WolfmanHarris

FD not withstanding this video sums up well one of the big issues I've been having early in my entering of my profession. The lack of pride in one's profession. I don't mean in the whacker, bumper stick and t-shirt way, any slob can do that. We don't seem to get too much of that around here anyways. I mean pride in the sense of: clean pressed uniform, washing the truck (not decon, just washing), keeping the station clean, fully checking bags, fully checking the truck. All things considered, and looking at the problems making the news in services south of the border, I'm confident in saying I work with a dedicated, well educated group of professionals. I rarely see a bitter, burnt out medic with crappy patient care, and when I do they are recognized as the oddity, someone to be moved to a quiet station to count the years until retirement. I find it difficult to find fault with how anyone I work with does their job, on scene. But I find the corners cut or missed on these fringe areas frustrating. What issues have you guys faced in your own time with pride and that sense of ownership? How has it been addressed? What worked or didn't?

That's where I disagree. I tried really hard to watch the second episode not as a medic, but as a normal viewer. I couldn't get into any of the characters. The time spent on flushing out the main characters was too little, but they've made them too flawed to pull a Law and Order or Emergency! where they are just professionals whose home lives we rarely see. Right now they're more caricatures then anything else; too much front loading left them with little to explore. As a viewer we can't even care about the patients as the calls are so short and fast we never see much of them either. Maybe they should have copied Flashpoint and Saved which did those little flashbacks. EMS issues aside I don't find anything here pulling me back in; they are severely lacking in a hook.

I lasted until the "I'm not a vascular surgeon" comment. After that I flipped over to another channel and stayed there. Wasn't even good for a laugh and my fiance got sick of the "OH COME ON!"'s coming from me.

From your post I respectfully contend that this is probably not the time or place for you to seek input on this tragedy. You obviously have not yet gained the perspective on this needed to discuss it with strangers (if there is such a thing). You have made this about the infidelity, not the brutal murder that occurred as a result. I feel like any attempt on mine or anyone else's part of minimize the temporary pain of cheating against the murder of two people and wide reaching permanent effects on their family and friends, not to mention the family and friends of the murderer (yourself included) would not be taken well, unfortunately that is the issue that is calling for attention. You have my sympathies, but I encourage you to seek help and solace from among your friends and family, not strangers online.

So this topic is twofold: 1) First I'm curious as to how much variation exists in STEMI bypass medical directives. So if you would be willing to post your local directive that would be great. I'd like to explore these different protocols and discuss the reasoning behind some of the variations (aside from the medic vs. machine interpretation argument if possible.) STEMI Bypass Medical Directive: (Only changed to remove identifiers for where I work.) When the following indications and conditions exist, a Primary Care Paramedic may bypass the closest hospital to transport a patient from within [Geographc Area of the Service] to [indicated Hospital] for Primary Coronary Intervention (PCI), according to the following: Indications: Patient who is experiencing cardiac ischemic “chest pain” or discomfort OR experiencing symptoms consistent with their typical angina / infarct events. Conditions: Patient is alert and ≥ 16 years of age Current episode of cardiac ischemia ≤ 12 hours in duration Paramedic interpretation of the 12 or 15 lead identifies an AMI (ST segment elevation in 2 or more anatomically contiguous leads: ≥ 1 mm in limb leads or ≥ 2 mm in precordial leads) Call location is based in [Geographic Area] Time from patient contact to arrival at [Hospital] will be ≤ 60 minutes. Contraindications: SBP ≤ 100 mmHg HR < 60 or > 160 bpm Left Bundle Branch block (LBBB) or Ventricular Paced Rhythm Hemodynamically unstable patient Procedure 1. Continue the care started according to the Acute Coronary Syndrome Medical Directive 2. Acquire and print a diagnostic 12 and/or 15 lead demonstrating evidence of AMI (based on paramedic interpretation and not the LP12’s interpretative software) 3. Confirm that the call is based in [Geographic Area] and that the time from patient contact to arrival at [Hospital] will be less than 60 minutes 4. Contact CACC to advise of the bypass and initiate transport. 5. Call [Phone number] as soon as possible to activate “CODE STEMI”. Advise you are EMS, from [service] and your ETA and the patient’s age and gender. 6. Continue care including oxygen administration, vital signs, pharmacological interventions and repeat 12 cardiograms. 7. On arrival at [Hospital], pick up the swipe card and bypass the Emergency department and proceed directly to the CCU on the 5th floor. 2) I know certain demographics are far more prone to atypical presentation MI's. I'm having trouble finding good info that really explores this concept and maybe has some numbers.

