systemet

But didn't he inherit a massive economic mess? I mean there'd just been a global banking crisis, the effects of which are still being felt world-wide, he got the fall out from the sub-prime mess, and inherited two wars. Are you sure that a republican president would have done better? It seemed like whoever was going to be in office for this term was going to have some major challenges to face. I'm not saying he's perfect. He ballsed up closing down Guantanamo, but he managed to end the military part of the Iraq invasion. There's major budgetary issues --- but this is also a consequence of running a deficit for years. Where you say he's had the time to fix this economy, I'd disagree. I'll freely admit that I'm biased towards Obama and the left, but I think anyone would have had trouble running the US economy during this period of time. This wasn't going to be a good couple of years, no matter who was in power. If you feel the government's actions in recent years have made the situation worse, and that republican policies would have been better, than I understand the criticism. But I don't think it's fair to just point at the economy, and say "Look at this mess!", and then blame whoever's in power. It was always going to be a mess, it's just a question of whether it was going to be a bigger or smaller mess.

The following is just personal opinion from playing around in the mountains a bit.... * In this situation the first priority is likely going to be activating rescue services. Unless there's minimal injury and he's basically able to self-extricate and support himself on one leg, you're going to need extra bodies. * Also, you may be walking into a technical rescue. If you are not equipped for this things are about to get very difficult and potentially risky. The worst thing to do, would be to charge in without summoning adequate help yourself, or ensuring that someone responsible is doing it right now. As for equipment, I would think that you probably need to be able to survive overnight, and be protected from the elements and any environmental hazards. This might be greatly complicated by terrain. There's a good possibility you may not be able to reach the kid, in which case, you're only useful to the point that you can provide psychological support, and assist rescuers in locating him / her later. Once you've taken care of your needs, and are confident you're not going to compound the problem by getting yourself lost or in a survival situation, you want to be able to keep the kid alive. So some compression dressings, tourniquets, warm clothes, maybe some blankets, something to put between the kid and the ground if you're able to access him/her would be good next priorities. I figure on top of that, I'd want an oral airway, some angiocaths for needle decompression, kit for IV access, some sort of hand-powered suction, and lots of analgesics / sedatives, perhaps some quik clot [stuff I imagine is not in your jump kit]. I'd probably drag along a cardboard splint / SAM splint and a bit of gear, in case there's a possibility of splinting and extricating, and for some relief of pain. Maybe a few cravats and a couple of hemostats to do a pelvic wrap if necessary. Beyond that, I don't know. I mean, I could make arguments for bringing a BVM, surgical airway supplies, a few LMAs, and some paralytics, but really, at that point it's getting into wilderness medicine fantasy-land. It's not stuff anyone's going to have in their personal vehicle, and in most situations where it's going to be needed, the end result isn't going to be good. I have no experience / training in this area, so I may be steering you wrong.

http://www.bbc.co.uk/news/world-middle-east-16283562 Seems to be off to a bad start.

I think it's a fatalities inquiry. So it's not a criminal proceeding, but the judge has the power to make findings and recommendations for changes that might be useful in preventing a similar case in the future. As I understand it, the information given at the inquiry can be used in criminal or civil proceedings at a later date, and pretty much any member of the public can come and ask questions to anyone called to give evidence. But some of these rules may vary by province. I'm not very familiar with this, so someone else might have better information. I agree with the spirit of this. I just wanted to point out that the OPALS Major Trauma Study only showed a difference in a high risk subgroup of patients with GCS < 9 (60.1% v. 51.2%; p = 0.03), and the issue identified was intubation (adjusted OR 2.8, 95% CI 1.6–5.0 -- i.e. patients were 2.8x more likely to die if intubation was attempted), whereas IV therapy had no measurable effect (adjusted OR 0.8, 95% CI 0.4–1.4) Much of this study suffers from similar problems to the San Diego RSI trial, with historical controls, etc. But what's interesting here is this group was reporting a fairly respectable 94% intubation success rate in cardiac arrest, but in this study with trauma patients, only intubated 71.8%. This might speak to lack of an RSI protocol in this region. I also agree with this. Most blunt trauma patients are non-surgical, or at least, aren't going to necessarily benefit from rapid OR intervention. The rapid transport concept makes more more sense when you have someone with penetrating trauma to the torso who needs immediate damage control surgery. I'm not saying these guys necessarily did the right thing. I think it would be optimal to start the IV en route, but maybe as Dwayne, and other pointed out, it wasn't possible given the situation. I think it's great that he took that stance. There's no doubt that ER physicians are experts when it comes to emergency medicine, but I've seen too many situations where they've questioned or criticised decisions made by field providers in environments they have no or little experience with, e.g. MCI triage.

