zippyRN

first a brief summary of the regulatory position in the UK http://www.hse.gov.uk/contact/faqs/manualhandling.htm "The Regulations establish the following clear hierarchy of control measures: 1. Avoid hazardous manual handling operations so far as is reasonably practicable, for example by redesigning the task to avoid moving the load or by automating or mechanising the process. 2. Make a suitable and sufficient assessment of any hazardous manual handling operations that cannot be avoided. 3. Reduce the risk of injury from those operations so far as is reasonably practicable. Where possible, you should provide mechanical assistance, for example a sack trolley or hoist. Where this is not reasonably practicable, look at ways of changing the task, the load and working environment." the first point there sums it up 'redesigning the task' was felt to be reasonably practicable the control measures in the case of loading a trolley stretcher into an ambulance are ramp + winch or tail lift you can also use the ramp or lift with carry chairs/ stair chairs , wheelchairs or to aid someone who is not very steady on their feet to get from the road level to the ambulance floor level with this we've also seen a move to hydraulic raise / lower trolley cots such as the Ferno falcon and Pegasus and it's electrically powered cousin the harrier to reduce / remove the lifting element of altering the height of the trolley as a note the trolleys are usually transported in the down position where the bed in 15 -18 inches from the floor and they have double folding push -pull handles on each end to enable this - rather than the operator at the side pushing that the 'transport high' trolleys such as the ferno 35a or it;s UK hybrid cousin the Pioneer adopt. http://www.ferno.co.uk/products/ambulance/trolleys-locks-accessories

I agree with paramagics assessment and management plan, it is the kind of call that the crews out in the sticks would be asking for helimed or Military/HMCG air for to fly them to the PCI centre ( and if it;s helimed they can fly to the roof of the PCI centre - i don't think the pad will take a sea king / merlin / s92 though based on weight)

my point there analgesia =/= ( does not equal) opiates or 'narcs' there's plenty of non opiate options , this has been part of the way in which I've been encouraging this discussion to go and by and large people have taken this message on board, with the discussion or non injectable routes and with the pretty extensive discussion we've had about Entonox, including positive reports from those who have only 'seen ' it being used. in before Godwin , calm down Dwayne please , grammar fascism has it's place and that's in learned work and in important business work rather than in the reasonably informal setting of a forum. Personally, based on a decade + of clinical practice as either A Student HCP or as an RN I feel this is an issue which is sometimes over emphasised, especially with appropriate dosing and titration, and in terms of the options we've discussed especially regarding none opiate or 'weak' opiate options is very rarely an issue. Injudicious use of strong opiates can cause altered levels of consciousness, hence the reasons many posters in this thread feel that restricting Opiate administration to Paramedics and other Health Professionals with a field role. Entonox can cause altered levels of consciousness, but as both myself and other posters have remarked the nature of demand valve administration and the rapid offset tend to make this self limiting. There is also the issues around education and preparation for practice to address such concerns of providers of all levels which ties back in with the issues surrounding preparation for practice in general and ensuring that people have an appreciation of the reason for cautions and contra indications for various options and emphasising the role of the pharmacological options as part of a whole picture of patient care, where other parts of effective patient and pain management are just as important i.e. splintage , psychological care ...

analgesia =/= Opiates or that horrible term 'narcs' Opiate analgesia has a place in the Health Professional Providers' scope, i don't think anyone has denied this in this thread, although the mindsets of some groups of providers are are differing, but given the training, (lack of ) education , legal and medical direction shambles that is US pre-hospital care that's unsuprising. elsewhere in the world first aiders and first responders as well as technician level Ambulance staff have access to a variety of analgesia medications, the principle considerations here are simple oral analgesia such as Paracetamol(Acetaminophen), NSAIDs or oral 'weak' Opioids such as codeine or tramadol. In addition there is the option of inhaled analgesia such as nitrous oxide / oxygen mixes (entonox) or methoxyflurane please see my previous posts in the thread for a variety of resources on the topic of inhaled analgesia.

