. I know plenty of ff's who would read that and puke too. Suprising as it is, many of them, just like us, prefer to spend their time DOING THEIR JOBS rather than trying to be heros. I think it would do the whole public safety field a world of service if we took all the slogans, and the T-shirts, and the syrupy inspiration stories, and put locked them away for a while. Stuff like that breeds people with many bumperstickers and lights on their cars.

Dude, I'm still 'celebrating' St. Patrick's day and even I'm still not drunk enough to think that was touching. Here's a better one: My girlfriend (shocking, isn't it?) used to volunteer at a pediatric cancer ward where she lived. One of the kids really liked ambulances, mostly because he had ridden in a lot of them, so when she told him what I did, he thought it was really cool. She was in a different city at the time, or boy howdy, you know I would have visited the little tyke, but instead I loaded up a packet of patches and ambulance stuff for him. When I came home one night for my nightly phone call to her, she was crying her eyes out, and when I asked her why, she said my package had come that day, but "he never got to open it." Real life somehow is always more poignant than what gets circulated on the Internet, no?

As for nobody owning a car in NYC, you've never been in rush hour traffic on the Franklin Delano Roosevelt Drive ("the FDR"), the LIE (Long Island Expressway), the GCP (Grand Central Parkway), the 'Wyck, the Deegan, the BQE (Brooklyn-Queens Expressway) "Trench", the Interboro/Jackie Robinson Parkway, and (dear to my heart) the "Belt". I've left a few of the major highways, expressways, and parkways out of this list, but others living in or near NYC will let youse guys know! Or the times I've pulled onto second avenue, taken one look, and muttered something to the effect "Man, I hope no one is in cardiac arrest right now"

I was told once that if someone won't quit tailgating, pull over the ambulance, get out, and tell them you will not continue if they stop. Its unfair to the driver to have the added stress of watching someone do stupid things behind them. I'm not sure if there is any specific case law written about or for non emergency vehicles drafting emergency vehicles, if you run a red and cause an accident following your dear sweet grandmother to the hospital after the ambulance, I'm sure it would probably be treated the same as if you ran the red on your own.

Same with me, despite being told otherwise by the ER doc, my captain, and even my medical director, I still felt like there was something I should have picked up on, or something that could have been done differently. This guy was indeed an 'East Indian', I think without sounding too racist, his normal skin color may have masked the onset of pallor, but there was no diaphoresis, and he was wearing about four layers of clothes which probably masked the fact he actually had cool skin. One thing that was interesting was that his sat would occasionally dip down to 85%, but when I see an 85% reading on a conscious, talking patient in no obvious distress, I tend to think the machine is off, particularly on a diabetic. You know, when people think of the stress paramedics have, they think of cardiac arrests, gory car wrecks, and the like. That's really not the case, most cardiac arrests, unfortunately, are really dead to begin with, and once you see a couple of traumas you've seen all of the traumas. That you can get used to. For me at least, calls like this are one of things that puts paramedicine, more so than almost any other field, so high in the stress category. It's like Russian Roulette, almost, give me a couple of months of homeless people complaining of difficulty breathing (or was it chest pains? Oh no, maybe their feet hurt) in the subway, and then drop this guy in my lap. It's taking me a little while to get over this call.

Okay, so here's how my life is going Call for difficulty breathing in subway. Upon arrival find a 60 year old male, indian, sitting comfortably in no obvious distress chatting with attending officers. Pt. states he has been having trouble breathing the past few nights. Quick pulse check reveals tachycardia, around 140, skin warm, removed to ambulance on stair chair on oxygen, because trying to do an assessment in the subway is next to impossible what with the screeching metal wheels and all. In ambulance, oxygen therapy continued, pt. reports having trouble breathing times 3 days, gets worse when laying down, denies chest pain, denies nausea/vomiting. denies headace, no history asthma, cardiac history, bronchitis, denies fever, denies, being sick. Has had surgery on his left eye. Reports history of type I diabetes. Difficult to gather complete information due to language barrier. P 148, RR 22, BP 140/90, SP02 95% on NRB. Physical exam reveals right eye cloudy due to cataracts, left eye reactive to light, negative cyanosis, negative JVD, trachea midline, mild accessory muscle use, pt. unable to take full breaths, auscultation reveals fine crackles in left lower lobe. PMS present x 4 in extremities, no edema. Skin warm, dry, unremarkable. EKG: Sinus Tachycardia/SVT rate hovers between 148 and 154. 12 lead unable to analyze due to rate. Established IV access 20 gauge in left AC, pt's only complaint is he is having a little trouble breathing. Attempted vagal maneuver, no response. My presumptive diagnosis tachycardia secondary to possibly a pulmonary embolus. Given his mental state, his symptoms, and his blood pressure, I chose at the time to NOT treat for an SVT outside of the vagal maneuvers, and transport. En route, pt. complains of increased difficulty breathing. Heart Rate is now 176, blood pressure 170/100. I now administer 6 mg of adenosine, no response, arrival at hospital preempts repeat doses. Enroute to bed in hospital, patient goes into arrest. Respiratory arrest, definitely, cardiac arrest, possibly, although he'd be the first person I ever seen have ROSC after 10 chest compressions. Who knows. Pt. is now intubated, rate is 184, BP 220/120. A few minutes later he is spitting up the pink froth of serious pulmonary edema, chest X-ray shows he is filled with fluid. Synchronized cardioversion attempted by ED staff, no result. Later, I am told pt. is in cath lab, he was having an MI. I assume because he was a diabetic he didn't feel it. Hindsight is of course 20/20 with this guy. Comments? Anybody have any similar experiences with the so called 'silent MI's'? How about flash pulmonary edema? Want to know what my heart rate was when I watched a patient who a few minutes ago was sitting up talking to me, and is now in cardiac arrest after I treated him?

