fiznat

In response to Tom:

Heh, it's actually post-morbid. This is a ROSC 12 lead from one of my very few code saves. In any case, it is still a wide complex tachycardia. I wouldn't (and didn't) treat this patient with antiarrhythmics either, but I am curious as to your rationale for so universally avoiding medications for these patients. ACLS still says that we should be giving drugs to those that fit in the "stable/symptomatic" category, and those guidelines were produced using the most up to date research available. If you (or anyone else) are going to go off on their own treatment paths, say cardioverting "early" or waiting on the drugs for a patient who remains symptomatic, I wonder what resource you would use to justify your decisions if things went downhill and the fingers start pointing at you. We're not physicians. Right or wrong, we don't get to make up our own treatment modalities. Don't take this the wrong way. I respect your assessment of the rhythm and I understand exactly your academic perspective. Still, shouldn't paramedics stick to the guidelines regardless of how many articles they've read? I think it's a good discussion....

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Another wide complex tachycardia. Would you feel comfortable about "ruling out VT" in this one? Say it was stable/sypmtomatic, which anti arrhythmic would you pick? (and don't give me that crap about cardioverting everyone, that's no fun haha) By the way, why was this thread moved to scenarios when all of the other "strip teases" remain in the patient care forum? Can we just decide which one they all go in, and leave them there?

I'm not sure I agree that this ECG has extreme right axis deviation. I use two methods to determine QRS axis, and by both methods this axis is in the right axis (bottom left quadrant), about +150 degrees. Method 1: The quick method using I and aVF. Negative lead I means that the axis is pointing away from the left shoulder, towards the right. A positive complex in aVF means that the axis is pointing downwards. Down and to the right is right axis deviation, not extreme right axis deviation. Method 2: Isoelectric lead. The most isoelectric limb lead here is lead II. The mean QRS axis should be at about 90 degrees from this lead. Since lead II is at about +60 degrees, our axis in this ECG should be about +150 degrees. By your own method ("leads 1, 2, and 3 all negative = ERAD") this still doesn't look like extreme right axis, as lead 3 is positive. In any case, I agree with you that this is still VT.

Try making your text white. The user will have to highlight the text in order to read it. Example below (highlight it!): SECRET MESSAGE REVEALED, IT'S VT!

Any antiarrhythmics? I've had some really good luck with both Adenosine and Cardizem.

There is this, and there is the AHA. I guess you need to decide which to believe, and follow your protocols. Neither this statement nor the AHA's is backed up with actual objective research, but that is because it doesn't seem like such research actually exists right now. In choosing between two sources of anecdotal opinions like this, paramedics probably should just pick the one that favored most in your local area. My protocols say to give amiodorone, so that is what I will do (if it can't be avoided).

I messed up my vote, sorry! I misread the question and voted "yes" when I should have voted "no." I think the answers should be posted in the original topics, to avoid clutter. If you want to obscure the answers you can highlight them with black so that users need to specifically "reveal" the text before they can read it...

Regular, wide complex tachycardia at 120-130ish. This is either going to be VT or SVT with abbarancy. This one I think I would call VT because of the rightward axis (about +150 degrees, so not extreme right axis), and the reversed R wave progression through the precordial leads. Wide complex tachycardias are notoriously difficult to identify though, so I admit I could be wrong about this one.

Ahhhhhhh I'm not so sure. Believe me, I understand where you are coming from, but I think we ought to be honest about what we actually do out in the field. I'm all about the medicine, I subscribe to and read academic journals, I research things I don't know, and I care a lot about the quality of my care. Still, I've found that the decisions I make in the field often have much more to do with operations than they do with medicine. I make decisions about WHEN to do things, and less often WHAT. I make many more decisions about HOW to do a procedure, and less frequently WHICH procedures to perform. I think it is a bit dangerous to assume that we are out there actually practicing real *medicine.* We're not. There is a reason why we have such detailed protocols and algorithms: because the education is simply not there for us to make truly independent decisions regarding plans of care. The area where I feel like I actually make independent (and important!) decisions is in operations. This isn't to say that medicine isn't an important part of the job, and shouldn't be emphasized and respected, but I really feel like operations is at least as important, and is something that people new to this field should establish first.

I'm not saying it isn't possible. I just think it is ill advised. You're not supposed to build a foundation at the same time you build a house. That's why it's called a foundation- it needs to be there first. The "respect for the job" that I mentioned earlier should come an honesty about how much a person can/should handle at once. Managing the medicine is stressful enough. The stress of being new to scenes and ambulance operations shouldn't be piled on top of that. ...And I think doing so could potentially be dangerous to both provider and patient.

