fiznat

Wait, am I wrong that first responder is NOT BLS? I was under the impression that BLS begins at the EMT level. Below EMT is pre-BLS or quazi-BLS at best. If that is so, then the article would be correct. Most firefighters arent EMTs, they are first responders.... meaning that, yes, they are not trained in BLS yet. I dont see too much wrong with that-- assuming that real EMS would be on their way to the call as well. I dont think we should expect firefighters to do EVERYTHING, I actually think its a bad idea. Fire and EMS are two different things, requiring different skill sets and different approaches to a scene. I never expect a firefighter to be able to do what I can do, nor should a firefighter expect me to do what he does. First responder, yes. BLS/ALS? No.

haha thanks guys, all good points! A lot of what you mentioned are pretty basic things- ambulance etiquette type stuff. I'm pretty familiar with that, been working EMS as an EMT for about 5 years now. Not that there surely isnt more that I could learn, but still- What about medical stuff? How aggressive to be on calls, how well should I know my drugs (every single detail, or know the when+when not+why+how+how much), what are some things I will likely get shaken up on during my first few good ALS calls, etc. I realize every preceptor will probably be different on what they want, but what are some experiences you guys have had- both good and bad? It'd be interesting to hear.

Dale Dubin's Rapid Interpretation of EKGs. /thread.

Wrong forum, momo! If you had looked in the correct forum for this (ALS), you would have seen that I already asked this question! You'd think someone with an "overactive brain" might have realized this on his own. I was way less verbose, also. :wink: haha.. Anyways, we were right bro. Dream Team: 1 DT: 0 http://www.emtcity.com/phpBB2/viewtopic.php?p=87425

I had to look this one up, so to aid others like myself:

Yeah thats pretty much what I thought. ...But not all chest leads are contiguious right? Like, ST elevations in V1 and V4 only would NOT be indicitive of a MI (assuming no other evidence) because they are not contiguious to eachother. V2 and V3 are contiguous because of the proximity of the anatomical locations viewed by those leads- not simply because they are both "chest leads." Just wanted make sure we're on the same page.

Jesus! Nothing like a little jail time and extorsion to take change your mind about helping random people in Bangkok. F that. I have a little face shield on my keychain that I carry. Its kinda old now, I dont know if it would even really do its job these days. I also have a basic BLS kit in the back of my car. Never had to use the shield before, and only cracked the BLS bag open once or twice for minor stuff with friends/family. There was a recent thread about what gear people have in their cars. Some people here have gone pretty overboard with it haha.

We had a bit of a disagreement in medic class today about contiguous leads, I thought some of you folks here might be able to help out. Are leads V2 and V3 anatomically contiguous? What about V4 and V5? We asked the instructor this, and he said that they arent-- but this didnt make sense to a friend and me. V2 looks at a septal part of the heart that is directly adjacent to the anterior part of the heart that V3 looks at. I was under the impression that "directly adjacent to" and "contiguous" meant the same thing. Our instructor maintained that the two leads are not contiguous because they view "different sections" of the heart: IE septal and anterior. We disagree. Discuss?

