BEorP

Hey Dwayne, In terms of the drugs, I think that your best source will likely be a good pharmacist. I agree that most drugs are probably good long after their expiration date, but some are not. There are also probably many factors that will affect how long they last, including how they have been stored. Also, of course, whether we are talking about weeks, months, or years expired is going to matter. If the choices you have there are between using expired morphine or none at all (i.e. if you took the expired morphine out, it simply wouldn't be replaced as I think you're saying), then the most important question seems to be that even if the morphine were waaaaay expired and didn't work, would it actually do anything bad to the patient or would it just do nothing good for them? Again, it will probably be a pharmacist who will be in the best position to provide advice on this. I know that this probably isn't the most practical suggestion for you, especially since you wouldn't want to ask a pharmacist who just wants to sell you more drugs and no pharmacist is likely to put on paper that a drug will be good long after its expiration date. If you can give some more specifics on dates and storage, I can run it by some pharmacists here, though that won't get you anything on paper to bring to your people.

Are you saying that methoxyflurane is addictive? According to their information sheet here, there is not evidence that it is addictive.

Very interesting to listen to that. Sounds like an impressive response with good organization overall. I doubt that most of us could honestly claim that our agencies would do as well in a situation like this.

Hey Dwayne, My understanding is that the ASA prevents the development of further clots but doesn't prevent further development of the clot. So that current clot is what it is, but at least we can reduce the chance of more forming before someone can fix it. If it works so well for MIs, maybe the ASA could have been good if someone were at risk of multiple DVTs concurrently? (No idea how common that is...) Still though, ASA won't touch the current clot. Once the clotting factors get going, they do a whole lot of amplification on their own and platelet aggregation doesn't have much to do with it as far as I recall. ASA only affects the platelets but has no impact on the actual clotting factors.

Hey Dwayne, I suspect that what the doctor meant was that aspirin only deals with platelets rather than the actual clotting factors. If I recall correctly, once the coagulation cascade gets going, the platelet aggregation doesn't have anything to do with anymore. I don't really know about whether there is "growth" of DVTs and what (if anything) anything could help in the situation you describe, but I don't think aspirin would be much use.

Shhhhh! Now no one is going to admit that their service still requires it!

Is this a formal policy at your service for your response priority to be at your discretion or just something that is tolerated?

I would question whether this is truly a formal policy. It seems like in many services, things simply become accepted as the way things are done. Sometimes this is so strong that people will refer to a policy, but if you go digging you will find that none actually exists. Certainly, the social pressures alone (without any formal policy) can still be quite strong. I am guilty of turning the lights on to call it a code 4 return with a chest pain patient when we're literally three blocks from the hospital. Why? Because it is the accepted practice at that service and to deviate from that would have either ruffled the feathers of my partner, the service, or the base hospital, despite there being no explicit policy requiring a code 4 return for all CTAS 2 patients. I know that that is not a good reason for a professional paramedic to do something that carries a degree of risk, but I have gotten to the point where I try to avoid conflict sometimes rather than trying to initiate change.

Thanks for your comments. I think that you may have taken my Aus/NZ comment a bit differently than I intended. My intent in the thread was to find out if there are places that still routinely do spinal immobilization for penetrating trauma, and obviously you guys would have moved beyond that. I don't mean to stifle the discussion, but there really is no question as to what is best for the patients (clearly there should be no routine spinal immobilization for penetrating trauma). Despite this, it still happens some places (whether written into the protocols explicitly or simply as the accepted practice) so I am just curious how prevalent it is and where it still happens.

Thanks!

Thanks, but would you also do spinal immobilization for penetrating trauma? I should have known better to think that I could type a typo-free post sans glasses!

(Note: Australians and New Zealanders need not respond to the question - this thread is not for that fancy evidence-based practice you guys think is so cool.) Hey all, I'm just wondering what your agency's protocols are for immobilizing penetrating trauma patients. Is this something that you would routinely do for someone who is short or stabbed in the head or torso? I don't particularly care to discuss what the best practice is (there's not much to discuss there anyway!) but I'm just curious what is actually done where you work. Thanks!

I haven't taken a thorough look through this paper, but on the surface it does not seem terribly useful. This was done based on ROC data that was really focused on things other than evaluating air ambulance efficacy. If we really want to know, then we need a study designed specifically to evaluate this in a certain type of system and area. One of the problems is that unlike testing a medical device or something similar, the setup of the system and the local geography will impact the efficacy of air ambulances a whole lot more. With this current paper, they say they found no difference in survival between the two groups, but the patients transported by air had more severe injuries. It seems to be like some could actually take this as being supportive of air ambulance transport from scene. Regardless of this, my first impression is that this doesn't really tell us anything new. (Still appreciate you sharing it!)

