the cableguy Posted January 13, 2010 Author Share Posted January 13, 2010 No. I'm in Republic, WA. Goodluck though. I sent a pt to Dr. Lamberton (orthopod) in Brewster last night though. I'm sure you'll get to know him if you get a job there. Nice guy. Link to comment Share on other sites More sharing options...
istat2 Posted January 13, 2010 Share Posted January 13, 2010 It's all in the disposition my friend: 1. Treat and release 2. Treat and admit 3. Treat and transfer Approach it from this standpoint and it will all flow for you! Have fun!!!!! You should have a blast:rolleyes: Link to comment Share on other sites More sharing options...
goldenbodhi Posted February 8, 2010 Share Posted February 8, 2010 I am back to looking for one of these opportunities. If anyone out there knows of any Crit Access ER low to moderate volume with 24 hr coverage available anywhere in the vicinity of the Rocky Mountain region I'd appreciate any tip or referral. I know that this is where I need to go for the progression on my career. Thanks a million. Link to comment Share on other sites More sharing options...
the cableguy Posted February 8, 2010 Author Share Posted February 8, 2010 I finally got to run my first code this weekend. Of course, she was elderly, very chronically sick and pretty much gone by the time she came through our doors so it took a lot of pressure off me. We worked on her for 30 minutes and then I went back in, after the family said goodbye, to practice intubations. I have a note in the ED now, "no matter who is working, call me if someone dies" so I can come over and practice my intubations. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 8, 2010 Moderator Share Posted February 8, 2010 WILL- if you get a chance take the difficult airway course somethime. www.theairwaysite.com the ems version is fine. Link to comment Share on other sites More sharing options...
1emt2PA Posted February 8, 2010 Share Posted February 8, 2010 I finally got to run my first code this weekend. Of course, she was elderly, very chronically sick and pretty much gone by the time she came through our doors so it took a lot of pressure off me. We worked on her for 30 minutes and then I went back in, after the family said goodbye, to practice intubations. I have a note in the ED now, "no matter who is working, call me if someone dies" so I can come over and practice my intubations. At the hospital I used to work at as a medic, many of the patients who coded and deceased had to go to the Medical Examiner (except DNRs), with all tubes left in. Be careful not to practice on a case for the ME, that could be bad! Link to comment Share on other sites More sharing options...
the cableguy Posted June 25, 2010 Author Share Posted June 25, 2010 WILL- if you get a chance take the difficult airway course somethime.www.theairwaysite.com the ems version is fine. Intubations skills improving. There is a another hospital an hour away that allows me to come over for advanced airway training. I have a standing invitation to intubate their elective surgical pts on my down days. I've been over twice now and have about a dozen intubations under my belt. It has been an INVALUABLE exerperience. I've picked up great pearls from the anesthetists. Of course, now I'm totally sold on using propofol but it freaks out the local pharmacist and the hospital admin folks. I don't understand why though since the half life is so short. It seems much safer AND effective than versed/fentanyl... Link to comment Share on other sites More sharing options...
EMSArtist Posted June 25, 2010 Share Posted June 25, 2010 ;)remember to "vomit" in a bad situation: Vitals O2 Monitor IV Transport Yes!! Excellent acronym- and a new one for me- Think I will teach that to our Paramedic Intern Tomorrow Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 25, 2010 Moderator Share Posted June 25, 2010 Think I will teach that to our Paramedic Intern Tomorrow I learned it in medic school as well.... Link to comment Share on other sites More sharing options...
EMSArtist Posted June 25, 2010 Share Posted June 25, 2010 That particular acronym isn't popular in EMS education here :/ But it is so good (esp for 'Terns prone to nervousness) that with your permission I will spread it around :-) Link to comment Share on other sites More sharing options...
istat2 Posted June 25, 2010 Share Posted June 25, 2010 That element is overstated by those who haven't been up here. You can take a contract job for 1-6 months up in Alaska to actually experience what like up here is like. Some position will fly your spouse up for a site visit during the interview process. Don't let others tell you what you will like , see for yourself. There are many flights every day from Seattle to Anchorage and many connecting flights from there to the interior .There are many good rea$on$ to come to Ala$ka! And each region in Alaska is different. Remember, the state is as large as CONUS east of the Mississippi! Link to comment Share on other sites More sharing options...
