Kiwiology

Now for you out in the sticks it may be different as onset of action is generally 15-30 minutes IV In what situations do you think frusemide is appropriate?

I have seen people using thier cellphone stopwatch for taking vital signs ..... so I guess we could be that cheap eh? Personally I am a fan of Casio G-Shock, had one for five years and it works a treat

That course sounds introductory in nature, which is better than the ten pages of A&P in your basic EMT textbook however may not be as in-depth as A&P I and II. My A&P course was a component of the Bachelor of Nursing (BN) and covered all body systems plus ECG, ABG, basic biochemistry etc over 13 weeks. If you could find something like that it'd be fab. I also recommend Marieb 8e A&P from Pearson-Benjamin Cummings; we used that textbook and it's just absolutely fab the DVD and online materials are great.

Absolutely!

I don't support lasix pre-hospital; it might have been a good treatment a decade or two ago (but heck so were M*A*S*H pants (MAST) and prophylactic lidocaine right?). A patient with a CPE is going to be third spaced and may infact be hypovolemic, so if we dose up him on lasix he's going to piss like a racehorse at the Kentucky Derby and deplete more volume. We also run the risk of causing him to become [more] hypokalemic or hyponatremic. Differential diagnoses is also really important and something I anecdotially hear a lot of medics are pretty bad at; it doesn't take a rocket scientist to work out a chest infection from a CPE yet apparently it's out there! The Los Angeles study cited includes differential diagnoses of LOWER BACK PAIN and HYPERVENTILATION as those who may or may not recieved GTN, laxis and morphine as the Paramedic assessment was a CPE. Does anybody see the problem with potentially loading up somebody on these drugs, and, more overarching, working up LOWER BACK PAIN as a pulmonary edema? It's 5am here and I tell you what in my semiconscious state, I can differentiate a CPE from wait for it, LOWER BACK PAIN! Now, where did I see LACoEMSA pull frusemide from lately, ah yes, Los Angeles .... suprised? I'm mixed on morphine use in CPE. Now I did see one study (retrospective) on CPE outcome in hospital where ambo had dished out morphine but it was poorly designed and I bet was riddled with false positivies. http://www.ncbi.nlm.nih.gov/pubmed/18973635?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=18 http://www.ncbi.nlm.nih.gov/pubmed/19234030?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=14 These studies suggest it may infact be of harm and not benefit. I was educated that morphine is not an effective treatment for CPE and is used for relief from anxiety and (possibly?) some of its bronchodialatory effects but I bet you there's better bronchodialators out there than morphine, salbutamol anybody?

Sounds like the ambo involved knew full well she was not doing what she should have; it's kind of niava to say oh here is my number, but don't use my name! Like hello, you're on a recorded line and its not like we can't just tap that number into the computer! Talk about your Metrowreck! (NYC 911 is at the Metrotech Centre, just on the Brooklyn side of the BB)

I have as many as people want. Anybody who wanta a copy please PM a a physical address that I can send it to

Anybody who wants a free, yes, FOR FREE, "Consolidated Resources for Ambulance Paramedics" DVD PM me an address Contains multi-format stuff, PowerPoints, video, audio, PDF etc -Practical aspects of ALS care (lots of great tips at all practice levels) -Chest Auscultation -Concepts of Mobile Intensive Care Paramedics (gives a fantastic history of ALS and US EMS history) -Clinical Problem Solving, -Respiratory Anatomy/Physiology -Cardiac anatomy -Chest pain -ECG review and quick print guide -Random drug questions Many Powerpoint files... -Including IN Fentanyl, Dexamethasone, Needle Decompression etc It's just a really great resource.

Try FDNY Engine Co. 54, I forget exactly where it is, somewhere around Times Square maybe .... good fellas. I also forget if it's Engine Co. 54 or Ladder 54, I think Engine, eh, I dno, Batallion 9? Sounds about right .... anyway they always stand out from and talk to random people walking past. Had to laugh at the sign on the door which says "don't enter station to report fire when company is not in quarters, nearest alarm box ...." like you ever hear of 911?

