p3medic

This is too funny. A 20yo firefighter, how long have you been doing EMS? Did you start when you were 10? Your running your mouth bashing folks who have been working EMS since before you were born, get a grip kid.

We don't have any volley EMS or fire around my parts. I'm just a little curious, you say you are a volley ff in a town with a paid fire dept. How does that work? Do the paid ff's resent you guys? I think I would have a huge problem if someone decided to volunteer to do my job for free. How does a full time paid ff make up for losing their job to a group of volunteers? I'm not trying to put you down, so don't take it that way, I'm just thinking about the paid professionals who stand to lose their livelihood's if the town can get away with providing the service for free.

Fiznat stated it perfectly, "lead by example". I learned the same thing in the army, and it applies everywhere. Our new recruits learn from seeing, and then doing.

We actually have a hyperkalemia protocol, and in the case of a patient on digoxin, a call to medical control is mandatory. We have the option of calcium gluconate or calcium chloride, at the MD's discression. The only time we would give calcium fast, i.e over less than 2 min would be in the setting of cardiac arrest, otherwise we administer it at 100mg/min. There has been a long standing debate over the use of calcium in the setting of hyperkalemia with patient known to be taking digoxin. There have also been a few studies involving animals (dogs, pigs, guinea pigs) that showed no increase in death when calcium administered to animals taking digoxin at toxic levels. With that being said, I know that digoxin causes an increase in intracellular ca+ and andministering ca+ could potenially interfere with the Na-K ATPase pump, causing an increase in extracellular potasium and essentially stoping the cells ability to depolarize. (bad) So, I would hope my medical director would be kind.

LOL! I would give the bicarb and albuterol, along with some fluid, and transport....if things get worse, (yes, I know, they will) yes, I'd give the calcium, very, very slow. There is a school of thought that hyperkalemia of this severity, i.e pending sine wave that tx with calcium is appropriate. There is also a long standing dogma that calcium can precipitate or exacerbate hyperkalemia with patients on digoxin. So, if the patient widens out more, become more symptomatic, I guess I'd give the calcium, short of that, no. Hows that for a cop out?

I know it has to do with the ferric state of hemoglobin, as opposed to ferrous, and the treatment is methlene blue, which I don't carry....also HBO can be used, and again, I dont have it....great case!

I saw this case on flightweb, so stayed out....I've treated a few pts with WPW, and adenosine worked just fine. There are better drugs these days, however AF in the setting of WPW should be considered a lethal arrythmia, and terminating it quickly is the best course of action, IMHO.

Any chance he had Nitrous as anesthesia? I like the thought on something occupying hemoglobin other than O2, or malformation such as sickle cell, but he has no pain, and no history. At 16 he probably would know wether he had sickle cell or not. How about heart sounds? Any murmur? Is there a possible R to L shunt taking place, and if so why???

Good case! So, she is taking her standard K-dur supplement, however is taking less lasix recently. She is also on digoxin. So, the million dollar question; is she hyperkalemic secondary to acute dig toxicity, or is she hyperkalemic secondary to increased (relative) pottasium load? Or, is there another underlying pathology, that would be unlikely for us to flesh out in the field? Clearly her cardiogram is of concern, and her sx's are worsening as we speak. I'd likely discuss this case with med control, but I'll make a leap and assume the radio is dead, no batteries, doctor is in the head, etc.... Fluid challenge sounds like a plan, nebulized albuterol, and NaHCO3....I'm on the fence with Ca+ because of the distinct possibility this is secondary to her dig, If I were to give the calcium I would go with gluconate v.s. chloride, preferably after MD consult.

Dig toxicity, while on the radar, is very rare these days. Lets see how the rest of our exam pans out.

ERDoc and Dust are of the school of thought that there is no need for working in a BLS capacity before ALS. I'm not so sure I agree. The analogy of a doctor not working as a PA or nurse first is a poor one. A doctor is afforded years of clinical experience during school, and a several year residency prior to being "on their own." Same with a nurse, very lengthy clinical experience during the education process. If your medic school provides extensive clinicals, and extensive field internship (not a couple of weeks riding "3rd" I would agree, however I don't believe many medic programs provide enough field time to make the provider proficient, and a classroom is no substitute. So, I would recommend getting some BLS experience with living patients with numerous pathologies that you can do assessment, take vitals and history on prior, UNLESS your program can provide you with a complete and lengthy field preceptorship, IMHO.

