kevkei

I think people tend to use terminology a little loosely. This is a battle between 'obligation' - something that you must do' vs 'discretion' - the ability to make a judgement or decision. By saying you are obligated (morally, ethically, legally, spiritually, etc) you shall stop and render aid at all times and at all costs. It is black and white and never ceases. You stop at every and all MVC (I'd never get to work on time), every unwell looking individual you see (have fun in the inner city with that one.) Sounds completely impractical. Don't worry about life safety or hazards, go and render aid post haste. By using your discretion, you take a multitude of factors into consideration, evaluate the risk vs benefit, and make a judgement call on the best information you can to come to a conclusion of act/don't act. To me, this does not sound like old, burnt out or not caring. It sounds reasonable and prudent. Instead of saying we shall stop (shall is stronger than will) under all circumstances because it is our sworn duty and there are professional and/or legal ramifications, do the common man test. What would the average person in the same situation do under the given circumstances? Sometimes I offer help, sometimes I don't. If that makes me a bad person, so be it.

Bad situation you found yourself in. The attitude and behaviour is unacceptable, as it the appearance and professionalism. To be honest, I care a little less about a person’s appearance compared to what comes out of their mouth and how they articulate. Meaning, you can have polished boots, pressed pants and shirt, etc and sound like an idiot... or, you can be a professional (not just look it) and act like one. If you can do both, all the better. That aside, did you take the time to apologize for a colleagues misgivings and try to make it a teachable moment? The point being you can diffuse a bad situation and minimize the negativity using the bad apple principle. Paint them as a spoiled fruit but the rest of the crop is sound. If you cast off the spoiled fruit and separate it from the good, you can salvage the crop. Every industry and/or profession has its share of bad apples and if any of them deny it, then they are part of the problem. I like to think that two wrongs don't make a right and taking the high road does more to gain respect and progress our industry than getting even. Is it possible that they felt 'the guy's an idiot?' vs 'Paramedics are idiots?'

Hey all, it is also with great sadness that I return. I must admit, the finality of this disease process has hit me hard even though it has been a long road. I remember when Rob shared the diagnosis with me, how do you respond to news like that? Knowing what lay ahead for him, all I could say was that I was sorry. Not out of pitty, but rather out of respect for ALS and the ravages we knew it would play on his body. He has been in my thoughts a lot since the announcement and will say it has been hard. I didn't know Rob on a deeply personal level but I have many highlights. I first 'met' him here we were both pretty new and ended up tag teaming against an adversarial type, whom I would eventually gain a lot of respect for. Squint, do you remember those days? I truly wish that distance and personal commitments wouldn't prevent me from being a part of a party or gathering in memoriam. Though he may be gone, he definitely won't be forgotten. And though I regret not being able to meet and greet in person, I will charish the opportunities that I did have getting to know him personally by other means.

Well, for starters, maybe trust the higher level of care and the experience he brings to the table and perhaps it isn't simply a case of withholding the O2. Based on what is presented here, I'd say it sounds like a chronic COPD pt and lower O2 sats may be normal. What is more of the history - meds, past medical history, etc. How about physical findings such as lung sounds? Underlying rhythm on the ECG? Remember, not all patients need 'VOMIT' = Vitals, O2, IV, Monitor, Transport. Also remember the saying of treat the patient and not the monitor. Based on the O2 sats, was it clinically significant? Do you have the possibility of disrupting the 'hypoxic drive' if she is a COPDer? As others have indicated, try using it as a learning experience and ask what their thought process was. It's not fair to assume what was going through their mind and questioning their decision making. You would probably find that their was a logical thought process.

I agree with what's been said so far. The day I become fearless is the day I need to find a new career. I think the challenge and the skill is learning how to control that fear, how to manage it, and how to apply it in a positive sense. I try to be pragmatic wherever possible. In theory, I know I can RSI this inhalation injury but the pucker factor is huge because I am aware of the risks, complications and outcomes. The stark reality is it needs to be done to do my part to minimize morbidity and mortality. If I am fearless, I take too many risks (short cuts, no back-up plan, etc) and have a higher liklihood of being unsuccessful. If I am fearful, I fail to act and respond accordingly. I think by not being fearful nor fearless, I can be aware of both extremes and it helps to keep me honest and patient focused. Everything I do is risk vs benefit based. In my example, failure to do anything obviously results in a poor outcome. If I am fearless, maybe I am lucky and I am successful with a positive outcome. The reality is, you're playing with fire and you will eventually be burned. It's not a matter of IF, rather, WHEN. The other factor is if you are fearless, you are the 'I' of the 'team' (there is no 'I' in team) and you are probably a burden to the rest of your crew.

