croaker260

OK for those who are randomly interested, here is aone of the daily little med math quizes for your pirating pleasure. 1. The Protocol Orders you to administer up to 324 mg ASA PO, but your patient already took 81 mg ASA PO just before your arrival. You have 81 mg tablets on hand in your kit. How much ASA do you administer? SCENARIO #1: Your patient is a 8 y/o little girl who is in hypovolemic shock from severe diarrhea and vomiting. She weighs 70 pounds. If you recall your protocol is for shock is to give up to THREE boluses of 20 cc/kg NaCl for pediatric shock patients, then adjust your flow rate to 150 cc/hour afterward. 2. How Many KG does this child weigh? 3. How much fluid are you going to administer for each bolus? 4. Assuming you have a 15 gtt set, how many drops a minute is will you un your IV line to achieve a 150 cc/hour drip rate? Scenario #2: You have a 10 year old diabetic who is hypoglycemic. She is approximately 100 pounds. You need to give her some dextrose. Your protocol calls for you to administer 0.5 gm/kg of D2W. You don't have any D25W on hand though. You do have on hand D50W, 25 grams in 50 cc. 5. How many KG is this patient? 6. How many grams per each cc do you have in this amp of D50? 7. Knowing you have to administer D25, and recalling from the pediatric lectures you have to dilute D50 in half to get D25, what would your final concentration (grams per cc) be when you do this? 8. Finally, how much Dextrose will you administer, and the cc of volume you will give to get that dose? Scenario #3-A: You have an adult patient who has overdosed on a new illicit opioid called "Death by Math", or "DbM" for short. 9. Since you are super smart, you recall that the antidote for DbM is likely what drug? 10. The antidote in question comes in 2 mg in 5 cc. How many mg/cc is this? 11. You also have special orders to administer 0.1 mg of this drug every 2-3 minutes until the patient starts breathing again. How much cc do you give to administer 0.1 mg? Scenario #3-B: Just as you are packaging this patient up, the police officer runs up screaming. It appears that your fine, upstanding citizen of a patient allowed their three year old daughter to get into the stash of DbM. After you decide kicking the patient is not the appropriate thing to do, you attend to your new patient. She is three years old and weighs a weee little 30 pounds . Since you have a bucket load of the antidote on hand, your well prepared. 12. What is the weight in KG for this patient? 13. You recall your pediatric dose for this antidote is 0.01 mg/kg. How much do you give? 14. All of your amps come in 2 mg/5 cc. How much volume (cc) do you need to give to get that dose? Scenario #3-C: Despite your administration of the antidote, and appropriate airway management, your three year old patient/30 pound patient continues to be hypotensive, mottled, cyanotic. You realize she is still in a shock state. The doctor orders THREE boluses of 20 cc/kg NaCl for pediatric shock patients, then adjust your flow rate to 200 cc/hour afterward. 15. How much fluid are you going to administer for each bolus? 16. Today you have a 10 gtt set, how many drops a minute is will you un your IV line to achieve a 200 cc/hour drip rate. Scenario #4: So, We say that in a fit of anger over the medical math, you lynch your instructor (me) , set me on fire, and leave me for the crows. ONE of you..honestly I cant imagine which one.... has a weee little bit of remorse and uses the fire extinguisher to put me out. Unfortunately I have suffered 70% BSA burns. I weigh 200 pounds. 17. How Many KG do I weigh? 18. How much fluids are you going to give me over the 1st eight hours? 19. Assuming you have a 15 drop set, what is your gtt/minute for the first 8 hours? 20. How much fluid are you going to give me over the last 16 hours? 21. Assuming you have a 15 drop set, what is your gtt/minute for the Last 16 hours?

Actually, if you are a volunteer for an organization, but on duty....in your area .then you have a duty to act regardless of your compensation status. Remember, even if you have a duty to act, you dont have a duty to be stupid. Many rescue situations, hazardous materials, and violence are all reasonable reasons not to rush in to a situation. On duty or off.

