Timmy

I’ve never been involved in a situation were we’ve had to respond to a patient outside of the ED car parking area (maybe 50meters from the ED doors) but this thread is starting to sounds very territorial. At the end of the day we should be working as a team in order to provide the patient with the best possible outcome. As a Nurse or Doctor in Australia we have to pay a yearly fee in order to be registered, within the registration is liability and malpractice insurance which cover us anytime we identity ourselves as healthcare practitioner so we can automatically rule out this ‘out side of hospital grounds’ comments. I fail to see why any ED staff running half way down the street in order to get to a patient with a bed in tow, maybe someone might head down for a sticky beak until the ambulance arrived. Within a responsible distance to the ED I see no problem with taking the patient on the hospital stretcher, I wouldn’t wait around for an ambulance to arrive, load them onto the ambulance stretcher, let the ambulance reverse into the ambulance bay, unload and so on… Just a waste of time. If things are that direr straight that the patient wont make it in time to get to the resus bay then we can bring the resus trolley out to them. The resus trolley has a monitor/defib, first line drugs, advanced airway equipment, IV/IO/CVC/Art Line access, fluids, anaesthetics equipment and what not. If there’s been an MVA or someone has spinal injuries then an ambulance would be called because we don’t normally stock KEDs and longboards in the ED. At the end of the day I think its important to assess how everyone is performing, if the ambos are there first and there doing a good job then let them be, offer some assistance, get them into the ED and visversa with ED staff on scene. There’s no need to fix something that isn’t broken but the sooner we can get them into somewhere that has medical imagining, pathology, specialists and specialist treatment I think the better off the patient will be.

I think your best bet is to actually call the ambulance service that responded to you and put your questions forward to them. No of us were on the call or witnessed the situation so we wouldn’t be able to provide you with accurate information.

I agree, I don't see a problem with this... The hospital invited you to collect the details, I’d just document that Doctors and Nurses from the receiving facility were in attendance and treating, no action required from EMS.

At the hospital we have ID cards which have our first and last name, qualifications, department we work in and a photo attached to a lanyard. We also have a swipe card which gets us into the drug rooms, staff entry, canteen and what not. I have my swipe card in front of my ID card attached to the lanyard so no one can see my name because I think the ID card displays far too much personal information. I introduce myself by first name to all patients and my uniform has ‘nurse’ printed just above the front pocket, which is enough identification in my book. If someone wants to make a complaint I have no problem in giving them my first name and employee number but after that you’re going through management in regards to any further correspondence. I also respond to ‘hey you’, ‘oi nurse’ and so on and so forth. Our EMS uniform comes with a name tag which has our first and last name and we get a photo ID card when you qualify to administer medications. I don’t wear the name tag unless it’s an official/ceremonial type event but I do carry my meds card in my pocket whilst on duty. Our fire turnout gear has our last name on the back of helmet and printed on our jacket and pants, no idea why. I guess it’s so we don’t get our gear flogged at the fire scene or they know who we are if we go down…

Thanks for the advice, appreciate it. I’m not quiet sure if uni has academic writing classes, I’m guessing that may be aimed at the 1st years rather than the 3rd years but I will investigate that. I’d love to have someone read over my essays but unfortunately I’m a little time poor and rush to submit the assignments before the due date. Example being I’m currently on placement for 2 weeks, we do 40 hours a week on placement, add 2.5 hours driving each day and I’m doing 20 hours at work this week. We have to write a 4000 word case study on a patient we select and this has to be submitted within 2 days of the placement finishing, it’s just so full on. Because were out on placement when most assignments are due I struggle to get back to uni to see the lectures because it’s a 2 hour drive each way, email is ok but its not as beneficial as face to face contact. But anyway, I guess I’ll just keep chugging along! Thanks again for the advice.

