melclin

I just can't understand how you could get a scene time of 10 mins. My scene times are routinely 30+ mins. When we're really moving that might peak under 20. Anyone got any insight into how jobs are being run to achieve these 10min scene times?

I've had: - ~3 male and ~4 female GPs/PCPs - 1 male dermatologist. - 1 female Intensivist. - 3 male EM physicians. - 4 male psychiatrists. - 1 female general surgeon. - 1 maxillofacial surgeon. I can safely say that on average, I couldn't give 2 stuffs whether they had lady or man parts; if I feel comfortable with them, I feel comfortable with them - simple as that. For me, it depends entirely on the individual.

True, but I think your missing my point about the fundamental focus of the paramedic vs nursing undergraduate education, which was really my original point. Most of those skills listed their are quite advanced and are not predominantly things that graduate nurses do. I keep saying, I'm not having a go at nurses and people list skills and talk about how wonderful nurses are. I concede that I was unaware of the extent of the scope of advanced practice nurses in some settings, however, that is not terribly relevant to my main point which was basically if you are looking for an affective way to educate prehospital professionals, the best way to do that is begin with prehospital qualification, because of the specific skill set required. I happily agree that good ICU/ED nurses would make great paramedics, but as I said, to require prehospital professional to be great ICU nurses before they can step onto an ambulance is an overly round about and unnecessarily long pathway to EMS (with the corollary being that a nursing undergraduate degree by itself is by no means equivalent or superior to a paramedic degree when it comes to prehospital care, which is a common argument in the states where the prehospital qualifications are inferior, and I wanted to provide a picture of a system where that was not the case). Some of the things I said "dissing" the average grad nurse was my attempt to explain to the Americans that a BSN in Australia is not equivalent to an American BSN which is a higher qualification as far as I can tell. Of course not, but to be far I didn't really suggest that. I have obviously touched on the a nerve that many nurses and paramedics have (students like me included) that involves raising ones temper when people assume a much lower level of practice that you actually have. It appears some of what I have said has been the equivalent of calling you an ambulance driver, and I do apologise for not being more familiar with the extent of higher levels of nursing practice. However, again, this was not fundamental to my point about the fundamentals of the undergrad education. Also, importantly, I often make a point of the fact that I'm a student. I don't claim to be coming from a position of any particular expertise and my point was primarily about something that I am familiar with, which is the nature of the paramedic and nursing undergrad education. I do however, maintain that almost every nurse, some of them quite highly qualified and experienced, that are now doing my degree have said that it is a much different ball game - that it is much harder than they thought when its all on them and them alone, especially without the support structure of the hospital. You can take or leave my undereducated and under-experienced opinion, but that is a pretty common sentiment from people who have actually made the switch. I was also on placement with two experienced paramedics, who were originally ICU nurses and wanted to return to nursing, who were complaining angrily of the re-certification requirement on the grounds that they do more as paramedics than they ever could do as nurse. So I feel my opinions are not totally baseless, but your're right, I know very little about the nursing field, but I never really said I did beyond the graduate component. No it isn't. But I can see how you would think that looking back on some of my posts. I apologise for my obtuse use of language and broad generalizations. Yes it is that way in America, but things are a little different here. I take your's and Vent's point about a false sense of autonomy, but I do think that depending on the extent to which you are willing to defend your decisions, we have more autonomy here than perhaps you realise. I think the point here is the difference between guidelines and protocols, while some here argue the difference is only the name, others feel that they can basically do whatever they want if they can justify it, and that is different to a lot of American systems, which is what you appear to describe. I don't of course want to start a pissing match about who can do more because it is evident that, one, I already did that without intending to and I don't want to continue it, and two, I obviously don't know enough about nursing to do it. What I will say however, is that I think the above paragraph shows a bit of a misunderstanding about some of the aspects of a lot of Australian paramedic practice. I don't know your background, so I obviously can't say for sure, but the above does sound like an odd interpretation of Australian practice if you are aware of its specifics, so I'd like to humbly and tentatively suggest the possibility that you may be more unfamiliar with modern paramedic practice here than you realise. Forgive me if I have misinterpreted your words, and that you are actually the CEO of Ambulance Victoria, which could be somewhat embarrassing on my part . Midwives absolutely do not need to be nurses first - http://www.med.monas....au/bmidwifery/ I can see that I have offended you and, as I said, I do apologise. I was wrong about a number of points but I also think you misinterpreted the main point of my post perhaps because of its inadvertently offensive nature....This feels familiar . Oh and the creatures remark...I just assumed that all health care professionals ate noisily from horse troughs and made abhorrent noises and gestures when displeased. Is that not the case of nurses?

