fiznat

Looks pretty normal to me. I would even wonder about the automated "sinus arrhythmia" interpretation, since your R-R looks very regular except for one single beat. Seems more to me that this might be movement or respiratory related rather than any genuine cardiac condition. I wouldn't post that complete ECG with your full name and DOB, but I suppose that is your choice to make. Congrats on your healthy heart though haha.

I did ask the doc what he thought I should have done. He said I should have given only 2.5 of versed, or "better yet," IM Ativan. ...Even though, of course, that would be out of protocol for me but hey he doesn't seem to be aware of that. The doc also suggested that I could have just let the guy keep seizing (also out of protocol of course, and we had a 2 floor carry down as well). The patient does have a history of Epilepsy. He takes dilantin, and his roommates said that they thought he was compliant with his meds. That was his only history/meds etc.

I had an active seizure today, a pretty good one: patient was seizing for a half hour before we got there in periods of tonic/clonic activity and then periods of unconsciousness. Actively seizing when we got there. Per our protocol I gave him 5.0mg Versed IM, 15lpm O2 NRB, and then (once he stopped seizing), started a line. I placed a NPA and monitored the patient's breathing quality on continuous end tidal CO2 monitoring. I noticed that the patient was extremely hot to the touch, and despite the 15lpm O2 I could only get a sat reading of 89 and 90%. At the hospital the doctor takes one look at me and asks how much versed I gave. When I told him, the doctor's eyes widened and he told me that I "just turned a seizure into an intubation." As if it was my fault that the patient was not maintaining his saturations. They tried two rounds of flumazanil with no effect, and then intubated the patient. Though he is the doctor and I am a mere paramedic, I thought that I was dealt with in a very disrespectful manner. The doctor took almost no time to actually assess the patient, instead turning almost immediately to me to place the blame. He more or less yelled at me in front of 3 or 4 nurses that I respect, chastising me for giving a dosage of medicine that our protocol specifically indicates. To be clear, our protocol reads that if a patient is actively seizing and there is no IV access immediately available, we are to give 0.1mg/kg Versed IM to a max single dose of 5mg. This patient was well over 180lbs, so I gave 5. It is extremely frustrating to be treated like this by the doctors who are supposed to be our mentors in these matters. This is not the first time where a doctor's misunderstanding (or complete lack of knowledge) of our protocol has lead to a paramedic getting blamed for something that is really not his/her fault: a route that it seems many doctors like to travel instead of taking the time to truly find out what is wrong. I'm sick of being the scapegoat for these things, it isn't fair. True my knowledge is not as deep as the doctor's, and 5mg of versed may very well be a high dose for this kind of patient. ...But if that is the case, then the protocol needs to be changed. Anyways, I guess I'm just frustrated. Anyone else experienced this?

As I'm sure you know Dust, nothing is truly idiot proof. Let's have a look at it though: It does seem simpler. Only one port to ventilate into, only one port to inflate through. It may be just the perspective but it does seem smaller than the combitube, so perhaps the chance of laryngeal damage is lower. I also like that there is no latex.

What I really look for is the basic information. Chief complaint, pertinent positive findings, and relevant history. Like dust said, don't waste your time with things that you found that are normal, or unrelated history. I'm interested in the "story," but hopefully a condensed version: without the rambling BS that the patient probably told you. Also, don't be offended that I will probably reassess and re-ask the questions you just had answered. It isn't an insult, but I need to be sure and sometimes starting at the beginning of the path helps me find where I am going to end up.

I'll have to try that! ...Although I tried to use a blunt tip to draw up Ativan last week and ended up pushing the freaking rubber stopper (what you put the needle through) all the way through into the vial. Whoops... had to explain that one to the pharmacy. Our Amio vials are pretty small, I wonder if the same thing wouldn't happen...

We turn the entire kit into the pharmacy, who handles the wasting or reusing whatever the case may be. In exchange, they hand us a fresh, sealed kit.