I prefer LUCAS from Physio Control I found it to be superior in the quality and predictability of compressions and even worked well on an 85 y/o female all of 5'2'' and 90 lbs. You can run it off of compressed air or battery depending on your version.

You have to love people that are motivated by litigation and CYA. If you follow a simple process of customer service, best possible patient care given the circumstances, and informed consent for all things, you won't go wrong. Due dilligence goes two ways: were you dilligent in meeting the standard of care and were you dilligent in respecting laws, human rights and civil liberties? What's the harm if a family asks you to remove your dirty footwear so as to not damage their flooring? Look at the situation and if there is no threat, why not? We are there as servants not the ultimate authority. What would you want done in your home if you had to call for service? (Hardwood floors caked with mud, grit and snow?) If the patient has ceremonial clothing, get their consent and do what you can to respect their dignity. The process of 'expose and examine' doesn't have to mean pulling out trauma shears every time, learn to think outside of the box a little. In order to gain respect, you have to give respect. Keep in mind, public and patient perception is the rule, they could care less about how well you treat them medically. It's the soft skills and interpersonal communication that they remember and how they perceive their experience.

Hey Mobey, Thanks for the response, that takes character and integrity and demonstrates positive professionalism. I have no issues with people calling these things into question as it is better to air perceived 'dirty laundry' to clear the air. There is no one perfect place of employment, they all have issues in one form or another so I appreciate people having the opportunity to investigate things on their own. It works better for people to come to their own conclusions based on facts, not heresy or word of mouth. The fact that you changed your opinion after looking into it is very respectable. On a side note, it appears that a higher starting salary based on experience is on the table up to the first class rate ($36.64/hr).

Hey Mobey, No worries, I don't take the actions of others personally! I can't speak to the individual horror stories as I don't know what the issues were but I'd love to hear about it, maybe send me a PM with an outline. I don't use the term 'rookie' and don't condone rookie treatment. Usually it depends on multiple factors like age, experience, life history, back-bone. I'd like to say all are treated with respect by all others, but that would be an utopian idea. Generally, the new guy stuff is taking initiative and being motivated to do station duties, etc. It can vary from station to station and platoon to platoon with some being awesome and some just okay. It usually comes down to 'individuals'. 'Initiations' for the most part, I haven't seen or heard of in a long time. The exception might be a soaking by a bucket or a hose, but even then... I never had any issues with anything along these lines. You can pass along to your 'friend' they will consider everyone. As the posting from HR said, all positions are filled on the basis of merit and experience is welcomed. (This is the position of HR who are the ones who actually have the power to hire) Medical director? Where have you been, it's the same as Metro. Sookram is the AHS regional director and for the integrateds it is Rick Scheirer. Before transition it was Chris Westover.

