Timmy

First of all this is a vent post but I would really value your opinion. I had a minor issue recently that I would like your opinion over, I stress minor issue here as nothing catastrophic resulted from it but it’s just been playing on my mind for a while. As you all know I volunteer some time doing first aid around the place. I was doing a first aid standby recently at the local motocross track, I had a 14 year old come off with pain to his right ankle, there was some localised swelling and 8/10 pain, I splinted it, gave him analgesia, loaded him into the ambulance and waited for the paramedics to arrive as were not allowed to transport from the event. Nothing wrong with the patient himself, the job ran with no problems, text book. When the two young paramedics arrived I welcomed them into my ambulance and began to give hand over, the paramedic started talking over me so I just stopped talking and sat back. She then gave me the evil eye, stood over me and questioned why I hadn’t applied a collar, I explained there was no MOI, low speed MBA, helmet intact, no LOC, neurological and spinal assessment NAD, full safety equipment worn, no motor/sensory issues so I didn’t see the need for spinal precautions but was happy to put one on if they thought it was indicated. She laughed and made comment at my ‘expert assessment skills and she could only imagine were I got my qualifications from’. Needless to say they did not apply a collar or even do any spinal assessment so I guess they weren’t too worried. They weren’t interested in my neurovascular assessment of his foot so I just left it at that… She then removed the air splint from his ankle, threw it at me, moved his foot around then told the patients father it wasn’t broken and not to worry. She then looked at me and told me never to waste there time like this again, I clearly had no idea what I was talking about. Anyway, they transported the kid end of story. The next day I followed up with the hospital, turns out he had a # lateral malleolus, distal tibia and proximal metatarsal fractures which required surgical intervention. I’m not a bitter person, I’m pretty easy going and what not but the option of writing a letter of complaint was raised. I’m a bit unsure of what to do so I just hand balled it to the patients father, it’s his son, he has the right to complain if he wanted, I’ve done all I can, did my job as best I could… Then I thought, well, if I stuffed up the paramedics are the first ones to jump down my throat on scene then follow it up with a letter of complaint then disjoint your reputation to shreds back at the station, so why can’t I complain? I mean, just because I have first aid written on my uniform doesn’t exclude the fact that I’ve done a year of paramedics and three years of Nursing at University, I’ve done first responder training, spinal injury care, motorsports rescue training, I’m very familiar with the Hans Device, know the motocross gear like the back of my hand, do education sessions for motocross officials on incident management, talk to all the riders at briefing, they know us, we know them, I know how the motocross guys think and breath, we’ve had the joy of resusing a few kids out there and seeing them back up and riding the next year, I’ve done some riding with them back in my teen days so I know how they operate. I’ve done over 300 motocross races so I didn’t come down in the last shower but 9 times out of 10 the paramedics will bring you down with some sarcastic comment and make you feel like a retarded Wally. It’s not just this call, they often pass stupid remarks to belittle you. I don’t know if it’s my age, if I look funny or what ever but I’ve really had enough, I shouldn’t have to put on my bullet proof jacket every time I call an ambulance, I do my job well, perform to my scope of practise and have never made any mistakes that would case further harm to the hundreds of riders I’ve cared for. Sometimes I just think to myself… Why bother going to University full time, working 30 hours of nightshift, then staying up til 3am the morning before finishing assignments so I can volunteer to help the guys out, missing out on weekend work… Just busting my ass to be put down. I don’t know what to do. I should really just have a cup of cement, harden up and move on I guess.

Indeed! Good for him! I was fortunate enough to escape any harassment during my school years, of course there were people you didn’t get along with but it never resulted in physical assault or the seriousness of the attached video. Back in the days of my high schooling we had a very multicultural and diverse population, the Italians were always brawling with the Iraqi kids and the Aussies were always brawling with the Italians, fortunately for me I was half Italian and half Aussies and if you left the Iraqi kids alone they were happy to hang around in there own groups. Luckily there was very little, if any serious incidents from memory. But I have heard it has since changed…

In a moment of professional downfall I too have been pulled up for a facebook comment. Something as simple as ‘having a quiet shift’ resulted in an anonymous phone call to the hospital and the nursing supervisor pulling me aside telling me to delete the comment. Of course I was quiet shocked with the whole situation and immediately deleted 90% of the comments on my facebook, I rarely commented on work related matters anyway but to air on the side of caution I did a mass clean up as soon as I got home. Fortunately no further action was taken, I thank my lucky stars it was merely a warning shot. I was actually a little shaken by the incident but we live and learn and I certainly won’t be doing that again! If there hasn’t been any further contact I think you should let sleeping dogs lie, I certainly wouldn’t recommend going through other people with an issue like this, it can only cause trouble and get messy. Put it out there if the complainant wishes to speak with you they may, if not then so be it. Delete the comment and move on.