Dispatched for heart problems to a local SNF/Quasi Hospital. O/A found 69 y/o male in no apparent distress in bed, surrounded by nurses holding the 12 lead ECG they recently obtained. Charge nurse states that this patient just had emergent PCI 10 days ago at a local hospital and is at the SNF for rehab. On a routine follow-up lab draw the patient's Troponin was found to be 7.65 and they are now noticing ECG changes. The patient presents AOx2 (hx Dementia and is at his baseline mental status) with NO complaint. No chest pain, no shortness of breath, no weakness, n/v, whatever else you can think of). HX: AMI c Angio + 2 Stents, HTN, Dementia, High Lipid, Parkinson's RX: ASA, Metaprolol, a few others that you'd expect... All: NKDA Vitals: BP: 122/76 HR: 78 RR: 20 Here is the ECG: I look at this and basically say oh, shit. Significant ST elevations in V2-V4 with QS waves probably from his previous MI. No reciprocal changes, QRS of normal width, no evidence of hypertrophy or other confounder... The patient is without complaint but at the same time he is demented and confused. He does look a little pale. I get an IV, give some NTG and ASA (without change afterward), and transport emergently to the hospital. At the hospital they shrug me off. Usually we get a "medical alert" for things like this, but for some reason the triage nurse seems extremely apathetic about this patient. We go through the entire normal registration procedure (which takes 5-6 minutes of us just standing there), and we are eventually sent to a normal ED bed, NOT in the critical area. I am a little pissed off and at the same time wondering if they see something that I dont. I find a nurse and explain the patient who has the same attitude, so I find the doc next and talk with him about it. He raises his eyebrows when he sees the ECG but pulls up the patient's old ECGs (from the date of his discharge after the PCI) and they look almost exactly the same. The doc points to them and says "see, this is just residual ST elevations from his cardiac surgery 10 days ago. You didn't do anything wrong, but this isn't acute." Same goes for the Troponin, he said. What?? I'd never heard of anything like "residual ST elevations." I remember specifically from class and various books that ST elevations MEANS something is acute. Q waves or ST depressions can sometimes be old, but when that ST segment goes up then we are talking about right now. Apparently not? I looked up residual ST elevations and a few other keywords in research on the net but am having a hard time finding a real explanation. It seems that there are cases where patients still have ST elevations a few hours after surgery, but ten days?? Anyone ever heard of this? ...Or maybe one of our docs can offer an explanation?

Carl, thanks for your reply! Would you mind if I contacted you off board with a few more specific questions?

Once again, here I am with a borderline ECG that I was hoping we could discuss. We responded for chest pains. On arrival found an 80 y/o male in bed in no apparent distress. Nursing facility staff say that the patient is baseline demented AOx1 and does not speak often "unless something is wrong." While ambulating to breakfast, the patient apparently twice complained of chest pains and SOB. SAMPLE stuff The patient now will not answer questions and verbalizes no complaints. There does not appear to be any pain or respiratory distress. Hx: HTN, High Lipids, CAD + CABG 2 years ago of 2 vessels, Angina Pectoris. Rx: ASA, Lisinopril, Simvastatin, PRN NTG (which he did not take today), Aricept. NKDA Assess: Lung sounds are clear bilateral, no JVD, no distal edema. Skin is warm/pink/dry. PEARRL. C-stroke scale is zero. Trauma assessment is negative. BGL 135 Vitals BP: 142/70 HR: 80 RR: 21 ECG Discuss I see a sinus rhythm with 2-3mm ST elevations in V1 and V2, T wave inversions V4-V6. No reciprocal changes in the inferior leads. I noticed a left axis deviation and POSSIBLY some evidence of left ventricular hypertrophy. The LVH is really the issue that I wanted to discuss with this ECG. The doc seemed sure that these ST segment changes are due directly to hypertrophy, but then again, let's count: V2 deflects larger than V1 and I add up the S wave to maybe 15mm . Adding in say another 15mm for V6 and we've got 30mm, NOT 35. I realize there is a LAD as well, which will tend to point towards hypertrophy and suggests also that there may be LVH, but this just doesn't scream out LVH to me. In the light of this patient's history and (?) complaints of chest pains, I didn't feel confident ignoring the elevations present in the ECG. I gave 0.4mg NTG SL and 324mg ASA PO and got this ECG: (12 lead #8 cause I had a hard time getting a clear shot but finally did) Watcha guys think? LVH? ACS?

lol.... any serious replies at all?

