boneknuckleskin

I hate keeping up with CEs. I am a full-time senior at a large university majoring in a non-medical area of study. I also work full-time as a paramedic in a non-EMS role now. I just don't understand why so many people struggle with the NREMT exam to begin with. I just renewed my paramedic certification for the third time by taking the NREMT-P exam. I believe it's a relatively painless and more efficient method of renewal. One must simply keep their AHA cards up to date (you should be doing this anyway), pay $110 to retest, print your abbreviated renewal form, and have your "medical director" sign it - that's it. For the past two paramedic recert exams, I spent no more than 10 minutes "prepping" for the test, and have never been required to answer more than ~70-80 questions during the test. It takes about 35 minutes of my time, far less time than completing CE classes - since only 12 applicable credit-hours transfer for 12 clock-hours of CE. And, depending on your employer - renewal by exam may be a cheaper method to stay current with NREMT. Likewise, the test itself is ridiculously easy. The questions are short & direct. I'm certainly not the best test-taker, and though I've heard about someone knows someone who finally passed it on their 6th attempt yet "they're the best medic I've ever known" countless times, I can't help but be a skeptic. I guess I just don't understand why people struggle so much with the exam. Does anyone else here choose to renew by NREMT reexamination?

And how did you rule out ventricular tachycardia/flutter as the cause of this wide complex tachycardia?

Can you clarify why you believe that a wide complex tachycardia at this rate in the hemodynamically solid patient must be aberrant AFIB/AFLU on a bypass tract?

Great scenario, much is to be learned here. Concerning the hyponatremia, this patient is gravely depleted. Loop diuretics and usually 3% hypertonic saline are used to correct this aggressively but very carefully as serum sodium must be raised slowly and precisely, usually occurring over several days. Raising the level too quickly may cause CNS lesions, particularly demyelination of the lower and mid-brain which can lead to devastating neurological deficits, some of which may not be immediately obvious but are usually permanent. Paralysis, dysphagia, dysarthria, or in the worst case scenario, what is known as locked-in syndrome. This patient may present with signs similar to advanced ALS. The patient is unable to move, speak, swallow, or breath unassisted; however their consciousness and intellect remain intact and may only be able to communicate by eye movement. Less devastating lesions may be seen in chronic alcoholics. Interestingly, hyponatremia is also seen in patients who have had a subarachnoid hemorrhage, and occurs through a process known as cerebral salt wasting syndrome. You'll notice in the acute stages these patients are sometimes urinating all over the bed in the ED before the nurse can get a foley in. I'm not entirely up to steam on any of these syndromes but I think there is some good information here, so perhaps the OP or one of the doctors or anyone who is more knowledgeable could enlighten us some more. I've found a wealth of knowledge can be obtained when you know the disposition of your patient while in-patient or upon their discharge. Just to be able to see some tangible lab results or read the CT dictation and contrast the patients actual diagnosis to your own clinical judgment is invaluable. If ever given this opportunity, such as working in a ER, reading up on some hematology and understanding the radiology concepts beyond what your paramedic school offered will help. Unfortunately, we are not granted this opportunity enough in EMS. We're the skid marks under the hospital. I understand some systems allow follow-ups on all patients, or pertaining to interesting or emotionally charged cases, especially flight services. I think opportunities like this in our line of work would allow for unyielding learning opportunities, but subject for another discussion.

Well, did your patient have a pulse with this rhythm? If so, I think SVT would be an appropriate interpretation. There is a lack of discernable P-waves and the tachycardia is not very rapid. QRS axis is difficult to ascertain, and R-wave progression is late in the pericardial leads which could be due to either injury or poor lead placement. Overall, in the horizontal plane it appears that the electrical activity is exciting the distal conduction tissue in a fairly normal top to bottom direction, affirming the suspicion of SVT. This is a common post-code rhythm seen induced by epinephrine. My priority would not be looking for P-waves and sinus tachycardia, it would be finding a palpable pulse to rule out PEA and keeping it that way.

Winter? It's 83 degrees down here in Texas and not a cloud in the sky. 8)

No, that is the general idiot's knee jerk reaction. When standard percautions are used, there is negligible or only theoretical risks to you or your patient. CDC estimates put 4-5% of the general population seropositive for Hepatitis C, and those numbers have been demonstrated to be higher among EMS professionals in certain locales, especially California. So it is likely that there are people reading this right now who are infected with Hepatitis, and they may not even know it yet. I think the problem here is city wide ignorance. You especially. If EMS personnel were more involved with their health and routine testing, then those hypotherical MVC scenes with the blood gushing from your open wound down your patient's throat could be avoided all together with some added vigilance. And Dust, do YOU micro much? How could you say something so stupid?

I've got a gripe about rural services. I recently was at a very large ER in a rural part of Texas that served the entire region, I saw an ambulance with the insignia of a three hour away county down the side parking in the bay, when out jumps a filthy looking young female all decked out in her unwashed, loosely clinging street clothes, hair unkempt, and a pair of flip flops. She had the appearance of jumping right out of the crackhouse and into the back of that ambulance. Granted, not the story with all rural services. I deduced her to be an ECA, maybe not. Some seem to think their sacrifice excuses them from all forms of professionalism. They often get their training in the same county they volunteer, classes held in the back of a barn. This makes me glad that NR is phasing out non-accredited schools in the approaching years. I wish all employers would do the same. In part it's our own kind that hold us back with lack of ambition.

