Timmy

I’m unaware of the requirements for the FPOS or PHEC courses but I’m quite certain first responders in Australia do not use LMAs. I’d just like to clarify your referring to first responders in the sense of a lay person who has completed the four day course and not a paramedic acting in a first responder role? Having trained volunteer first responders before I’d lean on the side of caution when it comes to advanced airway techniques. During my paramedic degree we spent quite an amount of time on LMA’s, there’s a lot involved regarding anatomy and physiology, remembering the different sizes to the weight of the patent, practising and going through the clinical practise guidelines and clinical work instructions – I think we spent a week all up doing lectures and practicals on airway management with an intensive care paramedic then of course we were examined theoretically and practically. Likewise with the nursing ALS course, lots to read and practise before you sit your assessment. Whenever I’ve been taught airway management the importance of basic manoeuvres and adjuncts is paramount. I think the student should be affluent with a good triple airway manoeuvre, getting a good seal with the bag value mask, using suction, inserting an OPA and maintaining good ventilation. I think these skills should be the focus of the first responder’s role rather than teaching advanced skills in four days. Moving the patient is another kettle of fish, they have to be confident the tube is secure, be aware of the risk of aspiration, tube displacement, ideally have cardio/respiratory monitoring etc. If these people are operating within close proximity (< 1 hour) to medical help then I think basic skills should be taught. Just my opinion, I haven’t meet your students.

I’ve used it twice in hospital, once for an obstetric emergency and the other was last weekend I had a 22 year old cystic fibrosis patient who had a large hematemesis event with EBL 600 to 700ml, initially hemodynamically unstable with ambulance but after fluid challenge and tranexamic acid he recovered well and maintained for 2 hour transport to specialist care. Haven’t had the chance to use it in trauma patient’s yet.

I think pain management and assessment is generally undertaken in a very insecure manner. I see a lot of clinicians worrying about giving the patient too much analgesia, to little or jumping to the conclusion that the patient is seeking. There seems to be little understanding on how to assess pain thoroughly and then working on a sound management plan and selecting the appropriate analgesia. No matter what your first thought is of the patient I think it’s still important to do the appropriate assessment, diagnostics and go from there – I’d hate to think someone would base there diagnosis or treatment on a half-hearted history on a patient with no physiological change in vital signs and merely dismiss the patient as a seeker . Process of elimination. Nociceptive pain may have no clear diagnosis, commonly nociceptive lower back pain patient’s present frequently for acute pain management even though the MRI/pathology suggests no cause for concern. Who am I to judge there level of pain? If I think there seeking I may refer them to a pain clinic or similar. As previously mentioned EMS has limited analgesia options, I guess that’s an upside of being an ED RN. The service in my state carries Morphine, Fentanyl , Methoxyflurane and I think there just about ready to start trialing Ketamine. I work in a large rural ED and we struggle to get senior doctors, unfortunately it’s common that the junior docs will prescribe unsuitable medications to patients who need more, in fact just the other day I had a young lass with acute abdo pain and the doc didn’t think it warranted opioids because she didn’t want to interfere with the surgical registrars assessment (even though she was some hours away from examining the patient)…

Try and calm things down a little to improve our chances of good assessment. What did he eat? Remove clothing. Did nana bring the child & maternal health book along? What’s the kid’s weight? Skin & appearance (cyanosis, rash, pale, flushed, moving all limbs etc.). Respiratory Assessment (rate, rhythm, depth, auscultation, SP02, use of accessory muscles). Temp & heart rate. AMPLE history, happened before? has the child ingested the same food before?

It’s hard to say with the limited details provided in a media report. Obviously you need to take into consideration the time and means of getting the kids to an appropriate facility via the quickest way possible. There’s no information on what services the hospital they bypassed has nor is there any real justification on why he called a helicopter. It also doesn’t state what type of store this incident occurred in nor does it say what was sitting on the shelving (normal groceries in a convenience store VS a bags of cement in a hardware store, for example). It states the shelving fell on the children, it doesn’t detail what the actual mechanism of injury or the height from which the shelving fell from – that being a possibility of compression fracture from direct impact etc. There’s no mention of any abnormal neurological findings, who’s to say one of the kids didn’t complain of altered sensation or have an abnormal vital signs survey. It could just be a simple lac to the head requiring suturing but on the flip side he could have arrived to find a pale and tachycardic child with laceration to head post head strike from a 1.5 meter falling object with initial abnormal neurological findings. I'd also take into consideration the motive behind a fly paramedic and nurse (who I assume have high clinical standing to be in such a position) decision to transport the second child by air as well.