I'm glad to see that the thread is back on the right track,and not diverging off into a discussion on drug seeking. I'm glad to see the support for Entonox from those who have used it or seen it used in other practice settings... I'm not sure exactly how long we've been using it in ambulance practice in the UK but i'm sure it's 30+ years and the original work / trials / research was near enough 50 years ago in obstetrics. I'm interested by those who are concerned about analgesia 'masking' symptoms - unless you are overdosing someone signs are still easily elicited and analgesia may actually help to localise the site of pain - i .e it only hurts when you get to the bit which is tender / guarded rather than the anticipation of pain and voluntary guarding getting in the way of the clinical examination. Transdermal using current techniques and devices is a bit of a no-go for EMS or acute pain in general as the current transdermal patches are designed for steady release over long periods of time - the largest fentanyl patch we get in the UK is 100 mcg/hr, getting an adequate plasma level for acute pain management with these devices is probably not viable. it's also a Schedule 2 Cntrolled Drug in the Uk ... the fentanyl lollipops are an option but it is still a schedule 2 Controlled drug in the UK and I suspect it will be in the equivalent classifications around the world which makes it's use without specific legal mechanisms being enacted problematic, there is also the issue of reversibility or otherwise and having to carry narcan - It is also outside the licence terms at the present time so would require the clinical testing etc that expanding the licenced indication needs. http://www.netdoctor.co.uk/medicines/100004492.html

We seem to be going round and round in circles and focussing solely on IV opiates with the usual diversion into drug seeking behaviour being the reason why EMS providers should not be providing analgesia ... any IV or IM analgesia whether opiate or not is outwith the scope of basic level providers, this doesn't mean that they shouldn't have suitable clinical guidelines and resources to give other analgesia. I would ask that people read the resources I've posted about Entonox and we can have a sensible discussion about that ... If you want a discussion about drug seekers start another another thread

sounds like a perfectly reasonable course of action as well as establishing what regular meds the patient is scripted, if they are scripted any PRN meds and finding out when they last took them. and further to my last post discussing Entonox - a link to the BOC safety data sheet and summary of product characteristics http://www.bocsds.com/uk/sds/medical/entonox.pdf

ah diddums get used to it, the fact is that ambulance operations in the Uk are vastly under regulated leading to all sorts of muppets and fantasists running Ambulances with all kinds of made up role titles and claiming to be able to do all kinds of things which would immediately cause a problem wit the fact you cannot 'turn off' your registration, and although not yet tested with the NMC, HPC 'case law' has seen a Paramedic struck off for not having 'essential' equipment see above really? care to dig yourself further in the mire with these kinds of accusations, which may be determined to be libellous. as for background checks and verification , All SJA operational members, Youth leaders and CTD employees in the Priory of England and the Islands (POEI), who may be required to teach children, young people (16-18) or vulnerable adults are enhanced CRB checked and this is renewed on change of appointment or every three years, SJA(POEI) members are also required to make a declaration every year when verifying their membership details and service with regard to any convictions, cautions etc. Every SJA (POEI county has a Safeguarding Officer and SJA(POEI) has a long standing relationship with the NSPCC over it;s safeguarding procedures and training. Every SJA county in the Priory of England and the Islands is inspected and audited annually by NHQ both in terms of clinical and corporate governance , also with regard to specific standards and targets relating to fleet, clinical audit, records handling etc. during this audit the asset register and servicing records for all durable equipment is checked to ensure that it is serviced in accordance with the manufacturers requirements . I can't answer for BRC in this respect but I have no reason to suspect that their practices will be much different. perhaps that's why there is an alledged 'easy ride' for SJA and BRC becasue oif their all ready in place systems of audit and improvement notices ... you are not being 'penalised' uou are being expected to adhere to the same standards as everyone else in the field , the NHS has come to dislike small provider units after occurences such as Shipman so it's unsuprising that that the CQC is following suit, given the actual and anecdotal evidence of the standards or lack thereof in some providers it's perhaps unsuprising that there will be consolidation in the market and unfortunately for some providers it will mean merge or give up and we may see the price of cover rise to sustainable levels to meet the requirements now placed on providers.

