WolfmanHarris

It's a mistake to drop more and more things down to a BLS level a it continues to reinforce a system of piecemeal skill based education. We shouldn't define ourselves by skills, but any change in skillset should first be compared against education to ensure that the requisite knowledge is part of the education for that provider. I don't believe an EMT-Basic has anywhere near the time spent on cardiac physiology and patho, or pharmacology to allow them to take ECG's, or give NTG as anything other than a rote skill under restrictive medical directives. I still spend a lot of time with Campus Emergency Response Teams, all of which are First Responder trained (40hrs) and some of which are EMR trained (80-100 hrs). One of the most common discussions that comes from these students is "we'd like to carry ______ ." My first question is always, "Explain to me how it works, why you'd use it and how it would benefit the population you serve?" The requisite knowledge is just not there in a hundred some odd hours of training. (Of course Kiwi, if by BLS you meant PCP or similar, well that's different.)

I'm not disagreeing with you, per se, but where would you place that line such that research, success and failure can be transferred between services and learned from? We don't want EMS systems to reinvent the wheel, but I don't think "not invented here" is as likely to cause repeat research as it is to encourage an attitude of "Sure it works for them, but our system is different. That's why we'll keep doing what we're doing." That attitude is all too common an excuse and the last thing we need is to legitimize it.

A case like this reinforces the need for investigation of any and all allegations of Police misconduct to be done by an outside agency, rather than internal. I am a big proponent of the Special Investigations Unit (SIU) that operates under the Ontario Ministry of Justice. This civilian agency automatically investigates any case of injury or death involving Police as well as any complaints received. By having any possible case receive automatic review transparency and accountability are maintained, furthermore the public can be put at ease. The vast majority of SIU cases find no wrong-doing (either criminally or under the Police Services Act) which allows the public to have faith in their Police Services without the appearance of a white wash. Look at the RCMP lately and their refusal to be transparent and how awful the force is coming off as a result. Here EMS complaints investigated by the Ministry of Health and Long-term Care's Emergency Health Services Investigation Branch in addition to the usual Service CQI and chart audit's by Medical Direction. When we allow any service that requires the public's trust in their most vulnerable times (PD, or EMS or Fire) to investigate themselves we create a recipe for disaster. The Chief/Management of these services have conflicting obligation. They want (or should want) to thoroughly investigate for the sake of the public, but they want to do so in a way that won't damage their service or otherwise make their own job difficult. How then can a frank and honest investigation really be expected?

I'm on peak shift until 0200 today at a somewhat quiet station (haven't moved since booking on at 1400), so we may watch it for laughs and snide remarks.

Here's something I'm having a small issue with that's only partially related. I quickly looked up SFFD online and found that apparently they have 42 engine companies, 18 truck companies and only 18 ambulances for the city of 1.4 Million. Is this like NYC where FD runs EMS, but a large chunk of the work is contracted out or what? The region I work for has a population of 1.1 Million (suburban, urban and some rural) with a large commuter population and some of the busiest highways in the country. At a time there are approximately 38-40 Ambulances on the road, 3 district supervisors in response units, 3-6 other response units (depending on the day), the Special Response Unit (Tactical, Bariatric, MCI, Hazmat, etc.) and the marine/ski-doo unit. The city of Toronto with 2.5 million people keep over a hundred Ambulances on the road in a given shift. I don't understand how a city like SF could be covered by so few Ambulances.

Never and have never texted or read a text while driving (work or personal), or for that matter attending a patient, giving report or otherwise completing duties that required my attention. I will not tolerate this from a partner either; though it's only come up once. Service policy does not allow the use of electronic devices while driving and while it doesn't specifically prohibit use in the patient compartment or on scene, I'd hope that would go without saying among professionals. I do not EVER touch my phone while behind the wheel of a service vehicle and extremely rarely and if then briefly when behind the wheel of my own vehicle. With the advent of the new law in Ontario banning the use of handheld devices while driving coming into affect this month, that too will end as I install my hands-free unit.

Because the resuscitation you would be doing while attempting to package and transport would be of a decreased quality decreasing their already slim chance of survival for no reason other than to have them die somewhere else. For cardiac arrest there is nothing that can be done in hospital that is not done by a Paramedic crew. Not the mention that CPR and defibrillation are the key treatment for an arrest and that is what you're sacrificing for an unnecessary transport.

