kevkei

Man would I love to attend! My department had the opportunity to do labs like this with the University of Alberta and I have to say it was the best anatomy and physiology learning points I ever could have experienced. The hands on experience of doing a surgical cric, using and seeing TTJV, doing pleural decompression, was amazing. To actually visualize the pathology and development of a pneumothorax was awesome and gave much better of how ominous a tension really is and how much of the mediastinum it takes up. The only other one time to top it was seeing a stabbing patient have their chest cracked, witnessing what V-Fib looks like in a live heart, what a pericardial tamponade looks like and it's effects as well as how fast a large hole (two) in the left vencticle can bleed out. To top it off, the patient was discharged to live a normal life. Those are the moments of clarity when the light bulb goes off in your head. Seeing is truly believing and understanding

I'm happy to hear that you have had some clarity and are feeling better about it. If my commentary did help, I'm glad it did. I wasn't trying too point fingers at you, but the 'suspicious' aspect is a manner of perspective and perception. Often when people try to tell a story about something that happened they will omit, alter or add information to sell their vesion of events. It doesn't have to be conscious, it's a matter fact that it happens. Take for example you didn't establish an open and patent airway - this might change the response you would get (not to suggest that was the case in your actions or lack there of.) As hard as it is to hear, if you learned from what happened, you and your patients will be better for it.

That would be great in the real world! The only argument I can foresee is protecting their area. I remember recently going to a Provincial building for a staff member that had an 'allergic reaction' to her seasonal flu vaccination. On arrival, the patient said "I don't feel right." The public health nurse felt she needed to administer some epi 1:1000 but didn't know how much to give "so I gave it all" (1mg 1:1000) I.M. No wonder she didn't feel right.

Now that you have had time to decompress and reflect, are you more comfortable telling more of the story to allow those here to provide more insight? To be honest, it's hard to provide honest feedback without knowing what it is you are holding back. On the surface, based on what you are saying a very slight increase in saving a life (0.01%) though statistically is possible, practically is impossible. It is probably speculation at best that anything would have helped. If what you missed truly was 'huge' then the statistical odds would probably have been much better in favor of the patient. I'm sorry to say that I remain suspicious of your intent. If you missed something huge and messed up, like others have said, accept responsibility, ask for forgiveness, learn from it and move on. It will make you a better practitioner. If it was a long shot in the dark, hindsight is always 20/20 and you can critique until the cows come home. You can't change the past, only what you do in the future. If you look at hindsight, you will always be stuck in the past and will never move forward and won't make progress. Learn to trust your instincts and respect the decision you made. If you can't, no one else will be able to trust you either. As long as you made the best decision based on the information that was available to you at THAT time, don't ever question it. It might not always be the right decision, but that's why you learn from it.

That is Stryking information

Got them today for family and myself. After doing my own research and considering the medical and ethical aspects of it, came to the conclusion that there lacks credible evidence to support not getting it. One thing to consider, it is almost pointless for a single member of a family to get it. If one person is going to, everyone should otherwise there is no point in getting it at all. With the H1N1 vaccine, you are less likely to act as a vector (carrier) and cross contaminate (read, bring it home with you.) What concerns me about H1N1 is it's effects and severity on young healthy people and the severity of illness which is disproportionate to the regular seasonal influenza (Influenza 'A' strains). I'm surprised by the lack of knowledge and understanding as well as the lack of consideration of strong and/or credible evidence but instead people will readily accept information from myth's or special interest groups. tniuqs, I hope you feel better soon.

The difference with this comment is yes they self medicate for angina (ischemia), but when we get called, it's more commonly for injury or infarction. That, or their self medicating isn't working when they have taken x5 nitro with no relief. I support the use of nitro for angina, but one should be able to differentiate between exertional angina and unstable angina as well as that of injury or infarct. IV access should be included, more for other reasons than just that of with nitro administration.

I liken the idea to utilizing pressure support on a vent, where they have to have active respiration and require enough negative pressure to trigger the vent. As for keeping them happy, I agree. I do find though that as delicate a balancing act it can be, I just prefer to keep them deep and if possible, knock out a respiratory drive as my transports at the longest are 15-20 minutes at best. At least then, they don't lighten and I can control most quantitative and qualitative values. If I have to RSI someone, it's for good reason. We used to carry Etomidate and Ketamine but had Etomidate removed due to the cortisol issues but Ketamine remains. There was a question asked regarding analgesia with Ketamine. Depending on the reason for RSI, if analgesia is indicated, yes I would use it.

One question I would ask is - for your area, when does transfer of care occur? At triage or when you off load your patient to a bed and give a report? For me here, point of care transfer doesn't occur until I give a verbal report and 'transfer care', which I typically purposely don't do until I've done all I want to do, including a top up if needed. Unless a Physician is present, I won't ask for their input as the patient is still technically in my care. If present, I'll ask for their support and have yet to be declined. So I guess I'll treat long after arriving at a hospital My philosophy is to treat my patients the way I would want to be treated if in their shoes. Does this said nurse have a position of power or authority over you? If not, don't waste your time. Typically when questioned, I will ask if their intent is to honestly find out or are they questioning my treatment. If they are questioning me, why would I need to justify my actions to them? Since I am already wrong in their eyes, what's the point of trying to change their attitude, bias and perception? I think you were completely correct in what you did and agree with your thought process. You did the right thing, for the right reason. Don't ever change that nor question yourself.

Whatever happened to looking at key indicators such as risk vs benefit, safety and efficacy? My answer is no. The educated person should be able to make their own decision, not be forced to get something that hasn't been found to be either safe or effective.

