croaker260

http://www.adaweb.net/Portals/0/Paramedics...uments/ob04.pdf

Depends on what it is. Cookies? no problem. teddy bears for ambulance? No Problem. Beer? Money? Dirty Pictures and a phone number? Say thank you very much, put a smile on, and then as soon as the door is shut, turn it in up the chain of command with a letter documenting that you did so. Problem solved.

Used to work in the nashville area. There are several privates in Metro davidson countyy, though 911 is handled by NFD. Williamson County EMS is actually run out of the hospital. As is Rutherford EMS I believe. The remaining ones surrounding the area (Dixon, Cheatham, Robertson, Sumner ) are small 3rd service model EMS, as is Montgomery County (clarksville) to the north. The surrounding counties are your best options, my memories of the privates in the Nashville area are not pleasant by any means. But thats been 10 yeara ago or more.

Shakes head and sighs.........

Well, you will have to do the math. Understand that we work a 48 hour work week, not 56, with everything over 40 is OT. This leaves a LOT of time off for fun, aOT, or school, or sleep, or your significant other. For a medic: It is basically about 40K a year. The benifits package (health insurance, etc) is about 19K a year worth of county contributions, and its the same retirement (State Pension) as the FD and PD. This is before any adjustment for experiance (up to 20%) and before the first additional shift (over your normal schedual) is worked.

New June Hiring test: Application and Testing Schedule: June 25-27, 2008 This is for planned expansion of several stations. DEADLINE: Thursday, June 19, 2008 no later than 1700 hrs ACP Education Office P.O. Box 140209 5870 Glenwood Boise, Idaho 83714 Wednesday, June 25, 2008 - Written exam, 0800 hrs - Physical agility, 11:00 hrs - EAGLE FIRE (Training Rm) Thursday, June 26, 2009 - Practical stations, TBA after Written Test Friday, June 27, 2008 - - Interviews - Glenwood - Conference Rm Just wanted to get the word out. Official Job Announcement is here: http://www.adaweb.net/departments/paramedics/apply.asp Home page is here: www.adaparamedics.org Standing written orders are here: http://www.adaweb.net/departments/paramedics/swo2006.asp Questions welcome, but my response may be delayed because I will be out of town for a week or so with limited internet access.

Considering the wide range of Mag uses (eclampsia, torsades, 2nd or 3rd line anti-dysrythmic, severe asthma) and its cost (CHEAP) IMHO there is no reason NOT to carry mag, urban or rural.

The research, as well as personal converstations I have had with a very well respected local OB (who trained at Harborview and has a lot of Pro-EMS respect) clearly shows a preferece toward MAG FIRST followed by benzos if refractory. If it is truely eclampsia it should respond promptly to mag. Heres the catch. She tells a very compelling story of a lady who had delivered less than 12 hours previous, with acutely altered LOC, and looking for all the world like progressing eclampsia. Ironically, oen thing felt off, and she ordered a stat CT, and she actually has a bleed from her HTN (she was Dx pre-eclamptic already). The point is dont discount the use of Benzos , and keep your options and mind open..but if it is truely Eclampsia, it will respond better to mag than benzos. If it doesnt, be quick with the benzos. Our protocol for it: http://www.adaweb.net/departments/paramedics/swo/ob04.pdf ALS SPECIFIC CARE: See General OB Care Protocol OB-1 - Assess and identify causes of complaints, treat as needed. SEIZURES AND SEVERELY ALTERED LOC - Magnesium Sulfate IV: 1-2 g every 5 minutes, repeat as needed up to 5 g. Take 2 g (4cc), Dilute to 20 cc to make 10% solution. Do not give faster than 1 g/minute. Maintenance Infusion: 5 g/250 cc or 2 g/100cc buritrol, run at 100 cc/hr (2 g/hr) - For refractory seizure activity see seizure protocol (M-6) - Consider Magnesium Sulfate (as noted above) in cases where a patient has not seized but is obviously and severely pre-eclamptic (medical control order).

Know of a situation, Pre-HIPAA, somewhere else other than here, where a medic went on a trauma code. The patient was a know diabetic coincidentally. So the medic decided to just give him 25 GM D50 in addition to the epi, etc. The real problem? Since he didnt have a line, he gave it down the tube. Again this was DECADES ago, and I dont remember what city, state, or country this was in.

Many Many Many years ago this was how the old Louisville EMS was run as part of the Louisville PD.

