fiznat

No way man, the Pilot G2 is the way to go!! Gel pen that dries quick (no smudging at all really) and writes great! Not too expensive, either.

I know it is poor practice, and I got yelled at it a few times when I was doing my ride-time and later precepting. I still do it on rare occasion though when I just can't feel anything and I need a little something extra. I don't know if it makes a tactile difference at all really, but it sure does psychologically-- and sometimes thats the difference between getting and not getting a line.

MedicAR, taking your followup posts into account I think you've got the right idea in general. I guess it is such a fine line between "tough love" for newbies who need to learn how to get things right, and going overboard with the restrictions and singling out. I think most agree that a "no sitting in the recliner for a year" rule is not good, while at the same time we all also probably agree that the newbie shouldn't TRY to sit in the best seat first, out of his own initiative and respect. A newbie who sits down first in the best seat has something wrong with him that needs to be corrected I think, but it is NOT "you broke the recliner rule," it is: "you need to have a little more humility and respect for those who were here before you." Newbies should be proud of where they work, feel excited to be a part of the team but also humbled by that opportunity. Exactly how to foster that attitude, I think, is somewhere more aggressive than letting people do what they want, but not as extreme as "hazing." A fine line, for sure, but if it were easy we wouldn't be talking about it. I think a good training program for this kind of environment needs to have everyone on board. All of your senior and intermediate employees need to have bought into the program, and support it whenever an issue comes up. If a newbie comes in and goes right to bed, EVERYONE ELSE needs to notice and say something. "Hey what do you think you're doing? You have things to get done first!" etc. I think this comes out of a strong sense of community, which should feel natural since you guys all work and (for your shift) live together. Every effort towards bringing in good people should be focused on making better what you already have. ...I dont know, I'm not in HR or anything, just some observations from my years on the road.

I understand the skills-based "hazing," if you can even really call it that, but I'm not really a fan of forcing newbies to do all of the scut work and whatnot. I don't understand how it teaches people to "be a part of the team" by making one newbie do all of the work nobody else wants to do. Is that teamwork? When given the opportunity, I try to lead by example. If I want the newbie to clean between the lugnuts, he will do it correctly because he saw me do it myself last time. Personally I feel like this kinda hazing is more about asserting the superiority and rank of those already established rather than helping a new person become an effective member of the team. That may be just me though.

.20 seconds from end of the S to the start of the T is kinda borderline I think. Someone correct me if I'm wrong but I THINK the QT interval should be no longer than .40 or so. Assuming this patient has a normal QRS (less than .20 sec), we are looking at borderline extended QT intervals. In any case, lots of things can cause this. It can be baseline (an inherited pathology or benign sign), or due to medications that influence ion channels and repolarization. I believe, although I am not sure, that digoxin is one of the prime suspects for pathological extended QT. I believe the real danger with extended QT is R on T syndrome (a T wave landing on top of an R wave), which can trigger all kinds of nasty rhythms like VT (more common) and VF (less common). I did a little reading and I guess Torsades is also fairly popular with extended QTs. As you might imagine, the closer the T wave is to the QRS, and the more tachy the rhythm, the more danger. By itself though, a QT interval like one it sounds like you are describing is usually not too much to worry about.

haha looks like you passed the Dusty test. Man oh man did he hop right on you though! hahaha what can I say-- when he sees he attacks.

I'm done!! Where do I submit?? PS I was way under budget! hahaha Sounds like a cool contest. Any one of the evaluators recently charged with the same task in real life, perhaps? :wink:

Yeah I've pulled my back lifting large patients before. Twice, actually. With a question like that and a username like you've got, it sounds like you're about to try and sell us something.

The answer is yes, no matter what words go in that blank space. Of course it is possible for a MD, or anyone, to make this kind of mistake. I guess the important question to ask would be WHY did he think you might have this condition if your sugars are normal? Did you have a certain complaint, or did he find something in his assessment? Is it possible your doctor simply wanted to let you know that you are at high risk for gestational DM, and wanted you to be mindful of your sugars because of that?