When Rabbit got shot you know what popped into my mind? Dumb and Dumber when Harry exposes his vest and Lloyd says "What if they shot you in the head?" And Harry stops his goofy laughing.

Agreed. Also, so far I haven't seen a single set of turn-outs. Must be at the trucks in a rehab post. I'd worry about their ability to fly out criticals with rabbit in there, but I forgot that their flight medics are interchangeable and ride up front. Also forgot, I wouldn't fire, I'd punch a medic on an MCI who started texting. Hell I'd punch a medic who texted on a BS call.

I've heard of some low budgets, but gotta lover their "tactical medical team." Fuck it's not even funny anymore.

We actually received a letter from him to the service following that article and the response he received from medics. It was a three page explanation, the full text of which I don't have available where I am at the moment. Essentially his quote was with regards to the thombolysis study when the reporter asked him why we were interpreting for STEMI bypass but not the STREAM study. His explanation centered on the medico-legal issues with it being an ongoing clinical trial. I will try to remember to copy the relevant sections when I get back to work on Tuesday. At this time I'm not cynical enough to discount everything else we've been receiving based on a TorStar article. We were all still taken aback when we read that article around here, especially when compared to the latest feedback we were getting from the CCU/cath lab on the program. Official average pt. contact to balloon time from anywhere in the region I work = 82 minutes.

And to be clear, under CREMS we don't just call and say "come see this guy." The expectation is that we discuss the case with CCAC in detail. They are provided with the run number and we document that interaction and it's details on the ACR. Not perfect, but short of medics actually then acting as worker for CCAC, I don't know what else can be done yet. There is some very promising work being done in the Long and Briars Islands in Nova Scotia that are very much worth looking into. A far more proactive approach that may be a good direction for EMS in the future. Here we'll be running flu shot clinics in conjunction with public health. This is where we enter a difficult issue, atleast under Ontario's PHIPPA laws. When my contact with the pt. ends, I leave the "circle of care" I no longer have access to their confidential information. Therefore it would be inappropriate and a breach to make formal contact after the call. Sure a crew could check in on a patient at the hospital or as they drive by, but it is a difficult gray area to stay in. Part of it though depends on how much faith you have in your local system. CCAC has an obligation to make a home visit after a referral and I have no reason to doubt that they will do that and provide options for the patient. But that is the whole purpose of CREMS, was to ensure that we could get a patient access to the care they need and not leave it to the hospital (who never sees their homelife), to the patient at our suggestion, the family or chance. Now if I feel there is abuse or neglect, regardless of the care or the referral, I will still make a call to PD and/or protective services to investigate further.

