theotherphil

Let's get the internationaloscope out

Australia - class LR required

UK and Europe - Class C1 required

Canada - Class 4 (in Ontario Class F) required

South Africa - Code 10 required

Each of these are a higher standard than a regular car license, a commercial class medical exam and a theory and driving test

Each of these jurisdictions (not sure about SA) also has very strict rules about rest breaks and limits of driving

Once again US falls to bottom, breaks my heart

UK: on top of C1 class I had to do D1 but this is no longer mandatory. We also do a 3 week advanced driving course. Week 1&2 covers the system of car control, reading the road ahead, controlling skids (on a skid pan in an ambulance and car - including FWD, RWD and 4x4), manoeuvring in tight spaces, "making progress", avoiding red mist etc. Week 3 is Emergency Response driving...driving on simulated emergencies under response conditions. It is extremely intensive and taught by Ambulance or Police Highway Patrol instructors. Pass marks are 95% and the failure rate is high.

On top of this, my service enforced a further 2 weeks driver training with the Police when gaining a position on a rapid response car.

So, on top of my normal licence, I had to have 3 yrs experience before gaining category C1 and D1 on my licence (vehicles over 4.5t and passenger carrying vehicle of up to 16 persons). I then undertook the 3 week driver training with the Ambulance Service plus a further 2 weeks for the response car.

On coming to Australia, I had to gain a LR category on my licence (roughly equivalent to my UK C1&D1 categories).

To the manager who thinks UK Ambo's have time to sit around and use facebook etc, then you are wrong! I've worked the UK system for the last 7 years and have been working in Aus for the last year.

You just cannot comprehend the sort of workload UK services see on a daily basis. London Ambulance Service covers 620 square miles and a population of over 7 million (over 12,000 people per square mile). There is 70 Ambulance Stations, 400 Ambulances and 100 Rapid Response vehicles. LAS CAD figures are 5-5,500 per 24hr period....yes 5,500 Emergency calls in 24hrs! Turn around times at hospital are monitored and you get a job dropped on you as soon as you clear...it's a full shift of work with NO downtime except for the mandatory 30min break.

As far as I am concerned, it is up to the service to ensure that there is adequate resources to meet demand. This is not my job as a Paramedic...managers are meant to ensure this therefore any deaths attributed to poor cover is NOT our fault.

Look, they posted images of themselves goofing off where the rest of the world can see....which the rest of the world obviously did as the Post approached their employers for a story.

Most employers have a clause that you can be fired immediately for "Gross Misconduct" and they will define a few instances of what is classified as Gross Misconduct. One of the definitions is bringing the service's name into disrepute.

As an EMT/ Paramedic, the public expect a level of responsibility and personal accountability for you actions. By posting pics publicly of you goofing off is never a good idea....especially if your employer is identifiable (as it clearly was in this case). Whilst we all agree that the punishment doesn't fit the crime, you need to remember that your employer will drop you like a hot stone should you bring any bad press to their door - no matter how good you are and how many years service you have. This then acts as a deterrent to their other employees.

Thanks for sharing....something I have never heard of before. I have researched it and it does indeed seem very unusual.

Treatment for me would have been the same regardless. If I couldn't justify Midaz for a seizure, I certainly could under my "patient management" guideline.

Yes, a woman with large breasts can be a challenge, but lead placement is no different. I actually saw someone try to place the leads on top of the breast because she was too nervous to move it. I corrected her, and said that like any other procedure, getting a poor result is no better than not doing the exam at all.

I've seen a few people mention this and I thought I'd share something from a Consultant Cardiologist when teaching on my ECG course. He told me that having the correct landmarks is more important that the slight change in amplitude caused by reading through breast tissue.

"Breast tissue appears to have a practically negligible effect on ECG amplitudes, and in women, the placement of chest electrodes on the breast rather than under the breast is recommended in order to facilitate the precision of electrode placement at the correct horizontal level and at the correct lateral positions."

Rautaharju PM, Park L, Rautaharju FS, Crow R. A standardized procedure for locating and documenting ECG chest electrode positions: consideration of the effect of breast tissue on ECG amplitudes in women. J Electrocardiol. 1998 Jan;31(1):17-29.

