Kiwiology

OMG OMG OMG DUDE seriously you have to go to Big Blue Burrito and get me a big blue burrito, I got addicted to then in Phoenix while I was on layover at Sky Harbour, I NEEEEEEEEEEEEED ONE One of our Intensive Care Paramedics is ex-Southwest from PHX

You make a very good point there Wendy; the actual physical skills of assessing your patient do not change at any pracric level you are still going to take vital signs, look at perfusion status and respiratory effort etc. What changes will be what you do with that information and how you use it to change what you are going to do with your patient. For example the very first call I went on that required some critical thinking was a guy who called up at 1am because his GTN (NTG) wasn't working on his chest pain. I had no real idea what I was doing and the Intensive Care Paramedic did all the work; I don't actually remember doing much of anything. I sort of stumbled my way through with a vague idea of what was going down and had no real clue what on earth the information gathered meant eg blood pressure, ECG, perfusion status assessment. Basically ask the questions the way the book tells you and hope they are right. Another call came down the pipe to us one evening to go and pick up a guy from urgi-care. Get on scene and it's an older gent is having chest pain; first thing the nurse does is hand me a 12 lead ECG; take a look and it doesn't look so hot with big ST changes in the anterioseptal leads (V1,2 and 3). The patient complained of being short of breath and nauesous; he looked sweaty and a little unwell. Now this second call went a million times better because I'd gone and hit the books and taken some nursing classes; I knew wgat was wrong with him, why he had the symptoms he did, how they were affecting his body, what we could do about them and what he needed. I knew to ask more focused questions and what might happen to this guy in the very near future while I have him in the back; e.g. he might crash. I didn't stand there with my thumb up my ass doing nothing without a clue what to do. This is why I advocate strongly that you need a good grounding in biomedical science before you set foot out the door as an ambo; doesn't matter if you are working the transfer nana van or going to emergencies.

Well said

Be careful here; ventilation and oxygenation are not the same thing, a patient can be barely breathing but adequately oxygenated or breathing fine and inadequately oxygenated. The two are very different physiologic processess which most ambo's never pick up on. If the patient is inadequately oxygenated then its appropriate to use a bag mask however do so at a slow rate; the good old ambo trick of "more is better" is not going to help you. A cautionary note that there is nothing "magic" about oxygen and it is often given to patients who do not require it or in quantities above what is required. 2-4 litres on a nasal cannula will do for 90% of patients who actually require oxygen. Should the breathing become adequate then stop bagging them, there's no point in continuing to do something they can do themselves Do you SEE any evidence of head or spinal trauma? Although it is wise to state the absense of evidence does not indicate evidence of absense I would use a head tilt, chin lift. Most cardiac arrests are primary arrests which are cardiac in origin, traumatic arrests well, there should be some evidence of trauma. Why are you inserting an NPA if the patient has a gag reflex? History of COPD is most likely a red herring designed to make you withold oxygen. Suction the airway and go from there; my guess is the old boy is going to require a lot of suctioning. I'd put him on a non-rebreather mask and see how that works, it may be entirely appropriate to just use that if he is getting good air exchange.

In this order Chemistry Anatomy and Physiology I and II Pharmacology Pathophysiology English / communications Scientific research methods Medical terminology Then you will be qualified to take your EMT class

Look for an orginisation with a good culture; one that is open and informal where the employees work together to achieve thier goal. Strong clinical support is a must; a good medical director who is involved and does more than review forms to disclipine people, the supervisors must be more than means to dole out write ups, a structured continuing education program. Does the company get involved in research or offer journal access, do they take part in trials or send people to conferences etc How does the company support continued professional development, who can you talk to if you feel you are having a problem about something of a clinical nature? If you want to go to Paramedic school do they encourage a Degree or just a quicky stop down at the local medic mill? Take a look around thier operation; do thier trucks work, are thier supplies up to date, is thier station falling apart; things like that. It is as much as them being a good fit for you as it is about you being a good fit for them Do not overlook the value of patient transfer. If you are serious about being a MEDICAL professional then you will see the benefit in doing low risk, sub-acute transfer work that gets you reading paperwork and building knowledge as well as the finite primary skills like communication and assessment. You should be taking college anatomy/physiology, pharamcology and pathophysiology; these combined with a transport job will give you a much better insight into WHAT is wrong with your patient, HOW the medication they take affects the body and WHY you treat how you treat. This will get you 1000% more VALUABLE AND RELEVANT experience when it comes to dealing with critical or complex patients than any Paramedic program.