Umm... I'm confused. I'm read this twice and haven't quite got anything but puff piece out of this story? Right now, my service is beating the Regional Cardiac Centre's own ED door to balloon time from anywhere in the region based on Paramedic 12 lead interpretation and STEMI bypass. We're also involved in a thrombolysis study, the ROC consortium studies, Community EMS, etc. As far as treatment changing based on 12 lead, do you not consider witholding NTG based on modified 12 lead/ 15 lead indicating an inferior MI and potential RVI? A 12 lead is not just a "much better view" it's diagnostic where a 3 lead is not. Are you not able to bypass ED and go straight to cath lab based on prehospital diagnosis? Are you able to transmit your 12 lead wirelessly to the cath lab for cardiologist confirmation while en route? Maybe the real story here is how behind the curve some areas are in prehospital cardiac care. Edit: Sorry Sasha, somewhere in there I missed your initial question and got kinda snippy. 12 ecg are part of the PCP (BLS) and ACP (ALS) scope in Ontario, including medic interpretation. This has been HUGE in early identification and rapid transport to regional PCI centres. The chief Interventional Cardiologist has been singing the praises of our service and medics in international conferences due to the huge success the STEMI bypass program and thrombolysis study has been having. There has been an incredibly low false positive and missed STEMI rates throughout the region. 12 lead ECG should be on every Paramedic truck around the world (if it isn't all ready). Edit 2: Fixed a few typos and outright mistakes. Shouldn't try to watch tv, plan tomorrows lesson plan, stop and do other things and otherwise distract myself.

You shouldn't be performing CPR moving anywhere as per AHA guidelines. Unfortunately, that's not always the case. For instance in my service PCP's are not currently part of the BLS medical termination of resuscitation study. So if for some reason a PCP crew were to respond to a VSA and not receive ACP back-up we would have to transport. This is frustrating, but remains a hypothetical as I'm yet to see a VSA not get an ACP on scene before we finish our directive. There is no way I can imagine to perform CPR effectively on a moving stretcher, nor can it be done effectively or safely in a moving vehicle. Essentially it's a crap sandwich and everyone has to take a bite. The patient will get crappy CPR, not perfuse and stay dead. The provider will have to place themselves in a potentially hazardous situation for minimal gain. So what I would suggest is: - lower the stretcher to keep centre of gravity low before considering riding the rail - place more then the usual two providers to move the stretcher - any interruptions in compressions (i.e. loading the stretcher) should be planned ahead and communicated to limit interuptions as much as possible - during transport, for ****'s sake, DRIVE SLOW!

I won't go so far as to say there is no such thing as "not able to stop." There's always the unpredictable drunk driver who appeared to moving fine and crosses the center line at the last second, but really, in the vast majority of accidents, "no time to stop" is a friggin crock. And if you hit someone, your duty is to the scene you've just created.

I'll watch it for the same reason I watched the first episode of "The Listener," morbid curiousity and perhaps a bit of masochism. The show might make a good drinking game. Take a drink (or shot) every time you wonder what else is on. First person to change the channel has to chug and buys the pizza.

We used to fax to the destination hospital but it took forever and was a pain in the butt. Service purchased a printer for the reporting room in each Hospital and we plug into that to print. Hospitals outside our usual operating area still get a fax.

You're absolutely right. I should have been more precise in my response. This is a dead horse, because the lines are firmly drawn between those who understand the issue and agree that proper education and driver safety is a must and one of the biggest risks and liabilities in EMS and those that throw out such gems as: "Seconds count." or "I know which intersections are safe." or "Some lights are okay to run." or "Maybe in your area but in mine..." in the face of mounting injuries and deaths from preventable Ambulance collisions. The deadhorse is trying to convince the idiots that they're wrong while the rest of us pat ourselves on the back for being such safe, diligent operators of emergency vehicles. Frankly I need the mental masturbation less then I need the frustration. I work in a system with a full time Driver Safety Officer, EVOC as part of school and as part of hiring, stringent requirements for clean driving records for Paramedics (both within the service and for Provincial maintenance of certification) and most importantly, a professional culture. About three months of driving L&S only with a partner up front (non Code 4 return for 20 shifts) pulling back the reins on the overeager tends to shake out most of the whacker tendencies. I'm not saying it's perfect, but I have confidence in the way this is being addressed within my workplace as part of Continuous Quality Improvement (CQI).

