T-minus 9 days for Alberta "take over"

[kevkei]

Hey, if EMT's are giving nitro then we should be allowed to interpret 12 leads and base our tx on that. I think it's stupid to allow one to administer a drug such as nitro without a 12 done first. It's in the ACoP scope for an EMT here, however several medical directors don't allow EMT's in their services to admin it and for good reason. That was the reason for the "shot" as you so call it.

Here are some points to consider relating to this...

CLINICAL COMPETENCIES/EXPECTATIONS (From the Edmonton Region Medical Director)

EMT & Paramedics

- must know how to recognize STEMI

- how to transmit ECG, how to PATCH to

physician, VHR process

- Administer ASA, no nitro unless RV infarct

ruled out

- Establish IV access if Nitro to be given

- Need to involve ALS or rapid transfer to

appropriate centre (BLS car)

- Serial ECG (q15-20 minutes) looking for

evolution of changes

- Continuous monitoring and serial assessments

even in triage and ambulance off load area

Right Ventricular Infarct Identify through 15 lead

Withhold Nitrates, Manage Appropriately

EMT and Paramedics

- will know how to recognize RV infarct using

15 lead ECG

- all inferior AMI/STEMI will have 15 lead

acquired

- No nitroglycerin (no SL, IV drips) in identified

AOCP Cross

EMS Mentorship Program April 2008

RV infarcts/STEMI

- Communicate RV infarct to on line med

control or VHR physician

- appropriate STEMI care

[tniuqs]

Kevkie:

Interesting post.

Is AHS going to foot the bill for 12 leads on all trucks in AB now .... bwhaa haa haa ! Or just restrict practice ? Good thing Sookrum is heading up Edmonton EMS he is so pro-active, no RSI, no ETI, (and Wangs studies are based in 6 centers that are Yall based F/F medics ) so no nothing !

Honestly another step back ass wards ..... "soo again: the Patient was rushed to the Hospital" (to wait in the hall way) jeeze the Snos was way more together with the trust issue with his staff.

So just when are all the CPAP machines coming into service (although CPAP is so not the way to go for CHF, Asthma or any end stage COPD ...Bi level support is the way to go btw, very clinician dependent success ratio, just how can one quantify that little issue > and most reciently discussed over beers and wings at the ACART critical care education day last week )

So but lets take furosomide off the trucks in the deadmonton too, because Alberta Trained Paramedics have no idea the difference between CHF and a Pnemonia ... honestly this is just a SLAP in the face, it is $1.20 a vial.

Ok so what if the typical angina patient that is already prescribed Nitro ? AND had one shot before his wife activates EMS ... EMT's can't assist because it cause its against the rules even though asa and nitro EMS studies are quite conclusive as to improved outcomes .... bhah but who reads that stuff anyway.

Can we even justify how many RVI given Nitro actually attributed to increased mortality/ morbidity either in EMS ? So barking up the wrong tree without EBM proving so and here I though the new improved "trendy" medical director had his poop in a group ?

What are the real stats in evidence based medicine research in regards to incidence of RVI vs inferior, septal, anterior or lateral wall infarcts (note the sequence svp) btw I Suck At Leads too ! Top that off with the fact that ECG changes ST can be a late sign cause so ... should we all look should to the monitor first ????? hmmm interesting concept after Lieperts public release isnt it ? and not to mention common sense.

Oh and sign me up for that free 12 lead course province wide ... I am a bit rusty and it will boost my CIMS credits too I missed that part of the budget I guess.

I'm so "on board" with TNT Diagnostics ... simply 3 drops of blood and look at the bars, its bloody EMR proof and the first bedside troponin done early increases % of properly dx by 35 % second in hospital Trops up to 78 % accuracy and then definitive care sought we are so behind the way times .. AND if you factor in the cost in education and 12 Leads on every truck and as if telemetry is available in all areas of the province too.

cheers way off thread .. in a way more or less.

Edited April 12, 2009 by tniuqs

[Siffiliss]

Here are some points to consider relating to this...

CLINICAL COMPETENCIES/EXPECTATIONS (From the Edmonton Region Medical Director)

EMT & Paramedics

- must know how to recognize STEMI

- how to transmit ECG, how to PATCH to

physician, VHR process

- Administer ASA, no nitro unless RV infarct

ruled out

- Establish IV access if Nitro to be given

- Need to involve ALS or rapid transfer to

appropriate centre (BLS car)

- Serial ECG (q15-20 minutes) looking for

evolution of changes

- Continuous monitoring and serial assessments

even in triage and ambulance off load area

Right Ventricular Infarct Identify through 15 lead

Withhold Nitrates, Manage Appropriately

EMT and Paramedics

- will know how to recognize RV infarct using

15 lead ECG

- all inferior AMI/STEMI will have 15 lead

acquired

- No nitroglycerin (no SL, IV drips) in identified

AOCP Cross

EMS Mentorship Program April 2008

RV infarcts/STEMI

- Communicate RV infarct to on line med

control or VHR physician

- appropriate STEMI care

Absolutely.

