vs-eh?

Critical care paramedics (CCP) are very very rare in Canada. Let's assume there are (and I'm really ballparking) 20,000 paramedics (PCP, ACP, CCP) in Canada. Out of that 20k, I'd say there are 500 recognized critical care paramedics. Alberta seems to be slightly different regarding CCP designation as their ACP's seem to encompass a lot of CCP scope but anyway... CCP's in Ontario are generally only in the aeromedical environment. CCP's operate with the provincial air service and are available from that single service for the entire province. Toronto is the only ground service in Ontario that does critical care transports with CCP's (and that's basically all they do, very very little 911). Toronto did a one time job call about 10 years (?) ago and basically that program will disappear with attrition. That being said there is a significant difference between a critical care paramedic in the US and in Ontario (and I assume Canada in general). The US critical care paramedic program (I believe) is a 2 week-ish course. It seems to be more of a cert. course. Ontario has the only CCP program in Canada that in accredited under the CMA (essentially the national standard). Here is the link... http://www.ornge.ca/edu-programs.html Obviously quite a bit different. A new person wanting to be a CCP in the end, starting today, will spend about 4 years in education and quite a bit of cash (2 year PCP + 1 ACP + 1 CCP - assuming that the ACP is flight). The provincial flight service providers (ornge runs the entire province, but they contract out to preferred providers) to my knowledge still supplement educational costs to an extent if you work for them and wish to enhance your scope. No land service pays for critical care education, because, well, currently it is basically only in the air. CCP's make in the low-mid $40/h range here though... Not bad...

1) What was the blood sugar obtained prior to attempting to intubate this "snoring resp" diabetic patient. I seriously hope one was obtained prior to attempting to intubate this patient... 2) What type of bigemeny was this patient in? If it was ventricular, were the PVC's conducting? 3) BLS airways maneuvers and oxygenation seem to have cleared up the ectopy. I'm gonna go out on a limb and say the patient is hypoxic secondary to carbon monoxide poisoning... What do I win?

As an educated person Vent, I assume you aren't defending this. What are the "case by case" basis' people are using for drinking alcohol while on volly or paid (or whatever) EMS/Fire stations?

Are you from Patterson, NJ?

Go on...

I agree.

This is obviously playing off this thread... http://www.emtcity.com/phpBB2/viewtopic.ph...asc&start=0 For those that haven't read it... Essentially, it contains arguments/explanations for allowing drinking at a Fire/EMS station (volunteer is mentioned) or at minimum tolerating alcohol to be allowed even on the premises and its ingestion given certain "circumstances". Now I'll say this... I've never worked as a volunteer and have been a professional paramedic my entire EMS career (as limited as that may be). I also work in a very large urban service and as such have never been privy to the assistance of any volunteer (what I would consider volunteer, not a lifeguard or something). My question as per the topic... If there is an indifferent or (dare I say) "yes" answer, I would like to hear the rational.

Questions and comments... 1) What is your work policy or "common sense policy" regarding ETT confirmation? Obviously there are multiple clinical and adjunct ways a tube can be confirmed to be in the right place. 2) You as a paramedic noted that you saw something clinically that may indicate that the tube was not in the trachea. Why did YOU not reconfirm the tube or AT MINIMUM ask the paramedic who intubated to do the same? 3) The reading of 6 mmHg ETCO2 if the tube was in fact in the esophagus would have been transient (regardless of anything). Does your system only have numerical display for ETCO2? What did the waveform look like? 4) Is it common for you to transport adult cardiac arrest patients (witnessed or not)? 5) During this movement of the patient and the 10 minute + transport, how many times was the tube reconfirmed? Is it not standard policy (rational policy) after any significant movement of an intubated patient ESPECIALLY in the face of a query INITIAL misplaced tube to reconfirm regularly? 6) What did the patient actually look like?

It's a joke Rid....

An obvious play on those "motivational posters". Yes I know what forum I posted it in. I don't care. Even though it is hilarious, it is more appropriate to post it in an EMS forum.

For the sake of arguement as a potential differential... Unknown sickle cell patient with an ayptical (acute chest) presentation? Meh?

As always this is a fairly subjective issue in my opinion, and based on your crew's system... Generally speaking a (subjectively urgent) trauma should get to an appropriate facility urgently. A query CVA (based on your systems guidelines and that meets your systems guidelines of urgent transport) should get there as well. I would also add "urgent pregnancy" like say breach or meconium present or something...There are other cases as well... Generally speaking it (again) is up to the crew and what they feel comfortable with treating en route. It is not "break neck" speed to the appropriate hospital....It is getting to a hospital more quickly than following normal traffic would.

Dude, think about that for one second.... This is a post-cardiac arrest pre-hospital... You would feel comfortable administering NTG to a patient given this scenerio (regardless of "vitals") that is post CPR and defib in your care....they are experiencing "chest pain"? THEY ARE? NO WAY... Maybe it's just me...