Have you considered working in management?

I hope that some relative stability remains in the region. I'm a little afraid of the law of unintended consequences, and what's going to happen with Iran and nuclear proliferation.

I hadn't really thought about the distinction between the two to be honest. I think I was speaking more to EMS in general, which of course is coloured by my own experiences and the particular providers I've met, and systems I've dealt with. This is great. I've been lucky to work with some awesome people as well. I've also worked with some people who weren't very good. There's been a real range. Do you really think so, I mean the part about us "hav[ing] a right to be?". I kind of feel like, as a group, we tend to underestimate the uncertainty involved in what we're doing. It seems like things would be all backwards if I'm bringing a guy into an EM doc with 9 years of medical training, on top of an undergrad, and I'm more likely to be right than him or her. For example, unless I have a field troponin kit, which few services have, I have no way to diagnose a NSTEMI. I don't have any meaningful way to detect a PE. I can suspect CVA, but can't really differentiate it from a TIA, because we don't have CT scanning. My patients can be hyperkalemic, if they have a particularly suspicious ECG and history, but can I really claim to diagnose other electrolyte disturbances? I can observe findings that might point towards them, but it's hard to really sit down and say, "this patient here is hypomagnesemic because of ....". Or conversely, this patient isn't. Sometimes it feels like we have a pretty narrow range of diseases we can identify, or at least find supporting evidence for, and we try and pigeon-hole the patients into these categories, often inappropriately. Well he may not be smarter than you, he just may be more educated. I've seen lots of educated people do lots of stupid things, trust me. I would argue, in a friendly way, that sometimes we have a lot more time on our hands than we think. Sometimes there just end up being a number of differentials that we can't exclude, that have a similar probability, then we end up stuck in the same situation, waiting for technology to provide other findings, or forced by the possible severity of the situation to do what we feel has the best risk/benefit. Obviously you know if the doc is being flippant or not. I can't disagree with you over that from the other side of an electron beam, and it would be foolish for me to try. But the attitude of gathering further information before committing to a diagnosis seems quite reasonable. I think those are the sort of people I was really thinking more about. When I started as a medic I was quite young, and had to really fight for respect. I was lucky not to screw up too badly in my first couple of years, and eventually got to a place where I didn't care so much about being respecting, and around that point, it felt like people started respecting me more. I think a lot of us have probably walked that path. But I have had to deal with a lot of people who are very dogmatic, and that have the attitude that the winner of any argument is the person who aggressively defends their position as loudly as possible while showing anger and emotion. The "he who shouts loudest is right" philosophy. I've worked in places as an EMT where it was possible to transport for several hours -- BLS services doing 911 as well. But as a medic, I've usually been within a half hour or so of some sort of approximation of a hospital, and an hour or two from a real one. The bulk of my experience has come in urban / suburban areas with shorter transport times, some of which have been in the 5 to 10 minute range. But, then, with redirect systems, and all the craziness that happens, I've done 45 minute transports in urban areas too. I won't even start about hallway nursing... I think that some of the generalisations about rural and urban practice have some validity, but I think they're also often distorted by the perspective of past experience. City medics have a reputation for being burnt out, under-treating, and running everyone to the ER. Or at least I used to hear this complaint from people in the rural regions a lot. But the counter-argument you often get from urban practitioners is that they simply see a large volume of patients, and that they're being conservative with their treatments because (i) there's only so much benefit in exposing the patient to a potentially risky intervention if they're a few minutes from an ER fellow and a real hospital with trauma surg, and specialty ICUs, and (ii) they feel that they see a wide range of presentations, and are more comfortable with which patients are truely sick and need aggressive interventions, and feel the rural guys over-treat. I think you still run into these situations in the city, as well. You can still show up at a code and have your laryngoscope die, or your monitor stop working. I don't know why I'm defending urban practitioners, perhaps because a large proportion of my time in EMS was spent being one. But I met good and bad people in both settings, and can't say that either population of providers seemed that much better than the other, on average. No, I think that's part of being a competent provider. I think a lot of what people describe as "sixth sense" is just keying in on subtle aspects of a patient's presentation that reminds you of something you've seen before (sometimes it still steers you in the wrong direction, of course, but c'est la vie). I used to play a game with students occasionally. Just sitting in the truck or in the station, we'd run through a scenario, and I'd randomly declare a piece of kit "out of bounds", and tell them it wasn't working, or was missing. They'd often protest about this being unfair, but it was surprising how many things it was possible to do without or improvise around. Enjoying the conversation, all the best.

