fiznat

Thats where you're getting messed up. It isnt the R wave itself that illustrates ventricular depolarization, it is the entire QRS complex. P wave: atrial depolarization QRS complex: ventricular depolarization (and a hidden atrial repolarization) T wave: ventricular repolarization Worth 1000 words. Normal 12 lead ECG:

Yes. This is true of all EKG tracings. I'm not sure if you've taken physics or not, but basically the readout you get on the EKG paper is a representation of a vector quantity. What that means that all lines (be they up/down, narrow/wide) are illustrations of the NET electrical direction. If you have a 2 volts going upward and 10 volts going downward, your net movement is 8 volts to the negative- and will result in a negative tracing. It has to be this way because the movement of these deplorizations would be too complicated (and probably unimportant) to measure in perfect detail. Instead, we just calculate the average (net) direction and magnitude of the movement. Just to confirm what we're talking about here though: are you asking about physiological or pathological q waves? The two arise from different circumstances, AZCEP has explained only the former.

They shouldnt be that hard to make up, eh? What is the primary goal of the first responder? O2, AED, first aid, call for help pretty much right?

Assuming this patient had pulmonary edema, yes. NTG is the first line treatment for that condition, and it makes a huge difference. ...Better than lasix, I'd say. Just 2 seconds of google searching: http://www.circ.ahajournals.org/cgi/conten...stract/46/5/839 http://www.chestjournal.org/cgi/content/abstract/92/4/586 http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum A quote from that last one: I've been to a couple conferences on the subject, and read some research on it: diuretics are getting phased out for treatment of pulm. edema. It's old and busted. NTG is the new hotness.

Heya dude. Honestly I dont think I would have done what you did. I wasnt there and I didnt see the patient or hear those lung sounds, but what you've written really doesnt seem to point towards CHF. She seems to be predisposed to the pneumonia, and even you admit that the lung sounds could possibly have gone either way. Without a cardiac history or Rx diuretics, and also a seemingly slow onset and normotension I'd like to think that I'd be looking elsewhere. All of this seems to point more towards pneumonia than CHF, although again I wasnt there. Did the patient have a temperature? It stands out to me that this patient may not have even had a respriatory problem. You say you heard air movement throughout the lungs, so even if it is indeed CHF it doesnt seem as if she is completely full. ...Probably not full enough to cause a hypoxic change in mental status, anyways. The SPO2 of 98 seems to also confirm this, although like another poster said you didnt mention the original SPO2. ETCO2 would be really helpful here as well. Was there any other possible source for the change in mental status? You mentioned a recent medication change-- what about BGL and a stroke scale? Pupils PEARRL but were they normal in size? How different was she when you saw her from her baseline? If you're convinced that this was a respiratory problem, and are even the least bit unsure about CHF vs Pneumonia, you should split the treatments a little differently. Our protocols specifically say that if we're unsure which it is, skip the lasix and do NTG only. Routine ALS also of course. The NTG apparently has less potential to damage a possible pneumonia patient than the lasix. I dont believe inability to lift the tongue is a contraindication for NTG. Just grab a 4x4 and lift it for her, right? ...Or paste, I suppose. Still, a good call dude. I wish I was out there learning these lessons.

Just wondering what the situation is for most of you guys here. Does your company give money to go to CMEs, conferences and things? I just went to the JEMS conference in Baltimore and all of the expenses came out of my own pocket. Our company does give us a ~$1300 stipend at the end of every year for recert/CME purposes, but nothing specifically for conferences and whatnot. How does your company deal with CME money? How is it distribuited and how much can you get?

Wow guys, thank you!! I just noticed this thread-- totally unexpected. Thank you everyone for the compliments! As far as the HIPAA stuff, all of it seems to have cleared up. What others have said about "what you write online can hurt you" is absolutely true. I was given this warning a few times by fellow bloggers and coworkers, but the reality of the danger was never as clear as it was once the crap hit the fan. It looks as if things have more or less cleared up (The original complaint - that I had used a patient's real name - turned out to be untrue. It also helped that the calls happened while I was on ride-time, not at work.), but the ordeal has certainly left it's mark on me. The entries I write now are MUCH more ambiguous towards individuals, and details are switched around quite a bit. A few of the recent entries are more combinations of a few calls rather than accounts of single patients. I made efforts before, but even more so now that all of this has happened. Again, thank you everyone for all of the compliments. I am flattered. :oops: O:)