Well... hopefully you can cancel from the job since the patient has deteriorate but is in hospital and it’s not what you’ve been called for… If they want your involvement then: Is he maintaining his airway? If not, triple airway manoeuvre and OPA as primary intervention. I’d like to provide positive pressure ventilation with an SP02 of 91% on high flow oxygen with a GCS of 8. What are pupils doing? What’s happening on ECG? Are they giving adenosine for SVT? What’s BGL doing? I’d like bigger IV access than a 20g at this stage. A total summary of IV fluids. Recent pathology results. Further respiratory status assessment, auscultation, skin colour etc.? Were the doc? Can we get a better history on the situation, how long ago did the symptoms start, has there been a rapid deterioration, what treatment has the patient received since being admitted to the rural hospital including what the nurses have done since the patient started to deteriorate? I’d still like to get a full past history and list of current or new medications. Treatment is really dependant on what your skills level is and what the hospital can provide? Sounds like the patient will need to be intubated…

In the Emergency Department we use it quiet frequently to lightly sedate some paediatric patients for suturing and plaster application. While I can’t provide you with specific pre hospital care information we run off what the Royal Children’s Hospital in Melbourne recommend and are assessed by our paediatric clinical nurse specialist against their assessment sheet which is in the link below. http://www.rch.org.au/uploadedFiles/Main/Content/comfortkids/Porter_nitrous_oxide.pdf http://www.rch.org.au/clinicalguide/guideline_index/Nitrous_Oxide_Oxygen_Mix/ http://www.rch.org.au/uploadedFiles/Main/Content/mcpc/Procedural_Sedation_nitrous_oxide__theory_.pdf#xml=http://ww2.rch.org.au/cgi-bin/texis/webinator/search/pdfhi.txt?query=Nitrous+Oxide&pr=ektron-ext&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&rdepth=0&sufs=0&order=r&cq=&id=51ec50905d

Deary me, this is the first time I’ve been back on EMTCity in a while and this thread was the first to pop up. Quite frankly your post gave me vertigo and left me feeling slightly nauseous, 1309 words mashed into one paragraph doesn’t make for easy reading. If you’re going to post such a detailed question I’d suggest not doing it on a tablet device. I agree with Mike, appropriate grammar, spelling and structure of your question reflects a professional persona and makes it easier for people to respond with purposeful, helpful and meaningful answers.' I’m not exactly sure I get what your question is? Are you merely asking our opinion on what we think of this services fitness assessment? Surely you had some idea of the company’s requirements before you presented to be assessed? Are you applying for a dual Fire/EMS position, if not then I think the fire part of this assessment is irrelevant. I can only comment from an Australian point of view but my structural firefighting assessment was similar, I’m by no means a picture of fitness myself but you need to maintain a relativity reasonable level of fitness for the job. When I did my fire assessment it ran over 5 days in 32 Degree Celsius heat, we were dressed in full nomex PPC with flash hood, gloves and wearing a breathing apparatus. We were made to carry two spare BA cylinders and marched around an obstacle course for hours on end. When we were engaged in active training of course we were made to go up and down ladders, crawl around, enter burning buildings and retrieve manikins. The whole point of being assessed is to see if your safe and capable of executing the required tasks and skills, the last thing everyone needs in a structure fire with entrapment is a firefighter going down due to lack of fitness or gaps in knowledge. The same principle applied when I sat the fitness assessment to get into my paramedic degree, we were put through a basic medical examination (general health, BMI, hearing etc.) and our fitness assessment consisted of 25 push-ups in various stages, 25 sit-ups in various stages, flexibility and a 10min bike ride were they increased the intensity every 2mins. This all reflects on your velocity, cardiovascular and core strength which are important aspects of any emergency service. This was a hurdle requirement we needed to meet to gain entry into the course to be eligible to attend clinical placement and I’ll have to sit the same test in a few months when I apply for a job. The point being you need to be fit enough for the requirements of your employment and if you’re presented with a rigours assessment then obviously you need to meet those requirements to gain employment.

