A junctional rhythm is a protective heart rhythm that occurs when the atrioventricular node (AV node) takes over as the heart’s pacemaker. To fully understand a junctional rhythm, let’s first take a look at the cardiac conduction system and see how it operates in a normal, healthy heart.

Cardiac Conduction System

The SA node is the heart’s natural pacemaker and is located in the right atrium. The SA node generates an electrical impulse at a rate of 60-100 bpm and sends it to both atria by way of the internodal tracts. This causes both atria to contract simultaneously and force blood into both ventricles. The electrical impulse then continues down to the AV node, which is located between the atria and the ventricles. The AV node slows down and regulates the impulse, then sends it through the bundle of His to the left and right ventricle. From the bundle of His, the impulse travels through the Purkinje fibers, which are inside the ventricular muscle, causing the ventricles to contract and pump blood throughout the body.

Junctional Rhythm

A junctional rhythm occurs when the AV node takes over as the primary pacemaker because either the SA node failed or the AV node blocked the atrial impulse. The AV node only generates an electrical impulse at a rate of 40-60 bpm, so you typically see a much slower heart rate. There are some circumstances, however, where the AV node develops an abnormal automaticity and exceeds the SA node rate. This is defined as either an accelerated junctional rhythm or junctional tachycardia, depending on the rate. A junctional rhythm is protective — the AV node serves as a backup for the SA node — so it should not be suppressed. The reason being is it would be more dangerous for a lower pacemaker site, such as the bundle of His, to assume the role of pacing the heart. Generally, the lower or more distal the pacemaker site, the less reliable and effective the pacing is.

How to Identify a Junctional Rhythm

A junctional rhythm can be identified by having a regular R-R interval and one of the following P wave characteristics:

• Absent P Waves: This occurs when the AV node sends an electrical impulse to the atria and ventricles at the same time.
• Inverted P Waves: This occurs when the AV node sends an electrical impulse to the atria first.
• Post QRS P Waves: This occurs when the AV node sends an electrical impulse to the ventricles first.

The absence or change of the P wave indicates the primary pacemaker has shifted from the SA node to the AV node.

Junctional Rhythm Types

• Junctional Rhythm: The AV node is the primary pacemaker with a rate of 40-60 bpm.
• Accelerated Junctional Rhythm: The AV node is the primary pacemaker with a rate of 60-100 bpm.
• Junctional Tachycardia: The AV node is the primary pacemaker with a rate > 100 bpm.

Visit the Junctional Rhythms page to learn more about the different types of junctional rhythms.

Junctional Rhythm Symptoms

Junctional rhythms can be completely asymptomatic or accompanied by any of the following:

• Palpitations
• Fatigue
• Dyspnea
• Lightheadedness
• Dizziness
• Syncope

Junctional Rhythm Causes

• Sick sinus syndrome
• Digoxin toxicity
• Ischemia of the AV node
• Acute inflammatory process that may involve the conduction system (e.g., acute rheumatic fever, lyme disease)
• Diphtheria
• Drugs that can cause bradycardia (e.g., beta-blockers, calcium blockers, antiarrhythmic agents)
• Metabolic states with increased adrenergic tone
• Isoproterenol infusion

As an EMS provider, one of the quickest ways to end your career is with a back injury, which unfortunately happens more frequently than you may think. A survey conducted by the National Association of Emergency Medical Technicians (NAEMT) showed that 47% of EMS personnel have sustained a back injury while performing EMS duties. Scary — right? Although this percentage is quite high, it’s important to realize this is a preventable injury and you don’t have to become part of the statistic. Here are four basic principles of body mechanics that will save your back and put you in a position to have a long and healthy career.

Four Basic Principles

1. Keep the weight of the object as close to your body as possible: The likelihood of sustaining a back injury greatly increases the further you have to reach for the object.
2. Use your leg, hip, gluteal and abdominal muscles to lift: These muscles can generate a lot of lifting power with minimal risk. Notice how your back muscles, which are drastically weaker, were not included.
3. Think “stacking”: Try to picture your shoulders stacked on top of your hips and your hips stacked on top of your feet. Once everything is properly aligned, move them as a unit.
4. Reduce the height or distance the object needs to be moved: This is where the phrase, “work smarter, not harder” comes into play. Sometimes this can be as simple as moving the gurney as close to the patient as possible.

The next time you’re moving a patient or equipment, make sure to incorporate these four basic principles. Your back will thank you — trust us.

Are you looking for a job as an Emergency Medical Technician (EMT)? The industry is extremely competitive and it can be difficult to get hired, especially if you have little or no experience. Here are 5 things you should know for your EMT interview that will put you ahead of the curve and help you get the job.

1. Hospitals

• Know the name, location and catchment area for each of the following:
1. Base hospitals
2. Trauma centers
3. Burn centers
4. Hyperbaric facilities
• When should you contact base hospitals?
• Know the qualifying criteria for trauma centers, burn centers and hyperbaric facilities.