Interesting point. Our Police call-takers and dispatchers are the only ones not to wear a uniform and that is purely because in order to wear a uniform with "Police" written on it requires you to be a sworn Constable, apart from that Fire and Ambulance both wear uniforms. The Ambulance EMD uniform is generically indistinquishable from the ambo's except if you look hard enough it says "Emergency Medical Dispatcher" on the patches as opposed to AO/Paramedic etc and St John has epaulettes which say "Communications" instead of "Ambulance", but I do believe they are being removed in favour of ones that just say "St John", probably a bright idea of some marketing twit. Our EMDs do a generic advanced first aid course as part of thier induction, but interestingly enough it does not carry a "scope of practice" and has no CTP/ATP issued as part of it. Legally they don't get an ATP and as a result they are not able to use the clinical procedures so I'm not sure how that would work if they ended up in a situation where providing some form of physical patient care was required. I immagine they would simply be acting as a layperson using thier first aid certificate. There has also been (as part of a uniform review over the past 12-18 months) the issue of people who sell sundry shit for the Johnno's wearing the same generic uniform as Ambulance Officers and problems around them being mistaken for ambo's at MVAs etc. <insert vehement displeasure at a "generic" operational uniform here, if not already alluded to> In the past Ambulance/EMD was white unders with dark blue on top and maroon eppaultes (which didn't look too bad truth be told) while other frist responder/events were black/white and Education was .... green? I think. This created a clear distinction between who was who however was abandoned in the early 2000s, in part to rid out the cultural divide you speak of. We could sit here and argue uniform semantics until I am hypoxic and pass out but I think the larger issue at hand is that what these guys did was inexcusable and makes me puke.

This is exactly what I wanted to see (or not see really) and why I put this up. Everbody is all bug-eyed about croup and oh lets give him adrenaline, well lets give him salbutamol, lets intubatge, naaaaah lets give 'em bloody midazolam! I'm not knocking you guys for this because when I got this presented to me by a Clinical Standards Officer I was like well he's got a history of croup, he's severely short of breath, one and one make croup. Truth be told the kid had been left alone for two minutes playing with the lego and he choked on one. The crew in attendance went with croup, tried adrenaline nebules that didn't work and while doing another round the kid arrested, they ended up doing a cricothyrotomy which didn't work and it all sort of went down hill from there. When we look at it in retrospect it all makes perfect sense; in the two seconds little Billy was left alone with the lego bricks what are the chances of him developing lift threatning severe croup with no history of being unwell? None! The crew got sucked in, I got sucked in, most of us here got sucked in and right from the outset of the job when the EMD asked if the patient had any PMHx the words "severe croup" cropped up and everybody just went with that, never mind tip the kid up by his feet and a quick whack on the back probably would have expelled the obstruction. Moral of the scenario is dont get sucked in, or just dont do peads calls Merry Christmas

Lets go back to basics - what could it be? I would suggest we do something pretty quick befofre this kid arrests; we've probably been on scene for 10 minutes, total time since this kid started having hypoxia is maybe 20 minutes

No Afebrile No You try 5mg nebulised adrenaline to no effect.

No and no. ALS (MICA) has been redirected to a cardiac arrest, a solo responder is being recalled from the city to come out. His ETA is six minutes. The hospital is 15-20 minutes away.

1) Welcome 2) If you run into a bum on Fisherman's Wharf who claims to be an ex Firefighter/Paramedic, he is Tim, great guy. 3) If you are called to an unshaven male who has been living at the airport for several days and is now seizing, that's me. Be liberal with the ~az~am's, heck, midazolam, diazepam, lorazapem, I don't mind! 4) Education is important. Get some college A&P, pharmo, English and pato under your belt! 5) Again, welcome. Ben

What do we normally do for laryngeal edema? Like we've said, this kid is pretty crook. Is there anything else you want to do, or ask the teacher?

MICA (ALS) are battling traffic, they have a three minute ETA; would you like some Firefighters instead?, they are getting bored watchin telly and playing boggle. ~ Low eighties More than you can shake a stick at The patient is still breathing at the moment Yeah, why, want some Ceftriaxone too?

You arrive to find eight firefighters already on scene in all thier getup, 6 are standing around doing nothing, 1 is attempting a blood pressure and the other is trying to turn the oxygen on. Oh wait wait wait, what am I saying, we think logically down here, so scratch that, they're back at the fire station where they belong watching telly and playing scrabble. Patient is a 4 year old male in severe resp distress. BP 110/P RR 30, laboured, sig increased work of breathing, acc. muscle use (back/neck/trachea/costals) PR 130 BS Rasping cough, high pitched stridorous sound insp/exp, sounds diminished in all fields The teacher keps on screaming about how the parents said he has a history of severe, life threatning croup. This is a real job, I am interested to see how we approach it.

If you have participated elsewhere please don't spoil. You are sent to a prision for children who's parents are out chasing the Capitilist dream daycare centre for a child with severe life threatning croup and a history of same. Hospital is 20 minutes, Intensive Care/ALS is following, ETA is 8 minutes. Response time is 6 minutes.

