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If a patient has an implanted pacemaker, will you always be able to see it under the skin of their chest, or are the newer models small enough to not be easily visible?

They are driving a car modified for rallying. They were probably reconing the rally route.

Does anyone know of any fire departments or county agencies in California (beside the City of SF) that hire single function paramedics?

I'm a geek, so I study all the time.

I'd like to get some opinions on doing nasal intubations on patient's with head injuries. I know that some systems that don't have RSI are pretty aggressive in doing these. I believe Denver is one of those systems. In my system we're allowed to do them on traumas except when we suspect a basilar skull fracture. Does a nasal intubation create more of a vagal response than an oral intubation? Does it create more of a spike in ICP than an oral intubation?

Nice save! And what a great Halloween story!

If you had, say, a serious lower leg injury that was bleeding heavily and you were having a hard time controlling the bleeding, would it be appropriate to use a thigh cuff as a tourniquet but to only pump it up part of the way so as to control the bleeding but not completely cut off circulation? By doing this could you cause blood clots that could then become emboli? I've never done this nor have I ever had a bleed where I needed a tourniquet, but I'm just wondering if this would be appropriate.

How is amiodarone administered for a wide complex tachycardia? Is it given by IVP or by an infusion? What's the dose? What's second dose? Has anyone ever used it for this application? What are the contraindications and things to watch out for?

Do all Lifepak 12's incorporate the Apaptiv biphasic technology?

Here's what the AHA says about atropine (taken from the just-published ACLS book): "In the absense of immediately reversible causes, atropine remains the first-line drug for acute symptomatic bradycardia. Failure to respond to atropine is an indication for TCP, although use of second-line drugs such as dopamine and epinephrine may be successful. For bradycardia, give atropine at .5 mg IV every 3 to 5 minutes to a total dose of 0.04 mg/kg (max total dose of 3 mg). Atropine doses of less than .5 mg may paradoxically result in further slowing of the heart rate. Use atropine cautiously in the presence of acute coronary ischemia or MI. An atropine-mediated increase in heart rate may worsen ischemia or increase infarct size. Do not rely on atropine in Mobitz type II second-degree or third-degree AV block or in patients with third-degree AV block with a new wide QRS complex. Hemodynamically unstable and clinically deteriorating patients require immediate pacing. All other away patients should have sedation before pacing." I'm taking this out of context, and I should explain that they say you shouldn't delay pacing if the patient is unstable and has a high-degree block.

ERDoc: if you were a paramedic with, say, a 15-minute ETA to the ER, would you hold off on pacing this patient? I'm thinking that I would be less aggressive in my treatment and just try to warm the patient and see how they respond to that before pacing them or giving them epi. Couldn't pacing a hypothermic patient cause their heart to go into VF?

Congrats to the guys who figured this out! Yes, the patient is hypothermic. What brought him to the groung initially? He may have had a stroke, he could have slipped or fainted and hit his head, or perhaps he broke his hip. This scenario was presented years ago in my EMT class, and I like it because it tricks most people (myself included) into overlooking the most obvious things and forgetting simple BLS treatments.

Thanks for all your interest in this scenario. I realized I did make one mistake that I will have to correct. I said earlier that his pulse ox reading showed 93. However, on this patient you probably wouldn't get a pulse ox reading because his fingers are cold. Per some of your suggestions, you bag the patient. To clarify, his pupils are equal and responsive but sluggish and dilated. He opens his eyes to painful stimuli, he withdraws to pain, and he moans. Per some suggestions, a 12-lead was done and it shows sinus bradycardia with occasional unifocal PVC's. Per another suggestion, you ask the son how long his father has been lying there, but the son says he doesn't know. He talked to his father sometime the day before. Per suggestions, you have considered that he is hypoglycemic (but giving him sugar has not had any effect), that he has suffered a stroke or head injury, or that he's had an MI (though the 12-lead shows only bradycardia with a few PVC's). Per other suggestions, you are also giving him a fluid challenge. The patient is c-spined and you are ready to take him into the ER. Are there any other treatments you'd like to perform? I'll post the conclusion to this scenario on Tuesday.