Sure, this is actually fairly trivial, you said that the bag was 30 inches about the patient, so 30 x 2.54 cm/inch = somewhere around 75 cm. Then I figured that the density of saline with a little bit of mag in it was probably pretty close to the density of water. There's probably other factors that modify that number a bit, but I'm no physicist. It's a rough ballpark figure. Dwayne, thanks for the kind words. I'm not sure how relevant what I'm contributing here is though

Right. That's the flow-limiting point. I feel a little silly for not realising that. Also, it turns out that the flow-rates that the manufacturers print on the side on the cannulae might not be accurate either. http://www.anesthesi...108/4/1198.full Wikipedia also has an ok entry on the Hagen-Poiesuille's equation/law for anyone interested: http://en.wikipedia....seuille%27s_law McPherson D, Adekanye O, Wilkes AR, Hall JE. Fluid Flow Through Intravenous Cannulae in a Clinical Model. Anesth Analg. 2009 Apr;108(4):1198-202. PMID:19299786 Abstract BACKGROUND: Predicting flow through an IV cannula is useful to clinicians if changes in flow are required and to guide selection of cannula. We sought the usefulness of manufacturers’ quoted flows in predicting actual flow and to characterize that flow. METHODS: We built a vein model and inserted cannulae between 14 and 20-gauge. In the first experiment, we compared the manufacturer’s quoted flows using deionized water, Hartmann’s solution and Gelofusine. In the second experiment, we varied the pressure feeding the cannula and measured the resulting flow. RESULTS: Flow through a cannula is not a simple ratio of the manufacturers’ quoted flow rate, even controlling for fluid type and feeding pressure. Flow is neither fully laminar, nor fully turbulent in the range of rates we have measured and in the International Organization for Standardization test. The Reynolds number is often below 2000. CONCLUSIONS: Flow through cannulae is not laminar at the upper range of clinically used flows, therefore Poiseuille’s law is not useful in predicting flow and the effect of changing radius is less than commonly believed. The quoted maximum flows are also not useful. There are many conditions for laminar flow apart from Reynolds number. Further work would determine useful predictors of flow. IMPLICATIONS: Flow through a cannula is not laminar at clinically used rates and not simply related to the quoted maximum. Neither Poiseuille’s law nor the quoted values can be used to predict the actual flow of IV fluid through an IV cannula. Edit : I apologise for the leftover html tags, but I'm not going to remove them. Instead, I'm going to get some sleep.

I strongly agree with that. I think you've put it much better than I managed. I know that my physical examination skills are fairly weak. I'm not that great at heart sounds. I have a very hard time identifying all but the clearest murmurs. I have great difficulty measuring JVP. I know there are many areas where an MD, an RT, an ICU or ER RN is just going to be plain better than me, because they see a greater number of particular groups of patients. For most of us working EMS, we don't see that many people, and we don't see that many people with unusual pathologies. If I worked in a CICU for a year as an RN (I'm not one), I'm sure I'd be a lot better at discussing heart sounds, or having a really confident idea of what a subtle pericardial friction rub sounds like. There are undoubtedly lots of medics out there that are better at physical examination than me. But I'd bet there's probably a lot that are worse too. We (with few exceptions) take relatively short training programs, don't get a ton of time in specialty wards, and we don't see a lot of the really rare presentations that get concentrated in some of these places. I wonder sometimes why we feel that our physical examination and history taking skills are so much better than everyone elses's, that we know, with an absolute certainty that that chest pain patient is having an MI, and that it's not a TAA, or a cholecystitis, or something. Why as a group, we tend to feel that we can identify drug seekers better than the hospital staff (usual something along the lines of poor + poorly differentiated abdo pain + dares to request the narcotic analgesia that worked last time +/- ethnic minority --> obvious drug seeker), or that our mid back pain patient is a PE (no D-dimer, no V/Q, no real considered thoughts about risk factors, etc.) and so on. There seems to be this pervasive attitude that somehow we are weaker if we admit that there's a huge amount of diagnostic uncertainty in what we do, and we are not experts. If something is giving an ER doc pause for thought, then maybe we should tread cautiously in the same situations. Why do we feel that we're the only group that can't improve our diagnostic ability with the aid of technology, as if paramedic programs were perfected in 1979. I've never been able to answer this question, but I have a feeling that this attitude is one of the major stumbling blocks in our evolution towards a profession. My apologies for a semi-rant, that absolutely wasn't directed at anyone in particular (especially you Dwayne). I just needed to vent a little.

