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This is a very realistic concern regarding any refugees coming to Canada also. In the end I support taking in refugees with a proper screening process but I'm concerned our own in country resources are not prepared to care for these people adequately.
To be honest I've stopped counting. I did 3 in just my last block of work (4 days on 4 days off) which is fairly common; so I'm willing to estimate a conservative 20+ this year. I work in a targeted service so I end up doing the pre-hospital intubations for an entire zone as opposed to a single unit. For those who don't have similar working opportunities, the body of evidence supporting high fidelity simulation practice and its resultant increase in first pass success is becoming quite clear. Practice, either on a manikin or a patient, breeds a higher degree of success.
Then do an IM or IN dose of an opiate to start out. An inhaled agent like entonox (50:50 mix of N2O2 and O2) is a bloody good stop gap while waiting for the IO to sit or IM/IN opiate administration to kick in (if it isn't contraindicated). If they're already in agony for whatever reason giving them one more reason to be in agony is far from a kindness. There are always options including the external jugular (assuming of course that's in your allowed SOP which I suspect it is if your doing nerve blocks and sutures).
The key is patience. Once the slow infiltration of lidocaine is complete you have to wait a solid 4-5 minutes before flushing or doing anything else. 4-5 minutes on an ambulance call seems like an eternity so very few providers wait long enough. If the patient is so crook you can't wait the 4-5 minutes you just have to accept you're going to cause significant pain. On the plus side, early administration of an appropriate benzo means the patient is unlikely to remember how much the flush sucked.
I wouldn't want anyone to feel as though they shouldn't participate just because a topic landed in a particular forum (ie. an EMT not feeling as though they could learn and participate in a topic that happened to land in the paramedic section).
I can share my own decision regarding CCP education (the rather lengthy Canadian version of said education). I decided to go for it. The reading has already begun with the main portion of the course starting in January and running over the following 2 years.
In the end it came down to desire for responsibility. My desire to take on that role and the education that goes with it exceeded my nervousness about whether or not it was the right decision. The decision to work in a targeted ALS response capacity was similar. Furthering ones education should be a humbling experience. It certainly has been for me. The more knowledge I acquire the more I feel as though I'm lacking in education.
I've used this technique for the last year with similar results to those reported. The concept behind it is that more prolonged vagal stimulation provided by the short term bump in CVP provided by the leg raise will increase effectiveness of the maneuver.
Frankly, it seems like a waste of money when a little bit of crew education could perform the same task. If I have a crook patient I make a phone call and notify the receiving facility. If I feel the hospital needs as much notice as possible, that phone call happens before I've even left the scene. The whole concept of sending a partially completed PCR to get the hospital started seems like a waste of time. If a patient's very ill my PCR is blank when I get to the hospital and their health card is in my pocket to hand to admitting.
Our current dispatch system does have the ability to flag addresses. Dispatch seems to be fairly good at flagging addresses with violence potential but quite lax in flagging addresses with CBRNE potential (possible TB, carbon monoxide, etc.).
Students force you to either remain up to date or become a lousy preceptor. For myself I find it re-invigorates my appetite for the job. It's also a wonderfully variable experience figuring out how to best assist any given student in the learning process. Some are academically strong and skill weak while others are the opposite with any combination of the above possible.
As of January 2 all of us will belong to provincial programs with class beginning on the 4th. It should be the most rewarding period of education in my career so far with an incredible amount of ICU time and a guaranteed 3:1 student:instructor ratio. Semester 1 is primarily about equipment management in the non attending role (pumps, vents, etc.) while semesters 2 and 3 really get into the medicine. The majority of the didactic portion of semesters 2 and 3 will actually be taught in hospital by ICU docs which will allow for immediate reinforcement of the concepts during ICU rounds. If it's an option for you I highly recommend applying. That calibre of educational experience, especially in a paid education format, is nearly unheard of for paramedics. Even if you were to decide on PA school after, the experience would be valuable without costing you anything financially.
At first I noticed this thread and thought to myself nope, not me. Then I looked at my profile and realized it's been over 8 years since my first post. A lot has changed since then. I joined as an EMR (think EMT-Basic) looking for work. Now I'm an ACP (think EMT-P) working targeted ALS and about to start another 2 years education to become a CCP (any number of variations on the theme exist. In Canada it amounts to about 5 years post secondary education). As my education has steadily increased I would like to think my opinions have re-shaped themselves appropriately. I can certainly say that characters like Dustdevil and Tnuiqs helped shape what I've become.
http://www.ncbi.nlm.nih.gov/pubmed/17229343 Nerve tissue abounds in the marrow space. The pressure from infusion Kat mentions causes extreme pain as a result. A very slow infiltration of lidocaine prior to the 10 to 20cc rapid flush to create an infusion "pocket" will help to numb the nerve tissue and dramatically reduce pain of infusion.
Those are not the conversations that will benefit you the most in your chosen career. Knowledge, leadership, procedural competence and professionalism will forever be the cornerstones of sound practice at any level. The conversations that enrich any or all of those factors will be of the greatest benefit throughout your career. Arctickat said it well. Eventually those one-up-manship stories will be your nightmares. Not because they grossed you out, but because as you age you realize there are human lives attached to said stories. Oh and welcome to the city. Hopefully our crusty selves haven't deflated your enthusiasm. Most of us really do still love our jobs.