fiznat

Cool, I forgot about this. I just made an ALS cardiac physiology quiz: have at it! By the way, any way we could add a comment system to the quizzes?

I had considered that the inverted t waves could be a symptom of her history and not an acute event, but like you said - without a previous ECG to confirm I have to assume it is a recent change. I dont know, I would have pressed the doc for more info but I feel he probably would have just shut down on me. This doc especially is one of those types to say something and then not have the interest to really explain what he means. Not all that interested in teaching. Not to mention I was a little put off when he said that you should ONLY do a right sided ECG if there are ST elevations in the inferior leads. That is simply not true at all, and I thought that he was saying something like that just to blow me off so I let it be. I dont know if that is completely true. I mean, I know that the inferior leads do look a little bit at the right side of the heart, but not completely by any means. I think that would be like saying that the septal and anterior leads give a complete look at the entire left side of the heart. ...Not exactly true, there is still a lot of muscle that you can't see without the more leftward, lateral leads. Right ventricular hypoperfusion often comes from an occlusion of the RCA, which starts fairly anterior but quickly hides around the right lateral and posterior portion of the heart... areas that you can't see with a left sided 12 lead. I dont know.... just cause it's rare doesn't mean it's academic to look for. Things like this are always "just academic" till you actually find something, then its like "oh shit, well.... good job finding that." Anyways I do have a technical question actually haha... I was a little unsure about this when doing the ECG. When switching over to the right side from the left, I popped off the leads (leaving the stickers so they would be in the same place) and placed V3-V6 on the right side in the same manner as the left. I wasn't sure about V1 and V2 though-- are you supposed to reverse their positions from the left (so V1 is on the left side of the chest and V2 the right), or leave them be? I reversed them, but I wasn't sure about it. I guess you're still seeing the same views (just in different spots), but the order of them is sometimes important to see proper progression.

The other night I had an 81 year old female complaining of general weakness times 2 days, nausea and vomiting for the same period. She's got a new onset of bilateral hand swelling, also. History HX: CABG X 4 (10 years ago), Angio + Stent in the RCA 1/07, IDDM RX: Couple beta blockers, ASA, Plavix, Insulin and Metformin (both, I know) NKDA Assessment: Lung sounds are clear bilateral, no JVD, no pedal edema but her hands are very swollen. Not quite the mickey mouse gloves but almost. Skin is warm/pale/dry, PEARRL, c-stroke scale is zero. Trauma assessment negative. BGL 210. She is without complaints of SOB or pain at all. Her vomit has been without heme and she says she hasn't been "feeling like herself lately." "Something is wrong," she says, and she states that she feels "like I am about to leave this earth." On the ECG is a sinus bradycardia at about 50-55. No ectopy. Here is the 12 lead: Not too much except for the fancy block and some flipped T waves in some of the inferior leads. I kind of wanted this lady to be cardiac. She had a fairly good story, she LOOKED cardiac (age, general presentation, etc), and the cardiac history was very significant. After finding out that it was indeed the RCA that was stented (that she had problems with before), and the presentation of "distal edema in the absence of pulmonary edema," I elect to do a right sided ECG: Now, it's nothing drastic, I know. ...But there are a lot of flipped T waves. I'm not going to fly off the handle and say that this lady is about to have an RVI and all that, but I bring the patient into the ED and show the ECGs to the doc right away. To be honest I was a little happy with myself for going the extra mile and finding a potential issue on the right side. The doc pretty much blew it off... Did everything but crumple up the ECG right then and there. He tells me that the right sided ECG was not indicated because there was no ST elevation in the inferior leads, and that the T-wave inversions I did find are "meaningless." Now, I KNOW that he is wrong about the indication of right sided ECGs based on inferior lead changes alone. No way there HAS to be ST elevations in the inferior leads before we consider doing a non invasive right sided exam. ...Especially in a patient with a history of right sided ACS and a presentation somewhat suggestive of it. It did get me a little down that he blew off the right sided "ischemia" so quickly though. I was hoping I could get a little insight from the more experienced people here... I know that t-wave inversion isn't exactly cath-lab-activating emergency stuff, but sometimes it is a sign of distress, and I thought I did a good thing in both looking for it and identifying what I saw. ...Or maybe it really does mean nothing? What do you guys think?

