Kiwiology

LFT normal CBC normal ETOH neg Lactate is 7mmol/l (normal reference range 0.5-1.0mmol/l) Normal Fe You muppet, 37 is mg/dl which is approx 1mmol/l; for your interest mg/dl > mmol/l is /18 and mmol/l > mg/dl is x18

Mike, stop being over welcoming or it's back on the FRU for you!

Internal bleeding is not an unreasonable differential diagnosis Fingerstick BGL is 37 (~1 mmol/l) No DKA or consitpation Has been complaint with his medications as far as it seems Since y'all have access to the clinic what bloods or additional tests would you like to order? NB I shouldn't have said he was alert + orientated; he is rousable to voice but not orientated

All UK ambulances have a tail lift for the stretcher as well mate

Think you can swap to one of these if I drive? Red base, November 100 available

Are these devices common in the US? I've never seen one here, and nobody I know has ever seen one, except on Grey's Anatomy. The only facility in NZ which could handle something like this would be CVICU at ACH (Auckland) and even then I an educated guess is that the number of people receiving them is extremely, extremely small

Fine, but it may involve some work on the FRU

Dude thats some talent you have, perhaps you might even be able to make me look photogenic!

There are many wonderful people on the internet that are exactly who they say they are, a few of whom I have met in real life and have established significant friendships with, its just another way to meet people I suppose Then there are lying pieces of trash who destroy your faith in humanity, like this bloke

Well it's late and you're stuck in Small Town Jericho, a little haven for us pick up loving, contemporary country music playing, pro-gun ownership conservative Christian Republicans about a yonder from civilisation. You're called to help out Tim, a 70 year old male who has been found by his daughter-in-law in the lounge chair very confused and lethargic. She stopped in to check on him before going to bed as he usually hurls empty beer cans at the telly while watching the late shows before going to be about midnight. PMHx DM, HTN, AF, CABG w/ stent 2005, anaemia, alcoholism SHx lives with wife who is away for weekend, smoker, drinks heavily, trying to cut down due to financial difficulties, rehab for etoh 2004 Meds insulin, metformin, warfrin, iron, coradone, inhibace, frusemide Today - awoke mane, ate breakfast, quiet day at home, dinner ? 7pm, found in lounge 9pm C/C feeling weak, abdo pain diffuse all quad, constant dull aching pain 5/10 began suddenly 1/24 ago, no back pain O/A in lounge chair, alert to voice Physical exam Neruo - alert + orientated, rousable to voice, PERRL, neg FAST, CN OK, peripheral neuro OK, no neuro symps Chest/resp - CABG scar, no trauma, respnormal, trachea mid line, good air entry, lung sounds ok, no crackle or wheeze, no tactile frementus, percussion normal Cardio - pulse reg + strong, pedal pulses present, tachycardia, S1/S2 OK nil added, no edema, no JVD, JVP 3, ECG ST Abdo - tender, painful to palpate all quads, percussion painful, not distended, no discolouration, +BS Extremities - ok, no clubbing or cyanosis, sunken eyes, very dry VS R23 P120 BP 180/130 SPO2 98% RA T 37.5 (~98 F) There is no Doctor at the local clinic so you're it tonight and unfortunately the helicopter cannot fly nor can the ambulance transfer out to Sugarland Regional in Big City. What are you going to do with this bloke and what do you figure might be wrong with him?

Intubating cardiac arrests? Using screw together preloaded drugs? ... sigh

Peptidoglycan is nowhere as brain-box melting as liposaccharide And bro, I was taking the piss, we've been through this before

I'm not trying to be a prick here mate; it's all very well to hand out some little pills to people but do you (figurative you) know the difference between Gram positive and Gram negative and what it actually means? do you know your macrolide from your cephlosporin or coccus vs vibro (no, not that thing by your ball bag or what your wife uses when she is thinking of me .. sick fuck get your mind out of the gutter) ...do you know your pathogenicity from your virulence and so on ...

LOL! Never underestimate the wonders of the high tech ambo blanket! Are yours still red like they were years ago?

Bloody hell thats a bit rubbish waiting three hours for backup!