Old news I am afraid. This was one of the research studies w used to justify the switch to intra-nasal Versed in 2005. Additionally, because we dont have Valium (national shortage for almost a year......WTF?)we have been useing it for adults as well. Hell I even used 1 mg of Versed with 7.5 of Morphine (both IV of course) for sciatica the other day with good results.

The rest I agree with.

I think the point most missed on here is the word Competent. To be precise, we re talking about capacity, a medical determination, wheras competency is more of a legal definition/declaration. Ti smay be splitting hairs, but the important thing is that we need to assess this. The point most have missed is this: If you want to release a patient/accept a refusal then you must assess for the capacity to make that descision, and then document those assessments. And I am sorry boys and girls, documenting CAOx4 doesnt begin to touch on capacity. The previous post links begin to illuminate those assessments that you should do to ascertain capacity.

A few questions: What does your narrative say? 1- Simply stating "CA&Ox3" is not the minimum standard for capacity to make decisions. I recommend you look at the following as tips of what you should assessment (and document) to make a more robust encounter should this happen again : http://en.wikipedia.org/wiki/Mini-mental_state_examination http://en.wikipedia.org/wiki/General_Practitioner_Assessment_Of_Cognition and I would document cognition something like this: "...Patient is a 70 y/o male found sitting in his recliner, attended by a private duty nurse. He is conscious, alert, oriented x4, and rather pleasant in his affect. He is interactive and appropriate, and demonstrates the ability to carry on a coherrant conversation over the course of EMS contact. The patient demonstration short term memory recall (EMS providers names), simple math (2 + 4), abstract counting (nickles in a dollar), and the ability to follow simple multi step commands (Pick up this pen and set it over there). He recognizes his residence, his private duty nurse, and is able to carry on a conversation about his past vocation as a Chippendale dancer and a brain surgeon. ALl in all, he is judged to be cognitive, appropriate, and in no severe distress. On physical exam....." 2- what does your documentation say about your informed refusal and offering of alternatives? Here is an example of the way I typically would document the refusal portion... ( I took some artistic liberties) "... After assessment the patient is informed of the assessment findings. Transport is clearly offered, and declined. The patient is again encouraged and again refuses further care and/or evaluation. When asked for the reason of his refusal, he states he is worried about the cost of an EMS transport. EMS makes it clear that while EMS transport would be preferable, and that EMS does not require payment now in any case. EMS also offers to gladdly call a cab or a family member to transport, all in an effort to facilitate care. The patent again refuses. EMS offers to let the patient speak with medical control, which he also declines. Finally, the nurse is recruited on location to convince the patient, in an effort to facilitate evaluation at a local ER, and this too is ultimately unsuccessful. The patient is offered the refusal paperwork to review, which he does. He is explained the risks of refusal, including occult injury and even death secondary to unrecognized TBI. The patient acknowledged this and again declines. The patient reads, verbalizes understanding, and signs the refusal form, and the NOPP/HIPAA form as well, with nurse on scene witnessing. The patient is clearly encouraged to call EMS at any time should he change his mind. EMS clears. "

No, but as a trial, I did require both a class thesus and an extra credit paper. the extra credit paper was on the students choice of one of 5 books. These books are non-EMS specific (though a few of them are medical). The paper has to address how reading these book(s) made the student a better provider. The books are: 1- On Combat, The Psychology and Physiology of Deadly Conflict in War and in Peace [Paperback] by Dave Grossman and Loren W. Christensen Publication Date: October 1, 2008 | ISBN-10: 0964920549 | ISBN-13: 978-0964920545 | Edition: 3rd 2- How Doctors Think [Paperback] by Jerome Groopman Publication Date: March 19, 2007 | ISBN-10: 0618610030 | ISBN-13: 978-0618610037 | Edition: 1st 3- The Checklist Manifesto: How to Get Things Right [Paperback] Atul Gawande Publication Date: March 19, 2007 | ISBN-10: 0618610030 | ISBN-13: 978-0618610037 | Edition: 1st 4- If I Knew Then: Life Lessons From Cops on the Street by Dan Marcou and Brian Willis Publication Date: May 9, 2011 5- The Gift of Fear and Other Survival Signals that Protect Us From Violence [Paperback] Gavin de Becker 6- Shock-Trauma Jon Franklin and , Alan Doelp Publication date: 1980 | ISBN-10: 0312717415 | ISBN-13: 978-0312717414