But at the same time, there's not usually a problem with anyone taking a knife into a bar, provided the bartender doesn't notice. I'm sure I've done this myself without meaning to on more than one occasion. I've only seen a few kirpans, but most of them have been about as offensive as a regular folding knife. It's not like it's typically a four foot long scimitar.

I would urge caution with this. I think you are probably using quite a long 16.5 gauge catheter, and have something in the system that is restricting flow. The flow rates should be much faster, consider: http://www.mcguffmed...V_Catheters.pdf And think about how quickly we could get fluid into someone with that large a catheter, back when every real trauma got 20 - 40 ml/kg, even without pressure-infusing. Even if your numbers end up good, they may be highly dependent on the particular secondary set and adaptors you're using. A change in the supply or brand used could result in a big change in these numbers. Oh, and vascular resistance shouldn't matter that much. CVP is typically somewhere around 5-10 mmHg, or 6-13 cmH20. You're infusing from a pressure gradient of 75 cmH20, so you're looking at worst case a 20% or so decrease with the catheter in a vessel.

Yep. Varies a little depending on which leads you're looking at, but it's around the 40% mark. My point, which I made poorly, is that flaming's sense of intuition is probably batting at <40%. Where the ECG does win, is at specificity. If you see a true STEMI pattern, in most leads, there's a 90% or greater chance that there's an actual infarction happening. This may occur in the period before detectable enzyme level arise, and is sufficient to give thrombolytics, or do PCI. This is an example of a machine we trust very very regularly, as a rule-in. I am certain that flaming's random guess that this patient is having an MI is <90% specific. [i am sure, Dwayne, that you're aware of all of this, but I'm putting this information out there for the basic providers.] While the ASA is certainly very important, the NTG and MS are adjunctive therapies with minimal proven benefit (some small amount of evidence exists for a negative effect of MS in NSTEMI, but it might just be noise in the data). No one's going around giving tPA without a positive 12-lead, because "this might be a STEMI". Perhaps this clears it up a little. Perhaps I'm just completely incoherrent today. Oh well.

How? And what percentage of the patients you think are having an MI will later be confirmed to be having an MI by troponin or ECG changes? And what percentage of the patients that you do not believe are having an MI will later be shown to be having one? If the hx is suspicious for TAA, I might well hold the NTG, and go for fentanyl instead of MS. But I don't think this is what you're talking about, although some consideration needs to be given to this if the patient is hypertensive on presentation. In the situation you describe I would administer the NTG and MS, but I would be concerned about the possibility of an undiagnosed RVMI. Nothing about the presentation you describe necessarily screams MI. There's a good possibility this could be angina, and despite the anginal-pattern pain, this could still be of non-cardiac origin. Crap. Well, you knew what I meant, and you'd agree that a troponin alone is not enough for TNK.