We carry 2 "kits" in each truck, which are plastic boxes with break away seals and kept in a double-locked cabinet in the truck. The narcs are signed in and out by each crew in a log book, although I admit I don't often open to the cabinet to make sure they are there. If we use a kit or one expires, we have to go to a local hospital's pharmacy to exchange them, where they are again double signed-for. I imagine it would be extremely hard to try and play games with narcotic drugs in this system. You might get away with it once or twice, but there are too many checks and balances- people would start catching on pretty quick.

Just to clarify, this may not be the case in every system. I know there are a lot of hospitals that will immediately pull prehospital lines and start their own (usually in that order, and sometimes to the patient's detriment) based on "infection" rates purportedly caused by poor EMS IV technique. 3 lines may be overkill if this is even remotely the case. ...Also, if you are going to do that many lines, the provider should be sure that at least one of them is #18 or larger, and nicely patent so that a clean draw can be made from it for a type + cross. Meh. I dont work at a hospital though so who knows what the REAL delays are in getting these patients upstairs. Is it really IV starts, or perhaps something else?

PLEASE LET THIS THREAD DIE!! :!:

Anyone here ever participated in the JEMS Games? I went to the conference in Baltimore last year and watched the final round- it seemed like a pretty fun (albit nerve racking!) thing to try. My friends from work and I were considering entering this year. Just wondering if anyone here has ever participated. Maybe they can share some of their experiences, how to best prepare, etc. Thanks!

I don't think thats a good idea. Just because you are able to retain basic information from your classroom work does not mean that you will be a competent provider. In fact I can almost certainly say that you will not be. You need EXPERIENCE to do this well, and jumping up to the highest, most difficult and responsibility-laden level is not the way to get your feet wet. I know other people disagree with me here, but I don't think this should even be tolerated by your school. You may pass the tests, but I can tell you: you will nave NO idea what it means to be a paramedic.

I guess we're both sorta saying the same thing, but from different angles. I feel that people who respect the job do well because they are self driven and seek out ways to be the best they can be. The part I ignored is that these people often choose to better themselves through education: a smart choice on their part. What I wanted to point out was the people who have college educations and various other educational experiences, and then seem to toss an EMT or medic cert into there as if it were something to brag about. Just because these people are educated does not mean they will be good providers. Excellence requires not only education, but education for the right reasons- if that makes sense. Simply passing classes is not enough, I've found that it really matters whether people care about why those classes are important. This relates back to the original discussion because I don't believe that piling up college credits is the shortest (or best) path to good paramedicine. I feel like a solid EMT experience reinforces for would-be medics the real reasons why we do this job, why education is important, and gives us reasons to be as good as we can be. That said, I think that there need to be real prerequisites for paramedic school, and that it should be at the least an associates level degree, not just a certification. I think this works in two ways: because we will attract the right kinds of people (people who understand why all this education is necessary), and weed out the people we don't want (braggarts and respect-seekers wanting a patch on their shoulder).

Right. I donno, like I said earlier, I decided to do a right sided ECG mostly because of the patient's presentation and history- both of which indicated potential red flags about the right side. The left sided ECG had some T wave inversions and (small) ST depressions in the inferior leads, so I thought I might as well do a right sided since I had the time. I thought I had remembered from class or possibly elsewhere that there is a potential for a patient to have an isolated right sided failure that doesn't show or shows minimally in the inferior leads. This makes sense to me as I think about the anatomy and where the RCA goes. Everyone seems to be saying that this isn't true, so maybe not... In any case, though, I don't think there is anything wrong with doing a quick 2nd non-invasive exam as a zebra rule-out. The bulk of the question was more about what the right sided ECG actually showed... T wave inversions all across the board. Is this really completely meaningless? Assume we had an old right sided ECG which indicated no t wave inversions and this was a new change. Still meaningless?

