kevkei

Based on this protocol, what if the HR is 64 and SBP is 108mmHg? Do you give it because it falls within the protocol? (This is why I don't like protocols to be black and white to people) What if the patient has an inferior infarct but no RVI? The liklihood is their SBP will drop significantly. To others that say "patients use their own nitro all the time" is very narrow minded and is missing the point. Yes, they do, but typically it is related to an episode of exertional angina (of which they have a history). When they call EMS, it is usually because it is atypical and/or doesn't relieve with rest and nitro, so the argument of personal use should go out the window.

In Edmonton EMT - $19.31 - $27.45 Paramedic - $22.99 - $32.39 Our shift differential is $1/hr We are currently in negotiations and can probably reasonably assume to get at least 3-3.5%/year.

The simple answer would be the following: The Health Disciplines Act: EMT Regulation. Duties of registered members 13 A registered member shall (a) execute duties in a safe and competent manner being guided at all times by the welfare and best interests of the patient; You have a duty to protect the patient when they can't protect themselves. -------------------------------------- Add to this The Mental Health Act Part 3 Treatment and Control Mental competence 26 For the purposes of this Part, a person is mentally competent to make treatment decisions if the person is able to understand the subject‑matter relating to the decisions and able to appreciate the consequences of making the decisions. 1988 cM‑13.1 s26 Part 1 Peace officer’s power 12(1) When a peace officer has reasonable and probable grounds to believe that (a) a person is suffering from mental disorder, ( the person is in a condition presenting a danger to the person or others, © the person should be examined in the interests of the person’s own safety or the safety of others, and (d) the circumstances are such that to proceed under section 10 would be dangerous, the peace officer may apprehend the person and convey the person to a facility for examination. ----------------------------- I won't even comment on the gong show going on at this scene. Simply removing ones self to the ambulance and locking the door doesn't make you safe. Driving about 10 blocks away would be a much better choice. As for the RCMP, never assume that they will be experts when it comes to medically related law. They tend to only be concerned with criminal law. Did they consider contacting online medical control for input? The crew was dumb, the cops were lazy and they should consider themselves lucky that the patient didn't die (yet).

Rid, the problem is they are arguing that the evidence suggests the ETT is no more beneficial at preventing aspiration than the LMA, Combi, King, etc. hence there is no benefit. Do you or anyone else have anything that says otherwise? Because I haven't seen it. At best, it's anecdotal. Because the ETT is passed through the cords, it is inherently more of a risk for causing nosochmial pneumonia, which none of the others do. As I said, I'm on your side and agree that ETI is appropriate prehospitally. I'm just arguing the position of the people against it. Of which, our medical director is one.

I don't disagree with anything you are saying. The single and simplest question that we should ask is, does it improve patient outcomes? End of story. Why invest time, energy and money training and properly educating Paramedics in the five W's and how if it does not benefit the patient? As far as I am aware, there is no evidence that suggests it improves patient outcomes. On the surface, what is suggested is that the blind insertion devices offer the same benefit with lower rates of complications (including aspiration and pneumonia).

It's not about the skill and how good we do it, it's about patient outcomes. We can't even educate the providers how to do other things properly with simple things, how do we now expect the majority of students to be able to learn good judgement, good ongoing assessments and good critical/clinical thinking skills? People are always complaining here about how bad XYZ school is, or the overall poor quality of students today. How often do you hear glowing reviews of a bunch of schools or the practicum students? We never hear the positive, it's always the negative. Trust me, I don't like it for how it applies to me, you and many others, but for the tens of thousands of Paramedics as a whole (plus some EMT-I's, EMTCC and whatever other letter combinations)? They are also saying they want to take ETI out of the hospital setting, so how should we think we are any better. I think we as a profession (as Paramedics) define who we are by the fact that we can intubate and we can do it well, some of the time. Take for example the airway Kings in Anesthesiology. Even they are moving away from ETI. Current literature suggests that the risk of aspiration from blind insertion devices (LMA, Combitube, King Airway, etc) is remote at best and can probably be suggested the infection risk is even lower than ETI due to the simple fact that the tube is passed through the cords. Simply stated, our arguments of using a 'definitive' airway are lost and don't hold ground any more. I have had this argument for the last year trying to say we need to keep intubation in our skill set, it is needed for the benefit of the patient, etc. and all the other arguments. If you do what I did and look at the evidenced based recommendations objectively, you would probably see their point. Try answering this, what are the arguments (benefits) in favor of ETI being preferred or needed prehospitally?

