1EMT-P

As someone who has used both of these medications, let me first start off by saying that they are both good medications. I think each medication has some pros & cons. Personally I like Phenergan for migraines, motion sickness, nausea, sedation, vomiting & with pain medications. If you dilute Phenergan & if you give it slowly in a patent IV or if you give it deep IM it works very well. Many times you can decrease the amount of pain medication given.

I have to agree with Dwayne on this one, moving & transporting patients can be stressful. If we can decrease their anxiety, improve their condition & make them more comfortable before we go enroute to the hospital then we should do that. There is a difference between working in a rural system with long transport times versus working in an urban system with short transport times.

Dilaudid or Hydromorphone is a very strong class II narcotic pain medication, it works really well for controlling severe pain, but you have to be careful when administering it that you don't give it too quickly & that you watch for issues such as respiratory depression. The usually dosage is between 1-2 mg IM/IV/SC.

Just because a patient is being transported home doesn't mean that we should treat that patient differently. Patients are patients regardless if they are Critical Care, EMS (911) or Transports & they should be given the same standard of care. We should be getting an H&P including baseline vitals, list of allergies & list of medications on all of our patients & we should be documenting who we got report from, what the patient's condition & problem was, any treatment, where we are transporting the patient & how we transported & left the patient. The patient in this case had Atrial Fib, Hypertension, Stroke & was complaining of a Headache. Given her chief complaint & her history clearly a detailed evaluation is warranted, sometimes things do not always show up on CT. I've taken care of lots of high risk patients in the ICU over the years who were evaluated in the ED for similar symptoms & later sent home, only to return hours later with a positive CT Scan & Stroke.

It sounds like maybe the ED didn't do a complete assessment. If they had then she would not have been discharged based upon her brief history & chief complaint . Instead she should have been admitted for observation on telemetry pending a CT scan of the head & follow up testing. In the future I would encourage you to review your patients vitals starting from admission to discharge, look for trends that suggest problems, also always document how you find a patient in the ED & if you do find something abnormal report it to the ED & document who you reported it to.

I've used Diazepam IM/IV & Versed IM/IV also with good results in the past, but personally I like Ativan IM or IV the best. It seems to work well for most patients.

It sounds to me like we have two problems here 1. We have an elderly patient with an allergic reaction and/or possible medication reaction with airway involvement & 2. We have a patient with an extensive cardiac history. If this were my patient I would have given her Oxygen. I would have also given 50mg Benadryl IV, 125mg Solu Medrol IV, plus Tagament or Zantac IV. I would have also considered giving an Albuterol Neb treatment.

"Just because we can tube, doesn't mean we should"! Instead we should assess each patient & select the best airway modality for that patient, BVM, OPA, NPA, BNI, CBT, ETT, King, LMA or CPAP.

I was shocked & saddened to hear about the passing of my friend Rob "Dustdevil" Davis. Rob & me spent a good deal of time talking about life & the issues facing EMS. Rob always challenged me to look at things in a different way, "to think outside the box" if you will. To his family & friends I send my thoughts & prayers.

It sounds to me like he is having an arrhythmia. I would contact his primary care provider ask them to do a complete physical & labs maybe a CBC, Basic Metabolic Panel, Magnesium & TSH level. I would also ask them to order an Echocardiogram to check his hearts function & ask them to contact a Pediatric Cardiologist.

I think it's great that the military has noticed this as an issue & that they are addressing it with more education. Too often education gets pushed to the side.

To be honest with you, I really can't see a reason for most medics to carry antibiotics, unless they are functioning in a disaster, expanded scope of practice or wilderness medicine setting.

There are always two sides to every story, but usually vital signs are taken every 15-30 minutes on stable transports. I would be very interested in hearing the crews side of the story, for example how much experience did they have, how long had they been on duty, how many hours had they been awake, what was going on prior to the transport, what happened prior to & during the transport.

At this point I am going to be wanting to head to one of the two trauma centers, reason being is that this is an 80 year old man who has just been in an MVA & who is experiencing chest pain that is 8/10. The patient appears to be " stable" maybe a bit too stable. I would start him on 02 4 LPM via N/C, I would start 2 IV's, I would also consider getting a second 12 Lead if there was time, maybe even a right sided EKG. I would also consider giving him some fentanyl for his pain.

I can't believe that they were carrying that many doses of D50 on each unit, especially with the price of drugs & medical supplies today.

In the past I've always used Alcohol to clean the skin with, unless I was doing a blood draw for a blood alcohol level or a procedure, but now I use the preps that come in out IV start kits at work.

I currently work in an ICU, but when I did work in the field we used Versed + Morphine + Sux + Vec. There have been studies done that suggest that pre-hospital intubation is causing harm, so it is likely that intubation will be removed from the scope of practice of ground based Paramedics in the future & be replaced with blind insertion devices unless we increase provider education, improve provider airway assessment & intubation skills..

I have not had a chance to review the new PA updates, but it sounds like they are trying to encourage the Paramedics to be more active in assessing the patients & that they are trying to encourage them to function as the provider in charge of the EMT's much like the RN's are in charge of LPN's in the hospital setting.

I would call this a 2nd Degree Type 2 with Junctional Escape Beats with a borderline Bundle Branch Block.

Given this patient's history & physical it appears that there are multiple things going on with him. ACS, A-Fib, also a possible Bowel Obstruction & CHF. I would have treated him with O2, IV, Monitor. I also would have given him ASA & Nitro.

I would highly recommend that you consider either applying with a busy 911 service or that you consider applying with a company that does both critical care transports & routine transports or maybe even applying with an ER, sometimes a change of pace is good.

We use NG's & OG's on a regular basis in the ICU & yes I have used them in the field in cardiac arrests, overdoses, respiratory distress & trauma patients. As a rule of thumb if you are going to tube a patient, then an NG or OG is a good idea.

The fact that the patient has no past medical history & developed these symptoms suddenly is very concerning, if he were my patient I would start with 02, IV & monitor. The patient is symptomatic & has already had 12 mgs of Adenosine, which really didn't do much, so I would consider a trial of medications to see if we could slow the rate. Amiodarone 150 mgs IVP over 10 minutes or Lopressor 5 mgs IVP. I would apply the pads & if he started experiencing chest pain, hypotension or respiratory distress I would go with cardioversion starting at 100J. As of right now I would call this a WCT of Uknown Origin ( A-Flutter/SVT vs V-Tach). I would love to know what his lytes were, especially his Magnesium.

I have been working in both critical care transport & ICU since the early 90's & I have never once read anything about or ever seen anyone clamp an ET tube. I personally would not recommend clamping an ET tube in a critically ill patient without knowing the rationale & without having a Physician's order.

Yes, Magnesium is very important, it plays a role in many physiologic reactions. It is used for Cardiac, Diabetic, Obstetrical & Respiratory problems.