While that is true, do you think ambos should get involved in doing something other than just treating and transporting?

First of all met me say I really admire the work Canada has done over the last decade; specifically Rob Theriaut, Mary Beth Gibbons and all the folks at the Ontario Ministry of Health, Canadian Medical Association and Paramedic Association of Canada. I think you guys have one of the best systems in the world and that you darn Kanuckistaniadians are a bloody smart bunch in putting together the NOCPs. It was just the other day I was watching a webinar with Ben Maartman and Dave McLean (BC/AB respectively) who have become the unoffical "champions" of the AIT movement. They are talking about a "national" regulator and a "national" scope of practice, well hang on .... HMMMM I seem to recall Canada having a NATIONAL occupational competency profile .... maybe, just maybe that should fit the bill? I must dubiously question the Alberta College of Paramedics' goals in putting together the "Alberta" comptency profile when a very, very comprehensive document exists in the "National" competency profile; thus creating a double standard, lets say Ontario creates one and maybe British Columbia too; then you have a quadrupile standard and before long we are calling you the United States! While I am sure there a bunch of legislative and financial issues at play here I cannot comment on as I'm not familiar with the inherent structure of the Canadian system. Looks to me to be another case of a bunch of jurisidictions (provinces in this case) wanting to stray from what should be an inherent national standard to ensure consistency. Now if you ask me, and nobody did, should this whole kerfuffle not just be as simple as updating the NOCP? If Alberta and British Columbia want to let thier PCPs start an IV why shouldn't Ontario? Lord knows they have the education to back it up, in Ontario at least; can't speak for the rest of Canda, if Alberta lets people register who have not graduated from CMA accredited courses lord knows that Quebec and the Neuf's are up too. Oh, and can somebody PLEEEEASE send me some mayple syrup eh?

We have a quasi-physician responder system called PRIME or primary response in medical emergencies for triaged life threatning emergencies. It is an exclusively rural program that intergrates the local family doctor (general practitioner) or nurse into the emergency response system if ambulance based advanced life support is > 20 minutes away. I think this program is rather dubious because it really prevents the ambulance service from having to increase the number of Intensive Care Paramedics (ALS) but it does take advantage of a health resource in the local community which otherwise might go unutilised. That was just a local perspective; but I don't really see the need for physician based ambulances except in the those jurisdictions where it is locally beneficial due to the health system operating modality or legislative restrictions where a physician is required for certian interventions; for example HEMS Doctors in the UK for RSI. I know that everybody makes mistakes but surely asystole in all three leads speaks volumes?

Honestly I don't see the point. In Circulation when Guidelines 2005 were published the AHA stated there is no point in transporting a non-ROSC arrest and I agree; except if the patient is hypothermic or has some problem the hospital can correct like cardiac tamponade .... maybe hyperkalemia? Think of the risk of rushing lights and sirens through the streets, the needless time ED staff spend wasting trying to work the patient and the needless stress it puts on the family.

Oh please don't tell me you still transport primary non ROSC arrests! Could it possibly be that EDUCATION and KNOWLEDGE are the answer here???

"Extend physician like care" makes ambo's sound like a doctor's bitch, hence, being subserviant to the house of medicine! What about the other 90% of patients who do not have some emergent life threat? Have you not been listening to me scream for pages now about how we need to get away from proving "life support" and do something about the other 90% of people that all the ambulance can do is take them to the hospital? Look at ECPs in the UK (dubiously, no press please Professor Malcolm Wollard), CARE/ECP in New South Wales, ECP (urgent community care) here in Wellington, CREMS (community referrals by EMS) in Toronto. Until EMS gets its thumb out its arse, away from the 10% of jobs that are "exciting" and takes the 90% of its workload which is not glamorous and exciting SERIOUSLY and develops appropriate linkages into the healthcare systems for these patients then I dont think it's going to get very far. So ... a Paramedic should be defined as at the VERY MINIMUM a "health professional who provides emergent community based health assesment, treatment, referral and transport as appropriate to the to enable them to recieve the most appropriate healthcare for thier needs" or something VERY SIMMILAR

