WolfmanHarris

+5 for new information. Didn't realize I'd been talking about "pre-load dependent" without thinking through what exactly NTG or MS will do to the patient systemically. Thanks for the great info and link! - Matt Edit: You're killing me FL_Medic. I hopped on here to take a break from a project and have spent the last half hour engrossed in that blog. I love the way he approaches topic on there, helps cement it way better than rereading my ECG book again. Highly recommend!

Thanks for the resource Vent. Word of advice for others though, if you want access to the full catalog of CME, don't check off EMS in your profile. I went back and checked "other" to get them all. Not all relevant obviously, but interesting.

Okay full disclosure first of all. I suck at picking screen names. I was given the nick name "Doc" years ago by a friend, picked it as a screen name back in 2002 and have used it since. Didn't have any problems until I came here and low and behold there are actual Physicians around. And the more this happens the more I'm thinking it's time to get a new name. Anyways, I am a recent grad from Primary Care Paramedic school here in Ontario (recent as in three days since classes ended) and still consolidating. I am a BLS provider. I love this profession, loved school and can't wait to work. I also thing long term the best thing for the profession is to phase my level out all together and replace it with a single four year degree with a post-grad program for our Critical Care Paramedics (already an 18 month program on top of the three years total to be an Advanced Care Paramedic). I am not an ALS provider looking my nose down at BLS, I am a BLS provider who sees significant room for improvement in our system. We're not going to get any where is we become so entrenched in our own little corner that we can't see the big picture. I wasn't going to take another kick at this horse, but I needed to make sure I wasn't misrepresenting myself. I know you're new here and this probably isn't the best start to the EMTCity experience, but use that search function real quick and you'll see how brutal this issues has gotten in the past. My best advice is keep an open mind, try not to take it personnally and you might have your assumptions shaken up. No one's questioning your individual dedication as a provider. What is being argued, quite regularly these days, is that the system (BLS/ALS education) you and all of us are working in is flawed and doing our profession and the public a disservice. Give it a chance. I did. Cheers, - Matt

I think you're confusing being against EMT remaining as a level in EMS with cutting the number of Ambulances or something. Were the BLS ambulances that are ill-equipped for dealing with the full scope of pre-hospital medicine (not even having defibrillation in some areas apparently) and replaced with ambulances only staffed with two well-educated (no medic mills) professional Paramedics that the public and the profession would be better served. This is the biggest dead horse on this forum, but as you're new I'd like to illustrate a couple of key points to consider. Not because I hope to change your mind, or to bash you, but in hopes that you'll understand some of where we are coming from. The rest you'll be able to find easily through the search function or by swinging a dead cat, lord knows you can't do that without hitting a thread on why EMS education sucks. First, anecdotal evidence. I'm sure you've had some good outcomes with patients, but this doesn't mean that you necessarily provided the best and most appropriate care for them. Personal experience is powerful because it feels more real, but it does not reflect reality. For example, if you have a patient with SOB from asthma that you give oxygen to and transport and arrive with at hospital with no difficulty breathing you may believe that this improvement is a result of your treatment. However, if you look at the patho, it becomes clear that while oxygen will help, the improvement was going to happen regardless as the histamine release was limited and passed without intervention. Were their condition to worsen your treatment would be of limited effectiveness without salbutamol and/or epi to counteract the bronchoconstriction and counteract bonchial edema. Second, cardiac arrest. While BLS care is linked to the best chance of survival for SCA an EMT cannot provide ACLS and thus cannot use the full range of treatment options. While these may be of unclear effectiveness, not being able to provide the full range of treatment for a cardiac arrest means you have to transport all of your arrest patients thus putting the public and yourself at risk by running L&S while doing CPR. A proper ALS system can work these patients safely in place, with more effective CPR and no risk to the public transporting dead bodies. Third, knowledge. Step one, know enough to know how much you don't know. No one is saying you as an EMT cannot help people, we're saying that care is not the best available and by not being the standard is doing the public a great disservice. As a profession if you're to advance (meaning EMS in the USA) and earn more than the low wages you currently do, you have to have the education. No one's going to pay high wages for a job that can be trained for in a couple of weeks and that almost anyone can get the cert for. I think I've managed to sum up the thrust of every education discussion we've had in the last few months in there. Hopefully that saved us a few dozen more pages of argument ending in the usual trolling. Maybe we should let every member post their own essay on this topic and sticky it or something, I've been getting major deja vu.

