WelshMedic

I was reading an article in the newspaper last week. It was about Mr. Obama's planned heathcare reforms. There was a lot of detail that I can't recall now, but one fact stuck out: The US spends more on healthcare per head of the population than any european country and yet something like 48% of the population is underinsured or not insured at all. That fact alone tells me that the system is broken and needs fixing. WM

Whilst heat stroke is a plausible diagnosis, it does not sit well with me that they are both suffering from it. It's too much of a coincidence. One of the other possibllities is an (?accidental) overdose of XTC or GHB. Both of these drugs are connected with hyperthermia and, if untreated, DIC (Disseminated intravascular coagulation). Read all about it here WM

Thanks Dust for the links. First of all let me say that I am not denying that any of this is true. However, I would like to nuance one or two areas, particularly in relation to the first article. First of all, in the current climate of polarization of the migrancy debate, it has to be noted that the comments were made by a politician. What will you hear from a politician? The vox populi, of course! That's how he gets elected for each term. The fact remains that it is a very small minority of immigrants that refuse to integrate and are intent upon being "a leach" on society. You may wonder why this subject is close to my heart? Well, that's simple: I have the same skin color, am completely assimilated into dutch society. However, I am and always will be a migrant. I am aware of the fact that there is a difference in work culture between the US and Europe. Note that I avoid the term "work ethic". To me, the term "ethics" is irrevocably intertwined with a set of personal beliefs and values. That is why I am so vehemenently opposed to any generalizing comparison. One of the reasons that we enjoy better pay and benefits in Europe is that we have a long and rich tradition of trade unionism. We have had a system of collective responsibility and representation for more than 200 years, something which I passionately believe in. Of course, there is a price to pay for all of this: taxation. However, this is a relatively small price to pay in camparison to the benefits we enjoy. In any society there will be opportunities to milk the system, one may also argue that it would be easier in Europe. It still, as I already stated, is a very small minority. Furthermore, it could also be argued (and has been for a long time) that when one looks at productivity levels, things are a much more even playing field. Take EMS, you yourself are a fervent opponent of the 24-48-72 hour shift patterns that are commonplace in some quarters of our profession. Working a 36 hr week and then closing the door to spend time with your family is of irreplaceable value. I, for one, do not intend giving it up. WM

That sweeping generalization is not worthy of you, my friend. WM

They were invited as part of the JEMS conference programme. They are both very experienced ER and pre-hospital RN's. That's why it was a shame. WM

I couldn't agree more on that statement. Admittedly this was not a clever thing to do, but everyone here should first take the time to research the politics of meal breaks in the UK before shouting their mouths off. Some people here are just determined to qualify my preconception of Yanks and their big mouths. Luckily, they are in the minority. WM

I'll hava a go, Bushy m8: 1) Helicopter services are run as private enterprises, no flights, no money. It even gets to the point where people helicopter shop until they find a crew willing to fly, whatever the weather. 2) Baltimore Shock Trauma is a leading trauma unit in the US, (some would say the world) set up by the famous R Cowley Adams. He was also responsible for the Golden Hour. Colleagues of mine from the Netherlands visited last year during JEMS and were stuck in a corner and basically ignored by everyone. So in my book it is not that great! Hope this helps... WM

He's altered if he's telling 2 different stories of the accident on-scene. So yes,yes and yes. (Not mentioning the fact that the elderly are an entirely different patient population that are extremely vulnerable, and you should have a lower index of suspicion with them). WM.

How many accidents have been caused by the stressed out newbie with red mist syndrome on the way to a BS call? Let 's face it, you are never going to win this argument on that basis. It's just done differently in the UK. Not better of worse, just different. WM

Denying pain medication to a pt. with abdominal pain is something still from the dark ages. There is a plethora of studies that disprove this opinion. Not even mentioning the fact that, with today's medical imaging capabilities, it makes no sense whatsoever. If your pt. is in pain, then they deserve pain relief. WM

Well, I think it's safe to say that Holland and Sweden are very similar. Here we are RN's with a post graduate critical care qualification and a year's training in prehospital care. I think Australia has more in common with the Uk though, ALS providers that are university educated, but not necessarily RN's. WM

Liz, Welcome to the sit here. First of all let me congratulate you on deciding to join EMS, it's a decision that you are likely not to regret. I think you need to be a little more specific with your question when it comes to druga and their dosages. Also remember that there any number of sources you can consult on the net. You will also find that a particular dosage varies from region to region, depending on the current opinion of your medical director. Having said that, feel free to pose a specific question here, I'm sure there will be someone willing to help. WM

I'm guessing that we are talking about the LP12 here, right? It's something that is a recurring problem here too. I find myself overrriding more often than not. For the most part, it doesn't stop you diagnosing STEMI though. WM

I think it's a sad indication of the state of EMS in the US that we even have this discussion. Before we go any further, I would like to state that it is NOT my intention to bash all things american. My participation on this website is enough proof of my interest and, to a large extent, my admiration for US EMS. Having said that: There is no way on earth any educated professional should be working this poor woman. To do so, would, in my opinion constitute assault. If I was family then I would hang you for it too. Please, please people can we get some perspective here. This poor woman has suffered enough. Do you think she likes being frd through a tube and being changed every few hours. I have never heard anyone say that they find that an acceptable state whist they were still fit and healthy. We have made great advances in medicine over the last 40 years, it's just a shame that we still don't always know when to stop. Leave your monitor and airway kit in the truck. Let this woman die with a little dignity, something which she has sorely lacked in the last phase of her life. WM

Thanks, Novisen, for your input here. From the name I 'm guessing you are somewhere in northern europe, right? I'm from Holland and so I know we don't differ that much when it comes to ALS. I'd like some propofol, though. WM