EMT's "technically" cannot squirt the drug without the nod of the paramedic. Edmonton has been very forward with its training of EMT's on how to recognize such events. And once one has been involved in a few ALS-managed chest pains or a VHR or two, it only gets easier for EMT's to recognize and help manage.

[a_shane2_go]

Before provincialization, ambulances were at times underutilized. For example… a Medicine Hat unit brings a wait and return angioplasty patient into Calgary…. They are supposed to be there for 6 hours (and we all know, that usually turns into 10 hours)… so, they drop off their patient, and go shopping to the Med bookstore at Foothills, Chapters, 911 Supply, and anywhere else they feel like going, and get paid to waste time the rest of the day. Under the new structure, now that unit can be utilized to do other things in the city, like transfer a patient from Foothills to PLC, which would free up a city unit to respond to emergency calls.

Sounds like a medevac? PFCC (the Provincial Flight Coordination Center) Does stay in contact with hospitals, and if the crews are not busy up here in the north and not being bagged, PFCC will call around to the hospitals for returns. I've gone 300km out of my way many a time for returns for all types of flights when we are going back empty.

And they will also cut our "vacation wait" short if an emerg call comes in when all the planes in the north are busy. Or when we can make it there just as fast as another crew from another area.

So this was utilized even before AHS exsisted. Hurray for Alberta Health and Wellness

Well its taken all of 16 days for the AHS promise that i was told that there will be no reduction in services to go up in dust.

Region A's 2nd up (transfer) crew (ALS) was sent out. And then region A's Day crew (also ALSO) was sent on a non STAT ground transfer that would usually be sent by plane (and injuries warranted it to reduce the long haul to the city)

Which left 0 ambulances left to respond in region A. Before region B's BLS crew could get to region A was 45 mins. But region A's day crew was told to leave before B's even left. So region A which has always had a crew (and 90 percent of the time ALS availible) was left with no coverage in town and and over an hour and a half to the east side of region A.

This never happend pre AHS and shows the "importance" of ground transfers.... Hell will be paid if any of my family or friends is hurt and waits 45 mins for an ambulance because someone thinks a non STAT ground transfer is more important then responding to emerg calls.

Edited April 18, 2009 by a_shane2_go

[tniuqs]

Ok .... so I am one of the worst when I get rambling.

Shane: Does it boil down to this ?

Your saying that new improved utilization (AHS model) of ground units in your area but roving deployment means that in the primary service area is going without coverage ? or just changed in type of coverage ?

But must agree Wait Times should be shortened .. I have seen up to 5 Aircraft sitting on the ramp in GP waiting for a "possible admission" @ the QE 2 ... what a bloody waste of resources.

Quote: emtannie

Under the new structure, now that unit can be utilized to do other things in the city, like transfer a patient from Foothills to PLC, which would free up a city unit to respond to emergency calls.

Something I missed from this OP.

There are citys that have bylaws concerning this item, and transfers limited to approved providers that is did those bylaws get suddenly vanish ?

Although on paper this "back-up" sounds like a good idea to assist it can get very complex to track with current methods and I foresee a logistical nightmare now with even fewer dispatch centers.

If transponder GPS tracking province wide does become a reality, maybe then a coordination of services will improve with this "improved utilization concept" I seriously have my doubts these days and I will not hold my breath waiting for any capital purchases.

The standard "Wait and Return" type call or "Prebook Transfer" will never go away but what should be reevalluated is bringing in extra staff locally to provide "E" services to the Primary coverage area .. and good luck with that because = increased COST.

I bet the next thing reported will be the mid route intercept concept (it makes sence managing trucks) You know arrange a meet somewhere in between 2 communities ..... like in the snow ..... in the middle of no where with patient in the back ..... frezzing ... a pass the patient deal ... this would be a disaster just waiting to happen and very negatively affect continuity of care.

The big question remains in my mind ... just who will get the hammered with the lawsuit or investigation when the system screwups cost a life ? AHS, Dispatcher, the individual EMS Provider ...?

cheers

[a_shane2_go]

Yes i J, i am saying that somewhere went without any coverage for emerg at all for 45 mins, ALS or BLS. (Of course it was 45 min in town and 1.5 hours for the east side of our MD. but that would of NEVER of happened pre-AHS unless the emerg car in town had gotten sent out... and that BLS crew could of taken the BLS transfer rather then an ALS crew.... I think some education may help this problem.. dispatch seems confused at times with this new system.