Crotchity, I think you touched on the essence of my questions in two areas. If we take race out of the equation do we see comparable results across racial lines when socio-economic status or even family education is used? How can a test be written to overcome this without essentially handing an increased grade to minority applicants? Slavery is a much a generalization here and doesn't do the issue justice as it is when talking about the civil war. It simplifies a complex issue and boils it down to buzz words. For example it doesn't address continued immigration from Africa and the Caribbean and how that hasn't significantly changed test results? Why is that when these people are coming from there own countries? Perhaps we need to look to past colonialism more than slavery as the source of problems like test scores? Seems to me like this not only considers the bigger picture but creates a far less exclusionary model for redress.

Provincial ALS standards say RVI indicated by V4R with any TWO of II, III and avF. According to my book approximately half of inferior MI's have right ventricular involvement and that "right ventricular MI's rarely occur independently on inferior wall MI's." (from Ontario Base Hospital Group ALS Pre-course. I'd check my Bledsoe or ECG book but don't have either at the base tonight.)

Personally I'm a member of the Ontario Paramedic Association and have been since before I even started my program. I've been active with the OPA's new PR campaign (sweet poster designs to watch out for) and have attended lobby days at Queen's Park for EMS. I don't even have a job yet. (here back Monday. Fingers crossed.) I hope I'm not alone on this board in being an active advocate for my soon to be profession. Having local representation is important, but there needs to be unification. For example, the Ontario Paramedic has local chapters throughout the province (not enough yet, but a start) and is itself a chapter of the Paramedic Association of Canada. While not perfect (see Alberta College of Paramedics and PAC) this does help present a unified structure for advancing the profession separate from the unions whose primary focus is and should remain advancing the standing of their membership.

It seems to me like another "So what?!" study that does nothing more than cloud the issue of climate change. Somehow I think it will be easier to switch everyone over to renewable energy than it will be to pry the cheeseburger from the fingers of the obese. We'd be better off encouraging the obese to get fatter until they become bedridden and thus end the problem of their increased fuel costs. Of course the increased health costs come into effect so it might be a moot point...

Why does already fractured EMS in the USA need another association on top of all the others one's pulling the profession in a potentially different direction than all the others. We need some unity of voice and purpose not another organization with a limited scope adding to the caccophany. Couldn't the issue of retention within Indiana (and the rest of the states) we addressed within the framework of another organization (save the IAFF or IAFC)?

I find this very interesting and have some questions I wonder if anyone else has insight on. Do we have reasons for this? What research has been done to look into these causes? How do the results compare across racial lines when socio-economic position during upbringing is considered? Do middle-class blacks, or those who were raised in a family with two parents compare similarly to whites in the same situation? Is this then a matter or a larger proportion of black people being poor or having single parent situations? If the exam dealt entirely with firefighting, shouldn't all candidates be starting from the same background and training and thus be equally qualified for at least the multiple choice section which would have objective marking. I'm willing to concede that if there is any institutional racism that the oral exam may be tainted by it. Not saying it is, only that it's forseeable. The problem I have with this accusation is it's really hard to prove that there are closer personal relationships between white FF's to the exclusion of black FF's in terms of being friends and passing on knowledge and mentoring. And if it can be shown, what could anyone do? Regulate personal relationships? I'm not talking nepotism here; HR and corporate policies should be geared towards removing nepotism as much as possible. I just don't know how you tackle such an intangible as this. It should be. Meritocracy should be the eventual goal. Yes we need a social safety net and yes efforts must be made to redress past mistakes, but in the end we must strive for a society that rewards hard work otherwise it will stagnate. Anyone know what these guidelines are and where they can be found? What are they based on? I don't currently understand what about how a Firefighting exam is written causes disparate racial outcomes. So the entirely objectively scored part was the flawed section? Wouldn't it be preferred for a department accused of having a culture of racism to have testing that removed any subjectivity from the brass, who must of course be complicit in the continuation of that racism? Please, please tell me what these numerous reasons are or what all the other things are AND how we can factor them into a test AND have it be equally fair to all taking it. If the other factors are historical, them I don't know how a test could redress these without writing "If you're a minority please add 20% now." Which is not fair to anyone, least of all the minority candidates who would have to face the clear implication that they cannot possibly pass the test on their own merits. This is why I get frustrated by the news when stories like this are covered. Tonnes of unsupported claims on both sides. If you have already taken a side there's enough there to feed into whatever opinion you previously held. If you don't have a strongly held stance, you're just way more friggin confused. - Matt

