J306

Wow thinking back this site and a lot of the people who have posted on this thread have honestly really shaped the Paramedic that I am. I've even worked a bit for someone I met here! I joined my first year on the job, and now at my 6th year I've already taken a step back from EMS to do some traveling and reflection. Actually writing this from a cafe in Malaysia! MedicNorth sounds like a good outfit, but not sure if I'm built for the month in month out rotation that they do. Rock shoes, when do you start your CCP program? I looked into doing either that or the PA program in Toronto for the future.

Not sure if I'm considered an 'old folk' but I'm still kicking! In Nepal right now and may be doing some disaster relief with GlobalMedic in the coming weeks.. MedicNorth, do you work for the company MedicNorth based out of the Yukon and NWT? If so, I'd love to ask some questions as I was considering applying in the new year.

Welcome. I hope you find this site as useful as I have while developing as both an EMT and as a new medic. You'll probably learn this once in EMT school, but most places in Saskatchewan at least use medic in relation to EMT-P or ACP, and not for first responder, EMR, EMT, or PCP. True that a lot of the messiest and nastiest calls a lot of us have been to also become the source of a lot of memories we wish we could forget. One of the most important lesson, for me when working with marginalized population groups is that everyone, every patient was once their mother's bundle of joy. Best of luck and don't hesitate to PM me with any questions!

The article regarding response times of STARS being slower in 20/21 responses than ground ambulance is an interesting one. I wonder how they would compare in Saskatchewan or Alberta. I agree that the training should be expanded from a 10 week program to a minimum of 6 months.. I find it hard to believe that there is such a large time difference between the BCAS/ORNGE and the STARS Critical Care transport program. The one about running out of epi is something that shouldn't have happened at all..The ground ambulance service was 5 minutes from a hospital and STARS insisted they intercept them enroute?? I sure hope Dr. Wheelers report sheds some more light on these issues.

Yes they have, most of the urban centers have there pcp's completely bridged.

Change your attitude right now or you'll go down the path to becoming what the industry refers to as a 'paragod.' Inflated ego and self importance are a dangerous thing in this industry which Paramedicmike is trying to point out. Its great to be prepared, but its also wise to understand your limitations, especially as a first responder. I was told once that only around 2% of calls the ambulance responds to are true life threatening emergencies where immediate intervention by the providers would make the difference between life or death (early cpr included). The industry is evolving to more community oriented focus, so if you want to get into the industry for the 2% of true emergency calls, you won't last. Your passion is much appreciated, but maybe just a bit misdirected that's all!

Could this be as simple as a pinched sciatic nerve? Can cause extreme pain to the regions the patient described.

Mobey, does your service use the Zoll X-series? If so, what do you think of them compared to the LP12/15's? Any issues with them?

Our organization is trialing the X-series and I planned to ask the rep about this during our in-service.. EMS being the way it is, I made it to about 5 minutes of the session before getting called out. I asked my boss if he could follow up with the rep and try and get an answer as to whether the problem has been rectified with the newer versions. Have you found out any more info on this?

In Saskatchewan we unfortunately do not have the scope of practice yet to use paralytics.. Our options include Ketamine, Midazolam, Etomidate, and Fentanyl. Protocol is only a couple years old and has had mixed reviews so far.

I've heard of Ketamine causing an idiosyncratic reaction similar to the one you described. I believe Ketamine was used as the primary inducting agent causing a trismus type reaction. I believe Midazolam 5 mg completely reversed the reaction with no complications.

Welcome

RIP

Yeah, I wasn't really looking at is as a tool to rule out MI, rather use as another tool to justify rerouting to the nearest cardiac center with a positive result. Thanks for the info on TXA! It was very helpful. Once this licensing exam business is finished, I'm definitely going to do my research and draft up a proposal.. Maybe once its completed, I could post it on here for some tips/feedback being that it will be my first one.

