HellsBells

Do any of you nice paramedic or paramedic students in Alberta know where I can find some good quality prep exams or material for the ACoP paramedic exam?

I don't know why Entonox isn't used in the USA, as far as I know just about every service in ALberta Canada has it on board.

NTG? Dose? IV? SL?- I'd start with SL @ 0.4mg Lasix? Dose?- meh, don't know if id use lasix- the dose would be 1mg/kg (or 20-40mg). The concerns I'd have would be the renal shutdown, but it seems acute, so it may be benefical The EKG findings point to Hyperkalemia, so Tx should include - calcium chloride- 8-16mg/kg - Sodium Bicarb- 1mEq/kg - ventolin neb- 5-20mg - insulin/glucose- 10U/25g- over 10-15 min So, why may be the cause of the renal issues? I think that the renal failure is caused by the cytotoxic therapy the pt is undergoing, but not sure of the specific patho behind it. Use the PICC? if IV access was a problem, I guess I wouldn't have much choice, although I'm not sure if it would be a good idea to put the bicarb down the same line as the other drugs, does anybody have an opinion on that?

Ah Fair enough, interesting.

Yeah, I agree that with the hypotension, its a good idea to stay away from the versed. Did you hold back on the Succ due to concerns over possible Hyperkalemia with the sepsis DD? Glad to hear that the intubation went well.

I have never used a drip at our service. The only drips we could potentially hang would be lidocaine or epi. I'm wondering if anyone here uses a Buretrol for eyeballing drips. One of the paramedics I work with swears by them for drips. Although I've never used one personally.

I'm curious Mobey, in the service you are at, do they have an RSI protocol, or RSS only? How did you find the intubation went with just fentanyl, any problems getting a tube?

An interesting dilemma, clearly this women is dehydrated. I'd say that even with the pneumonia, she needs some fluid. The good thing about the IO is that the fluid needs to be pressure infused and make an accidental over bolus less likely. I'd try a small bolus of NaCl @ about 250ml. Assess her after that. If the transport is 20 mins or longer dopamine would probably be indicated, if her pressure remained low. I couldn't see myself going with an Epi drip on this women, unless her condition rapidly deteriorated enroute.

Wow! I can't imagine a system where dispatch dictates what type of assistance you need on a call. We have some problems with dispatch, but I could not even concieve of a situation where they would refuse to send help that was requested by the crew. Its a safety issue for both crew and patient. My advice, if you are looking for a logical argument (although it doesnt sound like logic is your managements strong suit) is to fall back on the RSI protocol. It states that you are to have medical back-up for all RSI's. So if you are denied back up, then you are technically in violation of company policy. In that case either the protocol needs to be changed or dispatch has to be educated about what an RSI requires, in terms of manpower. If this argument fails to impress them, I would seriously think about leaving, as these ignorant dispatchers put both you and your patients at risk.

So, the Alberta labor boards decison has come down. It states that the AHS move to transfer all EMS union members into HSAA was, in fact legal. It looks as though CUPE may not be representing Alberta paramedics for much longer. Here is the statement from CUPE on their Calgary website: calgaryparamedics.com

So I don't have a lot of expierence with lasix, being that I'm in an urban setting. However, I think the point of having a foley is a good one in the rural setting. If your far enough out for it to take effect, then you should have a good idea of what type of output is happening. The issue of a sterile field may be a problem, but I think if your well organized then it is entirely possible. Our trucks are still running with lasix, but only if our SL nitro is having no effect. Sadly, it looks as though CPAP isn't even on the distant horizon at this point, judging fro the outright dismissive response from a field trainer when I suggested it.

I agree that that the I-pad is really just an oversized I-pod touch... Yet, don't underestimate the folks at apple. The bookreader feature may just be the selling point that makes this thing a great success. The recent success of the kindle shows that there is certainly an appetite for a book reader. The kindle retails for about $200, but doesn't anything else. The i-pad starts at around $400, but people will most likely justify the price point because of the additional features. Add to that the "coolness" of the online i-book store. Apple might have some real success with this item.

I can offer a few comments on the appendixes, mind you I have just skimmed over the report quickly, so if any of my details are incorrect please correct me. His data with direct wage and benefits compares what is referred to as the top wage for that position, but no word on exactly how long it takes to reach that level, or how many people are making those wages and benefits. The waters are further muddied by the nature of the numerous on-call and part-time positions in BCAS. In the body of his report he mentions the employees who are on $2/hour on call and make full wage when called out. To his credit he mentions that as a problem with the provincial service model, but I wonder if its properly factored in to his wage findings. Another issue that he mentions is the fact that people often travel long distances out of the communities they live in to work. Are these travel expenses paid for by BCAS, or does the employee bear them himself? I think that there may be a little cooking going on in these here books.

