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Congrats, Dwayne. I think you'll really enjoy being a medic after all the work you had to do.

Just like big corporations, unions can be either good or bad depending on who's in charge. Did you guys hear about the dock workers in LA going on a one-day strike yesterday (May 1st)? They are undergoing contract negotiations, but they claimed that the walkout was to protest against the Iraq war. Last time they went on strike they cost the economy literally billions of dollars. These guys make $100K+.

Hey, I worked for AMR Riverside for almost 5 years, but am starting a job in Kern County. Riverside was a good place to work when I first started, but it's not as much fun anymore. If you start there as an EMT, they will put you on a BLS ambulance for six months and make you run only non-emergency transports. Because you have prior experience, they may make an exception, but you should talk to Riverside management about that before you apply. AMR Riverside runs medic/EMT ALS units. However, about two years ago, the new manager stop letting EMT's go in the back with patients. So, even if the call is for a stubbed toe, the EMT has to drive and only the medic goes in the back with the patient. Also, all the Riverside city/county fire dept.'s now have medics, and they usually will beat you on scene. As a medic, I could go six months without an intubation. As an EMT, you will also be doing less because the fire guys will be running the show. As Dust mentioned, their school is pretty lame. It's also the most expensive medic school in So Cal! AMR Riverside management is horrible, and most employees are unhappy. I can't recommend Riverside AMR to anyone.

I notice that a lot of medics get master's degress in public health. What does that open the door to? Working for county health agencies?

You say you're an aspiring firefighter/medic, so why would you want to leave CA? There are obviously lots of opportunities here for people who want to do both. You may also want to be sure that you'll be happy leaving So Cal. If you're used to the weather/culture/lifestyle, you might get homesick.

"way bigger than normal", she says "I thought it might explode". I have no idea what would cause this, but if you can figure it out and bottle it, you'll be a billionaire.

Moonbeam895, Are you sure that the hypotension is not due to vagal stimulation? That would seem more likely, esp. with peds. Anyway, why would intubation have any effect on intrathoracic pressure?

Compared to lidocaine, is procainamide more likely to cause hypotension? Is lidocaine better to use if the patient is having an MI? Some of what I Googled seemed to say that procainamide can be harmful with a patient having an MI, but I couldn't find a clear reason why.

The protocols actually say give a 100mg slow IVP, followed by a maintenance infusion. So it's the best drug to use for stable VT? Would you not use lidocaine first (assuming you only had lidocaine and procainamide)?

I'm about to start a new job in a county that uses procainamide. I'm totally unfamiliar with this drug and don't know anyone who's used it. I've done a lot of Google research on it, but I'd like to get feedback from medics who've actually used this drug. From what I understand, it's basically a second-line drug used for VT, uncontrolled AF, or SVT that don't respond to other drugs. Like amiodarone, it can also be used when you have a wide-complex tachycardia that you strongly suspect is SVT with aberrant conduction. I understand that it can cause sudden hypotension, esp. if pushed too quickly. What about it's use with someone having an MI? One sources said that it was relatively contraindicated with MI's because it may in that case be more likely to cause hypotension.

I've enjoyed all the posts so far. Haven't seen anything counter-productive yet! So we already know this is WPW + AF. Could a rate this fast be anything else? I was thinking ventricular flutter, but I figured that ventricular flutter would only last for a very short while before becoming VF, so you wouldn't be likely to see it in a patient like this. Could AF produce such a rapid ventricular response without there being an accessory pathway?

CHBARE: Thanks for the EMedicine link. The article supports what you are saying about not using adenosine for WPW: "Although a therapeutic trial of adenosine had previously been advocated by some for both irregular and regular tachycardias and in some cases to distinguish SVT with aberrancy from ventricular tachycardia, this has fallen out of favor recently because of the possibility of degradation of the rhythm to ventricular fibrillation when used indiscriminately." It is surprising though that the drug insert doesn't mention any of this. The insert talks about avoiding the use of adenosine on patients with COPD and especially on patients with asthma, but it doesn't say not to use it with WPW. It seems like this could open them up to a lawsuit. FYI, the EMedicine article makes no mention of amiodarone. They mention procainamide but caution against its use except in some circumstances.

