the 100% directionless thread

GMCmedic

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Yea, a local hospital program. Trying to move on to get challenged and grow more clinically as well as just get a change of scenery for overall job satisfaction. I'm just very resistant to going fire here and that leaves me a VERY small pool of options.

I did. Solid program if anyone is looking into one. There are things within the critical care realm that I just dont do (or at least often) where I work and I would definitely have some topics to refresh. I still have all my UF material though, so that won't be hard.
It's constant refreshing unless you do things often. 2 years in and I have yet to do a balloon pump, use the fetal heart monitor, or insert a chest tube. To this point ive only done 1 Impella transport.

I have to carry cheat sheets fer certain things.
 

Chimpie

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@Chimpie is he a Mickey Mouse Clubhouse fan? Our 1 year old loves the Hot Dog Dance. He could do without the other 28 mins, all for that dayum dance...
all. day. everday. He loves the show. He loves the dance. He also likes the intro because he yells out (his version) of the characters' names.
 

Akulahawk

EMT-P/ED RN
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Lucky me... I'm training to be a Charge Nurse. In about a week or so, I get to kick off the training wheels and see how well I can manage a 29 bed ED that sees around 200 patients per day. Ought to be fun...
 

VentMonkey

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It's constant refreshing unless you do things often. 2 years in and I have yet to do a balloon pump, use the fetal heart monitor, or insert a chest tube. To this point ive only done 1 Impella transport.

I have to carry cheat sheets fer certain things.
This is exactly right. In almost 5 years there’s quite a bit I have not seen or done, and may never. However, having a fascination for almost all things critical care has certainly kept me afloat.

Oh, and I carry cheat cards, too.
all. day. everday. He loves the show. He loves the dance. He also likes the intro because he yells out (his version) of the characters' names.
Haha, that’s awesome. Our son loves howling for Toodles without fail.
Lucky me... I'm training to be a Charge Nurse. In about a week or so, I get to kick off the training wheels and see how well I can manage a 29 bed ED that sees around 200 patients per day. Ought to be fun...
Man, I distinctly remember how nervous I was the night before my very first supervisor shift. I didn’t sleep much for the impending 48-hour shift thinking about “all” I was going to be responsible for.

Luckily our administrator on call/ VP called me on the way out to my shift and put things into perspective for me.

It dawned on me that I really wasn’t in charge, and more importantly, in control of much. GL.
 

VFlutter

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Etomidate and Vecuronium RSI should be a crime. Can you call Department of Health and Senior Services about that?
 

DesertMedic66

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Etomidate and Vecuronium RSI should be a crime. Can you call Department of Health and Senior Services about that?
Why? That is a couple of the local hospital’s go to cocktail here. Haven’t had any issues with picking up these patients.
 

VFlutter

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Why? That is a couple of the local hospital’s go to cocktail here. Haven’t had any issues with picking up these patients.

Very high likelihood the patient will be paralyzed and not sedated either during the peri-intubation period or thereafter. Sure you can time it appropriately and quickly follow up with adequate sedation however in our area it is always Etom/vec and 30-45 minutes later think about adding sedation.
 

Tigger

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Very high likelihood the patient will be paralyzed and not sedated either during the peri-intubation period or thereafter. Sure you can time it appropriately and quickly follow up with adequate sedation however in our area it is always Etom/vec and 30-45 minutes later think about adding sedation.
That's awful.

We are the opposite (well at the place I work where we actually manage airways), I think our "medication facilitated airway" is a bit convoluted. Start with 2mg/kg Ketamine to "facilitate preox." Then, after an appropriate window like 5 minutes, 0.3mg/kg Etomidate and Roc, tube, and then immediately 100 of fent and 5 of Versed +/- more roc or vec. Can also post tube sedate with 3mg/kg/hr of Ketamine.

2mg/kg of Ketamine is an induction dose. Let's just use that as such and not add a big slug of Etomidate. We can do dissociative intubations if indicated with Ketamine only as well.
 

Peak

ED/Prehospital Registered Nurse
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That's awful.

We are the opposite (well at the place I work where we actually manage airways), I think our "medication facilitated airway" is a bit convoluted. Start with 2mg/kg Ketamine to "facilitate preox." Then, after an appropriate window like 5 minutes, 0.3mg/kg Etomidate and Roc, tube, and then immediately 100 of fent and 5 of Versed +/- more roc or vec. Can also post tube sedate with 3mg/kg/hr of Ketamine.

2mg/kg of Ketamine is an induction dose. Let's just use that as such and not add a big slug of Etomidate. We can do dissociative intubations if indicated with Ketamine only as well.

What’s the plan of the state takes away ketamine?
 

DesertMedic66

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Very high likelihood the patient will be paralyzed and not sedated either during the peri-intubation period or thereafter. Sure you can time it appropriately and quickly follow up with adequate sedation however in our area it is always Etom/vec and 30-45 minutes later think about adding sedation.
Correct me if I am wrong but from all the literature I have read both Roc and Vec have very similar duration of actions.
 

Akulahawk

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VFlutter

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Correct me if I am wrong but from all the literature I have read both Roc and Vec have very similar duration of actions.

Correct, at appropriate dosages the duration of action is pretty similar with Vec being slightly longer and the onset being the bigger difference. I guess a more general statement would be that a short acting sedative with a long acting paralytic isn't an ideal combination for inexperienced providers who do not understand appropriate post-intubation sedation.

Recently discussed a study on a CQI call that compared sedation/analgesia dosing in HEMS with patients RSI'd with Succ vs Roc and that those given Succ got sedation quicker and more frequently vs Roc and purposed that the Roc group and a much higher chance of periods being paralyzed and under-sedated. I'll try to find it.


AER-9-88-g003.jpg
 

Chimpie

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Haha, that’s awesome. Our son loves howling for Toodles without fail.
HA! If we're not watching MM Clubhouse, he points to the tv and says, "Toodles". Yeah, our kids are already brainwashed.
 

Tigger

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What’s the plan of the state takes away ketamine?
Who knows, though I think it is more likely that only ExDs dosing goes away. I am not sure how we would do dissociated intubations anymore, we could of course return to using Etomidate for RSI.
 

StCEMT

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It's constant refreshing unless you do things often. 2 years in and I have yet to do a balloon pump, use the fetal heart monitor, or insert a chest tube. To this point ive only done 1 Impella transport.

I have to carry cheat sheets fer certain things.
Yea I expect that to a large degree and thats more or less how it already is. I also expect shenanigans in an interview setting where they are asking me what to do when I see flakes with the balloon pump.

Unrelated note, I should be off the clock in 45 minutes and I won't have to set foot in an ambulance until the 17th. Off to Wyoming.
 

GMCmedic

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Yea I expect that to a large degree and thats more or less how it already is. I also expect shenanigans in an interview setting where they are asking me what to do when I see flakes with the balloon pump.

Unrelated note, I should be off the clock in 45 minutes and I won't have to set foot in an ambulance until the 17th. Off to Wyoming.
My interview was mostly questions relating to safety and public relations. They can teach you the clinical stuff, but it only takes one bad experience with a HEMS provider and youve lost calls from Hospital A.


I would imagine the interview doesnt vary much from company to company.
 

E tank

Caution: Paralyzing Agent
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Lucky me... I'm training to be a Charge Nurse. In about a week or so, I get to kick off the training wheels and see how well I can manage a 29 bed ED that sees around 200 patients per day. Ought to be fun...
It's easy...just learn one easy word..."No".
 
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