vs-eh?

Firstly, if you are not familiar with the system in Ontario which STAT is speaking of, please refrain from commenting on them and relating them to your system. With all due respect, they are probably at least dissimilar, and at the most, services that hire paramedics to do paramedic work with paramedic equipment. In your system it may be simply a semantics issue. In Ontario, it is not. Secondly, I basically agree with STAT on all points. I have said this in other threads in the past. I would love to see a company convince the MOH that they should take over the entire province's system. Yes, I would be talking about a monopoly (but Ornge monopolizes air right?). Standardize vehicles, uniforms, pre-training, etc... If I had several million kicking around, I'd love to do this. I'd make some serious changes. Some major things that bother me: - Yup, that "A" service that states they are "critical care patient transport". Wow, does that ever bother me. I wonder what Toronto EMS' CCTU paramedics think, or the guys and gals on 799 or any other GTA helicopter. The CCP's probably don't even bat an eye to it, but it still gives a hugely false impression. The irony is that they are basically the only company (that I can recall seeing) that look the least like "real" paramedics. - The whole stethoscope-around-the-neck-thing for these people or having any type of equipment on them. You're right, there is no real reason for them to have it. They don't take (required to take) vitals, nor will their assessment effect anything with regards to the reason they are transferring said patient. Now, that being said, I can see why PCP students may want to do this, and they should. Transfer services generally are (beyond preceptorship) the hands down best way to get patient assessment skills and vitals in the closest EMS environment you'll see. It basically won't make any difference to what happens with the patient (they will/should be stable), it gives you the practice. - The obvious "jokers", or drop-out's, or those that are "too cool". People wearing their own jacket's, their ECKO hoodies (yet with EMS pants), playing hackey sack with a white t shirt only on and EMS pants. I could go on... - Ambulances (that appear to be "real" ambulances that the general public wouldn't know the difference) that say "paramedic" on them. I believe a "C" service or a "P" service was the most recent transfer company that I have seen with those markings. I haven't seen them in a while, so I can't comment on if those markings still exsist as such. Yes, there are PCP's that work on tranfer services, but they do not function in EMS, and should know their limits. - Rumour's of a certain "V" service that has run L+S at times (mainly in KW region, from what I've heard). Which is ironic, because the "V" service is probably the best one, and should be generally a model based on general public impression (and my impression). What I would do: - Those sprinter type vehicles (with no L+S) and marked appropriately. - The navy/black uniforms (with EMS pants) is probably my least sticking point. Keep in mind that TTC wheeltrans operators also wear EMS type pants. As long as they had a standardized uniform (I believe a "T" service has lighter blue or maybe orange shirts) that clearly say "patient transport service" or something, I'd be cool. - Education requirements of standard FA/CPR with EMR/MFR as minimum. Huge preference would be given to current PCP students or AEMCA's. I'd also require an F class license. I actually don't think that an F class is required for transfer services. Yes, I did work for a GTA service for a short while (couldn't do it anymore) as a PCP student, and I didn't have my F class. This was years ago though. Meh, considering we're using sprinter vehicles the F class might be awarded points, but not a requirement. - Oxygen and a BLS jump bag (no cupboards). Whatever the scope of practice is (minus medications, MD is not worth it/too expensive) of the EMR/MFR, etc. I dunno, that's it for now. Yes, I do work in the GTA as a paramedic.

I'll respond to this post from an Ontario perspective. Unfortunately, I don't think (I could be wrong) that there are any people here in this situation, but I digress. While I still don't fully understand the semantics of 911 vs "emergency tranports" vs "80 F doing for dialysis goes bad" in certain contexts. I'll say this... Ontario has a system where there are truely emergency (EMS) vs. non-emergency (transfer) ambulances (non-EMS). EMS - keep in mind these are several of many legal obligations - All are staffed with paramedics (PCP, ACP, CCP) who have provincial certifications under the Ontario Ambulance Act to practice. As well as been unde a service and hospital scope of practice. - Are under employment with a municipal service - Have to complete provincial ACR's on every call - Respond to 911 calls, although all levels can and will do transfers as scope is needed. - Can run L+S (prn) These a several very basic aspects of the job...For comparison Non-EMS (transfer services). I don't think are under any "real" legal obligation, beyond those listed below. - Can be a random person who at least has a "G" License (keep in mind all paramedics, regadless of scope have "F" class). - Can have "certs" from FA to foreign MD, to paramedic student to actual provincial cert. (those may not be yet hired as per competition). - All of these services are private, FOR PROFIT. No municipal 911 service is for profit. - No vitals of any kind are required, or really even need given what they are supposed to transfer. - Have non-standard to irrelevant paper work. Meaning they will never be formally audited and "really" held for anything. - Do not EVER respond to 911 calls EVER. They are not legally allowed to and besides, don't have access to any kind of 911 dispatch. If they have a patient that (goes south) or are picking up a patient that "doesn't look good", two of many examples, they must call 911. They don't go direct to the ER or OR, or any kind of emergency situation. - It is illegal for them to go L+S. I hope this makes it (somewhat) clear how this argument works here. Do some of these people still wear stethoscopes around their necks? Yup, and I hope they are paramedic students. Are there ambulances that still say "paramedic" on them? Yup, and that one kills me. It's rare, but it kills me. There are probably about 60'ish (I'm guesstimating) EMS service in Ontario for 13 million'ish. Transfer services are maybe half that'ish.

