Kiwiology

These changes have been coming since the early 1990s (I think 1994) when the NREMT bought out the Practice Blueprint which led to the development of the Education Agenda. While very good, substantive change has not occured nor is it likely to occur (in my view) within the next decade. Substantive change is going to require further increases in education standards, the mandating two year degree for Paramedics as well as sensible increases in scope of practice for EMT (eg LMA, GTN, glucagon, salbutamol, entonox) because that is what is going to have the greatest benefit.

What resources are you using to try and learn these rhythms? Email me and we'll see if we can set up a live session mate

This bloke has a BP drop of 50 points, thats pretty significant, it may be that he is hypertensive and 180 is normal for him so him going from 180 to 130 would be like the rest of us going from 120 to 70

Damn it to the bowels of bloody hell mate, I've known you for ages and you're a top notch bloke, not like one of those shav scrote ambo who I hate, bloody dickheads they are I will not let you fail, I marked some wankers assignments the other week and they were absolute bloody rubbish he called junctional rhythm first degree block and he's a bloody Paramedic (ILS) now ....you know how to get ahold of me, I'm sitting on my arse for the next little bit, let me help you

1. What would be your primary assessment considerations with this patient? I was thinking pulmonary embolisim to be honest. With a hx of recent surgery it could also be very fast AF with ventricular conduction as surgical patients seem to get AF alot I'd like to know if this bloke has any history of cardiac disease 2. Prior to initiating drug therapy, what questions would you ask the patient? Again you have to consider "real life" vs "textbook" here; the real life answer is I wouldn't give him any medications, the textbook answer is probably allgeries etc 3. What is the most important step in the initial management of this patient? To terminate the tachydysrhythmia 4. Five minutes into your management of this patient, his BP drops to 130/74 and he exhibits a decreased level of consciousness. What would you do next? Cardiovert him, the more compromised they are and the more likely the rhythm is to be VT the more important it is to cardiovert. These are funny questions mate and your instructor is most certinaly looking for answers which do not fit into what I am going to tell you to do because the "textbook" answers probably dont make sense out in the real world of clinical medicine. There are a bunch of reasons this bloke might have a wide complex tachycardia, the recent surgery makes me suspect of AF with ventricular conduction, however he might have a history of ten massive bloody MIs and a nunngered ticker so its hard to say, for us that's not really important, he has a very fast wide complex tacyardia and an altered LOC which we can extrapolate (correctly or not) to that is causing his problem, without us fixing it up it WILL cause him further problems like you know, death.

Oh Jeebus why in the bloody hell didn't I learn Russian? WHY? *Komrade Kiwi smashes his head on the desk

Telecommunicator? WTF? Should we fire up the hearsebulance that is now radio dispatched and oxygen equipped? Most places use MPDS where the use of an AED is in the pre-arrival instructions for cardiac arrest (nine).

Sure can. Our cardiac arrests are very simple: LMA, CPR, defibrillate and adrenaline.

I am sure the delegated authority of your medical director permits for the administration of nebulised salbutamol, this does not mean you can dish them up somebody elses salbutamol. Oxygen and adrenaline are both prescription medications.

The principles of management of cardiac problems (cardiac arrest, VT, symptomatic bradycardia etc) are incorporated into the BHSc (Paramedic) during second year and specific guidelined are publishes by the Ambulance Clinical Management Group from the consensus of international evidence.

yes

I dno we don't have "ACLS" here

There is (locally speaking) no legal protection from prosecution under the Health Practitioner (Competency Assurance) Act or the Medicines Regulations for a person in this situation. An inhailer contains salbutamol, a prescription medicine. WIthout a practicing certificate which enables prescription or a legal instrument of delgation (standing order) it is illegal for somebody to supply-for-administration.