Well my approach would have to be a little different as a) he would not have been kicked out from a hospital for insurance reasons. had he been unable to afford a private NH, he would have been placed on a list for a public NH. Now while on that list it is common to run into pt's having trouble like this. My approach would be the following: - Ask if they would mind if I made a call that could arrange some further help for them (the exact wording of this depends on the pt. and how receptive I think they may be.) - Contact the Community Care Access Centre (CCAC) hotline and make a Community Referral by EMS (CREMS) - Establish whether they are already a client of the CCAC and to what extent. If they are a client I will be transferred to their case worker to discuss their needs vs. what I have experienced; if not I discuss openning a new file for them with an intake worker. - Provide my suggestion on what they may need (meals on wheels, homemaking, etc.) - CCAC follows up with a Social Worker visit to create or adjust a care plan. - My direct exposure ends with the call, but as it stands now I receive a follow-up letter through work outlining the outcome. So far I've only done this once (four months on the job). I had a hypoglycemic patient who lived with his wife. Place was a mess, smelled and she seemed unable to provide a good history for him or otherwise assist in their care. Pt. was known to my partner and to FD crew (first responder) and PD. After glucagon administration pt. began to express resistance to transport (but not refusal), so I dodged the issue as much as possible and transported to ensure we could get a meal into him and have a physician look at his current treatment plan. After offload of pt. I called CCAC and found that he was currently receiving a once a week visit and was waitlisted for a NH bed. Chatted with the worker and explained that that needed to be changed as he would NOT accept a NH bed without a fight. He now receives more regulat homecare and to my knowledge is not currently slated for a NH. Lots of detail I know, but I just received the follow-up letter last night so it's at the front of my mind. Agreed 100%. Regardless of the circumstances or the refusal, always attempt to leave the pt. better off than you found them.

It was so tempting to hit negative there.

What a great topic! Wasn't familiar with this device (thanks to Spenac for the links) and after a quick read through I just fired off an e-mail to our Medical Direction for some more info and guidance.

I'm not entirely familiar with all the details of the UK system, so could maybe provide a breakdown on the current model of practice? Also, doesn't the UK currently have an Emergency Care Practitioner that would cover a great deal of what the US has been calling Advanced Practice Paramedic. (Advanced Care Paramedic means something different in Canada and is our ALS level) Though looking at the short list you've provided I'm surprised this isn't already included in your scope. All of the listed interventions are within the ACP scope here (except CPAP which isn't anywhere until next year and will be a PCP and ACP skill). In other words I'm just confused as to where this would all fit in? In the meantime, this link will take you to the Central East Prehospital Care Program site, one of our seven provincial medical oversight programs. There you will find both PCP and ACP directives. Within the province there isn't a huge variation from program to program. If you have any questions let me know. CEPCP

You're both right, he was a FF who also had a SAG card. (How Hollywood) If I recall correctly he eventually retired as a Deputy Chief or some other big wig with collar brass.

Hmmm... wonder what got the negative? Was it A ) Drawing attention to the fact the my work orientation was longer then an EMT-B program? B ) Poking crotch in the eye? I'm going to guess B ). Oh well I can take a joke as I tell them. Inconsistently and incomprehensible.

Three weeks of classroom covering a wide range of topics. (just to be clear that 120 hours is not some EMT course. It's just employee orientation.) Three shifts as third. 20 shifts on driving restriction (L&S to a call, but not with patient on board; partner initials after each shift, reviewed by Superintendent before sign off) Six months of probation. And crotch, just because I've grown impatient with so much coffee today, what issue in EMS are we being blind to, how is it costing lives and how can I be made to feel guilty about it?

Put a nasal on 8 lpm and see how it feels up your nose. I have trouble believing that one personally.

Wait, I shouldn't be coming in uniform and then go to the pub in a t-shirt with Ambulance printed backward on it? How else will everyone know what job I have? I mean they won't be able to see my decked out POV when we're inside. Question: How do spot the Firefighter at a party? Answer: He tells you. And screw cadavers, I think we should all go with FireMedic. Edit: Umm... not pun intended.

Dust, you need to come ride with me for a day. Haven't had a female partner yet that was hard on the eyes. They're out there, but so far they're the exception not the rule.

