Kiwiology

That is my thought too right off the bat; - Fluids for tricyclics - ? naloxone for opiods, caution seizures - ? atropine for bradycardia, I'd probably give it - Nothing for benzo's specifically, don't carry flumazanil and don't want it No medical control required. Maybe but I do not look down on those who seek clarification or assistance when they feel they need it. I never have and I never will. You are not. Obviously there is disparity between an Emergency Medicine Consultant and an Intensive Care Paramedic. I am not berating people for using online advice but I do not think it is necessary really. If you are pushing things like adenosine and cardiazem then maybe because I have heard of people misdiagnosing SVT. No I don't think it will. What did the hospital tell you to give the patient? Not sure I would have rung up here, sure I'd pop the kid with some nox or maybe a bit of morphine to take his pain away but if the little bit of morphine we give the patient makes it somehow problematic for the hospital team then it'd be something out of the blue. Pain is a great narcotic antagonist so it's not like I'd give the patient so much morphine that when they reduce his knee he'd pass out and respiratory arrest. Our training is not superior to a doctor, never will be. I am not superior to you in any way shape or form. We do not intend to come off as arrogant and condescending and I do not believe all medical control contacts in the US are because the provider is undeducated or worried about liability. That said I just don't think online medical control is really necessary.

Not saying it is not how you might practice; look at places like Los Angeles where the Paramedics are given very, very limited autonomy to actually do anything of any real substance and must ring up on the Johnny and Roy phone to get permission. I know Paramedics in the US who do not use locks they must run an IV bag because thier medical director will not allow locks. These are two examples of "medical control", allbeit the latter is different from your original topic but I think it's important none the less. I have yet to see personally or be referenced to a good example of such an "extreme" case where contact with a medical control physician would be of benefit. Nothing, I do not and never will think that. That is why most of the patients I have encountered end up at the hospital where the physician is! No good medicine does not come from being narrowminded nor too open minded. It also comes from realising one's place within the food-chain, so to speak. I agree and you touch on a very good point. Realising weakness is a strength; so realise that those nations that do not require medical control contact or controlling, prescriptive practice have far superior education standards than the US which has some of, if not the, lowest EMS education standards in the developed world. While not all encompassing, I'd bet that a good degree of the "medical control" that exists in the US be it through standing orders, protocol or requirements for online contact exists because your education is inadequate. Did I mention Los Angeles recently? I am not painting your entire country and its multitude of systems at being opressive and backwards operations and fully realise there are many systems in the US who have a fantastic setup for medical oversight and whos medical director(s) allow freedom and flexibility for thier Paramedics. Then, there are those systems who do not and that is really what we need to focus on if any real change is going to be made. Case in point; BioTel which runs the medical control for the Dallas-Fort Worth metroplex EMS system, made up entirely of Firefigher/Paramedics who go to (ironically) a 24 week patch factory tech class, has very flexible Guidelines for treatment which thier Paramedics may deviate from if they feel justified in doing so.

Oh dude that is frickin hillarious

No we do not practice willy nilly and must stick within our scope of practice. Our "protocol" varies by which service you work for, the predominant operator has "procedures" which are a little tighter where the other service I have experience with has "guidelines". In contrast to the some parts of the US where "I have to do what the doctor says" we do not have to follow our guideline to the letter. We picked up a guy who we thought was having some sort of cardiac event but weren't really sure so rather than go down the ischemia protocol and dose him up on GTN, we gave him some aspirin because in our judgement that would be more beneficial. Every patient here does not get oxygen and when they do it's 2-3 litres on an NC 99% of the time, if we gain venous access it's with a lock and no fluid is hung, not everybody who is bradycardiac gets atropine etc. While these are not examples of "online" control they are indirect examples of the variety of "control" that exist in some parts of the US. While I think this is a seperate issue from having to call for orders to give midazolam etc it demonstrates that the US system is still very much under the thumb of a doctor and while some medical directors have a lot of flexibility in how thier people deliver care, some do not and are on them like a fly on shit; be it through standing orders which must be followed to the letter or through having an overbearing need to call for treatment orders. Down here in Kiwi and Australia moves are being made at the moment to remove the need for Ambulance Officers to practice under the license of a physician and give them thier own license, own professional body and independant prescribing rights which remove the need for an instrument of delegation.

