fiznat

Where I worked, preceptors got $1 an hour extra all the time- regardless of whether they had a student or new employee with them that day. Only preceptors were allowed train new employees, but sometimes (and usually only at the request of that employee), student riders would get placed with non-preceptors. Those employees wouldn't get any extra compensation for that day, but then again it usually wasn't an issue because it was at the request of that employee. If you have a union and an established work practice that preceptors get paid for a given function, I would imagine you have a pretty strong argument against forcing other employees to do that same work without the bonus. That kinda of setup motivates the employer to train new hires/students with non-preceptors to save money, which should pretty much piss everyone off. Get people together on it and bring the issue to your union or management.

I disagree. The more proximal the better. It's closer to where the fluids and drugs need to go (adenocard, anyone?), and the closer your IV is to the trunk of the body the less the catheter moves around when the patient flails. There is no such thing as the "vein of shame" in an emergency.

There are still 3 other extremities.... Also, just because you have a proximal infiltrate doesn't mean you can't still go distal. How do you think the blood still circulates when you blow a vein? There are tons of collaterals, and big ones too. I agree it wouldn't be my first choice to go more distal, but it's a bit much to suggest the distal arm is vascularly dead after you puncture the cephalic vein.

I started lines in the AC all the time, I think it's a great spot to go. I found that there is almost always good access there, it causes less distress to the patient (compared to more distal locations), and there is oftentimes a fair amount of connective tissue surrounding the vessels so that they don't move around when you introduce the needle. If the anesthesiologist thinks two 18g IVs isn't enough, he/she should probably think about placing a central line instead. Same goes for any patient who is going to be a long-term intensive care admit who will need large bore access for the duration. Anesthesiologists are famous for being quite particular about these things though, so no surprise he/she had some sort of issue with what you did. I wouldn't worry about it. Two 18+ gauge IVs in a fairly proximal location like the AC is the standard of care for peripheral lines pretty much anywhere you go.

Hey PCP, Generally it is a bad idea to solicit medical advice on a forum like this. The people here do know a thing or two, but the person you really need to be talking to is your cardiologist. My understanding is that tachycardias have lots of different etiologies- from accessory electrical pathways, to mechanical strains, to neurological problems, to chemicals. All of these problems have different courses and different treatments. Get this taken care of by a physician ASAP, and listen to the advice you've already received. There is no way you should be still going to work and exerting yourself on codes. Next time you might not be so lucky!

Ride time on an ambulance is a common requirement for physicians doing their residencies in emergency medicine...

Everyone keeps saying that. Nevertheless, I'm charged with learning that stuff or I don't pass (just as you were). It is probably my 1st year naivete speaking here, but I like to think there is some value in learning, if only once, those foundational scientific concepts before we get to the practical stuff. I've been pushing drugs and sticking people with needles long enough as a paramedic. For now, I'm happy to put off the instruction on glove application and focus on some abstract science haha. With that said and in keeping on topic, there is noooooo waaaaay I have time for ANYTHING else in this schedule! If EMT were going to be added, something else would have to give. What would that be?

I'm currently starting my MS1 right now and I couldn't imagine throwing in an EMT curriculum on top of everything else. There's just too much. The EMT cert would be looked at like it was a chore and the experience would be wasted I think. I'm glad I had my EMS experience before school, but I really don't think it would be worth anything at this point.

lol some of these things, you guys definitely SHOULD have been taught in class! A few of my own: - The need for resilient patient advocacy in the face of everyone else (partner, police, supervisor, fire department, family) wanting you to take a shortcut. Don't ever get lazy or forget that your patient comes first. - How critical the turn-over report really is. Specifically, the first 10 seconds of a turnover report. You make an impression either way, but it is up to you to capture your audience or not. They won't wait for you. - How little we really know. Be humble. You are the brains and experience out in the field but anywhere else in medicine you are just an infant with an ego. Try to remind yourself of that on a daily basis. - Don't fall into the trap of eating out all the time. - That it isn't your emergency. People say this all the time in school but it doesn't really hit home till you're out there for a while. It is your job to be calm and retain the ability to look at things objectively. That means you need to stay above the hysteria by whatever means necessary. - How important it is to look and act professionally at all time. It matters more than we realize, to both our patients and our colleagues. - Continuing education. Do it. Not just the minimum. Find out what the outcome was with your patients and reevaluate your approach constantly. - etc.

