Kiwiology

It really does boggle the mind eh, it's so simple to check and go aw snap, you're full of shite!

I agree with you in principle and this is pretty much what we have; you can speak to one of our medical advisors here but I can't even think of an example where we'd want to because it would be so far out there and inconceviably bizzare it's beyond formulation for me! Sorry mate but I have to nitpick here. This sort of thing shouldn't be something you need to consult for really it amounts to "does the patient need it?" in my opinion. On this topic, we've gone away from giving small boluses of adrenaline IV (I suspect for the reasons you alude to, too many people OD'ing folk on adrenaline) to using an adrenaline infusion; 1mg in one litre started at 2gtt/sec titrated. Yeah I agree this is something you might want to transmit the 12 lead to CCU for a cardiologist's input but even then I think I'm not sure, it's not something we do here and rely on the Paramedic or ICP interpretation of the 12 lead .... where's that Datascope when you need it? While absence of evidence does not mean evidence of absense ... I often spout the same principle as you here for retaining some form of online contact but I am as yet unable to think up an example of when it would be appropriate specifically beyond the broad "sick patient I don't know how to treat". My thinking on the matter is "hmm, does the patient meet any indications for a medication I can administger? No ... hmm, better support those ABCs and go to the hospital". Can anybody out there support fiz's argument and provide some example of a time when it was useful for you to consult with a doctor about something abstract? I think that some places have gone a bit crazy with medical control and made people call up for silly things like a bit of morphine and that it's been resisted because MC is seen as overly restrictive. Add in people outside North America who have no online direction and viola, you end up with people disliking the notion of online consults. That brings me to another question; who exactly are you talking to (and taking orders from prn)? Are you speaking to your service medical director or some random doctor in the recieving ED? Here, we would speak to one of our service medical advisors, but like I say, I have never heard of anybody doing it.

Did your contractor get busted mate? Shucks, back to working in the kitchen or mopping the floor for you then. You raise a very good point, it's interesting that here in New Zealand the term "basic life support" refers to lay-first aid and to the scope of practice of our Ambulance Technicians. The term "Paramedic" is currently unregulated and any jagoff can purport themselves to be a "Paramedic" with no consequence. Look at the UK for example where the word "Paramedic" is restricted in law to those who are registered with the HPC. It'll be the same here before long.

I thought Roy's wife's name was Joanne?

But what else has the IAFF to do?

Have you looked at the new 2009 EMS Education Standards?. Looks like the move is being made away from "hours" of education to scope of education which is pleasing to see, the content however remains grossly inadequte although it is an improvement on the 1994 update. I do agree it's a reasonable compromise given the medicolegal issues involved however as we can both agree, that needs to fall by the wayside in favour of increased education and autonomy. Now I think we're straying from the orginal topic ..... but thats what makes this place so fun right?

Good point. I certianly think GTN is one and that your Technicians should be able to administer it, as in not "help the patient to take his own after asking the doctor" but do a proper assessment and some critical thinking, whip out the ubiquidos little red squirty bottle and use it themselves.

Oh please what a lot of manure

1. That's like me saying oh "all Kiwi ambo's are 'Ambulance Officers'" it doesn't really mean anything 2. I've read a few EMT-Basic textbooks and yes, they are taught to assess but a. minimally and b. do minimal things with that information which really amounts to jack 3. Arguable 4. Won't argue there

Here's a thought, why dont you actually educate the EMTs to use nitro and remove the need to run off and ask "doctor may i?"

This is exactly how we work here in NZ I think the one service here who is regularly using thrombolysis (not on a "trial" basis) is doing so without using telemetry now, could be wrong; I know they WERE a few years ago when it was fairly new. I agree there should be no requirement to ask for a doctor's permission and that you should be able to independantly use your scope of practice. As you say rock socks that would require a big increase in education and clinical quality assurance for the US.

Me too .... but maybe what it's really trying to tell us is that we are no good bottom feeding suction eel

That's a little bit of a problem here too I supposed in some parts. Back in the seventies when Paramedic's got ten weeks of education in the spare room down at the fire station or hospital then yes online control was very much needed. We have now progressed far-and-beyond that at least outside the US anyway (sssh don't tell the Houston Fire Department....) which means that there is less of a need for online medical oversight. As I said before .... there should always be medical advice in Ambulance, ambo's are not subject matter experts, but the concept of "online orders" and "permission-based-paramedic" is outdated and needs to go.

Having almost four years of experience in the airline industry and with extensive air traffic systems experience as far as the guy at JFK goes; it's not as bad as the media have portrayed but I frown on it a little. But WRT this, WHO CARES???? Honestly!