Ketamine FTW Just ask the Consultant

Yes, because you know people in VT has a high incidence of .... dying? Our Paramedic Ambulance Officers can cardiovert and Intensive Care can sedate with midazolam prior

Damn bro that sucks, good luck with that

That Saffer bloke cracks me up but he is quite right, Indiana is quite rural with two trauma centres: one in Ft Wayne and the others in Indy? There's good geographic spread if ever I saw it. Let's just not see this go the way of the stupid bloody ORCON and Call Connect targets in the UK; those jumpy redneck rural volunteer firefighters are already hyped up enough wanting to cut people out of their cars and call in Lifeline

We have Intensive Care Paramedics on the Motorcycle Response Unit here and in Australia, I also believe they are used in parts of Asia e.g. JP and HKG

Stay as a pilot mate, trust me on this one Kiwi, CPL-MEL©, BAv(Man),

I think we have to use clinical judgement; a pregnant patient who has been in a road traffic accident who displays a massive seatbelt injury, abdominal pain, severe adnexal tenderness and vaginal haemorrhage has a higher suspicion of some sort of foetal endangering injury than that pregnant chick who fell over and broke her leg .... unless that broken leg happens to cause a fat emboli to break loose and travel to the placentae in turn causing placentae ischaemia, foetal death and septic retained abortion heck you never know! Clinical judgement is required

Determining whether or not a patient needs surgery is the job of the Surgical Registrar We do not run fluid unless the patient needs it, 99% of the time we start a lock Those "just in case" patients can be tricky to spot, a very wise Intensive Care Officer once told me "put a drip in everybody in case they arrest on you so that way you do not have to arse around getting one" which is good advice but not really practical. I suppose compared to the US we are a little bit conservative when it comes to harpooning people

1. No; abdo or pelvic trauma, RTA, fall from height etc yes but trauma is a leading cause of placentae abruptio not miscarriage 2. No unless there is a need for fluid or medicine, remember cold salty water does not clot or carry oxygen 3. See #2

I was just taking the piss mate, I have great love and much respect for medicine however the point I make here with regard to this article is that something must be wrong with the system of medical education in the US if the solution to the lack of interpersonal skills and teamwork ability of your medical students is to put them on an ambulance. Surely there could be some sort of solution to come from the auspicies of medicine themselves and expose the student to much more appropriate clinical decision making and an environment more suited to their future career as a physician than an ambulance? For example, from the outset of the MBChB here you are exposed to (and expected to be proficient) in interprofessional and interpersonal communications, clinical decision making and professional practice at an appropriate level for their knowledge. For example you do cardiovascular in Year 1 so you might be doing a discharge plan for somebody who is in CCU or in primary care doing assessments and planning for patients with hypertension or AF as examples. See here http://www.fmhs.auckland.ac.nz/faculty/undergrad/_docs/medical_structure.pdf We are the same with our nurses and paramedics, they have intergrated clinical and community praxis from Year 1 of the degree programs. When we are tested here you are not testing on a skill or abstract knowledge (well, that does form part of it obviously) but you are marked and scored on your ability to talk to the patient, built rapport, work with other health professionals or ambulance officers etc. I have many friends who are paramedics, physicians, nurses in the US; I worked in the US for three years although not in health care, I like to consider that I am fairly well educated and well read ... but that might be blowing smoke up my bottom

Not sure where you heard that but yes we have health system problems like any system I'm not trying to say we're better but it strikes me as odd that during the first two years of medical school in the US there seems to be little to no structured clinical exposure and cannot help wonder if that is part of the problem?

I did not say you taught the test, but cannot help wonder if that is somehow a confounding variable, or perhaps it is a false positive on my part. Myopic? Heck I am a blind bugger thats for sure so you have that right! LOL The article made mention that the reasoning behind this program was because medical students lacked fundamental interpersonal and problem solving skills, this is quite worrying Our medical education is quite different, we place as much emphasis during all years of the medical program on not only learning the science of medicine but also the art of patient touching ... you know, structured community and clinical praxis. Perhaps your model is why US doctors are so good at ordering lots of expensive tests? </taking the piss>