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I'm a medic in So Cal, so you can private message me and I'll answer your questions. If you're a medic, you can only work 911 in Riverside, San Bernadino, and San Diego counties. LA and Orange counties are 100% fire based. If you're an EMT, you can work on BLS amulances in LA and OC and respond to 911 calls alongside fire medics. What skills are you afraid of not being able to use in California?

Wow, I've never seen anything like that before. Letting a drunk person run out into the street? These guys make us all look bad.

I think tough love is just as much a waste of time as holding their hand. Some people are on a self-destructive path that they may never get off. I treat them respectfully and kindly, and I'm thankfull that I'm not in their shoes.

Got a call at 3:00 a.m. for a woman who needed assistance opening her bottle of Vicodin.

Ask him if he has a history of seizures. And, obviously, check his blood sugar now that ALS is here.

Sometimes the sternal rub doesn't work, but I have yet to encounter a patient faking unresponsiveness who did not react to an NPA. Before I use it, I tell them that I'm about to put a tube deep down their nose, and often that's enough to get them to respond.

What are his vitals? Medical history and meds? GCS?

I’ll just wrap this up early since there doesn’t seem to be much interest in the scenario anymore and since anyway I’m going to be away from a computer for a few days. This was a confusing call for us because at first we were thinking cardiac since the patient had apparently been in ventricular bigeminy. Things didn’t add up though because his skin signs were good and so was his BP. He was just totally unresponsive. He was a diabetic, but his blood sugar was also fine. We were told that he may have had some seizure activity, so that further confused things. He was way too altered (1/1/1) to just be postictal. On the way to the hospital, which was just a few minutes away, we were thinking that his sudden collapse and continued unresponsiveness must’ve been due to a stroke. At the hospital, they did a 12-lead and it showed ST elevations (don’t remember which leads). The computer gave the “acute MI suspected” alert. This further confused things. I spent a little time doing my paperwork and cleaning up. When I came into the patient’s room a short while later, he was sitting there talking to the nurses. That was a big surprise and at this point I just had no clue as to what had happened to him. As it turned out, this period of him being fully alert and oriented was only a lucid interval. They found a massive bleed on the CT and he was soon unresponsive again. I don’t know what his final outcome was. What accounts for the ST elevations? This is something that I’ve asked about previously on this forum. Head bleeds can sometimes cause ST elevation, as well as dysrhythmias.

No signs of trauma. Pt. feel onto carpeted floor. An engine company has shown up and they assist you guys in immobilizing the patient onto a backboard. Anything else you want to do before you transport? There is one thing that nobody has asked for yet. I've given you all the vital signs and you have an IV established. The patient has an NPA in him and his respirations (about 10 per minute) are being assisted by a firefighter.

To answer the questions about chemical exposure and the environment: it's a warm summer day and there's nothing obvious to indicate an exposure to chemicals. Vitals signs: BP: 160/90 HR: 80 s/r Lungs are clear, sats are 99% with the 02, RR of 10 Skins: warm, dry, pink GCS: 1/1/1 Pupils are PERL Glucose: 160 Hx of DM and HTN; meds unknown The fire medic is starting an IV. What else would you like to do?

To answer the question about bigeminy, here's the Wikipedia entry: "Bigeminy (Latin: Bi-Two Gemini-twins) is a descriptor for a heart arrhythmia in which abnormal heart beats occur every other concurrent beat. A typical example is with bigeminal premature ventricular beats, also known as a premature ventricular contractions/complexes (PVC). Following the PVC there is a pause and then the normal beat returns - only to be followed by another PVC. The continuation of this pairing of beats is an example of bigeminy. These descriptors can increase depending on the number of beats involved in the abnormal system. If every other beat is abnormal, you can describe it as bigeminal. If every third beat is aberrant, it is trigeminal; every fourth would be quadrigeminal. Typically, if every fifth or more beat is abnormal, the aberrant beat would be termed occasional. Bigeminy is contrasted with couplets, which are paired abnormal beats. If these concurrent beats number three, they are called triplets and are considered as a brief run of non-sustained Ventricular tachycardia or NS-VT. PVC's are not the only aberrant beat that makes use of these adjectives; others are premature atrial contractions, parasystole, and escape complexes."

His blood sugar is 160. :wink: He was in ventricular bigeminy. Fire medic doesn't know if the PVC's were producing pulses. Wife says he was just doing woodworking in his garage--no carbon monoxide. What else would you like to know?

Your patient is a 40-something y/o Hispanic male with a history of diabetes and hypertension, meds unknown. Your initial impression: A: the fire medic has tried to intubate but the patient still has a gag reflex. B: 10-12. Patient is now being bagged by a firefighter. C: skins are warm, dry, pink You glance at the monitor and see a normal sinus rhythm at 80. The fire medic has told you that he was initially in bigeminy.

It's late afternoon and you're almost done with your shift when you respond to a fall victim, the third one today. You're quite suprised when you walk in and find your patient, a 40-something y/o male, supine on the ground with snoring reps. A firefighter is just starting to bag the patient and the fire medic, who's been on scene just a few minutes before you, says, "Hey, he was in bigeminy when I first got here. His wife said she heard him collapse after he came in from working in the garage saying that he wasn't feeling well."

We pulled the tube once we lost the capnography reading. Even though the tube turned out to be correctly placed, I think this was the right thing to do considering all the other things that seemed to indicate that the tube was not in the trachea.

