Kiwiology

Hi mate, good to have you Interesting you mention working privately; do the JRCALC guidelines and PGDs and whatnot allow you to work outside the NHS? I never did understand how things work in the UK with delegated powers and such; I know for example you bloke's can't carry ketamine because your medicines legislation is a bit funny but that a State Registered Paramedic can purchase, supply and administer under their HPC registration (yes, yes I know its now just "Paramedic" since the Council of Professions Supplementary to Medicine became the HPC but let's not get into that...., what don't look at me like that, I read a lot) Now, you can drive while eat fish and chips? Red base, November one-hundred on location

Red base, November 100 located. Yes hello my name is Kiwi, this is my partner Kermit, I am the Grand Wizard of Emergentology and a State Registered Paramedic State Rejected Paraalmost, oh shit that looks like the LAS fast response car pulling up out front, best leg it Kermit, I am sick of getting nicked by the HPC, but you know what, the GMC hasn't found me yet! Thames, Medevac, mile and a half north of Tower Bridge, special VFR please, returning to Barts, apparently we're not welcome at the London any more! Sorry blokes, I couldn't resist taking the piss on this one

mein post excellent das wunderbar ja! um nein speak deustche just so we are clear lol Vorenus is right a bunch of volunteers running around when FDNY EMS already exists and is capable of resopnding is not.appropriate

if i was in your position i would seriously look at Queensland Ambulance Service as they do not work 12 hour shifts and the weather/beaches up there are awesome they also have a good scope/guidelines look here http://www.ambulance.qld.gov.au/medical/pdf/CPM_Complete_31Jan12.pdf You could also look at Ambulance Victoria but they do 2 x 12hr days 2 x 14hr nights and have had a few problems with suddenly taking on a thousand new Paramedics who are damn near all under 21 to make their numbers look good for the Government. Clinical Practice Guidelines are here http://www.ambulance.vic.gov.au/Paramedics/Qualified-Paramedic-Training/Clinical-Practice-Guidelines.html Should you want to come to New Zealand look at WFA (Wellington); two days 11 hours then two 13 hour nights; much smaller than St John so very friendly culture less PC bullshit 2011 guidelines here http://wfa.org.nz/resources/Comprehensive%20Nov%202011%20final%20-%20low%20res.pdf In NZ you'd make Paramedic without much trouble and get up to Intensive Care Paramedic without much trouble I'd imagine

You might want to see a doctor about that, unless of course you had one of those operations ...

you're welcome, but i might have to tax you a little ....

awesome thread revival, yes the overwhelming majority of 911 providers in florida are fire based most privates provide only IFT; lee county ems is the exception

I agree asys there really is no place for these "do good volunteers" in a jurisdiction which already has a well established emergency ambulance response; they are free to go join the FDNY or a 911 sponsor hospital that provides EMS

im only interested in finding out what level of response my patient has; give them a bloody good sternal rub

You can read the IAFC EMS Section response to the National EMS Education Standards below; there are other documents but I can't find them http://www.iafc.org/files/ems_NtlEMSeduStandardsSectionComments070731.pdf To directly answer your question yes I think care should be standardised but at what level (state, county etc) I am not in the best position to answer that; most of the other nations that have uniform guidelines or protocols are small (Ireland, South Africa, NZ etc) but Australia has state wide guidelines as do several US states so I think starting off at the state level is a good idea. A single standard of care ensures that patients receive the same treatment regardless of where they are and gives providers portability to move between areas and not have to reacquaint themselves with a totally different operating model (somebody who moves from Texas to Los Angeles for example). It also provides a platform from which to develop research and advance practice

gad zukes man you know that nurses need an actual edewmeukashin that makes them more likely to be employed than a 120 hour minimum wonder who as 3 dozen a nickel if the FDNY and 911 sponsor hospitals dont want to work with them then they should be removed entirely; if there is a particular sub-set of the community who have a particularly strong preference to the volunteers from that community because of faith or ethnicity then thats fine but the FDNY/NYC EMS needs to bring them up to the same standard as the paid service (not that I hear FDNY EMS is all that good ....) cant we go back to the old days when everybody rolled around with big afros n' staches and a lifepak 10 dressed in a white shirt and green pants driving in a ford carrying a big box full of lidocaine? ... central six xray be 94