I'm going to talk to my boss about getting one, or at least trialing one to show how beneficial it would be. The company I work for services a large geriatric population and is 45min from a cardiac center. Our air ambulance is also located 30-45 minutes away, so it would be hard to justify taking the only helicopter for the region out of service when the patient could be transported just as easily by ground. Our college of paramedics has also drafted a proposal for ACPs to be able to administer Heparin and Plavix for patients that show clear STEMI criteria. If we were able to get an trop reading, we could bypass our local hospital and travel straight to the cardiac center 45 minutes away instead of being called back 2 hours later to transfer them code 4. I also think a istat lactate level would have its place for those with a sepsis protocol in place. As stated in a previous post, we are now able to administer 325mg acetaminophen, 3L fluid challenge, and progress to norepi/dopamine as well as hang broad spec antibiotics. This could likely be managed by most local ERs, but the faster we can confirm sepsis, get that fluid, and administer antibiotics (for bacterial sepsis), the less likely they are to develop MODS.

I've skimmed over the CRASH2 study and did find it helpful. The best info I've gotten was through informal conversations with the Anesthetists while doing my mandatory intubations in the OR. Learned a lot more through that than I ever did in school looking at power point slides. Do you guys have an i-stat machine for Trop, Hemoglobin, and Lactate levels? STARS air ambulance here in SK has capabilities of testing for Trop levels, and a clinic I worked at up north had a Hemoglobin one, and I thought it was the coolest thing.

How are your PCP upgrades going Kat? Also, I heard the next step may be to align Sk ACPs with the NOCPs as well, which means a few more meds in our drug kit like Magnesium, Calcium Gluconate and possibly a beta-blocker for cases of A-fib with rvr. Not sure how reliable that is, but it would be nice to have a few more treatment options.

Thanks for the scenario David. I hope that you'll continue to post scenarios, I learn a lot from being involved in them, especially being a green medic. Are you able to give TXA and Octaplex in Nova Scotia? I was thinking about writing a proposal to our College of Paramedics in Sk, and try and get it approved for ground ambulance.

If this is was an ongoing viral infection it could have led to septic arthritis before seeking treatment. Painful joints and muscles could have prompted the patient to buy over the counter topical analgesics containing salicylates, such as Ben-Gay or oil of wintergreen causing unintentional overdose. One teaspoon of Methyl salicylate contains 7000mg of salicylate, 4x the toxic dose. Would explain potassium and magnesium deficiencies, ARF, metabolic-acidosis, and increased respiratory rate/effort. So, any topical salicylate containing creams or ointments used recently? Tinnitus? Sorry for the multiple posts, I'm studying for the ACP national exam and just happen to be studying this topic anyways.

Scratch the antibiotics, forgot that it was confirmed viral. Woops!

Does this patient have any allergies? How would everyone feel about infusing some broad spectrum antibiotics for this patient? My local sepsis protocol says we can infuse Cefotaxime 2g q 6-8hrs or Vancomycin 500mg q 6 hrs or 1g q 12 hrs would be indicated. Taking into account his impaired renal function, we should give a modified dose of Cefotaxime1g q 8-12hrs, and stay away from Vancomycin being that it is nephrotoxic.

When placing the patient on a transport ventilator, we should be aware that we'll be taking away his only compensatory mechanism since his renal function is impaired.

I say intubate him with Ketamine 0.5mg-1.0mg/kg and Fentanyl. The patient has responded to fluid boluses, but I'd like to have a Levophed infusion set up and ready to go prior to transport. I would ask the staff why they gave Lasix to an ARF patient, document how much they gave, and look in the charts to see if that's when our septic patients BP began trending downwards. How is our patients colour, peripheral circulation, distal pulse quality, mental status and affect after the fluid boluses and initiation of BiPap? I'd check lungsounds for crackles, if non are present, I'd be comfortable with one more 20 ml/kg bolus of Ringers Lactate to replenish some nutrients and to try to avoid making him more acidotic than with saline. Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid? Is air ambulance transport available? If not, I'd get either an RT or RN to join me during transport incase things go south.

A classmate of mine found an online exam practice site for paramedics, and having the Canadian National exam at the beginning of February I decided to buy a subscription to test my knowledge base. It has a test bank for both the Canada and the States as well as the BLS and ALS levels. Here's the link: emscram.com

I've seen a few docs use portable ultrasound to get central lines, and even saw an anesthesiologist use it to get a large bore IV, but it was my understanding that cutdowns were popular in the 90's and then were proven to greatly increase risk of infection so weren't even taught anymore..