HarryM

Well in the city where I work we have 4 ED hospitals within close proximity to each other and 3 of them are capable to dealing with critically ill patients and have ED's, ICU's, stroke teams, cath labs. So unless there was obvious major trauma (which only 1 hospital deals with) then go to the closest hospital by road.

Family are in the back with us and the patient. Seatbelt on of course. If a second family member then they ride up front or if the patient is sick and we are working on them in the back and don't want the family to see or get in the way.

Our service would code this as a "Green" priority which means anything coded Purple, Red or Orange would get priority over it. Green's have a KPI of ambulance arrival within 2 hours of the call. Maybe as it is the head it might be ProQA'd as a possibly dangerous body area and be an Orange which means it is a non-emergency dispatch but if the crew read the clinical notes from the call they can decide to upgrade to an emergency. I personally don't think it should be a lights and sirens job.

As per above (I also don't know what that BGL is): - NPA and bag mask to RR of 10/min = can we now get an SPO2? - Large bore IV access and push through 1L of NaCl = any change to BP or GCS with this? - 12 lead ECG = what does it show? - Naloxone 400mcg IV (worth a shot) - Scoop stretcher for extrication and go to hospital

We've just had a memo out from our clinical research team which has said that at the moment the evidence is against prehospital use of TXA, but that we will be taking part in trials ourselves and make a final decision from there. The rationale was that while studies did show TXA decreased mortality from trauma, the studies were conducted in countries that had much higher levels of trauma deaths than New Zealand. They applied the study results to NZ and found that as the rate of death from trauma was much lower here then TXA would have a lower efficacy and with a lower efficacy, the risks of pathological clotting are significantly increased which outweighs the possible benefits.

That's awesome. Trust me, it will lead to a lot less work immobilising a lot of patients and also increase comfort for your patients!

Hmmm you'd have to wonder why she is not paralysed and sedated if she is tubed. I'd start with some vecuronium and a midazolam infusion. Also maybe increase the NE infusion to maintain a systolic BP of 100. Also want to correct metabolite imbalances. The only fluid we carry is NaCl and I'm the first to admit that as this is the case I really don't have the knowledge to go an start talking about what electrolyte infusions she needs. Is there a toxicology screen/test available? Also be good to see results of a head CT? Therapeutic hypothermia is generally 32-34 degrees so she still has a way to go yet. Maybe once the vecuronium kicks in the lack of shivering will allow her temp to drop to that level. Otherwise consider cooled NaCl to help cooling enroute.

Also playing devil's advocate....does your system have nebulished brochodilators?

We never work an arrest if there are obvious signs of death. Generally almost never start a full resuscitation if initial rhythm is asystole. Of course there are exceptions, not a blanket rule.

Sounds tricky! No way that would happen here as our cops don't even carry guns! But am really impressed at Croakers' summary!

We use Suxamethonium for initial paralytic pre-intubation then Vecuronium post-intubation to maintain paralysis. Never seen or heard any problems with it. But again we only use it post-intubation and not pre-intubation. I'm not sure as to exact rationale of one over the other (not yet within my scope) but I do know that suxamethonium has shown to be superior over rocuronium when inducing paralysis for RSI.

As others have said, try and convince him to allow a quick ECG and taking of vitals and then if anything abnormal use that to try to convince him to come to hospital. Use his wife and call his GP and get them to try and convince him too. Then tell him he has a very high likelihood of dying today if he doesn't come to hospital. If that fails then document the shit out of it and leave him at home. He is competent to decline. If he goes unconscious then treat him as that is what the wife wants. If he had a fully written advanced directive and you can sight this then no treatment provided even if he does go unconscious.