You asking about Alberta in particular, or EMS in general?

WTF? I find the level of violence you guys face quite shocking, actually. Here in Calgary, Ab. we are issued slash vests as part of our standard gear, and I can't even remember the last time one of our Paramedics was attacked.

Yeah, I agree Dust, this quote kind of took me by suprise too. My immediate reaction was, what hospital uses sandbags under the pt's head? Is this common practice where anybody works? Actually, our service doesn't use foam blocks, we use blanket rolls. Same difference. Its an interesting study, of course a lot more research needs to be done on the issue. However, this quote somewhat limits the application of the study. Is it reasonable to change practice for an injury that few patients actually survive?

Fair enough. Sounds like a bit of a cluster, I agree with you that it is kind of unreasonable for dispatch to call an off duty medic, just because he lives close to the call. However, in the case of persistant V-Fib, I don't think its totally unreasonable to transport to the hospital, as occured in this case. As far as the issue of Amiodarone, obviously it is indicated in this situation, but its doubtful it would have made any difference for this pt. Of course your main question was about the intubation time, and I think that its a very valid point. On rereading the 2005 ACLS guidelines the other night, there is certainly a great deal of emphasis put on maintaining CPR and deferring intubation. Which really has me thinking about how we run codes in the city I work in. Typically, in our system, one engine and an ambulance are called to all code or potential code situations. I find that most paramedics will have the firefighters begin compressions and provide ventilations while we busy ourselves with the monitor, IV, medications, etc. Meanwhile, were not paying as much attention to the quality of of CPR as we should be. Some of the Firefighters are good providers of CPR, but the training in our city's dept. is kind of inconsistant, to say the least. It is interesting that many people in our service, including myself on a few occasions, are leaving what may be the most important aspect of the code in the hands of the least expierenced people on scene. But, I digress.

I wonder, was the pt in asystole, or persistant V-Fib when they transported to the hospital? I assume that since you mention amiodarone, he was in V-Fib. So, it could be argued that the pt may be potentially salvagable, although quite a long shot at this point. The paramedic may have been reluctant to call a pt that wasn't presenting with PEA or asystole. Not being familiar with your system, I don't know what medications you have on truck. I suppose the hospital would be able to perform an ultrasound of the heart to determine if it is contracting at all. As far as the issue at hand goes, I would agree that your paramedic didn't perform as prefectly as he could have in this situation. A couple mins of CPR between intubation attempts would have been ideal. Better yet, if he was considering transport, intubation in the ambulance would have been ideal. That said, I would also ask you what was done before he tried to intubate. How long had CPR been in progress? How many shocks had been given at this point? How many rounds of Epi had been administered? Was the V-Fib coarse or fine? That said, it might be a good idea to ask the medic in question why he did what he did, see if he knew some facts that you didn't about the situation.

In regards to the new AHS (AHSEMS.com) website that is accessable to all ambulance personal in the province. What do you all think of it so far? I have my own opinions, but I'd like to get some other input first.

We have Etomidate on our trucks Mobey. However, protocols state it is to be used only in hypotensive pts who are in the 70-90 systolic range.

There is a quote like this in the Stephen King novel "The Drawing of the Three" in the Dark Tower series "...The wheels in Roland's head grind slow, but exceedingly fine..."

I don't know if its fair to say that he should have had a DNR. A lot of times the cancer moves so fast that the pt and family havent even come to terms with the fact that its a terminal illness, sometimes Ca doesnt give its victims time to get over the denial phase. To answer the original question, no I have never been upset by a DNR.

Ok... safe to say Redzone will not be in on further disscussion

True, but there is some debate over whether they should have to provide pictures for their ID. In Alberta, Hutterites (Alberta's answer to the Amish) recently lost a court battle, where it was deterimed they will not be exempt from having their picture on government ID. Hutterites Lose Last Ditch Supreme Court Effort

Well Redzone, I'd say that you have contradicted yourself, obviously withholding or limiting your Nitro would count as an effect on treatment. In our Urban system, the 12-lead is very important for the outcome of a pt. STEMI patients have to be transported to the one hospital in our city with Cath lab facilities. Additionally, a lot of ambulance services, particularly rural ones are administering thrombolytics, so the 12-lead is becoming a much more important tool in EMS care. I do agree that hospitals will always take their own 12-leads, no matter what ours say. I imagine its a CYA issue, but the quality of their hospital machines is usually much better than those we use prehospital. Even with perfect placement, I often find it frustrating trying to obtain a 12-lead without artifact on an LP12. Now, Redzone, seeing that your post was written about 2 years ago Id like to know if your opinion, and/or knowledge of 12-leads has changed in any way. That is presuming you still post on this site.