VENT: Its important that to me that you and everyone else in this thread not think that I was having a go at nurses. In saying that I don't think they are educated to make certain kinds of decisions, I just mean that's not where I believe their expertise lays. As I say above. The critical care nursing you mention is quite different from intensive care nursing here as I understand it but I may be wrong. That's why I added the caveat about nursing appearing to be different here than in the states. Nurse in all fields do seem to have rather a lot more direct medical oversight here than they do in the states. But I'm no expert in nursing. Also, I'm certainly not saying that its impossible for nurses to be able to made clinical decisions, from what I've seen of chbare's posts I'd prefer him/her (?) treating me than most paramedics, nurses or doctors I've met. So at the higher level of CCT nurses, that may be a different issue. What I'm getting at it that if you have a field that requires not just the best (you CCT nurses in this example) but all practitioners, straight out of uni, to be making these decisions, you have to ask yourself, do you want a person who has been taught from the word go how to make autonomous decisions in the prehospital environment, or someone who's education is very general, focused on observation, advocacy and carrying out treatments ordered by others? Eg: You take the ~300 paramedic grads at the end of this year and compare their ability to make sound autonomous decisions in the prehospital environment to that of a nurse graduate. If, after uni the graduates then complete equal postgraduate formal education, the Intensive care paramedic is still above the Intensive care nurse in terms of the percentage of their education and experience that is devoted to autonomous decision making in the prehospital environment. Absolutely they are not mostly trauma and codes, but you asume the paramedic degree is predominantly about that, when in fact it is not (we have returned to our old problem of the difference between the American and Australian systems). One out of twenty of my units was trauma based, and code related components have been spread across about 3-4 of those units. The others are very much about community health and well ballanced understandings of many medical and psychosocial problems. Far more so than the nursing degree I believe. For example, among other things, this semester, I have to evaluate a community based disability support project using our previous book learnins in public health and using techniques for health project evaluation, I also have to design an education package regarding a issue of special needs in the geriatric population along with a plan for its implementation and target audience using our established knowledge of public health and epidemiological fundamentals. Unless you chose to undertake subjects of that nature, the nursing degree tends to be quite specific and it is fifty percent on the job experience, which, while useful, does not help you get a broad and formal education in way that a university subject does. Compare that to the wide range of community, ambulance, hospital (obstets, emerg, psych, ICU, theatre) and disability placements we have to do on top of actual three years of formal education. In our degree, roughly 45% people already have degrees, often in health fields (AnP, human movement, nursing, one girl even has a masters in public health). I wouldn't consider any skills learned in the nursing degree to be useless per se, but they focus on particular ideas more than others, while ignoring many issues that are important to prehospital care, let alone ignoring the much discussed skills portion of being a paramedic. Many nursing grads man learn to identify breath sounds only if they are in streams that are emerg specific, none can perform a patient assessment in the same way a paramedic can. The average nursing graduate cannot, for example, cannulate , its not part of the degree. I hope this just gives you a bit of an idea of why our nursing degree is less than you would be familiar with and why our paramedic degree is much more than you may have in the states. I have to qualify this all by saying, I'm not an expert in the nursing eduation system, I go by what I hear from double degree students who are undertaking both degree simulatneously over an extended time frame, from what I've read, and the classes I've shared. Here are some links to the nursing, paramedic and nursing/paramedic bachelors, that might be more informative (and accurate) than me. http://www.monash.ed...urses/0727.html - nursing http://www.monash.ed...urses/3892.html - nur/medic http://www.med.monas.../structure.html - medic