It's called the internet people, grow a pair. In the end you could be dealing with a person with big dreams, a simple mind, yet fast hands (like referencing medicine on google people, god, get your minds out of the gutter). I've been on this forum for a while. I don't ever recall "boo-hooing" about a response to a post I have ever made. It is either a response with a laugh, a response, a "ya, ok, I was wrong", or my head exploding that people can't comprehend things. I think there are too many people on this forum that think certain members have "immunity" from critique (my self included). And I kind of chuckle when those retort to "virgin posters" with something to the effect of "Hey there buddy, this guy has been here a while and has built a rep". Whatever, just think about what you are posting. Have some adult structure and grammar to it. And realize that people will critique it (beyond what their "rep" is). PS - I do realize that I am a terrible "grammar" and spelling poster. I have never tried to hide that. However spell check and reading a post over works wonders...

Gladly, I'll come down there to explain that to do a (what on many many many levels) appears to be an EMT-B's job, but requires 2 years full time post secondary education and one that (I'll provincially generalize) is a 10% chance to get into school. Most schools also have a fairly high attrition rate. Then I'll tell them that provided they make it thorugh 2 years they have a low (again, provincially generalizing 33%) chance to get a job. But once you get a job (which requires a 6 hour exam that upwards of 50% fail) and get accepted into a service (which requires more testing that you have too pass). Don't worry you'll be making $27/hour easy.

I have a crazy requirement that might perhaps eliminate this problem before it even begins... A high school diploma and perhaps (gasp!) required courses that average Joe Highschool doesn't necessarily have to take! EDIT - See this is a reason why EMS is general is such "nicety" to people. "Oh don't worry, this nice young (wo)man will take you down to the hospital." "Oh, fluid on the lungs? Ya, that's what I thought too." "See, I told you it was nothing, you shoulda (sic) just stayed home." This is what destroys EMS as a profession, shit like this. This is why you see people that think they can do EMS, and be a medical "professional". People (in this thread) say stuff like "what we see", gimme a fooking break. You see nothing, small town EMS throwing out shit likes this bothers me. Start treating and diagnosis a complex medical call without 18 of your buddies around (at least 4 per car according to this vid). People see trauma and cardiac arrest = EMS. People see this stuff on TV, on youtube, in People magazine (on that post53.org or whatever), and in the New York Times (also mentioned). I am tired of it. All of this brings down my profession. And people just shrug their shoulders. I didn't spend 3 years in college, and neither did hundreds of other professionals and (dare I say) thousands of others across North America, to see this shit. I'm getting really tired of it.

How many people see, and/or actually do this? EDIT - Sorry, I mean actually opening the book and reading them.

Man, it's been a while since I created a post... Anywho... Just wondering how often you guys decide (or need to) set up what is generally called here a "run". This happens pretty rarely, and I only recall being invloved in 2 or 3 (2 of them being pediatric arrests). A "run" is basically allied services (mainly police, but fire I have seen get invloved), blocking intersections for EMS in a "run" (not a silly run, but a slower brake run) to the hospital. This is a large urban city BTW. Now fair enough, we only have three municipal services for EMS, Police, and Fire so maybe it makes it easier. Just wondering if you guys do it on occasion and how well it has worked... I have to say in the 2-3 occasions I have used it, it went very well. Impressive all things considered...

Are there actual people that can be driver's and are not allowed to take part in care?

I'm also interested. Bill Bryson made a good arguement for Australia. Just wondering as well...