At our service we have a flexible station based deployment. That means that as stations get busy outlying bases are moved in to stage from these bases to provide balanced coverage. This can be a bit of a pain as it means your neighbouring base's 3am call, is also your 3am standby call-out. When our number of available trucks starts to drop below a minimum coverage threshold we start staging at major intersections, any non-emergency transfers are canceled (not that we do very many) and non-emergency calls are delayed. Aside from this between calls we return to a base (hopefully our own) and hang-out in the crew room. There isn't a lot of base duties to perform; just basic cleaning of the base and the truck. If we need to restock equipment we swing by one of the Pyxis equipped bases. Day shifts = reading, studying, hitting the forum or watching TV Night shift = sleep as much as possible

Agreed. Sorry this is very sadly becoming a dead horse. I have little else to add.

At our bases someone has to close the door behind the truck. Between that and not trying to scream out of the bay like a bat out of hell I've never given it much thought. I can honestly say, that if we could open the door from the truck, I'm not sure I would have thought to look directly in front of the truck. I will now.

Is it like a field reference, a full text or a workbook? I'd be interested in recommendations for all three.

I was browsing Amazon today looking for a good resource for 12 lead interpretation and I got to thinking. The further you move away from Paramedic specific textbooks the harder it can be to recognize an excellent text, that is relevant to the practice of prehospital care. So I thought we should share some of our recommended reading for furthering your education. Anything goes, but please provide a short blurb on why you'd recommend it. For me: Diagnostic/General Reference - Merck Manual of Patient Symptoms Provides some great information on some of the less obvious chief complaints including red flags for more serious conditions. Provides the prehospital care provider with a more in depth understanding of what will be done for a patient at the hospital in terms of diagnostic testing and definitive care. Most importantly, shows just how many "BS" complaints have lots of potential serious underlying conditions and reinforces the necessity of a good assessment. Small enough to fit in a gear bag, so great for bringing to work. Pharmacology: - CPS (Compendium of Pharmaceuticals and Specialties) Reason should be self-evident but worth noting how to get one. Make friends with someone in a clinical setting. At the end of the year when the new one's come out, you can often ask for one of the old one's that are on the way out. The book is $245.00 online. Pathophysiology - "Handbook of Pathophysiology" Merckle, Carrie. Lipincott, PUB: Williams and Wilkins Another small format paperwork that fits easily in a gear bag. Provides a patho-based explanation of conditions with a good background on diagnosis and definitive treatment. Not the best at any specific topic, but I've found it to be a good starting point. Trauma I don't actually have a good recommendation, but I do want to speak to ITLS and PHTLS' texts. I find the coverage in Bledsoe's "Essentials of Paramedic Care" to be better then the treatment given in these books. They are very skill oriented and despite some good pictures don't give provide in depth info on the patho of trauma. Looking for a good resource in that direction. Unless you need the merit badge course for work or school, you might be better off skipping these ones.

Agreed. But... before BC could even do this I think they need to get their practice models sorted out. BC still has an incredibly short PCP education compared to other parts of the country, and if we are to move to a proper degreed program for Paramedicine that is nationally recognized the short PCP programs (like BC's), offered from numerous technical schools (like Alberta and others) need to be pushed aside. Not actively maybe, but made obselete by a four year University grads filling the workforce. Healthcare yes, hospitals I don't think so. Look to the advent of the Local Health Integration Teams (LHIN) in Ontario for an example of various professions working together. If we're to practice with greater independence and move from Pre-hospital to Out of hospital care, the last thing we want to be entirely under is the hospital. With solidarity, - Matt

As per the poll: 1) Yes. When necessary for chest assessment or to place a 12 lead. 2) Yes. I recently had a pt. c/o severe thigh pain. Upon arrival she was naked and under a blanket. When asked if she wished to get dressed prior to transport, she declined opting for a robe instead. She did not care that she was naked and neither did I. We helped her get her robe on and get on the stretcher. That being said, when the same pt.'s other complaints and her hx made me suspicious of an atypical MI, I asked my partner to pull over so I could do a 12 lead. I also made sure to have him hop in the back to assist and cover my but. I didn't expect a problem, but that doesn't mean I don't take steps to minimize them and ensure professional conduct. That's also why, even though she was quite comfortable without it, I provided a pillow case to cover her chest while the leads were being placed. And Dust, I think you'd be able to show that the Pt.-provider relationship had ended, so provided it was legal and consensual I'm sure all you have to worry about is how well armed her father is.

