Kiwiology

maybe if we don't pay tax the hospital doesn't get any money?

You were the treating officer of record, tell yoru boss to get bent I say.

orignal interpretation deleted won't let me insert a spoiler

Tell me you guys don't still transport arrests, let alone traumatic arrests. Yeah that's um, kind of bad ..... Let me plays devil's advocate for a moment. Given the current divisions between (in the US) what "basic" and "advanced" are I think there is a definite need to seperate the levels of intervention that can be provided. The media is not our friend here when it comes to portarying EMS as being staffed with "Paramedics". I mean nothing personal y'all but I just shake my head and wonder when the US will come up with a system that isin't stuck in the dark ages of 1912 like the class divisions on the Titanic; where we have 120 hour "basics' who aren't even trusted to carry and administer nitro or take an ECG yet Paramedics who have 600 hours of education can potentially be out there doing rapid sequence intubation. Personally I think it's sad.

Can we be of assistance some how, a few Kiwi's around here

I think EMS needs to pull its head out of its arse. We take away, add or change procedures, practices and processes because they are of benefit to the patient (or not -- as the case may be). In my lifetime we've gone from shocking the heck out of people and pumping thier coded ass full of lidocaine, bretylium, atropine, adrenaline and sodium bicarb to lots of CPR and maybe a shock every second cycle and using only adrenaline and amiodarone. We no longer use the MAST pants for autotransfusion in hypovolemic trauma patients, nor do we run fluids wide open through two 14gu. IVs. Gone are the days of giving naloxone and 50% dextrose to every guy we find down and out on the sidewalk. All these things have changed because they have found to be in the best interest of the patient, remember, that person who we are treating and supposed to be helping? While the numbers may or may not be shady given the research methods of this one particular paper; if intubation is not found to be in the best interest of the patient then we shouldn't continue doing it! Bledsoe had it right when he said too many people are in EMS because it's "fun" .... well not intubating people may not be "fun" but if that's your perspective get the hell away from me!

Somewhat, yes. It seems we are taught a little about a lot. I would argue that no, we are not doctors or nurses, depending on where you go EMS has a larger scope of practice and less education than an ED RN (which strikes me as rather odd) but that to restrict onself to the required knowledge of the DOT curricula is (personally I think) rather narrow minded. Now, some widsom I was imparted: It's great to have all that knowledge about A&P and patho and pharm and whatnot but remember, it changes very little about what you auctually do for the patient; keep it simple and be quietly confident that you know the what and why but don't forget the how and when or you will get yourself into trouble out there.

call the fire dept they are good at this sort of thing

Check out Magen David Adom I did some Googling and they look like a serious system, well set up