We use it at BLS level (and above). With methoxyflurane and paracetamol being the only other pain relievers at a BLS level. We use it with a filter and mouthpiece, although you can also attach it to the same mask you'd use with BVM if required. From our clinical guidelines: Preparation: 50% NOS and 50% O2 Mechanism of action: Unclear but causes analgesia via CNS Indications: Moderate to severe pain Contraindications: Unable to obey commands, suspected pneumothorax, suspected bowel obstruction, SCUBA diving within last 24 hours, or has diving related emergency Relative Contras: Repeated use is associated with psychological dependence. bone marrow supression and neurological disorders. Patients with chronic pain syndromes who call an ambulance frequently are at high risk of developing adverse effects from repeated entonox administration and should be avoided in these patients. Onset: 2-5min Duration: 2-5min after stopped administration Common Adverse Effects: Sedation, euphoria, nausea, metallic taste, auditory disturbances Interactions: Increased effect when used with other analgesics or sedatives Notes: NOS expands gas filled spaces in the body, hence its many contras. Not contraindicated in patients with chest injuries but is if pneumothorax suspected. It should be discontinued if associated with worsening respiratory distress in chest injury patients. Not contraindicated for abdo pain but is for suspected bowel obstruction which most commonly presents with vomiting and abdominal discomfort. Abdominal distension and reduced frequency of bowel motions or passing of gas may be present.

Possibly may never give it. I've always had good relief with a properly done valsalva or spontaneous reversion. Our guidelines are to only give adenosine for SVT only if there is compromise or a hx of SVT responsive to Adenosine. It's specifically differentiated from A.Fib in our guidelines which is treated with Amiodarone. I'm not going to be the person to give Adenosine to someone in A.Fib and then have to explain it in an audit. I can use all the medical research in the world to prove a case that it was worth a try with a funky rhythym, but at the end of the day our guidelines are written by an intensivist and we follow them. We can go outside them provided we can prove we were correct. But as you say, you can't prove you were correct in a pre-hospital setting. If we revert the SVT with Adenosine we can leave the patient at home provided it's not their first SVT responsive to Adenosine.

Hmmm I'm not sure on that one. We use adenosine ONLY for SVT. You have to be 100% certain it is SVT. Otherwise for all other compromised tachydysrythmia's it's an amiodarone infusion and/or electric cardioversion for significant compromise. I'd be pretty wary of making a guess with any cardiac drug, but adenosine can be pretty nasty so personally I'd err on the side of caution and not go down that line unless certain it was SVT or consulted with clinical and got their view on the rhythm.

MariB am jealous that you guys are electronic! We are getting it in the next year or two and cannot wait! Do you print it out and give it to the receiving facility or email it directly to them?

Interesting to see how different people write out reports and great to pick up some tips and tricks from other.. My version of this is: "History of fall off bicycle at slow speed landing on R) knee. Ambulance called, O/A: pt supine on footpath -> conscious & alert ->good colour -> in obvious distress O/E: primary survey clear. Secondary survey reveals R) knee injury with nil signs of knee or patella dislocation or obvious fracture. Redness and swelling present. Pt very distressed with knee examination. Unable to determine FROM. ? soft tissue injury. Pain 5/10. Splint applied. Pt has nil other injuries. C-spine cleared. Pt has full recall of events and nil neurological deficits. Nil pmhx. E/R: pt pain decreased with pain relief and reassurance and pt become more relaxed. Nil change in pt condition. Meds: Nil Allergies: NKDA"

Our patient report forms are split into 4 sections: 1. Details relating to the job such as job times, job number, vehicle number, date, inital patient status and patient status at ED 2. Patient personal details and chief complaint 3. About 1/4 of an A4 page for you to write job details 4. Drugs and interventions section where there is space for RR, HR, BP, GCS, BGL, Temp, Pain For my written section in 3 I usually do history of what happened prior to ambulance being called. Initial patient assessment on arrival. In-depth examination findings including provisional diagnosis and pertinent negatives. Any changes to patient enroute or post-interventions/drugs. If I leave them at home I write what the patient was advised to do by me and that patient was told to call am ambulance again if significant deterioration occurs. I can usually fit it into the space given. You get better with time and experience with writing succint reports that still cover everything you need them to.