I dont know about most other places, but here we pronounce peopel all the time. The discussion on how to handle thses situations above apply to our train f thought. Other clinical factors such as PMHX, ETCO2 after 20 minutes, and H's/T's all play int o the descision. But the bottom line is we RARELY transport codes. In addition to the "calling the code" I personally believe that transporting them at all has a detrimental effect. For medical arrest, with ALS on scene: 1- Considering that we can do most everything that will be done in the ER, including pericardial centesis, and considering that the AHA recognizes that for most cases if a patient is not resuscitated by ALS on the scene, he wont be. So why take them to the rig to be transported if there is no benefit? Work them on the scene. 2- Efficacy of medications and therapies, as well as cerebral perfusion and coronary perfusion, is DIRECTLY related to the efficacy of CPR. Several studies have shown that quality of CPR both while moving the patient and during code 2 transport drops by over 50%. Therefore if PERFECT CPR only does 30% of cardiac output, we just dropped it to about 15-20% during the move and for the duration of transport. So: Work them on the scene. 3- The new 2005 AHA ACLS guidelines have extensive discussion on the problems with interrupting CPR even briefly. Even ETT and stacked shocks are re-evaluated in this light. Simply put SUCCESSFUL resuscitation is directly linked to good and SUSTAINED CPR. Since any interruption of CPR must be weighed as benifit vs con on the overall success of the resuscitation...and as discussed above there is minimal to no benefit to working them in the rig...and some benefit to working them on scene (provided the crew is ALS with all appropriate skills and such). Therefore: Work them on the scene.

Approx 300K live in county with about another 200K commuting in for work. We ran 21K last year, averaging between 3 and 12% growth for each year over the last decade. We now have 12 EMS units, 4 of which are 12 hour peak cars and the rest are 24 hour cars.

Dont forget the book "Shock Trauma" or "The Knife and Gun Club". As far as pioneers, I prefere to look up to the likes of R Adams Cowley, Peter Safar, and Dr. Copass for not compromising on a vision for better EMS medical care.

We use 10-33 for situations where we cant talk in the clear (as in responding to a security check when the bad guy is standing over us). We use "Request PD code 3" for everything else. We also have the emer button on the 700 mhz...

Stay away from Kaliforia, but try the pacific NW, great services all around. Look at mine www.adaparamedics.org And our SWO's http://www.adaweb.net/departments/paramedics/swo2006.asp

www.adaparamedics.org 1 hour from Eastern OR border. Other than that, what he said....

1- Just because its a lifepack 12, doent mean its a 12 leads...12 lead became integral with the LP 11, but I remember seeing an extra device before that for the LP 5 and 10. The LP 12 it is an extra feature, (read $$ option) 2- That said, we train out basics to do them here. Since we run an all ALS service it only is an assistance to the medics. But we have the ground work for future BLS only rigs.

Actually, Thom is GREAT people. He has written many many articles that, while not always technically focused, are always people focused, and are always ...uhmm..whats the word... oh yes... WISE. As a side note, Karen Powers was an EMT for most of her career at my service, and was a personal friend. Unfortunately she lost a battle to Cancer a bit ago. She too was GREAT people. Her experience for that article was directly related to her time first as a "reserve EMT" and then as an employee with Ada County Paramedics. While the program has changed a bit, the principles she discusses remain essential to functioning well in our system, where no one is "just an EMT".

(FYI- I use the term "medics" very generally....) There are some cases that knowing cervical dilation is beneficial, predominantly in frontier/rural settings where the medic is both trained and prepared to deliver the baby THERE, complications and all. Those settings, and those medics properly trained, much less those medics properly trained in those settings...are rare indeed.... Truthfully, 90% of the medics/EMTs I have met have only a rudimentary knowledge of OB issues, especially difficult deliveries. This "skill" (if it can even be called that) requires repeated practice to perfect, something that 99% of medics wont get at all, much less in volume. What we need is NOT a new technique/task that will expose the medic to increased liability (and yes there is increased liability, I have seen at least one case where an EMT came very close to losing his job and his department sued over this very issue) What we DO need is a crap load more OB rotations, and OB training, especially difficult deliveries....just like we need more difficult airway training, and difficult vascular access training, and hell, difficult everything training..... (or EDUCATION, if that word pleases you more Dust ) Address that BEFORE you talk about every Tom, Dick and Scary Hairy Larry sticking his scary , hairy, hands elbow deep in some patients hoo hoo to check for something he has only read about once and tried on a plastic topographic sheet twice..... Only once we are trained in OB in general to a REAL degree.....then we can discuss how to do it reliably, constantly, for every provider, for this not-so-risk-free task....then we can discuss if it is a useful data tool..which by the way with the advent of more accurate measurements of contractions through toc... ultrasound, and most important.....simple thorough physical and subjective assessment BTW , my opinion on the topic is that it doesn't add (IMHO ) much to the information base, beyond a good thorough assessment (something many have yet to master). Remember that 10 CM can be 5 hours away, even days away in some rare cases...., or five minutes away. While I understand your perception of a GAP in our information gathering skills, I think that this will not solve that gap, I think it will do something worse. Instead of providing us with information, it will provide us with MIS INFORMATION..can you see the new saying??? Treat the Patient , not the hoo hoo! Until we hit that point in education, Dust my friend, discussion of this task is much akin to discussing intubation and RSI for providers with out intense education of the anatomy of the airway and physiology of cellular respiration, another thing pre-hospital education is lacking at all levels. BTW TNIUGS... let me share my experience if I may.... Let me share my experiance.... My wife had a severe abrupted placenta missed by not one hospital but two , including the "High Risk OB hospital", missed by two separate ultrasounds.... that was not confirmed until the emergent c-section (indicated by Babies HR and failure to respond to terb.... not by the "normal ultrasound" or the toco). There was a near complete lack of external bleeding...anatomy can be a tricky thing.....and the ultrasound, like the ECG, only shows us a few select views and it is ultimately read by a human being with preconceptions, bias, and even simple exhaustion.

