nsmedic393

Hi there, been quite a while since i posted in this forum. Here in Nova Scotia, we have been running a community paramedicine project for almost ten years. It was started in a rural community with no physician access (actually on a island, two ferry boat rides and a hour drive from the nearest hospital). The model involves a nurse practitioner assesing and treating patients in a clinic setting with local paramedics doing home visits, follow up checks and blood draws. The paramedics perform such assesments as weight for patients being treated for CHF, fall assesment, dressing changes and suture removal. The program has had moderate success and is definatly a assett for this type of isolated community. Along the same lines we have started a new program in the last two years called the extended care paramedic program. This program is based in a large city and i feel offers a large benifit in terms of keeping ambulances avaliable for emergencies and keeping the elderly patients out of the hospital with alternative treatment options. The short of the story is that specially trained ALS providers respond to almost all nursing home calls. They assess the patient and treat them on site in consultation the patients physician, our medical oversight physician and the nusing staff. Sometimes these calls can take 4-5 hours. The patient is transorted to the hospital only as a last resort if x-rays are needed or treatments not avaliable to the ECP. Some treatments they do provide are suturing wounds, IV antibiotics. Here is a link with a basic overview of both programs. http://www.gov.ns.ca/health/ehs/

I know this is getting off topic, but spec, the fact that you cant even name the different levels of paramedic in canada speaks to the fact that you dont have a clue about the care being provided or the education that is behind that care. Nobody is confusing anybody. When you call 911 with a medical emergency, a paramedic shows up at your door. What level of paramedic depends on the avaliabilty or capabilities of the system. Either way its symantics...your system has its emts and our system has its primary care paramedics at the basic level... I believe that our basics have earned the right to be called paramedics

I completely agree...if that be the case then it would be well worth investing training more ALS than trying to upgrade BLS. I hate to get onto the whole "this is what we do here" thing...but i speak to what i know. In most areas of the province we have enough ALS. If one truck is not ALS than there is usually one close by. So i guess i was speaking to the MI numbers alone because the situation you portrayed is not happening here. 100% agree though...ALS problems need to be fixed first before trying to baindaid the problem by buying more toys.

tniugs... Once again you have beat me to the punch...and in a far more elegant fashion than i would have done. I sat here reading this thread with steam coming out of my ears getting ready to let loose with both barrels.... While i realise that basic training/education is not standard...here is what we have going on here in NOS. PCP aka. basics do perform 12 leads, they should (and i say should) be able to interpret that same 12 lead without reading ***ACUTE MI*** The benefits??? Angioplasty is not a option in 99% of NS as there is only one catha lab in the province...Like tniugs pointed out though...thrombolysis is a option available in every little back woods hospital let alone a regional hospital or tertiary hospital. Sorry dust, i don't agree with the whole loose ten minutes to gain five. We have all agreed that to some degree there is only so much a basic can do for a patient suffering from a acute MI right??? well how about this...instead of the basic sitting on his thumb for the ride into the hospital, they do a 12 lead, interpret it, fax it to the receiving hospital, call the receiving hospital...not to ask for direction but to give a verbal report on the patients condition and history so the doctor has the full picture...then they complete the provincial pre-thrombolysis checklist so upon arriving at the hospital for all intents and purposes the physician can immediately administer thrombolytics. The basis on our treatment of Stems has been to reduce the "call to needle time" and given the fact that we are in the process of rolling out with pre-hospital thrombolysis i think the debate is mute anyways. It all decreases the amount of time the patient spend infarcting before receiving possibly definitive care.

WOW...thats a strange thought process to go down... I dont think it is completely out of this world that a medic confronted with that situation would consider amputating the childs arm. Some of my thoughts would be... 1. is the child certainly gonna die because of the fire and am i going to bear witness to him/her burning alive?? 2. While i know i dont even have half a clue about how to amputate someones arm, would it be worth it to try knowing the child will die?? 3. Do i even have the equipment to perform such a procedure (even if im doing is half assed) I know the fire department has a half dozen tools that could do the job in a pinch, but if they are on scene i would want them concentrating on putting the fire out, not chopping limbs off. This is one of those theoretical things that no matter what anyone says...i dont think anybody can say they know for sure what they would do until they are standing there looking at a kid who is trapped by one of his limbs in a car that is on fire. By the grace of god hopefully nobody ever has to be put in that position.