2. Protocols

• Have a good working knowledge of your protocols (adult/pediatric) for each type of emergency.
• When can you apply restraints? What’s the difference between soft (medical) and hard (behavioral) restraints?
• Know your interfacility transfer (IFT) protocols. For example, if you arrive at the ER to transport a patient and the nurse gives pain medication, do you have to wait before transporting? If so, how long?

3. Practical Skills / General EMT Knowledge

• You should be dialed on your pratical skills as these are the fundamentals of being an EMT. Be prepared to be tested during the interview process.
• Have a strong understanding of the following:
1. Anatomy
2. Common medications
3. Normal vital signs
4. Signs and symptoms of common illnesses
5. How to triage using START

4. CPR Guidelines

• Know the current CPR guidelines. Are there any differences between witnessed/unwitnessed, adult/pediatric, and one or two-person CPR?

5. Cardiac Anatomy

• What are the major components of the heart?
• You should be able to trace the blood flow through the heart.

Visit the EMT Jobs page to find employment opportunities in your area.

There’s a lot of new EMT’s graduating each semester in San Diego and they’re always eager to start applying for jobs. Popular questions on EMT forums are what ambulance companies are in San Diego and who is the best to work for. As you can imagine, there’s a wide range of responses and you typically have to dig through multiple threads to find all the information. To make things easier, we’ve created a comprehensive list of ambulance companies in San Diego and the services they provide. The majority of these companies are well established and have been around for quite some time. In terms of experience you’ll gain in the field, we strongly recommend working for Rural/Metro, American Medical Response (AMR) or Mercy Ambulance. These companies have the main 911 contracts within the County of San Diego and great reputations overall.

Rural/Metro Ambulance

• Service(s): ALS, BLS, CCT, Special Events
• 911 Contract(s): San Diego
• Crew: EMT/Paramedic (ALS)
• Website: View

American Medical Response (AMR)

• Service(s): ALS, BLS, CCT, Special Events
• 911 Contract(s): Chula Vista, Imperial Beach, Bonita-Sunnyside Fire Protection District, La Mesa, San Miguel Consolidated Fire Protection District, Lemon Grove, Alpine Fire Protection District, San Diego Rural Fire Protection District, and Pine Valley Fire Protection District
• Crew: Paramedic/Paramedic (ALS)
• Website: View

Mercy Ambulance

• Service(s): ALS
• 911 Contract(s): Valley Center Fire Protection District and Deer Springs Fire Protection District
• Crew: EMT/Paramedic (ALS)

AmeriCare Ambulance

• Service(s): BLS, CCT
• 911 Contract(s): Camp Pendleton I-5 corridor and backup 911 services for Carlsbad, Oceanside, Vista, Escondido, San Marcos, Valley Center Fire Protection District, Deer Springs Fire Protection District, Elfin Forest, and National City.
• Crew: EMT/EMT
• Website: View

Other Ambulance Companies

We recently came across the ECG Guide app and downloaded it for the iPad. Bottom line: this is a must-have app for EMS professionals. It is extremely comprehensive — designed to help even practicing physicians — and has an abundance of rich features.

The ECG Guide was developed by QxMD and teaches ECG interpretation from a cardiology perspective. The app boasts the largest ECG library available on the iPhone with over 200 high-resolution images of ECG’s, a quiz section with 100+ multiple-choice questions, and also includes pediatric tables for quick reference. The amount of information and level of detail is astonishing, but can be quite overwhelming at first — especially for someone new to ECG interpretation. The good thing is it has even the most basic information, so novice users can quickly improve their knowledge and begin to utilize the more advanced features.

Features

• Quick reference section that covers ECG basics all the way to electrolyte abnormalities and differentiating between VT and SVT
• ECG basics and fundamental concepts
• ECG interpretation guide that includes axis and rotation assessments
• Waves and segments overview
• Types of chamber enlargement
• Types of ischemia and infarction
• Conduction and bundle blocks
• Types of arrhythmias
• A miscellaneous section that includes an overview of items such as hypothermia, myopericarditis, Brugada Syndrome, dextrocardia, valvular disease, pericardial effusion and pulmonary disease
• Pediatric tables
• An ECG sample section with over 70 categories that show high-resolution ECG’s for different rhythms, diseases and cardiac events
• A quiz section with 100+ multiple-choice questions and a rhythm identification practice tool
• ECG interpretation tool where you input findings and it tells you the rhythm

The ECG Guide app is available for Android, iPhone, iPad and BlackBerry devices. This is a paid app; however, it’s well worth the price and extremely useful for anyone in the medical field.

