theotherphil

Zippy, being an independant prescriber means nothing pre-hospital. You cannot operate to that level in the pre-hospital environment. Then you walk round to the Dr and say sign this....authorising your interventions. Sure, it's not the right way to do things but that's what happens....I know this as my partner works in A&E in a major hospital. Extended skills nurses are few and far between. In fact, they can't even afford standard nurses and are employing Associate Practitioners....cheaper nurses in all but registration. Isn't it right that you've been moved from the ED to a general medical admissions ward? I'm sure you'll find some way to big that up and make it sound like a promotion. In the pre-hospital environment, you are not a statutory responder and you have no rights on scene. If you get in the way, you will be removed...simple. You can wave your arms and shout as much as you want about NMC this and HPC that but it'll get you nowhere fast. Sorry, but if you turn up on scene, I don't know you from Adam and I couldn't care less what you can or can't do. You'll be there as my guest or not at all. Those arrangements only extend to the hospital environment and when you are during working hours. Pre-hospital, you cannot do anything more than a EMT. That's all I have to say on the matter, I won't be drawn into petty squabbling with you.

Absolutely! The funny thing is, there is no bickering between Paramedics and Nurses at the 3 major hospitals I service. The nurses do a fab job under difficult circumstances and they excel in their own environment. We have a really good working relationship. They never profess to being able to do our job and in fact, many say they wouldn't want it. The same for us, I wouldn't want to work in hospital and certainly don't profess to be able to do the job of a Nurse even if the roles are similar to some degree. Zippy's comments are his own misguided views and are not that of every nurse.

Zippy talks crap in all forums he frequents. He feels that ferrying around grandma's for routine appointments is "experience in pre-hospital care" :roll: Here in the UK, nurses may be registered but they are far from autonoumous as Zippy suggests. Almost all clinical interventions/ prescriptions/ administering of meds need to be authorised by the Dr first. Outside of Hospital, they can only practice to the level of an EMT (basic)...sure they can start an IV, but they cannot push anything through it without a script. No advanced airway interventions (RN's don't intubate here, that's for Paramedics or Doctors). So, at the scene of an RTC, an RN here wouldn't be much use to us other than for taking C-Spine control or applying dressings. To be fair though, there'll be 20+ Firemen that can do that for me so help not needed thanks! Whether Zippy likes it or not, if he gets in the way on scene he can and will be removed. Paramedics here are fully autonomous and work under their own licence. They can practice even when they are not on duty - and, indeed, would be expected to if needed. I have the utmost respect for Nurses, they are good at their job and it's one I couldn't do...that's why I'm a Paramedic.

I've also seen it once done by a Dr into the brachial artery. It did indeed travel back up the line and into the bag pretty quickly :shock:

Is it central bony tenderness? Right/ left sided radiating into trapezius? Any step off? Was the patient knocked out or has a reduced LOC? Any distracting other injuries (I'd argue an ache isn't distracting etc)? Any neuro changes (I suppose a reduced LOC comes into this catagory also)? Not every patient c/o neck pain needs boarding. Not every trauma patient needs boarding. As other have said, a full examination needs to be done and all the facts considered before deciding on appropriate treatment. Boarding every patient "just in case" isn't appropriate treatment. You can train a monkey to do that. My concern in this instance is a proper examination wasn't done...not that collar and board was inappropriatly used or not.

I really like seing this type of thread as it allows comparison with what you guys use on the other side of the pond! Over here in the UK, we are very safety oriented....both in hospital and pre-hospital. We go to great lengths to stop the usage of needles so far as practically possible. We use pre-filled syringes and minijets most of the time (which not only increases safety, but speed to administer as well) but in the instances where we have to draw up drugs using a needle, it is discarded the minute they are drawn up as we can administer straight into the catheter through injection ports. I have grabbed a few pics of our system. We use Braun Vasofix safety cannulae. Click to enlarge! 14G for ease of photographing. On withdrawing the steel, you can see in the circled area within the orange plastic, a safety device that slides down to cover the sharp point. It makes it a little more difficult to withdraw the steel. The top half stays within the patient <duh>. As you can see, the sharp is now covered and is reasonably safe. As close as I can get with my cheap cam showing the safety device. Now with the leur lock fitted. Fluids are administered through the port that the white cap is now covering. Top cap lifts to reveal an injection port for attaching a syringe/ minijet directly without needing a needle. It contains a one-way valve so cap can be left open with no risk of blood escaping.

It took us 5 minutes to get there so all the assessment and initial treatment was done in 7 minutes. My partner put on the O2 and got all the obs...12 lead, bp, SPO2, HR, blood sugars and gave the aspirin and GTN while I took the history, gained IV access, assessed all the obs and history to determine suitability for pre-hospital thrombolysis and drew up and administered the medications. The patient was in the Coronary Care unit in under 20 minutes from placing the call. We were shocked ourselves when looking at the times afterwards but everything went so smoothly and we worked well together.

