fiznat

http://www.amazon.com/Emergency-Complete-F...6539&sr=8-6 ? $112 though... Pretty steep. Its on my christmas list in case Santa reads EMT City.

I've never actually done this before, called a doc with an ECG and asked for advice. I imagine it would be really hard to describe the ECG over the radio to the point where the doc's determination would be THAT much better than mine. What do you do, sit there and say "...the deflection of the QRS in V1 is negative. It is approximately .17s in duration. There is some minor slurring on the terminal aspect of the wave.... blah blah..." I dont know, I've never done that before so maybe it works more smoothly in real life. It just seems like it would be difficult to describe in words an ECG like this, that clearly combines a whole host of pertinent nuances. I agree about the LBBB... I cant figure out why people seem to be absolutely sure this is a ventricular rhythm, except that the tachy bit "looks sorta like" the ectopy in the previous ECGs. There are a number of factors (perhaps more factors) that suggest that the rhythm may in fact be atrial in origin. ...It is tough to tell, and while I can't say with absolute certanty that this is not VT, I also can't say that it is definitely one or the other. Either the evidence isn't there, or I just don't know enough to decipher it. In any case, I don't think any of the points made thus far are enough to say with absolute certainty what the rhythm truly is. As far as dealing with wide complex tachyarrhythmias, I agree with you that we have to assume VT unless proven otherwise, but that doesnt mean that VT is the more common rhythm-- only that it is the more dangerous. That is an important point, and aside the fact that amiodorone takes the necessity out of making this decision, imagine for a second that we've got enough time and that determination of the rhythm is an important step in the treatment path. It isn't, as we all know, but it is interesting to consider.

Obviously the guy is getting Amiodorone, but we're after the fact now - monday morning quarterbacking as it may be - and now we have the chance to determine the rhythm in detail. I'm still not so sure that this is VT, and I was hoping we could get a few of our resident docs to weigh in on the subject. Interestingly enough, the medic who gave me this case did NOT give amio. His defense was that the patient remained stable as far as vital signs + mental status and was without complaint, so he "didn't want to mess with it." He got yelled at in the ED though, and I'm pretty sure I wouldn't have made the same choice.

I can post bigger copies if you guys want... I just thought I'd go easy for those who dont have huge monitors and fast internet connections. Dusty-- why cant there be a LBBB? The deflection is in the right direction in V1 and I dont think anyone would argue that the QRS is wide enough.... Huh, by the way, anyone notice that the arrangement of the limb leads on the printout is a little odd? I wonder why my friend has his monitor set like that... I just noticed myself.

:shock: LOL

I think Amio is going to be a pretty popular choice amongst most of us since it makes determination of the origin of the rhythm less important... I'd really like to nail down the reasons why people think this is VT or not VT.

This is the closest I've got to a "regular" 12 lead from this patient:

It really depends on where we are, to be honest. A lot of the time we will leave the car at the scene, lock it, and come back to get it later. If we are in a bad part of town, though, another truck will come by and one of the crewmembers will take the car to the receiving hospital. If the call is bad enough and there is no time to arrange this or we forget, the car will get locked and left. Never had a car broken into as far as I can remember, although I'm sure it's happened.

Are you sure about the VT? I was a bit split on the issue but I see a few things that point the other way: 1. Rightward axis. This is not common in VT if I remember correctly. In fact, I think it should be the other way around. 2. No concordance in the chest leads. Actually the progression seems to be fairly normal in that the deflection is away from V1 and towards V6, suggesting a downward path of depolarization. It could still be VT, but the origin would have to be fairly superior. 3. The minor abbarancy in the QRS morphology might suggest that this is in fact an atrial rhythm with LBBB? Figure you are 10-15 mins away from the nearest appropriate hospital. Any other thoughts?

This is one of my coworker's patients, so please forgive any omissions. I will find things out if need be. 56y/o male patient with complaints of syncope presents with the following ECG: Vital signs are: BP: 142/76 HR: As shown RR: 20 Another glance at the monitor: Whoops. Vital signs remain unchanged. At the radial artery the paramedic can feel a regular pulse at about 80. 12 Lead: Again vitals are unchanged, again the radial pulse says 80 BPM and regular. The patient is without change in any other aspect of presentation. He does not seem to notice what the monitor is saying. The patient denies any past medical history, meds, or allergies. Discussion points: What do you call the rhythm? How do you consolidate the ECG, vitals, and unchanged presentation? What about the radial pulse? What is your treatment plan?

It could be a CNS thing, or also because people are exerting themselves quite a bit during major seizures. Even still though, these temps were measured a good 30 minutes after the patient's last seizure, and - I believe - he should have come down by then. The low SPO2 is not normal as far as I know.