As you all know Im currently in my finial year of this nursing degree, I only have 4 months to go yet the end is still so far away! I have no problem what so ever with practicals, I love them, Im happy with my practical skills, I always get full marks in every practical assessment yet Im a hopeless Harry when it comes to academic writing. I recently received feedback from 2 major assignments and what I read was quiet disheartening indeed! To sum it up, my academic writing skills need development and my assignments need more clarity because there hard to follow, just what you need to hear when you have 4 months to graduation. I know Im the most NON academic person youll ever meet, I freely admit that but Im competent when it comes down to the crunch and my day to day work. Im one of the youngest nurses to work in my hospitals ED and ICU, I always get good feedback from work, I get good feedback from all my placements, I even got a job offer from my last placement and as I said, the practical exams dont phase me at all. Unfortunately in the last year of nursing we have no practical exams, getting full marks in my practicals last year is what got me through. I can stand there in front of an arresting patient, assess the patient, tell you all about the pathophysiology, the rational behind the treatment, the pharmacodynamics of the medications but get me to write a 3000 word assignment on transition problems to residential aged care or care planning for a patient with APO I cant seem to put pen to paper without looking like an incompetent retard. Im just wondering if you academics can point me in the right direction or offer some advice as I feel Im falling behind and fear I may find myself back at university next year!!

Back when I was a paramedic student you had to pass a medical and fitness test every year in order to undertake the required amount of clinical placements, this involved a visit to the doctor for a medical (blood pressure, BMI, cardiac/resp assessment and general check up) and the physical involved a 10min bike ride with a pulse oximetry type monitor in situ, a flexibility test, about 50 push ups in 3 stages and 30 sit ups in 3 stages. I only just passed but I’d defiantly have to get into shape now if I ever needed to re sit it! Certainly my state ambulance service has a fitness, psychological testing and medical as part of the recruitment process. I’ve always been a little overweight but ever since I started nursing I’ve put more on than I’d really like to! I simply don’t have the time to commit to a regular exercise routine or even participate in team sports anymore, my diet is all over the place, I have no set times for meals just eat when ever I can depending on what shift I’m on. Between university, work, driving around the country side, volunteering and life in general my week can range anywhere from 60 to 80 hours. My partner is a 6 foot 4, Maori who is heavily into sport/rugby but even now his becoming a bit lazy, we try to walk along the river for at least an hour twice a week but I’d really like to get into the rugby scene again but have absolutely no time during the week to train let alone attend the odd match day on a Saturday. I think nurses should involve a little fitness here and there, probably not as much as paramedics but some is better than none I guess. I work with quiet a number of nurses who I’d classify as morbidly obese, there very competent, professional clinicians and great colleagues but boy, the 6XL work shirt does them no justice. If you attend Blue Calls you need to be able to run up a flight of stairs, down the corridors and be ready to start compressions without arresting yourself. There is a down side to being the bigger nurse, you’re often called upon to help out with all the manual handling, patient transfers, you’re the one everyone stands behind when there’s an aggressive patient, people expect you to tackle patients but you know what just because I’m 6’2 doesn’t mean my back doesn’t get sore too! I must say, recently there’s been an influx of young paramedics, they all look pretty fit and ready for action but I’ve rarely seen an obese paramedic. Must be all that spare time they have on there hands!!

All our ambulances carry ceftriaxone, for what I'm not sure...

I guess in conclusion the emergency ambulance services in Australia (every state has one service) are very good, they provide well educated paramedics with a pretty good scope of practise. That being said the ‘Private Industry’ in Australia is growing rapidly, that being non emergency transport that the state ambulance services contract out to and private event standby mobs which are not regulated.

That is such a good idea! I did my PALS course last week and they didn’t mention this, the tricks of the trade hey!