My work supplied all the nursing staff with a bat belt (pick pocket). In it I carry: - Alcohol swabs. - Calculator - IV Bung Caps - Arterial forceps - Scissors - Gloves - Watch - Pupil Torch - Pens - Micropore Tape - Assorted prompting cards including admistration of blood products, IV infusion rates, complex medications calculations, ECG card, rhythm analysis, pathology normal values, respond blue prompts and phone number extensions. When I’m doing my event standby I sometimes carry a radio, my phone and a pair of gloves…

I think your correct with your lesser people comment there Josh, as someone who has been heavily involved with Johnnies but is now coming to ‘see the light’ and gradually withdrawing involvement out of frustration in the way St John deliver there training and assessment. It all boils down to money and bums on seats, you attend some events to find 90% of the volunteers on duty just have a pulse, a first aid certificate and not much else… Recently I’ve been involved with some really sick patients and it just blew me away at how some volunteers handle the situation, there barley competent. It all comes down to system error, why do St John have doctors and nurses going out to events with no more equipment than what the average first aid volunteer carries? Why is it when we request advanced care equipment our requests are denied? Do you not trust our country doctors and nurses to perform to the same standard as our metropolitan counterparts who get allocated there own personal ALS drug kits, cardiac monitoring equipment, airway management gear and standing orders? Perhaps rural Australians are not entitled to advanced life support? Why do you hand out Certificate II and Certificate IV level qualifications to people who can’t even take a blood pressure or communicate like normal human beings! It all comes down to money… St John covers about 95% of the major events in Victoria, I can go on duty in Melbourne and work in a St John field hospital that has 12 brand new ferno stretchers, infusion pumps, syringe drivers, massive plastic containers of drugs, cardiac monitoring, intubation gear, suturing material, POP gear, ISTAT analyser, emergency registrars, critical care nurses and MICA paramedics but were still sending a doctor and a hand full of first aiders to provide care to 400 motocross riders in the country with BLS gear and a few ampoules of methoxyflurance. We have one event here that gets a half hearted health response team that carries half the ALS gear that you would see at a similar event in a metropolitan area, maybe its because we don’t charge 40 grand for our ‘low risk events’. I’ll highlight a recent incident I was involved in, we attended a state motocross event in a remote area. Our crew consisted of 3 first aiders and 2 RNs. We had a kid come off, unresponsive, decorticate posturing, bleeding obvious he had a massive ICB, couldn’t maintain an airway, the initial response from the ambulance service was to send a community officer backed closely by a single ALS paramedic. Not much any of us could do accept call a chopper, transport him back to the rural health facility which has one ED bed and twiddle our thumbs waiting for the doctor on the helicopter to arrive and RSI the kid. It was over an hour before the kid got advanced care despite coming into contact with 7 healthcare professionals. Now, common scene here (either that or I’m going crazy) shouldn’t the service covering the event identify the risk involved with this event would put a strain on local services if things started going down hill? Geez, maybe we should send someone who can RSI and perform advanced life support next time… Doubtful… Similar situation recently were I had a patient with severe asthma not responding to Salbutamol MDI, well unfortunately dying patient I can only give you that medication and if it doesn’t work I just pray to god the paramedics are just around the coroner. 30 minutes is a long time to wait when you can’t breath and when you have 2 RNs, one being an emergency nurse specialist you look like a pair of incompetent buffoons. But phone orders for steroids or even putting the patient in our ambulance and meeting the paramedics on the road is not part of the services policy and procedure. After all, what’s wiping off an extra 15 minutes in this situation really going to do to benefit our patient outcome anyway? Just like Granny Smith and Jolly Volly sitting at the drag car racing… I mean, what more do you need than a few first aiders when your car impacts the wall at 250km/h?? Or when the sprint cars bounce, roll, tumble, twist and burst into flames at high speedway at the local speedway? St John have actually started to pay people to attend events using the volunteers vehicles and gear which makes volunteering not very appealing when you could be getting paid $36 an hour for exactly the same thing! Unfortunately private companies are not a big deal were I am, you rarely see them. If St John isn’t covering the event or we don’t have enough volunteers 10 bucks says they’ve either pulled a lay member of the public with a first aid certificate and handed them a first aid kit from Safeway or there hoping someone will respond to there request over the PA for ‘any doctors in the house?’. On the rare occasion we’ve worked in co location with private companies but there not all that flash, there’s no way of telling if the ‘paramedic’ is actually someone who is employed by Ambulance Victoria or merely a 21 year old who’s just finished there degree, 90% of the time there just patient transport officers. I’d much rather work with Ambulance Victoria if were doing co location gigs. I don’t mean to be on a big downer here, it just frustrates me when were not participating in proactive/best patient care!