I'd like to add my perspective here as an ALS provider in mainland europe. First of all, it's wrong to make blanket statements about Europe as a whole. Europe is a group of entirely independent countries, not states. Each one has its own form of EMS. IN the southern half of Europe ALS intercepts from hospital staff are used widely, in Germany there are trained EMS physicians that respond from a central location. That's not the whole of the story though, in most of the scandanavian countries and the Netherlands (where I am) EMS is nurse led. We are critical care trained nurses that have a great deal of autonomy, I really can tell someone that they are not getting into my ambulance without having to refer to any sort of higher power. We also have no form of medical control. Everything is also standardized within national protocols. I would certainly hope that there are NP's and PA's here in the Netherlands. It would certainly make my Masters in Advanced Nursing Practice, that I'm starting in September, otherwise obsolete. We actually have a new breed of nurse practitioner here that is trained in EMS and primary care. One minute you could be suturing an elderly patient at home, the next sedating and intubating a head-injury patient. (something akin to the ECP in the UK). Last but not least, education is the key to advancement. We refuse transport, advise on alternative pathways and treat at home because we are trained to do so. We are degree level entry, no if's or but's. And have been for the last 10 years. If the pursuit of knowledge isn't enough motivation, then try this: $62,000 a year for a 36 hr week and 7 weeks paid holidays a year. Now who's up for that BSN? WM

http://www.nbcphiladelphia.com/news/local/...3-Year-Old.html This tragic accident must be our collective worst nightmare. My thoughts go out to everyone invollved. (Please take time to read the comments underneath the article..they are enlightening). WM

Google Perfalgan and you'll find it all....(in Dutch )

No, that was Aspartamine.

That's a shame, it really does work! WM

Paracetamol IV is used to top-up the effects of opiates resulting in lower dosages being necessary. WM

Lack of pain relief Above is evidence that the problem is not limited to EMS. And here a relevant quote from the Merck Manual of Geriatrics: [quotePain management in the elderly has been addressed in clinical practice guidelines by the Agency for Health Care Policy and Research and by the American Geriatrics Society and in reports by the American Society of Anesthesiologists and International Association for the Study of Pain. Adequate pain management may improve cardiovascular and pulmonary function and, by preventing the stress response to postoperative pain, may lower the incidence of postoperative myocardial events. Decreased ventilatory function after thoracic or abdominal surgery is caused mainly by surgical trauma and by splinting due to postoperative pain. Pain management cannot restore ventilatory function but can help prevent splinting by enabling patients to breathe deeply and cough, thus improving mucus removal and avoiding atelectasis. Prevention of atelectasis reduces the postoperative risk of pneumonia and hypoxia. Generally, adequate postoperative pain management helps patients walk sooner and improves functional status, hastening their return to the community. Pain management also enables patients to be discharged earlier, thus reducing medical care costs.

P3, I'm not suggesting that we would cut mortality in half by decent initial pain management. However, I do think that it could play a role in reducing the figures. Poor pain management, whether it be pre-hospitally or otherwise, leads to poor wound healing, longer stays in hospital and extended revalidation periods. All of this has been researched, by the way, and is not just my unfounded opinion. What I would therefore suggest is that EMS takes a leading role in providing decent pain management. Take the following example: Doris, 80 yrs old, has taken a tumble in her kitchen. She is BLS'd (= no pain relief) into her local ER where she is put onto the corridor as a multi-vehicle MVA has just occurred. After an hour she is written up for opiates as pain relief by the ER attending. That therefore means that Doris has now gone almost two hours without any decent form of analgesia since her fall, but well, she doesn't like to complain because the nurses are so sweet, but oh so busy. Those busy nurses then leave Doris another 45 mins before they get around to administering the Morphine because of the back log of work. Doris is finally given her pain relief almost 3 hours after her intial fall. She is ever so grateful and thanks everyone for their help before going up to the floor. It's just a shame that she was given such a poor standard of care. Now, we can all see why that happened and would be at pains not to point the finger at anyone. The fact, however, remains that she was left to lie in agony for three hours before her pain issues were adressed. You can bet your a$$ that it has affected her morbidity significantly in the long run. All of you that have been in EMS for any length of time will recognize the above. It's fictitious, but let's face it, it could happen anywhere. None of this need have happened, if Doris had been properly managed pre-hospitally then she would have a far more comfortable wait on that gurney. That's why we need to take a leading role. WM

I would not agree with removing the patch is this case. The patch provides a baseline analgesia that can be continued. Any further pain relief can be titrated to the pt's pain. Just remember that anyone in a lot of pain will need a lot of analgesia. Using set protocols and medication dosages just boils down to cook book medicine. I have been known to give a pt 25mg of Morphine without problems, if thet need it, they get it. Period. WM

I guess I am a little late in answering this poll. My excuse is that I have just spent a week sampling lovely Bavarian beer in Germany. Now the guy/gal that comes up with effective pain relief for a hangover will win my vote for the Nobel prize for Medicine! Pain relief is a subject close to my heart. One of the problems in EMS is that not enough time is spent on the subject during training. Those of us that have nursing backgrounds tend to have a more thorough understanding of the subject. Pain is a devastating mechanism that can even affect mortality and morbidity, particularly in the long term. It should be avoided at all costs! Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure. My own preference: For the initial treatment and/or extraction of the patient: Ketamine in combination with midazolam For ongoing treatment: in the elderly it's Fentanyl, in the young it's Alfentanyl (it's great stuff, but tricky to dose in the elderly). All supplemented with iv paracetamol because it reduces the the amount of opiates the patients need in the medium to long term. WM