I am interested in doing a little bit of EMS instruction, maybe helping out with an EMT or medic class from time to time. I have been in EMS for 6 years now which isn't a long time, but I feel that I have gained some experience over this time that I might be able to pass on to some students. I was hoping some of you EMS instructors out there could give me a little bit of advice. I actually have a few specific questions: -What does an EMS-I cert (not intermediate, but instructor) really mean, and what are the cert requirements. Is it absolutely necessary to have? -What kinds of things do I need to know before I walk into a classroom and expect to teach new students? There are a lot of things I know about EMS, but I don't know much about teaching. Any advice would be helpful.

I'm glad someone else said it! I feel the same way about JEMS. Occasionally they will come out with a few interesting articles, but in general I feel that most of it is poorly written, hardly researched, and very basic. It is sort of like reading a comic book. JEMS does do a good job with the JEMS conference, though. I went last year and had a really good time, and I will be going again this year. Anyone else from here going?

Wow Vent! haha I'd say that answers the question! Nice post.

Yeah I think so too haha. Since I think at this point we can abandon all hope of the original topic, I'll clarify: I feel that the only part of the hospital that is providing a "public service" (in the respect that EMS does) is the Emergency Deparment. I was pointing out the fact that the only portion of the hospital that provides public service is also the only portion of the hospital that tends to run in the financial red. Providing a product (medical care) to anyone who wants it - with "instant credit" granted is loosing business. Collection rates are extremely low, costs are high, and legal liability is high. You asked me to explain (I think? haha) how it is that private hospitals are able to provide high quality public service despite the fact that they are for-profit entities. My rebuttal is that ONLY the ED is truly public service, and ONLY the ED loses money! In fact it is not true that the hospitals are able to provide quality for-profit public service, because it would be unable to do so if it weren't for the support of the remaining, highly profitable non-public service departments. The coorelation is that if a entity wants to provide a high quality public service, it is extremely difficult (if not impossible) to do so unless that entitiy is accepted as losing business, and funded by some other source. AMR manages to bridge this gap by providing a highly profitable non-public service which funds the 911 side of things: transfers. ...But as any AMR employee can attest, this arrangement tends to impinge on the QUALITY of the emergency service. With this experience in mind, it is my opinion that there are very few other arrangements that would make finance of 911 service possible while at the same time keeping quality high, except through municipal funding. I agree with you that a large percent of the profitable hospital patients do enter through the ED doors, but I disagree with you that the ED still needs to lose money. The marketing department of a cooperation loses money because it is nessary for that department to first make a faithful investment. There is no such requirement in the ED. The ED does not need to spend money to make money, because canidates for high-dollar procedures could be selected at the door and seperated from the rest of the non-paying population. It is the public service aspect of the ED (which I admit is required by law) which loses money. The private portion of the hospital (that which is not mandated by law) is the part that makes money. That is sortof my point: public service loses money, private business makes it (or fails). I know what you mean man, and I hope you can believe (or at least see, by what I am saying) that this isn't my intent. I have no interest in fire whatsoever, and to be honest I dont think it would benefit EMS to be anything like them except in who pays the bills. Honestly I could give a shit about being a "hero" or whatever.. although I do believe that with quality service, education, and professionalism, that aspect would probably come on it's own.

YA RLY. lol. The hospital phenomenon? What do you mean by that? If we are going to be fair and compare hospitals to EMS as far as ability to produce profit, then we will have to compare the ambulance with JUST the ED. If we do that, I think you'll find that the hospital would be in a very similar financial position if it weren't for high dollar procedures and surgeries on the upper floors that are consistently and regularly paid for by insurance companies. There is a portion of the hospital that is allowed to pick and choose patients, a decision that I dont doubt it as at least somewhat effected by the all-important "ability to pay" factor. That is how hospitals are able to stay afloat, if they even do at all (because still there are hospitals that are on the financial razor's edge). The ED works because it's annual deficit is supported by the rest of the hospital. Is it no surprise that the perceived "quality" of a hospital often has more to do with the availability of high dollar surgical options, equipment, and personnel rather than the effectiveness of it's emergency department? Tell me which advertisements you see more: for a specialized ortho or cardiac group, or for timely care in the ED? I don't think I've EVER seen the latter. Hospital's brag and compare based on the 2nd floor and up, always. EMS has no second floor.