Possibility 1: The pulse ox is wrong, and the patient is acutely hypoxemic, and cyanosis is due to a unhealthy amount of deoxygenated hemoglobin. This would make so many of the people posting on recent threads ecstatic, but is probably unlikely in practice. Do we have a good pleth? Is there another pulseox we can use to verify our values? I realise that we have a venous gas, but is there the possibility to get an ABG and SaO2. How's the SvO2? Do these things support our pulse oximetry? Possibility 2: The patient's hypercapnia is baseline, because they're one of those relatively rare CO2-retaining COPDers. The pH argues for an acute change, especially if the bicarb / BE is normal. Another process is causing altered mentation, e.g. a CVA. The cyanosis is due to another cause, e.g. methemoglobinemia. If we can get an ABG with MetHb% or use a co-oximeter (as inaccurate as they are) for an SpMet this might help. There is a single case report on methemoglobinemia with cephalexin in a mixed overdose on pubmed. It's also possible that there's been another exposure, e.g. well-water, home-preserved meats, etc. http://www.ncbi.nlm....themoglobinemia Possibility 3: The patient is in acute ventilatory failure and has CO2 narcosis (supported by pH, mentation, PvCO2, past hx). However, if his CO2 is baseline high, then 80 mmHg might not be that high for him, even if it's in the danger zone for CNS / cardiac effects for most of the rest of us. Is it possible that he received a large dose of benzos, opiates or neuroleptics, or some other CNS depressant from the hospital? I've seen small facilities do this sometimes. This still doesn't explain the cyanosis, unless methemoglobinemia is also present. But then, I'd expect the saturation to be lower if there's a significant amount of MetHb present. Concommitant CO poisoning seems unlikely here. --------------------------------- I think that we have too little information here to make a dx. We might want to try a NRB if he's moving any tidal volume first, just to see if the cyanosis resolves with a higher FiO2. If that fails, Given the patient's mentation and pH, I think we can probably look at intubating. We can then ventilate with a target PETCO2 of 60 mmHg, which should bring the pH up to about 7.37, give or take a bit. Hopefully we can check that with a serial PvO2 if they have any point-of-care. This would be an excellent time to call an EM physician in the city for a little help / advice. EMS hates patching, but it's these situations where a physician's input can be really valuable. I'm curious to see how this one works out. Edit: punctuation

Further to what mobey posted. * Who thinks that they can diagnose an MI without an ECG? * Who thinks that they can determine whether the previous patient should receive TNK / other thrombolytic de jour?

I've actually never read the research on mag. I should maybe go and look it up. My anecdotal experience has been seeing the results of giving it too fast a couple of times (I know, once is too many times). We typically gave it over 8-10 minutes, but in both these cases they received it in a little closer to 2'. I should mention this was only a 2g dose for asthma. Both patients became quite flushed, and quite nauseous. One complained of "feeling like [their] skin [was] on fire". Neither vomiting, although they both seemed close, and while both had downward trends in their blood pressure immediately afterwards, neither became < 100mmHg systolic. Honestly, I feel that I was lucky in both situations that it wasn't worse. This was given in a 50ml bag with a secondary set on a primary line. Regarding croaker's original post, I wonder if there's a possibility to get magnesium in a 2g preparation? We used to draw out of (I think) 5 g / 10 ml, and this seemed to run a bit of a risk of drawing up too much. The major risks here are hypotension, and.... hypermangesemia. http://emedicine.med...766604-overview While hypermagnesemia might not sound that bad, at high enough levels you can get cardiotoxicity, e.g. bradycardia, AV block, and you can also see inhibition of presynaptic ACh release, causing flaccid paralysis and apnea. Looking around, I found that giving 2g of Mag over 20mins, usually equates to approximately a doubling in the normal serum concentration or 1.3-2.1 mEq/L. Typically events like paralysis and heart block occur at somewhat higher concentrations (one sources suggested 10 MEq/L for paralysis). Where this might be a very big problem, however, is if the patient has renal failure. But in that case, we probably won't be giving magnesium in the first place. If I find some time, I'll try and take a more thorough look.