But Dwayne since Rob died who is going to keep reminding you of that all important fact if nobody says it? I mean I know you know it already and it kills you a little bit inside each and every time we foreigners talk about how fucking awesome our systems are (actually our system sucks, did I tell you that? Because it really does...) I think you need significant changes to reimbursement and education to make it work. If Medicare and insurance pays you for assessment rather than transport and your people are educated enough not to leave people at home who should not be (even we're not perfect at it) then yes, it could work quite well. The ability to filter people out of the response grid at time of call is also a good tool like the Clinical Advice Paramedics in London who take green category calls (MPDS alpha or bravo) which would normally wait a couple of hours for a big yellow box are now given telephone advice or referred to their GP or NHS Direct. We have a similar program where very low priority calls are screened out and sent to Healthline. All of our ambulance crews have the ability to leave people at home or refer them elsewhere e.g. GP or urgent clinic. It is not about having a fancy bag of tricks i.e. being able to do more it's more about being able to send the patient somewhere else more appropriate than the emergency department. Take a look at the CARE Program in New South Wales http://www.changechampions.com.au/resource/Katie-ODonnell.pdf

Keep an eye out for Kiwi; he's a crazy funny talking person who knows way too much for his own good, has had a few short circuits in the brain box and view the world in a somewhat upside down perspective but it might be something to do with location? I agree with Mike - speeling and grammerz are very important on this forum, it goes a long way to present yourself as a professionally educated person capable of putting forward a logically structured, well rationalised and properly presented post. It'll also help you get little green reputation points (like mine!) so one day you can be as awesome as me! All of use (especially me) have a vested interest in the development of Paramedics as health care professionals who are more than loser cookbook medic trash and will do all we can to support your learning and growth, we don't answer homework questions outright and will challenge you to do your own research to show us that you are trying to learn rather than asking for the answers without putting in any effort. We have many, many extremely intelligent and experienced people here from all over the world who bring their unique perspective to the table, please respect and make use of us. If you don't mind sharing we'd love to know what sort of Paramedic program you going through (Fire based, private (e.g. NCTI), college degree etc) and where you're based at (even if it's just the state or country). Above all, welcome, and once again, watch the bloody hell out for that Kiwi bloke, oh and Dwayne, nobody likes him

Once I am fully qualified I'll seriously consider it Yes hello I am Kiwi, this is Craig, but nobody likes him, now love how long have you had these pains in your chest?

Last I heard was median is just over one RSI per week Without RSI I'd take a guess and say maybe each Intensive Care Paramedic intubates a dead person maybe once a month? It might even be less and it would not surprise me if it were. Since 2009 we've been actively discouraging ALS people from intubating without medicines as the mortality rate does not appear to be changed by intubation and if a well working LMA is in place then why change it over? No failed RSI patients have required cricothyrotomy A "failed" RSI here is extremely rare (2-3/100) and a "failure" here is defined as - unsuccessful after two attempts at intubation, or - unable to visualise cords within 15 seconds of laryngascopy, or - unable to intubate within 30 seconds of laryngascopy, We can RSI patients with "poor airway and/or breathing" who have a GCS of less than 10 be it of medical or trauma aetiology. Most of our RSI patients seem to come from trauma, but others include post cardiac arrest, stroke, poisoning, pulmonary edema etc I think there is also a role for anaesthetising and intubating the multi-system or severe trauma patient who does not have a poor airway or breathing in selected circumstances where otherwise gaining adequate analgesia to enable the patient to be treated and transported is going to be very, very difficult. Again this is something that the Doctors on London's Air Ambulance do now and again it seems. Our Intensive Care Paramedics respond individually, you may get two ICPs at a job but it's certainly not common unless the patient is very unwell or heavily trapped. Here's what a Paramedic vs. Intensive Care Paramedic can do Paramedic OPA, NPA, LMA, PEEP, tourniquet, 12 lead ECG interpretation, defibrillation, cardioversion, NaCl 0.9%, aspirin, GTN, salbutamol, ipatropium, glucagon, 10% glucose, ondansetron, loratadine, entonox, methoxyflurane (where used), paracetamol, adrenaline, amiodarone (cardiac arrest), ceftriaxone, morphine, fentanyl, midazolam (seizures), naloxone Intensive Care Paramedic Paramedic + intubation, intraosseous access, cricothyrotomy, chest decompression, pacing, atropine, adenosine, amiodarone (fast AF or VT), ketamine, midazolam (sedation), vecuronium*, RSI (selected Officers only) * All Intensive Care Paramedics can sedate and paralyse an already intubated patient (i.e. dead person) but only selected RSI trained ICPs can anaesthetise and paralyse to intubate, the difference is subtle but important. Well, we are pretty awesome, now if only we could convince the Ministry of Health to give us more money!