what benefits would ambulance transport bring the care of the patient ? if you are looking at isolated trauma which is not overly painful and any bleeding is controlled and you have no concerns about bleeding disorders based on proper history taking what dos the patient get from that ambulance ride other than 1. a wait for transport becasue it's a cat C call 2. a bill if you are somewhere that bills ' medical' calls withthe exception of 2 scenarios - transport should be the default ( the exceptions are Hypoglcaemic episodess or seizures in known diabetics/ epileptics that have full recovery and no unusual features and there's a responsible person on scen to keep an eye on the patient)

while i voted for yes a weekend class for basics to administer pain relief it would not be for paramedic levle drugs , just what the rest of the world has at First Responder / EMT / Tech level i.e. entonox ( premixed nitrous oxide + oxygen via demand valve ) and paracetamol - the aussies have methoxyflurane but that's not a licensed drug outside aus due to the side effect profile when it was used in anaesthesia while wikipedia may not be a sufficiently learned source for some it sufficies for this kind of informal discussion http://en.wikipedia.org/wiki/Methoxyflurane http://en.wikipedia.org/wiki/Entonox http://www.entonox.co.uk/en/discover_enotonox/story_and_heritage/index.shtml http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/a-z/drug/entonox/ Entonox has been used in clinical practice in the Uk for nearly 50 years and there's decades of experience with first aiders / first responders and emt / tech level providers using it. Entonox does work but the patient has to be be encouraged to take it appropriately - taking if at or after a painful move etc is not the optimum - they should be loaded up and then you move etc. I've also seen plenty of anterior shoulder and some knee/ankle dislocations go back with entonox alone ... and i've reduced a circulation critical ( and therefore limb threatening)lower leg / ankle fracture under entonox before with good results

lifts and ramps on Uk vehicles are because of the manual handling laws in the UK and the fact that it has been felt by the HSE that 'easy load' or 'roll in' stretchers are not sufficient to meet the requirements in road ambulances unless you have a powered loading tray ( as per the rogertastic Staffs / Wmids Ducatos)

look at the gas flows produced by a venturi mask - that is high flow of a fixed concentration A bvm or NRB is a medium flow of a high but variable concentration - seal, minute volume etc i think the issue is much less of one now the majority of defibrilation is 'handsfree' and the Oxygen away is a practice from the old days along with the 25 Lb thing

the UK FBU is against the fire service expanding into EMS provision beyond 'incidental' provision as part of rescue and providing good care for personnel injured on scene , although there are some fire services that do provide first responder assistance to the ambulance service - though it's often none FBU retained crews doing it. That said a lot of services have full 'first responder' kit plus entonox and extrication / casualty handling kit on appliances as it;s considered part of 'rescue' to be able to provide some casualty care while awiating the EMS response ...

which in the UK even some First responders are doing and middle tier, volunteer and tech trucks have as mandatory equipment in Entonox but we'd already been down entonox in this thread ...

number of factors here top two as to why there is a resistance to doing more than the bare minimum on scene 1. risk of being bawled out by receiving hospitals " why did you spend 20/30/45 minutes on scene when the transport time is only 5/10/15 minutes ?" especially if they are providing your medical direction or any aspect of OLMC or QA ... 2.(lay) management pressure to reduce total call time and therefore increase the number of Jobs per shift - so scoop and run esp if transport times are short has become the norm to stave off pressure over scene times - especially when people start bandying 'platinum 10 minutes' and 'golden (s)hour ' about ... add in laziness of not taking adequate equipment in and trying to sometimes inappropriately ambulate the patient to the vehicle ....