Advanced life support requires performing increasingly omplex assessment and treatment (often on persons with many co-morbidities such as [N]IDDM, asthma, COPD, cardiac problems, obesity etc etc) where there is exponentially increased potential for catastrophic and fatal harm to be caused through substandard practice. Example: PubMed lists two cases where adenosine was given by paramedics for symptomatic AF, the patient went into asystole and died. Now, does that not strike you as odd? Hmm, diagnosing AF vs. SVT .... see what I mean? Practice must therefore be linked back to a wide knowledgbase of anatomy, physiology, pathophysiology/etiolgy, cardiology and pharmacology with the ability to reflect, critique and improve upon practice through self-directed quality improvement and research based upon evidence based medicine. Now to put that into terms we can relate to the real world (blasted real world, why must you constantly remind me that I live here? ) is that you need a good education. I am surely no expert on the DOT Paramedic curricula or how it is taught but I've seen some fairly shady classes out there on the net. At one point I thought I was pretty hot shit because I could recite protocols off the top of my head and knew how to perform them, now, I quickly got bought down to earth when I took up some college science classes because I realised I knew sweet F/A and just how important getting as much knowledge as you can is! My suggestions are as follows: Do: Take college level A&P (with lab), pharmacology, pathophysiology, English and math. Do it because: You will learn far more than is probably required by the DOT curricula and this will lay the foundation for practice and quality improvement. I'm talking proper, nursing level (if avaliable) A&P, patho and pharm not those "fundamental" classes taught for Paramedics over two weekends. The DOT states the biggest problem for Paramedic level students is lack of grasp on english and mathematics and I'd believe it! Do: Get the list of A&P objectives out the Appendix of the NHTSA/DOT 1998 Paramedic curricula and answer them Do it because: It'll reinforce all important knowledge! (It's a fairly big list, I was quite impressed) Do: Take a college level research methods paper Do it because: You will be running into journal articles and research and "evidence based medicine" in your medical audits and QI stuff as EMS begins to focus on it more and more. Knowing how to pick apart a research article or journal paper is important because often a lot of shady and misleading numbers can be slapped together and make something we do look bad (look at the skermish about intubation a couple topics over) Do: Look around eMedicine, PubMed, ScienceDirect etc for articles and journal papers on things you want to know more about Do it because: You will gain a better understanding and wider perspective on what is practiced and why it is done Do: Learn 12 lead ECGs to begin with Do it because: You will also learn how to interpret a 3, 4 or 5 lead ECG as well so in the event your service doesn't have 12 leads yoiu won't be at any disadvantage; and if you get 12 leads it won't be an extra learning curve Do: Stay the hell away from cookbook, accelerated or unaccredited programs Do it because: You are doing yourself a disservice by getting "minimum" education! Now, as for textbooks I have used the following and found them to be excellent! - Marieb & Hoehn: Human anatomy & physiology (7th Edition) - Lippincott's nursing series 12 lead ECGs (little brown book) - Walraven: Basic arrythmias - Lehne: Pharmacology for nursing care - Springhouse: Pathophysiology made incredibly easy - Bledsoe, Porter & Cherry: Essentials of paramedic care (note you have to supplument this with the other books as it's often superficial) Hope this helps!

I still think it's bonkers .... I knew we needed more practice working cardiac arrest, so is that how the UK gets it?

Dude that's funny I agree 100%

New Zealand is simmilar to the United Kingdom (after all, for a century or so we were thier bitch and hey lets not forget where all you American's left to get away from, but you just hide it better than we do what with the Revolutionary War and all) We operate a mixed Anglo-American/Franco-German model whereby practically out in the street we are completely autonomous and have no "medical control" to speak of; we don't have to call the hospital and ask for orders. We are responsible to an in-service medical director for our actions and clinical practice. Unlike in the UK (or the US to a lesser extent) we are not responsible to any Governmental body for our practice, ambulance officers' here are not registered as a healthcare provider (unlike in the UK) but we are working on it, slowly. Education here is varied and follows both the "in-service" model and the University (UK/Australia) model. Most states in Australia only employee degree graduates (NSW and Qld. being the exceptions I believe). In-service education is fairly good but is not as thorough or diverse as the University system (mainly because the service must compromise to allow achievable education to be avaliable to the volunteers). Anybody here who wants to become an Advanced Paramedic (ALS) must compete the University degree (or parts of it, if they are already a Paramedic (ILS) as they recieve cross-credit for the rest). As for drugs, scopes of practice and protocols these are not standardized between services but near enough. The scopes of practice and titles are different but only slightly; for example one service here (Wellington) allows ALS to thromblyse whereas the others do not (St John is conducting clinical trials at the mo). Our drugs are on one hand good and ther other bad; only one service (Wellington, again) carries adenosine, corticosteriods (hydrocortisone), anti-histamine (promethazine) and CPAP but we (St John) carry ketamine. Our scopes very different from the USA; our "basics" (ambo officers) can give GTN, glucagon PO/IM, salbuatmol, oxygen, entonox/methoxyflurane as well as insert an NPA, OPA and LMA. Intermediates (paramedics) can manually defibrillate, insert IVs and give NS/10% dextrose and soon (this is currently a level above) give adrenaline, fentanyl, metaclopramide and naloxone. I am suprised the UK does not allow for cardioversion.

