the 100% directionless thread

Bishop2047

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When we're OOS for maintenance, or other reasons I'll try and rotate IV starts with the nurse while running calls in metro. And yes, doing the occasional OT ground shifts certainly seems to help keep things fluid.
I prefer playing cards with the nurses in my downtime.

I do a fair amount of scene calls for flight so I end up starting the second line fairly often. Certainly doing far fewer now that I do flight than when I was on car.
 

RocketMedic

King of the Improbable
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I’m stranded at our transfer station and I am very over it.


There is nothing more demoralizing than the wheelchair van and repeated BLS IFT. I mean, I get it...but I have worked hard to become a clinician, an educated man and a paramedic, and I feel insulted that the company I work for sees no better use of my time and talents than a medic who should smile and say “Yey!!!” For a wheelchair van. Like...start a real CCT program in our area! Or a community medicine initiative! Anything but the chair van.

I will literally take a 30 percent pay cut to go to someplace that doesn’t look at a motivated professional and ignore their potential to contribute.
 

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Akulahawk

EMT-P/ED RN
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The rant about racist fire departments has been removed. Carry on.
 

StCEMT

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Hit my 2 year mark at my current job. Went in thinking it'd be a fun balls to the walls night. Nope. One VA run, a refusal, and a blood sugar check.

I did get paid to play a lot of pubg so I guess it wasn't a total loss.
 

StCEMT

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Interesting call of the week follow up. Metabolic encephalopathy secondary to renal failure and non-compliance with meds and stuff.

That actually makes sense in hindsight, because while I recommended him to get a stroke work up, I wasn't at all sold on it.
 

RocketMedic

King of the Improbable
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So why stay?
It's the golden handcuffs challenge....it pays a lot (mostly as a result of the 24/48) and I need a job to find a (better) job with. Rent, bills, insurance, general life costs...it's frustrating, and thanks to this lease, we're relatively locked into Houston until 1/20.

With that being said, I'm actively exploring other opportunities, both in EMS and not, and I've already made up my mind to jump at the next good opportunity. This place isn't worth fighting for. Using those "baller" checks for education, licenses in expensive places, maybe some airline tickets or something.

But long term, definitely not staying.


Also, looking at some healthcare consulting gigs here in Houston. I reckon I know the EMS industry pretty well and have a somewhat decent grasp on healthcare, have some insights, etc. So I go to a consulting firm asking for people. Suit, tie, professional-mode, right? I show up to a Galleria-area office tower. It's nice. I go to the office. A dude in shorts and a ragged, dirty polo, with 2-ish days of beard growth and a lawn table alone in an empty office, two other dudes in some conference room. Everything's dirty. "No we don't need people", rudely. Reckon the clients they bragged about are easily impressed; I certainly wouldn't hire a consulting crew that looked like hobos in their own office.

The interesting part is that I recognized one of them from my MHA program. He certainly didn't dazzle there, but he did have connections urging him to go through it, so IDK.
 
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Tigger

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"Childbirth is a BLS skill."

Mom partially delivers placenta and baby has a BGL of a 31.

Never once have I participated in a "normal" delivery.

*shudders.*
 

PotatoMedic

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Baby bgl is normal. Less than 30 is hypo. The partial placenta is the issue.
 

PotatoMedic

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31 is not a normal newborn BGL.
"Neonatal hypoglycemia, defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter."

I will add less than 40 is considered low but monitored for 24 hours if asymptomatic. If it remains low after 24 hours or the baby is symptomatic then it is treated.
 

Bishop2047

Forum Probie
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"Childbirth is a BLS skill."

Mom partially delivers placenta and baby has a BGL of a 31.

Never once have I participated in a "normal" delivery.

*shudders.*
I often forget about the American blood glucose metric. To us in the rest of the world a blood sugar of 30 mmol/L (540 mg/dl) would be cause for alarm lol.
 