Canada is a great country. One of the things that has made it such an amazing place, is how it's been able to integrate people from hundreds of other cultures without forcing them to give up their identity. As tniuqs correctly points out, it's possible to be both Canadian and Scottish, identify with both cultures, and yet not be considered less of a Canadian for doing so. I see no reason why this shouldn't be the same for a Somali Canadian. I find it helpful in these situations to look at the cost of changing or prohibiting a given practice, and the benefit. With the first situation being discussed, the argument is put forward that allowing a woman to cover her face for religious reasons during a citzenship oath implies support for female subjugation and exploitation. The proposed benefit of this legislation is that Canada will reaffirm it's support for women's rights. The cost, is that an observant Muslim women who wears a niqab or burka will be forced to choose between becoming a citzen, or following her religious traditions. A choice that may not be her's to make, if indeed, she is being oppressed by her community (*not that all women following this practice are doing so unwillingly, but sure, some are). To me, this contravenes Canada's long held values of multiculturalism and pluralism. It implies that one must choose between their religious faith and being a citizen. It says that Canada is a place for everyone, except burka/niqab wearing observant Muslims. To me the cost of this decision to our society is too high for the perceived benefit, which is intangible at best. Our laws protect women's rights, they're reaffirmed every day in a hundred different ways, and allowing someone to take a citizenship oath with their face covered, seems a minor issue. There are other situations where the niqab / burka decision becomes more difficult. These include passport identification, preservation of banking information, welfare fraud, and airport security. I can understand arguments on both sides in these situations. But for an oath of citizenship? I disagree very strongly with this. If indeed some Muslim women are being forced to wear full face coverings against their will, perhaps the best thing we can do is ensure that they are protected as Canadian citizens, that their children are protected, and they are given the benefit of time to adjust to a new culture and a welcome to a vibrant multiethnic society. Any discussion of this topic would not be complete without a brief note that the Islamic faith includes some 1.5 billion people, or about a quarter of our planet. A very small proportion of these people are actively engaged in religious war. A very small proportion of these people perpetuated terrorist attacks. Most Muslims are not that different from most Christians or most Hindus, or most Jews, in terms of religious tolerance, and part of mainstream Muslim orthodoxy is the idea that Jews, Christians and Muslims are all "people of the book", and that they are honor bound to respect the traditions of others. The practice of full-facial covering, or of female circumcision is peculiar to a number of small, isolated, and largely backward countries in Northern Africa, and is practiced by a tiny minority. Most of the larger Muslim community does not engage in these behaviours. I apologise if I offend anyone with these comments, but I feel very strongly about these issues. With the RCMP, I'm a little less personally volatile. My understanding is that the precedent for the decision to create a "uniform" turban for Sikhs was set in England some time ago. The police force was having difficulty operating in neighbourhoods with a large Sikh population. They were perceived as outsiders by the community, who were reluctant to report crimes or cooperate with ongoing investigations. The police force noted a lack of Sikh officers, and identifying their religious requirements and the uniform design as a stumbling block to recruitment. The introduction of a turban was not done simply to appease the left wing (although this is my opinion), but because there was a perceived value to the police force. I expect the same was the case for the RCMP, which for some years has had affirmative action, which should be far more controversial a policy than a minor redesign of the uniform. It might be worth remembering that the original RCMP uniform has been redesigned to it's current form to reflect the realities of modern policing. No one is suggesting that members should be wearing the Red Serge while doing their daily duties. Is enabling observant Sikhs to wear a uniform turban that different from moving away from a red cavalry jacket? Or is it just that some people have come to like the stereotype of a Mountie being a 6'2 250lb white farmboy? http://news.rediff.com/report/2010/may/12/baltej-dhillon-rcmp-on-20-years-in-the-force.htm Below an image of RCMP in daily working gear, for any non-Canadians: http://www.landairsea.com/gps-tracking-blog/wp-content/uploads/2011/06/RCMP.jpg