OK, back on the FRU for you it is then? Seeing as how needles has never driven a right-hand drive or on the left we'll take the risk of having me drive the big yellow box Red base, November 100, available local area Oh BTW needles is Big Al a Freightliner by some chance?

First of all, where in the bloody hell is my cookie and is it a chocolate one? Missed injuries are one of the biggest causes of preventable trauma death but I don't think the mechanism alone can be used to determine whether or not clothes are cut off. You have to use clinical judgement and what benefit its going to give you. I've never cut anybodies clothes off and I don't really think it's very common here. Excellent work on preserving the patient's dignity and privacy; the high tech ambo blanket or sheet is a great bit of kit! It also helps to keep the patient warm

Very true mate, I've heard the average "cant intubate, cant ventilate" encounter for an anaesthetist is two or three times in their entire career. You can reduce your risk with a good pre-intubation assessment and back up plan as well as plenty of experience. This is why we restrict RSI to a select group of upskilled Intensive Care Paramedics so it is tightly controlled and has a high rate of utilisation per Officer. For Ambulance, the risk of a "cannot intubate, cannot ventilate" situation may be slightly higher; people with massive facial trauma etc. In nearly ten years we have a 3% failure rate of RSI and all have been managed without cricothyrotomy Early intubation for some people is a good idea; for patients with severe multi-system trauma, traumatic brain injury, unconscious with poor airway of whatever aetiology etc I am quite interested in the use of prehospital RSI of patients who have severe trauma but do not have traumatic brain injury. Such people might included people with amputated limbs or multiple severely fractured long bone but that's for another discussion. I notice the Doctors on London's Air Ambulance often do this. As for the asthmatic patient; again if we've got a prolonged transfer of a very sick asthmatic then I might consider it Yes, we ventilate an asthmatic at six breaths per minute and have had a big push on to get people to understand the problems of hyperinflation and the seriously bad ju ju that brings

Erm, not exactly, I still don't think using sedation alone to facilitate intubation is a very good idea True, some bloke who fell off a roof and needs RSI for his severe traumatic brain injury probably doesn't have a card in his wallet that says "I have a family history of malignant hyperthermia" I think this speaks more to your pre-intubation evaluation, back up plan and tools available; if you don't have the resources at your disposal to manage a failed intubation with paralysis then you really shouldn't be intubating regardless of whether you are using suxamethonium or not Intubating an asthmatic carries a hefty load of bad ju ju and they're probably more likely to die because you intubated them then hyperventilated the snot out of them inadvertently causing dynamic hyperinflation and cardiac arrest. Many patients with asthma can have attacks that last hours and the ambulance is only called when the patient has already started going downhill and/or respiratory arrested. For somebody who has life threatening asthma and an extended transport time it may be appropriate to intubate them, I would want to discuss the problem with the Consultant at the hospital we are going to first. If we have a transport ventilator it's probably much easier to tube and ventilate them than if we have some bloke sitting on the end of a bag mask for two hours

Any paralytic will cause aponea lol Suxamethonium can cause hyperkalaemia and malignant hyperthermia which is why we avoid using RSI in patients at high risk for these problems IOP I am not terribly concerned about, Nana with glaucoma who has been hit by a bus and has severe traumatic brain injury; which is more immediately problematic? We are specifically cautioned against using RSI in asthmatic patients indeed even a Consultant I have spoken with said he avoids it unless absolutely necessary If an asthmatic patient is still spontaneously breathing then they are not in need of ventilatory assistance or so we are taught If you're worried about not being able to intubate the patient then maybe you shouldn't be intubating them