I've helped proctor a few national registry exams, and I'll tell you around here we let people know why they failed. You should probably consider the possibility that this incident has more to do with your local administration than it does the NR altogether. That said, when you take the MCAT (or any other professional exam) you don't get a detailed report back listing the exact questions you got wrong. You simply get your score. National Registry practical testing isn't so complex that people shouldn't be able to learn the sheets and do well. If your friend missed three stations, chances are he did something stupid in each one and he should probably practice the sheets a little more before he goes back. Even "good students" are capable of making mistakes. Is it really that big a deal?

Someone else answered but to reaffirm: the line can still be patent even though it doesn't draw. Usually good lines will draw blood, but not always. As far as who's fault this was, I think you already know the answer. Of course it is the nurse's fault. Not only from the specifics of your story, but also because as a student you are working underneath that nurse who is responsible for everything you do. That said, who gets the BLAME will be a different story. You are the low man on the pole and even though it is unfair you will most likely get blamed for the whole thing. There really isn't anything you can do about it. As long as it doesn't effect your ability to continue working and learning, I think you may have to just suck it up and move on. It really isn't that big of a deal anyways.

My experience has been that the difference between a good paramedic and a bad paramedic boils down to one thing: respect for the job. I have found that respect for this work tends to motivate people to pursue additional study, encourages people to be constructively critical (and honest!) about their mistakes, and instills a sense of humility that so many in this field seem to lack. I believe experience and education are the foundation for good medicine, but in the end it seems those that WANT to do well, do. Those that don't care, or are (as a result?) unwilling to put in the effort, don't. That said, I believe paramedic candidates need at least a year on the job as an EMT before they move on. My reason for this is because this job isn't simply about the medicine. In addition to caring for patients, we need to know how to handle a scene, to be aware of our surroundings, to elicit histories from uncooperative patients under stress, to properly handle equipment, interact with other medical providers, and coherently write a report. There are logistics to this work that students ought to have mastered before they attempt to build on them. Paramedics are tasked not only with managing the medicine, but also to function as a leader on scene. For that reason, I think we need people who know their way around a scene and an ambulance -- so that they can focus on the rest.

No, but thats really a different situation... I don't doubt it, but discussing something on an internet forum and actually making that decision (and taking the potential liability for it!) in real life are different things. Those docs may be able to sit in their armchairs and speculate about the chances that a traumatic arrest will see ROSC, but when it comes down to it I bet each and every one of them would want to make sure that there were no reversible causes- and that requires an ED.

The AHA has a section on this in their most recent (2006) guidelines. This is the same place we get our ACLS algorithms from. Part 10.7: Cardiac Arrest Associated With Trauma

8 pages later I'd like to reaffirm that I believe this patient should absolutely be worked. I know bringing up our individual protocols is generally not looked on well here, but I do find it interesting how widely our protocols differ on this subject. It seems that some people work under physicians that would like to never see one of these patients come through their doors. By contrast, my protocol specifically identifies traumatic arrest as a type of cardiac arrest that we will generally always work. It is right there listed alongside cardiac arrests due to hypothermia and electrocution. Protocol aside, though, I think it makes good rational sense to work this patient. I think it is important to remember that "calling a code" is one of the most profound and final things we do. Even though EMS providers in general tend to take it somewhat lightly, this is one of the few decisions we make that we REALLY can't take back if we make a mistake. That said, I think we should be extremely careful when we decide to go down this road, and be fully aware of the consequences of a potential mistake. In a situation like this I think we have very little information or reason to stop resuscitation. PEA (or even asystole, really!) doesn't mean a patient is beyond help, especially if there aren't any major physical deformities. We simply do not have the tools on scene to fully eliminate all of the reversible causes. This guy needs (and I would argue, deserves) more than we can give him.

I'm sorry, but how can anyone justify not working this code? "Traumatic arrest" does not equal "we can't do anything about it." Not in the least! Unless this patient had "injuries incompatible with life" (like decapitation, transection, ejection of brain matter, etc) which it doesn't sound like he did, this patient needs an ED assessment and potentially an OR. It isn't up to us to decide what can and cannot be done for this person when he gets to the hospital.

What are some of the qualities you've noticed make good preceptors or FTOs (whatever you call them where you work)? Have you had an especially good or bad preceptor before? What was it about the experience that made it good or bad? What advice would you give to a new preceptor? (btw I'm talking about both preceptors as those who train new paramedics, as well as those who train new employees)

Ive done that. I carry a pocket drug reference guide but sometimes it is just easier to google. I do it sometimes with diseases I've never heard of as well.

Nicely put sir. I have a tough time believing that any 17 year old possesses the maturity necessary for this kind of job, but I admit there are always (rare) exceptions. In any case, the above poster is right: there are a lot of other things you should be thinking about doing right now other than worrying about your next few months as an EMT-B.

There is a demand! I have some interesting ones as well, we could do some tag-teaming of it.

LOL I did a call JUST like this last week!!

If this were EMS, and that dispatcher worked for a private service, he would be fired without a second thought. I suppose the fact that he wasn't goes to show some of the differences between private and municipal public service.