Sepsis?

We have digital radio systems. The handsets have a nice little orange button that when pressed, brings up an alert on the RT operators screen which cannot be cancelled for 30 seconds...it locks out everything else. The channel on our handset then stays open allowing the RT op to hear everything that is going on at scene. The handsets also have GPS so the co-ordinates are also sent allowing the RT op to identify our exact location. Our handsets also have a facility for the rt op to remotely open the channel and listen in on conversations on scene without our knowledge and to also geo-locate. This can only be done by the Duty Deployment Manager under certain circumstances...ie, we don't answer our radio for extended periods etc. See here for info.

My service covers 3200 sq miles (rural/urban) and a population of 2.6 million. We generally average 900 emergency calls per day. 383 Paramedics and approx 474 EMT's. Each ambulance at my station (the busiest station in the patch) averages 10-14 emergency calls in a 12 hour shift. I've just been speaking to a friend who works a little south of me at London Ambulance service. It covers 620sq miles and handles approx 4000 emergency calls per day. It has 407 Ambulances and 150 Rapid Response Vehicles (Cars and motorbikes). It employs 840 Paramedics and 1,550 EMT's.

Looking at the ECG, yes I maybe should have done a R side. I chose not to as the Systolic BP was 137mm/hg. This only dropped to 130 with GTN and Morphine over the short (< 0.5mile) journey to the Hospital. I guess if the patient was hypotensive or if it was going to be a longer run into the Hospital, I would have done that R side ECG. I'm kicking myself for not doing it though....just for completion.

Had this late last year. 61yom - could see he was having an MI as soon as we walked through the door, no need for monitor! Classic signs and symptoms right down to the "sense of impending doom". Oxygen, 300mg Aspirin, 2mg Buccal GTN, IV access, 10mg Morphine, 5000u Heparin and 9000u Tenectaplase then transferred to local Coronary Care Unit. Call to needle time of 12 minutes! I checked back on this guy about 6 hours later and he was sat having a meal, pain free and looking well. ST changes had almost reverted. As far as I am aware, he was transferred for salvage PPCI. As of 1st Jan, we can now directly admit for PPCI as the Hospital that performs it has now extended it's catchment area.

Don't forget, UK Para's have a +25% unsocial hours bonus which makes it closer to $62,000

Yep, exactly the same happens here in the UK. My point is I don't worry about medicating the 1 seeker in a hundred patients that I see. I cannot say that somebody isn't experiencing pain....only the patient can tell me that. If they say they have got pain, then they get pain relief in whatever form I feel necessary. Control of pain is important not only for humanitarian reasons but also because it may prevent deterioration of the patient and allow better assessment. Sure, they may be lying through their teeth or I may have my doubts about a person but at least I can say, hand on heart, that all my patients get adequate pain relief. As soon as you start becoming selective about who gets pain relief, innocent patients are going to lose out because you don't believe them. Pain is a complex experience that is shaped by gender, cultural, environmental and social factors, as well as prior pain experience. Thus the experience of pain is unique to the individual. It is important to remember that the pain a patient experiences cannot be objectively validated in the same way as other vital signs. Attempts to estimate the patient’s pain should be resisted, as this may lead to an underestimation of the patient’s experience. Several studies have shown that there is a poor correlation between the patient’s pain rating and that of the health professional’s, with the latter often underestimating the patient’s pain. Instead, Ambulance Clinicians need to seek and accept the patient’s self-report of their pain. This is reinforced by a popular and useful definition of pain: “pain is whatever the experiencing person says it is, existing whenever he/she says it does". - (Joint Royal Colleges Ambulance Liason Committee 2006) People usually ring an Ambulance because they have an acute problem which may be an acute exacerbation of a chronic illness. Having chronic pain doesn't mean that they don't deserve immediate pain relief before stabilisation of their condition and a review of their treatment plan and medication. Here in the UK, we are totally autonomous from the hospitals. We don't work under an extension of a physician's licence, we are a licenced practitioner in our own right. Yes, we do keep in mind the bigger picture of what will happen at the hospital, but it has no real influence on what interventions I perform pre-hospital. I assess and treat my patient on how they present at the time of my assessment (and re-assessment). It is of no concern to me what happens once I hand over.

This is exactly how I see things. It really doesn't bother me if I get caught out by a seeker - I know that everybody I treat gets adequate pain relief. A vial of Morphine costs pennies which I don't pay for.