Peak

ED/Prehospital Registered Nurse
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Infants with a nadir below 40 are more likely to have a myriad of metabolic disorders and should be observed in the NICU. While rarely treated when unsymptomatic and greater than 30 (other than feeds) that doesn't make it normal. Many infants will not have need for further treatment, but that doesn't negate the need for evaluation.

Many infants who have a normal CHD screen will go on to be found to have disease that was masked by a left to right shunt (especially if performed later than indicated); many who fail the screen with have a benign echo.

In both cases the screen is just that, and the majority outcome does not remove the risk to all patients nor the need for appropriate intervention.
 

Tigger

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Infants with a nadir below 40 are more likely to have a myriad of metabolic disorders and should be observed in the NICU. While rarely treated when unsymptomatic and greater than 30 (other than feeds) that doesn't make it normal. Many infants will not have need for further treatment, but that doesn't negate the need for evaluation.
What are we defining as symptomatic? There was discussion on scene that baby was symptomatic so a line was started and D10 given. Somehow it was an easy stick, if it wasn't I certainly don't think an IO was needed. A friend of mine is interning in the NICU and she says they just mostly use a little oral glucose for this so maybe we'll try that next time.
 

Peak

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What are we defining as symptomatic? There was discussion on scene that baby was symptomatic so a line was started and D10 given. Somehow it was an easy stick, if it wasn't I certainly don't think an IO was needed. A friend of mine is interning in the NICU and she says they just mostly use a little oral glucose for this so maybe we'll try that next time.
Unfortunately I think that is a bit hard to nail down, and the answer is going to change from clinician to clinician.

To me speaking from more of a peds ED/PICU (we take premies through adults if they are cardiac) perspective I look at tone, perfusion, breathing, neuro status, and ability to feed. We tend to be a bit more on the aggressive side just because of the high risk nature of our patients.

If everything looks good and other than being low the kid has no symptoms I would probably just feed them, a newborn mom really isn't likely to have her milk supply come in well yet so I'd probably give them formula or we can give donor milk if the family prefers. Colostrum also doesn't have a great concentration of carbohydrates so for a kid who is low I wouldn't rely on it.

If the kid has less ideal tone (like poor hip strength or less than vigorous cry, not even close to a floppy baby) or has poor suck-swallow-breath coordination but otherwise looks good I would consider an OG for a first small feed and then reassess, since we have such a large number of cardiac kids we tend the pull the trigger on NJ placement pretty early but that certainly isn't universal.

If the kid has poor tone, altered neuro status, any form of distress, or is known to have any kind of medical issue that prevents feeding like a TEF then I would have no problem with UVC/IV placement and giving parenteral glucose. NRP/STABLE allows for a solution of up to D12.5 through a PIV (I would just stick to D10 initially unless there is an issue where we are concerned with overload), if there ends up being an issue where we need to give higher concentrations then we need to look at central access but that isn't really applicable to 911 systems.

I hesitate with the idea of oral glucose only because often the products that EMS carries are thickened and I'm not comfortable enough assessing swallow reflexes to give it to a newborn. We often think that thickened liquids are safer because that is what we give to older kids and adults with various dysphagias but I wouldn't be comfortable assuming the same would hold true to a newborn. If you wanted to give a glucose solution in lieu of formula or breast milk we give sweet-ease all the time which is essentially just D24, I think the recommendation is based off of D5 for oral feeds.

NICU nurses who see more normal births, pediatricians who see newborns in hospital, well baby nurses, and so on may have a bit different of a view just because of the population they see on a regular basis.

I don't think that a 2-4 mL/kg dose of D10 from EMS is inappropriate, especially if you have longer transport times and the kid is fairly easy to access. Keep in mind that you can also use an angiocath (without the needle introducer, historically we have used 20 guages) in the umbilical vein as a makeshift low line if needed, I believe they are still teaching this in NRP. My personal opinion is that all field births are inherently high risk, either something didn't go to plan with a home birth or something prevented them from delivering in a hospital/birthing center as planned (whether it is a precip, result of trauma, substance use, or whatever else); as a result I tend to be a bit more aggressive with field birth management.