My experience with IM midazolam has not been great. I find that basically all patients that I have administered it (or seen it administered) to don't acquire the properties you would like them to :wink: . I basically limit non-IV versed to IN (via MAD), which I find is a much more rapid onset and more predictable action. I would imagine that the versed admin was not the cause of the termination of the seizure activity (given it onset IM). Prophylactic actions are obviously of benefit though... That being said, 5mg of midazolam (especially IM) isn't THAT much medication (especially if they are chronically on benzo's for their seizure disorder). Certainly not enough to warrant flumazenil administration, especially given the presentation and the fact that now you are eliminating benzodiazepines as a treatment. From the scenario that you presented, it sounds like there are bigger issues here and that the symptomatic status seizure is part of a much more serious problem that would account for the patients need for intubation. In my opinion there is no way the 5mg of versed somehow "bought" this guy a tube. I would have asked the doctor what he would have done, if the patient simply remained post-ictal in the ER and began seizing say at triage. Ten bucks said he would have administered a benzo... Any further info/hx on this call? PMHx, Meds, etc...

I'll offer this reply as one of the only ACP's that post on this forum (remotely regularly) and the only one that is in the same province as you and has done similar education. I took the 2 year PCP program and I started ACP less than 2 years after working full time. Eliminate any comparisons people may draw from the US viewpoint of going straight to ALS after BLS (or asap) especially with Ontario's 2 year PCP program. There is no comparison. Your questions... 1) I would wager that the majority of people since the advent of the 2 year program would like to do ACP (and maybe CCP). I would assume that most would like to do so within 3-5 years of working as a PCP. School dependent, PCP encompasses 85% of the ACP schooling (in my opinion). The move (at least from an educational standpoint) is not that difficult. 2) I too had "excellent" grades in my PCP program. While it influenced my (relatively) faster move into ACP, it didn't override the need for experience at the PCP level. 3) Yes, it is difficult to get work as a PCP in southern Ontario. It is hardly the part-time PCP, part-time McDonald's employee that you exaggerate with. I think the $30+/hour you'd be making as a PCP would easy negate wasting time in fast food. Also, Alberta and BC are hiring PCP's. Maybe not the same cash as in Ontario, but it is an option. 4) ACP/CCP does give you more freedom to work nationally, however... You would be basically wasting your money on ACP if you did not go to a CMA accredited ACP program. To my knowledge there are only four currently CMA accredited programs: Toronto EMS (in house only basically - 5-6 years+ seniority as PCP needed working in Toronto), Durham, Conestoga, and Ornge. Even if you decide to go to a unaccredited program (big mistake) I believe basically all ACP programs REQUIRE working as a PCP prior to enrollment (anywhere between 6months - 2 years as I recall). The only one that doesn't (as I recall) is Durham. As a person who has who has applied out of province, CMA is the gold standard. 1) You should. I'll explain in a sec... 2) Another reason you should work BLS first. As you are probably aware it is EXTREMELY rare to non-existent for someone to go straight from PCP (AEMCA) right into an ACP program within minimal or no PCP work experience (I'm talking < 1% and I have never heard of anyone doing it). The reason being: 1) In house/contracted colleges usually require X time in/seniority to get into a class. 2) Only recently have more colleges cropped up that do ACP/ are letting "external" PCP's enter a class. 3) The cost issue 4) This is pretty big... Not a lot of service's are going to be willing to hire a new ACP who has little to no autonomous road experience in a municipal EMS service. Even as a PCP, at least you gain "standing" within your respective base hospital and are "known" to be able to practice sans preceptor. Base hospital's will chat when hiring paramedics from other services, they certainly will be looking at one who is ALS. If you have no prior service at any level, it may raise a few flags, right or wrong. Listen, I appreciate your desire to go to ALS. Trust me, I shared that desire only a few short years ago coming out of the PCP program. Working autonomously is a hell of a lot different than preceptorship (regardless of the freedom they give you). The cliche of "BLS before ALS" from an Ontario perspective is one that is basically forced to be put into practice. My assessment and basically core of all my own paramedic practice has had only minor minor changes after honing it as a PCP. In all honesty the move to ALS only added an enhanced scope and procedures, nothing more. In Ontario, the deck is stacked against you big time for what you want to do. Follow my advice, give it a year or two as a PCP, make some money, and then move on to ACP.

