Timmy

And the point of this is?

I had a 14 year old coming into the hospital one night (baring in mind there was only 3 nurses on, no doctor or security) in psychosis. We watched him throw a fire extinguisher through the wall as he walked down to the nurses station. I told him to stand were he was (I was behind the desk),he went on to say he'd been on the methadone program but went back to using so he got kicked, he'd been buying Endone off the street, then this night had been harassed by the Italian boys, went back to smoke a joint and came in with full on psychosis screaming for the psych team (the psych team is an hours drive away). He threw him self up against the wall then fell to the ground, I started talking him down while the others called the psych team. I thought things were going ok so I came out from the desk, leaving what I thought was enough room to bail if need... Needless to say he dropped me (I'm 6'2 and 220 pounds) luckily I got the upper hand on the floor, he freaked and ran out screaming. By this time the others had activated duress and I went down to lock the emergency doors. He drove his car into the ambulance bay and proceeded to take off his attire. By this time 3 cops cars rolled up, he ran down the car park screaming, 5 cops dropped and cuffed him. About 5 minutes later (his old, bombed out car) had caught fire.. That was a night to remember. Needless to say, I'm much more aware of psych patients now.

Envy? I doubt it, very much. Anyone can become a volunteer firefighter. I too am a volunteer firefighter in a small country town. I joined because I wanted to help the community, we don't have a hug amount of volunteers, I enjoy the company of the other volunteers, I enjoy the training and associated challenges and I'd like to think that if something went wrong that appropriately trained people are there to help. I have no desire to become a Career Firefighter or do Firefighting full time. I like having the flexibility of being a volunteer, there is no pressure to attend calls you attend when you have time. Training is also flexible to a certain extent depending on your level of involvement and training. I'm at an intermediate level, I have all the basic skills needed to preform wildfire suppression, basic structural/urban assessment and suppression, hazmat and minor rescue. I'm happy to turn out to this level, I also take responsibility of maintaining this level of qualification and it's requirements to maintain competency. The option is there to take the next step up into a leadership or advanced firefighting role but I feel I have insufficient experience to preform at this level and working full time would put me under increased pressure to maintain these skills. In Australia EMS and Fire are totally different services. While I am the crew medic our appliances only carry basic first aid equipment, I do not respond in a medical capacity. If we get to a scene were someone is injured I will apply basic first aid until the paramedics arrive, the local paramedics know I'm a nurse and will ask for help if they need it. There is no need for all this “them and us” rubbish, we all flying under the emergency services banner – we should all work as a team.

Make sure you never make mention of the physicians handwriting. I mean, part of a legal drug is clear, concise, accurate and legible hand writing... I'm yet to see this lol! Good luck.

Waist deep in a lake with Police trying to coach a drunk back to shore then being thrown up on by another drunk on the foreshore, she proceeded to be very apologetics and gave me a hug which mooshed it into my uniform more! Tonight I will be at a major RAVE party in Melbourne... Oh the joys lol.

I have a Ex Time Extreme Watch that I use for nursing and EMS. Not to sound like a whacker but it clips onto your belt clip, it's out of the way, there's no issue with infection control, it has a LED light and it's durable but a little on the expensive side. http://www.nursestuff.com.au/ex-time-extreme-watch-4

Here in Australia EMS and Fire are two totally different government funded services. Each state in Australia has a Metropolitan and Country branch of Fire Service and each state has there own Ambulance Service. In my state Melbourne has the Metropolitan Fire Brigade which is all paid, full time firefighters. In the country interface we have Country Fire Authority which encumbers just over 1000 fire stations, they have about 3,000 paid full time fire fighters and 30,000 volunteers. The larger rural city's and large coastal towns have paid full time staff and the remaining stations have volunteers. It's no walk in the park to become a paid firefighter, the entry test is quiet extensive and so is the 4 months of academy. The Ambulance Service is all paid full time staff, we don't have volunteers in EMS apart from CERT in remote areas. Again it's quiet a vigorous entry requirement to become a paramedic, most have 3 years degrees and undertake graduate training. We don't seem to experience the conflict and problems between EMS and Fire as you guys do over in America.