The reason I feel the way I do is because I believe that EMS should be a public service. I believe that interest in profit margins does not always correlate with quality service. In fact, it is VERY often that the opposite is actually true. You are wrong in your assumption that I want municipal funding because I think it will benefit ME. To the contrary, I feel that if the service is funded without hope of profit, the only benchmark that need be placed is on quality service. EMS is an expensive proposition with very little hope of recouping the money spent. At the same time it is an essential service that any county/city/town cannot do without. Those two points together seem (to me) to suggest that it should be publicly funded. I am actually against socialized medicine. I agree with you that the VA sucks, that the government in general does a poor job of regulating medical care. Still though, I think EMS should be a municipal service because - unlike the hospital - it is a public service that cannot be performed properly while maintaining any hope that profit can be made. That is a bit harsh. There was a 2nd paragraph to the post you replied to-- re-read that!

I'd like to hear about a few things from the physical assessment: -JVD? -Distal Edema? -Skin color/temperature/condition? -Any N/V? -Weakness? What kind of dishes was he washing? Could it be considered a strenuous activity for a person of his size/age/etc? Any additional stress at the time of onset? LBBB has the potential to create, as well as hide ST segment changes. If this person has a decent story and presentation (and it seems he does), I would not use the 12 lead as a rule-out for ACS since there is a LBBB. My suspicion is still high for AMI.

I agree about AMR, and to be honest I feel that this is a problem that is not only specific to AMR, but to private EMS in general. This is a symptom of placing public health in the hands of private industry. As long as this is the case, the drive will NEVER be towards proper patient care unless that aspect has some sort of effect on the bottom line. If counties/states/cities/towns want emergency medical service that has a primary concern of patient care, then they will have to get off their asses and implement a municipal service, as it SHOULD be anyways. This is a problem generated by misplaced priorities by the public itself. It is simply assumed that if a person calls 911, he/she will receive timely and competent medical care. When using a private service, this assumption is NOT valid. I like to think that our Union is interested in more than securing higher pay and benefits for ourselves. We work together to implement a face of professionalism that is above and beyond that which is expected from AMR alone. We are pushing for more money for medical training, for certification-based bonuses, and other incentives for proper medical care. The company may have a primary interest in their bottom line, and for that we truly cannot blame them, but the outward effects of how the employees work can absolutely be effected by a strong Union with the proper priorities. Though we work in private EMS, there ARE things we can do to make things better. Anyone else got any contracts?

Jake nah that isn't us... thankfully. I hadn't heard about that. zzyzx thank you! I'll send you an email soon.

Do you have someone I could contact over there who might be able to help me out?

I work for AMR in the Northeast, and our contract will be up for renegotiation fairly soon. We are trying to get a little more organized this time around so that we can present some solid arguments come negotiation time. In order to do this, we are trying to build up a collection of other AMR contracts from around the country. We have been going through them and picking out parts that we like, compiling them into our "ultimate" contract. So far, though, we've only been able to get the NEMSA ones off of their website, and a few extras that we've stumbled upon. I was wondering if any AMR employee members of this forum would mind sharing their contracts. A digital copy would be awesome, but I am willing to pay for shipping if you would be kind enough to send me a copy. Please reply here or send me an email: fiznat@gmail.com Thanks guys!!

Not that I know of. It is starting to cool off up here, so even people without A/C (most everybody in the poor sections like this one) are fairly comfortable temperature-wise. I think the 'lyte depletion is pretty much all from the extremely frequent urination secondary to his increased BGLs. He told me he was draining the lizard at least once an hour or so, and this has been going on for a week! Thanks dusty!

^^ Yeah haha me too. To be honest I doubt most of or docs really have any idea about how our protocols work. There are a set few of them who are very involved, but 90% have no idea what we are/aren't allowed to do. Recently a doc at one of the two major hospitals we frequent was absolutely shocked to find out that we cannot RSI patients. I seriously doubt they are in tune enough to know what drugs we carry, what we don't, what is standing order and what is not.

^^ you have to call your medical control doc for all of those cases? As in, actually talk to a doc and ask his advice? How do you find time for that? We have to patch to some hospitals before we get there... some hospitals want a patch for every patient, some want notification only for critical ones. Is that what you are referring to? I cant imagine having to call a doc for all of those circumstances, just to see if he/she has anything they'd like to say/add.