Has this been posted here before? I know it is likely 10+ years old and I know there are numerous "points of concern" people may have with this video. My question is this... Was it/is it a normal procedure to give a POST ARREST patient SL nitro prehospital? Regardless of presentation/vitals/whatever? I know...there are a lot of things that are "wrong" with this video...

Maybe we are running into an issue of semantics. I will attempt to clarify... An ALS crew assesses (whatever XYZ complaint you can think of) as being within the scope of a BLS provider to take care of. Are you then allowed to transfer care to a BLS ambulance crew? Is the "equal or greater medical authority" mean you as an ALS provider see the patient as? Or is it a "first contact happens to be ALS so regardless of the complaint, I have to hand this patient off to an ALS or ALS+ provider"? If your system works in a "BLS complaint but ALS first contact, therefore ALS all the way to transfer to the hospital", then that's fine. I disagree with it. I don't think that is an adequate use of resources. But again, I work in a more subjective system.As long as there isn't an active or anticipated ALS treatment plan by an ALS provider, that a BLS provider can't provide, they can be handed off to a BLS provider. You can quote me on that last one. And of course I'm not talking about a CP that an ALS car is treating as ischemic (when a BLS car can as well), I'm saying a generally benign call. I don't equate "abandonment" to stopping on accident/flagged down scenes as long as it is reasonable and rational. As long as you are not leaving the patient alone in the back of the ambulance, and as long as your delay will not impede them getting to hospital where emergent tx is needed (in your subjective opinion), I don't necessarily see an issue in stopping. The whole "stopping is wrong" thing (believe it or not) actually can be a subjective issue. But again, I don't come from a PROTOCOL, PROTOCOL, PROTOCOL, driven system...Guidelines aren't cut and dry...

Again scratrat, you are speaking from the perspective of your current system. If you moved to a system that didn't follow these rules (like mine), your opinion will change. If you held these views tried and true, you would not be able to function long in my system. Maybe we play in a more subjective system? Judging by the posts here it appears we do. Again, as long as I can rationalize and it is reasonable... Why can't an ALS crew hand off a BLS patient to a BLS crew? Especially one that you're babysitting in hospital? Again, this happens many many times daily here... Sorry? I don't quite understand how that would work but....You are driving to a sprained ankle across the city and are being redicted to a cardiac arrest that you are closer too? This doesn't happen? Happens many many times daily here. Hell, I have even pulled up to a call (no actual patient contact yet) and been pulled off for a higher priority patient. Even to the point of having to shout or tell family/by standards that we have a higher priority call and another ambulance will be by shortly. It happens man, all the time. Different perspectives from different systems and ways of thinking.

http://www.wrongdiagnosis.com/sym/wide_pulse_pressure.htm

I don't think there will be a consensus on this issue. People base it on personal experience, company policy, and what constitutes abandonment (amoung other things). People can come up with all the ridiculous scenarios they want. In the end, if it is spelled out in black and white that you don't stop (regardless of anything) you don't stop. Obviously not all situations are like this in EMS and in medicine. My opinion is as always, as long as you can rationalize your decision and it is deemed reasonable, you go with it. I assume the service I work for has a policy outlined for stopping after being flagged down/witnessing an accident. I can't recall ever reading it or know where I could find it, but I'm sure it's there. I am of the opinion that unless you have an "emergent" patient, that you can take the minute or two to briefly assess this new patient. You aren't abandoning anyone (your partner is still in the back), it is just that your 15 minute ride to the hospital, may take 17 minutes now. Surprisingly enough, your brief ABC professional assessment could actually benefit this new patient. But people will always come up with the "what ifs". What if this "new patient" has a gun? What if your knee pain that you were transporting goes into cardiac arrest while you are stopped? That's fine. Again the word reasonable always applies in these situations... I'll extend this wordy post by providing a personal example that (generally speaking) is not grossly uncommon here... During my ACP preceptorship we attended a psych call. General BS psych call, a young girl, no self harm or anything, she may have been "off her meds", I don't recall. Basically your standard "pysch" questions, her in the jumpseat and a taxi drive to the hospital. Shortly following transport a PCP car asked for ALS for a cardiac arrest on the street. We were less than 1 min from that scene. My preceptor radioed saying we had a stable patient and would be able to render assistance. We arrived on scene, received report (ROSC with just CPR), traded off patients and rendered appropriate ALS care to the patient who actually needed it (intubation, IV, etc...). Our original patient was never abandoned, just switched off. And you know what, if it came right down to it and we needed the paramedic that was watching our pysch patient? I would have sent a FF in to watch her. People can disagree all they want. That's fine. I'm sure a lot of things that happen in my system would surprise people, and vice versa.