those suggesting littman classic ( master or IIse) or select are about on the money, personally i don't find much difference between a select with soft eartips and a classic ... the select i've had for 15 years is probably due retiring due to the tubes getting a bit ragged. cardiology scopes are overkill for most things other than being a cardiology specialist ...

the problem is that your probable cause may well be fulfilled for the purposes of needing the images for the crash investigation

the OPs father needs to take the advice of his cardiologist whether he is fit to travel, he also needs to get the cardiologist who treated him while he was away to speak to his Spinal Injuries Doc and to find a Cardiologist acceptable to all three parties... much beyond this is into the realms of specific clinical advice ... OP , what level and ASIA score is your dad ?

the biggest 'problem' with the concept of the '|Golden Hour' is when it moves from a concept aimed at reducing 'second peak' deaths and becomes a target or even a performance metric, It's another scenario where education vs training comes into play. another factor to consider is how many of the 'prevented' second peak deaths become third peak deaths?

do they not have carry chairs or evacuation chairs on ambulances in the US ? they are one of the most widely used pieces of equipment in the UK primarily due to the fact a lot more homes in the UK are small and /or multi storey because of the high land prices in this crowded island ...

there are a number of factors which drive the needs for and utility of 'ALS intercepts' one factor in USA type models is the fact that EMT-Bs really are BASIC and in international terms the USDOT core curriculum for EMT-Bs is at a level somewhat lower than volunteer and/or 'middle tier' crews elsewhere in the world , the other main factor is time to definitive care - in a urban or suburban setting unless the ALS unit that will intercept is very close by it will be quicker to pre-alert the recieving ED and make your way in at whatever level of driving authorisation the crew has. - if you are 10 minutes from the ED and the response time for your ALS support is going to be much more than 5 minutes is it worth waiting at the side of the road ?

Several hundred hours ab-initio for Ambulance assistants who work with Paramedics (excluding driving) Several hundred hours across a period of time with hundreds of documented patient interactions as first aider / first responder for volunteer staff (excluding driving again) and a requirement to undertake a preceptorship period with HCP crew before being let loose

or we could just become the Penn and Teller of EMTCity !

if you are starting from a clean sheet of paper and you have the support of legislators , the obvious answer is Degree level paramedics , prepared in the same manner as Nurses and other Health Professionals, but with an obvious and necessary pre-hospital and unscheduled care bias to their placements experience ( for thousands of hours - the EU directive that covers Nurse pre-reg education in Europe specifies 2300 hours of clinical placements). if legislators are unwilling to create a new type of health professional and empower them to independently possess and administer the relevant medications ( which will include controlled / scheduled drugs i.e. opiate analgesia and benzodiazepines for seizure control and sedation) then a post registration programme for RNs may be the most straightforward way to achieve the outcome , but there are still issues such as possession and independent administration of Prescription meds to square away. there is an increasing body of experience with Higher education preparation for practice in the Anglo / Canuck / Antipodean model of degree educated paramedics ( with the UK having full health professional status for it;s paramedics) as well as the Dutch/Scandinavian model of post graduate RN paramedics. the issue of the 'other half' of the crew needs to be addressed as while a dual Paramedic crew may be ideal for certain situations it's also expensive overkill for the vast majority of 999/112/911 work where the only paramedic 'skill' used is patient assessment, while it causes much gnashing of teeth and wailing in systems where there have traditionally been 2 'trained providers' each with their own scope of practice on the vehicle , the move to a Professional + (still) highly trained but definitely subordinate Assistant / associate practitioner is appealing given the cost advantage of the AP over another practitioner even if the other practitioner has few in any more 'interventions' because autonomy and independent scopes of practice are what influence pay rates - especially if you job evaluate compared to other healthcare roles. - an irony of this is that the Assitant practitioners in the UK still recieve more in quantity and depth training than EMT-Bs ... Paramedics do not have 'complete autonomy' in any jurisdiction on the planet, there are few countires where paramedics are treated as proper health professionals and even then they do not have the level of access to treatment options that other None physician health professionals have. I am unaware of anywhere where paramedics can actually 'prescribe' medication rather than administer it , where as increasing numbers of places have Nurses , pharmacists and other none physician heralth professionals who can prescribed across the full formularly I am unaware of anywhere in the world ( apart from the places who require RN as entry to Paramedic programmes e.g. the Nerthrerlands and some Scandinavian countries) where paramedics are required to have more education pre-registration than RNs it ranges from similar to dramatically less - remembering that the USA currently has some of the shortest RN programmes in the world - the associates programmes which do not count elsewhere in the world - the EU specifies 4600 contact hours in Nurse pre-registration education 2300 in practice and 2300 in university - in the Uk this is mainly delivered as 3 *40-45 week academic years. i really don't know what to say here other than the pat you on the head, and then run round the corner and start laughing at your naivety over what is in Nurse education . totally incorrect pats on head, makes comment about naivety and then runs around the corner before startign to laugh that's male bovine excrement