The correct way to document this would be to state "Strong suspicion of drug overdose" if that is what your presumptive diagnosis is. The way I swing on this issue is, I'm not a cop, while I work closely with the police and I am mandated to report certain crimes (child abuse), reporting evidence of a crime such as drug use in my capacity would be a violation of patient confidentiality. I have had heroin users toss their needles in the sharps container before we enter the ER, there have been many a pot pipe, crack pipe, and and little baggies disposed of in my presence after a physical exam. Drugs are illegal, you also really shouldn't do them, but it's not my place to enforce drug laws.

I suppose the forehead would be out of the question. Why not just use a Sharpie on the forearm when you think you might be in a situation such as mountain biking where a necklace might get torn off? I write on my hand all the time. You there, stop laughing.

I had one poor 86 year old lady who set her shirt on fire, 1st degree burns to half her chest (9%), with pockets of second degree and localized third degree burn. Covered with Vaseline by home health aide s/p being burned. We took her to the shower and used a gentle stream of water to try and remove gross amounts of the Vaseline, as we believed it was still trapping some heat. It worked with mixed results. I suggested using a mild emulsifier (baby shampoo) to try and break up the oil and do some impromptu decon, but my partner, not being as adventurous as I, said we had to work in protocol. I still think it woulda worked.

OFFICIAL REQUIREMENTS: Run 1.5 miles in 10 minutes Benchpress 95% of own body weight 40 push ups in less than 2 minutes 20 pull ups without stopping 2 mile swim Oooops, wait, that's the requirements for the Navy SEaLs. Don't sweat the physical test. Some of the people who get on look like they're the ones who are going to need the ambulance. If you can crack your knuckles without getting winded, you'll be all right.

You know, I once had this small fear rattling around in the back of my head, that lay people tend to confuse 'heart attack' with 'cardiac arrest', as in a story will list someone as 'having a heart attack and dying in front of me,' when of course it should say 'went into cardiac arrest and died'. So I had this fear that someone would learn CPR, and figure that is proper treatment for a heart attack. I thought, this is silly, but, knowing the people in CPR class, well... So I'm working and this nice lady comes up to me and says she learned CPR. I congratulated her. She also said that she had a member of her church group, who had problems with his heart, he started sweating and had to sit down, said he felt like he was having a heart attack, and she wondered, should she have started compressions on him? True story. I can't make this stuff up.

Quite frankly, if someone is in the care of good ALS, I'd rather them take the ride to a place with a cath lab. IV, Morphine, Oxygen, Nitro, Aspirin, 3 leads, 12 leads, bloods ready to go, tell me why exactly we need to stop at East Bumblecrap General if the hospital with the cath lab isn't to far down the road?

Remember that whole part about misfeasance, nonfeasance, good samaritan, etc. etc. that was covered in like the first chapter of EMT class? Go back an reread it. Maybe you need to fill in some more info, but you said "he did CPR, and the guy died." As stated before, he was already dead. If your friend did CPR on a LIVE person, and killed them, yeah, he's in some trouble, boy howdy, no one has a sense of humor about that stuff anymore. CPR doesn't kill people. Paramedics do.

Remember the old adage, treat the patient not the numbers. I can fall off of a 3 foot ladder and be no worse off than a long streak of curse words. An 87 year old can fall off the same ladder and be worthy of a trauma note. I once had a nursing home slip and fall from standing who managed to split her parietal suture. She was a trauma note.

I can't find any pics for you, but I can give you a fair description... Track marks are not to be confused with puncture wounds or injection scars, all of which may be present on an IV drug users arms. Track marks, in my usage, are when the carbon residue that occurs when the drug is heated and injected actually 'tattoos' the vein and surrounding tissue around the vein to form a black shadow of the vein as it travels up the arm. My best description would be akin to when someone gets 'borged' on Star Trek and those black veiny things form across the face and arms. To get a make up effect, I think the best way would take someone with easy to see veins (a pale skinned Irish type like me works the best) and use perhaps an eyeliner pencil or a light charcoal pencil and trace along the veins that are visible through the skin. Good luck!

>

>Asys, >I found your Risperidone, have you been non compliant again? The Welbutrin made me quit smoking, the Zoloft didn't work, the Paxil gave me shakes, and somehow I'm still a jerk. Now that's poetry. I'm going to send that one into the New Yorker.

Cindy, e-mail me at asysin2leads@yahoo.com and I can try and get you arrangement info

This video really made me sick to my stomach. I think the worse part was hearing the little kid in the background who seemed to have a better handle on the situation than the guys on the line. I really think this video needs to be mandatory video in all firefighting and/or EMS classes.