I'll attach a couple of links from various programs, keeping in mind that this is largely from the view of NICUs and not EMS/Peds ED management. I'm not sure if your department has an affiliation with either of the pediatric systems but both offer outreach, we have a neonatal specific education team including premature and newborn simulations and I think that they are a great resource.

 
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Tigger

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Unfortunately I think that is a bit hard to nail down, and the answer is going to change from clinician to clinician.

To me speaking from more of a peds ED/PICU (we take premies through adults if they are cardiac) perspective I look at tone, perfusion, breathing, neuro status, and ability to feed. We tend to be a bit more on the aggressive side just because of the high risk nature of our patients.

If everything looks good and other than being low the kid has no symptoms I would probably just feed them, a newborn mom really isn't likely to have her milk supply come in well yet so I'd probably give them formula or we can give donor milk if the family prefers. Colostrum also doesn't have a great concentration of carbohydrates so for a kid who is low I wouldn't rely on it.

If the kid has less ideal tone (like poor hip strength or less than vigorous cry, not even close to a floppy baby) or has poor suck-swallow-breath coordination but otherwise looks good I would consider an OG for a first small feed and then reassess, since we have such a large number of cardiac kids we tend the pull the trigger on NJ placement pretty early but that certainly isn't universal.

If the kid has poor tone, altered neuro status, any form of distress, or is known to have any kind of medical issue that prevents feeding like a TEF then I would have no problem with UVC/IV placement and giving parenteral glucose. NRP/STABLE allows for a solution of up to D12.5 through a PIV (I would just stick to D10 initially unless there is an issue where we are concerned with overload), if there ends up being an issue where we need to give higher concentrations then we need to look at central access but that isn't really applicable to 911 systems.

I hesitate with the idea of oral glucose only because often the products that EMS carries are thickened and I'm not comfortable enough assessing swallow reflexes to give it to a newborn. We often think that thickened liquids are safer because that is what we give to older kids and adults with various dysphagias but I wouldn't be comfortable assuming the same would hold true to a newborn. If you wanted to give a glucose solution in lieu of formula or breast milk we give sweet-ease all the time which is essentially just D24, I think the recommendation is based off of D5 for oral feeds.

NICU nurses who see more normal births, pediatricians who see newborns in hospital, well baby nurses, and so on may have a bit different of a view just because of the population they see on a regular basis.

I don't think that a 2-4 mL/kg dose of D10 from EMS is inappropriate, especially if you have longer transport times and the kid is fairly easy to access. Keep in mind that you can also use an angiocath (without the needle introducer, historically we have used 20 guages) in the umbilical vein as a makeshift low line if needed, I believe they are still teaching this in NRP. My personal opinion is that all field births are inherently high risk, either something didn't go to plan with a home birth or something prevented them from delivering in a hospital/birthing center as planned (whether it is a precip, result of trauma, substance use, or whatever else); as a result I tend to be a bit more aggressive with field birth management.

I'll attach a couple of links from various programs, keeping in mind that this is largely from the view of NICUs and not EMS/Peds ED management. I'm not sure if your department has an affiliation with either of the pediatric systems but both offer outreach, we have a neonatal specific education team including premature and newborn simulations and I think that they are a great resource.

This is some awesome info. Definitely a precipitous delivery with an initial APGAR of 8 and mostly from some blue hands and feet that improved with warming. Baby appeared tired to me, but seems expected. Definitely not floppy but again I think EMS is kind of afraid of non-feisty infants.

I did learn to do UVCs but have not ever done one.
 

Qulevrius

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I often forget about the American blood glucose metric. To us in the rest of the world a blood sugar of 30 mmol/L (540 mg/dl) would be cause for alarm lol.
I think the mg per decilitre are only used in US and Germany, the rest of the world is using mmol/L. But it is easily converted either way, after all it’s based off of glucose’s molecular weight.
 
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