I was in the ED today dropping off a patient when I overheard a patch on the c-med radio saying that a trauma was coming in. ...GSW, 4 shots from a handgun into the patient's back, through the torso, and 4 exit wounds out the chest. You can hear yelling from the back of the rig as the driver is giving the patch, he reports that the patient cannot move his legs and is beginning to become combative as the hypoxia and blood loss begin to take hold. The crew did a good job. The patient was spine-neck immobilized, the chest twice decompressed, IV established with fluids running, O2 provided along with assisted vents via BVM. Sinus tach on the monitor, and the little bleeding seemed to be well controlled. ...All this performed with a combative patient and --as I was told later-- a group of rowdy onlookers on-scene. It wasnt until they rolled into the trauma room that the chaos began to ensue. Seriously the worst cluster I have ever seen. Had to be 15 ED docs, nurses and techs cramped into a trauma room designed for probably half that. Immediately people start yelling. "Get me gloves!" "Get this guy tubed NOW!" "Give me a blade! Give me a blade! Give me a blade!" People are pushing each other out of the way, lines are crossed and steps are missed. I watch a resident insert a chest tube and then - once its inserted - look around and wonder where the rest of his equipment was. He didnt set it up before cutting, so he starts yelling for it. Nobody gets any respect. Nurses are treated like idiots because they dont instantly provide equipment to doctors, techs are pushed out of the way as they struggle to help. Everybody is yelling. By the time it was said and done, this patient got his chest cracked right in the bay, tubes inserted and lines of blood run. Probably 10 minutes in the trauma bay and he was rushed up to the OR. As the bed was rushed out of the room, the femoral line almost gets pulled out as the bags of blood fall to the floor. Someone gets knocked down. I have never ever seen such horrible communication and teamwork before. This was not a trauma team, as the called for on the intercom, it was a collection of bigheaded doctors and angry nurses-- each screaming to have their voice heard over the chaos. I've seen this trauma team work patients before, but not like this. Usually it is a moderate trauma -- an MVA or a fall. This GSW was one of those rare and fantastic traumas: the kind you get to pull all the tricks and procedures out for. Hell, the medic got to decompress the guy in the field -- twice! How often does that happen, right? ...But the rarity of it and the added stress seemed to take the trauma team and fracture it. What is normally a cohesive team performing organized assessment and treatment became a frantic collection of angry demands and rushed decisions. Not exactly what you would hope for if you were that poor patient on the stretcher. Anyone ever seen this before? How does your ED trauma team work? Do you find that doctors tend to yell over the crowd as the issue demands, or is there actual calm collected teamwork? ...Even on the bad traumas? I know we struggle with this all the time in the field-- and I'm sure most of us are familiar with that whipped-up exciting urgency that can sometimes become overpowering on the really bad calls.... but we all consider it to be the mark of a good medic/EMT/firefighter to be able to rise above the chaos and organize. It bothers me that these (mostly) experienced ED physicians found this basic principle so difficult to achieve. I have 5 years of experience in EMS as an EMT and now (almost! haha) a medic, but I have never seen this kind of frantic response before from an ED trauma team. I know this is a long post and a long story (I tried to make it interesting), but I'm interested to hear other people's observations of bad traumas run in the ED. Whats the best youve seen? The worst?

In my belt, each in nylon holders: -mag light -company pager -cell phone In my leg pockets: Left side is a handful of gloves Right side has multiple sections to the pockets: -Notebook -Quick reference book (meds etc) -EKG calipers -2 Pens -Trauma shears -1/2" clear tape I carry my scope around my neck. Make fun of me if you must but I never ever forget it, and its always there when I need it. Besides that, wallet + watch is about it. I know people who carry alot more, and people who carry alot less. Whatever works for you I guess.

I dont think anyone on the forum can really make an accurate determination whether this patient needed to be bagged or didnt... Its a matter of seeing the patient and really taking in his full presentation that would help lead good providers to that kind of a decision. The main problem is that there are a number of pathologies that could be the cause of this presentation BESIDES hypoxia. The fact that the SpO2 reads at 96% and the patient was not cyanotic are points against hypoxia as the cause, and raise suspicions about other possible causes. Given an extra set of hands that are otherwise doing nothing during transport-- sure why not, bag him. Given only myself in the back? I think I'd probably spend that time trying to do a more complete assessment, first.

1) Doesnt really matter, but ok 2) Exactly my point. EMTs dont treat cardiac arhythmias unless it is a code-- and even then they dont treat, they support. Looking at the ECG really does nothing for your BLS assessment except bring factors into the mix that will have no bearing on your treatment. By all means, bring the ECG along with the rest of the paperwork so someone else can have a look - but please dont ask the question "is this heart rate more irregular than the one thats on 5 day's ago ECG" because that really is immaterial. Ironically enough, your "real story" included an ECG that had frequent PVCs, for which the first line treatment actually IS BLS (supplimental oxygen)... but you should be giving O2 anyways, not because you think the patient's pulse is irregular. 3) I'm having a hard time understanding what you're trying to say here. Yes every patient is different, yes sometimes acutely ill patients are not obviously acutely ill. ...My point stands, though. Reading the computer-generated analysis off the top of an old ECG is probably one of the worst diagnostic tools you (as an EMT) could possibly employ to assess your patient.