While I can sympathise with your guys who earn $12 an hour at Intensive Care (ALS) level and work three jobs to pay the bills; these are not valid reasons for Fire based EMS as they simply don't fix the problem, but rather they continue to support the problem. Industrial representation in the Fire Service is strong and it is clear the IAFF and IAFC have a very concrete agenda of bargining for thier members which is after all what they exist to do and they seem to do it very successfully. Now it just seems to me that comments like the above (see my earlier post) taken from official union documents do not seem to support the future of EMS in the United States and ultimately will detract from any professional advancement. The issues you describe eg pay and hours would simply not be allowed to exist here by the Union. It is screamingly obvious the vast majority of your workforce needs to get thier thumb out thier arse, form a decent union and collectively bargain. IAEMS anybody?

Well at least somebody there doesn't have thier thumb up thier arse I think the problem is that they come from the IAFF/IAFC and they have alot of power both politically and industrially; the CoAEMSP requirement to be affiliated with a College was dropped and I can bet you dollars to defibrillators it was at the heckling of the IAFC/IAFF when you read statements like that above. Why don't they want people to have EMS degrees? I bet its because they would not get enough people to ensure a Paramedic on every tour on every engine which might make them look bad and heaven forebid they might loose some money or show better patient outcomes! Australia has them, we are developing them Yes I also believe they are to blame as much as, if not more, than the Fire Service.

Unless a physician brings the emergency department, a radiologist with an x-ray/CT machine and a diagnostic lab tech with him on the ambo he is no more use than a properly qualified Intensive Care officer. Europe, parts of South America and Isreal use doctor (nr RN) based ambulances; SMUR/SAMU in France as an example. Germany uses prehospital physicians (as does Quebec in Canada) because the legislative arrangements do not permit Paramedics to perform restricted interventions; look at the Canadian definition of a "Paramedic" it is any ambulance attendant who can perform one or more controlled medical acts. I don't think physician or RN based ambulances are required nor I venture a guess do they provide better ouctomes for thier patients; anedcotally they may because a physician or an RN might be able to use thier extra knowledge and training to perform a better assessment but I don't have any evidence for this. As for who should lead the paramedic profession; well, paramedics; not firefighters or anybody else and that includes doctors. Ambo's should draw upon the resources that are out there in thier subject matter expert colleagues such as cardiologists or paediatricins but they should not be "led" or "overseen" by a physician. Legislative arrangements, education, a definition of praxis and both an industrial and clinical leadership body is what is required. I would propose the definition of a "Paramedic" be a health professional who provides emergent community based health assessment, treatment, referral or transport as required to ensure patients recieve the right health services for thier individual circumstance. This includes a variety of tasks including responding to life threatning emergencies, unscheduled care requests and health promotion and prevention activities. There can be subspecalties in Paramedicine just like in many other professions; be they neonatal transfer, critical care transport, intensive care (ALS), speciality rescue (high angle, caves, swiftwater etc) etc etc but they all fall under the title of "Paramedic" just like you can have a private, commercial or airline transport pilot but he is a still a "pilot" just like all you Canuckistanadians have a 4 (or F in Ontario) endorsement on your drivers license; doesn't mean you don't still have a "drivers license". Ambo's need to stop letting the bull take charge of them and take charge of the bull; need to get out from being owned by doctors and firefighters. There is one service provider here that has thier thumb so firmly up thier arse I wouldn't mind being owned by the Fire Service right now.

And that right there is what is soooo wrong; I call it the "top heavy" approach ie more education at higher levels rather than a foundational approach with a good solid base of education where the hardest part of learning new things is the "skill" and not the "knowledge". That is the reason I really like how Ontario educates its Primary Care Paramedics ("BLS" if you want to call it that)

Good luck man

hey i am not an it! aw shucks my one weakness how did you know 20/200 (6/60) R ~20/80 (6/24) L