I'm not entirely getting what you're asking here. I certainly would not deviate from a recognized "standard of care" that is currently recommended by your service by what people on this forum suggest. Same goes for reading about a "new standard" in a journal that may differ from your current treatment modality. While there are generalized global standards of care regarding most situations, in the end the physician that dictates your practice can "do whatever they want". If you have a concern regarding your "protocols" then bring them to the attention of your service and medical director. I would recommend not "doing what you want, just because it doesn't actually go against 'protocol'". Some examples - My service started doing the "up-front" chest compressions (and new compression ratio's) for unwitnessed arrests quite a while prior to them being "standards of care". I (and others) found that it lead to a significant increase in prehospital ROSC. I would not expect people on this forum to institute that modality until it is recognized by their service/physician. I don't have any standing orders regarding treatment of a hyperkalemic patient. So, should I come across a renal patient in a wide complex bradycardia say, I can't simply administer sodium bicarbonate and salbutamol (the only medications we carry that are in the standard treatment) without calling a doctor first. Even though they are "standards" and I'm not going against "protocol" (because there isn't one), I still have to have a chat with the doctor. Same goes for the oral administration of D50W that was talked about on this forum. Just because it can be administered by that route, I doubt that very many people have this option spelled out in their orders. Therefore you are giving a medication by a route not specified and must call for administration. A similar example is midazolam. Initially we didn't have IN as a route available, and even though it is an accepted route, you cannot simply do it. Unless you have something in your orders to the effect of "administration may proceed by all acceptable routes per drug insert" (or something), you can't simply do it. I can give morphine to a ischemic chest pain patient, but I don't have to. I have read some journal articles questioning morphines efficacy in this setting and personally refrain from it. People do administer it though, but I find most patients prefer not to have it. Same goes for the subjective nature of treating a chest pain patient in itself, you may treat, where I wouldn't. That is the beauty of having guidelines rather than have-to-do's. Again, if you are questioning certain treatment guidelines that your service does, based on new information, approach your service/physician first before you take things into your own hands.

The last VF arrest I did (keep in mind witnessed by medical personal with CPR, patient was young, and we were on seen quickly), the hospital applied the ROC study hypothermia treatment to them within minutes upon arriving to the ER. It looked promising. If I shake their hand, I'll let you know.

Ya, I don't know where the author of that article got their information from. Toronto does not provide vests to employees in general. Tactical paramedics are provided vests (I don't know if they are individually issued or not), but there are only like 30 (?) of this type of paramedic in the city. Also, generally speaking, they only wear them on ETF calls, which are uncommon at best. Now, there are people who are on "normal" paramedic duty that wear vests. These people (I presume) paid for the vest themselves. Again, these individuals are certainly the exception, rather than the rule. Maybe 2-3% of "normal" paramedics wear/have a vest (my assumption). This issue gets brought up every now and again, and it still might be in the works for standard issue. I have not heard of it in a while.

Yes

I think it's safe to say that body art has been around for far longer than today's dominating monotheistic religions... http://magma.nationalgeographic.com/ngm/04...line_extra.html But I digress... It is totally based on where you work and what the culture/religion is (though I work in a vastly more multicultural/multireligious community then well, any of you). I have never heard of, nor seen an issue come up about piercings or tats. I have mentioned this before, I have 2 unconventional visible (though subtle) ear piercings that have probably been brought up a handful of times (and I can't honestly recall when the last time was). A lot of my co-workers have visible tats and piercings that many of you would cringe at. The population that I serve (read the former) have no issue with it. I have never heard of an issue from my most "tatted" friends.

So God, who's son is Jesus, but Jesus is also God...Anyway... So God, somehow made a mistake in its initial rules. Amazing how an omniscience, omnipotenent, omnipresent being can simply "make an error". But then... Meh...

Ummm Beegs, I don't think God is specifying body placement here. You're probably a sinner for even thinking of it. Repent soon...

So laws and rules to live life as per Leviticus, are good to live by?

That was a joke right?

Again, a tremendous story there. I thought I had read something similar before... http://www.emtcity.com/phpBB2/viewtopic.ph...sc&start=30 Looks like some of the details of the story changed, maybe you just forgot. I'm sure it still happened... You also never answered any of the questions that I posted regarding your ability to practice in Ontario on that call. Maybe you can answer them now in this thread.

Is it C. diff?

C. diff.... How fat is this kid. Hyperglycemia could explain her symptoms...

Considering the relative rarity of pre-hospital childbirth and the general unwillingness of paramedics to deliver pre-hospital (i.e. run for the hospital), it seems pointless. Concentrate on properly assessing duration and frequency of contractions, getting a decent history, noting crowning, recognizing (potential) life threatening complications (placenta previa, abrupto, etc...), and be up on NRP. These are more improtant than assessing for cervical dilation. Again, why add such non emergent physician procedures to an already under-educated system? I don't get it...