My bad. Base Hospital is a misnomer and an old term. We now have Central East Prehospital Care Program, or Sunnybrook-Osler Centre For Prehospital Care, or some other long name. Guys on the road still just call them all "Base Hospital" which is their name from years ago. The "base hospital" consists of a group of 3-4 medical directors who provide the license for the various services. They together determine the medical directives for each service. Under the medical directors are a list of approved Physicians who can provide online medical direction if required. As it stands now we only contact a BHP for a pronouncement, or for combative sedation (long story), or circumstances where we would like to go outside directive (hitting max allowed dosage and wishing to continue) or would like advice. I've only needed to call when on with my ACP preceptor and we wanted Fentanyl for a pt. who didn't meet the letter of the analgesic directive. Online medical direction is very rarely utilized. Also within "base hospital" are the educational and quality improvement staff, most of whom are Paramedics. They handle yearly recertification, retraining, continuing education, chart audits, etc. All of this exists separate from the service. Now to make things more complicated, all the various prehospital care programs are part of the Ontario Base Hospital Group which is a council of all the medical directors who meet and agree on provincial directives. There is some variation from service to service, (dosages, conditons, etc.) but the actual protocols are essentially the same. Research does throw another iron into the fire. As part of the ongoing STREAM study ACP's do need to contact the on-call cardiologist for direction on the thrombolytics study. The cardiologist first has to confirm pt. meets study enrollment criteria and then has to review the 12 lead and randomize the pt. before calling the crew back to instruct them which side to enroll them in. The base hospital approved the protocol, but does not run the study.

I'm going to have to start studying again in advance.

Nothing on the front, but when leaving the bay the passenger needs to be out of the vehicle until it clears so that they can close the door. Used to hate this system (vs. a garage door opener) but after this and the lady crushed under the garage door I'm very much in favour of it. We also have a back-up camera on all the trucks. Not that I don't use a backer.

That's the frustrating thing about one of the regional base hospitals here. They recently changed their directives for a nearby service to remove Paramedic interpetation, despite zero issues of false positives. It was done purely to harmonize their protocols with Toronto. Which is a back asswards service in terms of cardiac care (only ACP's do 12 leads and must use machine interpretation. And this is a medic with three years formal education.)

Here we bypass the ED entirely and go to the cath lab directly. Our STEMI protocol is to ID the STEMI in the field (on Paramedic's interpretation NOT machine), verify they meet conditions for PCI and begin transport to cath lab, bypassing local hospitals. On route the crew calls the cath lab hotline and calls a "Code STEMI" which activates the cath lab team. We transmit the ECG so that it is waiting for the cardiologist when he or she arrives but the activation and bypass is on our field diagnosis. Apparently it's working quite well with our pt. contact to balloon time actually beating the times for the Emergency Department within the same hospital as the cath lab. (Not by much, but a nice feather in the cap) Dr. Warren Cantor the Chief Interventional Cadiologist has continued to push the importance of Paramedic interpretation over transmission or machine interpretation as the most reliable method. In the first 100 STEMI patients enrolled in the bypass program EMS had a 13% false activation rate (including false positive ECG and cases where criteria for PCI were not met), which is comparable to the rates found in ED Physician interpretation. (His words, not mine.) Currently ACP crews do need to transmit a 12 lead for MD interpretation when enrolling a patient in the STREAM prehospital fibrinolysis study, but as per Dr. Cantor this is an issue of medico-legal concerns and research ethics, not Paramedic competency and if the study shows fibrinolysis followed by later PCI to be a better route it is expected that wireless transmission will continue to augment Paramedic interpretation. I've tried to attach some of the resources and stats we have on the service intranet, but their citrix virtual desktop does not let me link to it from outside. Cheers, - Matt Agreed. I actually think we may be on the same page on this one. No disagreement. Now we need to make this the rule, not the exception. Luckily we have large research programs that not just covers our service, but is part of the Rescu program at University of Toronto. This has brought even smaller services into research. Ottawa is like the rest of Ontario doesn't have a small number of Paramedics, it is an ALL Paramedic service, with a moderate number of Advanced Care Paramedics. Not sure of the exact percentage for Ottawa, but currently 36% of my service is ACP and growing as more PCP's are selected for ACP. Not truly important, just wanted to clarify. I didn't quote the rest, but I do think we're essentially in agreement but approaching the issue from a different direction.