FROM THE IAFF AND THE IAFC THEMSELVES .... (with sources so you can CHECK I am not, unlike the first statement, talking shit) And yet, I am unable to find any evidence of this nor do they site any reference for such studies. UBER FAIL, the IAFF is selling a nicely packed lie to promote its product I notice the IAFF convienently left out the full APA source for that study; after extensive Googling it appears this study published TWENTY YEARS AGO looked at single third service EMS survival from cardiac arrest vs. Firefighters with AEDs in a first response cabability. MEGA UBER FAIL; what a bunch of retards, of course ANYBODY showing up with an AED is going to improve survival rates. Without considering the context or timing of this research, the IAFF uses it to promote itself as being superior, FAIL! Why is the IAFC against have to have Paramedic programs affiliated with a college? Why do they want to continue the back room training of ambo's by ambo's? OMG how retarded do you have to be to get onto the IAFC EMS Section? Maybe because the United States has the lowest standards in the developed world which still count "hours of training" and were written in 1994, 1985/1999 and 1998 (EMT-Basic, Intermediate/85, Intermediate/99 and Paramedic respectively)? But as said in #2, the IAFC obviously cannot understand the difference between KNOWLEDGE and SKILL because they are retards and a couple hundered hours of skills based training seems to be adequate for them. Then by all means, lets WATER DOWN THE STANDARD so a bunch of firefighters can meet it and it won't cost the fire daprtment too much lord knows we can't have that, that's a wonderful idea, never mind the fact that it might further deprofessionalise EMS and negatively effect patient care; but the IAFC doesn't seem to think that is important; see #2 If you can't meet the standard, maybe you should not be in the game? But of course the fire department can't have that now can they? Again, how retarded and arse-backward do the IAFC EMS Section have to be? They are supporting the old tech school medic courses which elsewhere in the world have not existed for at least a decade. As for the staff, oh yes LETS CONTINUE TO WATER STANDARDS DOWN so a bunch of minimally educated fire service or tech mill paramedic instructors don't have to get a REAL EDUCATION and know WTF they are on about. I guess it's acceptable to keep teaching smokeys about "Sidney Sinus", that CPAP "pushes lung water" and so on and so forth because that is what they learnt. Never mind that in the UK, Australia and New Zealand all college Paramedic instructors have a Masters Degree or above. Is it any suprise they get a portion of the blame when you read statements like the above, that THEY WROTE?

LMAO!! There is a midget Firefighter somewhere in Maine if I remember rightly Seriously I have known one or two monocular medics and they do fine For what its worth you can be totally deaf here and still get a CDL, not that you require one to drive an ambo, only a fire truck (weight)

No offense taken mate Of course the concern is there, I would be lying if I said it wouldn't be and quite rightly so! Phew OK so we've started an IV and got him nice and tubed, now, who is gonna drive?

Assessment should not change between BLS/ALS except 12 lead ECG Education should be focused upon acquiring a comprehensive knowledgebase of A&P and patho at the entry-to-practice level so you can begin to consolidate that knowledge as soon as you hit the street Where is one of those two year degree educated entry-to-practice Primary Care Paramedic's from Ontario when you need 'em? You read my mind! I hope your P_Students who have you as a P_Instructor (lol) are made to take something more advanced than the quickie A&P overview in the Paramedic book; my A&P book (Marieb) is almost as thick as my whole Paramedic book (Bledsoe et al)

Who says Fire/EMS works well? Miami with its one intubation per Paramedic a year? Los Angeles where breadth of protocols have not changed in thirty years? Dallas who are considering removing Paramedic training from UT/Parkland because many firefighters fail and its costing them too much? Houston with it's 12 weeks of Paramedic training? Maybe the answer is Naples, Florida! If Fire/EMS works so well why have both the New Zealand Fire Service Commission and the Professional Firefighters Union fought so hard to stay away from doing any medical calls stating it is not in the best interest of either profession? And yet none of that is relevant. This is not about who gets there faster or does the most work or makes themselves look best come budget time. Why does fire based EMS now work? well .... because it reinforces that minimalistic education is acceptable because "well I am required to get this Paramedic cert but I really want to be a Firefighter, I'll never use it anyway" and keeps progression down as most Firemedics rot on an engine and might stick in an IV once or twice before the transport ambulance shows up. You bitch and moan and cry about working for barely livable wages, with next to no benefits and how you know of some ambo's who are so barely educated it is scary. While the Fire Service is not the one-and-only cause for this, they don't help! This issue is partly industrial but 99% of my argument is that why is Fire based EMS a bad idea? It detracts from the professional progression of Paramedicine and patient care suffers

California requires 20/40 for a regular DL so he's at least that if not better. Hey I can start IVs and intubate people fine, heck, and I R blinderder than all of you!

Then you're not taking appropriate BSI, FAIL!