Earnings: $98,000 (AU)

Job Title: Intensive Care Paramedic

Experience: Nearly 1 year as AU ICP, 2 years as UK SR Paramedic, 3 years as UK Advanced EMT

Type: Government

State: NSW

Avg OT: 12 hrs/fortnight

Average fortnightly take home pay is $2,850 AU. I work 2 days then 2 nights then 5 days off. Shifts are 12hrs.

6 Figures is common for rural officers here, with metro around 90K US.

I'll echo what Phil is saying. I am Metro and as can be seen above, I earn $98k AU ($88k US) with minimal OT. You are given some nice incentives to work rural and it'll be easy to crack $115k AU without overtime.

OT boosts the pay massively....a weekend OT shift (12hrs) can gross between $1,000 and $1,200 AU (>$1k US)

I've gotta say that I also disagree with your view kiwimedic. You really should get that 12 lead before administering the GTN. A full assessment should be made of your patient before implementing treatment options...you need all the info at hand to make an informed decision. Administering GTN beforehand could drop that BP irreversibly in the case of RVI....and you'd be wishing you had started that IV as well.

When I was working in the UK, my area used to have thrombolysis and PCI available to us depending on the patients location (and whether they were in the catchment area for PCI). All of it was done autonomously based on our interpretation of the 12 lead and the patient's presentation. We were able to transmit directly to the respective Coronary Care Units but it wasn't a requirement. We'd just call the unit and tell them we've either thrombolysed and need a bed or that we have a patient suitable for PCI and to get the cath labs ready. No passing through ED needed and we were also beating the ED's call to balloon/ needle times by a significant amount.

Here in Australia (NSW), cardiac care is behind the UK by a large amount. Only Intensive Care Paramedic vehicles have 12 leads but the ICP's only get sent to Cat 1A and 1B calls routinely. Chest Pains are usually categorised as a 1C so a BLS crew usually deals with those without the benefit of 12 leads and ICP backup is only sent if requested by the BLS crew. We can bypass ED for STEMI's but only after 12 lead transmit and you guessed it - only ICP's can do that

Paracetamol

Methoxyflurane

IN Fentanyl (paed and adults but no max dosage for adults)

Morphine (paed and adults) 0.5mg/kg max, can be repeated after every 30 mins as required

Midazolam can be added to Morphine if required.

I started a thread on this a few years back I think when this article was new and a Brit replied with some intelligent comment and paper to back it up if I remember correctly...

S/he was frustrated at the bad press and hated the fact that people seemed to believe that they would "choose" to ignore such calls when in fact they were obligated to ignore such calls.

My point being, to our British friends, couldn't this medic have been sanctioned for taking this call during his meal break?

If the Paramedic was on an unpaid break (my service in the UK had unpaid breaks), then they were OUT OF SERVICE. To respond in these circumstances would effectively mean that they were off duty (by law) therefore, not insured.

10mg IV is an appropriate dose for many people. While many providers (docs, nurses, medics) get the idea that any more than 5mg of morphine will stop your breathing and kill the patient and revoke your paramedic license and reprogram your DVR and spook your pets, multiple studies in adults and children have demonstrated the safety and efficacy of 0.1mg/kg of IV morphine for pain relief. So she's right, 10mg is a dose. An appropriate dose meant to reduce pain, not a homeopathic dose meant to make the provider feel better.

'zilla

Even the most traumatic injuries rarely need more than 20-30mg's so 300mg is a large amount - especially in a single vial. We have some quite useful pain relief options here and we can titrate up to 0.5mg/kg of Morphine and repeat that every 30 mins if pain persists (we can see long transport times). I've never used more than 30mg's in one go and have never induced respiratory arrest either.

After what happened in the last driving thread, I won't even mention what happens in the UK

Speed doesn't kill btw, inappropriate use of speed does. If it did, I'd have killed loads of cute puppies today and maybe a fluffy bunny or two

DRABC? That's a new one on me.

Is this an Aussie thing, or am I just out of the loop?

DRABC is used in the UK as well as Aus. Danger Response Airway Breathing Circulation etc

Once cardiac arrest is confirmed with an initial pulse check, I wouldn't check again unless there's a rhythm change (and after finishing the 2 mins CPR). No pulse check straight after a shock due to myocardial stunning, although this is lessened on biphasic defibs.

edit: speeling

Are your medical educators going out on FAKE runs with paramedic students? Or are they being sent out with field medics for that experience?