Yeah its been a few years since I took that exam, but it is pretty basic. If I remember right, there were a few people who didn't do well and they got another chance before they were dropped completely. We had a practical exam as well, which was a verbal scenario (mine was a trauma, fall down stairs secondary to syncope IIRC) and a hands-on BVM/O2 skills stuff. The "trick" part of the exam was the regulator o-ring was missing and I was supposed to notice and correct the situation haha... Don't stress it, it is BLS and just the basics at that. You'll do fine.

here: http://www.emtcity.com/phpBB2/dload.php?ac...ry&cat_id=8

IVs can be really tough when you are first starting. Don't sweat it if you are missing a bunch, because we all do when we are new to the procedure. It may sound silly, but I honestly feel like self confidence is one of the most important components of getting an IV. Personally, when I don't think I am going to get a line- I often don't, regardless of anatomy. When I feel good about my IV sticks, when I know I'm going to get this line - surprise surprise - I do. Try to keep your head up. Be positive. Don't get upset if you miss a line, because we all do. As far as practical advice, try a few different techniques on your next few sticks: 1) Try not going for the vein right away as you stick. Get your catheter under the skin first, and then go at the vein from the side. This helps with those "rolling" veins quite a bit, and to be honest I use this technique in the ambulance a lot because the needle is easier to control once it is under the skin. Start your stick a half inch or so distal to where you see the vein, then go right up towards it. 2) Try the other way: "stabbing the vein" directly with the needle as you enter the skin. This works especially well for deeper veins where you can't feel too well but can see the color of it. Try to be as exact as you can, and move slowly, because these deeper veins are harder to judge as far as depth, so your "X axis," as I like to put it, needs to be dead on. 3) Remember to keep moving the needle forward a little bit even after you see the flash. Keep in mind that the needle tip is longer than the end of the catheter, and you get flash before the catheter is actually in the vein. If you try to advance at this point, it will feel like you've hit a valve even though you haven't. Don't be afraid to keep going with the needle within the vein until you are able to feed the catheter to the hub. 4) If you need to use a tiny needle - #22 or #24 - remember to move really slowly. The bore of the needle at this size is really really tiny, and it will take longer than normal for flash to show up in the chamber once you have entered the vein. Make very small motions and have patience. 5) Don't worry too much about the patient's pain. I know this sounds like bad "patient-care" advice, but it is better that you just get the line (even after fishing a little) than have to stick them again. Apologize to your patients and thank them for being patient, but don't let your worry about their pain hinder your ability to get the line. Just get it. Anyways, hope that helps. The key to all of this really is just to practice practice practice. I don't think I was really proficient at IVs until after my first 100 or 150 sticks. I know that is a lot, but it really did take that long before I felt confident about getting the line on just about every patient. ..And these days, when I do miss, it doesn't bother me that much because I know that the patient was a tough stick. No big deal. Keep at it man.

I'm not sure I agree with the concept that penetrating trauma causes injuries that are "always" immediately translated into neuro deficits. Why cant it be that the penetrating force causes an unstable disruption to the spine just like any other kind of injury might? This seems like a generalization that is usually - but definitely not always - true, and not suitable for a c-spine rule-out criteria. C-spine is a huge CYA procedure. We do it to patients who "probably dont" have spinal injuries all the time, not because we think they do but out of respect for the potential. I dont see how penetrating injuries differ in this respect. There is a potential, and given that there is a distracting injury, stress, and most likely AMS, I dont believe these patients should ever be c-spine ruled out by EMS in the field.

It isn't really that important with Amio I dont think, either. I mean, I wouldn't put it in a 500 bag but I might squirt a little out of a 250 and just give it that way. The point is just to dilute it a little instead of giving one big bolus... It's all going into the vein within 10 minutes anyways, so who cares if it is accompanied by 100, 200, or 138cc of fluid?