Ok, so per your suggestions, you suspect stroke and do some supportive treatments. He has a gag and just to keep things simple let's say you can't do nasal intubations in your protocols, so you put in an NPA. You have him on O2 and watch his breathing, and you're giving a fluid challenge. He's still sinus brady on the monitor, and his BP is around 90 palpated. Anything else you want to do???????? Any other suggestions as to what's wrong with this guy?????? There's something very important that's been left out here....and you're in for a suprise when you drop this patient off. I'll post the ER diagnosis when I get back on Monday.

One other bit of info: you found the patient incontinent.

You've never worked with this EMT before, but you knew not to trust him when you saw him pull into work today in a lifted Hyundai with a bumper sticker reading "My Phone Number is 911." Ok, so you want to give him sugar since he's a diabetic with ALOC and a low blood sugar. However, you can't get a line (much to your partner's delight), so you give him 1 mg of glucagon IM. You load the patient up and begin transport to the hospital, which is only five minutes away. You understand that the glucagon won't take effect until after your arrival, so you don't expect any change in the patient's mentation, if hypoglycemia really is the cause of his ALOC. Just before you arrive at the ER, you do get a line and give him half an amp of dextrose. Funnny, but this doesn't wake him up at all. Per someone's suggestion, you give him a fluid challenge. (His lungs are clear.) To answer one of your question, his pupils are reactive but sluggish. Anything else you want to do before you arrive at the ER???????

Per the other suggestions, the patient is now on oxygen and his sats improve. You have trouble getting an IV. He moans when you give painful stimuli.

Per the question about a possible overdose of HTN meds...you're told he takes atenolol and HCTZ but don't find the pill bottles. Your EMT partners says, "Dude, why don't you just light him up with some atropine or start pacing him?" Do you agree?

Okay, you have your EMT check his blood sugar. It comes back as 60. You're popping the caps of your dextrose when your EMT partner says, "Dude, are you sure you want to do that? What if he's sustained a head injury or if he's had a stroke! Making him hyperglycemic is just gonna make his brain injury worse!" Do you agree?

At seven o'clock in the morning, you respond to a 82 y/o male, unconscious/unresponsive. The patient's son meets you at the door. "I was supposed to go to breakfast with my dad today, and I found him like lying in the kitchen. He's got heart problems and he just started taking diabetes pills, but he doesn't take insulin. He's breathing okay, but I can't really wake him." You find the patient lying prone on the kitchen floor. There's a pool of coagulated blood on the white tiles of the floor next to him. He has bleed from a small lac on his head. He's wearing pajamas and looks thin and barrel chested. The son tells you that his father has been a smoker all his life and has COPD for which he takes an inhaler. He also says that his father had a CABG done recently but has never had a heart attack. He also takes blood pressure medications. He has diabetes that was diet controlled, but recently he's begun taking glyburide. Your patient is reponsive to pain only. Gag relfex intact. Pupils are equal and responsive. He is breathing at about 10 breaths per minute with adquate tidal volume. Lung sounds CBL and a pulse ox showing 92% on room air. He is sinus brady on the monitor with a rate of 48. His skins are pale, cool, dry. His BP is 94/66. The son also says that recently when has was over at his father's house he had to call 911 because his father experienced a brief period of confusion along difficulty speaking, but it resolved before the paramedics arrived and he stubbornly refused transport to the ER. What else would you like to look for? What treatments do you need to perform?

I agree with Dust Devil that we need more education in EMS. Medic school should be two years, and students should already have taken A & P before they even apply.

Well, the problem is that if we suffer hearing loss, how do we prove that it's job related? No doubt their lawyers would ask if we've ever attended a rock concert, auto race, whatever. I'm thinking that the reason my company may not be providing hearing protection is for this reason---that it would be pretty much impossible to prove that any hearing loss was job related. Of course I'm not sure--maybe the noise levels inside the ambulance are not loud enough to cause hearing damage. What decibel levels are considered safe?

Besides its effect on the SA node, atropine increases the automaticity of myocardial cells. Considering that the myocardial cells probably already have increased automaticity due to being ischemic from the VT or from whatever event is causing the VT, giving atropine could send the heart into VF.

Excuse this rookie question, but can you really see lividity on a person with very dark skin? How long does it take for lividity to show? A half hour, or is it longer?

I started this thread because I was wondering if the noise inside the cab might be loud enough to cause hearing loss over time. My company does not issue any hearing protection, and I'm wondering if they are violating any OSHA standards.