RE: Scrubs: Yes the are common in the medical profession..Nurses, Doctors..but also the Janitors, CNA's, Lab techs, etc. No, Scrubs are not professional. RE: Flightsuits/Jumpsuits- To look good you must 1- Not be grossly Obese, otherwise you look like a piece of chocolate in a bright reflective wrapper. Two- It must be properly sized. The cost of a custom sized uniform (so it doesnt look like you dropped a load in your shorts) is many times the cost of a regular uniform. There is something to a "command" style uniform..When you have to take command, it helps the masses to listen when you have a uniform that commands resect. Remember that cops and FF don't model their uniforms after each other, they model them after the military, and so should we. Crisp, Functional, Sharp. That is professional. Badge or not. If you look like the business man, the doctor, the nurse, all skilled professions, but not IN CHARGE in a crisis in the streets. just my 0.02 ...as someone who is not trying to be a cop or FF...but is former military, and appreciates a good sharp military like uniform. And no, I am not talking about saggy BDU pants and bloused boots.Im talking about a crisp UNIFORM. BTW, we wear white two pocket button up shirts, badges, blue pants. The only peopel who think we are cops are kids. No one thinks we are FF's (when they see us that is), not because of our colors, but because we don't have wrinkled worn uniforms under our turnouts going on medical calls.

The adhesive on most non medical tapes (and some medical tapes) is indeed unsanitary and a great medium for bacteria. Duct tape is for some reason the worst for this, dont know how electrical tape rates. Not saying that we shouldn't use tape, but that we shouldn't use tape for long periods of time with out swapping it out or expose/use it on multiple patients. Essentially, I think your fellow crews have a point. Case in point: those nasty strands of tape last shift hung from the grab rail "just in case" for their next IV.... Now do think you have a neat Idea, but its you execution that is poor. Perhaps the rubber bands would be a good idea, as mentioned. Plastic clips would be better. Dont know what type of monitor your using, but for us, these would be impractical as we (99% of time) put our limb leads on the ...ahem...distal limbs not the chest. This is our preferred site for 12 leads and is quicker for regular limb lead use. Therefore with our system (the LP 12) the leads are just long enough to be useful in most patents, and bunchig them together would shorten their reach a few inches. Now if you place 99% of you limb leads on the chest....then I can see your point. As a final note, if you have 4 leads, then it isnt technically a "3 lead ECG". Its simply "limb leads" because they give you I, II, III, and AVL, AVR, AVF (the augmented leads). But then maybe I'm being anal.