Well, no, but what else have I got? There seemed to be a 'paramedics aren't educated enough, so using nurses would obviously be better' vibe going on and I thought I'd present a view from a place where your average paramedic actually has slightly more education than the average nurse, not to mention that the entry requirement for a paramedic degree are much higher. Specific to the dutch system, they clearly have a system that works well, but I do think they are requiring unnecessary amounts of nursing specific education for ambulance professionals. If you go back to the question of should I have a nurse or EMT based service and you live in the Netherlands, then it would make more sense to have nurses given they don't appear to have paramedics in the same sense we do. I was commenting on what I thought to be the ideal, rather than what was practically the best idea for someone for example wanting to staff ambulances because I think the conversation has moved significantly beyond giving advice to a general discussion of pathways to EMS. I would say though that I can't really make these assertions with any confidence without knowing the educational systems intimately. I do, however, know a little about the Australian bachelor of nursing degree, and I know what its students/graduates are like, I go to school along side them after all, and while they may have many talents I don't, I wouldn't want to see them in the back of an ambulance. Its by no means derogatory. I couldn't be a nurse with a paramedic degree, and I don't think you can be a paramedic with a nursing degree, and I especially don't think you need to have nursing degree and experience before gaining paramedic qualifications.

I have to say I don't like the idea of using nurses in the prehospital setting. Here at least, a nurse and a paramedic are very different creatures. Paramedics have a greater scope and almost complete autonomy. They also have slightly more education than nurses although the more important point though is that it is different education. Paramedics here tend to be taught along the lines of diagnosis. Critical thinkers who can problem solve and apply their knowledge appropriately to figure out whats wrong with a patient and treat accordingly. In this sense, our training in more in the spirit of medicine rather than nursing. It has to be that way, because we don't have medical control: we sort of have to be watered down doctors. Nurses are the educated eyes, ears and hands of doctors, and while in practice, they are much more, their training is still based entirely around the idea that they are part of a team that necessarily involves direct medical oversight. Take away a nurse's support structures, other nurses, doctors, fancy gear and I think you've got problems. I've often heard nurses saying, well the doctor should be doing this and that and the other thing, but I wonder how confident they would be if the decision to paralyze and intubate or thrombilyse over PCI, decide on the amount of fluids that post-severe haemorrhage pt should get, leaving a pt at home after deciding that they aren't sick, actually rested on their shoulders. Most of my degree is about educated clinical decision making. When it comes down to (and correct me if I'm wrong), clinical decision making doesn't lay at the heart of nursing. (I have nothing at all against nurses, I'm just saying the fundamentals of their education are not suited to the requirements of autonomous care. I think it is also important to mention that nurses in American appear to have more education, a greater scope, and a slightly different role than nurses here). Also, I think prehospital care is different enough for it to be its own qualification. It would be a pain in the arse if I had to do a nursing degree and, sit on a ward for 3 years, do my ICU grads, and then start learning about prehospital care. You don't have to be a nurse first to be physio, or an OT or a midwife, because while they are related in some ways, they are different enough to have separate qualifications - so is paramedicine.

I gotta say, for what its worth, I think the script is getting better. "Mmmmmm hot and nasty". "Yeah, just like my men".

I only skipped through this thread, but there are also some arguments out there that suggest that Fentanyl is better for certain types of pain than morphine and vice versa, but I think evidence for this is largely anecdotal. The criteria for analgesia is pain. End of story. I can't stand seeing some of these guidelines you blokes have over there..."if pain score >7 contact medical control for 2mg of morphine". Something worth mentioning about fentanyl is that it is highly lipid soluble and can be absorbed through nasal mucosa. So in the event of a difficult/delayed/impossible IV access, atomizing fentanyl up the nose is a good option. We have that option here, largely because we created our own evidence base for it. One of those professional things, building a discipline specific evidence base and all . Also on the list of uses, is in break through pain in chronically painful conditions..cancer etc. It can also be given in anesthetic doses without the haemodynamic effects of an equivalent dose of morphine for procedural sedation/analgesia (Synchonised cardioversion, RSI etc). Demerol I don't know anything about. Its use is very limited here because of some nasty interactions and we certainly don't use it. -USE OF PETHIDINE FOR PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT - A Position Statement of the NSW Therapeutic Advisory Group Inc. August 2004