A bit of help here? My patho book was not helpful, A&P had nothing and here's what I got from Bledsoe on dystonia: "The dystonias are a group of disorders characterized by muscle contractions that cause twisting and repetitive movement, abnormal postures, or freezing in the middle of an action. Such movements are involuntary and sometimes painful. They may affect a single muscle, group of muscles or the entire body. Early symtpoms of dystonia include a deterioration in handwriting, foot cramps or a tendency of one foot to drag after walking or running. These initial symptoms can be mild and may be noticeable only after prolonged exertion, stress or fatigue. In many cases, they become more noticeable and widespread over time. In other individuals there is no progression." - Matt

Your head is superior to your feet, that's why we walk all over the poor bastards. The digits are your body's minions but need order from middle management (the spinal nerves). Middle management needs to be in close proximity (proximal, get it? ) to the boss to suck up. Unfortunately my little story breaks down for the rest, but I found these help. Medial = middle. Lateral = if I'm making a lateral pass in footbal or rugby it's going away from the safe place in tight that I was carrying it. Posterior = I'm going to kick your ass. But I don't want to curse. And for bonus, how I discribe decorticate and decerebrate posturing to people who keep mixing them up. Decorticare = the t-rex. (Don't get it? Move your arms into decorticate position and walk around roaring. It'll make sense) Decerebrate = the penguin. (Same problem? Go waddle around while decerebrate posturing.) Which one's 2 and which is 3 for GCS? Simple, the t-rex eats the penguin. Cheers, - Matt

If 12 lead shows ST elevation in the inferior leads conduct a modified twelve lead looking for ST elevation in V4R with any two of II, III and avF. Also consider this rule of thumb, if the ST elevation is higher in lead III over lead II it is more likely that the RCA is involved over the circumflex branch (which only suuplies the inferior wall in ~20% of people).This may indicate a potential RVI or in may indicate and inferior wall MI. In terms of clinical presentation look for JVD, or more specifically Kussmaul's sign where JVD becomes evident on inhalation. Expect hypotension due to reduced cardiac output. Expect lung sounds to be clear (pertinent negative to rule out cardiogenic shock) Since RV AMI's occur most often due to occlusion of the right coronary artery expect that the RVI may occur in conjuction with an inferior wall MI. As such expect clinical signs of inferior MI such as nausea and vomitting due to vagal stimulation. Vagal stimulation may lead to an underlying sinus bradycardia or AV block. Had to hit the books briefly to make sure I had the details right, but I surprised myself and remembered almost all of that. *Pat on back to self* I don't follow on this at all. Common sense doesn't tell me dick about left vs right side MI. Common sense might tell me big fat guy, chain smoking with a huge cardiac history is more likely to have an AMI and keep my index of suspicion high, but this saying is for once incorrect. I cannot be sure (from my understanding) that a patient is not having a RVI without a 12 or 15 lead to rule out RV involvement. If I don't treat the monitor and jump to MONA than I'll drop their preload and potentially place the patient up a creek. Don't confuse common sense with good, well-honed clinical judgement tempered by experience. Common sense lets us say "yep, you need a dressing for that bleedin." Clinical judgement let's us say, "these signs and symptoms suggest an MI, and the Kussmaul's sign, BP and N/V are making me think inferior or RVI. Let's take a closer look." Cheers.

Because an intern gets experience as a new Doctor under supervision with their full theoretical and most of their practical education. Working as an EMT has no direct supervision other than luck of the draw of a good Paramedic partner who's willing to teach and the training given in a Basic course doesn't even speak the same language as a good Paramedic course. This experience they are gaining as an EMT is without clear direction and isn't an education; not in the way an MD intern is part of an organized residency program to complete their education under an attending physician. Sorry, but the parallels aren't there. Now if EMT's start getting relevant education with a heavy focus on A&P, patho, pharmacology, etc but are held back from some of the ALS interventions than the experience gained here might be relevant. But without this their experience is based on a foundation of sand. Here the convention is generally accepted that you do 2-5 years of BLS before moving onto ALS (though there are exceptions). However, our 2 year BLS education is designed to form a foundation for ALS and includes two full courses in A&P, one full course in Patho, one full course in Psychology, one in human growth and development, one in legal and ethical issues on top of our two years of patient care theory, practical lab, clinical rotations and ride outs. The text books we use are ALS text books as well. I've read two EMT-B books. They don't even speak the same language and read like the First Aid manuals I teach from. I'm still in favour of combining both courses into a three to four year degree for one level of Paramedicine, but if you're going to have multiple levels, have them actually build on each other.