The SAMPLE acronym is usually taught within the first few weeks of EMT school and is a fundamental piece of the history taking section of patient assessments. Unfortunately, many students are only taught that the “S” in SAMPLE stands for “signs and symptoms” and they should use the OPQRST acronym to determine what those signs are symptoms are. The OPQRST acronym is great for assessing cardiac and traumatic related emergencies, but it shouldn’t be used for every type of chief complaint. For instance, OPQRST can be slightly modified to work for a patient experiencing a respiratory emergency; however, it’s generally a better idea to use the PASTE acronym instead. By using PASTE, you can gather more relevant information about the patient’s chief complaint and therefore conduct a better assessment. Below are lists of questions you can ask patients for each type of emergency when doing your SAMPLE history.

Questions to Ask for the “S” in SAMPLE

Respiratory

• OPQRST or PASTE (generally a better alternative)

Cardiac / Trauma

• OPQRST

Altered Mental Status

• Description of the epsiode.
• What was the patient doing when the signs and symptoms first occurred? Was the onset sudden or gradual?
• How long has it been going on?
• Are there any associated symptoms?
• Is there evidence of trauma?
• Any interventions?
• Possibility of a seizure?
• Does the patient have a fever?

Allergic Reaction

• Is there a history of allergies?
• What was the patient exposed to?
• What are the effects?
• Is it progressing? If so, how?
• Any interventions?

Poisoning / Overdose

• What was the substance?
• When did the patient ingest or become exposed?
• How much did the patient ingest or how much were the exposed to?
• Over what time period?
• Any interventions?
• What is the patient’s estimated weight?

Environmental

• What was the source?
• What was the environment?
• How long was the exposure?
• Was there a loss of consciousness?
• Are there any general or local effects?

Obstetric

• Is the patient pregnant?
• How long has the patient been pregnant for?
• Is there any pain or contractions?
• Is there any bleeding or discharge?
• Does the patient feel the need to push?
• When was the patient’s last menstrual period?
• Is this the first pregnancy? If not, were there any complications with the previous pregnancies?

Behaviorial

• How does the patient feel?
• Does the patient have suicidal tendencies?
• Is the patient a threat to themself or others?
• Does the patient have any medical problems?
• Any interventions?

There comes a time when every EMT student needs to complete a ride-along as part of their clinical experience. For most students, this is typically their first exposure to the EMS system and therefore a critical step in the learning process. If you’re an EMS professional, you certainly know how these shifts can be either very rewarding or a complete nightmare! With that being said, we’ve developed a guide to help prepare EMT students for ride-alongs and hopefully ensure a positive experience for everyone. To keep it simple, we’ve come up with the “Three P’s” system: punctual, professional and prepared.

Punctual

You should show up to your scheduled shift at least 30 minutes early to become familiar with your surroundings and ensure the crew has enough time give a tour of the ambulance or fire engine. Showing up early lets the crew know you’re a responsible, dedicated and motivated student. On the other hand, if you’re late to your shift this can be interpreted as you don’t take the career seriously and the crew members might be reluctant to teach or include you on any patient care. Keep in mind you might be applying for a position with this agency once you’ve finished school. It’s extremely important you set a good example to show how important this career is to you. If for whatever reason you won’t make it on time, call your class instructor immediately so he/she can contact the agency. It is also equally important to leave on time as well. For instance, don’t hang around after your shift ends since the agency is only responsible for you during the scheduled time.

Professional

Being professional can mean many things, but in this case, let’s focus on your appearance and attitude.

Appearance

• Black boots or sneakers
• Navy blue pants
• Black belt
• Plain, white Polo shirt (no logos and tucked in)
• Do not wear make-up, jewelry or hats
• Men should have a clean shave and women should wear their hair up

Attitude

• Your attitude is everything and it’s important to remember you’re there to learn through hands-on experience. Don’t be shy or reluctant to make patient contact when instructed to do so. This is a critical time in your training where you’ll start to learn how to interact with patients and apply some of the technical skills you learned in school.
• Stay positive. The crew members know you’re a student and don’t have much practical experience. If you have a good crew, you should receive a lot of feedback on how you’re doing.
• Be a sponge. Your number one goal should be to learn as much as possible. Ask a lot of questions and take initiative by asking if you can assist or help out.
• Remember, you are a guest so act like one. Do not engage in jokes, use your cell phone or handle equipment without permission. Be respectful and make sure you thank everyone for their time at the end of the shift.

Prepared

The ride-along is designed to give you an opportunity to practice your skills in a real-life setting. It’s extremely important you have a strong working knowledge of your practical skills, local protocols, medications and dosages, normal vital signs for infants, children and adults, etc. It’s not uncommon for crew members to quiz you on your knowledge, so make sure you’ve studied and have a good understanding of what you’ve learned so far. Depending on how busy it is, you might have some downtime. It’s a good idea to bring your textbook or notes so you can study during this time. Also, the shifts can be long so bring a lunch and some snacks to ensure you have enough energy for the day. If you don’t want to pack a lunch then make sure you bring cash. Often times, crew members have some favorite spots they like to eat and the business might not accept credit or debit cards.