Yup I'd say so. A quick review of PubMed evidence says that survival (but not necessarily outcomes) are better if we prevent hypotension (i.e. promote cerebral perfusion) and secondary brain injury (but interestingly intubation to prevent hypoxia was not mentioned as being of any benefit, or, made outcomes worse). Interestingly one study said that TBI patients treated by EMS show increased signs of stress markets e.g. glucose and lactate, hell, dare I say poor treatment provision? I think numbers are very subjective; one Austrian study said > 110mmHg, we say 120, I've heard 80 or 90 and everything in-between. Not sure if a number game is the best path to follow here but I'd be lying if I said I wasn't reaching to think of some marker of adequate brain perfusion that we could use instead of BP beyond say, good basic vital signs, SPO2/ETCO2 (airway dependant) and lack of posturing or tachycardia .

I agree!

Paging Eugene Nagel, paging Dr. Nagel, Dr. Nagel .....

WTF!!! What the hell kind of operation are you guys running? In a system that large (Miami-Dade ~ 2.4 million people) a Paramedic is averaging ONE intubation a year? Last I heard we were getting about 1 intubation a week per advanced paramedic in the Auckland metro area (pop. ~ 1 million) Heck I'm not suprised this data was so bad ...

Here if the New Zealand study on intubation/RSI (although tis is a bit old, I'll talk to our medical director and see if we can get some better numbers) http://adhb.govt.nz/trauma/Forums07/prehos...ehos_intub.html Questions that come to mind: 1. If we remove intubation, what do we replace it with to deliver definitive (?) airway control? and 2. Do we need more airway control beyond what a King airway or LMA can provide?

Now there is a dandy notion that might just have some merit

Well that brings new meaning to the alternate names for the LMA i.e. "fanny gag" or "lesbo lollipop" huh????

I think Vent is right ... oh if Eugene Nagel could see Miam-Dade Fire now. Look at the skills that EMS has thrown out over the past decade as the evidence has not supported them (big fluid volumes, MAST pants, etc) and I think perhaps endotracheal intubation will go this way. In saying that I am not totally convinced even though some of what I've seen presented in the journals is either negative or neutral (I did see one positive study a while ago). For RSI (which is a very controversial topic here, the studies have been abismally negative from what I have seen) Here in New Zealand endotracheal intubation is still a skill taught to and practiced by our Advanced Paramedics (ALS) although I don't know at what frequency or with what success rate; perhaps could be something we could look at studying. Beyond the OPA and NPA we use the laryngeal mask airway (LMA) and although I don't have any hard data to back it up I personally believe it's a cheap piece of shit because the mask only partially seals the laryngeal opening of the pharynx and gaining a seal can be difficult in a patient with high airway pressure. Perhaps we should be looking in-hospital at practices around airway control there. I know of some systems where only RTs and anaesthesologists are allowed to intubate (i.e. it's been taken away from emergency physicians and nurses) because presumably they are doing it at a high enough rate with enough success to be of some benefit. Some EMS systems seem to follow this logic around ALS (such as Tulsa, Boston and Phoenix; restrict the number of Paramedics to ensure high skill utilization and relative success; there was a big writeup in USA Today about it a while back). I know that in the OR the LMA is quite popular (BUT in saying that, they have better monitoring and patient control). So the question remains do we take away intubation or say, give everybody bougie's and video laryngascopy or something heck if I know but that also begs the question ..... do we need to be intubating people in the first place? I believe we need some form of definitive airway control but as to what that is, I'm not sure.

The negative deflections point me to some form of bundle branch block meaning the electrical impulse is travelling in a different direction than towards the positive lead (creating positive deflection). I am also seeing some ST elevation in II, III, aVR, aVF

The travel to Fiji and mozzie bites are probably unrelated; although it's hard to say. So I'm told. As I read this I saw ... mainly asymptomatic patient with normal vitals signs, sore throat/feeling like he has the flu and recently got back from vacation. I was ready to chalk it up to some infection, call him non transport and recommend he go see his family doctor, get back in the truck and drive to the station to lie down on the couch. Then I looked at the cap refill of > 3 seconds and all those nasty, ugly purpura and I thought something was a bit odd ... I honestly had no idea what to call it ecept probably early consepmatory shock so OK might have to transport him .... couch is not very comfortable anyway.

From what I understand this is a case of meningococcemia which is a form of septicemia not meningitis which is why it's not producing the classic meningitis symptoms - headache, stiff neck, photophobia, N&V etc