I was the first one to ask about obstruction but you didn't run with it (good on yah Ben haha ) that's why I was banging the drum about croup. Just reinforces the fact of starting off your treatment and assessment in a basic manner then working your way up. Anyway, good scenario!

I think I have given everyone the wrong impression here, I was basing my treatment on a croup presentation. I understand I haven't been througher in my investigation and assessment but in the initial states of Ben's assessment my diagnosis was leaning towards sever Croup based on the raspy cough, high pitched stridor Phx of croup and use of accessory muscles which are all characteristic of croup. I only had a kid present to ED with similar symptoms the other night. Now, I did go to work today and I did read up on the clinical practise policy (feeling bad that I'd completely messed up and to ascertain my sanity level) in regards to paediatrics presenting in sever resp distress secondary to sever croup. Someone has mentioned nebulised salbutamol, whilst a good idea there isn't any evidence to suggest wheezing and I would agree with chbare that salbutamol is not the drug of choice in this situation because stridor does not indiate bronchospasm. An adrenergic agonist like Neb Adrenaline as a front line drug is a great idea (while it did cross my mind I didn't think to put it into my treatment at 2am when I initially published my first post.) Alpha receptor stimulation (that is a therapeutic effect of adrenaline) may contribute to mucosal vasoconstricting which interm can reduce the amount of oedema in the upper airway (providing the kid has croup, which hasnt been specified at this stage) A corticosteroid like Dexamethasone can also be benifical in reducing the inflammatory response in the upper airway by reducing the number of certain white blood cells (I forget the appropriate name for this process but it's something to do with leukocytes). Prednisolone could also be used but in an emergency situation Dexamethasone would be the drug of choice as the onset, peak a strength of the medication are greater. When you have a kid this sick (deminised bi lat lung sounds, extremely low SP02, tachypneic and general poor perfusion) then intibation, establishing an airway and getting some more oxygen flowing around is of great priorty, espcially in kids... As I'm sure your aware once your oxygen haemoglobin dissociation curve goes blow 85% it's very hard to establish there stats again, especially in kids because they use most backup mechanisms and crash pretty quickly because they have nothing left to fightback, per say. But yes, I do agree... Poor assessment on my behalf, I defiantly should have assessed the patient to greater level before I go all out on a pharmacological rampage. But I would definitely like more info on this patient. Could I also please have a general picture of the seen, is the kid crying? Is he floppy? Sitting up? Lying down? Alert? High amounts of 02 at this stage in an upright position. Maybe give Mum a call to gather a better picture on any relevant past history. Anywho, I'm probably completely wrong (only been an RN for 2 weeks) but I appreciate any feedback... I'm here to learn

Why do you ask? Last time I checked, SP02 is part of a comprehensive vital signs assessment...

So we have a 4 yo in sev resp distress, Phx of croup, SP02 in the 80's, tachypneic, cyanosis, nill know allergies, your indicating its not asthma and not anaphylaxis. What was the kid doing when the symptoms began? Has he been unwell lately? On any meds?

Allergies? If so, to what? And has the kid been exposed?

The kid obviously has an upper resp tract infection with localised oedema and by going with what Ben has portrayed in his assessment the kid is pretty sick. By giving a corticosteroid (i.e.Dexamethasone) your reducing the inflammatory response, reducing the need to intubate the kid and Dexamethasone has an optimal discharge rate in presentations of sever croup with a decrease in re presentation of symptoms. Obviously you need to check of other reasons (Asthma, obstruction etc) but I'm taking it the kid has croup?

Get on the dog and bone and tell MICA to put the foot down or you initiate transport, no time to waste here! What are the 02 Stats? Any cyanosis? Treatment really depends on the severity but I'm treating for worse case here, based on your primary assessment. Assisted ventilations. IMI Dexamethasone. If needed you'll need to pop down an ET tube.