You course appears to be recognised (by state education authorities - that means you can use the credit to transfer around). That's a good start - some aren't. I had a look at the course materials though and they are a bit misleading. There is no such thing as an EMT in Australia. Not in the sense that that it is an officially recognised position. If a person wants to read the wikipedia page on first aid and buy themselves a uniform that says EMT, they can. More correctly if a private first aid company wants to piggy back on the popularity of American TV and call their employees/trainees EMTs..they can. Its doesn't mean anybody employs "EMTs". That said it seems that QAS recognise you qualification as a minimum level of entry into a Patient Transport Officer role. Thats something. Also, I understand QAS still take people out of highschool and train them entirely within the service. They might look favourably on someone who had gone to the effort of doing such a course as you mention and you may even be able to get some RPL, but there are no guarentees. The only way you can know for sure is to ring someone from QAS and tell them exactly what you doing and ask them what your options are. You best bet is probably QAS, because those diploma type things are quickly becoming obsolete in most other states. If you go off and play first aid on an oil rig for a while, you may come back to find out you can't use your diploma in an Ambulance service anymore.

That's the whole point. Its the deadpan delivery that makes it so funny. I want one of those always blow on the pie t-shirts.

"Oh and when I said he had no complaint, I meant to say that he fell down a flight of stairs and when I said resting comfortably I meant he is unconscious, I already promised the family that they can go to their local hospital which does not have trauma services" What a LOL!!

Yes, persistent VF. Stayed the same way as he presented until shocked into asystole later in hospital. We cannot call patients who are in anything but asystole. Which is why I think that the transport occured simply because they figured it was a done deal and needed someone to call it. I'm not sure he was necessarily considering transport when he intubated. I think someone else suggested it, which harks back to another issue I had with the management of he scene, but that is not the issue and it was not this particular medics fault. In his defence, he was not on duty when he got the call and agreed to respond POV because he lived nearby. Why, the dispatchers even bothered, I don't know, we (with another MICA medic) were not far away and he didn't have any MICA gear anyway so I'm not sure what use they thought he would be. Anyway...when we arrived with another MICA medic and MICA gear, the pt had already received 2-3 x epi, 5-6 x DCCS. We arrived with the gear but our medic didn't intubate, it was the bloke who had already arrived who intubated after two more rounds of compressions and one more DCCS (making a total of 6-7 at that stage). I think in total the pt had 5 rounds of adrenaline, but I don't recall the specifics on that. I think i mentioned the times a little earlier. I asked about the amiodarone, and it seems it was simply forgotten. The transport, I didn't and I won't get a chance to ask anyone who was there. It was a long way from home, and even if it wasn't, the uni and the service are completely separate entities for the most part, there is no way I could really get in contact with him.

White board sessions...they're fantastic. Either with friends or by yourself, you pick a topic, idea or set of things to remember and then you teach the person you're with (preferably someone for class so its useful for them. Also then they can ask questions and expose cracks in your knowledge) or even just pretend u have a class (I do this with disturbing frequency) and teach "them" the concept. Understanding the idea well enough to teach it raises the level of understanding you yourself have and it exposes weaknesses in your knowledge when you realise you thought you knew something but can't really explain it well when you "student" asks you too expand. Also, because its interactive, its much easier to get through large amounts of material without blanking out like you do if you sit down to read a textbook, when you'd prefer to be doing something..anything..else. You tube is an under utilized resource. If there is a concept you don't understand, plug it into youtube and there is a fairly good chance you'll find some wonderfully educational video that explains things better, or just differently (because often all you need is a slightly different perspective) and helps you to understand things much better. There are many videos for things like the development of an atherosclerotic plaque, cardiac electrical systems and mechanical function, muscle contractions and endocrine/biochemical topics. Basically anything that involves a dynamic process (something that occurs over time) is better described with a video than a picture in a text book. Don't be afraid to ask guidance from wikipedia. Don't ever take anything it says as gospel truth, but I don't care what anyone says, it is a helpful tool for quickly gaining an brief and simple overview of topics related to what you're working on but that you don't necessarily need to know in detail and would require literally hours of pouring through text books to find and understand. The online Merck manual is also good for this, searchable through google, and can be taken as gospel truth as much as any textbook. I have a copy of a number of helpful free e-books which are particularly useful because they are electronically searchable unlike their hard copy counterparts. PM me if you're interested and I'll figure out a way to get you a student copy.