Well, our state has very little to require in the name of hours. It has gone to a competency based model...wich is ripe for abuse IMHO. It does set some clinical requiremnts, just not in the way of time. To paraphrase, It does require: 15 admistrations of medications 20 patents ventilated 25 IV sticks Yeah, I know...not a lot. I am teaching the AEMT course at out local CC, it is about 220 hours long, and this is what I came up with... 2 12-hour rotations with RT on the floor and in the CCU to get the ventilations, and to get exposure to trach care and nebs. 2 12-hour rotations with the local ED's to get everything 2 12 hour rotations with EMS to get everything I also require, in addition to the "clincial rotation evaluation form" for every rotation at least two completeded SOAP charts per rotation. Honestly, next class I will require more. Also , 220 hours didactic is a lot tighter than I anticipated, surprisingly. Although I know some people doing a lot less as well. I will probably redue the class closer to the 250-275 hour mark. Any future classes are on hold however, Due to some factors beyond our control, our normal clinical locations have stopped accepting students over the summer and possible the fall. I wish we had known that prior to starting the class ... ;( Anyway, until I have the clinical component completely locked down, the discussion is purely academic (pun intended). I am telling you so that you can learn from our mistep. Let me know if I can help in any way. Steve

We use it here. 10 mg nebbed, or if intubated, all 10 mg squirted directly down the tube (i.e. in a code where Kyper-K is suspected) and bagged in.

I sent you my email, let me know if you didnt get it...

I have old texts and references pointing to Combat medics doing IVs in the field during WWII. Dont know if that helps.

We use standard epi nebs (5cc of 1: 1,000 , not racemic*) in anaphylaxis for acute laryngeal edema only, otherwise we use albuterol/atrovent nebs. Combining with CPAP might have been useful as well. The epi neb (if indicated) is given in addition to any epi SQ/IM you may give. We follow this up with Benadryl, Zantac, and Solu-medrol. * side note: the WHO organization found little difference between racemic epi and epi 1:1,000 when nebbed for epiglottitis. We use standard epi nebs for epi-glottitis and any other form of laryngeo-edema, including burns or anaphylaxis.

Thanks all!

Hey all, I was wondering if anyone had a huge bank of medical math problems (i.e. drip rates, boluses, etc) they could foward me. My AEMT students really struggled with my last test which included some med math. Going to give them a series of take home exercises to remediate on simple medical math, but I dont like the ones that came with the text. Was trying to avoid having to sit down and write out a hundred question med math test if someone else already has one. Like everyone, life is busy and I hate to reinvent a test if I dont have too. Any other instructors want to share some of their work? Will be happy to exchange the favor. Steve

Well done. We have been doing "officially" SSI here for 12 years (I wrote the original protocol for my agency) and unofficially for longer. I only have one simple thought on terminology. I would remove the term "clearing c-spine" from the protocols. At least around here that involves a very specific in hospital standard that requires imaging. Obviously not possible in the field. We instead "selectively immobilize" (wich you did use...good job) or we "defer immobilization according to protocol" BTW, our trauma surgeons have been pushing for c-collar only immobilization for penetrating trauma without deficits for a few years, but our docs are waiting for an official position paper from the ACS, which is expected at any time now.

He hit it on the head. If you do not pass the course, you do not pass GO and and you do not collect 200 dollars.