Hey everyone, it's been a while since I've been around but here is a selfish post. I have added some emphasis to the posting below to highlight some points. Emergency Services Personnel - Permanent Full-Time Emergency Services Personnel - Fire Services - Permanent Full-Time St. Albert has been called "Alberta's Finest City" and for good reason! St. Albert is an amazing, family-oriented City that is well known for the quality of services it provides to citizens. With over 100 years of service to its credit, St. Albert Fire Services plays an integral role in shaping and serving our community. The Opportunity: -------------------------------------------------------------------------------- St. Albert Fire Services is currently seeking dynamic and qualified individuals to fill permanent Emergency Services Personnel positions. As a fully integrated team, all of our Emergency Services Personnel are trained to provide excellent fire suppression, rescue and emergency medical services. In addition, all employees have the opportunity to: participate in enhanced training opportunities, contribute to the ongoing development and integration of best practices and to provide public safety education to future generations. Qualifications: -------------------------------------------------------------------------------- Candidates seeking an Emergency Services Personnel position must have the following qualifications: A Grade 12 diploma EMT-A Certification Current registration with the Alberta College of Paramedics N.F.P.A. 1001 Training or equivalent A valid Class 3/4 License with Q endorsement Ability to pass a medical assessment Ability to obtain a security clearance A minimum of 20/30 corrected, normal colour vision (wearing glasses is considered 'corrected') No hearing impairments Preferred candidates will also have: EMT-P Certification Experience providing Advanced Life Support (ALS) Superior interpersonal and communication skills A strong interest in continuing education Experience working with diverse teams A passion for the field of emergency services and applying best practices. The City of St. Albert selects all candidates on the basis of merit. Please note that an eligibility list for filling future vacancies will be created from candidates that successfully complete the recruitment process. So what does this mean? It means the City wants to hire Paramedics and if you are looking for a change or to get away from some of the burdens of AHS direct delivery, now is your chance. In the past they have hired EMT's that don't have their 1001's. I'm hearing from 2-10 to start with the possibility of additional numbers if funding is given for additional ambulances (speculating on that). There has been some discussion about the process, not sure of the exact specifics yet and how it will pan out. The City is aware of a number of different issues such as starting wages (credit for previous experience), fitness testing, interest in working only EMS, etc. and it sounds like they are working on resolutions to these issues. The big one is the eligibility list for future vacancies so get your name in if you are interested.

That's what my thoughts were. One step further, is it undiagnosed or is it perhaps known to the patient?

Actually, this isn't accurate Differential DX? I thought he walked away with a hot blonde?

Sorry to you, can't stir the pot with me I've said repeatedly you need to treat both, with respect. ACLS Principles and Practice - "When a LBBB is present, the delayed LV repolarization of LBBB distorts interpretation of the ST segment, preventing accurate identification of ST elevation." 2003, pp 407.

How can you say anterior STEMI in the presence of LBBB?

Stand correct, LBBB

crotch, I completely agree, I've never suggested not treating your patient. That said, when you have the tools available to you, you need to use them to treat the patient based on quantitative data otherwise you are going the 'coma coctail route'. Like any tool, if used properly, it increases and/or narrows sensitivity and specificity. What do you do with a patient with no chest pain or anginal equivalents but you have a 12 lead that screams of LCX infarction? Do you treat the patient? My position is and has simply been, do a quick 12 lead before doing anything else to intervene, then continue on with the rest of your treatment. I still see there hasn't been any response to the protocol I posted earlier, good, bad or indifferent. I'm going with RBBB, but not entirely until a 12 lead. In RBBB, I would be concerned with elevation. In LBBB not so due to early repolarization and is an infarct imposter. What I would be concerned about in LBBB is new vs old. New onset, could be treated as conventional infarct pattern. I'd hold off on Retevase though. Generally, LBBB has a better outcome than RBBB. RBBB (the right bundle of His) is more delecate and more sensitive to progression to a complete heart block. Hemiblock, fascicular block. 1st degree, second I, II, 3rd (complete)... I'd be looking at the long haul, and best get going. I'd be preparing for atropine, inotropes and/or pacing down the road. Oh, and due to to elevation, I'd probably look at going to an NRB, partial pressures and all. - O2, IV, continuous monitoring, serial 12 leads, I'm happy with the ASA but could go with another 160mg PO due to transport time (unknown ECASA?). I'd like to see a 12 lead to, which would have been done before anything else

I know it wasn't directed my way, but here is a link, the pdf was too large. Vital Heart Response - Dr. Robert Welsh Here is our worksheet (protocol if you will). Read the 8th section from the top "Oxygen to keep SpO2 ≥92%" If the order is to indicate sequence of events (nothing specified as such), 12/15 lead occurs prior to O2, ASA, IV, Nitro (IV before nitro and after 12 lead? ) VHR Worksheet1.pdf

No, I'm dead serious. Yes I would and routinely do. You (and others) are making assumptions, I said withold the treatment (O2) until a baseline 12 lead is established and proven to be clear and readable (no artifact, intererence, etc). Once that is done, continue on with standard of care. O2 as appropriate, IV, ASA, Nitro, Morphine, etc. The diagnostic test is the standard of care in nearly our whole Province as is early physician intervention (consultation) to triage to either PTCI (proimity, availability of cath lab, which cath lab, etc) or prehospital thrombolysis (tNk) , if warranted. This followed with Plavix and Enoxaparin (low molecular weight heparin). I'm sorry, but this is one of the few definitive times where you do actually treat the monitor (12 lead/15 lead) with more importance than the patient. And tniuqs, the Wellens discussion comes from a Cardiologist and 2 residents at UAH. Not specifically O2 alone, but our global treatment for cardiac ischemia (MONA if you will) has evidenced many occasions resolution of 12 lead indicators but our early 12 lead establishes evidence of the pathology. Hence why Cardiology loves EMS 12 leads.