It's so hard to educate people on their own health, I've done community health promotion and I'll tell you now... Not many people give a crap. When I did diabetes education and community health promotion I think I suffered from hypertension my self over the general lack of interest or effort people would put into optimising their health even though they have a chronic health problem. I'd have ten tone tassy come in who has uncontrolled diabetes, hypertension and cholesterols up the creek. There nutritional intake is not at all desirable for diabetes, they were none compliant with medications, sat around on there fat ass all day, smoked and generally couldn't give a stuff what I was telling them, they were just there because they had a referral. You give them reading material, talk to them, give them lectures, show them a movie, tell them the ways to improve there lifestyle habits and the detrimental effects but at the end of the day only YOU can make that difference. After you put in all this time and effort into improving their health guess who presents next week to A&E with a headache and you find there in hypertensive emergency... But don't worry, I'll just put a GTN patch on, IVT you some Labetalol and get an order to increase your regular beta blockers and its all sweet yeah? Its the same with the programs they run like FAST, Slip/Slop/Slap, QUIT... How many people actually take notice? Everyone has to do the best they can, I have seen 2 deaths this year that resulted in lack of resources and staffing to get them the help they needed. We have one ALS truck in my town and the paramedics do an awesome job under the trying conditions. They can be extremely busy (most of the time) and not so busy (some of the time) They have an one hour trip to the base hospital with a 3 hour around time. That's 3 hours our town is uncovered, backup is at least 30mins off. Were coming into peak holiday season with campers flocking to the river. Starting next week and into new years they will give the hospital and ambulance a flogging because the towns population boosts by about 20,000 and no further health resources are added. We have a 4 bed ED with 3 to 4 RNs on each shift, no xray after hours, only on call GPs after hours and 2 paramedics who go on call after 1830, not a great deal to deal with what comes in and when does stuff start getting busy and hitting the fan? After hours, when our resources are at it's lowest.

Which Uni did you get an offer from Chaser? From what I've heard the LaTrobe course appears to be 2 years of general health science, A&P, community and chronic health, mental health etc etc and your last 2 years are bases around emergency health. It's a new course so I guess you just have to jump in and have a go to find out how good it is. Remember its a double degree and masters program, you'll have your work cut out. Nursing placement must be so different to paramedic placement. DARE step out of line or display unprofessional behaviour and your out. At my last placement we had to be at handover 10mins before the start, shoes polished, uniform clean and ironed, had to give up your seat for regular staff and doctors, we were assessed on professionalism, attentiveness, communication, posture and body language. I feared the clinical educator, she made me feel sick every time she looked at me in fear she'd race over and scream at me for a minor fault. We were given a pathological and medication research assignment each day, it was expected we complete this in our lunch break and present our findings in evaluation at the end of shift. Not that the thought ever crossed my mind but if you ever wanted to become a Registered Nurse with this clinical educator then you better pay attention and at least pretend to be extremely interested in every thing that was offered to you no matter how trivial.

I live only 20 minutes up the highway from were this incident occurred. It's not uncommon to wait for an ambulance because there are such limited resources in this area. My town has one ALS truck and Yarrawonga has one ALS truck, if both trucks are already on a job then the closest ambulance is an hour away. It's very unfair on the paramedics, they work very hard and extremely long hours with minimal backup to take another job or if they go on fatigue leave. It's not uncommon for the smaller rural communities to have no ambulance coverage or a single paramedic for a few hours when the ALS trucks have to transport a patient to the Regional Base Hospitals (an hour away). It's also not uncommon for a paramedic to come in on there day off or fatigue leave to respond one up to a job when the on duty truck is out and about. The government needs to pull there figure out and get more ambos on the road, this is not the first time someone has waited for an ambulance in this area... at least this lady survived.