[Freaknuggetz_chick]

well, i agree that there's certainly been a reduction in coverage stuff.... against all that AHS advertised and swore they would not decrease......

yes, AHS will be getting the new monitors so that BLS can do 12 leads. EMTs cannot diagnose STEMI's, so they will be able to give ntg prior to a RVI being diagnosed (or suspected).

medics will have the chance to see initial 12's, and this is better for the patient in trending etc once they're at the docs.... and with Vital Heart, should be interesting for patient out comes.

i am totally new to c-pap myself, so this should also be interesting. however there have been studies that support no intubation = better pt outcome... introducing an ETT increases chances of infection and longer recovery times....

all in all, there are alot of broken promises, and promises yet to be fullfilled by AHS. I wouldnt hold my breath for them for anything.

[tniuqs]

'Freaknuggetz_chick' date='Jun 14 2009, 09:46 PM' post='217235']

well, i agree that there's certainly been a reduction in coverage stuff.... against all that AHS advertised and swore they would not decrease......

Yup ... politicians they never lie ... hell there is more "middle managers" now than believable .. swing a dead cat in a room in Red Deer and you will hit at lease 4 ! Just saying from what I have already observed and hear this "transition" its not looking very timely (ie current global economics) nor with any strong leadership / direction since the inception.

yes, AHS will be getting the new monitors so that BLS can do 12 leads. EMTs cannot diagnose STEMI's, so they will be able to give ntg prior to a RVI being diagnosed (or suspected).

Is the start of the "dummy down" back to protocol monkey treatment instead of guidelines or increase scope of practice to allow EMTs to WELD at will ... good grief no offence but flashboxes are way more cost effective, and less liabiliy risk besides just what the hell will this 12 lead at the EMT level assist with to improve the patient care .. give TNK ?

I JUST LOVE the New Ambulance Services Act referring to protocols yet there are none ? HUH ? just under development ... but aint that putting the legislative cart before the horse ?

i am totally new to c-pap myself, so this should also be interesting.

Interesting oh yes.

however there have been studies that support no intubation = better pt outcome... introducing an ETT increases chances of infection and longer recovery times....

YES and NO ...

Agreed most evidence based medicine on CPAP a substantial majority of cases that have "early" intervention with NIPPV is more cost effective and can reduce hospital admission times.

Some things not NOT factored in with these studies for direct application to pre hospital care and outcomes.

Lets be realistic .. Firstly f when the ER docs do the "flip consult to ICU" when NIPPV is ordered, its the real realm of Respirologists and then most patients then are managed in ICU post NIPPV implimentation, and an art line placed the vast majority of the research has been done IN hospitals with RRTs applying NIPPV. Now throw a ton of CPAP machines in trucks with "first timers" coaching, heck this could just turn around and slap EMS / AHC in the face HARD in just one lawsuit challenging the "education" of the provider .. just saying. and hell, I certianly hope they don't get the "vendors" to teach the "how to put on the mask" IMHO it is imperative that independent instructors teach and not a Paramedic or RN that are just book smart only or this experiment will most certainly FAIL.

CPAP only is NOT the best way to go with NIPPV (non-invasive positive pressure ventilate) Bi level support is the way to go, IMHO ... sure hoping Ventmedic has comment as well.

In fact CPAP will increase WOB (ie forced exhalation requires accessory muscle usage) this can most cases increase WOB... that said YES CPAP does increase Zone 2 where improvement in V/Q mismatch occurs, (improved oxygenation) and increases FRC but at a cost to WOB.

If the patient ABGs suck and like hell your going to have Istat on every truck then this could delay definitive ALS intervention, I sure hope that someone has a good strong Respiratory background to advise when AHC do decide to purchase, teach and implement these Ventilators. They just may find out that without good education this trial may be a huge waste of money and cost lives having every Paramedic/ EMT putting any SOB patient on CPAP ... hmmm (in HDA PPV is written into EMT scope of practice a "a throw back to the Flynn and BVMS and is included PPVin the current scope of practice i.e. positive pressure ventilation.

Thing is I have serious issue with is every EMT using CPAP or PEEP as this should be treated as a drug, as any thing that directly affects LV Preload, PVR, wedge pressures and/or LVF is not just a "lets put on O2 and start an IV" monkey protocol, no disrespect but way beyond the education of an EMT in this province.

The success of BI LEVEL SUPPORT is quite dependant on the practitioner and extremely difficult to quantify! What if it Fails ? My observation is that those that were "delayed" with this bridge to ETI, this puts that patient at far higher morbidity mortality rates ... YES ... save one from "chewing on plastic" saves lots of ICU time BUT if the patient does fails "the experiment" then they are closer to circling the drain. That said of course Invasive Procedures have far more complications .. not rocket science there.