I'm not sure about this on a national scale, but I know that my division is always running just a tad light on medics. When I finished medic school and called our HR lady, she seemed excited to hear we'd be getting another medic and told me I'd have "absolutely no problem" finding a full time position. I wouldnt say that medics are rare, but they are definitely in demand here. If you're worried about spending on the visa and not finding a job, wouldnt it be possible to arrange your employment first before you shell out money? EDIT: also FYI a lot of AMR divisions pay sign-on bonuses for medics. I know my division does, and it is somewhere to the tune of a few thousand dollars. Ask about that.

My company has a linen exchange program with the local hospitals, so we're not exactly "stealing" those at all. Besides that though, there really isnt much to take. The other day I borrowed a few 10 drip sets cause all we had were 60's... I asked for them and it wasnt a problem. Occasionally I will get stuff that we dont carry, like pedi O2 sensors (the stickey ones), or child ETCO2 nasal prongs... but I always ask first. Usually its no big deal. I hope no-one here really seriously steals from the hospitals they bring patients to.

AMR is a fine company to work for, although keep in mind that the divisions across the country are individually run, meaning that your experience will most definitely differ from one area to the next -- even though it is the same company. Add to that union contracts vs non-union contracts, differences in medical control etc, and you've got yourself quite a diverse company. Asking what AMR is like is similar to asking what living in this country is like. It really depends where you are. That said, I work for AMR and I feel like it is the best EMS company I have worked for yet. Here in CT I make just about $20/hr as a full time medic-- which isnt stellar but fairly decent considering what other people get.

Roger that. ...Part of the reason why many here, including myself, will suggest that you work as an EMT-B for a while before you attempt to go for your medic. Trust me.

Interesting subject. I was talking about this with another medic a few weeks ago, and she insisted that peds will show Cushing's signs later than an adult would. She cited the often-preached fact that peds tend to compensate longer than adults do, and then crash. Still though, like others have said, I imagine ICP (and the resulting cushing's symptoms) would manifest at a rate almost directly in relation to the speed of the bleed/insult. A patient with a fast bleed will present with changes fast, while one with a slow bleed will present slower. ...Regardless of age Perhaps this medic is confusing shock symptoms with ICP symptoms? Any thoughts?

LOL... uhm haha... those are sometimes hard to find too! My point stands!

Alright alright, lets not get too high on our horses. Puses are sometimes difficult to find. In hypotensive/hypovolemic patients especially (read: the kinds of patients we check pulses on!), it is often very difficult to detect a pulse by palpation alone. This is why - even in the ED - you will have 2 or more people feeling for pulses at different spots during codes. It is a subjective test that has LOTS of potential for error, no matter how well trained you are. If you say you can *always* detect a pulse on a patient who has one, you are fooling yourself. The danger is definitely there, and inexperience surely plays a role... but please dont assume that this is something professional providers dont have to worry about as well.

Our protocols dont specify a minimum BP for administration of lasix, although I think it is assumed to be a precaution. ...Especially when you're also doing NTG and CPAP. NTG and CPAP both require a systolic over 100mmHg. Morphine we would have to call for, so I assume BP would be a precaution there as well.

I report my (manual) blood presures in both even and odd numbers, without regard for this "accuracy" argument. This is not a question of significant figures, it is a matter of convention. To hell with the nurse that tells me a systolic of 144 is more accurate than a systolic of 145. Non-invasive blood pressures are estimations anyways. I feel that it would actually be LESS accurate to argue that the BP is more accurate than it actually is! One point in BP is not significant to TREATMENT, and thats what really matters. To the guy who said that 1mmHG of BP matters because of his "100 systolic" cutoff for NTG: :violent1:

Understaffed, undersupplied, underfunded, and overworked with the distinct potential for disaster and an ensuing liability. Hell no. I am very suprised that the insurance company is only requiring 3 first aid responders on scene. I think, as another poster mentioned, that there are other requirements that must be filled per state or local law. I work for a large company in an urban area that often has to provide "event coverage" for gatherings much smaller than what you are describing. I seriously doubt that my company is getting hired out of the pure generosity of the event organizer. These kinds of things are required. Tell your organizer that he needs to discuss with someone who knows about the applicable laws.