I had no idea he was lost....

A2E, welcome....looking at your flag of Israel reminds me of a study regarding penetrating neck trauma done there, with the conclusion as already state that neurological damage is done at the time of injury, or not at all....http://linkinghub.elsevier.com/retrieve/pii/S0020138399002983 Not sure if this one was posted already, but all seem to come to the same conclusion...

The only time I won't roll someone to assess the back is if they are already boarde, usually by fire, and they didn't look.....my report at the hospital usually starts with "I haven't seen his back, he was boarded when I got there...."

I've never seen a row of ribbons from the Military worn, however I used to wear an EFMB under my badge.....

I'm not sure what your all so bent out of shape about, we report stuff all the time. I end up going to court to testify regularly regarding statements made in my ambulance, "dying declarations" for example. Ever had a victim of a violent crime tell you who did it, only to go on to die from their injury? I have. Ever found money, drugs, weapons on a patient? Do you throw it in the trash? How about a meth lab? Would you not report that? I'm no cop, and couldn't care less if someone is growing a little weed in their closet, but someone cooking meth in the kitchen, or a bunch of timers and electrical crap lying around? Bet your ass I'm going to mention it. We have a fusion center here, were all public safety agencies share information....The police will update us weekly on gang activity, broken down by neighborhood...who's beefing with who, who got shot, who is out of jail and likely to be a target or a problem....We share info with the cops regarding victims of gang violence, etc....I don't spy on people. If its isn't out in plain view, I'm not looking, however if I go into your home and you've got bomb making crap lying around, even if its your radio shack science project, I feel an obligation to report it....What would the average law abiding citizen do?

We frequently accomodate EM residents from the local programs, rarely have I had a nurse ride, its not required.

NREMT, it is clear that you really haven't heard anything that anyone has said here. It sounds like you are trying to get support for your notion that as a member of a DMAT team, you are a "tactical medic". Failing to gain that support, you are making the argument on your own to others who know far more about the topic than you do. 'zilla Thats exactly what I was thinking...If you sleep better at night taping your blood type to body armor in preparation for armageddon and like to tell people you are a "tactical medic" knock yourself out....your a volunteer EMT with a state sponsored disaster team...without a disaster....

I hate late calls, but I love my job....

You can beat the "what if" horse to death, I think its a waste of resources to send EMS to all fire dept calls.....Should we go to all PD calls? After all, the domestic violence call is the most dangerous.....perhaps we should stand by for those? How about doing stand bys at construction sites, labs, food processing plants etc? It is unfortunate that the fire fighters in this incident didn't have EMS standing by, but neither do people doing other dangerous jobs. Just my opinion of course.

We have one notorious loud mouth surgeon, been a surgeon since the Ice Age, who likes to yell and throw shit, usually at the surgical residents, but occasionally at the ER doc's, nurses and emt's....Its pretty funny to watch sometimes. My biggest gripe is he won't let you plead your case. I'm all for having a discussion or pissing match if need be, but it needs to have two sides.....

There are NO absolutes unfortunately....There are different criteria people use to differentiate the two, I was a product of Marriot's, however Brugada's criteria seems to be more specific, and easier to remember, at least for me. I'm also leaning towards v-tach on this one.

The cops here have done it plenty, usually when the patient is an officer...also, presidential motorcades operate like this, for those of you who have done them....

We will send a BLS and a supervisor to all confirmed structure fires, as well as hazmats, confined space etc...ALS will get sent on the 2nd alarm, with report of occupied structure, confirmed victims or at the request of the BLS or supervisor...I don't think EMS belongs at all fire calls any more than fire belongs at all EMS calls....

I'm not saying that at all....look at the qrs complexes in v1 and v6, see? negative and wide in v1, positive and wide in v6....thats a LBBB "looking" complex. If this was a clear cut sinus rhytm with qrs complexes that looked like that, with the same progression you wouldn't say that appears to be a LBBB? This ekg could very well be V Tach, its the MOST LIKELY regular, wide complex tachycardia, but it doesn't make it a fact. I've made a valid arguement using well studied criteria why it "may" be something else....Lead placement would do nothing to change the precordial tracing.