If it works for medicine, why doesn't it work for driving? Sounds to me like you guys have simply invented a level of bureaucracy that you now cannot imagine ever living without, even though it serves no valid purpose.

It's funny, but what we would term as FAKE runs are those undertaken by IMAGINATION or on a TRACK.

Bureaucracy doesn't come into it. We don't just place a field medic, however experienced, into a training position. Over here, it is a legal requirement to hold a teaching qualification in adult education before you even go near a student. Then you need specific qualifications in the area you are going to teach. Just because you can drive, and have done so all your life, doesn't make you a driving instructor This system ensures the highest caliber of teacher, and education delivered to the student....not just "this is how we've always done it". Evidence Based Practice is a big thing over here - prove we need to change and we will.

With the attitudes you guys (I say that loosely as at least some of you can see there's other ways of doing things outside of the USA that may actually be better - shock horror) have to progression/ education, it's small wonder you are stuck in the dark ages with regards to EMS. You'll never move away from protocols, you'll never gain the same autonomy of practice, you'll always be calling OMC, you'll never hold professional recognition, you'll never have the pay that comes with all this unless you embrace change...but that means doing things differently to how you've always done it

I completely disagree. This must be debated, because it is only a matter of time before some idiot here in the US decides that we should do it too. Why wait until it is thrust upon us to give it any consideration? Be proactive about it! Know the issue ahead of time!

What exactly are you afraid of? Maybe it's the failure rate? Our student failure rate is massive before they are even let loose on L&S - we lost 8 out of 20 students on my initial course. These guys were then not progressed to clinical training - RTB, EndEX, game over.....back to their old job. Some people can't acquire the necessary skills so will never drive on L&S. Maybe if this was introduced in the USA, it'd cull too many and you'd be out of a job?

I think what we need here is a midway solution to the problem of letting new providers loose on the roads running L&S.

Obviously closed track training must be the first step, but it can only go so far. There seems to be no disagreement on this point. The main point of contention seems to be whether these closed course trainings should be followed by practice runs on the road and whether the educational opportunity is worth the risk. Especially given the lack of evidence to back up the clinical benefit of L&S.

DocHarris, we do 2 weeks worth of regular advanced driving and track work before using what we have learnt on "FAKE emergent" runs. We clock up 9hrs driving/ theory a day, every day for the entire 3 weeks. Then, some services insist on a further 2 weeks driver training (a lot on L&S) if the Paramedic is to be a solo responder on a rapid response car.

There's no evidence to suggest that there is any better way of doing things as this has been the LAW of the land since time began. Looking at the accident rates of emergency vehicles in other countries vs the UK, then things become a little clearer. Why would we WANT to change something that WORKS so well? If it's not broke, don't fix it! Have you ever thought that the public actually know what to do now when an emergency vehicle is behind them rather than just panicking? See, we're training the public as well

The key term there is "real patients". They really are patients! They really do need to be intubated. That is not even close to being a valid analogy to running through town on a FAKE run, that is not a real emergency to a real patient.

Yes, they are real patients but their airway could/ would have ordinarily been managed by an LMA. By changing to ET tubes just for us to practice our skills is surely unethical? How can you justify that?

An old army saying...."it's all about the barrel time", exposure to the real thing, or as close to, is the best form of training. I guess I'm just old school after having a forces background where the 7P's are drummed into us....Prior Planning and Preparation Prevents P*** Poor Performance. I'm a big believer in the most realistic training available, not just imagining scenarios and imaging our reactions and then imagining the instructors reactions I guess I lack imagination.

This is all by the by though, it will never change when our accident rates are so low in comparison to the rest of the world. Things will change quick sharp if we start mowing down pedestrians or wiping out other vehicles. As can be seen in the above link posted by Scott, it seems it is the USA that needs to change it's practices. This then might stop you guys wiping out pedestrians and mowing into other vehicles

Okay, if this is such a valid educational theory, let's just go ahead and carry it over to the rest of our duties.