Axis deviation is relatively simple. * Ignore the chest leads (V1... V6, etc.) * Look at the limb leads, e.g. I, II, III, aVR, aVF, aVL. (1) Simple method (The "Fonzie sign"). Look at lead I and aVF. If the complexes are mostly positive in both, i.e. "two thumbs up", you have a normal axis, i.e. between 0 and +90. * negative: this method will lead you to identify some rhythms that are lead aVF negative and lead I positive, that fall in the normal range of 0 to -30 as being left axis deviation. (2) Most strongly positive limb lead. Find it. Find the next most positive lead. The axis lies somewhere between, e.g. if lead II (+60) is the most positive, and lead aVF (+90) is the next most positive, then the axis is between +60 and +90. Roughly. [Note that to do this, you mentally (or physically turn lead aVR upside down, producing a lead at +30, intermediate to lead I and lead II, this is called the "Carbrea rearrangement". A variation on the same theme, is to find the most isoelectric lead (i.e. the lead with the smallest QRS), and understand that the axis is perpendicular to this. So if lead I (0 degrees) is roughly isoelectric, we know the axis is either roughly +90 degrees (normal), or - 90 degrees (left axis deviation). If we see leads in the direction of 90 degrees, e.g. aVF (+90) III (+120), lead II (+60) showing mostly positive QRS complexes, then we can guess the axis at about + 90 degrees. * This method is quite quick, but gives a rough answer, and requires that you know how the leads are oriented, i.e. Einthoven's triangle. Look here: http://t1.gstatic.com/images?q=tbn:ANd9GcRjhqeBYB4xNkxmFUv6OTpDk8RoGkFcwGikxNRiiWOkqMjU1pjI (3) Geometric (pain in the ass) method: Take any two leads. Measure the height of the Q, R and S waves in the respective QRS complexes relative to the baseline. Find the net deflection, i.e. height (R wave) - height (Q) wave and height (S) wave. Draw a pair of axes corresponding to the leads in question, e.g. a line a 0 for lead I or a line at +60 for lead II. Mark the relative net deflections of the QRS complexes in arbitrary units across each axis. Draw lines perpendicular to this point. Where they intersect draw another line through the center of the graph, and the angle of this line is your axis. This can also be solved for with trignometry. This is sort of explained here: http://www.madsci.com/manu/ekg_axis.htm (4) Just use the reading on the LP12, but confirm that it's somewhere in the realms of reality using (1) and (2). ---------------- Pericarditis is hard to diagnose via ECG. Classic findings are diffuse ST changes, PR depression, concave upwards sloped ST elevation, and an ST/T ratio of > 0.25. Sometimes QRS alternans is present. But these are very insensitive for pericarditis. Physical exam can give you the triad of hypotension, JVD and muffled heart sounds (i.e. Beck's triad) +/- pericardial friction rub in acute cases with tamponade. But this is also quite insensitive, and depends on how familiar you are with cardiac auscultation. Typically the pain associated with pericarditis is pleuritic and relieved by leaning forwards. However, it's a really hard dx to make prehospitally, and the ECG is only helpful in a very small fraction of cases. I'm in the middle of a thread on another site debating this issue. I really believe that we should default all interpretation of WCT in the field as VT, outside of maybe a few situations where you're doing long distance interfacility transports. There's just too much risk in giving beta-blockers or CCBs to patients with possible preexcitation or VT. That being said, extreme axis deviation (also called "intermediate axis" or "northwest axis" i.e. between +180 to -90 degrees) is fairly specific for VT. That being said, VT can present with any axis. A right axis points toward VT when a LBBB-like pattern is present, as we would expect LAD with LBBB w/ aberrancy. This page descibes this particular situation well: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=57&seg_id=1074 This sounds like a good book. I don't have it, but would love to pick up a copy. This one looks pretty decent too: http://www.12leadecg.com/full/ I do have a copy of Ken Grauer's ECG Pocket Brain. I like it a lot. http://www.amazon.com/ECG-Pocket-Brain-Guide-Interpretation/dp/1930553145/ref=sr_1_1?ie=UTF8&qid=1323612648&sr=8-1

No problem! That would be BC, yep. Both systems have changed a lot in recent years. I think that there are probably other people that can give you better information here than me. It used to be that you were trained by BCAS after you applied (I think the NHS used to do this / still does?), and bid on postings and further training based on seniority. This resulted in a lot of junior people being exploited. I hope this is one of the things that changed. But rather than me giving you a bunch of out-of-date information, maybe we'll let someone else comment on this, who has more recent knowledge. Very much so. But, as I understand it, this is less of a problem than it was in the past. This also varies a lot with location. In some areas there are combined fire-EMS systems, where you may be expected to do fire suppression, extrication, etc. in addition to EMS duties. Some stand-alone EMS systems have specialty teams that would with fire department hazardous material teams, or HUSAR, or are attached to SWAT / tactial teams. I don't have any specifics on BC. If working as a firefighter is an interest of your, firefighter training is very short in Canada. There are also fire-based services that need paramedics very badly, but can't afford / aren't willing to spend a couple of years training their own. They often hire qualified paramedics (the ACP or level III, or whatever, fully-qualified medic), and then provide this training, paid. However, I'm unaware of any fire department-based serviecs in BC. No problem.