I have dealt with this many times in the hospital setting and as far I know the ambulance service does not have a specific guideline for such a reaction, it would most likely fall under the anaphylaxis guideline. In my experience commonly people react to blood products (blood, platelets, and immunoglobulin) due to the rate of the infusion rather than intravascular haemolysis, anaphylaxis, febrile/bacterial sepsis etc. it would be interesting to know taking into consideration she has not reacted to any previous infusions, whether the staff increased the infusion rate on this occasion. Do you know how long the infusion had been running for before the symptoms started? It would be rare, taking into consideration she has been receiving ‘weekly’ transfusions for ‘months’ that a reaction would be caused by antigen build up leading to an anaphylactic event. I’d be interested to know: What her platelet and neutrophil levels are on the last blood test? What her level of respiratory distress is? What her SP02 is now on oxygen? Has she improved with the salbutamol & antihistamine? Does she have any fever/rigors? Interesting choice of pharmacology using methylprednisolone for a blood reaction, did they use that directly for the reaction or as part of her treatment for the thrombocytopenia (assuming this is why she is receiving platelets). I think the treatment was ok, generally if a patient reacts we: Stop the infusion Obtain vital signs Manage any life threats Get secondary IV access (I wouldn’t be flushing the same line) Back track your paper trail – confirm the right patient is receiving the right blood product Get bloods for FBE, UEC, CRP, Cultures Send blood product back to lab for testing Give antihistamines/steroids/adrenaline/antibiotics Once the patient is stable/symptom free the infusion can recommence if clinically indicated

I'd like to rule out meningococcal with a petechiae/purpura rash... does this rash blanch?

Must be an aussie thing

Pupils equal and reactive to light. Also, I’d like to add an immunisation status.

PEAL? GCS? Neck pain on flexion/extension? Photophobia? Chest Auscultation? Approximate fluid balance (intake + output) Skin turgor/mucus membrane? Abdominal examination? ECG? Are any of the other 8 people displaying symptoms? Has she been in contact with anyone who is unwell?

I agree with Dwayne but certainly without a comprehensive history or list of medications it’s hard to paint a full picture and formulate a constructive answer. Saying that and coming from an Australian background I find it quiet bizarre an ambulance would be taking a patient back home, but anyway… Like Dwayne indicated, non symptomatic hypertension is generally not a great cause of concern in the elderly, especially if the lady is already medicated and her BP was generally normotentsive in the ED. I’m sure if you didn’t speak a word of English and presented to a hospital your BP would be up as well. Your reassessment is also important because when things get busy in ED sometimes the nurse in charge is foaming at the mouth to clear the beds and things get missed, if you ascertained that she was still symptomatic with a headache and hypertension then reassessment by the treating doctor may be necessary because there really discharging the patient with no change since there admission, kinda defeats the purpose of attending an ED I guess. Never be afraid to pipe up and say you’re not happy with a patient, get someone to reassess them, that way if things go south on the way home at least your covered and attempted to advocate for the patient. Certainly in the limited Emergency Departments I’ve worked in its common practise to call the family or a responsible individual to take the patient home after we’ve explained what treatments have been attended to in the hospital and what care might be needed at home. This lady has a history of a left sided weakness and can’t speak English, to me the next questions here after medical consultation certainly reflect towards discharge planning. Is it safe for the patient to return home to there current environment? are there support measures taking place? If she can’t speak English does the patient even understand why funny looking people were poking and prodding here for a few hours? Is she a frequent flyer for similar presentations, if so why? Does she not understand how to take her medications and that’s why this “uncontrolled” hypertension occurs? I think observational skills for a paramedic are quiet important, I mean its all well and good for the hospital to ask a few questions to our non English speaking patient in regards to discharge planning but you guys are actually in there homes and have a front row seat to the home environment and can report back to the hospitals. I’m assuming the ambulance was needed because the patient has ambulation issues? I’d be more worried about discharging this lady home if there isn’t some support structures in place more so than her blood pressure.

Thanks for the feedback everyone, appreciated. I’m extremely new to cannulation, my second IV ever was the other day on this patient who was in sever anaphylaxis which rebounded for 2 hours, he was semi conscious and dropped his BP so I just went for the 2 biggest veins I could find. Live and learn I guess, I’ll know for next time! Thanks.

G’Day Guys, Just a quick questions in regards to placement of IVs during Trauma or Medical Emergencies. Anatomically speaking, were is the best place to start large bore IVs? I was recently in a situation were the patient was going down hill quiet quickly, I popped two bilateral 18g into the cubital fossa but when the anaesthetist arrived he wasn’t happy about having the IVCs placed there and proceeded to place another two 18g into the lateral aspect of the patients lower arms. The patient needed a dedicated line for an infusion and another line for fluids but didn’t really need four bungs. On rapid assessment he had great basilica/cephalic veins in the cubital fossa so I just went for them…