Remember AZCEP, what the full EMT-I curricula entails. Intubation of dead floppy patients, breathing treatments, basic cardiac rhythm recognition, your basic first line ACLS drugs, dextrose, and a hand ful of other stuff. I think they may even get nasal tubes, I dont remember though. Basically what many rural ALS services (not all, but many) are doing anyway. The new curricula also includes basic pain management. My argument is a well trained EMT-I with medical control contact can do better than a poorly trained medic working on his own. You want to put well trained/educated medics in rural settings, fine. I agree that they are needed. But show me how this can be SUPPORTED clinically, so that the system quality is self sustaining, so that in 5-10 years, the system is as solid, and the care as good, and the provider is as good (no skill degradation) as when the program started. Sure people say..."well, we will train harder". It just doesn't happen due to limited resources, etc. (who has the 30K $$ for the sim man with difficult airway modules?) Sure people say "we will get them in the OR" well, even a recent article in "Prehospital Emergency Care" discussed that this is extremely (and increasingly) difficult. so again, this doesn't happen like it should. Just because there may be the resources or will to keep the medics certified, does not mean there are the resources or will to keep them competent When that happens there are a few outstanding medics that the extra mile and a lot who pass time. This is as true in urban settings as it is in rural settings. The big difference is in an urban setting, most ALS patients (excluding those with airway issues, and sometimes even then) will survive incompetence long enough to get tot the hospital. All this goes back to my point is that I believe that there must not only be a "certificate of need"(CON), but a certificate of ability to support (COAS??). Especially if this had to be renewed. If this was the case , then areas, including the public, would put pressure on agencies to raise the bar. They would ask hospitals why they were not letting medics in their OR's. They would be as concerned about intubation success rates as they were about response times. Otherwise, stay at and function at the ILS level. You will kill less patients that way as a system, and do about the same amount of good. I guess I believe that good ILS is better care and a higher level of care than poor ALS. Would rather see someone (ILS) ventilate some patient on in , than have someone (ALS) RSI a patient and have a gut tube because they were too stupid to know the difference..which appears to be a major issue in many ALS systems today. Wnat some more examples, simply look at that "other web site" where there is a discussion on PSVT, and some medic who SCV a DKA patient. I believe your response was "God help that community"? If a system cant correct obvious problems like that, then perhaps they dont need to be ALS, and would be better off ILS? Keep in mind that if the New scope of practice had kept the "Paramedic" and the "Advanced Practice Paramedic" we wouldn't even be having this disucssions...as most rural communities could have the "paramedic level" which is pretty much what they can support, and progressive places can function at the advanced practice paramedic..but alas, the advance practice paramedic..and the degree requirement..was dropped at the request of...guess who? In summery, I am in favor or ANY community, urban or rural, that can prove the ability, and prove that they do, actually support their ALS program, getting medics (only in numbers they can support)....but I am not in favor of the idea of letting areas have medics (regardless of size or location) have medics because "well , they are doing the best they can..they are small...what do you expect?". I expect competence from a system. Which brings me to re-emphasize my closing sentence.... Dont know if that ramble made sense, but I hope you can see where I am coming from.

simple, in the event that there is not ALS unit timely available, the unit you call is the one who can get there the quickest, regardless of level or affiliation. Hopefully your availability of system BLS/ILS transport units would be such to take up the slack. Remember we are talking a LOT more BLS/ILS than ALS transport capability. I am thinking 3:1 as a conceptual starting point, but don't know anyone who has actually studied it. In an urban system, even most ALS patients can survive BLS, not optimal...but there you have it, and in trauma may be better served by it. QA and systems review should look at these events and make sure they are truly a fluke, and not a system weakness. In a tiered and targeted system, the need of RRVs would be minimal in suburban and urban settings, unless they were command vehicles. Since no one has , IMHO , figured out a way of consistently delivering a QUALITY system of ALS to rural communities, short of Air medical response to BLS served areas (which is not very cost effective or safe in most communities), the possible excpetion being RRV's type response systems. I really do think that RRVs (or what ever you want to call them) shows real promise for rural areas, providing they belong to an agency that has the clinical and political motivation to support them clinically, but not much more than sending an ambulance out with the same crew. The one advantage is an RRV may be more cost effective on a case by case basis, depending on who is paying. Bottom line is there is NO EASY WAY TO PROVIDE CONSISTENTLY SYSTEM WIDE ALS CARE TO RURAL COMMUNITIES. I say again, many rural residents would receive better care by well trained ILS service than a poorly trained under utilized ALS service. Any system design for rural communities needs to take the challenges of providing ALS care to a sparse population with lower call volumes in effect. Can it be don? probably...but in most cases is too much work for the stake holders.

Well, this use to be the norm here, but as we have grown and the pool of local ER docs have grown, this is not always the case. Still, relationships with our docs is a thousand times better here than elsewhere. We do have a full time education department, and two very involved doctors. Our FTO program has been mentioned in Best Practices in EMS journal. I think most rural ALS agencies run a tiered system by default if not design...but not a targeted tiered system. In most rural areas , they likely cant afford, nor (asimportant) have a call volume to support a targeted and tiered system. In rural systems, I think its important that, for a rural system to have paramedics, they must be able to support medics. Im not talkign about a certificate of need alone...wich is mainly to prevent competition in a fragile geographic marketplace, but the call volume and logistical and clinical support to support medics. Those that cant should adopt the ILS rout instead. In reality, many ALS rural agencies, not all mind you, but many...are operating at about the latest EMT I level anyway. I say this with my vision of a paramedic being a clinically sophisticated medic with advanced rescusitation skills and scope (i.e. RSI). Something most agencies of all types, rural, suburban, or urban, wont throw the rescources at to obtain or maintain...not cant...but wont.

This is the first time in recent weeks you and I have been in total agreement.