Can relate to dirty jobs as well. The fun you have going out to the motocross when its pouring rain or a 40 degree day and the dust is so thick you can barley see 5 foot in front of you. Also entering a rolled speedway car that’s on its roof in mud or even going out to the ‘mud bash’ were the aim it to drive through a dam that they’ve emptied the water from and attempt not to roll your 4x4 or the jet boats who get up to insane speed through a track of half a meter of muddy water. We have green cotton overalls (or I think you US guys call them jumpsuits) with reflective tape around the torso, arms, knees and lower legs. The pants are a similar style to cargo pants with plenty of pockets. We also wear a 2 tone yellow/green reflective jacket which displays your clinical level. It can get hot in them but there comfortable to wear.

I to have completed cultural subjects within my nursing curriculum but it certainly was not as ‘practical’ as you describe Wendy. I agree with Bieber on his above comment but I sometimes find myself a little confronted by some cultures and struggle to accept what I see. I never let my professionalism cloud my judgement or the way I treat people but sometimes I come home and just think, wow, what the hell just happened today. I really don’t see the point of getting the nursing class to role play as you describe, I really can not see the learning advantage with that. There are certainly better ways to educate and promote cultural awareness. Maybe if they let you spend a day with a family from a different culture and then report your findings or something similar to that would seem more beneficial. Our cultural class merely consisted of a few lectures, a talk from a person from a different culture, some group activities then we were allocated an assignment were we researched a culture and reported our findings to the class. This was all based around just heightening our awareness and acceptance of different cultures as we come across them in our job and how to deal with certain situations. I work at a hospital which services quiet a diverse and multicultural population, I like to think I’m an extremely open minded, easy going and accepting person but as I mentioned above, sometimes I struggle. I do a lot of work in the paediatric and emergency departments of this hospital, this certain culture practises incestuous activities as part of there normal relationships, we often have kids coming through with major deficits, abnormalities, deformities and various health conditions related to the they were conceived – often the children have a short life expectancy. I remain very mutual and professional when dealing with these families as I believe everyone is entitled to quality healthcare and after all, its just a family dealing with a sick child, they need help and support as much as the next person. One shift I was caring for this child, possibly feeding it by a NGT, chatting to the family when the mother asked me why I wasn’t married to my sister and thinking about having a child. First of all I don’t have a sister but that’s beside the point. I really didn’t know what to say while all the family were staring at me waiting for an answer, they really did catch me by surprise. I ended up just laughed it off and joking that I didn’t have a sister so it wouldn’t be a problem … I come from a very Australian, farming background so having those sort of questions asked was just so out of the ordinary and something I’m really not use to. We also have another group of ethnic people here. I struggle to deal with this group even more than the above. They complain that we don’t treat them right and are discriminative, the government hands them welfare packages in order to provide them with basic services and necessities but they insist on spending it on alcohol and other things and choose to live in dilapidate conditions. I’m not at all being racist here, I can show you the statics and data on there healthcare, living conditions, attitudes, unemployment rate and what not. They come into work and demand to be seen immediately, there almost always intoxicated and abusive, they throw chairs and beer bottles at the triage window and yell extremely offensive things at us. When we do treat them there very unappreciative and expect us to organise extra social benefits. There at increased risk of chronic health conditions but do nothing to help themselves. I’ve been assaulted by these people at work on a few occasions, once a man cut himself rubbed his hand in his blood then purposefully scratched me resulting in an occupational exposure. They roam the streets in gangs causing trouble and despite as much help as we give them nothing improves. Now, saying this, of course there are people who fall into this ethnic category who are functional and well respected members of the community but we give and they just take, there is no reasonability on there part to improve the way they live and that just makes me angry. I guess at the end of the day nothing they can teach you in class will totally change your mind about other ethnic groups, merely increase your awareness, acceptance and to maintain a professional boundary when dealing with there complex social situations.