The reasons why are complex. Whatever power is not explicitly granted in the Constitution to the Federal Government is the domain of the particular state (10th Amendment) and each state has done its own thing as it sees fit. The EMS Systems Act of 1973 does provide a standardised framework and some requirements that must be met to receive Federal funding but there is much variation as at the state level there is often additional legislation. Each state has sort of adopted to what it needs for its purpose; for example when determining levels of certification e.g. Virginia used to have a "Mine EMT" or something of that nature, which would not be appropriate in say, Nebraska. At one point I petitioned IDHS in the Great Nation of Indiana to create an EMT-Tractor because I sick of going to blokes stuck under tractors who were still stuck when we got there because the local volunteer Firefighters were too busy closing the road in preparation for the Lifeline helicopter landing than digging ole' Jim Frank the farmer out from under said tractor, hmm looks clear, Fire have closed the road, yep look there, he's still under the bloody tractor I gather by the gaggle of people around it; Lifeline descending will call you again airborne .... OK I'm taking the piss but you get the idea Historically the development of EMS in US was very much led by Physicians (originally Cardiologists like Nagel (Miami, Cohen and Cobb (Seattle) and Criley (Los Angeles)) and has just been "one of those things" that has just never died. Part of it is that EMTs and Paramedics do not have independent legal ability to supply or administer prescription medication to patients and need an instrument of delegation (a standing order). There is little Paramedic-led interest in changing things and there is also no single national body that represents EMS across the US; there are some pseudo organisations like NAEMT, NASEMSO, NAEMSE etc and this makes change, especially positive change very slow. The EMS Agenda for the Future: A Systems Approach is a great example it was created off the back of something called the EMS blueprint (or near equivalent) in 1994 and nearly twenty years later there has been very little positive change. By international comparison places like New Zealand, Australia and Ireland have achieved 50x as much is as much or less time. This document did not really consider what is going out outside the US which would quite easily highlight the gross inadequacy of it. It is the stated policy of the International Association of Firefighters and the International Association of Fire Chiefs to run EMS wherever possible. Both of these organisations are industrial unions. Let me repeat that, because it is quite important. It is the stated policy of the Firefighters union to run (including running by taking over) EMS wherever possible within the US. They have poured millions and millions and millions of dollars into this goal and pursue it aggressively; which I must say they have done a fantastic job of it as far as industrial representation and marketing go they are just expertly awesome at getting what they want, the problem is what they want is not good for patients or Paramedics. The Fire Service is an organisation steeped in tradition and structure going back many hundreds of years so be can quite change resistant. Also many Firefighters have no interest in EMS and go and get their Paramedic card to look good and get a Fire job; some places forces Paramedic certification on Firefighters (LA County, Houston, Dallas, most of Florida etc) so the Fire Service (and their unions) have a vested interest in keeping education standards as low as possible. The IAFC EMS Section is actually on record as opposing increases in EMS education, I did an awesome post about two years ago picking apart a document they submitted on the topic of EMS education but I cannot find it now, bugger! In some places Paramedic education is as little as 12 weeks plus a couple hundred hours of "skills internship" (Houston) and in some places you must have a college two year degree (Oregon and Kansas). Most Paramedics out there get a quick watered down couple of weeks of A&P and a week of pharmacology. Because of this each Medical Director will give his or her Paramedics what he or she is comfortable with. I have had a medical director tell me that he does not know from where his Paramedics are coming e.g. a 12 week patch mill or a two year college program taught by a University School of Medicine so he has to take the view that the worst possible Paramedic in the world will be using the protocol he writes. There is also little interest in Paramedic led research in the US which doesn't help as research drives practice especially with the push towards evidence based medicine. Some states have state-wide protocols e.g. MA, GA, PA but they are not overall particularly good; they are at least a state wide standing order so that's a step in the right direction.

Let me give you an international comparison which may prove helpful In New Zealand, EMS (known as "Ambulance" the term EMS is very uncommon here) is delivered by about 1,000 paid and 3,000 volunteer Ambulance Officers to nationally consistent standards. Ambulance Officer is a generic term for anybody on the ambulance although we have three distinct levels Emergency Medical Technician (volunteer level, some paid Officers, one year course) OPA, NPA, LMA, PEEP, tourniquet, defibrillation, 12 lead ECG acquisition, single lead rhythm interpretation, entonox, methoxyflurane (where used*), paracetamol, oral ondansetron, loratadine, nebulised adrenaline, aspirin, GTN, salbutamol, ipatropium, oral 10% glucose, glucagon, IM adrenaline for anaphylaxis only (upon direction of an Intensive Care Paramedic) Paramedic (Bachelors Degree) EMT + 12 lead ECG interpretation, manual defibrillation. synchronised cardioversion, IV cannulation (including external jugular), adrenaline, amiodarone for cardiac arrest, morphine, fentanyl, ceftriaxone, naloxone, midazolam for seizures Intensive Care Paramedic (Graduate Certificate) Paramedic + intubation, intraosseous access, midazolam for sedation, pacing, atropine, ketamine, suxamethonium, vecuronium, chest decompression, adenosine While most ambulances have two Paramedics some have a Technician and a Paramedic, a few have two Technicians (mostly volunteers) and "ALS" will have an Intensive Care Paramedic + another level, most of the time it's a Paramedic but sometimes a Technician. All of our actual patient care is delivered consistently using guidelines, we do not work to protocols and can choose what is best for our patient at the time, we work totally autonomously and do not have "online control" Hope that helps you draw some comparisons, if you have any other questions I would be happy to try to answer them for you!

Bah I can totally top that!

I think Sarah Chalke is hot and I stayed at a Holiday Inn Express, does that count? Of course I'd probably say something "G'day bro you look a bit crook, are you feeling a bit nunngered? like do you have pain in your noggin, ticker or gizzard?" ... hmmm that might not help

Yes but when you were a volunteer the FDNY got around by horse and the Engineer thought in gallops per bale [of hay] not miles per gallon Is there a reason why there is not a stronger push by the FDNY and the hospitals that provide official 911 cover to eliminate these groups or to actually work with them? If I remember correctly I think there might be one or two volunteer organisations who are e.g. Jewish and exist because that is who the community would prefer come to them in a time of need as they are the same ethnicity or faith?

They need to try harder

I would still perfer an elastic gum bougie

Good point,.I can use a styletd tube if I absolutely have to its just.my strong preference to use bougie

I like the way you think, but why not try the bougie first; if you get it in there's an absolute 100% guarantee you've intubated the trachea when you slide the tube overtop. Maybe it is just me, but I do not like using styleted tubes, I have used them a small number of times and just didn't really think it was for me

No but it was rather amusing to be told not to say "mega" if I wanted to not get murdered because it sounded like I was saying "nigger"

I was warned in US not say "mega" because it sounds like I was saying "nigger" ... cultural sensitivity training for people with accent

promethazine is very sedating as its an older H1 blocker unlike newer blockers e.g. loratadine which is non-sedating man they had me talking to sky elephants and pink dogs and all sorts on that shit

What a magnificent post I agree As I learnt doing adrenaline upskilling the decision to do something is more important than the physical action of doing it.