1EMT-P

I think you should be good. If you are looking for a stethoscope, but don’t want to purchase an expensive one. ADC & MDF make good quality ones.

Should EMS abandon the use of Fentanyl in the field? Based on the fact that it’s a highly abused and addicting substance. It’s not like we don’t have alternatives. Please share your thoughts.

Unfortunately there is no way to answer your question without having additional patient information. Including the patient’s Allergies? Medications? Past Medical History? Events prior to the emergency. In all honesty this sounds like a real situation.

Ruff, You will do great! Go show the kids how it’s done! All the best

I contacted the ED Physician, he said to contact the receiving ED Physician which I did three times. Neither Physician wanted to address this patient’s pain. Their reason was they couldn’t assess her if she was medicated. I explained to the Physicians that the patient was in severe pain and that she needed medicated, when I arrived I spoke with the Chief of Trauma and Anesthsia both of which agreed with me that the patient needed medicated and that the ED Docs were both wrong. The patient was given 100 mcg of Fentanyl IV, 4 mg of Zofran IV and an additional dose of Ketamine

Does your agency require PALS or PEPP or other pediatric course? Does your agency have pediatric equipment?

Well here is the problem. The ED wrote orders for a one time dose of Ketamine & Zofran with orders to contact Medical Command for additional orders. The problem is the transport was 3 hours long. The Medical Command Dr was young & not a fan of Ketamine. There are no standing orders for pain management for inter facility transports.

So let’s say you have a priority one trauma patient with open fractures to the radius & ulna plus tibia & fibula plus free fluid in the abdomen. The patient’s vital signs are BP 100/60, HR 120 ST, RR 24, Spo2 95% on 2 LPM. The patients pain is 10 on a scale of 1-10. The ED that is transferring the patient has hung a unit of blood and gave orders for 0.1 mg/kg of Ketamine for pain. Plus 4 mg of Zofran IV x1 dose. This made the patient comfortable, but 1 hour into a 3 hour transport the pain returned. The medical command physician is contacted, but refused to treat the patients pain. What do you do?

I am starting to see more & more Meth related calls. It’s not uncommon for the patient's to have elevated temperatures with altered mental status and they can and do become aggressive.

It’s sad to see patients suffer because of health related issues. We should be able to provide these patients with additional resources so they can improve their health.

How does your EMS agency handle bariatric patients? Do they send additional resources? Do they have specialized equipment to move these patients? I’ve noticed that my patients seem to be getting bigger with complex health problems, but yet we aren’t being given any additional resources.

The real questions should be 1. Can we safely transport two patients and provide high quality care to both? 2. Can we protect the patient’s health information and personal identifying information? I would argue that you cannot safely transport two patients in the same unit and that you cannot protect the patient’s personal health information.

Spock, Does your agency have the patient sign the electronic medical record directing payment to your EMS agency? If they do and the insurance company sends the payment to the patient then it would seem to me that the insurance company would be responsible. I would speak with your billing folks and your agencies legal counsel about sending a letter to the insurance companies to recover the unpaid bills plus associated costs.

Why on earth isn't someone from billing following up with the hospital to ensure that they have the right information? The patients register at the facility, why not require a copy of the facesheet to be scanned from the facility.

Its difficult to comment on this patient with the limited amount of information available. I would be interested in seeing a copy of her EKG tracing as well as her medication list. Based on what you have told us it sounds to me like your patient was experiencing a second degree heart block. Did your patient have any history of tachycardia or any ablation therapy?

I seriously considered CPAP and also a trial of Dopamine, but after talking with the ED Physician I learned that they had tried CPAP and Dopamine in the past with this patient and that CPAP significantly increased his hypotension and that the Dopamine caused him to develop serious tachycardia.

I was curious as to how the ED was going to manage this patient so I stayed to see what they did. The first thing they did was address his code status, then the Dr. ordered stat labs, a portable chest X-ray and a 12 Lead EKG which showed a SR with a 1st Degree AV Block. The Dr. ordered BiPAP in addition he also ordered Duo Neb treatments to be given to the patient. Plus he ordered 0.625 MG of Vasotec IV and he ordered an Echocardiogram at bedside.

This patient proved to be a challenge, because of the fact that he had CHF and Pulmonary Edema. Normally we would have used CPAP along with Nitroglycerin, but given his low blood pressure those weren't viable options so I consulted with a Physician. The Physician ordered a 250 ML fluid bolus of 0.9% Sodium Chloride, following the fluid bolus then BP was 80/60, the Physician then ordered an additional 250 ML fluid bolus which brought the BP to 92/64 followed by 40 MG's of Lasix IV given slowly.

So here is a case that I would like you to comment on. I was recently called for a 78 year old male complaining of shortness of breath & generalized weakness times three days. The patient was allergic to Penicillin & IVP Dye. Medications included ASA, Plavix, Zocor, Metformin, Lasix, Metoprolol, Digoxin, Proscar, Flow Max, Albuterol, Lantus & Magnesium. Past Medical History included AMI, CAD, CHF, COPD, Hypertension, Diabetes, Arthritis, Parkinson's VTach and ICD. Vitals were as follows BP 72/52, RR 24, Pulse Ox 88, SR with PVC's, Glucose 120. Assessment: Patient was alert & oriented to person, place & time, skin was pale, cool & dry, pupils were equal & reactive, + JVD, trachea was midline, lung sounds revealed crackles in the bases with some wheezing noted, abdomen was firm, CMS was intact & there was trace amounts of pedal edema. The patient denies any pain only increased shortness of breath and weakness. What is wrong? What should we do?

I would have been reluctant to give ASA & Nitro to this patient. I would have been more inclined to administer either Amiodarone, Cardizem or Lopressor.

I would recommend Dr. Nancy Caroline, Bob Page, Dale Dublin, Dr. Bledsoe just to name a few.

We still use backboards, but on a very limited basis. We primarily use them for auto extrication, cardiac arrests and severe trauma.

When I first started in EMS we didn't have ETCO2 or Pulse Ox. I use both regularly in the field because they give me additional information. Micro stream technology is a wonderful tool!

Off Label can you please explain why you feel that nasal ETCO2 is not a diagnostic tool in the non intubated patient, but that it is in the intubated patient.

I can think of several types of patients who can appear fine, but when you assess their ETCO2 you could find problems including Asthma, COPD, CHF, Heroin Overdose, Sedation & Seizures just to name a few.