I once revered our brand new Mercedes Sprinter into a tree in front of 200 professional drivers while they were having driver briefing at a high performance challenge race standby… No damage to the vehicle, merely my pride and plenty of offers for driving lessons throughout the day…

Wasnt directed at you.

@ crotch - Holly cow batman! I'm sure you're just teasing in your posts with your naive comments in order to get a laugh out of peoples comments.

I’m not at all pro St John here, merely remaining on the fence because I have never worked with St John in WA but your criticisms seem a little far fetched Ben. Referring to an ambulance service as “killing people” when you have no first hand knowledge of the events they were involved in, merely second hand gossip from news reports and friends of friends. Running an ambulance service in Western Australia is no easy task, they cover a vast/huge geographic area which is extremely remote and isolated, in fact you could put St John WA in the running for the largest area covered by a single ambulance service (possibly). They rely heavily on volunteers in rural areas because it wouldn’t be feasible or financially viable to have full time paramedics in such areas with low call volumes. They have paramedic shortages as there staff are gobbled up by large, international mining companies who pay there paramedics far more than any state ambulance service could in Australia. I could pull hundreds of news articles and data on any ambulance service in Australia in regards to there mortality rate. Ambulance Victoria are often in the media for slow response times secondary to limited staff leading to death of patients, there paramedics striked over it, the public makes some noise about it, the government makes promises to fix it – its just the way the wheel turns but at the end of the day your going to get busy times when demand beats supply with a stick, there’s not always enough resources and people die. For the last two years our local news paper has complained about the ambulances services response to an ectopic pregnancy who died because there wasn’t enough ambulances… Sometimes its just the way the cookie crumbles…

That may be so but nursing is more mentally demanding than physically. My little brother is an apprentice builder and he certainly has a lot more benefits than I ever will as a nurse. He didn’t finish high school but you don’t need a high school certificate to become a builder, a monkey could pass there building exams, they don’t have to work shift work, his paid to study and attend work, they don’t have to work weekends and no matter how many post graduate degrees I ever obtain he will always be paid more. I pay $17,000 to do a 4 year nursing degree, I work night shift and weekends to pay my way through university, I attend university full time and my work is 2 hours away which equates to 14 hours driving per week on top of 30 hours of night shift and 16 hours at university plus study and assignments. At the end of my 4 year degree I’ll be paid an average wage and about $40,000 less than a qualified builder. So fire me, maybe I could find a better paying job with a better lifestyle.

What's the benefit of washing the puncture site before venom detection takes place?

I don't think St John have online CPGs available to the public. I could be wrong though.

Oh ok. I can’t speak for the paramedic degree but certainly in the first year of the nursing degree we have a subject called bioscience which encumbers all your anatomy, physiology, chemistry and physics to various levels. It forms a big chunk of the first year and there are about 15 assessments/exams/assignments at various stages which forms your overall mark. It’s been 2 years since I’ve done this subject but I remember touching on electrons, atoms, ions, kinetics, clusters, hydrogen bonding, atomic nuclei, matter, energy and so on. It’s all a bit hazy and I’d certainly need to go over my notes again if I had to sit down to another exam! I’d certainly encourage anyone undertaking a medical related degree to brush up on these subjects, even though on the odd occasion the content can become a tad dry!

I have a very limited understanding of what your educational requirements are in the US but wouldn’t fundamental physics and chemistry be apart of your paramedic and nursing degrees?