12 lead? Axis changes? Did you get any strips with less artifact in the baseline? Those things would definitely help in determining the origin of the rhythm. What about other factors? Mental status? BP? Circulatory and respiratory assessment? H&PE? In order to decide where to go from here on out (especially in the face of a hinky ECG), I think it should definitely be prudent to talk about whether the patient was stable, symptomatic, or otherwise. Remember, your patient is not defined by their ECG. If this patient was symptomatic at all (not unstable of course) and fluids haven't worked, I probably would have done a trial run of the atropine. *Maybe* call on-line medical control beforehand but possibly not depending on how the patient looked. 0.5 mg of atropine isn't going to hurt even if the origin turns out to be in the AV or lower. Don't forget about causes! Most common causes of symptomatic bradycardia in adults are electrolyte imbalances (K!), ACS, and medication overdoses/changes.

We have "EMS coordinators" where I work, hospital employees who serve as intermediaries between EMS and the medical control physicians. They have a lot of other jobs I'm sure, but they manage EMS paperwork like cert and con-ed maintenance, CME classes, field complaints and concerns, general Q&A, etc etc. Out of the 3 in the region, two are paramedics with BA degrees, and one is a paramedic/RN. If there is a basic question like "what are we allowed to do," though, shouldn't that question be easily answered by consulting the written protocol in your area? Scope of practice and "what to do when" stuff should be pretty much black and white save the occasional weird issue. Around here, EMS workers are expected to know the protocols cold, and if there is an issue the documents are posted on line and at the hospital.

There was no exposure! The lady touched his arm! That's it! There's absolutely no reason to suspect an exposure, no blood transferred, no broken skin, nothing! Should we REALLY start generating a "paper trail" for every "exposure" of this level? What about if someone coughs in my direction, or shakes my hand to say thanks? That's the level we're talking about here... You think this was the right thing to do? It sounds like a ridiculous overreaction to me. Asbestos isn't freaking VX gas, people. How can we expect public health officials to take "exposures" seriously if we constantly flood their offices with these unnecessary reports?

Its because he double posted.... http://www.emtcity.com/index.php/topic/20350-should-i-have-reported-this-as-a-bloodborne-pathogen-exposure/

I kept waiting for you to get to the part where there was actually an exposure... You're good brah.

I usually try to do it while compressions are still going. If I'm having trouble I'll have my partners pause for just a second. The bougie has been really helpful in maximizing my success. I pre-load the tube with a bougie instead of a stylet and let it protrude a few inches beyond the end. $$$ I like intubating codes because it is a definitive airway that does a reasonably good job at protecting the lungs from blood and vomit. That, and I like to take every opportunity I can to practice the skill. I won't sacrifice time or compressions to struggle with the tube, but when I can I like to intubate.

In Connecticut, EMTs are certified and paramedics are licensed.

The changes that I've seen (and expected) have been more personal changes rather than having to do with the whole system. I've grown quite a bit since I started doing this around 10 years ago, and while I haven't changed my system I can definitely say that I've altered my daily experience within it. A lot of times people are really negative about the state of EMS, but I've found that for the most part people can neutralize much of the negativity simply by being the best providers they can be. When we are out on calls it is just you and the patient, and the outcome from those encounters has everything to do with our own individual choices. The happiest people I know work hard not to be lazy, to treat every patient with kindness, to learn and follow up, to keep going to school. Our coworkers (both in EMS and in the hospital) notice those things, and it has been through those means that they've altered their personal "EMS realities." Focus on yourself, not the system. If more people did that I think larger change would follow on it's own.

That's awful! NO! 1 hour of work = 1 hour of pay (or more if it is OT or holiday, etc).

Did the OP ask us our opinions on how we might redesign worldwide paramedic education? I didn't get that from his post. Every discussion here seems to devolve into this "problem X would be solved if we just had better education" trap. Sure, we all agree. We can definitely improve on the educational system we currently have. That doesn't mean that those considering entering the field NOW (like the OP....) don't need reasonable, practical advice for the current state of things. I still think its a good idea to get out in the field before you move on to a more advanced level. Paramedics, among their other duties, are managers. I've never met a good manager who didn't put his time in on the line.

Where I work we used to give epi SQ but now we give it IM-- even when not using an autoinjector. The only answer that makes sense is IM.

Around where I work I can think of one or two truly "progressive" services. They are similar in that they are both small services with very tight QA/QI, they both have very solid and continuous relationships with their sponsor hospitals/medical control, and they both do 911 only (no private interfacility transport).

That's like asking why people can't learn to intubate from only mannequin experience. Simulation always fails to capture the challenges of the real world, and it is never about the isolated skill. When we KED someone out of their car, there are many other concerns such as safety, directing resources on-scene, managing other injuries, multiple patients, deciding on a hospital, figuring out what level of care the patient needs, etc etc etc. I've never seen an in-class simulation that really captures all of the forces that exist on a real emergency scene.

tniuqs - you GOTTA stop formatting your replies like that! I'm so confused as to who is saying what with all those nested quotes and multiple colors!