BEorP

Hopefully the attachment works! Sorry that the quality isn't magnificent. I am interested in hearing thoughts on the rhythm since this generated a bit of discussion. Basic clinical details: 67 year old female complaining of chest pain radiating into her back with associated shortness of breath. Reports a history of a previous MI and angina. Thoughts?

AHA says 160 mg to 325 mg Source: http://circ.ahajournals.org/content/122/18_suppl_3/S787.full

Time for the obligatory post-CAP Lab report. The EMT City representation quantity was less than previous years, but the quality of participants was high. The day was even better than previous years, with many of the similar stations as discussed previously but with various tweaks and new aspects (for example the added realism and challenge in the pig trachea station of having simulated skin and blood). As always, all of the doctors were eager to teach and to answer any questions. Definitely something to watch for next year if you missed out this time.

It is good to hear your thoughts on this. So if the patient had been brought to you in ED and presented exactly as Kiwi outlined here, do you think that there would have been any difference in outcome?

Does she want the blankets over her head specifically?

Welcome, Jay. It is wonderful to hear of your enthusiasm. What I would suggest might not sound as exciting, but it will make you a better EMT or paramedic in the future if you're really looking for some concrete way to take a small step in the direction of your desired profession. I would suggest that rather than worrying about a first responder course at this stage (when you won't be able to be in a position where you could use any of your skills), focus for now on learning the science. So many qualified EMTs and paramedics lack a solid knowledge of anatomy and especially physiology that can be so important to understanding what is going on in our patients (and figuring out how to best help them). So this isn't probably the type of thing you were thinking of, but I'd suggest working on learning about anatomy and physiology bit by bit. Much of what we deal with is shortness of breath and chest pain (possible heart attacks), so learning a lot about how the heart and lungs function in health will make it much easier to learn about how they function in disease at some point down the road. Unconventional, I know (and I'm sure someone else will call me out if it is a bad suggestion), but if you were to go ahead with it I'm sure that someone could recommend a good textbook and that there would be lots of help from the forums if you had questions about anything you're reading. (On second though, it is 2013 so you could probably just use things like Khan academy videos to learn about this stuff... though a traditional textbook is still nice to have!) Good luck!

Registration is open. It is sure to fill up, so if you're thinking about attending I'd suggest getting registered soon. I'm going to try to make it for Dec 3rd (the first day).

PM me with the details if not.

Thanks, sorry I didn't notice the little error to switch the picture at the top.

Interesting! Any pictures of the inside?

For us non-Americans who can't remember the conversion, is that blood sugar high? Also, is the room bright? (just trying to confirm whether that pupil size is concerning) In terms of immediate interventions: - With GCS 3 and respirations like that, I would suggest an OPA/NPA and ventilating. - I'd also like IV access to give some fluids to try to get that BP up to a more reasonable level. For trying to sort out what is going on: - I'd like someone to gather the medications for us so I can take a look. - Can the boyfriend tell us anything more about the history or does it seem like a lost cause? (I'd especially like to know whether anything like this has ever happened before and even if we might just know what kind of specialist doctor she's been seeing for her medical issues that could be helpful) - If we have the hands, a 12 lead would also be nice.

Anything else about the house that catches our eye as we walk in? (signs of medications, recreational drug use, any medical equipment) What does she look like as we approach? (position? where on the bed? clothed? pallor/cyanosis/jaundice? obvious breathing or not?) Confirm that she is unconscious Check ABCs (may need to consider an airway adjunct or getting her on her side if there's been no trauma) Vitals (HR, BP, RR, temp, SpO2) Also GCS, blood sugar, pupils, ECG (and taking a peek for MedicAlerts while obtaining vitals) While we're doing this, can we get a story of events leading up to this as well as medical history, meds, and allergies for this patient? That should be a start at least!

"Do you?" and "Should you have to?" are two distinct questions in this. If your service's policy is that you do, then it probably would be wise to follow that (while also trying to prompt change). In terms of whether this should be the policy, I think it is clear that driving lights and sirens is something that adds significant risk (often with little benefit) and should not be taken lightly. It seems unlikely this patient would benefit from the time saved.

Thanks. Sorry, yeah "you" meant paramedicmike, PA-C in the ED. I wonder whether the D-dimer could end up leading to more confusion than clarification though given the lack of specificity?

Surprised I haven't come across this before. Interesting stuff! Does this have any implications for how you investigate COPD exacerbations, especially when there doesn't seem to be an infection or other obvious cause?

It would probably be into the thousands to do it properly between the cost of the instructor course, mannequins, other props, and general training supplies.

Great to have you here! Some of the best paramedics I have met are South African. I have a lot of respect for the particularly challenging job that you do over there.