Unfortunately I have been in a similar predicament, while not from the academic perspective I certainly surcome to some troubles on my last clinical placement in my nursing diploma class. I didn’t see eye to eye with the course coordinator (not many people do), an issue arose to which I questioned and unfortunately it was taken as ‘how dare you question me in front of a patient’. I was failed on professional conduct and effective communication to which the issue blew up bigger than Ben Her and resulted in me fronting up to the Nurses Registration Board to please explain. Anywho, it all boiled down to personal conflict, everything was dismissed and I was awarded my registration to the course coordinators dismay. In the diploma class I was often put down for ‘focusing on the medical care rather than nursing care’, being to in-depth, being to advanced, I needed to be mindful of working to my scope of practise or even being irrelevant to class discussion. I’m finding University much more suited to my learning needs, were encouraged to research further and extend our knowledge as much as we desire. The only problem I have is being from a rural campus all our lectures are broadcast from our metropolitan counterparts, there’s often technical issues, you can’t ask questions and our teachers aren’t familiar with the content that’s being broadcast and sometimes it takes weeks for them to consult with the metropolitan teachers in order to correctly respond to our questions. Sometimes the content can be a tad overwhelming and very fast paced, I particularly had trouble with the medication module, it was very in-depth with pharmacology, cells, pharmodynamics and the like. Trying to get a grip on all that then moving onto drug calculations (which certainly isn’t my strong point) mix in some practical skills labs, the stress of upcoming exams and you suddenly find yourself knee deep in stress and information! Needless to say the teachers were more than happy to spend some time out of class with smaller groups and on occasions individually which proved invaluable. I can certainly relate to your situation Wendy, especially in our diploma class. Some teachers had the mentality of I don’t know, lets just stick to the course curriculum, that’s all the information I’m required to give you on these powerpoint slides, stop asking question its pay day tomorrow! My suggestion is to get some mentors or the like outside of class, I had some very knowledgeable RN friends and doctors who helped me consolidate my learning.

Do we know how much of each medication he took or were they all mixed together? Just because the patient states his taken 100 tablets doesnt necessarily make it true. So, we have cardiac medications (one being slow release), an anti inflammatory and ETOH on board… Do we know how much booze his had? Id like a better idea as to what influencing his GCS, the medication or booze. Can we get a past history? Id like to know why his on beta-blockers? hypertension? Heat Disease? Metroalol is a Beta1-adrenergic antagonists so his symptomatology is quiet text book in regards to the bradycardia, hypotension and Im guessing we have respiratory depression from reduced myocardial oxygen consumption (also a symptom of beta blocker overdose). Likewise with Verpamil which is a calcium channel blocker which adds to our cause of vasodilatation causing hypotension. Not a lot you can do for ibuprofen overdose, its probably already punching holes in his liver. First things first, lets do something about this man respiratory depression, to start with could our partner please maintain his airway, perhaps with an OPA to start with, have suction on standby and ventilate the patient with a BVM, 100% 02 at a rate of about 17 to 20 a minute while were doing something about the mans blood pressure. Id like his blood pressure to come up a bit, just so we at least bare some resemblance to adequate perfusion. IV access please with large bore cannular, push fluids. Id like to get an ECG before we start giving to any medications just so we have a baseline. We could also give glucagon (10mg) IVP to increase cardiac contraction. Atropine to rectify the bradycardia and maybe some adrenaline if were having no luck brining his BP up with fluids. Evaluate his respiratory status and GCS with current treatment, if theres no improvement consider moving onto an RSI. Monitor and transport.

Scene Safety? Primary Assessment? Secondary Assessment? Signs and symptoms? Vital Signs Survey? We need to find out what his overdosing on, with a past history of suicide attempts I’d take a stab at any number of the following… monoamine oxidase inhibitors, tricyclics, tetracyclics, selective serotonin reuptake inhibitors, benzodiazepines, azapirones, barbiturates and the list continues… and go from there.