I guess the down side coming from a nursing background is we don’t get to play with all this fancy equipment, needless to say I haven’t had any training on the application or use of a KED but I have seen it used a hand full of times. After consulting a book I have called “A photographic guide to prehospital spinal care” written by a man called Anthony Hann and reviewing an article written by various people from the Department of General Medicine at the Toronto Hospital in regards to extraction and immobilisation of spinal injuries there appears to be very little literature provided on this very subject, in fact I have struggled to find anything to suggesting pregnancy is a contraindication. The article did briefly mention the use of KED during pregnancy but it wasn’t strongly supported and certainly didn’t go into great depth. I guess it comes down to the providers knowledge and assessment of the situation and patient as to when to apply such an immobilisation device, like they always say, everything in moderation – if you don’t pull the straps to tight around the chest/abdominal region then I guess there isn’t a strong potential for things going pear shaped.

At the end of the day I’d rather have a complaint put against me by an angry resident who wants to claim for minor property damage than stand in front of the coroners court with my pants down trying to explain why I waited 30 minutes for the police or locksmith to arrive while there’s two fire trucks and a couple of ambulances sitting in his driveway. As luck has it in my state in Australia the Fire Service is covered under the Fire Services Act (approved by parliament), it stipulates that the fire service can reasonably gain access to a premises or any place (public or private) in order to protect property or life. In this situation, if reasonable steps have been taken to raise voice contact but failed, there is no visual confirmation and you have first hand information that this person has pre existing medical conditions then one would assume it is reasonable enough to make a forced entry, you never know when they have hypo’ed in the basement, had an MI on the toilet or may have been deceased for the past week… Who would know… Just to clarify reasonable forced access to rule out further questions so I don’t give you the impression that the fire service can run around entering anyone’s property at anytime. The fire service can not turn up to a property that has a smoke alarm operating and force access unless there is smoke, flames or another provoking factor, they would have to wait till the locksmith or owners turn up.

- Tell the fire truck to move, it’s a medical call, not bush week. - No need for 10 firefighters, tell fire chief to send 3 or 4 to help break in, others can wait at the truck. - Search the house for open windows, try to ascertain voice contact – if no contact or way in then break ONE window and the medical staff enter the building with maybe one or two firefighters.

I’m sorry but none of this makes sense at all… Your occupation states you’re a “medic” yet on page 2 of this thread you state you run on an outreach first aid team? You state you carry pepper spray, tazers and handcuffs and you’re not a police officer? I’m sorry but I’m sure if a paramedic in Australia was carrying this sort of equipment they would be unemployed within 5 minutes. I you cant walk into a situation and at least have an inkling that there’s even a small risk of people “throwing punches” then you should take a class on incident assessment. While I do admit on the RARE occasion someone can take you by surprise it surely wouldn’t warrant carrying all that around to every call…

Gosh, that’s a lot of gear… Expensive choice to buy and maintain an AED. Are you a police/paramedic?

As your skin was still intact I would classify this as a very low exposure, maybe submit a near miss report but I don’t think there is anything to actually report about… If it was a needle stick injury or blood to blood contact then that’s a different story.

Just an intresting article I came across... http://www.cbp.com.au/Portals/0/240409MACNew%20-%20Newsflash%20Insurance%20Group%20April.pdf

I agree, without further information I’ll assume were under timed critical conditions secondary to severe asthma. If were heading on the down hill cascade then we need to act quickly. -Need at least IVC X 2, I’d go with OI if we need to be quick. -Continue with Salbuatmol 5mg and Ipratropium 250mcg. -Methylprednisolone 1 mg/kg IV -Aminophylline loading dose of 10mg/kg, if were still not winning we can set this up as an infusion depending on the weight to reflect the infusion rate. -If were having no luck with the NEB Salb I’m a bit reluctant to give Salb IV because it has limited benefits in timed critical situations and we risk toxicity if we’ve been giving him Nebs then an IV. -RSI

A Is the Airway clear? Patent? B Rate, Rhythm, Effort? Breath sounds on Auscultation? SP02? C Pulse rate? Blood Pressure? Cyanosis? BP? Capillary refill (core & peripheral?) Perfusion Status? Monior? D Glucose? E General Appearance? Past History? Allergies? Medications? Oral Intake? Hydration status? Have 02 on by now, getting Salbutamol nebuliser ready until we have further information. EDIT: Based on the further info while I was posting the above. Holly cow! Silent! Get some Salbutamol into him. What’s his weight? Drawing up some prednisolone and Hydrocortisone ready to push when we have more info. I’ll also start drawing up RSI drugs as per weight and have more info on respiratory/perfusion status.