Dude WTF so why were you even called? If this guy told the Fire Department he didn't want medical help then why call you guys? If the EMT/Firefighter needs a refusal why not get one himself? I agree with you it's pretty weird and think your supervisors logic is pretty fubar.

No point in avoiding the issue at heart really mate, one thing the Kiwi's and Australians do quite well is call a spade a spade. I think medical control in the US is a joint product of the education and legal inadequacies of thier system. That and theyve been using it for so long as you touch on below WM, it's just standard. I am sure there are some who advocate for medical control because it keeps education standards low and means that the minimally educated can never get into a situation where they exceed scope of education because oh well they can just call the doctor and ask him. I would say that's about right. As I've said before, that big green bag I carry only has a limited number of tricks that can be pulled out of it. Nobody can yet give me a good example of when online medical consultation would prove clinically beneficial. To that end I know my scope of practice very well, it's not hard if you are well educated, well read and keep ontop of the ball so I don't see any need why Ambulance should be ringing up the doctor for something novelle.

Can you give me any examples because I can't think of any??

How??? Can medical control bring me a radiologist, an intensivist, a CT machine or a cath lab to my truck? In New Zealand our Guidelines and medical oversight are sufficently broad to allow for full autonomous use of scope of practice and this gives Ambulance Officers freedom to apply thier skills. Like I say, I have never needed to speak to a doctor or wanted to right-then-and-there. If I am confronted with something totally bizzare that I just have no idea how to treat, what is better; focusing on good ABCDs and taking the patient to the hospital with as much early notification as possible or pissing around ringing up medical control? There are only so many drugs in that big green bag I sling over my shoulder and I know what each and every one does and what its indications are. I am not an Intensive Care Officer but bet they'd say the same as me. The only limitation we have here is that we are not doctors and do not have the facilities of the hospital .... which is why most of my patients end up there! Here's what I went to last week, if you can think of how talking to medical control would help I am all ears: - Young female with tonsilitis, left at home - Male in his 40s with inferior STEMI - Facial burns patient - 20yof with sinus tachycardia ? smoked a little pot 7/24 ago, left her at home - Kid about 10 with haematemesis - Drunk who got into a fight - Guy who tried to scale a wall on his BMX after 12 beers - Female in her 20s with a broken ankle I am sure I forgot one or two in there ....

Not about handling them or not handling them its about as you touched on, knowing the limits and specality of the place of EMS.

No, this is where there is expanded possibilites for EMS to refer to the falls team, GPs, social services etc How are my examples not relevant?

That is not what Phil is saying. He is saying it is not up to Ambulance Officers to fix what has caused the problem hmm, let me see if I can give you examples - You dish out some midaz to a seziure patient who had a siezure because they have a massive brain tumor; are you a neurologist? - You give O2, GTN, ASA, CPAP and a bit of morf to a CHF patient who has CHF because of his poor lifestyle and eating McDs 24/7; is it our job to give him a lecture about his lifestyle and diet, no, and don't think I don't feel like it sometimes! - An old lday who lives alone has trouble remembering when to take her insulin and becomes acutely hyperglyceamic; is it my place to make sure she complies or to deal with her her more pressing problem is massive dehydration? - Some dude tried to scale a retaining wall on his BMX after 12 beers and broke his foot; should I counsel him on not doing dumb shit when drunk? I am not saying we should be dishing out treatment willy nilly without proper knowledge of pathology and physiology (eg GTN in RVI, frusemide in CHF, suxamethonium in hyperkalemia). What I think Phil is saying, and I wholeheartedly agree, that ambo's provide a level of care (which is some cases very highly sophisticated) but that our place in the chain should be realised.

I want to complain about my UN food package, you call this relief; could at least have added some sort of sauce or something, where is Kofi when you need to complain to him? Welcome.

Most people will tell you they are "allergic" to something when they mean they get anything from a tummy upset to bit of a rash to anaphylaxis. I generally write the degree of reaction eg "rash" or "nausea" etc next to the med name.