I agree, things don’t feel right here, everything seems to be a bit airy fairy with no direct pathway of action. I don’t know what you DNR orders look like in America but certainly here things are a little different. At the top of the form we have the not for resuscitation orders, this specifies that in the event of cardiac arrest (were your heart has stoped beating, you have stoped breathing and are clinically dead) the attending medical team are to withhold CPR, ETT, Defib and other life saving measures, so you tick the boxes as to what you want withheld. So when this patient goes into cardiac arrest, I can look down at the tick boxes and see that they want i.e. only want CPR but no other treatment or they want no treatment at all. In the middle of the form we have a limitations of medical treatment order, this specifies that in an event were the patient becomes acutely ill or unresponsive the following medical interventions are to be withheld. Again tick boxes: to withhold intubation and ventilation, IV antibiotics, to withhold all medical treatment and to follow a palliative care pathway and there’s a few other interventions which I can’t remember. At the bottom of the page is were all the parties involved sign there life away. It’s pretty easy to follow, all you have to do is look at the tick boxes to know what interventions the patient wishes you to take. It sounds as though your DNR is only valid for a cardiac arrest, which the patient is not suffering from which makes the order not valid. With the possibility of foul play in question I’d say tube the patient until a legal directive can be made and the decision to withhold life saving treatment is all above board and legal. This patient might have a directive, medical power of attorney or any number of things that the people present, telling you to cease treatment are not actually included within. These family member could be hovering around waiting for her to die to inherent her millions of dollars… I don’t support keeping people alive to prolong there zero quality of life, I respect there wishes and palliative care pathways but in this situation were the DNR only specifies what to do if the patients suffers from Cardiac Arrest you need to keep her alive until a better, more legal directive has been reached or the patient goes into cardiac arrest. I follow the CARE theory, Cover Ass, Retain Employment.

I wasn’t aware such technology was actually available. After doing a bit more reading on this product I’d be really cautious about using it. I briefly tried to find some research articles on it with limited success, I’d like to know what its success rate is in regards to successfully resuscitating a patient in sudden cardiac arrest. After I watched the youtube video there didn’t seem to be many electrodes on the patient. There just seems to be to many ‘what ifs’ running through my mind, what if the electrodes got wet, what if the machine failed, what if an electrode came lose ect… But without reading some solid data on its success, patient feedback or actually seeing a device I’ll remain open minded. I don’t think it should replace an ICD. I really don’t have a direct answer for you Kyle, the website states the defibrillator unit is the size of a paperback book so I’m guessing it would be quiet visible upon approaching the patient and I guess you could easily turn it off and take over the resuscitation efforts with your equipment.

I guess a luxury of working in the hospital is we have flexibility as to what analgesia we give to patients. In the Emergency Department I haven’t seen or used Fentanyl as a first line analgesia. Morphine tends to be our drug of choice in most, if not all situations were patients experience moderate to sever pain. We seem to use Morphine on any array of medical issues whether it be cardiac, trauma or ‘other’ pain related ailments. If were having trouble managing pain with Morphine we tend to add some Codeine or ketorolac tromethamine or perfalgan and if all else fails we can pick up the magic phone and call for an anaesthetics registrar who can wave there magic wand and cure the world of its problems with epidural, regional nerve blockades and all there fancy anaesthetics. Fentanyl is used quiet a bit in orthopaedic patients, when I’m on surgical ward its quiet common for patients to have a controlled infusion (PCA) of Fentanyl with PRN Morphine or Oxycodone which we strongly encourage patients to ask for. It’s quiet common to have patients who suffer from chronic pain to be on Fentanyl transdermal patches but overall we don’t seem to use Fentanyl as a loading dose or front line medication. Even in kids we seem to Tirade there morphine dose and complement it with inhaled analgesics. To be honest I really haven’t experienced any adverse reactions with giving patients analgesia (touch wood!) I’ve given morphine to patients until they have slurred speech and can barley talk or open there eyes but are adamant they still have sever pain with no ill effect. It’s our standard practise to give Metoclopramide before we give any opiod medication. You’d be surprised how many patients state they are ‘allergic’ because they vomited when administered Morphine but when you obtain a thorough history you discover they were never administered an antiemetic and amazingly with 10mg of Metoclopramide they experience no ill effect (miracle workers we are!) I think analgesia is one of those ‘horses for courses’ topics were everyone seems to have differing opinions based on there experiences. I thinks it’s necessary to have multiple analgesic agents available because everyone has different pain thresholds and metabolism. I’ve seen a fractured leg respond well to something as simple as inhaled methoxyflurane and other patients who you think you’re going to narcatis because you’ve given them so much morphine but there still bellowing and screaming bloody murder, everyone’s different I guess.