Let's just start intubating people without medical indications, just so the first time we do it on an actual emergency patient, we have plenty of "real" experience behind us.

Wait, why waste time with intubation on those people? Go big or go home! Cricothyrotomies for everyone!

I'm sure you'd like to know that we practice intubation on real patients over here as well! I had 57 tubes in 2 weeks on real patients from 18months old upwards...all done under the supervision of a consultant anaesthetist before being let loose on my own. The LMA's on the list were dropped for ET tubes to allow me to learn. Real practice, for real situations. It helped immensely and gives the student the confidence required to be real slick when it come to doing it for real. That's in addition to all the hours on a dummy that doesn't vomit/ stink/ move like a real patient.

Just face it, we do things differently over here. It's not worth worrying about though.

Are you sure the claim of over 100,000 emergent responses in the UK daily is correct?

Sorry, a rogue 0! I meant approx 10,000 Emergency responses by just the Ambulance Services daily.

Learning emergent driving can be accomplished without this obnoxious nonsense.

You're obviously not reading any of the replies, so what's the point in discussing this any further? To me, it looks like you'd really like this system and are a little annoyed that you don't have the authority to do it in your part of the world.

As you keep quoting your "English Friends" being forced to give way and being unaware - I'd just like to add, yet again, that the vehicles are fully marked up as TRAINING vehicles. Nobody in the UK is forced to yield/ give way to emergency vehicles. If they don't want to, they don't have to and that's why we stop at red lights and proceed when safe.

Dust: We are not debating whether using L&S is of any benefit for the patient. We know it isn't and it bugs the hell out of us. What we are debating is whether advanced driving courses is a good idea to lower accident rates/ personal injury claims/ reduce insurance costs. The evidence is clear....over 100,000 L&S runs in the UK daily, from the Ambulance service alone, with nary an incident.

Man, what a load of crap being posted in this thread

I'm a Paramedic in the UK and has already been posted previously, we have to undertake a minimum of 3 weeks advanced driving and this includes driving on L&S through built up areas. The vehicles are CLEARLY marked as TRAINING vehicles so the public are all too aware of it's purpose.

Included in those 3 weeks is advanced car/ ambulance control on a skid pan learning how to control FWD, RWD and AWD vehicles in slippery conditions. As a point to note, the driving part of the training is usually done before the clinical as more people FAIL this 3 week driving course. A large percentage of staff are binned (8 out of 20 on my course) as they are deemed not suitable for various reasons.

As a Rapid Response Paramedic, I did a further 2 weeks advanced driving 1:1 with a Police Traffic Officer in a high power Volvo T5. Over here, we can quite legally claim speed exemptions with no maximum as long as it's safe to do so. On this course, we regularly hit speeds of 120mph + down country lanes/ motorways. The emphasis is on safety and hazard perception far into the distance.

The training we have is second to none and as such, our accident rate is extremely low. In the past 5 years, I have responded L&S to 10-14 jobs per 12 hour shift (that's over 10,000 responses) and have never had an accident. On quite a few of these, speeds in excess of 100mph were used.

In doing this training, we a protecting the public by having the most highly trained drivers in control of emergency vehicles. In comparison to actual number of calls, our accident rate is extremely low....in London alone, the Ambulance Service respond to 4,500 emergency calls per day with pretty much zero incidents. I think that speaks volumes for our training.

Why is that? I'm not challenging you, just trying to figure out what I'm missing...

Dwayne

I just can't see the immediate need for siting an EJ IV for a hypo. We carry glucagon that we can fall back on should we need to. I really wouldn't like to leave a patient for 30 mins or so after removing a 16-14g from their neck for fear of haematoma. If it's gonna bleed, it'll be my luck it'll be significant. It'd be a different matter if I was going to transport to hospital as they have the staff and resources to monitor the patient after IV removal.

2mg IV Bolus? Yikes! I always use 2x 400mcg Narcan IM and just bag them gently round with O2. Acute Withdrawl Symtoms make people nasty

I've done a few EJ's now but all were on Cardiac Arrest patients. I don't think I'd ever go EJ on a Hypoglycaemic. We treat and discharge at scene most of the time with IV Glucose and a referal to their own Doctor. I'm not sure I'd be comfortable doing an EJ and then removing it to leave the patient at home. I'd certainly use EJ as my first choice in medical/ trauma emergencies if it were time critical though. Never had an ACF that I've missed though.