I agree, but this wasn't the case (give me some credit!). Vitals in transport were: BP 100/70 HR 124 RR 26 SPO2 91 (on 15 lpm O2 NRB) ETCO2 30 with normal waveform The guy was belly breathing a bit and in general his respirations did look a little odd. They commented about it at the hospital also, but nobody bagged him until right before they intubated (half hour later or so). I chalked his respiratory "difficulties" up to an altered mental status, which I believed would improve as he got farther away from the time of his seizure. Besides, his sat wasn't THAT bad and there seemed to be good gas exchange as evidenced by the ETCO2. After a half hour and the routine stuff in the ED his sat was down to 87, so thats when they decided to intubate. I do wonder if perhaps he aspirated something while seizing, or maybe had some other infectious problem going on since he was very hot. Temp read at 102* in the ED. I will try and follow up today when I go back into work, but I might not be able to since we never got any demographics for the guy. I will try though.

Sorta. I happen to know that the bill collection rate in the poorer parts of our coverage area is usually less than 20%.

If that be the case than I might make the (probably unpopular) point that your demure 110 lb female partner should not be doing this job. This is part of the work, and I don't think it is fair to say that patients in pain or at risk of worsening heart conditions be forced to walk so that your employer may say that their hiring practices are fair and equal. In my opinion, this is a misappropriation of priorities. In addition, if the stairs and large patients are truly that prevalent in your area, your company should invest in those fancy stair chairs with the tracks in order to make your descents easier. I do agree though that EMSers shouldn't have to constantly worry about litigation from situations beyond their control. If it is not possible to carry a patient, it is not possible and that should be the end of it. Still, this doesn't preclude us from doing the best that we can and avoiding laziness at every turn.

To be clear, ABC is a joke... I mean, yeah we'd rather not carry patients if we don't have to of course, but when it is necessary for the patient, this is part of our job. Forcing a patient with ACS, altered mental status, pain, or any other number of medical necessities walk is inappropriate regardless of where you are. The point is that we should be able to make these decisions ourselves based on clinical presentation, history, and assessment. To say that a patient should never be carried is just as silly as to say that he should always be. It is a case-by-case thing, and a decision that we as professionals should have the autonomy to make.

hahaha nicely put, medic26, nicely put.

lol yeah I think most of us here know that FP-C is for flight paramedics. No need for the redundancy, unless you REALLY want to make sure people know you take care of patients in the air lol. Welcome to the boards.

Patients should be carried if it is medically or physically necessary that they be carried. Otherwise, remember your ABCs!! Ambulate Before Carrying. lol I think it is ridiculous that any system would mandate that "every" patient be carried. Why not also mandate that every patient get transported on a priority 1, or that every patient gets oxygen. Its silly.

Dusty has already said a lot of it, but learn the main streets first. In every town and city there are main north/south or east/west streets that everyone uses all the time. Get those down first. Make sure that even if you don't know what (side) street you are on, know which direction (north, south, east, west) you are heading and which main street you should next come into contact with. Know how to get to the hospitals, from anywhere. This is of particular importance because when driving to the hospital you will probably be by yourself in the front of the ambulance. By the time your partner tells you start moving, it is then too late to be looking at the map. You need to know where you are going, even if it is the slightly longer way that uses more main streets. Don't be embarrassed about looking at a map. You can't be expected to know every single street, and even if it is a main area it doesn't hurt to take a quick glance to re familiarize yourself. Lastly do NOT guess on which way to go. If you are unsure, you need to ask. There is nothing worse than working on a patient and then looking out the window to find we are halfway across the city in the wrong direction. There is no excuse for not asking and then doing the wrong thing. If you don't know, swallow your pride for the sake of the patient. ...Then, when the call is done, look on the map and retrace your route.

Some good points, Captian. The problem is - and I'm sure you realize this - is there is no motivation to do these things. Run down that list again with the perspective of a private EMS owner. Most of those options decrease profit, not increase it. Though they may all be good things for the health of our patients and of the system, they do not seem to jive with the current model for profit-based, private EMS. I'm not saying the government should step in and fix things for us, but at the least we need a savvy businessman to come up with a model that makes these kinds of things possible while also maintaining the potential to make a buck on it. Otherwise I just don't see it happening, sadly.

Your abbarancy could be a whole host of things, most likely ranging somewhere between the unimportant to the irrelevant. You don't have the clinical signs of any actual pathology, and to be honest I wouldn't be surprised if the ECG were to be taken again, you might not even see those rabbit ears. My ECG instructor taught me a phrase for these kinds of situations: "one of something is one of nothing." In order to identify real disturbances, you're going to need to see the effect in more than one place. You'll need to see the effects of that pathology reflected in other areas. To see "something" in one spot is usually small enough to simply ignore.

No. Its a normal ECG my friend.

Check this one out: http://www.myfoxcleveland.com/myfox/pages/...mp;pageId=1.1.1

We use the Melker at my service, and though I have never had a chance to actually use it on a patient, I do feel like it is somewhat complicated and has lots of pieces. The benefit to this kit compared to the quicktrach though is the size of the airway that you get when you are done. The one in the Melker is much bigger than the one in the quicktrach. Not sure about other kits, but this should be a factor in your decision.

But yea, that is pretty much what I had to do. Nod and move on. ...Doesn't change the fact that it kinda sucks our docs don't know our protocols and instead choose to point fingers.