I can understand your frustration! I to have been pushed around on placement and not given the full opportunity to learn. Were often pushed into doing all the showers and vital signs while the RN does all the medications and various clinical aspects of the job. There seem to be a lot of stigma associated with students coming onto placement, that being we will lighten up there workload. I do admit, I have been on placement were the shift has been nothing more than insane, tense, frightening and in fact, dare I say the nursing to patient ratio was dangerous. It’s not fair at all to expect an RN to care for 10 post operative patients who require close observation and monitoring, strict analgesia, we had multiple patients on PCA fent and everyone required opioid analgesia whether that being as breakthrough, stat or routine administration, had an insulin infusion running, neurovascular observations, we had a medical emergency call, all post op patients are on strict fluid balance monitoring and IV fluids. The level of staffing this hospital had was nothing short of distressful and by the end of the shift you just felt nauseated. That being said, the majority of placements are sensational and well organised. Your clinical placements sound interesting... Coming from a nursing perspective our placements seem to be a little different. At the start of placement were allocated a clinical educator who is responsible for our overall learning and how we spend our time on the placement. This person’s job is to supervise a group of students (normally 4 at a time) and there our major reference point for the whole placement. At the start of every shift were allocated a preceptor, generally a senior RN or clinical nurse specialist who have undertaken preceptor training, these people are to supervise and direct us on the floor and give feedback to the clinical educator. Normally we spend most of the shift on the ward but spend the last few hours with the clinical educator and the other students in a learning type forum on a daily basis. In these forums we have to pick a medication that were not familiar with and write a short essay on its pharmacology, pharmacodynamics, adverse reactions, indications, precautions, dosages ect and present it at the forum the next day, likewise we also have to select a disease, procedure or condition and explain its pathophysiology, symptoms and treatment. This is the time we can also ask any questions or address any concerns we may have. The clinical educator will generally float around the wards, watching us like a hawk, any areas we seem to be lacking in confidence or knowledge they’ll step in and take over from the preceptor to offer more intensive mentoring. While were on placement the requirement from the universities perspective is generally an assignment associated to a clinical case study, normally 2000 or so words. We also have a clinical learning tool which is about 15 pages long of competencies that need to be signed off by the clinical educator, these competencies range from communication skills, research skills, clinical skills, acute care skills and so on… A few times on placement we’ve done ‘clinical education series’ on various topics, we then have to research the chosen topic, construct a presentation and deliver it to the staff of the hospital. We did a series on alcohol withdrawal as it was identified that patients were being mismanaged in the clinical setting. We had to research alcohol withdrawal, its signs and symptoms, pathophysiology, management and treatment and present it to about 150 nurses, doctors and various other clinical staff. Quiet nerve racking indeed! I’m always excited and look forward to clinical placement but it’s very intensive, draining and tiring. We normally head out on blocks of 4 weeks, after we get home from a 9 hour shift were often up to all hours researching our university and hospital theoretical requirements only to be back into it a few hours later.

