Kiwiology

Here in Kiwi we are moving to a hybrid Canadian-Australian model of tiering our response. Rural areas served by our volunteers will get BLS as a first response (our BLS is much more expansive than purist American BLS) Paid areas or crews providing backup to a BLS volunteer crew (80% of our national workload is paid staff) will either be Paramedic or Intensive Care Paramedic. A "Paramedic" will do everything except a few fancy ALS skills like (at the moment) IO cannulation, midazolam, amiodarone, ketamine, pace and a few cardiac meds. Under the new system the only difference between a Paramedic and an Intensive Care Paramedic treatment of cardiac arrest is that the IC Paramedic will intubate them whereas the Paramedic will use an LMA. I am told Paramedics will be getting amiodarone for cardiac arrest and midazolam IN or IM for seizures, they already have adrenaline, morphine, naloxone, cardioversion etc.\ The logic behind this is to create a "super skilled" base level which can handle all but the most challenging calls (life threatning asthma, patients needing intubation/RSI, dysrhythmias etc) and essentially keep Intensive Care for them.

Good thing we don't have those here eh?

Our procedure for RSI is Fentanyl 1mcg/kg Ketamine and sux 1.5mg/kg Vec 0.1mg/kg Midaz 0.05mg/kg Fent and midaz is used for patients with TBI or neurogenic cause of coma (GCS < 10) while ket and fent are used for everything else For standard analgesia ketamine is 5-10mg IV prn q 3-5

Depending on your current system you might find it a bit difficult working in my city, our system has no online medical control to speak of and no particular desire to change. .... and we don't have to transport everybody!

Used them for years with the aviation industry; very helpful

A good A&P text will cover all the resp physiology you need, i recommend Marieb 8e by Pearson-Benjamin Cummings

If somebody finds $22 worth of misplaced New Zealand stamps with your DVD, can I have them back please, FML!

Those who have requested a DVD, I am on my way down to send them off now. Those who want one, for free, yes, free I am doing another batch next week Here is an updated list of what is included • Consolidated Resources for Ambulance Paramedics Collection - ECG review software and printable guide - Dozens of PowerPoint files on a range of clinical topics - Practical aspects of ALS care videos with many great tips, over two hours - Mobile Intensive Care Ambulance lectures c. 1994 by Dr. Frank Archer (includes a good history of US EMS in particular) - Common ALS drug audio questions (can be played at random for review) • Interactive Physiology DVD (supplement to Marieb Anatomy & Physiology) - Fluids and electrolytes - Endocrine - Cardiovascular (including cardiac action potential) - Nervous - Respiratory - ... many more (and worksheets) • Emergency Medicine by Henderson • Manygan’s ECG Interpretation and Management Guide • Workbook for Anatomy and Physiology for Dummies • Basic and Clinical Pharmacology 10th edition • A range of journal and JEMS articles on important clinical topics and concept • New Zealand National Diploma in Ambulance Practice learning materials and ILS Paramedic pre-course assignments

That would be helpful

My thoughts exactly!

Little oxygen, say 3-4l on a NC, and take the patient to the hospital. No other treatment as it's not clinically indicated.

Oxygenation and ventilation are often confused and the concepts used interchangably. They are not the same thing are infact two different physiologic proceses. The amount of air breathed in is not the amount of oxygen that will reach the brain and tissues. - Air is about 21% oxygen, yet in Denver it's lower (I don't know the exact forula to figure out how much lower) so altitude plays a part - The ability to change pressure inside the thorax is also important; if Stanley my immaginary grey pet elephant sits on your chest you will have a very hard time creating a negative pressure gradient to draw air in as you can't expand the throacic cavity enough. - Just because oxygen is inhailed does not mean it will reach the bronchioles, alveoli, blood, cells and tissues. Any number of obstructions may prevent this - eg choking, hypovolemia, obstructive lung disease/pulmonary edema, carbon monoxide poisioning or a haemothorax. It is also important to recognise that not all the air inhailed will reach the respiratory zone for the oxygen to diffuse out of the alveoli and into the blood. The lungs have what is called dead space either anatomical (bronchi and bronchioles that do not have alveoli and pulmonary capillaries, I believe this is the first 20 or 21 divisions of the bronhcial tree) or alveolar; alveolar dead space is any buggered alveoli that can't exchange gas either because they have collapsed or are full of puss or the marbles I ate for dinner. Dead space is an important concept as about 150ml of air will occupy the anatomical dead space at any one time, this will increase if there is additional alveolar dead space such as in infection or APO/CPE. Let use consider your patient who is breathing, say 30x a minute and his tidal volume is say 250ml. AVR = RR x (TV-DS) so 30x(200-150) is an AVR of 3,000ml/min .... nowhere near adequate considering only 21% of that is oxygen so this poor guy is only getting about 630ml of air a minute heck no wonder he passed out! In theory (I am not a pulmonologist) if you are bagging say 10x a minute and your BVM has a volume of say 750ml you should have an AVR of 6 litres a minute, or about 1.2 of oxygen Shallow breathing (at any resp rate) is nowhere, nowhere near as effective as normal or deep inspiration. Also remember taking the opposite approach and bagging the snot out of someobyd will not help them much either, but I won't ramble on about hyperoxemia and pH washout. Do hope that helps, this sutff is interesting.

