kevkei

Shayne, I agree that it is still a dangerous job. What I think I (we) am saying is that it typically isn't the dangers of the job itself. Failure to use PPE won't protect you from many of those dangers while PPE in others makes no difference. On the flip side, many of those dangers are avoidable and you can mitigate others (those tactics and strategies). There will always be the unavoidable and unpredictable events.

Had he been wearing a B.A, this wouldn't have been an issue. Again, it's not the dangers of the job itself.

The question that I have with this, how much factor is related to the job and how much factor is related to underlying health? The way I see it, poor underlying health is exacerbated by strenuous activity and catecholamine response. With this information, we know that the vast majority of job related deaths are related to cardiac events. Then, truly is firefighting that deadly of a job? I mean, if you are 10 times more likely to die of a massive MI than from a flashover, falling debris, etc, it's not the job itself, it's poor health. Yes, doing the job contributes, but if you have 90% occlusion of your LAD due to poor lifestyle choices, maybe you shouldn't be fighting fires.

I've never been. That is not to say I never would, but I think that there would need to be some unique or extenuating circumstances to guide me to wanting to attend. If people do choose to go, I would hope that they exercise caution and respect and try to keep a low profile and not arrive in uniform (I've heard it's been done).

Some good discussion! Great points by Ridryder and EMS49393 about treating the total patient, I whole heartedly agree. I have prayed for patients in the past, but it isn't frequent. When it is of my own choosing, it is usually because it is the type of call where only God or a miracle will save them. Most often if I pray with patients, it is at their request but I do sometimes I feel led to ask them the question and every time they have said yes. I have found regardless of it being their request or my question, you can see the burden lifted from their shoulders. IMHO, regardless of everything else you did or do, that is what they will remember and that is what makes the most improvement in their overall condition. Ruff, I can relate. I have shared this story before. As I indicated above, on one of those only God or a miracle will save them calls, I felt the same thing. We transported a guy that was one of the few people that actually was in the wrong place at the wrong time, and happened to an innocent guy. Long story short, single penetrating injury to his left sternal border, just below the nipple line. He looked like death, pressure of 60/50ish (I didn't really care and didn't fully trust the value). Taken to trauma centre, intubation and thoracotomy done (while still aware of his surroundings :shock:) to find a through and through injury to his left ventricle. I actually had to hold his right arm to keep from reaching into the sterile (loose term) field. He had two 1/2 inch holes in the myocardium. Devastating injury right, with a high mortality rate >95%? I'm thinking that there is no way he can survive this kind of injury, especially because they couldn't occlude or close the holes. They tried everything from sutures, fingers, to foleys (incisions were too large, they just flopped out). Now I'm thining he won't make it becuase nothing was going right in the immediate interventions, because of that prayed for him (also due to the fact he wasn't a gang banger, dealer, etc, he was a good guy). Despite thinking that he wouldn't make it, I knew that he would. I had such a strong feeling that he would, the hair on the back of my neck stood up, I had goose bumps, and I heard a voice say that he will live. The odd thing is, after he was up in the O.R, everyone from the ER and trauma team that was there during the resucitation had stayed in the theatre and I said, "he's going to survive, neurologically intact". Everyone in the room that I could see either said yes, I agree or nodded their head. Others said that they too had such an overwhelming feeling that he was going to live. Three actually said they felt that there was something in the room watching over him and others nodded their heads.

Gotcha! I agree, if the ship hits the fan, it is a valid option (as long as it is available to you). I would just hate to have to do it if it was I that screwed up. :oops:

Sure, start an IO to save your a$$ as well as the patients, or how about an EJ or central line while we are at it? Now not only are they hypotensive and their ischemia/injury worsening because of it, they also have osteomyelitis and/or bacteremia from an invasive procedure. What about the simple philosophy that an ounce of prevention is worth a pound of cure? Absolutley it can be said that if your patient bottoms out, we can do something about it and respond appropriately, but you shouldn't be there in the first place. It's called putting the cart before the horse IMHO. Speaking of 12/15 leads, what about the 50+% of MI's that are NSTEMI's? Your diagnostic tool that you depend on to screen goes out the window and is potentially useless.

Isn't that half the problem (fun)? Understanding concepts? From a student Paramedic perspective, isn't the concept they need to understand first in order to apply the complex physiology? The simplest concept to understand in my view is preload is the pressure coming into the heart and afterload is the pressure exiting through the atria. The simple concept, once understood helps create a more clear picture to the individual (all of us), right? To take chbare's description, it is accurate. It would also be fair to say that preload is relative to each chamber of the heart with respect to the pressure exerted upon it from the location the blood is coming from. In essence, preload is not constant through each respective chamber. Consider RVH (right ventricular hypertrophe), it's preload might be within normal limits but due to increased afterload (realative) through the pulmonary vasculature in PPHN, it enlarges due to workload. It also commonly results in cor pulmonale, but again, it is afterload that is the issue. We could talk about PCWP's and such, but that I think that is semantics, it is the concept we are trying to portray. Put yourself in cfaulknor's position, what are they trying to understand? What does RVH matter to them if they have no idea of the concept of pre/after load?

With the utmost respect, I would agree with AZCEP. Preload is what causes the right atrium to fill (without it, it wouldn't) The higher the preload, the greater the filling of the atrium due to stretch (Starlings law) and the greater the atrial kick you subsequently get to the ventricle.