I like the idea of having educational prerequisites prior to medic school. To be honest, though, I know lots of paramedics both "educated" and "uneducated" and I don't think the differences between them is as consistent as many would like. I know lazy, educated paramedics who think they are too good for this job. I know of a college graduate paramedic who is very intelligent, who truly does not care that much about this profession and spends little time in improving himself in it. There are lots of people like this. I know some "certificate only" paramedics with high school educations who are extremely focused on the job, consistently present at the CME opportunities, and to be honest: absolutely amazing paramedics. I have thought about this alot actually, and I think that the real difference between good paramedics and bad is not education and not experience (to a degree), but interest in medicine and a strong desire to do well. People who care about EMS, about prehospital care, are the people who go out there and stay up to date on the research, who look up pathologies after the call to refresh their memory and improve themselves "for the next time." People who are not burnt out, who have a strong belief that what they do matters, and an interest in performing their job as well as possible. Those are the people, to me, who make great paramedics (and EMTs!). Education is great, believe me I am all for education. ...But don't get carried away with it's benefit. It makes a difference in the right hands, but even with a million college credits under his belt, the under motivated and directionless person will still perform poorly. Required education will elevate this field because it will attract people willing to jump through the hoops and spend the time to do the job. I believe THAT is the difference. If we raise the standard, we will cut ourselves free from the people who only "kinda" want to be here, and are not interested in what this is all about. ...And plus we will get people who can write a little more clearly. As far as the original question, I think the following are necessary prior to medic school: 1. A REAL interest. Not in just the paycheck or the "respect." Interest in the medicine and the opportunity you will be given. However long it takes for you to make this decision truthfully is time well spent. 2. At least some road experience. More than half of good paramedicine is scene control, knowing how to talk with patients, ambulance operations, and the knowledge necessary to make tough decisions like "stay and play" vs "load and go." ALS is mostly BLS, and trust me: EMT school does not teach you even close to everything you need to know.

I think the RBBB does account for a lot of the R, R' business in V1. Not sure how much evidence there really is for right ventricular hypertrophy, especially when there is a left axis deviation. Normally the axis will deviate towards hypertrophy and away from infarct, no? The LAD probably has more to do with the BBB I think, although in this elderly patient with such a significant history who knows.

Rogerrrr!

This place has a HUGE archive of really nice ECGs, along with discussions of the pathology and tips for identifying sometimes subtle clues. Absolutely worth a look for anyone wanting to brush up or just fool around for a while: http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

Dusty, feel free to rephrase if you are going to do it like that. Nicely said. Only bit I would change is about the perception of the public towards EMS. Unless other areas are vastly different from mine, I don't think that the public truly has any interest in what we do until they call, and honestly no understanding in how we work whatsoever. What would you estimate the percentage of laypeople who have no idea what the difference between an EMT and a Paramedic is? 60%? More? This is actually one of the reasons I feel... how do I say... less full of pride about my job. Most people have no idea what Paramedics are capable of, believe them to be blue-collar ambulance drivers, and could probably give a shit about their medical opinion. To many people, I am a ride to the Doctor-- and that hurts the pride a little bit, despite any self-satisfaction I am able to pull from the work. As far as from within the EMS community, though, I have to say that I do have quite a bit of pride about where I work. My service is looked upon as one of the more "serious" places to work since we cover a large urban area with a notoriously high crime rate. I know from working elsewhere that it is assumed by many outside of my service that we are very selective about who we hire, and maintain fairly high standards about who we keep around. Seeing the service from the inside, though, is sometimes different. I would like to hear about how other people feel about these points at their jobs, though. Keep it coming!

Thank you for the replies (and votes) so far. I know there are a lot of variables to the question, and I am aware that our feelings about our jobs probably peak and trough depending on so many day-to-day factors. ...Even still, though, I think many of us can come to a conclusion about this issue if we are honest with ourselves. Dust, I think this is a huge factor towards job satisfaction. In fact, I think that it is an indicator of how we feel about our jobs. If you believe in where you work, that you make a difference, that you are part of a cohesive team and deserving of respect, I think pride comes along with that. This is more the point I'm getting at anyways: how happy people really are with their work and station. With all of the frustrations, are the benefits enough to outweigh? How do you feel at the end of the day, at the end of the week, at the end of the year? I know it is a tough question though, so again- thank you for those who have replied. I thought it would be an interesting subject.

It is a simple enough question, and I'm interested to know. Are you proud of where you work? Try to include all of the possible aspects. Are you proud of your coworkers, of your protocols, of your department/service? Do you wear your uniform with pride? Would you tell someone where you work without hesitation and without a caveat? The other side would be the opposite. Does your department have bad apples that you feel you need to explain? Do you feel like you need to be the exception to a rule? Do you believe your service is truly interested in proper medical care? It's a yes/no poll to avoid any BS. Ya gotta make a decision. Feel free to explain your choice!