Ah so that why the US Mail don't work lol. I am not arguing that somebody has to pay and that tax is our way of paying and we get off the Govt whereas you pay for insurance. If you can pay, you should and that's just basic principle of being fair and how the world goes around. However speaking of being fair I think solidarity says those who unable to pay should not have to; we're not talking about me paying your restaurant bill or something like that but rather an essential human service. I don't mind that some of my tax dollar goes to paying for those who can't pay so they can get healthcare, welfare etc. A healthy population pays for itself over and over.

Touche my friend. However, if your house burns down the fire department will come and put it out free of charge, the police don't send you a bill for helping you out if you need it, most local libraries are free, you don't have to pay to get US mail and so on and so on .... all of these things are regardless of income or how much you have "put into" the pot. Why is it that healthcare, one of if not the most basic and essential human services is not seen as so in your parts?

Healthcare is a right, not something you earn. Until the US gets that through thier head, I don't think you guys are gonna get very far.

Oh yeah you're onto it, hang on Nana I have to call the doctor to .... aw poo Nana had a respiratory arrest. Wow that's pretty bad, sorry to hear that mate

ILS? Wow it's existed here at even the lowest level since at least before 1985. Boggles the mind how you guys get away with no analgesia below ALS level.

Don't forget the air horn.

Agree. In Los Angeles "medical control" is your best friend because you can't so squat on your on page of orders without it; whereas in Dallas or Seattle it's not so strigent. No, it shouldn't have to a be a doctor; see my earlier postings, here if we need some advice the most common perso to ring up is the Team Manager on the ambo phone. Keep in mind that sort of thing is quite rare. Our Clinical Support Managers are not doctors. Yes we have medical advice in Ambulance. I'm sorry mate but I do have to agree with Phil here. So lets say Nana is two years post-MI but in status asthma, moving very little air, becoming increasingly confused and getting ready to crash. I would have no problem giving this patient adrenaline because in the balance of risk vs benefit what is going to kill her right now? Agreed we might get a few premature complexes and there is the possibility of ischeamia but again, what is the bigger, more life threatning problem? I agree with what you are saying in notion; that we shouldn't go pushing meds willy nilly without considering the consequences but in this situation or any other situation requiring adrenaline I'd say the patient is at greater risk of dying because of thier asthma/anaphylaxis/cardiac arrest than the percieved notion of myocardial ischeamia. Now I've heard of sparky people giving somebody with a bit of a rash some adrenaline for "anaphylaxis" and spinning them off into VT .... but that's different. There is more to our patients than what we see at face value. But, once again I agree with Phil in principle. To the thinking and in-tune Ambulance Officer it's possible to build up a good picture about what is happening and begin to treat it while transporting the patient to a higher level of care. Good examples are fruseomide in cardiogenic pulmonary edema, GTN in inferior (RVI) infarct, suxamethonium in hyperkalemia, excessive fluid in hypovolaemic shock. These are where ambo treatment can be harmful and have very negative consequence. To take it to the extreme of a "symptom only" approach we'd dish out lasix to every SOBer with shitty lungs who didn't get better after a ventiolin because it must be cardiogenic edema, wouldn't bother with 12 leads in chest pain patients etc. Did I mention Los Angeles at all? This however is not what Phil is saying however it was something I wanted to touch on to address the perception some people might be getting, too often I see people educated under the "top heavy" approach focusing on skills with little foundational knowledge. What Phil means, and what I agree with very much and have seen people get stuck, is that we shouldn't sit on scene for an hour looking at the cardiac monitor with the pathophysiology book out going "hmmmm, I wonder if it's this or that" and meanwhile your patient has arrested thirty minutes ago but you didn't notice because you had your nose stuck in that cardiolody epidemiology manual. So things have really gone to shit major; you have a critically sick patient who you just have no idea how to treat. Do you put patient in ambulance and take them to the hospital or piss around on the ambo phone ringing up and doing a consult because your arse has puckered up so much you're gonna be pooing orally for the rest of your days? Again I'm not knocking the idea of getting help and support as they say two or three heads are better than one but .... the situation would have to be so far out there that I just can't think of what it would be or what is in that ubiquidos green bag that might be able to treat it. Below are our drugs, can you think of some alternative use for them that I can't which might necessitate calling up and doing a consult? - Adrenaline - Amiodarone - Aspirin - Atropine - Entonox - GTN spray - Salbutamol neb - Glucagon IM (don't carry enough for a BB OD) - Ceftriaxone - Fruseomide - Ondansetron - Morphine - Midazolam - Naloxone - Ketamine Now this is a sort-of-maybe-possibly deal. I've recently had the "5am stare" going on at an ECG strip that I just couldn't work out, I was tired and just not sure. Now this case wasn't serious and no intervention was needed but I just couldn't work that ECG out! If you guys are going to be pushing adenosine or cardizem or something after 12 hours of getting smashed with P1 jobs and 20 minutes sleep then it would be a good idea to either call telemetry with the ECG or .... put more vehicles on the road! You're onto it rock socks ... this is how we Kiwi's work.