WOW! I had no idea Australia was lowering its standards this much! I have heard of AREMT but haven’t really taken much notice of it, I’ve been in my little world of nursing for a while and haven’t had much time to partake in the prehospital side of things as much as I would have liked. I think the introduction of the Australian Health Practitioner Regulation Agency (for our international friends, this year they nationalised the registration for Nurses, Doctors, Pharmacy, Physiotherapy and all those allied health people out there. AHPRA is our agency who regulates all health professionals, investigates claims of unsafe practise and ‘protects the public’ from the evil perils of unsafe practitioner) is the best thing since sliced bread! It gives you so much more autonomy to travel around and what not. The sooner the state ambulance services have registration the better in my opinion. I think all Health Care Professionals should be registered and regulated by a professional body that reflects professionalism, accountability, responsibility and comes down on professionals who are unsafe. I’d have no problem in reporting someone who displayed unsafe care, likewise I’d expect someone to report me in the same situation. Does this EMT mob reflect the same values? I always find the private sector a little on the dark side, it pretty much comes down to you don’t know what your paying for, I mean, anyone could call themselves a paramedic, paint up a van and toddle off to a standby to provide care, who would know! All of you know I’m a volunteer with St John, although I don’t have as much time for it as I used to nowadays. St John is like bread and butter, everyone knows it’s a first aid service and the scope of practise pretty much reflects that, we certainly don’t have people running around waving there 10ml syringe full of morphine around just because they have a Certificate 2 qualification in basic care and are registered to this EMT mob. Anyone who is registered with AHPRA as a Doctor or Nurse can practise to there registered level within St John providing they can provide yearly evidence of registration, likewise with any qualified paramedic who has one year of employment with Ambulance Victoria can practise to there level of training. We’ve done some co location standbys with private services before, some are great and some are really less than desirable. There’s a particular mob that make me laugh every time, this particular raceway hires this group to cover all there major car and motorbike racing and St John provide cover to the crowd, in previous years we did provide an on track transport vehicle which we no longer do. This mob are very financial because they cover a lot of high profile events with volunteers and charge through the teeth, they only have high performance sedan response cars that have to be trucked in because there not street legal. During the breaks of racing they race there response cars around the track, doing burnouts and carrying on like pork chops really. They carry all the latest and greatest equipment but the motorsports body provide its own medical director on race days so I’m assuming this is how they can legal administer medications. I think the racing people are being ripped off for what they paid. We also worked with a company that had “First Aid – Paramedic” written on there vehicles, I mean, make up your mind!

Hi Guys. Thanks for taking the time to respond. To sum the situation up a couple of people refused treatment, even though I highly suggested they be checked over by the paramedics, which they did but still refused treatment and a couple went to hospital in spinal precautions, I haven’t heard anything more… I followed up the so called ‘paramedic’ but from the information I received I couldn’t find anything to suggest he was in fact a paramedic. Just a bad day I guess!

I know we run Emergency Departments in Australia a little diffrent from the US, we tend not to encourage primary health patients to attend ED rather to seek assistance from there local doctor at a medical clinic. But this does not always work as we still see a high number of minor treatment cases present. I think posting billboards around town is a waste of time and money, just think of the how ever many thousands of dollars the hospital is spending on getting these things set up, hiring the signs ect. Could we not use this money to provide a better service? I mean, at the end of the day... You either need a doctor or you dont...

If you volunteer with the service I do work with its like clown college, seriously. Some days you just want to bang your head against the brick wall or crawl into a small hole and die then endure some of the embarrassment the volunteers find them selves in. Just a few weeks ago we attended a motocross, there was a rather large accident on the table top jumps in front of the grand stand, officials are waving the medical flags, the hundreds of people watching on - all eyes on us, we pull up in the ambulance, lights flashing and all that jazz, my partner gets out and in front of everyone trips on a tyre and face plants hardcore on the track. So his down, we have a couple of riders down, I continue onto the track leaving him there to pick up his pride and dust him self off but how embarrassing, you could just feel the crowds awkward silence beaming down on us. I’ll admit, an embarrassing moment. When I was first allowed to drive the ambulance when I got my licence we were called to a ‘cardiac arrest’ at an agricultural show. I decided the quickest way to take our 2 tonne GMC ambulance was straight through the sideshow alley (were all the rides and amusements are). We had a young police officer running in front of the ambulance screaming at people to move, almost at the incident location and a loud noise occurred, I’d scrapped the top of the truck against an amusement ride and made a 3 meter dint in the top of the back compartment, the crowd was screaming at us to stop and banging on the sides of the ambulance, luckily that was as far as we could get the ambulance. We dealt with the situation, the paramedics arrived and we began to extricate the patient from the side show area to the ambulance and almost rolled the stretcher between 5 of us, the patient was rather large and going across the uneven ground we just became a bit unsteady but how embarrassing! I could only imagine how much faith the bystanders had in us!