Kudos to Chbare for getting this so quickly! Yes, the patient an AAA. I ran this call about 9 months ago. Our patient had a cardiac history and took his nitro when he began having chest pain. I remember seeing his bottle of nitro tablets next to his half-eaten dinner plate. He called 911, but before anyone got there, his aneurysm ruptured and he collapsed. His abdomen became progressively more distended not because of gastric insufflation, as I thought, but because our CPR was slowly pumping his entire blood volume into his abdomen. By the time we got him to the ER, his abdomen was HUGELY distended. The poor compliance with the BVM was due to all the pressure against the diaphragm. The loss of the capnography reading was due to there simply not being any blood left to circulate to the lungs. I'm sure some of the veterans on this site have seen this before, but I've never seen anyone with that much blood in his abdomen.

I ran this call about 9 months ago. Xlnt responses, and yes, we did pull the tube. There was nothing wrong with the tube, as it turns out. So what do you guys think was going on with this patient? :roll:

You are dispatched to a “chest pain” at a private residence. As you walk in the door, you see the firefighters doing CPR on a 55 y/o male. The fire medic tells you that this was a witnessed arrest (by the family) with a downtime of perhaps 5 minutes. The patient had been eating dinner when he started having chest pain. He took his nitro with no relief, so his wife called 911. Before anyone arrived, the patient collapsed. When the fire medic got there, he was in fine VF and was shocked once into asystole. The fire medic intubates and you get the IV and begin drug therapy. There is no change on the monitor. While you’re working the patient up, you notice that the patient’s abdomen looks distended. You point this out to the fire medic, but he says he’s sure he saw the cords, got breath sounds, etc. The patient hadn’t been hooked up to the capnography yet, but this is quickly done and you get a reading of 6 mmHg. After the second round of drugs, there is no change in the patient’s condition. The decision is made to transport. About 10 minutes later you are close to arriving at the ER, and by this time you see that the patient’s abdomen is HUGELY distended. You are now getting poor compliance from the BVM and you no longer get a capnography reading. You use an esophageal intubation detector (Tube-Chek), and it reinflates quickly. However, the capnography is still reading zero. Do you pull the tube? What do you do next? What might be going on here?

Broken, I'm sorry to hear about your accident, and I'm glad the surgery went well. I'm only hearing your side of the story, but from what you say it sounds like the EMT's did a substandard job. Wanting to logroll you onto your injured leg was stupid. Not calling for a base order for pain meds (if they were indeed paramedics) was also stupid. Refusing your request to go to your hospital of choice was also probably illegal, even if they thought you were making a bad choice. You're absolutely right in that you had every right as a patient to request a hospital destination, and to refuse any treatments.

I had a patient last night with a mid-shaft femur fracture who had only a minor complaint of pain. Granted she was drunk, but still, I couldn't believe it. I felt the broken bone and put a traction splint on, but until I saw the ER x-ray, I just couldn't believe that she could really have just broken the biggest bone in her body and not have hardly any pain. The last time I had a guy with a broken femur, he was a 400-pound biker who was cussing about every little bump in the road on the way to the hospital.

I had a patient yesterday who's pacemaker was pacing at just over 100 BPM. I confirmed that each beat was paced using the 12-lead. His rate later when down to 70, still paced. I had another patient recently who's pacemaker was also pacing at above 100 BPM. I always thought that a pacemaker wouldn't pace above a whatever the setpoint is, which I think would be somewhere near 70 BPM. What gives?

A true save on your first full arrest?! That's awesome. Congrats!

Yes, sorry, I meant V1 and V2. :roll: I did have another patient a few months ago who had what turned out to be a massive intracranial bleed, and he also had a funky rhythm on the ECG. It looked like bigeminy, but it only lasted for a short while and he was back in a normal sinus rhythm or a sinus tach by the time we got him into the ambulance. This really through us off because we started thinking that the cause of his being unresponsive (with only a weak gag reflex) might be something cardiac, although that didn't make sense since his skins were flushed and his BP was within normal limits. When the ER did a 12-lead, it showed that he was having an acute MI (the computer actually gave the alert). As it turned out though, this was misleading. Our patient turned out to be having a massive head bleed. He was pretty young, 40ish. After we'd dropped him off at the ER and I was doing my paperwork, he woke up and became fully alert and orient. The crappy thing about this call was that I, thinking that he must've just had a seizure and been postictal (though of course I'd never seen anyone postictal be totally unresponsive like this), told his wife that he would be totally okay and that he'd just had a seizure. It turns out that he was just having a lucid interval, and that soon after I left he became totally unresponsive again and that they found a massive bleed on the CT.

Emmy, Being a paramedic is a great career! It's wonderful that you are considering getting involved. Be aware that many paramedics do get burned out, and they may only have negative things to say about this job. I suggest that you learn as much as you can about EMS. Also, be sure that you really want to help people and that you are ok with being around sick people all the time. Don't get into it if you want to just be a hero and drive around with lights and sirens.

The other day I transported a patient with an intracranial bleed from one ER to another. I told the receiving doctor that the patient had also shown ST elevation in a few leads (If I remember correctly it was S1 and S2) on a 12-lead that the first ER had taken. He told me that it was quite common for people with intracranial bleeds to present with ST changes and other ECG changes. Does anyone know why this happens? (I could just research this myself on the net, but I figure this topic might be of interest to others.)