That depends on what kind of income you expect and whether you're planning on working for yourself or someone else. If you do your own thing you have a lot of start up costs for equipment and need to worry about finding the business and doing all of the admin stuff yourself. You can also make reasonable money at this though, but you do often need to work for it. Alternatively, if you teach for a company that has the equipment, finds the business, and deals with all of the admin stuff you're likely to make much less (maybe around $20 an hour, but again this is something where my knowledge is getting a bit dated and it varies significantly by company). What part of Toronto are you in?

If it is what you want to do, then do it. I didn't mean to be discouraging, but it is just important to come into this aware of the realities of things. If you got on part time somewhere then you could probably keep teaching while working as a paramedic but this opens up a whole bunch of other points for discussion such as whether you are planning on only seeking work in the GTA (thus limiting overall opportunities) and whether working another job will slow down your rise in seniority to eventually secure a full time spot. You can cross this bridge when you get to it though.

I don't know the answer to your question, but I would suggest that if no one answers you email the program coordinators who should be happy to help. I would suspect that you're unlikely to have more than one whole day off a week (and maybe not even that), but my knowledge on this is not current. Good luck! I should add that if you truly can't stop working, you might want to look at Loyalist's program. Again, my knowledge isn't so current anymore but they did have a program a few years ago that would be much more conducive to working compared to Centennial or Humber. The educational quality of Centennial and Humber is unlikely to be matched though. And I'll add one last thought while I am here, are you aware of the current job market for paramedics in Ontario? This should be an important consideration before diving into this career change.

I think what others are suggesting is that there isn't often much room for ambulance dispatchers in Ontario to actually make decisions when it comes to how calls are prioritized. Certainly there can be some decision making when it comes to overall vehicle movement (although even this will likely be based on a written deployment strategy), but this isn't the case in terms of how the information is obtained from the caller and how the call is prioritized. As much as I admire your determination to get back out there, it would seem prudent to consider where your career is going to take you. Even without considering this injury, ask yourself whether you will be working on an ambulance at 64. If not, you need an exit strategy (we all do!). Now seems like as good a time as any to start thinking seriously about what that is, even if you don't need to use it for another 20 years. Having an exit strategy for future use shouldn't impact on your determination to get back out there now. Best of luck with your recovery! I hope that your employer has been supportive through this.

Great point, Dwayne. Thanks for sharing! Along with that, the other thing we need to consider is how important it is that if the junior crew member has concerns, they need to speak up. All too often it seems that we respect seniority so much that if our more senior partner says it is "just a psych patient" or isn't anything to be concerned about that the senior gets their way even if the junior has a genuine and legitimate concern.

Thank you all for the replies. The list here largely lines up with what I planned on focusing on. A couple points of discussion: Has anyone other than Ruff had any anecdotal experience with strokes presenting with behavioural symptoms? This was suggested to me by someone else who I had spoken with prior to posting but I haven't seen it myself and a quick (but by no means complete) search on the topic didn't reveal much. Secondly, we have a great list here of important things that should not be missed in the patient's overall emergency care. How many of them do you think prehospital providers should actually be identifying specifically rather than just noticing that there is a serious underlying problem and it isn't "just a psych patient"? For example, there might be a hyponatraemic patient presenting with delirium/agitation/anxiety/perception disturbances. We might be able to suspect an electrolyte issue depending on the history, but since we won't have the bloods to confirm that it seems like it would be sufficient for us to simply identify that there is something going on that isn't a strict mental health issue. Hypoglycaemia is obviously the other end of the spectrum where there is a clear treatment that can be provided prehospitally and that should not be delayed. I've rambled a bit, but again my ultimate question now is: Which of these conditions do you think prehospital providers should actually be identifying specifically rather than just noticing that there is a serious underlying problem?

For full disclosure, I will preface this by mentioning that I am working on a lecture for paramedic students about this so this discussion is likely to help with that. Still, I think that it is an interesting topic to have a discussion on. My question is what underlying medical problems that might be interpreted as a mental health/psych/behavioural issue prehospitally should paramedics be sure not to miss. There are obviously many illnesses that could present this way, but I am wondering which you think prehospital providers should be able to identify specifically (rather than just recognising that the patient is sick based on their overall assessment and taking them to the hospital). Hypoglycaemia is obviously the first one that comes to mind, but what else do you think should be high up on the list? I appreciate any thoughts. I will share more of mine later, but I didn't want to risk stifling discussion by sharing my opinion too early.

I am preparing a talk for a large group of paramedic students and given that Rob was one of the people who really helped to set me on the right track as a paramedic I want to acknowledge him. Does anyone have access to higher resolution photos than what are available from the obit page? I would specifically be interested in finding the one of a very young new EMT by the looks of it and the one of him in Hamilton (in his white shirt standing by the ambulance cab). I think the Hamilton one may have been posted somewhere on the forum years ago, but I can't seem to find it. I appreciate any help!