=D> =D> =D> The most to the point response. I don' think the issue is whether or not intubation is successful. Our system reports an intubation success rate of 92%. At the surface, that sounds pretty good but there are more questions to ask: how many attempts did it take? What do you classify as an 'attemt'? Compare this to cardiac arrest data. If someone has a 50% 'success' rate in ROSC, they are probably not using Utstein criteria. What has to be considered is patient outcome. Each of us here that defend prehospital intubation are probably aware of the complications and the morbidity caused by the procedure and how to minimize the effects of the same. However, what percentage of our fellow practitioners can say the same? With the wide variety of educational and clinical requirements, the monkey skill that we can do can and does do more harm than good. Consider a traumatic brain injury. Any result in one or more of hypoxia, hypotension or hypercapnea signifcantly increases both morbidity and mortality. What do we often do with these patients? RSI them right. So now we give a bunch of medications that typically have hemodynamic effects, take away their ability to breathe and they end up hypoventilating, become hypoxic and hypercapnic. If you aren't aware of these issues and how to observe for them and how to mitigate, then you shouldn't be touching a laryngoscope blade. So what if you as an individual have a 100% intubation success rate on your first attempt if it takes you over 1 minute to pass the tube.

LMFAO! ROFL :laughing5: I still have diaphragmatic spasms and my intercostals are aching from laughing at that idiot. What, he can't clue in as the CO2 releases and is blowing out of the corner of his mouth but he continues to drink it????

Paramaniac, thanks for the references. For this one that you included above, can you refer to the source of the article so that I can obtain a copy? We are also well versed in th DH document "Taking Healthcare to the Patient, Transforming NHS Ambulance Services". Out of curiosity, are you involved as an ECP? As well, which trust are you working in and if you don't mind me asking, which municipality? Cheers

Great place to work is different than being innovative and progressive. If they are innovative, how and why? They have nothing on their website that says that they are like this.

Isn't that kind of like the same thing except that innovative sounds a little more sexy? These were only some limited examples, but I would like to hear what anyone has to offer, whatever it may be. Call it what you want, different, creative, innovative, etc. Something outside of they typical call progression of: person calling 911 -> EMS responds -> transports them to the hospital.

Hello all, I thought I would put out one last plea due to the dismal responses so far. Some of you must know of some EMS systems that are doing things differently than what everyone else is doing. Things like not responding to low priority calls or transferring them to a more appropriate telehealth system, ability to refer patients to other serivces, or how about the a policy or the ability to refuse to transport a patient?

Out of curiosity and no offence intended, but why would you end up in court over it? It's an honest question becuase I'm not familiar with your judicial system and how it would apply (civil or criminal).

Are you familiar with how media obtains their information? They review arrest reports and themselves determine what is news worthy. It seems that your comments of their crimes going un-noticed/mentioned is based on your perception. You obviously heard this news report and it struck a nerve because of your personal bias to it being reported. How many news reports are there nationally on a daily basis reporting people being arrested for child pornography and child molestation? Probably thousands. The majority of these would be normal citizens with normal lives, some are probably in a position of respect or authority within the community. You probably miss it because it happens all the time and we as a society become desensitized to it. You agreed that "While as public servants, we should be holding ourselves to a higher standard" so too does the media and society as a whole, hence why it appears media. Do you think that it impacts the overall opinion of us because of this one incident? Do a media search and you will find that I am right. Does it suck that this gets reported? Absolutely. The fact is, no one is immune to what is reported by the media regardless of who you are or what our occupation is.