Adenosine may be used for a multitudeof tachy arrythmias, not simply "SVT". It is just most likely to be efective in the SVT/A-Tach side of the house. With the A-Fib/A-luter, adenosine is NOT contraindicated, it simply may not be as effective..or effective at all. What it MAY do ...emphasis on "May".... is allow some transient slowing to allow better assessment of the actual rythm. Now, why the medics gave adenocard is really a question only they can answer. I would also wonder if they attempted vagal manuevers prior to the adenocard. I would assume (and we all know what an assumtion does) that the HR combined with a presumable diaphoretic, pale and SOB patient (remember he was just post running)..and a lack of critical assessment of the context of the situation may have contributed to the situation. I agree with Artickat..I doubt I would have given the patint any Rx if he was as your presented him. ...but who knows. I try not to get comfortable in the arm chair of the monday morining quarterback. Please remember that patients seldom look the way they do inthe ER as they do on scene. Their stories change, their presentationas change, and often it is assumed (again with assumptions) that the medics were somehow dropping the ball. The reality is...medicine is a fickle , moody bitch that changes directions at a whim.

Agreed... IM EPi, followed by H1 and H2 anatagonist, Solu-medrol, an EPi Neb for laryngeo-edema and either repeated epi IM or an Epi drip for refractory hypotension. Fluids can easily exceed 2L in these situations. While Nor-Epi (seldome carried around here) or high dose dopamine (20-30 mcg/kg/min) might be an option, I think we all agree that an Epi Drip would be your best bet here.

OK remember "Every EMS system is different". This BS about guns and EMS dont mix..is well BS. Every situation is different, every provider is different, and every policy is different. Simply look across the pond ..well several ponds actually..to Israel They provide EMS, yet their service is different, their gun policy is different, and their situation is different. Trooper-medics on Marylands HEMS carry. NYPD ESU medics carry. I bet a lot of medics carried in NOLA after katrina. I know of a number of TEMS teams that carry who are not LEO's. We cant always rely on LEO's . LE is NOT the cure all for any unsafe situation, our own mind and tactics are. The carrying of firearms is just like any other tool. When trained appropriately, when deployed appropriately, and when used appropriately, its not the end of the world. Its a training and logistical issue..not an ethics one.

You are a young'un. Go Pen-n-Paper-n-dice table top or go home!

So in a HIPAA SAFE galaxy far far away.... I am taking care of this patient with an emergent but not critical condition, who has a history of subsance abuse, mental health disorders, and other related issues...on TOP of the current emerergency that involves an altered mentation. ....... In the middle of transport, the patient SCREAMS... "OH MY GOD , ITS A SPIDER..ITS CRAWLING RIGHT THERE..ITS GOING TO GET ME!" OK, to say I was doubtful is an understatement. I tried reassuring the patient, to no avail. The patient keeps screaming and pointing. Finally I look over my shoulder...and sure enough is a little cousin of a camel spider, rapelling down from the ceiling, gigggling I am sure at the chaos he caused. Now I dont know which is worse, trying to appologize to the patient or trying ot catch the spider that was swinging like a pendilum accross the ambulance toward my patient. Uggghhh... somedays I still feel like a rookie. Just had to share...

uggggghhhhh

Well, it is not uncommon here to delegate management of the BVM to the FF post ETT, and for the medic to cop a squat next to the monitor and the med port. Yeah there are several things here that could be an "oh shit" but all in all nothing out of the ordinary. Rememeber, EVERY EMS SYSTEM DOES THINGS A LITTLE DIFFERENTLY.

We use the Care-vent ATV plus on all of our rigs. We cover just over 1000 sq miles, but most of our 300K is in a relatively narrow band of real estate. http://www.otwo.com/prod_atv.htm Decent gas/pressure operated vent. Like the eagle and LTV better, but this is not bad. regardless, no vent is idiot proof, and playing "knob-ology" with a vent without understanding the pulmonary and hemodynamic effects will cause major problems.

Ahh, fractile times per minute....hmmm...IDK. I didnt know lifenet would pull that data, or do you have to crunch that manually?