usapride2004

ahha, well, clearly, if you did not know that you were supposed to attack, then you must be an ub3r n00b. I love typos

I don't palpate the artery anymore. I have a decent idea where the scope needs to be, so I just give it a go. If I have a problem hearing it, then I'll give it a feel. As for how high to pump the cuff... I usually go to about 200 mmHg, give or take. Why? Psychologically pleasing number, lol.

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Of course you would have suction ready. You ALWAYS have suction ready when managing an airway. And, you just listed all the reasons why I said I try to avoid bagging conscious patients.

Rate alone is not enough to determine the need for a BVM. Look at your patient, is he perfusing? Is he cyanotic? Diaphoretic? Pale? How is he mentating? What are his other vitals? What kind of hx does he have? You have to look at the bigger picture and not get tunnel vision. There is no formula for good patient care. For example, last week I came down with gastroenteritis and a upper respiratory infection (thank you nursing homes!). When I got to the doc I was at 44 bpm. I was short of breath and needed some O2, but I didn't need to be bagged. I had a patient this afternoon, CAOx3/3. Seemed just dandy (he was quite hypertensive--call came from a outpatient surgical center) RR=40 bpm. Did not need a bag. He got 2 LPM via NC and was just fine. In this case... did the pt have a hx of dementia that would account for the mental status? If no, then I would consider that enough to say he is not breathing adequately. I would much rather not bag the patient because based on your scenario, I say he was in failure. I'd rather not lay him down to bag him if I could avoid it. I would sit him up, get him on some O2, continue to ignore the nurse, whose opinion means more or less squat to me, and evaluate my patient. I can't say how I would treat this gentleman specifically, since I don't know all the facts and was not there, but I would not say that just because he was at 36 bpm that he needed to be bagged--he may have--but I don't know. And yes, you absolutely can bag a conscious patient. It's not the most fun you will ever have, but it is sometimes necessary. Just drop an NPA and go to town. If the guys GCS really was 5 (I am betting it was not, since it doesn't really sound like it with the info I have read)... you probably should have been bagging him. It seems this guy really needed BiPAP or CPAP and some pharmacology.

The way I figure it, if they need fluid, I'll give them fluid... if the don't, then why hang a bag? If it's not called for, it's just one more thing to get snagged while t/f the patient. All of my patients are getting a lock attacked to the drip set at a minimum anyway, so it's not even an extra step.

We just got it in RI pretty recently, and my company gives us enough for a one time 300 mg bolus. We have 2- 150 mg vials. We are required to have PVC everything to give it as a drip by protocol, and we need a pump for it as well. We don't have the PVC free stuff, or the pumps... so no drips for us. We can give the bolus through a standard IV line, however. I haven't seen the premixed glass vials thus far, but as I said, it's still pretty new around here, and it's still a med-control option, which is code for everyone is still going to use Lido.

Central lines are wonderful, but since you can place an IO in about 45 seconds, it's a great option for the emergency setting. That doesn't mean you can't also get the central line...

Psych patients need to be closely monitored, that's why they are in an ambulance. We have a lot of "swallowers" that we transport, and you know what happens if you aren't paying attention, they take stuff out of the cabinets and EAT IT. I know, it's happened to a colleague of mine. Guess who is at fault for THAT. My company does an unfortunate number of discharges and boring doctors appointments, just because the patient isn't actively dying, does not mean you should just ignore them. 1.) No patient should ever feel alone in an ambulance (as someone else said), 2.) I've had to divert quite a few patients being transfered for "non-life threatening reasons" to ERs because they developed a life threatening something-or-other. It happens all the time, and you know what, if you're not paying attention, you'll miss it. And there is a big difference between "can" be monitored, and "actually is" monitored. Yelling, "How you doing?" every few minutes is not the same as quality patient care. Regardless of the reason, you are equally responsible for the care of that patient. If someone wants to call me an idiot for caring about ALL the patients I transport, knock your socks off. I bet you can figure out what my opinion of your patient care is as well. As for the article above, if it accurately depicts what it claims to (accurate quotes, etc), than this guy is a tool bag, and has no place in this business. I know people like him, and I can't stand them. Anyone who would jeopardize the life of their patient like he seems to have, has NO PLACE in EMS.

Well, I don't have any sources for you, sorry, but I can tell you that one of the bog reasons for not using it is because it is inconvenient. Having to worry about PVC bags and the like...

You don't need O2 in your car. You can single handedly save the world without it. This is surprisingly common among newbies... if you want a bag... ok. Be reasonable, you just don't need O2.

I'm with you on this one 100%. Of course... it would be nice to have Adult IO access allowed in the first place... It's a paramedic only skill right now, and there aren't a lot of Paramedics running around Rhode Island. The primary ALS provider is the EMT-Cardiac, which I like to describe as "Paramedic Light" less training, most of the scope of practice. IO access could easily be part of the Cardiac scope of practice. I would love that.

It's a basic adjunct in RI, but my company won't buy it. They seem to think that it could cause issues with people using it on scene, and pissing off nurses at SNFs, subsequently causing the company money, because that's what it's really all about, not patient care... that would be silly

This is a very interesting topic. I live in Rhode Island, the smallest, yet second most densely populated state in the country at 1,003.2 people/mi[sup:d65e5f5c7f]2[/sup:d65e5f5c7f]. In out tiny little state (1,545 mi[sup:d65e5f5c7f]2[/sup:d65e5f5c7f]... and 32% of that is water) we have a total of 13 hospitals with emergency departments (not including the 7 other hospitals we have without ERs). Of those 13 ERs, we have one Level 1 Adult Trauma Center, Level 1 Pediatric Trauma Center, one Level 2 Trauma Center (trying to move toward Level 1 status), one Primary Stroke Center (certified by JCAHO), three fully functional Cardiac Catheterization labs (and a bunch more "diagnostic" catheterization labs), two hyperbaric facilities (one 24 hour--not including the U.S. Naval Hospital)... We have a pretty substantial hospital system. Yet, we seem to always have facilities diverting. The way we are set up, no more than 2 facilities in the north or south can be diverting at a time (our Level 1 is considered to be in both the north and south). Once the third facility diverts, it forces everyone open. The most I have waited because of this is about a half an hour... If I were waiting for 4 hours, I would be having a shit fit (on my way to another hospital). Lately, there have been a sharp increase in the number of diversions. I had never been diverted before 2008... it had just never happened. Now, it happens once a week to me... and God help you if you take a patient in when they are diverting... you'd think you just shot their dog, lol. It had better be a code... It goes to show that we need more/bigger ERs to handle to demand... and more staff to move patients faster. When I was doing my clinical time, my very first IV went into a 40's hispanic gentleman who came into the ER with chest pain. Pt was s/p AMI 3 months prior, and states that the pain is similar to what he felt then. Priority patient, right? Wrong. He got some ASA and NTG a couple HOURS later. I had thought that he had gotten it from the RN when I wasn't around... nope. He did get a stat 12-lead... whoopee! Sometimes I wonder if our patients would be better off if we just kept them in our ambulances, instead of bringing them to the damn ER, lol. That ER was diverting. That says to me, clear as a bell, that they are understaffed. Not to mention, only our Level 1 has any triaging procedure. I swear, no one else knows what the word means... So, back to the topic. yes, we have a diversion plan in place, and yes, it sucks being diverted all over the damn place, and waiting in bust ERs, and then watching your patient be ignored by nurses and doctors who are busy with other things.