I sure hope that when AHC purchase a devise that has more than just a CPAP mode ( ie multi usage) and longer term applications on Trucks ... then every ALS truck would be capable of doing Critical care transports ... ah improved diversity, what a concept <sarcasm>

all in all, there are alot of broken promises, and promises yet to be fullfilled by AHS. I wouldnt hold my breath for them for anything.

Holding ones breath = Hypoxia!

Edited June 15, 2009 by tniuqs

[HellsBells]

Hear is some news about AHS plans regarding their promise that there will be no reduction or degredation in service.

[email=http://www.calgarysun.com/news/columnists/michael_platt/2009/06/23/9895681-sun.html]The Calgary Sun

News Columnists / Michael Platt

Union boss warns ambulances no longer guaranteed to include paramedics qualified in advanced life support

By MICHAEL PLATT

That comforting wail, telling you an ambulance is on the way, may not be so comforting when Calgary follows Edmonton's lead in creating a two-tiered EMS service.

In Alberta's capital, ambulances are no longer guaranteed to be Advanced Life Support units -- that is, a vehicle carrying at least one paramedic trained to keep you alive, when a hospital emergency room isn't close at hand.

Instead, at least some ambulances are to be staffed only with emergency medical technicians, who are trained to handle basic medical situations, but not life-threatening injury or illness.

According to Gerry Wiles, that city's paramedic union boss, both Edmonton and Calgary are moving to a system that will run both Advanced Life Support (ALS) ambulances and the lower-level Basic Life Support (BLS) ambulances.

"Edmonton has some BLS units in the downtown core, which is less than five minutes from the hospital," Wiles noted.

"They tried this on New Year's Eve, and it seemed to work OK, and from what I understand they're looking at doing it in both Calgary and Edmonton, in the downtown cores."

Wiles said the two-tiered system is expected to start this week in Edmonton, and officials with the paramedic union in Calgary confirm they are awaiting a provincial edict to do the same here.

The reasoning comes down to dollars, cents and manpower.

An EMT can be trained in six months and hired for much less than a full paramedic, who requires two years of additional training.

Finding ways to cuts costs while maintaining service is the medical mantra for Alberta these days, since the creation of the health superboard, which replaced nine regional health boards last year.

As the superboard looks to slash costs inside hospitals, it makes sense that those working elsewhere in the system would look to do the same.

The province took control of Alberta's municipal EMS services in April, inheriting the big-city problem of clogged emergency rooms and paramedics stuck waiting with patients.

Alberta Health Services, which now runs EMS, confirmed late yesterday that the two-tiered ambulance system is being tested, in response to a summer shortage of paramedics.

A spokesman said BLS units are only being used in close proximity to hospitals, with paramedics ready to roll in as backup, if needed.

Whether the two levels of ambulance care continues won't be determined until October, when the province unveils its blueprint for Alberta EMS.

Still, running a two-tiered ambulance system in the big cities makes sense, from a logistical perspective.

It means more ambulances available for emergency calls, and an ability to keep Advanced Life Support crews on the street, rather than jammed in line at a hospital trauma centre.

At least, that's the ideal scenario.

The reality, in a world where things eventually go wrong, is a call where the ambulance crew responding can't handle the emergency.

It could be the sore gut that turns out to be a ruptured appendix, or the minor head wound that develops into a life-threatening brain-injury, or a death like actress Natasha Richardson's.

Because 911 calls involve two people, one usually in a panic and the other trying to determine the best course of action, there is plenty of room for human error.

Right now, the person answering the emergency call need only decide whether to dispatch paramedics -- add a second tier of ambulance care, and the decision takes on a whole new level of responsibility.

"We might get called for a stomach ache, but a stomach ache isn't always a stomach ache.

"It could turn out to be something more severe like an aortic aneurysm," said Rick Fraser, president of CUPE local 3421.

"When you have a least one paramedic, a decision can be made in the best interest of the patient."

MICHAEL.PLATT@SUNMEDIA.CA

[tniuqs]

Still, running a two-tiered ambulance system in the big cities makes sense, from a logistical perspective.

It means more ambulances available for emergency calls, and an ability to keep Advanced Life Support crews on the street, rather than jammed in line at a hospital trauma centre.

So the justification is that Paramedics are too busy babysitting patients in hospital hallways ?

WELL THERE's YOUR PROBLEM !

"Edmonton has some BLS units in the downtown core, which is less than five minutes from the hospital," Wiles noted.

I guess this is the "improved utilization concept" .... in action .... just how will dispatch implement this ?

Wiles said the two-tiered system is expected to start this week in Edmonton, and officials with the paramedic union in Calgary confirm they are awaiting a provincial edict to do the same here

This 2 tiered system is NOT NEW ... its an OLD throwback to the good old days and its more costly in the long run having backup ALS and 2 trucks on scene instead of just one.

Next watch me pull a rabbit out of Liepert's ass !!!!