Evolute Posted June 28, 2010 Share Posted June 28, 2010 ;) you will do fine. regarding dpl: the atls recommendation is to NOT to do dpl unless you have a surgeon there ready to do something about it. anyone with significant trauma needs c-spine precautions, 2 IV's/IO's, o2, portable c-spine/cxr/pelvis xrays, stabilization and immediate transfer to a place with a surgeon, preferably a level 1 or 2 trauma ctr. a positive dpl doesn't help you unless you can do something about it so don't waste the time. I work 1 weekend/mo at a rural facility and we fly all of our traumas out asap if they look like they need more resources then we have available. remember anyone with a pneumo gets a chest tube before they go on the helicopter because pneumos get bigger/worse with altitude. if the ems report sounds bad call the medevac service before the pt even arrives at your facility to check their availability and put them on standby( or activate them if you know it's bad; for example mva with 2 victims ejected through the windshield, hypotensive on scene). that gets their team on the pad on their end warming up the bird(or in the air) and if it is as bad as the ems report says they can be in the air within a min or 2 of arrival at your facility. you can always cancel them if it turns out to be nothing. at my rural gig we have activated 2 different medevac services for a bad motorcycle accident at the same time just based on ems hx and had both pts out within 30 min of the initial ems call, both with stabilization done and chest tubes in place. medevac #1 was on the pad with #2 hovering nearby waiting their turn. I should have gotten a pix. regarding intubation/airway issues. take the difficult airway course (ems version 350 dollars) asap. see www.theairwaysite.com remember to "vomit" in a bad situation: Vitals O2 Monitor IV Transport I could not agree more. I work in a rural ED in Montana. SP backup 15-20 minutes out about 50% of the time the other half is phone backup only. I’ve been there two years now. It does get easier with experience. Link to comment Share on other sites More sharing options...
the cableguy Posted August 26, 2010 Author Share Posted August 26, 2010 Had my first gun shot victim a few days ago. Not too bad. Good introductory case: Small caliber, entry and exit wounds in LLQ and RLQ anterior abdomen. I had only seen two GSW pts during training, both self-inflicted to the head and DOA. Next week marks a year on the job for me and I feel like I am getting better at controlling my adrenaline and focusing my thoughts, especially after I was notified the pt was enroute. We prepped our small ER and I pepp talked our ER crew. It went really well. I even remembered to get the IV abx started which tells me that I'm getting more comfortable with my primary survey to move on to the smaller details. This was also my first RSI. My other intubations have been done urgently on respiratory failure pts. Turned out to be a another night from hell. I got to bed about 4 am after four ambulances came in, including MVA with broken femur and soccer-ball size hematoma. Plus, a handful of low-acuity pts. Definitely a good night. No one died and I went to bed with a smile on my face. Loving this job... can't believe I'm livin the dream. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 26, 2010 Moderator Share Posted August 26, 2010 strong work! Link to comment Share on other sites More sharing options...
the cableguy Posted August 28, 2010 Author Share Posted August 28, 2010 strong work! Thanks EMEDPA. Definitely a compliment coming from you. One of my favorite cases that night (aside from the GSW) was an appendicitis. He presented atypically including a normal sed rate. CRPs are send outs for us but I'm trying to get that changed. Anyways, I was tired and debating whether to stick him in the CT scanner or not, sorta questioning whether it was overkill since his pain was mild and not localized. In my tiredness and indecision, I did a test I've never done before. Turns out he had a positive "jump test" so I decided to go ahead with the scan and sure enough... I got his CRP back a few days later and it was through the roof... Link to comment Share on other sites More sharing options...