Like everyone else said, excellent post and big time kudos for your willingness to be completely honest about your capabilities. First I'd like to respond to something another poster said: DONT ever try and obtain a 12 lead ECG and "read the interpretation at the top" like someone suggested. Not to be rude, but this is an absolutely awful idea. Not only are those interpretations often completely incorrect, but even if they are correct it is silly to assume that a BLS provider would have the knowledge or means to treat such a rhythm. Not to mention that SNFs NEVER perform acute 12 lead ECGs (so what you are looking at is likely old), and an ECG is probably the absolute least important clue for you to consider at this point in the game. Okay, sorry... had to get that off my chest... Here is something to consider that I think might help. EMTs are trained (or at least I felt I was) to recgonize specific patterns and make treatment decisions based on that. Like you said, his resp rate was "too high" so you were taught to bag him. The problem with this manner of assessment is that you are not considering your whole patient. ALS providers are trained to recgonize certain peramaters, no doubt, but more importantly they are instructed on the difference between "stable" and "not stable." A good example of this is with heart rate. In general, bradycardia is defined as a heart rate of less than 60 beats per minute. Presented with a patient who's heart is beating at 45 beats per minute, a newbie medic or EMT might think "his heart is going too slow, I need to do something about that!" ...But that isnt correct. What medics (and good EMTs) need to do is to assess the entire patient. Is the patient mentating properly (or at least to his baseline)? Is the blood pressure good? Is the patient perfusing his organs with this heart rate and blood pressure? All these questions-- and really you're just asking-- "Is 45 beats per minute too slow for THIS PATIENT?" Transposed to your patient, you need to ask questions and do an assessment surrounding the question "is this patient stable?" Given the clues you found on your assessment, I'll help you make that decision: 1) The patient was unresponsive to pain. This is generally a very bad sign -- but again, if this is his baseline, it may be a completely insignificant finding. You need to find out about baseline mental status on every patient, every time. If this patient is not normally unresponsive to pain, this patient is UNSTABLE. 2) The patient had respirations in the 40's. The question you need to ask is, "is he achieving proper oxygenation at this resp rate?" Look at his skin color temperature and condition (specifically for cyanosis), check his O2 sat if you can, listen to his lung sounds. Given the rest of the patient's presentation, your decision to increase the O2 to 15 lpm by NRB was a good one, and your decision to ventilate was also probably correct. 3) The patient had a thready pulse and you were unable to get a blood pressure. Again, is this patient perfusing? The answer is probably not, but you need to look for other clues as well. Mental status is a big predictor of perfusion (and this guy is unresponsive), blood pressure another (you cant get it), skin color/temp/condition, capillary refill, etc etc. Given what you said, this patient is most likely, again, UNSTABLE. Notice that the things you are looking at follow the initial assessment that every EMT should learn: 1) Mental Status 2) Airway 3) Breathing 4) Circulation Check and do your best to treat those things, every patient, every time and you will always do the right thing. Err on the side of caution for your patient, and dont be afraid to call for ALS if you think your patient is unstable. Good luck man, hope some of this overly lengthy response was helpful haha

...Because it got me interested in medicine, and is my foothold towards med school ...Because the job is flexible, I can work any time I want and fit in schooling as I wish. ...Because it is different every day. I am rarely bored, and I never know what to expect next. ...Because it helps be build skills that I think are valuable elsewhere. Not just the medicine, but the repetition of thinking on your feet, analyzing situations, talking with people who are stressed, remaining calm when everything else is going crazy, etc etc. ...Because the pay is just enough to get me by for now. haha. I would love more pay, but I dont think I could do this job (financially) for even a single dollar less an hour. ...Because of the occasional (even if unvoiced) "thank you" we get from patients. It doesnt happen all the time, but when it does -- it makes alot of this worth it.

Correct me if I'm wrong here (perhaps we are both right...), but I thought Bicarb was used in TCA OD in order to retard + prevent metabolism of the injested drug? This is the reason why Bicarb should only be given to TCA OD if the injestion was recent. Ingested TCA that has already been metabolised wont be affected by Bicarb, if I am remembering correctly?

When you give a report, make it clear and concise-- usually the latter being the most important. ED nurses are SO busy, they rarely have a lot of time to sit down and hear what you found on every detail of your assessment. As long as its not a major trauma or medical, give them the highlights, give them the paperwork, perhaps tell a joke, and get the heck out of their way. As far as they are concerned, you are just bringing them more work to do. Do it professionally, and do it quickly- thats really all that matters IMO.