So, the problem with making a comparison like this, is that health care is provincially regulated in Canada. So each province has its own licensing / regulatory bodies, and legislation governing scope of practice. There's no central organisation, so there's a lot of variation within the country. There's a slow movement towards national standards, and a national registry / registry exam, but this is probably a few years away. On the upside, if you can get registered in one region, you can often transfer that registration / licence to another. This can get a little complicated, but from what I here it's become easier in the last couple of years. The skills you describe seem to put you at about the Primary Care Paramedic level. This course varies from around 6 months, to as long as two years, depending on location. As I understand it, it usually includes IV initiation, basic ECG monitoring and nonvisualised airways, e.g. King LTD, combitube, etc. In Alberta, this would be the EMT level. For a UK paramedic, it's hard to know where they'd fit in. Obviously they have 12-lead skills, they have TNK, which is used in Canada, and has been for over 10 years, but only in some regions. I know a lot of these guys also have BSc degrees now, in which case they've had more education than most Canadian Advanced Care Paramedics. On the other hand, the ACP scope at a national level includes more second-line ACLS drugs, and sedation-based intubation. There's also a critical care paramedic level in Canada. These guys have an ability to start central lines, RSI, monitor balloon pumps independently, initiate arterial lines, interpret chest X-rays, etc. The problem is, not all of the provinces scopes really align. For example the Alberta Paramedic level is recognised national as an "Advanced Care Paramedic", but encompasses a lot of skills that are found in the "Critical Care Paramedic" level in other provinces. AB, for example, doesn't have a separate Critical Care level yet. Here's a couple of links that might be helpful: Take a look here for the proposed (and fairly old / out-of-date) national levels: http://paramedic.ca/nocp/ And here's the AB levels for comparison: http://collegeofparamedics.org/pages/Practitioner_Resources/Scopeofpractice.aspx Are you thinking about moving to Canada? Do you know where you'd like to move to? Because if you can narrow it down a bit, there might be someone from that region who can give you specifics.

Let me start by saying that I think we would have a great time if we could sit down and chat about this in person over a couple of beers. You seem like a really nice guy, and you're a great contributor here. Please understand that while I disagree with you, this isn't an attack on you personally. Personally, I'm happy to pay higher taxes to have cheaper (or free) education than in the US, and to have free healthcare. Like anything in life, this is a personal choice / taste / preference. I don't live in the states, and there's little danger that I'm going to clone myself 150 million times, move to somewhere with mountains, and subvert the entire democratic process to force everyone in the US to live the way I think they should I'm sure you're proud of your country, as I am of mine. I see my taxes as money I contribute to my society, and to my country (or right now, the country I'm living in temporarily), that helps provide for my family, and for others. I'm ok with the taxes I pay (although, right now, they're very high). You might not be, and that's fine. But this is your highest marginal rate, right? I assume you still have a basic exemption level, and then you pay lower rates for certain parts of your income, and the 40% is just what you pay on income earned over a certain amount, right? And if you don't want to pay more, then great, vote republican. We can agree to disagree. Ultimately both of us are probably going to be living in countries where we have to pay some form of tax and get some sort of services back for those dollars for the forseeable future. We may just differ on what services we expect, and how much we're willing to pay for them. I'd rather have less money to spend on goods and services, and get a wider range of services provided by my state. I've never experienced not having universal healthcare, and to be honest, I'd be scared to live without it. But you're probably ok with paying taxes for road construction? Or schools? Or the military? These are government interventions in the economy as well. I'm a socialist, in the social democrat sense. Where we probably differ is in what services we think government should provide, and how much should be funding via taxation versus user fees. Which is fine. If you want to chat more, I'm here, and you're welcome to pm me. But this is a personal opinion too, right? I mean, I kinda feel the same way here, although I'd probably be willing to pay more for better services. I just can't imagine what I'd want that's not provided where I'm currently living.

Wow! I'm doing well today. Bush didn't play so well overseas.

Well, in that case, I think I owe Herbie an apology for some of my comments on his post. Sorry! I didn't realise there was actually an age requirement. Thanks for the link, it was quite informative. My comments about "leader of the free world" aside, I find a lot of aspects of US society and the political process fascinating. What happens in the states does have an enormous influence on the world around it, as we saw during the Bush years.

I like Obama, but could never understand why the Norwegians gave him the Nobel Peace Prize. Is there an age requirement in the US? How old? And, not to be a dick, but how do you barely meet a birthplace requirement? Isn't that binary, you're either born in the US or outside of it? Don't you either meet it, or you don't? Isn't this also a bit of a bad deal if you're the child of US parents working / living abroad? How does that work? The rest of the world might want to point out that while the US is a very powerful nation, and the world's dominant economy, most of them probably don't regard the POTUS as the free world's leader. Especially in recent years. This seems to be a very US-centric view.