Not only is the ISS higher in EMS patients, it was significantly higher (63.45%) than the ISS of the non EMS patients. (Thus they have an automatically higher mortality rate. As well, look at the numbers of enrolled patients - 4856 EMS patients with 926 non-EMS patients (5.2 times the amount of EMS patients). You can't compare these two groups as you need to have equal numbers to account for any other factors. What would the results have been if they only looked at 926 EMS patients to compare with the 926 non-EMS patients?

I'm not debating it, as I agree with your that CPR is good regardless of who is doing it. Timely CPR and defibrillation (regardless of who does it) is what saves lives, not ALS (it is in the periarrest state where it makes a difference). My problem is that I don't think we can't define EMS based on cardiac arrest survival rates, as it is a poor prognisticator at the best of times and is typically such a small part of our total call volume. Out of hospital cardiac arrests have a horrible outcome in general, most services (Like KCM1) only report success rates when VF is the initial rhythm (selective criteria to exclude those that have no chance of survival). So, everything else - PEA (high mortality rate due to underlying cause) and asystole are excluded. There is still not a universally applied international standard for collecting and reporting data to compare apples to apples, although Utstein is a start. Likewise, we can't define how good a Medic is by how many tubes they get in a year. Are we trying to let the system define the Paramedic or the Paramedic define the system? What I'm trying to suggest is there is no perfect system that can be implimented everwhere. What works for KCM1, may not work in most other states.

Steve, I have never suggested or indicated that I don't believe the over saturation argument. What I indicated is that the oversturation argument by itself is inadequate and inaccurate. If it occurs in a system, it can be overcome through continued training, education and clinical exposure in other areas. The danger is those that oppose an all ALS system because of skill degredation of it's Paramedics, which is also inaccurate on a global perspective. I don't think we can generalize with a broad brush that all systems are similar or equal. Sure King Co. has a pretty good system with a good survival rate, but can that only be attributed to the system itself? What about other factors such as more frequent bystander CPR?

Not my position, and it was in hospital. :dontknow: We are getting CPAP though (finally)

I don't think anything would be referred to as 0.01 mg as standard dosing, I would agree with AZCEP that micrograms would be better. Even then, that is only 10 mcg's (as stated, for dopamine would be 0.01 mg/kg or 10 mcg/kg.) If there is, I'd love to hear what it is.

Wow, great discussion! It amazes me that stuff like this can be debated professionally and eloquently. Would your perspective be to trying to limit it to one or two agents to maximize as much of a broad spectrum as possible? Have you looked at what the evidence suggests from a research perspective? It sounds like a big part of this is the significant delay to primary care, which for the most part is not common so I doubt there is much from an evidence based perspective. Now to be a troll, tniuqs, we carry Polysporin, if you would like I can grab you some from Pyxis.

Even that philosophy is flawed. Just because you see a higher number of patients, that doesn't mean you will keep your skills up. What about those highly skilled practitioners that work in services with low call volumes? It should also be mentioned that continuous training and education will keep your knowledge and skills up. I think this is something that people neglect more than the number of patients they see.

And there is a reason Basics shouldn't be giving NTG, but that is a whole other thread. It will also work just with the BVM. If you need to assist ventilations or if the patient will tolerate the mask being held to their face, you can utilize the PEEP (although not often practical).

What about valium, ativan and gravol?

Lasix is being removed from our inventory. Cited reasons are that it poses more risk than benefit and that even in the in hospital environment with radiographic imaging, pulmonary edema is only correctly diagnosed 40% of the time.

A 40% save rate as found and reported by USA Today, now that is reliable. I'm assuming they have no knowledge or understanding of the Utstein Method which is the standard. What method did they use to come to their conclusion?

That's fair enough and pretty much what I thought, but what is it based on? If you were to compare the high taxes in ON with 'tax-free' in the states, what are you comparing? Not only that, but what is being deducted, how much and what for? What is the value for dollar. What is the cost to you for benefits such as medical, dental, vision and life insurance? Not to mention your dislike of socialized medicine, which I don't neccesarily disagree with, but we don't have any co-pay or out of pocket costs to access health services.

I just have to ask, what's with all the comments relating to the taxes?

I don't think you would look crazy at all. I think it takes more intelligence to recognize something outside of your comfort zone and want to get direction than not recognize that what you are doing isn't working and effective and keeping on. It shows you are thinking outside of the box. Especially if it falls outside of your standing orders/protocols. For example, you don't have a protocol for epi in asthmatics but you do for anapylaxis.

Agree'd. Good posts too by crazycanuck and Ventmedic. If you are in need of beta II activation to mitigate bronchoconstriction, you can also go different routes. It isn't going to hurt to use the albuterol, as was pointed out, you have to consider the affinity of the antagonist (betablocker) and the agaonist (albuterol). Although the betablocker has higher affinity to bond, it can be displaced by a higher concentration of the albuterol. You can also look at an agent that has a higher natural affinity at lower doses, like epinephrine. You can also consider the route of administration, SQ, IM, IV or you can also nebulize epi. I would add that this is where adding another class of drug would help too. Atrovent (Ipratropium bromide) would be beneficial as would Mag Sulfate as well as a steroid. I guess part of the question is, why do you ask? Are there limitations to what you can do? Is it a theoretical question looking for an answer? General interest?