I let this thread run before replying from what I can see there are a few key issues 1. the legal and professional position of the paramedic 1a. legal first - this depends on your local laws about the use of medical devices and the possession, , 'supply' and 'administration' of medication If your local laws require medical devices to be sold 'by or on the order of a physician' then you are somewhat snookered if the law makers won't change - you must have a Medical director to be nominally responsible for the acquistion of supplies and equipment, if this is not the case then there is no requirement with regard to medical devices. If your local laws require that a Medical Director sets the protocols/ procedures or guidelines for administering medications and/or the law requires a physician sign off on the drugs orders - then you are stuck with requiring a medical director, However if as in the UK the majority of your Drugs are given by paramedics under specific legislation ( e.g. the 'statutory exemptions' from requiring a prescription enjoyed by Paramedics and various other groups of Health Professionals in the UK and for 'any person' in relation to administering certain meds like IM adrenaline or glucagon) then perhaps you do Need a medical director - unless, again like the UK there are drugs you wish to give that aren't in the exemption but you can provide another means for paramedics to have access to and administer or even supply the drug - in the UK case it;s 'Patient Group Directives' and similar legal mechanisms ( as certain drugs or routes don't actually require a full blown PGD). 1b. The professional position of the Paramedic - is the paramedic a registered health professional in his/her own right , does the legislation require them to have a medical director or can they function as a paramedic , order and use their own medications and supplies etc etc 2. Safe preparation for practice it is interesting that the USA despite have a supposedly standardised system of Qualifications for ambulance personnel has so many local variations and programmes which are both short on time ( in the class room and out on the road as a student ) and academic accreditation. Aus and Canada have made huge strides towards education even if professional regulation has lagged behind , the UK has made the jump with professional regulation and education is now on the catch up - despite the fact that 'traditional' IHCD route paramedic training has already been assessed as equivalent to NQF level 4 ( a bachelors degree is NQF 6 , school leaving qualifications are NQF 2 or 3 university entry is at NQF level 3) ... the short duration of EMT-B and i-85 courses is one of the reasons the USA is stuck with medical control at present and until the water fairies stop seeing EMS as a way to prop up their budget for big red trucks, and 'helmet and pole polish' and start working in a much more integrated way on the fire and rescue side then not much progress will be made 3. integration and critical mass of personnel within the service it's interesting to note a common factor in the UK, Canada, Aus and NZ is that the Ambulance service is by and large composed of larger regional services rather than services based around a locality or muncipality ... there's a dozen or NHS ambulance services that cover the whole of the UK, NI, Scotland and Wales have one each, the rest are regional services in England ... the AUs model is based on state wide services in the main and Canada has at least a degree of co-ordinatation and management oversight on a province basis - a larger service makes it easier for the service to take control of professional standards and will reduce the number of 'Medical Directors' potentially to one per service - although within that regional service there may be assistant medical directors as well as on call clinical advisors and field physicians etc but there's only one on the Board ...