What was the reason for calling the ambulance? Waiting times?

I would have to disagree, why should an advanced first aider with a one month qualification be able to practise at the same level as me having 4 years of university under my belt? I bet they even get paid more! Crazy talk…

I incorporate a GCS (separate values) into my standard vital signs survey, I also comment on there alertness and orientation in the notes. When I’m working ED Peads or on the Peads Unit we us a PGCS scale which is tailer to infants and younger kids, it covers smiling, orientation to noises, orientation to objects, crying ect. A GCS is just one tool to help form an assessment on patients, there’s a lot to take into consideration when doing a patient assessment. I wouldn’t base any treatment purely on a GCS.

I tend to disagree, coming from a rural area were 90% of our paramedics are ALS qualified I think RSI, ETT and Ventilation are more than indicated in patients with head trauma and raised ICP. The “Golden Hour” is generally not possible were I live so good ALS/Intensive Care on scene is paramount to a positive patient outcome. The more you can stabilise the patient (Pharmacology and airway management) before movement the better, we tend not to “scope and run” here.

After a quick search I struggled to find any substantial articles or documentation to suggest a supraglottic airway would affect ICP directly, rather ICP would cause oedema to various pathophysiological orientations such as sixth never palsy or Papilledema but these are not directly related to trauma. I did read an article which suggested that patients with head injury -laryngoscopy and intubation may lead to increased intracranial pressure in the unanaesthetised patient, which proves the importance of RSI. In the context of a trauma patient with raised ICP your priority is to secure the airway and provide ventilation support to promote oxygenation and to improve cerebral perfusion. The importance of providing good pharmacology (paralytics, sedatives and analgesia) to these patients in the form of an RSI would substantially decrease the associated risks such as reflexive bradycardia, risk of aspiration from vagus nerve irritation ect. Medication management and administration is your key player in decreasing ICP, you would need to weight up your options… Would my LMA cause a rise in the ICP enough to potentially impact on a negative patient outcome? Or would poor airway management contribute to negative patient outcome? I think proper airway management would always supersede any associated risk of never irritation. In Australia both in the intrahospital and pre hospital setting the use of Supraglottic Airways in trauma patients is rarely indicated, the gold standard being RSI with ETT and ventilation, but you must use what you have available.

Welcome Back!

Well the whole situation sounds immature and unprofessional. If you can’t work in a professional manner or work as a team with such a trivial matter then how do you function as ambulance professionals? The issue should have been solved there and then, instead it escalated to potentially impact on a call when you were being dispatched. Maybe some education in conflict management for all employees wouldn’t go astray.