I think I would still have had to. The patient was demented and really was not answering questions at all. Altered as he was, I didn't feel like absence of chest pain complaints was really of any diagnostic significance since he was not communicating anything very well at all. True, this goes against the "treat the patient, not the monitor" mantra, but that is really tough to do when the patient is baseline GCS 12,13,14.

Who is the defendant there? To run a legitimate ambulance (and this, at least in a legal sense, is), application and approval must be obtained through the STATE office of emergency medical services (OEMS). It is the state who made this possible, who I am almost certanly sure is immune from these types of prosecutions. Yeah I remember hearing that, but I wasn't sure if it was true or not so I didn't want to say it. Ditto for them, then.

Ohhhh yes. We've got quite a mix actually-- from the extremely super rich towns, to country bumpkin villages, to major(ish) urban cities with some of the highest crime rates in the country. Naturally, I chose to work in the latter... Hopefully you put in a few good words for EMS anyways! ...Not that JL is too interested in upsetting the status quo anyways but hey.

Sounds to me like more of a problem for long-term care rather than emergent, prehospital care? If they can't breathe they cant breathe... I can't imagine that worries about potential drug interaction induced hypertension really would stop a provider from doing everything they can to get a patient breathing effectively.

I work in CT (not Darien though, that's in the southwest "rich" area of our state), and I have to say I am ashamed that something like this happens this close to me. I agree with all who have said that this is a horrible idea, and a disgrace to our profession. It makes me sick to know that people believe this job can be handled properly by people barely old enough to get a driver's license. It is a reflection on how EMS is generally viewed by the public, and I think a very poignant example of how low the EMT curriculum standards truly are. Let's raise the freaking bar, already.

This is true, however it was in fact a full-fledged EM doc.

Also, sometimes our own interventions will induce nausea and vomiting. Morphine has this effect on some people. What's the point of reducing pain if all we are doing is replacing it with nausea?

What was the complaint/why were you called? The progression in the chest leads makes me think that this is VT, although other posters are right that the mean QRS axis seems to be downward and to the far left (LAD), which I don't believe is common in VT. Still, the width and negative complex in V6 really makes me lean towards a ventricular origin. The history and age (which I assume is older since you mentioned dementia) might also contribute to this suspicion. I don't know, to be honest. I don't even know how to tell for sure. Surely someone on here does!

I dont think one can really make this kind of generalization. How quickly the tissue dies is a direct result between the ratio of supply and demand. If the patient has a small blockage and a huge demand, that tissue is going to die just as fast as if he has very little demand and a total occlusion. Saying a heart will "last" a certain period of time without knowledge of a whole host of other factors is incorrect at best... That said, I too was surprised to find out how low the sensitivity was for 12 leads... it really is our most powerful single diagnostic tool in the pre-hospital field, and it hurts to find out that even with the best we can give them, we still really have no idea. I guess this is why they try and teach us to be thorough with our patient assessments, and to consider the "whole picture" rather than getting tunneled in. The ECG alone does not rule in, and it does not rule out.

Our coverage area includes a major(ish) city/urban area, and a number of the surrounding towns. The longest transport time I have done (with lights + sirens, without is much longer) was perhaps 15-20 mins if that. We have 4 major hospitals within our primary service area, all of which have cath labs. Of those 4 hospitals, only one allows us to activate the lab from the field, which is a decision that we make as paramedics based on our assessments and our own interpretations of the ECG. This is actually a new program which is just getting started. If it works well, I imagine we will have this capability at most if not all of the other local hospitals. We dont have telemetry capability at all.

Some do, some dont. Things are pretty fragmented here- protocols/equipment/standards of practice tend to vary widely by region. We don't have telemetry at my service, which is fine by me since I cant imagine using it all that often anyways considering our average transport times. Yikes