I work in a rural hospital, we have no hospital medical officer. During business hours the medical clinic (which is branched onto the hospital) has a roster of general practitioners who will be on call to come into or be a referral source for phone orders, down side is if there called over to the hospital this puts the medical clinic patients behind. The same for after hours, there will be a doctor on call (most of the time) or available by phone (most of the time). So when someone comes into our 4 bed Urgent Care Centre (we see about 15 patients in a 24 hour period but can reach 60 patients during summer when the campers flock in) it's really 50/50 to whether the doctor will come in, most of the time there happy to come in (can take up to 30mins by the time they fix up there tie) but they'll give you a phone order while your waiting. There is a standing order in place for the RNs who have completed the front line emergency care course to initiate certain emergency medications e.g. Adrenaline, glucagon, salbutamol, certain analgesia, certain antiarrhythmics, start fluids and so on. They can also put down LMAs, initiate a cannulation etc. But it's less paperwork to get a phone order from the on call doctor which only takes 2 seconds. If something challenging comes in we call the ambos then the doctor, it generally takes 10 mins for the the ALS crew to arrive but can take an hour for the MICA crew to come over and if your really unlucky and our ALS crew is already out it can take a fair while. Your assessment initiates what level of response comes in. So there is some room in a rural setting for RNs to have an extended scope of practise and work without a doctor or with only a phone order. I do admit it's not the world's busiest ED but when things start going down hill there is only a very small team of people who play a vital part in keeping the patient alive until the next level of care arrives.

You could always work for RFDS doing retrievals and play paramedic, nurse and doctor in the back of a plane... That would be an awesome job!

I had to laugh in disbelief when I read this! How naïve, I'm dumbfounded....

I have exactly the same problem! I've done my Diploma of Nursing and have a Certificate IV in Health (Ambulance) which is nothing exciting (similar to EMT B with basic pharmacology) I'm off to university next year to do my Bachelor of Nursing, going into the Nursing Degree already having a Diploma wipes a considerable amount of time so it's an easier option continuing with Nursing than going onto paramedics which is a four year degree. I'm currently pushing around the pill trolley in a large aged care facility for fininical benefit, whilst not the most exciting job in the world and I don't necessarily enjoy having crushed up temazepam and risperidone in apple sauce spat back at me its good constantly being surrounded by basic pharmacology whilst waiting to further my education... Good news is I've got a large amount of shifts coming up in A&E! But I do agree, there isn't much room as a nurse to initiate much without a doctors order which can be quiet frustrating. I find there are a lot more educational advantages in Nursing. I was reading the nursing journal the other day and it was saying we had something like 342 courses both at a local and tertiary level for nursing but I'm not sure how many paramedics have. Once I finish my degree I look forward to doing a post grad diploma in emergency nursing then venturing onto paramedics (theres a pathway from ED RN to paramedics)

I've never heard of this, interesting thought though. Maybe it's used more as a diversional therapy?

And his Temp? There's no vomiting? What meds is he on? Renal calculi can cause radiating groin pain but you haven't mentioned anything about flank pain. Peripheral artery aneurysms could be another possibility, as is end stage renal failure. Were not going to get far with this until we get back to hospital. I think we should just provide oxygen therapy, monitor vital signs, offer position of comfort, reassure and monitor vital signs. Once in hospital I'd like: Abdo CT. Ultrasound. ECG. Urine analysis. Full bloods including proteins, potassium,WBC, U&E, KF, LFTs, serum, creatinine etc etc. If you could shed some light on the results of any of these that would be awesome? Treatment: IV access. Morph. Surg consult. If our BP isn't improving with morph then I may consider Labetalol or similar. Awaiting results for further treatment.

Turn around and go back to the hospital. High flow 02. Is there any abdominal pulsating mass? Any difference in bilateral blood pressure? Could we get an exact location of the abdominal pain? Rebound tenderness? Is there any difference in the level of pain with change of position? Does he have a Phx of angina? Why was he in hospital? Does he have pain on excretion of urine? He needs a CT and bloods please. As for the brachial artery pulsating from his arm... Was it actually pulsating or just distended? This may be caused from the increase in systolic stroke volume. The hypertension can be caused by renal problems like glomerulonephritis which can occure in patients with ARF. Has he just had dialysis? I'm not sure what your scope of practise is but do you have access to analgesia or ECG (even 3 lead)?

You've got that right! It's any wonder why Australia is thousands of Nurses short...