I highly doubt there's any research on this. As Vent mentioned a degree is not required for the vast majority of Paramedics in the United States making comparisons of this sort unlikely. I'm also not aware of any research being done to justify or examine education standards here in Canada as their upward creep was somewhat gradual and based more on practical changes in EMS rather than science. Jurisdictions have set their education for various reasons and I don't see science being top of the list (otherwise OPALS would have killed ALS in Ontario.) nor do I see countries comparing themselves in this field where we're already lagging in research. I think outcomes is probably a poor place to start with such spotty coverage by degreed medics and the unique nature of each patient. A better starting point might be accuracy of field diagnosis, or accuracy of STEMI recognition. These are more specific, easy to identify goals that can form a starting point. This research could be done starting with a single region and then be repeated later by other regions until hopefully someone takes it and runs and we get some better national research. And Vent thanks for posting that link. It's incredibly frustrating but understandable if you filter it through the author's perspective. He views EMS from the end point of transport to hospital and looks for whether increased education is necessary for this limited role. Whereas I don't see the increase in education standards as just changing how we operate in this framework (which realistically it won't) but being the impetus to a whole new model for practice. Anyways, I skimmed over some of that article as my frustration increased. Time to go back and finish. - Matt

I think one of the key points being missed here is that the Army's recall on Wound Stat specifically mentions that their own studies found no improvement over direct pressure with Combat Guaze. If that's the case and their research is valid, then I'd say there's enough reason to remove wound stat based on it not working. The complications with clotting just made it a no brainer. 'Zilla it seems like you've got access to some good info on this, any chance the Army has released the research they did on Wound Stat? I'd be curious to read it. - Matt

My feeling is that playing arm chair attorney while being stopped on the side of the road is a bad decision as it will likely escalate the situation. I do not believe you should abdicate any of your rights. Were I subject to a search that I believed was illegal, I would politely decline and allow them the option to place me under arrest. Contact my lawyer and allow them to argue against the search. I would not, however, get belligerent or actively resist in any way aside from stating my refusal to comply with the search. That is unless I'm in a rush, in which case I may honestly just go along to get along. The price of freedom is eternal vigilance.

I wish I could help but I'm living off my fiance's unemployment benefits until school's done and I get a job. Good luck!

I just loved the instant change on everyone's face and the sudden thunderous applause, not that she didn't deserve it, but it highlighted everyone's guilt over their initial assumptions. (mine included)

The service I'm precepting with has toughbooks in every truck. They are used primarily for PCR completion and have no link with dispatch. They do have a mapping program in the laptop, but it does no turn by turn or GPS even though the trucks all have AVL's. I give them a big fail for missed opportunities. The computers and software were a big investment aren't being used to their full potential.

Aside from the personal complaints (smells, productive cough etc) I'd say you have cause to dismiss this volunteer. Provided you have documentation of these deficiencies and have made effort to couch the volunteer to improve. If not, you need to start approaching this not from a "I need to get my papers together to cut this guy lose" but from an actual QA end where you really do intend and would like to see him improve. If you can't do that, you need to delegate this couching to someone else to ensure it's done in good faith. And if he successfully completes the remedial couching and starts doing the job, then you need to suck up disliking him and let him continue. I've had to let volunteers go before and I found the first important step was to recognize that just because they're not paid, they have to still meet the requirements for the job. There were two ways I've terminated volunteers. The first was for violation of P&P where I followed the policy for termination with written warnings, meetings, etc. The second was a termination based on patient care deficiencies (which at the time were not covered in the manual). I met with the individual, stated the issues and provided documentation from the call and informed them they were on suspension until successful completion of a remedial training plan and successfully completing a mentoring program and scenario training to show their improvement. In the four times I did this two went through all the requirements and returned as excellent responders. One gracefully stepped aside from an active role with no hard feelings. The fourth was a nightmare, but that's another story. The key here is to set aside your personal issues. You're doing this because they are not competent to do the job and not meeting the requirements for the position (training, etc.), not because you can't friggin stand them and neither can anyone else. Once you make it personal you've created room for trouble.

That's excellent that you got even that much. In my 200 clinical hours we didn't spend any time on psych. Didn't notice at the time, but now I wish we had.

One thing I'd like to see considered in Ambulance design is limiting or eliminating all the little traps and crevices that are impossible to clean properly and provide breeding grounds for bacteria. With just a few rounded corners and screws that are inlaid and then covered we can start making our deep cleans more effective.

I agree with all of Squint's points. From what I've seen of ACoP this is not a model you want to follow and it's left me worried about a potential college in Ontario copying this (or being lumped in with another job). Only thing I'd add is change the name. College of Paramedics of British Columbia. If they're not a PCP or higher, kick them and their first aid certifications to the curb. You don't need to self-regulate a first aider.

Once again we see the results of making someone do a job that they have no interest in or desire to do.