1EMT-P

I am seriously thinking about leaving the hospital setting to return to the field after a long but needed break, any ideas about how best to transition back into the field in PA? Just looking to get back to my roots. Thx

To be honest with you I am not sure as to why the medic placed an IO, as a rule of thumb most providers will look for an IV & make at least two attempts with in about 90 seconds before they consider an IO. Narcan can be administered several different routes so I am not sure why the IO was used.

I have never had Versed in any of my drug boxes, we always carried Valium. The one service that I worked with that did have Versed, keep it locked up with the Morphine, but not in the drug box.

The real question here is why is your patient in a heart block in the first place.... Is it because they had an Acute MI or is it because they have taken too much medication & they have blocked down. If you can figure out what the cause is then you can address it. In any case I would do the following for this Pt: 1) Consider Causes + IV/IO Fluid Bolus 500 ML x1. 2) 0.5 mg Atropine IVP x1 3) Applying Pacer Pads 4) PACE 5) Additional Fluids and/or Dopamine Titrated to SBP of 90.

Yes Glucagon could be helpful in a Beta Blocker Overdose, but the fact is that most EMS agencies do not carry enough Glucagon with them for something like this, so with that being said another possible option would be to follow your ACLS protocols & to also consider mixing an Epinephrine Drip in the field you could try 1mg of the 1:1000 solution in a 250ML bag of NS & start at 30 gtts/min with a microdrip set & titrate or you could also try a Dopamine Drip.

I would encourage you to practice your palpation skills as much as possible, also please don't forget that you need to have a 10-14 ga IV cath 2" in length.

CONGRATULATIONS! MY ONLY ADVICE TO YOU IS FOR YOU TO FIND AN EXPERIENCED PARAMEDIC MENTOR WHO CAN HELP YOU! GOOD LUCK!

With all do respect there are different levels of Emergency Medical Technicians, just like there are different levels of Nurses & they have different levels of education & skill. All Emergency Medical Technicians assess their patients & then treat what they find accordingly & then relay that information to the hospitals. The real question we should be asking is which interventions make a difference & what do we need to do to make EMS care better....

First off, 1) We are all Emergency Medical Technicians ( Basic, Intermediate & Paramedic ). 2) If you read the EMT- Basic scope of practice & you review EMT-Basic texts you will see that EMT-Basics are taught to assess their patients & they are also taught to treat what they find & to relay that information. 3) EMT-Basics are an important link in the EMS System & it is counter productive for you to degrade them! 4. FYI Paramedics do not prescribe, that is a function that is reserved for mid level providers such as ( CNM, NP & PA's ) & Physicians!

As I am sure you are aware here in the US we have a complex medico-legal system, EMT's & Paramedics do not practice independently, but act as Physician Extenders working under a Medical Director/ Physician's licensure. EMT's & Paramedics do not run off & ask doctor may I, but instead consult with Medical Command regarding the best treatment for patients. Ok, but why do you disagree? If an EMT and/or Paramedic is working under a Physician's licensure acting as the eyes & ears of the Physician in the field & assess a patient & relays that information to the Medical Command Physician and the Physician issues a Verbal Medication Order to the EMT and/or Paramedic based upon the assessment is that not the same thing as a prescription?

I urge you to carefully read my post again. At no point did I say anything about excluding or eliminating Physician input. If we are going to allow EMT's to use AED's, Blind Insertion Airways ( CBT's, Kings & LMA's ) Medical Direction & review is essential. I am sorry but the simple fact of the matter is that Nitro is self administered by patients around the world everyday for chest pain without 12 lead & without IV access! If a patient with no medical training can administer Nitro then why can't an EMT with medical training administer life saving medications like Epi Pens & Nitro? Explain your rationale!

I am in favor of giving EMT's access to life saving medications with medical supervision including, but not limited to Activated Charcoal, Albuterol, Aspirin, Epi Pens, Nitro, Oral Glucose, Oxygen & Tylenol.

All EMT-Basics in the US are taught the signs & symptoms of shock & how to treat it. They are also taught how to assist patients with their own life saving medications. If an EMT can assist a patient with his or her own medications then why should they not be allowed to carry & administer those same medications during a life threatening emergencies when ALS is not available?

I always like to have as much information about my patients as possible, sometimes you can get clues about what may have happened. Did he have a history of CAD, CVA, Diabetes, HTN, Seizures orThyroid etc. AMI, CVA, Diabetes, Drugs, Hypothermia, Infection, Seizures & Thyroid would have been on my short list.