Entonox is not used in any EMS system in the US to my knowledge, representing much lost opportunity.

Good post Chris. I agree with you wholeheartedly. Until education and preceptorship in the US comes out of the dark ages then I don't see medical control going anywhere soon. To give you an example; from 2011 the new program will look like this here Ambulance Technician: Diploma, basically a safe level for the vollies; LMA, nebules, nitro, glucagon etc Paramedic: Bachelors Degree plus one year preceptorship; can do IVs, adrenaline, 12 leads, cardiovert etc Intensive Care: 2-3 years exp as a Paramedic + Post Grad Diploma + one year internship; ALS

I have to say I agree with Phil, all systems have some sort of clinical support (as does ours) but that it does not always have to come from a doctor. Each watch here has a Team Manager who is an Intensive Care officer and a very, very experienced one at that. They are the default clinical support, one of the Officers I was with the other night rang up the TMO to ask about ketamine, and within ten minutes the patient was shitfaced and floating in orbit! When stepping outside of scope of practice, we can eithr ask an Intensive Care Paramedic or a doctor be it an ambulance medical advisor or the senior physician (consultant) in the ED we are going to. This sort of thing is pretty rare. It's 100x easier to ring up the TMO on the ambo phone. Within some systems in the UK the clinical support is from Paramedics, here it's generally from IC Paramedics, don't know about Australia but I know Victoria has the "Clinician" who is an IC Paramedic, I guess your clinical support shouldn't always have to come from a doctor although might be helpful to have one around once or twice. I must also agree very much with Phil and say medical support and advice in Ambulance should not be an adjunct to replace poor education and subcompetence. Did I mention Los Angeles already?

... and yet, achieving 90%+ on the NREMT-P practice exams doesn't even involve breaking a sweat, makes you wonder why they didn't just take the friggin test

Not at all, as they say two-or-three heads are beter than one! Aw shucks there goes 90% of the basis for my ambulance practice ..... Intensive Care Paramedic's can give salbutamol for this, but Technician or Paramedic can but would be steping outside scope of practice. In this situation you'd either call for backup, do it and then write it up or ring up Comms and ask to speak to the regional medical advisor or consultant in ED. I suspect its 100x easier to just do it and write it up later as the RMA may be unavaliable or have no cell coverage, or the consultant you get in ED might have zero interest in helping an ambulance crew. But what are they going to have you do specifically? Fluids? Drugs? If you carry the stuff to do something about it then sure, but we don't so I'm not sure how to respond to that, well I suppose I am because I just did! If you can ask somebody else for help I say go for it! We cannot transmit ECGs here except one or two places that do thrombolysis 1) because there is really no need for it, 2) it's really, really expensive and 3) it makes the doctors work! Should your compromised VT patient be refractory to amiodarone; cardiovert. I can conceede that locally given different drugs and guidelines there may be a need for some form of online consultation; I always say two heads are better than one and do not belittle or look down upon anybody who asks for help. Even here we do have a system of online contact I've never used it nor seen it used nor been in a situation where I would want to use it. My point is this - while there should be a system of medical advice and support within Ambulance practice; be it from very, very experienced Intensive Care officers (like is generally the norm here by recall to the watch manager if we get stuck) or a doctor, it should not be required routeinly for standard everyday treatment. Los Angeles is a shining example of medical control gone a lil crazy.