We have classes 1-6 based upon weight and 8 endorsments depending on vehicle type or type of driving; e.g. F for forklift, P for passenger or T for tracks (e.g. tank or bulldozer). Say you want to drive a bus, you need a Class 2 as a bus is over 4,500kg but < than 15,000kg AND a P endorsement as you carry passengers for hire or reward. Amublance has an exemption which means they do not require a P endorsement and as such, are subject to "private" medical standards. That however does not mean you will be put on the driving course, I know somebody has to approve it but I largely believe the test of fitness relies upon the driver licensing system. While Australia's licensing system places Ambulance under what is called class LR (or light rigid) it is not subject to CDL medical standards; however, many services such as ASNSW and AV choose to hold all applicants to CDL medical standards as a cheap and effective way of getting around the loophole in the system. I think we should do the same. Standard drivers test.

Upon closer examination it appears the goal of teaching abdominal palpation at our BLS level is simply to document whether the abdomen is soft, tender or gaurded (either uniformaly or over an individual area). Now I might be a lil' bit niave but I don't see anything of major intrinsic value to the Ambulance Officers' treatment of an acute abdomen but it gives the hospital a few clues to start with anyway.

You're sent two suburbs over to pick up Charlie fron a walk in medical centre and take him to the hospital. - 84 year old male complaining of severe SOB - Immeadiate hx of feeling sick for 5 days, no significant prior history - Looks sick; pale, sweaty, nauseous, feels fluey, markedly increased work of breathing - HR 63, RR 24 laboured, mid & basal crackles, speaks 4-5 words per sentance, temp 38.5°, ECG new onset 1° AVB with bigeminy PVCs - No meds, NKA The doctor is trying to find some chest films he took and it'll take a minute or two. This is a two part scenario: a) BP is 96/86, how do you treat? a) If BP was 136/96, how would that alter your treatment?

You spelt New Zealand wrong but I'll let it slide Except us, I've spent many hours at the comfy station watching telly and sleeping on the couch.

Jack Stout would be proud.

..... but you're taking all the FUN out of it; I may as well go back to Reno, at least they have an arch

I personally believe a few things Ambulance Officers at the BLS level do are of only extrinsic value as they aren't taught very much about them. I know I've examined patients and noted something down but I have no idea what it means or how it might be clinically significant. The clinical knowledge of the registrar in the emergency department would leave me for dead when assessing somebody with abdo pain because he knows more than I do. Likewise, my clinical knowledge when assessing a cardiac patient would leave one of our BLS AO's for dead because I know more than is taught in the BLS cardiac course. All I can tell the registrar is "this patient has pain upon palpation over the RUQ and hasn't pee'd in a day"; to me it means very little and I might be able fumble my way through whatever diagnosis they give; an ambo who hands me a rhythm strip and says "it doesn't look normal Ben, this guy has some pretty bad chest pain" might not know what the rhythm is, I can look at and go 'aaaaaaah T wave changes with PVCs". Even if the ambo who is poking and prodding me doesn't know all the endocrinology in the world, they can at least pass it on at handover. Might mean nothing, might mean something .... Probably makes the patient feel better too!

Standard of care, duh. When I went to the hospital with a sore tummy and puking up nasty green stuff the doctor poked and pressed and prodded and percussed my abdo, I would expect the same of any ambo. Our BLS level officers are taught Ryle's answers, palpation, percussion and asc....oscil....auscul....eh whatever, listeng to the abdo with a stethoscope.

New Zealand has just developed a new BLS level qualifcation called the National Diploma in Ambulance Practice. The didactic theory component of this course is run online through Moodle. It consists of 6 weeks medical, 6 weeks trauma and 2 weeks of core skills learning online and 21 days in the classroom doing practical skills and some revision. Clinicals are spread out over a varying length depending on how quickly you compile the required mentor reports, skills log, research and case log. One service here runs the Diploma about 9 months part-time but it's not unrealistic to complete it sooner.

The Class E license was obtained by holding a Class B (car) license and passing a CDL medical, like your class 4 (or Class F in Ontario) or the green DOT CDL card required in California. It was dropped in 1999 when we introduced photo driver licenses and moved from 15-20 types of licenses down to 6 classes. The new classes are based upon weight and not vehicle type. Because an ambulance weighs under 4,500kg it is considered a Class 1 vehicle which is subject to "private" medical standards. A passenger endorsment requires passing the full Class 1 practical license test (unless sat within the last 5 years), a CDL medical (the same standard taxi, tow truck and heavy tractor-trailer or commercial vehicle drivers must pass) and a police check. They are not hard but the cost is extremely prohibitive ($500 up front to obtain and then again every five years to renew) and it is not a cost the ambulance service is prepared to meet for every volunteer ambo because it would cost literally over a million dollars. If I had my way, we would reinstate the P endorsement requirement for ambulance.

We used to have a Class E license for emergency vehicles which was the same medical standard as a CDL (required for heavy vehicles, taxis and tow trucks). This was the same as the green DOT medical card California requires for it's ambulance endorsment. Ambulance is now covered under Class 1 (standard light vehicle) and is subject to "Private" medical standards, which have significantly more leeway for exemptions and waivers. A "P" (passenger) endorsement, which is subject to CDL medical standards, is not required for Ambulance as the cost and process of obtaining one is seen as prohibitive and a disincentive for volunteer recruitment (it costs around $500 for said endorsement, which a 5 yearly cost). Just because one legally holds the required license to drive an ambulance doesn't mean the employer will let them, it would be at their discretion. The Fire Service require Class 2 or 4 for thier trucks because of the weight (anything over 4,500kg or 10,000lb requires a Class 2 and anything over 15,000kg or 33,000lbs requires Class 4). Both these are subject to commercial medical standards.

I agree with what you are saying mate, although we could also argue if you're running out this guys volume over an extended period (say an hour or two hours for transport) is that going to be worse? Well, then again, whats worse, dehydration or death?

Summer of '69 - Bryan Adams