A few others that I dont think people have mentioned... -When you start the shift, introduce yourself and make sure your partner knows you are new. Tell your partner what you are weak on, and ask him if there is anything specific he likes his partners to do for him on ALS calls. -Learn how to be a good ALS assistant. Spike a NS bag, set up the monitor (3 lead), get a blood sugar off of the IV sharp (if your service does this). ASK before you do this stuff for your medic until you fall into a routine. -NEVER EVER EVER make anything up. If you dont understand something, even if it is something that you probably should know, just admit it. It will be 10 times worse if you try and pretend you know something you dont. NEVER make up vital signs. If you didnt hear it, try again or admit it. -Going along with the previous one-- dont let yourself believe that you know more than you actually do. Paramedics arent gods, but you need to be humble and know your limits. There are lots more, keep reading. Great thread!

lol yea youre right Shane, but its more fun to talk about meds isnt it? haha. Fluid bolus and O2... how boring is that?! lol Yeahh I never think about Procanimide, even though I guess I should since our service for some reason still carries it. Its not included at all in the new ACLS, and medic class has pretty much all but completely disregarded the med since. Do the protocols specifically call for it, or do they just say "follow AHA guidelines?" Wonder when we're actually gonna get Amio for all the trucks. I know of only 1 med bag that has it, and even then it only has 150mg which is just the single 10 minute dose. :roll: Guess theres a lot of stuff we "should" have, yet dont.

Osmosis can be summed up by simply saying "water follows salt." The idea is that water moves so that the concentrations on both sides are equal. Water flows towards a hypertonic solution because that side has more solute ("salt"), which needs to be balanced out by more water. A cell placed in a hypertonic solution --- water flows out of the cell (towards salt), cell shrinks A cell placed in hypotonic solution --- water flows into the cell (towards the salt in the cell), cell blows up A cell placed in an isotonic solution --- no net movement of water (already balanced), cell remains unchanged Notice that there are always 2 fluids used for comparison. I used "the fluid within the cell" and "the fluid outside of the cell." The user above used "the fluid in the vasculature" and "the fluid outside of the vascularture (the intersticial)." It doesnt matter which example you use-- the point is that you have two volumes of fluid with varying concentrations of solute, separated by a semi-permeable membrane through which water can flow.

I started medic class in January of this year (06), been going since with A+P, Clinical sessions (ED, Pedi Clinics, OR for tubes, CICU, MSICU, CHF units, L+D, OBGYN, etc etc etc), and lots of lecture material. On November 12th we FINALLY get to start our ride-time, which we have all be eagerly awaiting this whole time. I absolutely cannot wait to get into the back of the truck and start learning how to do this with real hands-on practice. ...Also it feels good to be just about done with all of this. We are scheduled to take the National Registry practical exam on January 6th, 2007. We will be the first class in the nation to use the new computer-based testing for the written exam, too-- so hopefully we should all have our results by mid January. Wish me luck guys, I wish you all the same!

OMG R U 4 REAL!?!??!!!!!111one

woah woah there. I can read regular sized text just fine. My understanding is that hyperkalemia usually results in an abnormally wide QRS, flat P waves, and tall peaked T waves. I dont see why the combination of hyper-k and bundle branch couldnt produce the rhythm posted. Just because the QRS is abnormal doesnt mean that the T wave is insignificant. Of course hyper-k is pretty much a Dx of exclusion in this case. No medic of sound mind I think would jump right to calling this hyperkalemia... doesnt mean it isnt a possibility though. The S+S are there, the EKG supports it, and its one of the "H's and T's." We should consider it, along with everything else.

Didnt anyone else think CHF from the story? Transient SOB, increasing on laying down (typical of pulm. edema), elevated diastolic BP, rales can easially sound like rhonchi, normothermic, and a compensatory tachychardia which eventually gets out of control... I donno... As I must I preface everything I say in this forum with the acknowledgement that I am still a medic student (almost done though), but I find it hard to justify the adenosine in this case. Even though the guy's rate was 170, I still have a hard time believing that this was a rate-related problem. By your own admission you said you thought it was a PE... so why treat the rate? I feel like I would have tried to focus on his breathing instead... I was thinking more along the lines of diuretics, nitro, and beta II agonists... I'm a student though, so-- anyone agree?

Ah ya beat me to it! Yeah its a wide complex, tachy rhythm with hard to see (if existant at all) p waves. The bundle branch is also fairly obvious, which does help to explain the width. They've been telling us in medic school that any wide complex tachycardia like this should be assumed as VT unless proven otherwise. Amio would of course be the perfect drug for this patient since it work either way-- the only problem is if it does work, you still dont know what the rhythm was. Also is it just me, or are those T waves a little tall? Possible hyper-k?

LOL well I guess this issue is wrapped up!! :laughing6: