WelshMedic

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

The one time that I decide not to let my annual US trip coincide with JEMS, you get together. I hate you all................................. :twisted: :twisted: :twisted: WM (PS - don't forget to go to the Wharf Rat opposite the conference center and drink a pint of real "ale"...) http://www.thewharfrat.com/

Which is why I suggested titrating

Arrest scenario- Well, it depends upon whether it's a shock or no-shock situation. I don't think we need to go into the exact specifics here, I'm sure we are all familiar with the ERC (or whatever the governing body is in Aussieland) guidelines. I think there should be some attention to the 4 H and T's here though. Was the arrest run any differently because of the patient's history? WM

Ahhhh.....gotcha..!

Then he's FUBAR........... (Sorry, not a very clinical answer, but with this degree of underlying pathology and rapid deterioration then I don't give him much chance) WM

Bushy, I'm sorry to be dense and spoil the antipodean in-joke but I was wondering something: if you are already ALS, what's the benefit of a MICA? What do they do differently? Carl.

Well, sit the boy up then!!!!!

I like my own opinion so much I wrote it twice........

Timmy, Can you be more specific on the cardiac history? It may help us to put certain things into perspective, the AFib, for example. This is certainly pathological in a pt so young. What would I do? Oxygen titrated to Spo2, possibly starting with a NRB @ 100% 12 lead to further investigate the Afib on the scope IV access I'm not inclined to do anything about his Afib, this is obviously a complicated case with a lot of underlying cocomittant pathology, the rate and haemodynamic response does not warrant intervention, pharmalogically or otherwise. I would however take him to the larger facility. To not do so is delaying the inevitable. I think that he is, at this point, haemodynamically stable enough to endure the 50 minute journey. You want any more? WM

Although this could only happen Aussie land....(Sorry Tim, I found it and couldn't resist...) Look here wm

Well, I'm with my antipodean friends on this one. I don't suppose it would occur to anyone here, but this discussion would probably only ever take place on a US website. GUNS+EMS=Disaster! WM

The only thing that these three subjects have in common is the termination of a life. This may sound somewhat cold and clinical, but to me, it's a fact. That's not to say that I don't have an opinion on these matters. As with all things in life, it's just not black and white. Here's my take on the subject; The death penalty: I always thought that I was against it. There can be a no more heinous crime than a state execution whilst someone is innocent, however small that possibility is. However, I now have small children. If something was to happen to one of my children and it was the doing of another individual, then I would be willing to commit the deed myself. That's a hypocritical statement which I cannot sustain. I believe in making clear choices (no sitting on the fence for me..). So, I'm afraid that this ship has turned and now supports a (well-founded) death penalty. Abortion: No lack of clarity here! Why? Well, there are enough reasons but just indulge me whilst I tell you a story: I recently responded to a domestic emergency where a 6 week-old baby had been battered by it's mother. The child was brain-injured and died a few days later. When the post-mortem was completed they'd found old (!!!!) fractures of both arms. That child had been physically abused since it's birth. The mother had become pregnant and the partner's family had forced her to carry it, against her wishes. That child was unwelcome, and it ended tragically. What's better, termination of an embryo or letting a small baby suffer so horifically? That's why I'm pro-abortion. Euthanasia: Definitely pro. I have been in nursing for 21 years this year. I have seen my fair shair of suffering, even if I say so myself. I am lucky enough to live in one of the very few countries in the world where (strictly controlled) euthanasia is allowed. I don't believe in endless suffering for a greater good. It's counterproductive and destroys the precious little time that a person with a terminal illness has. Everyone has the right to decide what happens to them and their body. We just take that a step further and grant them the same rights when it comes to the cessation of life. As an aside, EMS in the Netherlands is also directly involved in this process. We are frequently asked to start IV's so that the family doctor can administer the lethal cocktail after which the pt dies at home. We do, however, have the right to refuse on religious or moral grounds. Just my 2c worth... WM

Nice relevant DUTCH research even..... My feeling would also be to immobilize. The research just backs that up. WM

No, I agree with all of your comments. I use the principles that Peter Canning set out in his " Letter to a Preceptee" http://medicscribe.blogspot.com/2007/03/le...-preceptee.html

Learning to interpret an ECG is a basic ALS skill. I hate to think that this test will replace that. WM

It would depend upon your definition of doing well. Although Philly FD doesn't have a great name, there are plenty of other EMS organizations in the area that do work at lot better. The two that spring to mind because I have experience of them are Crozer EMS and New Castle County. New Castle County is just over the border in Delaware but is certainly commuting distance. On a national level, I hear the same name all the time: ATCEMS in Austin, Texas. WM

That's a worthwhile amount of training and education. I'm not sure how long it is on this side of the pond but I did find something here: http://www.nhscareers.nhs.uk/details/Default.aspx?Id=485 WM

That clip is great!!!! I never really paid much attention to Scrubs in the past, maybe I will in the future though.. And thank you for the explanation, Dust. WM

Dust, Never a truer word sproken. The same RN who passes the buck will not enjoy any degree of respect within the team. It's the same in EMS, as far as I'm concerned. I am not too good to do this sort of thing. Besides, is everyone aware of how much you can tell about a patient's condition from their stool sample (now there's a nursey comment for you..... )? By the way, a quick question: what is a PCT? (Patient Care Technician.....?) It's not a term that we use on this side of the ocean. We do have NA's but here they are Nursing Auxillaries. What's the difference between the two? WM

There is a world of difference between the different specialities in nursing. An ICU nurse is very good at comprehensively caring for the most sick of patients whilst also supporting the family. It requires a great deal of clinical knowledge for the former combined with a healthy dosis of social skills and tact for the latter. An ER nurse needs similar competencies but is also required to be able to triage efficiently and deal with differing patient categories in terms of complexity. As far as dealing with bodily functions is concerned, I'm not sure how it's relevant. Why does the term nurse and wiping arses have to feature in the same post at all? If it needs doing, it gets done. I am not ashamed of that fact. Even now, after being more 10 years in EMS, if a (non-critical) patient has soiled themselves then I will take the time to clean them up before transporting. It's the least I can do, surely? WM

Here in the Netherlands nightflights were forbidden by federal law. Then the organizations involved in HEMS used political lobby to get their own way (unfortunately they did this by portraying the ground providers as basically well-meaning but largely ill-equipped to deal with serious trauma, distance or enhanced speed are rarely factors in a country half the size of Kentucky). There is now 1 helicopter that is allowed to nightfly but has to follow strict guidelines. For example, the landing sites are agreed upon before hand. WM

It's a deal!!

I would love to attend as well but I'm afraid I would drink far too much and fall over and make a fool of myself.......I couldn't possibly damage my carefully groomed image here. OR I could tell the truth and say I don't have the cash to fly transatlantic at such short notice.....why couldn't you do this in september of next year? I would be over there then anyway. (hint, hint, we have to organize something in september 2009....) The one and only well groomed and very well bred (it's the british blood ) Welsh Medic P.S. To all the lucky souls that are attending, enjoy and don't do anything I wouldn't! (Errm...never mind)

You forgot the heparin, plavix and aspirine prehospitally on-route to the cath-lab