In Australia I really dont think its possible to become a paramedic in 12 weeks, the way you guys from abroad go about somethings just makes me wonder, its so foreign and bizarre. I think when Ive finished my training, education and have some experience under my belt Id like to come over to America and just see how it all works, from what you guys tell us on here I just have a burning desire to come over and see it for myself! I think our non emergency patient transport course is longer in duration than some of your paramedic courses over there, to be a junior non emerg transport officer I think its a 3 month certificate level course then we have a one year diploma to be the senior transport officer and a 3 year degree for the emergency paramedics. Believe it or not Im actually in my 4th year of full time study and I still dont hold a tertiary qualification, merely a nursing Diploma but figures crossed by the end of this year Ill be holding a shiny Bachelor of Nursing degree! I just cant wait to get out there and let the real learning begin! One of our 3rd year subjects in the degree course is professional transition in nursing, its basically a course telling you not to stuff up when they let you out into the big wide world and what were in for from transition from Student to RN but it occasionally has some quality content. Part of the module is to make a career education plan, it basically makes you think that this degree is just the key to the rest of your life, never stop learning and gaining further education. Part of my plan is to ascertain post graduate qualifications in paediatrics and critical care which is another 2 years of work/study type learning after that Id very much like to do the RN to paramedic bridging program which is another 12 months of study but I think having a solid, well educated and skilled background in nursing will make you a much better independent practitioner being a paramedic. I guess the take home message is dont take short cuts, you only live life once so why take the half hearted way when your missing out on so much education and extra knowledge and skills. If you want to be in the hard core section of medicine you might as well have the hardcore qualifications, skills and knowledge.

Coming from a smaller rural community volunteerism is a vital part of country life, not just within the fire service but right across the greater community and in all walks of life. I can certainly understand his willingness to want to help his community but leaving your kids in an unsafe manner like this just stinks, it's irresponsible, ignorant and dangerous. Certainly in my fire service we view it as only volunteering, everything else comes first (family, friends, work ect) if you cant respond then you cant respond, there is not expectation to drop everything and run, if you have time and your in the position to respond then great, your more than welcome. Certainly a situation like this would not be tolerated. I guess coming from a smaller community were everyone knows everyone its easier to address and implement a plan when theres a fire call. We have a firefighter here who can take his kids to Mr and Mrs Jones from next door when theres a fire call and know they will be safe and well looked after. On the occasion weve had a large fire or were short on numbers the communications officer will contact the wives of the firefighters and ask them to come down to the station to look after the kids for a while, here we can secure the kids in the training room, the wives bring there kids down, they can watch DVDs on the projector screen and everyone can leave there kids at the station knowing there safe and looked after while were doing our thing at the incident. The thing I love about being in small community is everyones wiliness to get in and help, especially recently with the catastrophic bushfires and large flooding weve enjoured, the community just pulled together so well. You can always rely on people who have no direct involvement with the fire service to be there willing to lend a hand in anyway they can, everything from the wives looking after the kids, to having meals ready for us when we return, to employers giving volunteers paid leave from work to attend the calls. Anything to make it easier for us to do our jobs, especially as we are short of volunteers.

Either that or make your way to an emergency room in a timely manner for assessment, chest pain is not to be taken lightly!

Thanks for your help guys. I think it best if the patients farther submits a complaint, after all I’m not a paramedic so who am I to scrutinise them! We don’t have mandatory protocols per say, we have similar clinical practise guidelines to the paramedics when it comes to basic life support. We have flexibility in moulding our treatment to interlink with what we find on patient assessment. As I said, I had no concerns about the kids cervical assessment, it’s one of the first things I assess on every rider when they come off. If he fell off riding at greater than 40km/h, had been projected from the bike, had damage to his helmet, had been struck by another bike, had a significant mechanism with a distracting injury or had any symptoms remotely resembling a cervical injury then it’s a completely different story. If I collared every person I went out to see then I’d be filling the local ED with 10 to 20 riders per day! The paramedics didn’t manipulate his injury, in fact they thought it was not fractured at all. From what I saw they merely removed my splint, did some dorsi and plantar flexion to see if he had pain, which he did. I’m not sure if they re applied a splint because when we transferred him to there ambulance they blocked us out, which is fair enough, I need to get back out to the track anyway. Is it to much to ask for a little professionalism on a call, it only takes 30 seconds to hand over. I don’t find anything pro active about coming in with a negative blanket over your head, ready to fight just because first aid is on scene…