I can't really comment on #2, as I am not really familiar with flight paramedicine and logistics and such... In #1, I assume these are the same patients? While uncommon (and minus the drama), these scenarios do happen here. If the crew is able to hand off their patient to another crew (with a quick story and minus a stretcher) they will respond if they are able. BLS crew dispatched to a cardiac arrest with no ALS. Dispatch will call an ALS crew babysitting a patient in a nearby hospital and ask if one or both paramedics can respond. It does happen, I have seen it. As long as you have someone to observe the patient, the original crew (if able) will go. Crews hand off patients to other crews in hospital ten's, if not hundreds of times DAILY in hospital here. We have a major "offload delay" issue here, and patients are constantly being handed off to other crews. They are not being "abandoned" just handed off... You have to discuss these scenario's via the perspective of your system. That is how things would happen in mine.

People are so paranoid in the US about suing and such. Working for several years in the largest system in Canada, hundreds of thousands of calls a year, I can't even recall ONCE a person stating they would "sue" regarding an issue in EMS. I'm sure it has happened, but I can't recall any specific instance. Truly amazing the mentality of people... The fact of the matter is that here, assuming that you have a "stable" patient on board and are not leaving them by themselves, people stop. People can come up with all the scenario's they want. As long it is reasonable to assess the patient after witnessing/being flagged down (i.e. the are observable from the ambulance) and your current patient isn't being left alone, people stop. In the end, it is a form of triage. Your knee pain can probably wait if you are flagged down and see a person doing chest compressions to someone on the street... In the end, all of this is going to be fairly rare and will be at the digression of the crew, the acuity of your current patient, and the reasonable nature of assessing the patient you are stopping/being stopped for.

It involves PRPG, NREMT-BASIC, RID, and myself... It's old, it's long....But you know what....It may enlighten some of you on some things... http://www.blogtalkradio.com/hostpage.aspx?host_id=1509 JAN 19 FEB 2 If you have a few hours, it may be interesting to you...

I haven't read all the responses. That is the main thing that bothered me. That is abandonment in its purest form. The fact of the matter is that if a similar thing happened here (with an assumed "stable" paed post-ictal, assume febrile), a crew would stop (all other things not withstanding). This is a very large municipal system (300k+ responses a year) where YOU are the only service allowed to respond to calls. In the end it is up to the crew (believe it or not) to decide on the stability of their current patient and the need to stop at the call/accident. This obviously doesn't happen on every call or crews stop on every accident. However there are times if an ALS crew (with a "stable patient) who is close to a BLS crew who is asking for ALS assistance (honestly this happens fairly rarely). This happened last week (but probably happens daily). A BLS crew requesting ALS (keep in mind we are a municipal system and the only EMS service) for a patient with a HR of 200. We had a "stable" BLS patient on board. Had we been close, we would have intercepted that unit, reassessed and traded off patients. That's how it would have worked. Turns out the guy was cardioverted in the ER, etc....No ALS was available. Same thing would have happened here. "Stable" patient in the back (regardless of age or nature). Come across accident, assess, ask for unit. If ALS intervention is required stay on scene until unit arrives. Switch off if BLS/ALS needed/switch patients, etc.... That is just how it works here from my perspective with a "stable" patient. People simply don't worry about people suing people or lawyers here. I am not saying leave NO ONE with the patient, but at least have someone with a more critical patient. And you know what, I have had patient's say "maybe you should both help that guy instead, I'll be ok".... Different mentality I guess...

The point is spenac, that seeing these posts ad nauseam wears on you. You are forced to see said "BASH" threads because they appear scrolling by on the home page. Either consolidate these threads into one or forget them all together. One or two is fine, six or seven is old. Again, it gives a poorer impression to those who are new on this site, or to those who (god knows why) are looking for some sort of educational benefit. As an aside, "retarded" can mean intellectually limiting and perhaps not the definition you were applying... The former definition is appropriate though...

What are they going to receive in hospital? At minimum they will receive the diagnosis/differentials from one or more physicians that you certainly cannot provide. They will receive pharmacological management that you cannot provide. Blood work acquisition and interpretation that you cannot provide to aid in a solid dx....Shall I go on? Stroke patient only eh? Trauma, query MI, eminent pregnancy.... Listen, obviously you guys have issues with your "drivers" going L+S. That is more of a system problem. than a "benefit to the patient" problem. In certain cases (not all) and certainly more than query CVA patients, time to definitive care = survival sans deficits. We don't have an issue with going L+S to the hospital here. Everyone here is a paramedic of varying level. They have driver education, specific specialized licenses, etc... They don't drive L+S like idiots, the generalization being that your's do.

Any recent falls prior to the onset 3 days ago? Basal skull issues/injury? Obviously my opthalmology knowledge is quite limited but perhaps a cranial nerve issue or an ischemia/injury/infarct issue which my explain why she has no pain now? Maybe she gets some type of cool cybernetic eye? Or maybe, just maybe...No, it couldn't be....SHE IS A CYBORG! Doc, you cheeky monkey you...