While I support increasing the educational standards for EMS providers in the USA, I have to take issue with calling our system a joke. As I am sure you are aware just because a system is different does not mean that the care provided is not good. The USA has some very good EMS agencies including Medic One & Richmond Ambulance Authority just to name a few. There are pros & cons with each of the international systems that you mentioned. In other words my friend " people who live in glass houses shouldn't throw stones".

Please keep in mind that a pulse oximeter may not be accurate in states of low perfusion ( cardiac arrest, hypothermia etc).

I am sorry, but you must of have misunderstood what I said... I did not say that saline locks prevent you from pushing fluid. What I said was that I am not a big fan establishing saline locks only in these patients without fluids. As I am sure you are aware strokes are a leading cause of death & disability in the US. There are an estimated 700,000 strokes that occur each year in the US. It has been reported that over $23 Billion is spent each year on the care of these patients. In many parts of the US EMS agencies have stroke protocols & they work hand in hand with designated stroke centers to not only rapidly assess these patients in the field, but to also get them to one of these designated stroke centers so they can be treated aggressively. If a patient is going to be taken to the Cath Lab or OR for immediate treatment then it is important that we in EMS do everything we can to "prep" the patient, including having IV access x2.

If you would please explain your rationale for saying that fluids are contraindicated. The purpose of IV fluids is to 1. allow fluid replacement & 2. provide for medication administration. The usual indications for IV fluid administration are as follows cardiac emergencies, dehydration, diabetic emergencies, respiratory emergencies, stroke, poisoning, seizures & trauma.

A saline lock does not prevent you from pushing fluids, but there are some places that do not hang IV fluids on CVA patients. They start saline locks only!

I am not a big fan of starting saline locks only on CVA patients, especially if they are neurosurgical patients & going to be going to the OR. I can tell you from experience that during neurosurgical cases for cerebral aneurysms that they will sometimes induce moderate hypothermia by rapidly infusing IV fluids for cerebral protection.

I think you are missing the point, the patient was 1 month Status Post CABG & he developed Atrial Fibrillation & Atrial Flutter in the hospital after his surgery, he was treated with an Amiodarone Drip & 2 Grams of Magnesium IV & converted back to SR & discharged to home, three weeks later his symptoms returned. He developed palpitaions along with some shortness of breath! The patient was not in a ST, he was in Atrial Flutter!

I am sorry, but I have to respctively disagree with you on the ancedotal evidence. A patients history & physical can tell you a lot more than a 12 lead! As I am sure you are aware Atrial Fibrillation & Atrial Flutter are fairly common among Status Post CABG patients. This patient had a history of Atrial Fibrillation & Atrial Flutter following his CABG surgery. The ED & PCP were the ones who did the interperetation of Atrial Flutter vs SVT on the 12 lead. So a patient who is 1 month S/P CABG with Atrial Flutter, palpitations & shortness of breath is stable??

Dust, I am sorry but I have to respectively disagree with you. When I first became an EMT in the 80's we were taught how to do an assessment & what was considered normal vs abnormal & what that might mean & why. It is important for all EMT's & Paramedics to be able to not only assess their patients but to document & relay their findings to the ED staff. Examples: Decreased Circulation, Motor & Sensory with a dislocation/fracture, Trauma: Flail Chest, Fractured Femur etc.

I was talking with a Paramedic who told me that he respond to a primary care clinic 30 minutes away from the hospital for a 50 year old white male patient who is 1 month S/P CABG. The patient went in for a routine appointment for palpitations. Upon arrival you find the patient on an exam table, on 2 liters of oxygen with saline lock in place & Dynamap in place. The patients vs were as follows HR 130, BP 110/50, RR 20, SPo2 95%, T 98.7. SAMPLE History was as follows: Hx of Palpitations. Allergies: NKA, Medications: Lopressor 100MG, Aspirin 325MG, Zocor 40MG, Lasix 40MG, Nitro SL, Plavix 75MG & Multi Vit. Past Hx.: CAD & HTN. Last intake breakfast. Events leading up to patient was resting at home. Enroute the patient was placed on 4 liters of oxygen, an IV of NS was started an additional 12 lead was obtained HR was 130 Atrial Flutter vs SVT, The Medical Command Physician ordered Adenosine 6MG IV x1 & the patients rate slowed to 113 with Atrial Flutter 3:1. If this was your patient what would you do?

The reason that we teach EMT's to palpate is because we want them to assess their patients. As the senior provider on the truck you have an obligation to mentor the EMT. Yanking his hands away in front of the patient served no purpose!