I'd say that for most of us, we are compassionate and empathetic the vast majority of the time. I'll stick my hand up and say I'm not particularly compassionate or empathetic to those people who "attempt suicide" with a half-assed attempt and let someone know they are doing it. I feel for those who actually do want to die and are caught in the act. You can say I'm a wanker and give me all the mental health lessons in the world, but it doesn't change the way I feel about it. Does it mean I'm unprofessional and rude to those people? Not at all. I treat their physical injuries, ensure they are taken to hospital and ensure they are aware a psych consult is needed. On the other hand, I find that treating a criminal (drunk driver, murderer, rapist, paedophile -> all of which I have treated at one time or another) does not bother me, where I have witnessed other co-workers treat criminals very poorly. Guess what I'm trying to say is that no one is going to be compassionate and empathetic 100% of the time. Everyone is different with what triggers those feelings in them and what doesn't. I think though that the moment people start acting unprofessionally and treat people with disrespect, then you need to wonder whether the job is still for you. On another note. I guess it all depends on our own mood at the time. I can tell you that my patients receive more empathy and compassion at 1pm than at 4:30am.

I think your setup sounds pretty good so far. One thing I would recommend is one Paramedic who is car-based who goes to low-acuity calls with the intent on referring them to their normal doctor, an accident and medical clinic via private transport, or an ED visit via private transport. Or just leaving them at home because they have overreacted to a minor injury/condition and do not need further treatment. If you have one of these vehicles on 24/7, then they can also be available as fast-response when no ambulances are available, or for ALS backup when required. If you only staffed the 3 ambulances with 2 people (1x EMT and 1x Paramedic) then you could put this low-acuity vehicle on with minimal extra cost. It would also ensure that the Shift Supervisor has more time in the office to get their work done. Use tablets for both Mobile Data Terminals and electronic patient report forms. Work with local hospitals and clinics to enable patient files to be accessed remotely by ambulance crews, and for ambulance crews to send patient report forms and ECG's to the receiving facility. In terms of equipment, I honestly think it comes down to you making your own decision. Everyone one here will have opinions on Lifepak 15 vs Zoll vs Phillips MRx. Although I would look at electronic Stryker stretchers to reduce crew lifting and workplace injuries. Have you considered bariatric equipment?

Another one here. Hopefully will see some of the most recent evidence based research being put into play!

In NZ we are using prehospital fibrinolytics to thrombolyse STEMI patients. Mainly used in rural areas with time to hospital is greater but one metro service uses it as well.

Ah right. Missed that. Not sure what your clinical guidelines are but if you are suspecting a dissection/aneurysm then the best thing to do enroute would be to keep HR under 60 and BP between 100-120 to reduce aortic wall stress. So maybe a beta-blocker and an anti-hypertensive. But otherwise you are a bit stuck unless you want to query the diagnosis with the D doctor.

Did they do a chest CT or MRI at ED?

I'd suggest the best thing to do is to have a chat with him about he thinks he needs to improve on and what you think he needs to improve on and then use that to work out how you will run jobs and how you will mentor him. If you sit down and get on the right page with each other then when you do mentor him on the job there won't be any surprises for either of you and he won't feel as if you are undermining him or being a bully, as you've already worked out a mentor plan. I personally find the best strategy is to work out how your partner works (from observation) and if you need to provide advice/guidance/feedback/mentoring you can tailor it to their working style. On the way to a job you can get them to run through with you what their thoughts are based on the known info before you get there and talk over with them what they need to be looking for and thinking of. Then let them run the job (unless you need to provide any advanced care) and unless they are doing anything clinically dangerous, let them do it their way. Afterwards you can provide some feedback on where they went well and what they could improve on. When they get in the same situation again then just watch and see if they have taken onboard your feedback and if not have another talk and reinforce it. Not sure if that helps, but honestly the best way is just to be straight-up and honest and talk things over with him. Otherwise it's just going to be you getting impatient and snapping, and him feeling as if you think he's incompetent and not helping to further his skills.