You do realise that in contrast to PCP in Ontario, which you know is a two year course from the first world, the entry to practice standard in the US and esp. in CA is like 120 hour course that teaches you some advanced first aid and how to use an AED? It's going to be difficult if not impossible to get reciprocity; I rolled up to LACoEMSA in Los Angeles and was told "well your training doesn't fit Basic (too advanced) or Paramedic (not advanced enough) so you will have to start all over again at Basic". California has a proud history of the local taxpayers saying well, we have to pay for a Fire Department and a Police Department we don't really want to pay for EMS as well so what happened, in comes the Fire Departments they get a medical director and a few drugs; go to the break room and say right you, you and you, go to Paramedic school on Monday. Hence why California is still a heavily restricted "telemetry" based state where you have to call for online orders for most things, some are better than others but it's a very 'mother may I?' system and most of the jobs are for crosstrained, dual role Firefighter/Paramedics. My two cents are go back to Canada.

I'd love to see how long people wait in ED to be treated, like if we said on the phone "oh your condition is (immeadiate/urgent/non-urgent) the ambulance will be there within X" people freak out and say "oh but it's an emergency!". Well you go to ED and tell look at you and say, go sit in chairs the nurse will be out when they can. Nana who goes to ED with a good story, history of CHF and eh, sort of SOB but few crackles will probably wait what, 30 minutes? If that job comes down the pipe to ambo it's immediate priority one, lights and sirens off we go! See the disparity? My bet is that this "poor response time" blowup is to whip up a bit of fear and get some more money. Here's what I'd like to trial: Immeadiate life threat - Category red, ten minutes 90% from time of dispatch - Cardiac or respiratory arrest - Choking - Life threatning asthma or anaphylaxis - Undifferentiated chest pain with no cardiac history - All trauma that is not "obviously simple" - etc Potential life threat - Category yellow, fifteen minutes 90% from the time of dispatch - Chest pain with cardiac history - Uncomplicated known seizure patient with single seizure < 5 minutes now stopped - Known diabetic history that is altered but no recent history of non compliance - etc Unlikely life threat - Category green, thirty minutes 90% of the time - Isolated trauma - Flu - Controlled, minor bleeding - The "not sure you should be ringing us but we'll see what we can do for you anyway" crowd Five Key Questions - Address - Phone number - Is the patient conscious (NOT "is the patient completely awake?") - Is the patient having difficulty breathing (NOT "is the patient breathing normally?") - Has this happened before? The goal of the category green's would be to funnel them out of having to send the ambo's and having some sort of alternate referral pathway.

Let's be objective and clinically rational here. 1) The public deserve, expect and are entitled as a) people with basic human needs and b ) tax payers, an acceptable standard of response and care 2) There are few (and we're talking fingers on one hand here) truly life-threating, time critical emergent cases that justify zipping round lit up like a Christmas tree playing Traffic Twister. I think personally you aren't going to die or have significantly increased M&M in 7:59 (or applicable response standard) unless you have: - Cardiac or respiratory arrest or near arrest (things like your life threatning asthma, anaphylaxis, poorly perfused VT, epiglottitis, croup, significant APO/CPE) - Choking - Seizure (clonic, tonic annoxic event type seizures) - Uncontrolled exsanguination / shock Nana with known history of CHF who has a few basal crackes eh she's a bit unwell but the kid on the ground who is unconscious and contionously seizing is pretty crook and that should be first priority but does not mean we have to drive like Juan Pablo Montoya!. Although we can be cold and clinical and say "you are not dying" we must also consider M&M, splinting, analgesia etc and good quality human centred care which people deserve regardless of be they a crank addict with no nasal septum and a history of seizures, hypos and getting into fights or not. Response times are a good way of whipping up public and funder fear and getting a bit more money out of the Government when infact it's probably a symptom of a broken funding system or a system built on half-truths and conjecture - just look at the UK and it's obsession with "call connect". They are required, however, are not probably clinically significant in terms of M&M if you have the right level of response in place and we don't get all zany and say "well, half an hour is acceptable". Nor should they a bearing on budget (I come from a country with universal, public healthcare so the budget of the Ambulance Service is largely derived around compliance of key performance indicators as opposed to degree of payment by private insurance) if anything, poor resoinse times should be a reason to increase funding and resources not take them away! We must be very careful not to lower the response standard as this will increase morbidity; the trauma patient who has to wait longer for pain relief, nana on a cold floor with a NOF who has to wait longer to be picked up, the parents freaking out coz little Timmy skinned his knee and they don't know what to do etc etc etc.

I hear that's your best feature mate! Um, oh dear, that came out wrong ..... hmm, I, er, um, I'll just quit while I'm behind I really am no good at this ....

This is just blatantly abhorrent and I am disgusted that they did nothing but get thier coffee and donuts. You know this isin't the first time I've seen something like this on here and may infact not be the first incident involving FDNY*EMS to be mentioned. I bet if they were sitting in thier truck eating bagels and some dude rolled up and beat on the window because he'd just been shanked they wouldn't say "go call 911 mate". Absolutely discraceful. ... and what, Nicholas Cage and that black guy Marcus in 6-2 Young weren't free?

I do remember one Christmas when I was given the gift of being told I'd ruined the family, FML