To gently nudge the thread back to the subject, why not? I can't stand the argument that you can't be proficient in two disciplines at the same time. I have enough experience seeing EMT's and Paramedics maintaining proficiency in the one profession. Does doing ambulance calls maintain one's proficiency? I do both, and statistics speak for themselves. 87% of my call volume is EMS in nature, regardless of the apparatus I am on. This means that even on an engine, I still get a lot of patient interaction, especially if they are actually sick. I get regular ride time on both the engine and the ambulance, either a 1/1 or 2/2 rotation. I take pride in being a Paramedic, I had been in EMS for 15 years before looking at other options for career longevity and work life balance. Basically, is this the norm? No it's not. I know and have seen the horror story's but the problem is generalizing and paintin all people and situations with the same brush. Do I support the NFPA and IAFF's positions on EMS? Not particularly, but I do feel it can work, can work well and without stealing from Peter to pay Paul.

Hey man, congratulations! That is definately a blessing, good for you. All the best to you and the Mrs'.

Actually, part of the reason ACoP is difficult is their goal was to meet AND exceed all of the NOCP's, which is why interprovincial movement was always problematic. MI/MEDIC, you might want to get a ton of help if you are going to write ACP in June. The written and scenario's are fun!

Okay, ya, good point Duh!

If you don't look, how do you know there is with certainty? Or if V1 and V2 appear normal, how do you know V8 and V9 are clear? Not all injury presents with reciprocal changes. (Playing Devil's advocate). I understand if it talks like a duck, it's probably a duck.

FL_Medic thanks for posting this, that strip is a good example of where V8,V9 posterior leads would be nice to see. You see T wave inversion in V1 and V1 as well as ST depression in V2. I'd be highly suspicious of posterior involvement. What is the point? It has evovled from an inferior STEMI to Inerior, posterior and right ventricular infarct. Probably a proximal occlusion of the RCA. These patients have a high mortality rate, respond very poorly to SL nitrates (IV drip only) and an example of why EMT's giving nitro, nitro without a 12 lead and IV are all bad things. Also an example of treating the monitor and not the patient. Yes these patients are few, but these are the ones we can kill if treated improperly.

Specific reference, had to search to find my textbook... - The 12-Lead ECG In Acute Myocardial Infarction, Tim Phalen pp 42. Mosby Lifeline ISBN 0-8151-6752-0 Supporting reference - ECG's Made Easy, Second Edition, Barbara Aehlert pp 213. Mosby ISBN 0-323-01432-1 - Sensitivity 70-93%, sensitivity 77-100% ( Chou, T, Knilans TK: Electrocardiography in clinical practice: adult and pediatric, Philadelphia, WB Saunders) J Lopez-Sendon, I Coma-Canella, S Alcasena, J Seoane, and C Gamallo To clarify, 40% of inferior MI's involve the right ventricle, but >95% of RVI have inferior involvement. DocHarris, we're saying the same thing.

To check for RVI, do a 15 lead. Move V4 to the contralateral position on the right side (V4r) and move V5 and V6 to the posterior (=V8, V9), these three new leads now complete the 15 lead. As for moving V4-V6 to the right, you can accomplish as much by only moving V4 as it has 90% sesitivity and 90% specificity. The mention of ST elevation in II, II, and aVf is inaccurate as only ~40% of inferior STEMI involves the right ventricle. Some hints in a standard 12 lead: - if there is elevation in V1 only, especially with inferior changes, be suspicious of RVI (proximity to V4r). - If there is ST depression in V1,V2, be alert it may be reciprocal changes from V8,V9. Clinically, there is a triad that is common with RVI, this is hypotension, JVD and dry lung sounds, signs common with right heart failure. As for the comment of treat the patient and not the monitor, that is horrible advice. STEMI is one clinical acumen that is quite definitive with specificity. How else would we give tNK if not for a positive 12 lead in addition to history and clinical findings?

A point to ponder, EMS can't even get EMS straight so why worry about this? At least with NFPA or IAFF, there are international standards. Within EMS, you have every end of the spectrum from the horrible to the amazing and everything in between.

Here are some points to consider relating to this... CLINICAL COMPETENCIES/EXPECTATIONS (From the Edmonton Region Medical Director) EMT & Paramedics - must know how to recognize STEMI - how to transmit ECG, how to PATCH to physician, VHR process - Administer ASA, no nitro unless RV infarct ruled out - Establish IV access if Nitro to be given - Need to involve ALS or rapid transfer to appropriate centre (BLS car) - Serial ECG (q15-20 minutes) looking for evolution of changes - Continuous monitoring and serial assessments even in triage and ambulance off load area Right Ventricular Infarct Identify through 15 lead Withhold Nitrates, Manage Appropriately EMT and Paramedics - will know how to recognize RV infarct using 15 lead ECG - all inferior AMI/STEMI will have 15 lead acquired - No nitroglycerin (no SL, IV drips) in identified AOCP Cross EMS Mentorship Program April 2008 RV infarcts/STEMI - Communicate RV infarct to on line med control or VHR physician - appropriate STEMI care

Nope, just 2000 posts! 1738 and counting! 1737...

That's the problem, they don't think. It's usually an impulsive thing - "I'll show you" and they live with the results and consequences for the rest of their life. Most 'suicide attempts' are just that, a cry for help looking for attention. The legitimate ones are the people that are successful, they take their time, are very methotical and have a plan for success. These are the ones that people usually don't see coming. We have one local that 'tries' to kill herself about once a week. Get's kind of annoying after awhile...

Understand... The point here is, Ontario still doesn't get 100% reciprocity. I would suggest if ACP gives you a hard time, it might be easier to get the Ontario reciprocity and then transfer out here if you were interested. (Kind of coming in through the back door.)