Unfortunately I see myself in a similar situation to yourself. Im a manager of a volunteer BLS EMS event standby division which is run on a national level, Australia wide I think we have around 5000 volunteers. Unfortunately the organisation has taken a more corporate focus and is more concerned about bums on seats and brining in the bacon than good clinical care and solid training and education. Time and time again I see volunteers who are completely incompetent and clueless, bordering negligence. The majority of the volunteers are made up of less than desirable people who are worthless, wanker, chauvinists. I audit the patient reports, provide re education, we do weekly training, we do yearly re accreditation, I work hard to provide good education but get nothing back expect complaints that the material was to complicated and not relevant, if its not relevant then why are you still completely miss managing patients who present with chest pain after weve spent hours and hours going of the theory and practical aspects, how is it possible that you still havent learnt this, are you that intellectually challenged you cant remember what Ive told you 70 times over? You still cant even explain to me basic patient assessment. Is it because you left school when you were 12 to smoke pot and live off welfare payments? I submit incident reports time and time again to our line mangers and clinical coordinators but get no feedback or action what so ever. Im sure there all silenced from the executive team because if we cracked down on training and education theyd lose a good 80% of the volunteers which means no income. Im told theres nothing I can do about problem volunteers because it would be classed as defamation, bullying and harassment and all that crap, if people want to volunteer than apparently they can, Im powerless to stop them… Were often referred to as the band aid patrol which is quiet true if you look at the calliper of our volunteers. Over the past 4 months Ive managed 2 patients who required rapid sequence intubation, one of which required pre hospital emergency bur holes to relieve intracranial pressure then emergency surgery to have a craniotomy as soon as the helicopter touched down on the pad at the hospital, Ive had a patient who needed needle chest decompression, a patient who needed thrombolysing, a patient who had a metal pole impaled through his foot, many cervical injury patients, a patient suffering from sever asthma who needed steroids and non invasive ventilation… All of which I can only perform BSL interventions while I wait over 30mins for ALS to arrive. I may as well attend some of the events by my self because even though I may have 6 other first responders with me they panic and carry on more than the patients family. I had no idea how hard it was trying to manage an unconscious 17 year old with a respiration rate of 8, I was managing his airway, ventilating, trying to coach a first year student paramedic on how take a blood pressure and BGL, trying to calm the family and mange my first responders excessive anxiety. I cant even rely on a first responder to scribe for me without having to tell them word by word what to write on the form. Dont get me wrong, we have some very competent first responders and quiet a number of doctors, paramedics and nurses who volunteer on there weekends off to help out but they never seem to have as much time as the ferals on welfare payments, so Im often forced to send these lovely people on duty praying to god they dont crash our new ambulance because there barley confident to drive… Im at the stage were Im ready to throw in the towel and walk away, Ive done my best to improve things but theres no point in fighting a losing battle. Some days it really gets me down, Im only 21, Im dealing with these people and the situations they put themselves in, I generally let me social life lack because Im so scared the first responder will kill someone, I make myself available to attend all these events from the pure fear of if I wasnt there and something goes wrong… What if? I do get tired, I attend university full time, I work as much as I can and in between this Im flicking through books and material trying to make basic care presentations to teach these people something. Some nights I only get an hour or so sleep before I have to drive to uni or be at work. I really do enjoy the work and the demand on our services are in ever increasing demand, I have some great friends in the service and I work along side some really well known and knowledgably health care professionals but at the minute the negatives seem to out weight the positives. I love pre hospital care and once I complete my nursing degree (not even a year left!!) Im hoping to go into the paramedic degree. The problem I have is living in the country there are no other EMS services (unless I travel nearly 4 hours to Melbourne) apart from the state ambulance service so if I throw in this gig Ive got no pre hospital contact. I completely understand why the paramedics roll there eyes at us every time we drive past but our service covers most of the biggest events in Australia so you need people who are competent and eager to learn. I sometimes get angry at the government, they spend money on such ridicules things but they cant even spare a couple of thousand of dollars to support our service, were still classified as a charity even though the government are the first to call us to respond to staging areas of flooding, bushfires and major incidents to provide 24 hour standby for weeks on end. I really dont know how to answer your questions because I cant even answer my own. I guess I really dont agree with EMS being volunteer, if we were a paid service then maybe I could enforce clinical competents and some form of quality standard in our ranks but as a volunteer service there really isnt a great deal you can do to manage trouble makers.

I think there’s a fine line between trust and teamwork. It takes a while to build trust, I think you need to know the person very well, have respect, trust is something you can’t build overnight. While I don’t necessarily trust you, I’m certainly willing to work within your team. I’m willing to bounce ideas from you, ask questions, ask for help and likewise if I can offer you any assistance I’m more than willing to help. But at the end of the day I’m not just going to sign your drug checks, I’m going to actually work it out and check it appropriately, I’m not going to sign your notes or anything like that. At the end of the day I’m just as responsible as you are and if my signature or action appears anywhere in a court of law I need to know everything I have done or signed for is 100% my action. As much as you may trust someone you’ll never know what sort of back flip they’ll do if it all hits the fan and ends up in the HR office or in front of the coroner. I work as an agency nurse within a large regional hospital. Every shift is in a different department and I’m lucky if I work with the same people twice, I don’t know you from a bar of soap so offcourse I’m not going to trust you. I certainly don’t trust the doctors, at the minute we have 25 new interns, a hand full of new medical registrars and residences, I understand there still learning but some of the questions they ask you are just bizarre and certainly don’t build my confidence in you. Sometimes you wonder why they spent all that money on going to medical school. Anyway, that’s a different subject.