As unpopular as it may sound, I'd recommend witholding the O2 until your 12 lead is complete - clear and readable. There are examples of missed opportunities for recording ischemia, unique injury patterns (Wellens syndrome) and the like. Cardiologists love our early 12 leads, the earlier the better (before O2, ASA, Nitro).

I believe most services that have the LP12 with EtCO2 capability do (can't speak for the individual practitioner though). For sure Edmonton, Strathcona and St. Albert are. It's a great tool if you understand it's use and can interperate the capnography. Good point that I was unaware of, if your values are dropping there would be up to a 20 second delay. Do you know if this is standard with all LP12's, or maybe an issue with older or non-updated models? I guess the bonus is I tend to default two of the screens each to SpO2 and EtCO2 to monitor waveforms (quantitatvie and qualitative). Like you said with EtCO2, it is good for trending as well. I don't know how many times I've seen someone get an SpO2 of 96% on a cold or red nail polished finger but there is nothing for a waveform. On a side note, it's also a good way to assess distal perfusion on fingers or toes in trauma, splinting, etc.

I'd tend to agree with John. Post resuscitation dysrhythmias are very common and it is recommended to put your hands in your pockets and watch, no electrical or chemical cardioversion right away. 1. How long after you got pulses back would this be? Short time vs long time. What was the PEA, narrow/wide, fast/slow? This wide complex tachycardia of unknown origin, are there P waves present? Is it VT or is it a LBBB? Does this rhythm closely resemble what the PEA rhythm looked like? 2. As above, quantify vital signs (BP, SpO2, EtCO2, BGL). If he is stable, he can wait, treat potential underlying causes hypoxia, respiratory acidosis, hypovolemia, etc). If not stable, then you need to treat the rhythm. Sustained I would suggest would be a couple of minutes. If VT, it tends not to sustain for long and will deteriorate to pulseless VT or VF. 3. Is he intubated? How old is the patient? Any meds? Previous medical history? 4. Anything else remarkable on physical exam from head to toe? What I don't like about Amiodarone is the time to infuse as with Procainamide. I do like Lidocaine because I've found it works well in refractory VF/VT, and it is single dose IVP. It's also a nice option if you do decide to cardiovert to pre treat with the Lido.

Who said anything about a BVM or JR? First, I can't assume anyone doing BVM ventilation has an absolute closed system, it was an arbitrary number to prove a point. Sarcasm yes to a point. But practically speaking, prehospitally if you are flowing only enough O2 to keep the resevoir inflated, or preferrably giving an appropriate amount of FiO2 based on patient need (not all pts need 100% O2). Sarcasm to indicate a VQ mismatch perhaps? Are you suggesting it may be possible to think outside the box???? Considering physiological PEEP on the healthy individual is ~ 5 cm and a high flow rate of any type would be higher, ahhh... um... I guess.... Yea. Would this perhaps be why a JR should only be used with a pressure gague?

In the words of my hero Forrest Gump, stupid is as stupid does.

You don't suggest people are unaware of the difference between oxygenation and ventilation let alone ventilation and perfusion?!?!?! He has an FiO2 of 90%, PEEP of 10cm, but he's still hypoxic?

Yes you can put the cart before the horse, but why do we need to change the tools instead of changing how we 'educate' staff and students, new and old. (I purposely did not use the word 'train'). Educate people to use the right tool for the right job. If it happens to be a smaller volume BVM, then so be it. How many people (EMT's, Paramedics) have a good grasp of tidal volume, I/E ratios/pressures, PEEP, etc. It is a great pet peeve of mine to see an intubated patient transported with the least trained person ventilating with a BVM (firefighter, first responder, etc). Having a focus of "ventilation during cardiac arrest and the effectiveness of different sized bags" is nice in theory, but what happens if you have a ROSC? Do you change BVM size?