Do you guys understand what I'm getting at here? One the one hand we've got the smart people who wrote this article saying, "Don't use adenosine for WPW or wide-complex tachycardias." On the other hand we've got the drug manufacturer saying "Use adenosine for WPW." So who's right?

The reason I posted this scenario was because I disagreed with what the authors were saying about the use of adenosine. I wanted to put it out there to see what other people have to say. The other thing that should be addressed is whether this patient is really stable. AZEP wrote, "stable tachycardias afford the luxury of time." Although I'm always impressed by AZEP's knowledge and experience, I'm gonna have to respectfully disagree with him on this one. Yeah, stable SVT is no sweat, but is this guy stable? I don't believe that someone with WPW + AF is gonna be stable for long, and I don't think we have the luxury of time in that situation. I would expect him to deteriorate into VF pretty quickly. Anyway, considering how fast his heart rate is, it's very suprising that he is still able to compensate.

So we should not use adenosine for WPW? The authors of this article seem to say so. They recommend amiodarone or lidocaine and rapid transport. But about adenosine they write, “Adenosine should never be used in a wide-complex tachycardia because it “stuns” the AV node, thus preventing further AV conduction for a short period of time. This can result in diverting electrical transmission through the bypass tract and increasing the heart rate, potentially converting a stable tachycardia into an unstable one. It’s also especially dangerous if PSVT is in reality very fast atrial fibrillation that appears regular due to the extreme rapidity of QRS complexes.” Here’s what the ACLS protocols say about adenosine in this regard. “Adenosine is contraindicated in wide-complex tachycardias unless they are know to definitely be re-entrant in origin.” On the other hand, the drug insert that I have with my adenosine preload (made by Astellas) says, “Adenocard slows conduction time through the AV node, can interrupt the re-entry pathways through the AV node, and can restore normal sinus rhythm in patients with PSVT, including PSVT associated with WPW.” It goes on to say, “Adenosine is not effective in converting rhythms other than PSVT, such as atrial flutter, atrial fibrillation, and ventricular tachycardia. To date, such patients have not had adverse consequences following administration of adenosine.” So is there no consensus on using adenosine for WPW, and whether it’s safe to use with a wide-complex tachycardia? Or are the authors of this article just wrong? I would tend to believe the drug manufacturer more than anyone else since the manufacturer has the most to loose if they were wrong.

Wouldn't we suspect WPW? So what about trying adenosine?

Hey guys. I'm stealing this scenario from a recent issue of JEMS because the treatment recommended by the authors (three doctors) goes against what I've been taught. I'd like to hear what other people think about it. You respond to a 52-y/o male who got mildly short of breath after going for a jog. You hook him up to the monitor and he is in a wide-complex tachycardia at a rate of 310. He is no pale and diaphoretic, but he is fully alert and oriented and has a stable BP. No significant history except asthma. Besides basic treatments like O2, positioning, IV, etc., what advanced treatments do you provide? Sorry, don't have a copy of the ECG.

I see that this article is from 10 years ago. So how have things worked out?

I've looked into the LVN to RN thing some more and have found that it's really not the way to go. Looks like I'll apply for an RN program and hopefully get in within 2 years or so. FYI, I'm not turning my back on prehospital care! In the future I still hope to work as a medic, at least part time. I've been working on an ambulance for almost 6 years now, and I still enjoy it as much as when I first started.

Yeah, it's really hard to get into a nursing program here in California. It's also frustrating that each program has different prerequisites. I'm going to have to do a lot of research to see what program is best for me.

Hi, Does anyone know what is involved in challenging the LVN test when you're a paramedic? I'm considering becoming an RN, and I'm thinking that the best route would be to challenge the LVN test and then do an LVN-to-RN program since that seems to save about a year's worth of schooling. I've also looked into the medic-to-RN on-line program (found it under an old thread on this forum) but it's not recognized here in California. Thanks!

I also bought"Trauma Junkie..." after I read some positive reviews here on this site. I have to say that I was really disappointed. In fact, I threw it in the recycling bin after reading only a few chapters. It reads like an episode of "ER." It's more a book for people who don't work in EMS.

Track event? NASCAR? Which one of these is our patient: http://deadspin.com/sports/coke-and-heroin...nces-276226.php

Dust wrote, "My mechanic gets dirtier than you everyday, and has more education and experience too." Sad but true.

Never ever heard of that before. Very interesting. Great scenario!