the cableguy Posted August 31, 2010 Author Share Posted August 31, 2010 Well my first weekend of call did NOT remain uneventful...My first pt was a "routine" medical clearance in order to be shipped to a psych unit. Well, the guy turned out to be agitated and combative not because he was off his psych meds but because he wasn't sat'ing due to a big, fat multi-lobe bilat pneumonia. Fortunately, I had already called in my doc to assist with another complex pt that had arrived shortly after the first, so... we were standing together next to the 330lb pneumonia pt discussing what to do with him when his sats dropped down in the 20's (!). Talk about pallor and ashen complexion. Wow. It was something to watch. My doc nailed the intubation on the second attempt. During our full blown code we shocked him three times and successfully resuscitated him. Intense. We shipped him...I LOVE this job but I'm glad my doc was on scene when "Mr. 330lb-tree-trunk-for-a-neck" went south... Guess who's back....Mr. 330lb-tree-trunk-for-a-neck was brought into the ER yesterday for increasing lethargy. I worked him up and found him to be in CHF and with another pneumonia, so we admitted him. I was on call through the night last night, slept the entire night, and first thing this morning a frantic nurse calls me (while I'm cooking up some eggs) and tells me "Mr. 330lb-tree-trunk-for-a-neck is trying to code!" I turn off the stove, throw on some scrubs and sprint across the street to the hospital. When I get into the ER his heart rate is in the 40s and sats are dropping. Nurses are in the process of bagging him I ordered epi which brought his HR back up and then try to intubate him unsuccessfully. He still had some muscle tone and he's got a ton of oropharyngeal flesh caving in from all sides. I tell the nurse to draw up the RSI meds hoping if I kill his muscle tone maybe I can get him tubed but then decide that would be disasterous if I can't get him tubed. I'm told my doc is on the way so i inform the ER crew I'm not going to parlyze him until doc shows up. Sats are hanging out in the 60s. I give it another shot,(sans RSI meds) visualize the cords this time but can't get the 8 ETT in. Back to bagging with an OPA in. Sats drop to 40s. One more time with a 7 ET tube this time. I FINALLY get it in. Good bilateral breath sounds, good CO2 return. His sats came up to high 90s and his color returns. This all happend about 90 minutes ago. Medstar just lifted off. Holy snikies, it was freakin intense! The slight tremor in my hands from the adrenaline just subsided. Turns out, my doc never made it in because of a miscommunication (!) so I am glad I didn't wait for him. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 31, 2010 Moderator Share Posted August 31, 2010 You need a backup device. I recommend the king LT airway. sounds like you got it handled though. and good call not paralyzing the guy...if he's tough to bag don't paralyze or you may end up doing a crich. Link to comment Share on other sites More sharing options...
MikeyBoy Posted September 1, 2010 Share Posted September 1, 2010 Awesome stories, well done! Link to comment Share on other sites More sharing options...
medic25 Posted September 1, 2010 Share Posted September 1, 2010 Agree with EMED, not a great candidate for RSI. Just wondering, did you attempt BiPAP/CPAP with this guy? It can be a nice option for the CHF'ers that are getting tired; I've seen it turn them around from the edge of intubation, and at the least it will often buy you some time before they need the tube. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 1, 2010 Moderator Share Posted September 1, 2010 excellent idea m25! I should probably think of cpap more often... Link to comment Share on other sites More sharing options...
the cableguy Posted September 12, 2010 Author Share Posted September 12, 2010 You need a backup device. I recommend the king LT airway.sounds like you got it handled though. and good call not paralyzing the guy...if he's tough to bag don't paralyze or you may end up doing a crich. Agreed. I've been reading the difficult airway manual at nights in preparation for the vegas conference. Its a great read. Link to comment Share on other sites More sharing options...
the cableguy Posted September 12, 2010 Author Share Posted September 12, 2010 CRP's are sendouts for you guys? what else can't your lab run? Lipase is the other one that comes to mind. I've been told that if I continue ordering these tests they can make them in-house. Still waiting though. I've had a couple of elevated lipase levels with normal amylase (already in-house). Link to comment Share on other sites More sharing options...
the cableguy Posted September 12, 2010 Author Share Posted September 12, 2010 Agree with EMED, not a great candidate for RSI. Just wondering, did you attempt BiPAP/CPAP with this guy? It can be a nice option for the CHF'ers that are getting tired; I've seen it turn them around from the edge of intubation, and at the least it will often buy you some time before they need the tube. Never thought of it. I have little experience with them. Doe't they require spontaneous respirations though? Link to comment Share on other sites More sharing options...
medic25 Posted September 12, 2010 Share Posted September 12, 2010 They do require spontaneous respirations. I wasn't thinking of using it when he was peri-arrest; hen you talked about the patient being lethargic and in CHF earlier that night, that would be the time to initiate NIPPV. The thought is to turn him around with the CPAP and hopefully prevent him from reaching the point of needing intubation. We've seen some fantastic results with the combo of NIPPV and aggressive nitrates; it seems like a lot fewer patients are requiring intubation for failure these days. Link to comment Share on other sites More sharing options...
ionux Posted November 5, 2010 Share Posted November 5, 2010 Very inspirational posts for this pre-pa student. Thank you very much for sharing your ER experiences! Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.