The key words in that sentence are "...in MI pt's." Of COURSE ASA helps in the AMI patient, absolutely. No one is arguing that. The danger is if the patient is NOT having an AMI, and is instead suffering from something that can possibly be made much worse by the ASA. You can't possibly be defending the idea that every chest pain patient gets ASA without thought as to the true etiology of the complaint. Same goes with NTG in RVI. "You should be okay?" Are you serious?

I thought lactate metabolizes into bicarb?

You got it VS! This is diabetic ketoacidosis. The patient had persistent hyperglycemia despite normal insulin dosing over the course of a week, had been drinking water like crazy and urinating every couple hours. The patient had weakness, malaise, decrease in appetite. The SOB was not SOB but a mild version of kussmaul breathing. Due to the frequent urination, the patient's electrolyte balance was swayed (particularly K+ and Na-) resulting in the leg cramps. All of these are signs of DKA. At the ED the patient was found to have a mild acidosis, and profound hypokalemia + hyponatremia. Rapid precautions were taken for potential cardiac issues arising from the imbalance, and the patient was immediately given an extra IV line for electrolyte replacement. After that came the insulin. I thought this was interesting because though I remember this lesson from paramedic school, I have never seen this presentation for DKA and I admit I was a bit mystified about the relation between hyperglycemia and 10-10 painful leg cramps in this patient. Thinking about it more, I wonder about what things we can do in the ambulance for this. We are supposed to give lots of fluid for hyperglycemia for obvious reasons, but I wonder if given the electrolyte balance it might even help to use ringers instead of NS, which has both sodium and potassium. Not enough to replenish, but maybe it could help....?

Right, because that is outside of my scope of practice. Scope of protocols is simply which items within my scope of practice that a MD has pre-approved me to perform based on standing order. Are you sure you aren't confusing these two definitions of scope? I don't see why a doc couldn't order me to perform a procedure that I HAVE been trained on, but simply am not allowed to do daily on a standing order basis.

I dont understand that-- if the doc gives you permission via on-line medical control (presumably a recorded line), how does the liability fall on the EMS provider? How is this different from any other ALS provider calling medical control for something above and beyond the standing order protocol? The doc gives you specific permission to perform a specific treatment under his own licence- whats the difference whether you have previously established ALS protocol or not? The point of on-line medical control is to supercede/augment those protocols anyways!

Heeey now we're talkin! The blood sugar reads at 400. When you get the readout, the patient looks at it and nods. "Yeah," he says. "Its been high all week." So high, in fact, that his home monitor wont even read it. Instead it has been simply reading "hi" for 7+ days. The patient has stayed current with his bid (50u) insulin, but it doesn't seem to have helped. Everyone is on the right track now... let's talk some pathophysiology. Why is he cramping, what kinds of things do we want to be aware of, and what can we do about it in the ambulance?

The pain is bilateral, there is no tingling of the extremities. Cincinnati stroke scale is zero, PMS/CSM is equal times 4 extremities. The patient stands up to get into the stair chair even though we told him not to, and though there seems to be some pain, he does have full range of motion of all 4 extremities. On palpation the muscles seem to be rigid. The patient says the pain comes all at once, then relaxes in waves. It sounds like muscle cramps the way he describes it. I was thinking about these things as well. Still, there were other things I found that swayed my opinion. ...Things nobody has asked about yet :wink: Hint: it isnt anything exotic. Think about what we routinely check on all of our patients. Especially THESE kinds of patients. No strenuous activity/history at all. I asked a lot of questions about this kind of stuff and it appeared as if the patient is completely atraumatic. No numbess/tingling. No bladder problems at all, in fact the patient mentions that he has been urinating quite frequently. I'm off to work till 2300 tonight, I'll check for replies when I come back. ...Just think about routine ALS-- the key to this is nothing exotic.

He took his puffer once this afternoon and his SOB has not changed. The skin is without any noticeable blemish. He has been laying down more than usual due to his weakness/lethargy, but no traveling and he has managed to get up to go about his daily business for the past week. As you are talking to him, the man grabs at the backs of his legs and yells in pain. He is rubbing his legs like he is sore, and when I ask, he says that rubbing his legs seems to make them feel a little better but the pain still comes and goes. He is at a 10-10 now and asks if I "have anything I can give [him]." What else would you like to do?