I completely agree.... First impressions are very important. Make sure your uniform is clean and tidy, you have all the necessary equipment and paperwork you will need for the shift as a student. Come in with a positive and open attitude and make sure it is clear to them through your words and actions that you are there to learn. I know personally as a preceptor i like it when a student has the attitude that they are there to learn as much from me as they can... I have had students with the "know it all" attitude and if it doesn't change in a hurry than i usually tell them that if they know it all there is nothing more i can teach them, and say goodbye. Reviewing the calls with your preceptors is also a great way to learn and build your preceptors confidence in you. Be prepared to explain not only what you did, but exactly why you did it. "because it is the protocol" is not a acceptable answer...we are talking A&P and pathophysiology here... Im sorry...but im gonna have to disagree here... Not every patient you see is going to need all of these treatments...EKG and BGL are pretty standard on every call but not necessarily a priority. I would be more impressed by a student that was able to evaluate a patient and decide on a appropriate treatment plan based on what this patient actually needs than one who is just running down a predetermined list of things to do... And lastly...the advice i give to every student and all paramedics in general. Everyone makes mistakes...What makes a great paramedic is that when you do make a mistake, you own it, learn from it and apply what you have learned to future patients. You follow that philosophy and you wont go wrong...

While it appears that this thread may have gone off topic a little...ill throw my two cents into the ring... While this little gatget appears pretty neat, and in some places with limited dollar resources where a ekg machine is needed it may be a more affordable option, in my ambulance and among my regular gear, i have no use for it...Come talk to me when they can fit all the functions of my LP12 into a palm pilot...

And the poster boy speeks :wink:

My advice...learn to memorize... When i was a student doing my ride time that was the philosophy that my preceptors had and it is the approach i still take today, and it serves me well. You may not always have a pen and paper but you will always have your memory. That being said, if i am running a really crazy call than i will key in blank events on the lifepack (if its a busy enough call that i have trouble remembering when i did treatments, the lifepack will be hooked to the patient and within reach). Then all you have to do is remember what order you did stuff in and match it to the events. Everyone will develop their own techniques for chronicling what happened on a call but i use my memory and if you are able then i recommend you do the same.

Here in Nova Scotia, we have one ambulance service which is responsible for all patient transports withing the province, be they emergency or transfers. Aside from a handful of ambulances that are dedicated to patient transfers all of our ambulances are marked in the same fashion, because the same truck that is taking granny from one hospital to the other will be available for emergency calls as soon as the stretcher is clear. Our normal ambulances are marked with the provincial providers name as well as "paramedics" decaled down both sides. "ambulance" is decaled on the hood and the rear doors in smaller lettering. I feel this emphasizes the mode of transportation as well as the health care providers that occupy that vehicle. Transfer ambulances have "patient transfer unit" decaled on all sides and have amber where normal ambulances would have red and white lights. As far as terminology goes, it is very rare to hear someone in my area refer to a ambulance as a bus. When you do hear it it is usually a fairly new medic or occasionally a senior medic that has been wathcing too many third watch reruns. Happily enough this type of slang is usually met by odd looks and disapproving glares from any paramedic standing within earshot. Common terminology for ambulances in my area: While on the radio they are called by their unit number only. ie. "136 copy control" While talking to a patient or nurse in the hospital they are called ambulances ie. "we are going to lift you onto the stretcher and move you into the ambulance" When conversing with other paramedics I usually call it a truck. ie. "if you ever finish your charting ill be waiting in the truck" "136 go mobile for a incoming call" (responding) "copy that, going to the truck"

Here it is required by the schools for all students to have two preceptors, 500 hours with one and 500 with the other. Personally i think it is a great practice, as far a quality control the student is evaluated by two independent preceptors. From the point of view of the student, they have the opportunity two learn from 4 medics instead of two (partners included). You can never go wrong learning how different people approach the job.

I know when i was a student, especially a PCP student, i had difficulty nailing down my patient assessment to the point where it was fluid, comfortable and effective. My main complaint was that i knew that there was a difference in parroting the SAMPLE OPQRST assessment that we had all practiced over and over in class and how a competent experienced medic did their patient assessment. I remember wishing that i could just once or twice sit back and watch my preceptors do their thing instead of always being the one out front stumbling along trying to find my own way through it. Thats why now when i preceptor a student i usually offer to do the patient assessment a couple of times while they listen and watch. I know that my patient assessment is way different from what was taught in school, i like to quickly get at anything big that has a chance to iimmediatelykill the patient and then work out into the smaller more finite issues that may be the cause of their current medical condition, but thats just me and i ddon'tfault students for for having their own style of patient assessment as long as is effective. If i were you i would ask to simply watch your preceptors do it as they normally would without you a couple times. You may pick up little tricks or techniques or styles that they employ and then you can take that and incorporate it into your own style.

I work a 42 hour work week. 24 on and 72 off. Max shift time is 36 hours straight.