Thread was a pissing match long before I posted. I still don't have any clarity on the professional inequality. I read about EMS and low education standards and I hope that NREMT's attempt to phase out non-accredited schools is just the first step in a lot of changes, but with EMS being so young I understand the division. Nursing schools did not start out as BSN programs all those years ago. It took nursing a long time to get where it's at but all this about nursing education being well structured and held to the highest of standards is a myth. Looking at local options, the busiest nursing school is not college based and awards no college credits beyond the nine prerequisites you take prior to entry, the school is hospital based. The second in line is a 12-month program for those who hold a baccalaureate's degree in any field, including non-science related such communications or composition. These students don't attend formal classes or lecture, but work through online modules and attend a total of 500 hours of clinical time for the program in its entirety in addition to "boot camps" at a cost of $26,000. Students who complete these requirements obtain a BSN and there is no shortage of willing applicants in sight. I suppose these "nursing mills" are the answer for the purported nursing shortage. The university does offer a traditional BSN program. The EMS program can award either a diploma or a degree, but both last 24 months with one having a lighter course load and both are college based with credit. Students that complete the first degree can progress to Bachelor's in EMS at that point. Regardless, a nurse and paramedic holding similar degrees can graduate and enter the workforce with the nurse making considerably more than paramedic while taking half the responsibility and risk to themselves. The only local health care profession of three that requires a minimum associates degree to practice is the respiratory therapy program. Also, isn't it right that the Florida RN's must hold an EMT certification before challenging the paramedic exam? If true, I still think of anyone who tried to do so with concern. As Ventmedic said, most paramedics lack the 3 - 5 years experience in the ICU feeding patients ice chips and bathing them post-op but equally so, nurses lack the 3 - 5 years of hands on working experience that paramedics have on the streets without a safety net. Nursing isn't for everyone and it's definitely not for me. Academically, it would be a breeze and I also have a two year old so I already know how to wipe an ass, I just don't want to get paid for it.

I'm not understanding the professional inequality. RT, RN, EMTP, they're all associate degree programs, and even the non-degree paramedic certificates generally require 24 months of college time on the clock. Lets not forget that a good majority of the RT's are certified and not registered. All have the option of a higher degree. So forget Ventmedic with his exaggerations and embellished tales. An off duty associate degreed RN, licensed Paramedic, and degreed RT all roll up on a scene, who is the highest level of provider?

disregard

Worth repeating.

Bless your old heart. Leave it up to the battle axe nurse to draw blood first. He's got an agenda. Nurse dusty camps out at his keyboard night and day waiting for every opportunity to spit venom at the basics. No one is sure why, but I have a theory. I suspect what he really doesn't want to us to talk about is how under trained paramedics are. Consider the scope. Add up the clock hours, subtract the BLS semester, divide by two and what do you get? An overblown sense of self importance. How does that one fit, D? In consideration of the practice, I would support 4-year programs. This may be a hard pill for you to swallow, but try it with water. I'm tired of all the gagging.

You're confused, by you own admission you state P-waves are visible but "don't quite" march out. Where? And please explain when isolated, discrete P-waves became identifiable at all during A-fib? Show us all. Atrial fibrillation is a multifocal rhythm. Nothing more than a run of "irregularly irregular" multifocal PAC's. The baseline should be too fibrillatory to discern any junctional activity, and many PVC's witnessed during A-fib are often later found to be Ashman's phenomenon during an EP follow-up. This is a problem. Ashman's is an abberation that occurs when a stimulus falls in the absolute refactory period. That period is lengthened during a slower heart rate. Remember, the slower the rate, the slower the refractory period, the faster the rate, the shorter the refractory period. During A-fib, when ectopy appears following a short RR interval, preceeded by a long RR intervral, it can be assumed that the long RR sets up a slower recover period for the conduction tissue. The distal conduction tissue is not completely recovered, and when challenged by an early impulse, will result in a intermittent RBBB. Not a PVC. This is common and not exclusive to A-fib. The moral of the story? Don't treat with lidocaine. It can speed AV conduction and turn your somewhat stable A-fib patient into a code. Ask an electrophysiologist. If your PR interval is changing and the morphology of the P-wave is as well, as in this case, you're dealing with a wandering atrial pacemaker or multifocal atrial tachycardia - depending on rate - both of which are multifocal rhythms and almost exclusive to the elderly populations. It's not uncommon for these patients to self convert between multiple arrhythmias and ectopy patterns in a short period of time. Look at the big picture. I am. And what I see is a practicing paramedic who is clearly in need of a refresher course in basic cardiac rhythm strips, as well as 12-leads. As a provider, your decisions may help steer the pre-hospital treatment of a patient and you are dangerously incomptent until you can correctly identify simple dysrhythmias, so until then, use an AED.

You're all wrong. Especially you. Can any of you highly educated EMT-paramedics explain how it would be possible for PJC's to co-exist with a underlying junctional rhythm? Or PAC's within PAT? Or PVC's during the occurence of VT? Enlighten me. Dustdevil's interpretation of P's and R's that just "don't quite" march out doesn't qualify it as A-fib either. I might know, because in addition to my intermediate training, I once upon a time I was employed as a ICU monitor tech --- and it's because of this that I can tell you the following three things with 100% certainty: True A-fib will never present semi-regular. More often than not, any 'ectopy' observed during A-fib is nothing more than aberrant conduction. RN's are rarely the best judges of any rhythm. If you were thinking A-fib but still dissecting make-believe P-waves that just aren't lining out, then you should be thinking more along the lines of WAP/MAT, in which the PR length will vary as much as the presence and presentation of P-waves will. At a glace, I'm inclined to learn towards a run of PAT followed by a bigeminy pattern of upper origin, possibly progressing into a wandering pacer, and then to stop glancing, because in a 98 year old heart, it doesn't really matter. They often run all the above, self converting between every rhythm and ectopy you can interpret, and some you can't - and at this point everything seemed to be supraventricular appearing, so treat the patient and not the monitor.