Here in the UK, Paramedic (and EMT) training has normally been paid for by the employer. To ensure that they aren't wasting their money on you, the trainee will have to sign a contract with the employer saying that you can't leave for x amount of time.

Then to make things even harder, they cherry pick candidates from experienced EMT's. When I was going through the process, 96 of us applied to sit the Paramedic entrance exams. Only 21 of us passed. We then had to do practical assessments - only 12 of us passed. Then there was an interview - only 9 passed and went on to do the Para training. Of the 9, only 6 of us passed the course.

Things have changed slightly now with most Paramedic training done via University to foundation degree level. This is still usually paid for by the employer.

Here in the UK, we have Rapid Response Paramedics in Cars which provide an initial response to be backed up by BLS/ ALS crews. This is used extensively to meet government set response times. In amongst my normal shifts in a regular Ambulance, I work RRV shifts.

Sometimes, it helps the patient just to know somebody is there who can take control of a situation. Other times it is not very nice to be with a really poorly patient and you've been waiting a long time for a real Ambulance (my record is 1 hour 20 minutes but I routinely wait 40-50 minutes). There's only so much that can be done before you need to get the patient into hospital. I've nearly been hung by family members wanting to know why there's no ambulance to move their loved ones.

note my emboldening

also note that should someone happen to be there when contracted to an NHS organisation... it doesn't apply

also you need to consider the situation where the person you claim is 'obstructing' you is already on scene and by virtue of that already has a legally ( and professionally ) established duty of care

Yep, just getting in the way is a reasonable excuse. Displaying your arrogance and attitude is getting in the way. Stopping us from doing our jobs is hindering us in the eyes of the law. If you are on scene first, your duty of care ends when we turn up. If you are helpful then you can stay. Try telling us how to do our job and off you go.

As SJA contracted to the NHS ambulance service, every Cat A and B you attend needs a Paramedic to back you up as you are not acting in the capacity of a RN. You are acting as an Ambulance attendant with less skills than an NHS EMT. Basically, a clock stopping 1st responder. SJA and Trust clinical governance won't let you act above your station.

As a Nurse off duty, you are not acting on behalf of an NHS organisation.

Sorry Zippy, you're wrong again :roll:

Ok, then. Is this really a global problem? Are EMS providers constantly having to remove nurses from the scene?

Take care,

chbare.

Nope, we are quite happy to have the help of any person who is competent. I have never ordered anybody off scene but if somebody turned up with the attitude that Zippy displays, I'd be more than happy to.

We have a new law over here, the Emergency Workers Obstruction Act which pretty much gives us the right to have any person removed from scene who is not acting on the behalf of Fire and Rescue, the crown or a statutory Ambulance service. Turning up off duty saying you're a nurse/ doctor/ whatever means nothing if you're getting in our way. The NHS Ambulance service is the statutory provider of pre-hospital care.

1 Obstructing or hindering certain emergency workers responding to emergency circumstances (1) A person who without reasonable excuse obstructs or hinders another while that other person is, in a capacity mentioned in subsection (2) below, responding to emergency circumstances, commits an offence.

(2) The capacity referred to in subsection (1) above is—

(a) that of a person employed by a fire and rescue authority in England and Wales;

( in relation to England and Wales, that of a person (other than a person falling within paragraph (a)) whose duties as an employee or as a servant of the Crown involve—

(i) extinguishing fires; or

(ii) protecting life and property in the event of a fire;

© that of a person employed by a relevant NHS body in the provision of ambulance services (including air ambulance services), or of a person providing such services pursuant to arrangements made by, or at the request of, a relevant NHS body;

(d) that of a person providing services for the transport of organs, blood, equipment or personnel pursuant to arrangements made by, or at the request of, a relevant NHS body;

(e) that of a member of Her Majesty’s Coastguard;

(f) that of a member of the crew of a vessel operated by—

(i) the Royal National Lifeboat Institution, or

(ii) any other person or organisation operating a vessel for the purpose of providing a rescue service,

or a person who musters the crew of such a vessel or attends to its launch or recovery.