I think there are probably two ways to ask this question: 1. Do cocaine antidotes exist 2. Are there cocaine antidotes currently in use on a large scale The answer to 1 is, as others have posted, yes. To 2, though, the answer is no. I asked our medical control doc about this one a few weeks back and was given this same answer. There are a few ideas that are currently being tested, but nothing that really falls under the standard of care. Come back to the East Coast Dustyn. We prefer heroin in these parts, which is much easier to treat .

We hem and haw about it quite a bit in my system, especially since a nearby service has recently obtained permission from a local medical control (meaning: not regonal) to use etomidate for sedated intubation. Our medical advisory committee (docs that make the protocol decisions) is using this other service as a test-case on the subject. I have done quite a bit of research review on the subject, and have found a few major points: -Sedated intubation does make a large improvement in successful tubes when compared to non-sedated intubation. Another poster above has referred to these numbers. Successful intubation of sedated patients, however, remains low: around 60-70%. Still, this isnt necessairly a bad thing. These patients (who are getting sedated) are tough tubes to begin with- patients who probably would not have gotten a tube otherwise. 70% kicks the hell out of 0%. -Versed and Etomidate have been shown in clinical studies to have similar hemodynamic profiles when used in the dosage ranges necessary for sedated intubation. Based on the literature that I have reviewed, neither drug has been shown to have a significant effect on blood pressure or heart rate. I'm not really sure where people are getting the claim that versed will "dump your pressure." Research has shown that to be untrue. -There is argument as to whether these drugs are effective in relieving trismus. Some studies have shown that they do, some insist that it does not. It depends who you ask, and (probably more likely) which research they have chosen to believe. I think the issue really is what posters above have said: trust. This is a potentially dangerous procedure that - if performed incorrectly - could significantly shorten a patient's life. Paramedics in general already dont have such a great record when it comes to intubations (although I expect this should change with the advent of ETCo2), its no suprise that medical controls nation wide are reluctant to give us more oppertunity to screw this up.

Well there really isnt just ONE way to set it up. As long as you can do the math and know the dose. As we know, dopamine dosage spans the range of 2 to 20 micrograms per kilogram per minute. The most common way to do this is to make a mixture at the concentration of 1600 micrograms (1.6mg) per ml. A few examples of this concentration: 400mg in a 250 bag 800mg in a 500 bag 1.6 grams in a 1000 bag etc. Now just do the math. Pick your dosage range and multiply by the patient's weight, then plug into the formula: ( fluid in bag (in cc) / drug in bag (mg) ) * mg (dosage) * 60gtt = drips per minute OR just buy one of those ALS pocket guides and they will give you the preferred concentrations and a nifty table that gives you all the drip rates for various weights/dosages.

Trach deviation to the left AND no sounds on the left? Weird. Obviously when intubating and you dont hear sounds on the left you think right mainstem but it sounds like you thought about that.. I looked up tracheal deviation quickly on google and found a list of differentials: # Pleural effusion # Pneumothorax # Pulmonary fibrosis # Lung cancer # Pulmonary collapse # Surgical removal of a part of the lung # Atelectasis # Hitatal hernia # Kyphoscoliosis # Mediastinal tumor # Pulmonary tuberculosis # Retrosternal thyroid # Tension pneumothorax # Thoracic aortic aneurysm You know more about the patient's history/presentation than we do: any of these stand out?

Hey Brett, didnt know you were on here! ...Nerd!! -Foster

It is a grey area. What you are supposed to do is what the original poster did: call medical control and explain the situation. In the meantime, you are supposed to start working the patient until you get confirmed orders. By law, you need to work that code unless there are obvious signs of death (rigor/lividity/asystole x 3 leads/etc etc), you have a valid DNR, or medical control orders you to do something otherwise (you are passing the buck to them in this case). To the OP: well done. Like others have said, you did the right thing for yourself, the patient, and the family. I, and I think any other responsible member here, would do the same thing.

Yeah, I know... I meant mostly to distinguish between aerobic and anaerobic respiration in my post, but you are correct in that the Kreb's cycle is definitely not the only step in production of ATP in the presence of oxygen. Good clarification.

Good havin ya around, Doc. You dont happen to have AIM do ya? I wanted to pick your brain a bit if youve got a sec...