Somebody can give you greater info than I can, but here is my 2c Morphine and fentanyl are both opiods; however fentanyl is an outright synehetic opiod which is manmade; morphine may very well be able to be synthesised but it can also be made from opium. Fentanyl requires much smaller doses in mcg (micrograms) whereas morphine is talk about in mg or milligrans so fentanyl is said to be roughly 10x as powerful ss morphine. Pareternal analgesia (IV/IM morphhine or IV/IN fent in this case) is given here for moderate to severe pain that is not controlled by entonox. You might start out with some nox and then move onto IV morphine or just go straight to IV morphine. As an example if I have a guy with a broken leg he might do swimmingly on sone nox but if his leg is totally shattered with an open # and he is in severe pain I would start off with morphine and go from there. Cardiac chest pain and acute severe pulmonary edema are also candidates although for these conditions the use of IV analgesia is not really an effective treatment but it is good at reducing anxiety and pain. Here we can use combination analgesia with morphine and midazolam or ketamine. We are looking at removing morphine and replacing it with fentanyl. Paramedics have morphine and Intensive Care Paramedics have morphine, midazolam and ketamine.

Pretty much. In New Zealand it differs by service. The predominant service has clinical oversight (managers) who are not physicians and retains several part time medical advisors who are physicians (emergency medicine/intensivists). Collectively the medical advisors and clinical managers make up the Clinical Management Group who are responsible for developing procedure and looking at clinical issues. The other smaller services may have one or two clinical managers (who are not physicians) and retain a part-time medical advisor (physician). Under NZ law a standing order from a phyisician or other appropriate licensed healthcare professional is required to administer prescription mediciation so this is the main reason a doctor is still attatched to the ambulance service. Now in the future this will change with the advent of Paramedic and Intensive Care Paramedic becoming regulated health professions with independant rights to carry and administer. They will work under thier own license and not that of the doctor. We have no online control and do not have to seek orders; we do not work to "protocol" but rather to a guideline which can be deviated from depending upon the individual Officers experience and knowledge provided he has a good cause to do so. Medical advice as a collegual relationship with subject matter experts will always be retained and I think it is a sensible step because Paramedics are broadly educated on a range of areas but are not experts in say paediatrics or cardiology so we need to draw upon the knowledge of those who are. I think the whole "remote control medicine" concept of having to ask for permission to do something is a slap in the face of professionalism of ambulance practice and should go by the wayside if education and training are appropriately sufficent. I mean I cannot think of any circumstance where I would want to talk to a doctor on any of the jobs I have been to. There should always be medical advice in Ambulance, ambo's are not subject matter experts, but the concept of "online orders" and "permission-based-paramedic" is outdated and a bit of a laugh to be honest.

No

Yes, I see a major problem. What is this succinylcholine you speak of? I am uneducated about the ways of you foreign devils; we use suxamethonium! Seriously, no.

For the "oh my god she is gonna croak right now!" and/or "has alreayd croaked" patients I don't think that bit of smart is an issue. Like our Paramedic level officers being able to cardiovert w/o midaz .... I think if that is required a bit of pain is better than not getting adrenaline or cardioverted. But these sort of things respond well to my magic line "oh look mate we're helping you, honest!"

Yeah most here have a monitor/defibrillator with at least one Officer who is a Paramedic or Intensive Care and can read an ECG. Interestingly 12 lead interpretation is dropping down from an Intensive Care skill to a standard Paramedic (ILS) skill here. I think in your specific jurisdiction where PCPs can draw up and administer adrenaline no they are not required. As our old IV/Cardiac officers are upskilled to Paramedic (ILS) level which includes IM and IV drugs including adrenaline it will be good as it increases its availability. However that said there will still be ambulances out there with two Technicians (predominantly volunteer) where it would be nice and handy. Also how long do you reckon it takes to draw up .3 mg of adrenaline out of a glass vial in a critically ill anaphylactic patient who is crashing or about to crash? 1. Open up Thomas pack 2. Select a 1ml syringe 3. Select filter needle 4. Attach filter needle to syringe 5. Do a drug check with your partner ... this is adrenaline 1mg in 1ml, expiry 10/11 ok? 6. Prepare and break ampoule of adrenaline 7. Draw up .3mg (.3ml) 8. Change needles 9. Prepare skin with an alcohol prep 10. Inject drug .... wouldn't it be easier to pop the cap of your epi-pen, hold against the thigh and click the button? But that costs $120 .... and a syringe, two needles and a vial of adrenaline costs like $1 is what I will be told from the bean counters

You're onto it mate! Seems that cuppa brewing and a ten minute chat are within the scope of practice after all Work wonders they do.

Perhaps we can liken this to AEDs on ambulances back in the day? While they may be expensive and seldom used I think autoinjector adrenaline is important.

And those big words in anatomg and physiology are just too much man!

Now, now you can't be revealing the secret methodology of the California and Florida fire service!

Only if on the short bus