I might as well speak up on behalf of us in NS. We do have a operational community paramedic program in one community in the province and are in the works of developing several more. The community currently being served is Freeport/Westport. They are located over a hour away from the closest hospital and are in fact two islands at the end of a long neck of land. We have a unit stationed there 24/7 as part of our SSP. Due to the small but elderly population, being unable to get a doctor to cover the community, and the large ammount of down time for the medics working in that post, the CP program was established. The paramedics work in co-operation with a nurse practitioner and a medical control physician from the local hospital. As the link indicates, they do wound care, suture removal, daily injection meds, blood draws, home visits for CHF assesment and falls assesment, they also have a adopt-a-patient program where the doctor identifies a patient in the community requiring specific attention and they are assigned a specific medic that monitors their overall condition. Hope this helps

Fiznat accuratly described what diagnotsic mode does. To get the machine into diagnostic mode if it does not com on automatically is a little complicated. 1. Turn the defib into manual mode by pressing the advvisory button and selecting yes to manual mode. 2. Ender the alarms menu by pressing the alarms button and turn of the vfib/vt alarm function. 3. Enter the options menu and select print. 4. In the print menu select diagnostic.

When out of nowhere the patient turns white, clammy and turns to you with a look of fear on his face and says "man....I think i'm gonna shit". We know what happens next....

I would stop working someone if they were in asystole after being treated with full ACLS. There is aboslutely nothing more that is going to be done in hospital. Why take them there with the L+S going only to have the doc pronounce as soon as you wheel in the door????? :? Do your ACLS, call the online doc and then terminate your ressuscitation efforts. Dead is dead. I would like to know exactly why you think that they need to be in the ER before efforts are terminated.

I am going to assume you mean for the patients We use IM/IV gravol.

We have a c-spine clearance protocol. Basically it says if any of these conditions ie. fall greater than 6 feet, high speed/roll over mvc, significant MOI...to name a few, you must secure c-spine. Like anything else it comes down to common sense. Go where your assesment leads you and be ready to justify your actions.

This thread has provoked the hamsters in my head to do some serious running... While i have stated previously that I am not opposed to bending the rules, the things that I am willing to do that bend the rules are things that the medic has been educated in, but not necessarily allowed to do. I don't believe people should be doing procedures that they have not been educated on or even seen done. To do such a thing, in my opinion, is dangerous and stupid. If i could make the analogy of fixing a car.....I would change my own oil because I have seen it done, read about it in books and am fairly certain it would not make my car blow up... I would not say attempt to fix my engine with a mechanic giving me directions over the phone because I am not reasonably sure that the outcome would be positive. All that being said, how many people here would be comfortable doing a procedure that they know nothing about. For the basics- If the online doc told you to intubate or decompress the chest or even start an IV would you??? For the ALS providers lets use the previously mentioned example of a traumatic arrest of a patient who is 8 months pregnant. Would you perform a c-section with instruction from the online doc even though you have no formal education in how to do it? I'm just trying to guage where people think the line is. What is an acceptable deviation in protocol and where do you draw the line and just say no?

That would be a little bit of slang/humour and I'm sure you won't find it in any textbook. Think of the 1-10 pain scale. This would imply that 1 is not sick and sick (at the other end of the scale) is sick like you have never seen sick before...

i gotta side with Magic here. I don't find this video the least bit offencive. If two consenting adults want to slug it out in front of the camera by all means go ahead, and if someone wants to post it that is their right too. If you don't like it don't watch it. I also saw many movies like this in school along with some of the grossest pictures my instructor could find. We even had a silly name for these photo/video sessions but i can't remember what it was at the moment. This is a textbook case of snoring respirations, although i'm sure it would have been just as effective as a learning tool without including the brutal beating i doubt that magic knows how to edit it out. Kudos for putting up a video that demonstrated a textbook learning case evne though it included a brutal beating.

In reading the replies to this thread, and i think i'm noticing a little bit of a trend (feel free to correct me if i'm wrong). It seems to me that the ALS providers are opting not to perform the procedure and the BLS providers are saying they would do the procedure. So a question for the BLS providers....At your current BLS level, presented with a situation like this and no ALS avaliable to intercept would you consider doing this procedure at the direction of an on-line doctor?

I on the contrary think that this is the type of protocol breach that should not ever, ever happen. I have given my opinions on basics pushing meds and have admitted deviating from protocol but performing a pericardial centesis is absolutely out of the realm of anything i would consider doing. At least with a basic pushing meds, someone in the same room as the patient is educated in how to do that procedure. With a basic starting an IV or even intubating (for arguments sake) for their medic is still a better scenario than pericardial centeses again because at least there is someone there that is trained in the procedure and can intervene before/if something goes wrong. I know that it is not even close to being in my scope of practice,I have never even seen one done and the clincher is that it is something that I am not comfortable doing. Will not happen. I don't condemn the basic that pushes meds for their ALS partner, I condemn the basic that does something he is not comfortable doing.

As for the question of where to draw the line, I say let someone else draw it for you. If your medical director would hang you out to dry for operating outside of your protocols/scope than I would suggest you not do that. Here we have always been given the benifit of the doubt and our director and QCMs have been very understanding when we have needed to bend the rules a bit for the sake of the patients. In some cases we bent the rules, explained why and then the rules were changed.