As many of you are aware, EMS in Ontario is almost entirely single role third service (some services are shared admin; none are dual role), but that doesn't mean there aren't Firefighters who are also Paramedics (second job). At my service we also have many combined bases and work a bit closer with the local FF's. In dealing with the Fire Service I've found myself drawing a few cultural comparisons between the two professions, and all ribbing or outright bashing aside, I think there is some room for discussion on lessons EMS could learn from the Fire Service. 1) Care for vehicles and equipment. I have a huge pet peeve with medics who don't check the truck at the beginning and clean the truck at the end of the shift (provided there's time), don't properly check and prepare their equipment and generally take a cavalier attitude to care for their vehicle and equipment. I think there's some modelling here to copy. 2) Health and Safety. It only takes a quick perusual of a scene watching a Fire crew working to see how much time and attention is paid to this. Every FF that shows up at a medical call (as First Responders) in my area has proper PPE. Vehicles always have a backer. This committment is far from universal in EMS, leading us to take unnecessary risks. These are my two big observations for discussion; feel free to disagree or add your own. Obviously all departments are different, but let's try not to make this anecdotal about how "Fire in my area doesn't" or "My service does all that all the time." I talking about the prevailing culture in two professions as I've observed them. Besides, the next topic I've been milling over is: "What do we need to copy from the hospital/clinical setting?"

1) Stop going to school. You're sick and exposing others. 2) Get some rest; you're sick and need it. As for the rest... I don't know. Virus? Bacteria? I'm confident in saying it's possibly one of those. Seriously though, you're doing no one any favours continuing to expose them to you. Go home and stay in bed until you get better or sick enough to warrant a trip to your family physician.

I followed the links to the original article and one of the comments says that the leg was amputated in the crash, not by EMS and suggests a press release to that effect was distributed last night. Just FYI.

I actually think we can make these potential issues worse by getting ahead of ourselves and making judgments based on seeing a crucifix on the wall, a star of david around the neck, certain dress or the like. Within any religious or cultural group is a wide spectrum of observance. My policy is to approach every patient contact with full professionalism and respect and let their actions and attitude dictate our interaction. If you jump the gun and assume certain behaviours out of a group that you're not fully familiar with you may end up offending someone by trying not to offend them. I work in an incredibly diverse area with one of the largest populations of visual minorities in the country AND one of the largest populations of new Canadians. You have a job to do that involves assessing and treating your patient. Do that with respect and be responsive to your patient and you should be fine.

This is an issue I have with both a too many cooks situation and creating ranks and positions for the benefit of the person being promoted rather than the organization. I don't care whether you call your supervisory and management staff, Superintendents, Chiefs, Lieutenants, Crew Chiefs or Grand Pubbahs, the initial questions needs to be what purpose does this position serve? Then, what are their duties going to be? Then, what qualifications, experience and education is required for this job? And finally to double check, do we need this? How is it that you have an individual placed in a position of authority who is too young to complete the duties of those they are supervising? Age isn't the issue here, per se, but being fully qualified is. I don't see you as an individual being liable in this circumstance, but I do see potential issues in your organization. Please understand that this is shooting from the hip based on the impression I've gained from your own description. How is a new, young provider already so complacent as to not to a proper assessment? This speaks to the senior personnel this individual is taking their cues from. Blunt force trauma leading to cardiac contusion? That's my best stretch from that. Honestly I have trouble wrapping my head around the way complex concepts are explained in EMT-B training. I ended up getting rid of my copy of "Emergency Care" during school as it wasn't even speaking the same language as the rest of my text books. (Still don't know why it's on the booklist for the SSFC PCP Program)