I agree with you. This guy is just not sick enough to need pressors in the prehospital environment. If a consultant EM or intensivist reckons its a good idea with considered assessment then maybe, but Charlie doesn't need me to mess around with those kinds of things in the 15 or so minutes I'm with him.

I'm not sure that dopamine is a good idea given its chronotropic affects and I don't think its worth the risk - the pt isn't ill enough to warrant dopamine in the prehospital environment. I don't think he's at the blood pressure at all cost stage yet and I wouldn't be comfortable giving a drug that affects his heart significantly, while not knowing exactly whats wrong with his heart. Is dopamine indicated for endocarditis/mycarditis? I would have thought you'd want all inotrope and no chronotrope for that sort of thing. Maybe if we had noradrenaline. I would move up to CPAP only if I couldn't get good oxygenation from ~100% and frusemide is best left for when fluids I/O and electrolytes can be monitored and managed, if at all. As for GTN, I don't feel like killing a man today, so I'll keep that safely tucked away The MD, did he ever find those chest films?

I think you can reasonably assume that it would be Celsius. Other than the fact that pretty much everywhere in the world uses Celsius, I would imagine a patient with a temp of ~3 degrees C (38.5F) would probably not be 'complaining' of anything. Seeing as though, I've seen this on another thread, I won't give away the answer - but these were my first thoughts when it over at the Life. The apparent sepsis, minus a tachy and with an ECG showing me a heart in a bad mood - I thought one of the carditis' or maybe pneumonia causing some kind of secondary ischaemic heart troubles (as with secondary UA). I would consult for appropriate use of ceftriaxone although I don't think he's sick enough to warrant it in the pre-hospital setting. Other than that I would load and go with a couple of liters depending on the pulse ox I reckon. Who asked for salbutamol? That seems like a silly thing to do.

All in all I thought it was a poor effort, the first attempt seemed doomed from the beginning because of the patients position precluding the medic from visualizing the airway properly. But thats something that should have been remedied before hand. We get crucified for not moving the pt to a more suitable position for airway management and CPR at uni during pracs, so its certainly not beyond a MICA paramedic. The pt didn't receive any amiodarone, because it seems, the medic simply forgot. To make matters worse (IMHO) after about 15 mins they (not my crew) transported to hospital, CPR in progress, and we all know how good for the pt/safe that is. I can see no proper clinical reason why that would be and I was quite surprised to hear everyone on scene agree with it when someone suggested it, maybe I missed something. The hospital did nothing we could not do except call TOD (pt have to be in asystole for us to call it), and I suspect that may have been the reason. Anyway, whats the go with tubing with compressions in progress? (Ben, do you blokes pause for LMA?) It seems to make good sense to me, or at least to do as much as possible and just cease for a few seconds to do the difficult bits, what ever that may be. I've never tubed a real person, so I wouldn't know if this is rubbish or not, but I've heard of it being done.

Posting from work so I must be brief. More info on request. To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable. This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube. I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

I am all for harm minimization, although I'm sure of the efficacy of pamphlets specifically. I listened to a couple of speeches recently. One by Dr Alex Wodak and another by Norm Stamper. Both on the uselessness of the "war on drugs" (seems likes its been a popular topic on ABC radio of late) and the supposed benefits of the legalisation and regulation - it seems solid to me. They've got my vote. People will always want to have sex, get wasted and seek various other thrills. Simply trying to stop them doing it is short sighted and unrealistic. Chastity this and promise ring that, prohibition, banning condoms, zero tollerance drug policies...none of these things ever seem to work. You may as well accept that people will always want to be involved in this kind of behaviour and try and minimize any harm that comes from it.