How about Mag Sulfate? As well, fluids in asthma has been proven through studies to have no value and doesn't improve patient outcomes.

Wow, you had me royally peeved there for a minute until I went back and re-read my post. I do apologize as I had it bass ackwards :? I guess that's what I get for not reading it before hitting the submit button, not that it would have helped :oops: . And it is indeed indicated in acute bronchospasm.

Because there are very few reasons why you would want ipratropium (Atrovent) by itself, purchase it in the Combivent/Duovent form. We use it in pre-mix of 2.5 mg albuterol (salbutamol/Ventolin) with 500 mcg of Atrovent but add 2.5 mg of albuterol for a 5 mg/500 mcg dose. Atrovent only really works well in reactive airway disease (asthma) and doesn't do much for chronic bronchitis and/or emphysema (the COPD pts). It works well in the younger patient with isolated bronchospasm from asthma and doesn't generally do much for the COPDer's. Why? The reasons have been indicated, it is synergistic in it's effects when combined with Albuterol but also works by a different mechanism. As it is an anticholinergic, obviously it works by a different mechanism, essentially it is working through the back door. As opposed to trying to stimulate Beta II receptors to cause bronchodilation it blocks the cholinergic effects that cause, as well as the secretions (the asthma triad - 3 S's - spasm, swelling, secretion). It's onset of action is slower than albuterol and is delayed but it has a longer duration of action. Similar to a corticosteroid, it can help reduce a rebound effect.

I adimantly disagree. I will agree with the fact that it doesn't neet to be sensationalized in the media because of his occupation, but as a member of a profession that is expected to be held to a higher standard by the public as well as our co-workers or other industry professionals, it matters more. It is an abuse of the trust that we are sworn (figuratively) to uphold and respect. It's bad enough to live in society with people with this kind of issue and I do feel sorry for them, but it's worse if I have to sit beside them and work with them every day. Think back to the day that you had the febrile seizure that your partner disrobed and cooled with tepid water or that 12 y/o female multisystems trauma he 'exposed and examined' and you wonder, 'what was he thinking' or 'what was his motive'? He explained to the parents what he was doing and why and they agreed because they trust you implicitly without question, saying 'do whatever you need to do.' Sure maybe it is a person that has some issues and problems that need to be dealt with. But what if it is someone that is a predator working in this field with specific intent and a purpose? I guess that it doesn't matter and it doesn't need to be viewed differently based on their job function. I guess that's why he ends up losing his license/registration to practice and is banned from the industry.

Like tniuqs said, I can guarantee that if you look at Alberta you will have no difficulty finding any work with an average starting salary of over $20/hour and easily topping out at a current average rate of $31 (with plenty of larger services more in the $33-34 range, plus add holidays, overtime, etc) Add to that excellent benefits which add another $8-10/hour of comparable salary. I won't even mention industrial/oilfield work but if you are a family man, probably wouldn't be considered (huge money potential if so desired). The difficult part would be the equivalency process and getting registered but coming from the UK, may not be too bad. If you are willing to invest the time, effort and a little money, it can be done. Plus you would probably be better suited to our scope of practice where you may feel more at home. Not to mention the fact we are a Commonwealth country (unless you are wanting to run from the Monarchy), we even have the Queen stamped on our coins and printed on our bills.