Because the fire profession is working themselves out of business. Fire prevention has done too good a job, but the call volume must be kept up to justify funding. Many Toronto fire stations do about an even split between false alarms and medical assists (automatically tiered) in an average shift. It has nothing to do with benefiting the patient.

Maybe I should have explained more fully in the initial post. This picture is from Toronto and in Ontario fire and ambulance are independent. I would not be too keen on delegating airway management (probably the most important thing for this patient right now) to someone who is not a health professional.

Hint: Ontario doesn't have any fire medics. I sometimes truly wonder whether the IAFF teaches FFs how to be sure they are looking at their best in media shots. In all seriousness though, I wonder about the patient care here. (Yes, there are countless factors that we don't know because we weren't there.) In general though, why would a paramedic have a first responder managing a patient's airway? If you were the paramedic responsible for this patient, wouldn't you prefer to be up there yourself to make sure everything is as it should be?

I am curious to know about things that you were taught or that you know are still being taught that you now know to be wrong. I am not so much thinking of things like the benefits of spinal immobilization or other things that we do in the field, but more the medicine or physiology. I remember being taught at one point that concussions involved a loss of consciousness but then had no long lasting effects. Certainly it isn't something that matters to our prehospital management of a traumatic injury, but I now know that there is often not a loss of consciousness and that there can be significant long lasting effects from concussions. One that I am a bit embarrassed to have just sorted out recently is about oral hypoglycemics causing hypoglycemia. I remember having always been warned about the risk of recurrent hypoglycemia with patients who are taking oral medications for diabetes. Only recently did I learn that metformin is not known to cause hypoglycemia (though others certainly can). Something that I unfortunately see being taught wrong, or maybe just not entirely correctly, is how CPAP is beneficial for COPD. If you are going to be in a position to treat a patient with CPAP for a COPD exacerbation, I expect a whole lot better than "it splints the airways open" when asked to describe the mechanism. Unfortunately, this is all that is taught sometimes because the instructors do not seem to know any better. I'd love to hear what you now realize you were taught wrong or what you see being taught wrong to our future field providers.

I agree that the lights and sirens can help to get the adrenaline flowing before a call, even if it they aren't so helpful in saving meaningful time (not that I would advocate continued use based on this!). Even though I may admit this on our own professional forum here, I don't think that it is the message we should be giving to the public. If we need to say this is a "calling" and use that to promote our profession, I wish they at least could have found someone who could have said pretty much anything other than doing it for the girls or the lights and sirens. Good point. I don't think that it should be a week to pat ourselves on the back (though this is probably what it is now), but it could still be a week when we promote our profession. We could do this in a way that shows what we do. To many members of the public, we simply drive people to the hospital in a horizontal position. It would be nice if we could promote paramedicine in a way that doesn't say "we're awesome" but instead says "we're happy to do what we do and here's some of what we can do." Maybe that isn't as good for our egos though.

Toronto EMS is helping out with the cause! Reminding us that not only is EMS a calling, but you realize this the first time you're in an ambulance going lights and sirens. I think I just threw up in my mouth a bit.

This came through my email this morning: I hope that I haven't missed a thread on this already, but this just seems ridiculous. Whether you believe that EMS is a calling or not, it certainly seems like there are much better options for a "theme" for what is supposed to be our professional week. What about, "Our profession. Our future" and we can have a contest to write about what you have done in the last year to promote it? I'm sure many of you can think of even better ideas. I don't know how official this theme is (is this just an EMS1 thing?) so I probably shouldn't get too worked up, but it just doesn't seem like it is much help!

Not to completely thread-jack, but are there any of the on site medical companies that are easier to get in with than others when you're a foreigner? I certainly haven't had much luck! (though maybe my problem is that I'm only looking for work during breaks in the academic terms)

I hope you have a good time here! Unfortunately I'm burred in the books a couple thousand kilometres from you.

I guess I should have explained my complaint... the sedation from it isn't always great and it would be nice to have an option that can do something for nausea from chemo (not that we see a lot of that, but as you know dimenhydrinate is useless for it). Certainly in some patients it can definitely be a useful antiemetic though.

I did a search but didn't seem to find anything addressing this specifically. I'm just curious which antiemetics are used most commonly and if you are happy with what your service uses or if there is something you would prefer. It seems like we're a bit behind the rest of the world with our continued use of dimenhydrinate in Ontario...

Done. Good luck with your project!