tniuqs, thanks for your support. I'm humbled by your public statement of your current position, not that I actually think you were that opposed to it before as compared to you wanting to push some buttons. As for the question at hand, I would be willing to do it and somewhat comfortable with performing the procedure in this situation. I think that it is clearly obvious what is happening with a high degree of specificity and selectivity. A patient with known effusion, clearly demonstrating Becks triad, showing signs of obstructive shock that deteriorates into a PEA arrest. Let's call a spade a spade. Given this scenario, I think it is quite clear as to what your course of action should be. You have two choices, do nothing and continue on with a futile attempt to resucitate an arrest or do the centesis. To follow 'ACLS guidelines' for a PEA arrest, you can estimate they have about a 99.9% chance of remaining dead at upon arrival at the hospital. Unlike the vast majority of patients that we work as an arrest, this patient actually has a healthy and viable heart. You can not perform effective CPR with any respectible amount of cardiac output when the atria and ventricles will not fill with blood due to the compression of the effusion. In essence, you confirm the patients death sentence. If you perform the pericardial centesis, I would find it hard for anyone to successfully litigate your actions or to have an autopsy find that your procedure was a contributing factor to, or the cause of or death itself. If anything, it is possible to be suggested that your lack of actions were actually a contributing factor. I would even go so far as to suggest that the odds are at least 2:1 in favor of the patient surviving compared to you being sued or losing your license. In my opinion, if it is within your scope to perform a pleural needle decompression and it is within your comfort zone to do the same, you should be more than able to do the pericardial centesis. You can use the same equipment as well as has already been suggested. Even if you don't have a long enough angiocath that would be preferred, a regular 1.5 or 2 inch should be sufficient if you used the left sternal border approach as opposed to the sub-xyphoid location. Keep in mind that the effusion at this point is probably <100 ml's as the pericardium has been able to accomodate with a slow stretch. This subsequently provides you with a larger target both in size as well as proximity to the chest wall as well as having a larger buffer zone to avoid hitting the epicardium, unless you lacerate a coronary vessel or rupture the myocardial wall, isn't significant. Even incising the pericardial sac would be an acceptable result with probable patient improvement. I think that what is guiding a lot of people opposed to performing the procedure are a lot of assumptions. You assume one of or any combination of the following: - discipline or reprimand from your service or medical director up to and including dismissal - discipline or loss of licensure from your regulating body - making things worse with the patient - litigation from family - others not listed but can easily be a factor The problem that I see is that these assumtions are just that, people assuming what the end result of their actions would be. What about if the family brings litigation against you because you - refused to follow the orders from online medical control. Or, what about your medical director coming down on you too? - you failed to act by not performing a procedure that in this scenario will have essentially a 0% complication rate (either it will work or it won't) - you failed to perform a procedure that is known to be the only thing that will give the patient a chance to live another day? A 10% chance of survival (this is being extremely biased, it's probably greater than 75%+ chance) is better than a 100% mortality rate. From a statistical perspective, this is very significant and in your favor. I agree that there is no right or wrong answer although I do disagree with those that simply say "no I wouldn't do it" or "I can't do that procedure". Consider this, what would be acceptable to you if either you or one of your family members were this patient? I have a tacky analogy for you to compare it to, think of it like this well known saying: "It's better to have loved and lost than to never have loved at all." My personal comfort zone as a patient advocate is I would be willing to lose my job, license and livlihood with this patient in this situation if they were able to have another christmas. If it were an end stage or terminal illness, that is a different story all together.

I used Bates' 8th Ed and really like it. Haven't seen Mosby's though so I'm biased.

Are you calling me a moron?????????? What we would be looking at doing though is trying to change what needs to be changed regarding scope of practice (although that isn't as big a hurdle because it is pretty much already expanded as I'm sure you are aware) as well as legislation. It is futile to expect to utilize something 'special' if there isn't a system or process that formally supports it. Hence the work we are doing.

To help a Canadian brother out, what is an "advanced paramedic" and what do they do. More importantly, is anyone employing them, and if so, where, and what are they doing?

You are correct on Queensland, although it is more in depth than that. Dust, there are places in the good ol' U.S of A that are doing something like this, although most are either hospital based or are municipally (or county) based services. Once I get more info, I can post here who and where they are if you would like.

Does anyone else have anything to add to this at all?