Yes, I totally agree that the idea is good in priciple. Where it falls down is certain Crews don't want to take on the extra responsibilites that the role has evolved into. Many are long time paramedics and EMT's that joined the service when it was little more than a van, stretcher and first aid kit! This leaving patients at home lark goes totally against all they have done for the last 30 years and the safety net of the ED that they once had is gradually dissolving. Their mantra is "cover your ass!" - which translates as "pass the book and don't take responsibility". This job is now as much about the paperwork as it is the examination and treatment options. To me, it is vitally important that I dot all the I's and cross all the T's. Every part of my examination is documented including the checks I have made where I've found nothing of interest....if it isn't documented, it didn't happen! Looking at the HPC fitness to practice hearings (something I do on a regular basis), a lot of cases are down to incorrect documentation or failure to perform an adequate examination and formulate a proper treatment plan. The way I see it, if you do a full examination, document all your findings and provide treatment, transport or referral then all the bases are covered. If you do your job to the standards expected of any paramedic then you have nothing to fear. It's when you tell somebody they're a waste of space without an examination and leave without documenting your visit that you leave yourself open to critisism - and rightly so! Unfortunately, many crews will take the easy road once they've jumped to the conclusion that they are dealing with a timewaster and take them to the hospital thus passing on responsibility and extra workload to the hospital staff. They have a fear of losing their licence which they think goes away if they take everybody to hospital. Unfortunately, this is not the future of the Ambulance Service in the UK. If you can't embrace the changes and evolve with the role, then you cannot carry out your duties effectively and arguably, your fitness to practice is impaired. It is envisioned that in the near future we'll be taking bloods, urine samples, prescribing anti-biotics and god knows what else. It is an exciting time for pre-hospital care in the UK and the role is evolving very rapidly. Entry requirement are going to be foundation degree with progression onto BSc (Hons). Unfortunately, it's sink or swim time for many staff over the next few years I believe :?

I don't know where you work, but all our paras earn £32k....the new student para's are on less though but then they are training. There has been no para courses in our trust since A4C was implemented Aug 05 therefore all para's went accross at the top rate. Lets not split hairs on what is the basic rate though. All our para's/ EMT's get +25% unsocial hours allowance every month, even if we are off sick or on leave. It is not calculated on actual unsocial shifts worked. All our Para's/ EMT's get £1500pa to be available during breaks. This is also paid if we are on leave or sick. That's why I regard it as a basic rate....which is actually closer to £33k for a para. I fear you have missed my point though :roll:.....we are pretty well paid for what we do and I believe we should put our training and skills to use and earn our cash. If you just want to take any old dross to the hospital and not use your training, experience and judgement, then you are in the wrong job.....you should be working for John's taxi cab co. As you know, the NHS way of healthcare is totally different to the US model. We are putting in place measures to stop unnecassary admissions to the hospital and referring a lot of patients on different pathways to healthcare rather than transport everything. Treating in the home is a buzzword at the moment. Many of our regular Para's (not ECP's) are able to glue or suture lacerations at home to reduce the need for hospital admission. We are trained in advanced assessment skills. I can directly admit to coronary care or medical/ surgical wards. I can refer directly to a patients GP, District Nurse, Diabetic Nurse, mental health teams or social services etc. I've just got in from a 12 hour nightshift in which it was fairly quiet and had 9 callouts - none were transported to hospital. 2 were time wasters and I educated them in the error of their ways. The other 7 were suitable for treatment at home and referal to a GP/ District Nurse/ Social service. The funding for the Ambulance service is ultimately via central government and therefore they want to save money. The EMS services in the US are, as far as I am aware, run as a business and seek to recoup the cost (or at least part of it) from the patient/ government. In this instance, it is only good business sense to transport everything to hospital. I am pretty sure if private healthcare insurance was introduced in the UK, then there would be no need to train paramedics to such high standard of clinical assessment and there'd be no need to be totally autonomous in our practice. Our referal pathways would go out of the window and we would be told to transport everything to the ED. The cash saved in this area would then be ploughed into the ED's. Hey, just call me cynical

We can use Entonox, Paracetamol, Ibuprofen, OraMorph, Tramadol IV (up to 200mg prn) and Morphine IV (up to 20mg prn). It is up to the Paramedic to decide what pain relief would best suit the patient's condition and the starting dose. This usually comes with experience. Eg for severe trauma, I'd probably start at 10mg Morphine and then titrate the further 10mg to response. If I knock the resps out, I wouldn't break out the Narcan....I'd just bag the patient for a while - at least their pain is under control. There's been talk of us getting Ketamine to be used in sub anaesthetic doses but I don't think it'll be for a while yet.

Where I work, every Emergency Ambulance is equipped with a lift. They are excellent! Door on one side, lift on the other.

We already have the option to totally deny transport to patients who have no clinical need to go to the hospital. As long as we do a full examination and document the findings then there is no issue. It is done all the time where I work....if they don't need hospital treatment, we tell them so and refer them to their family Dr. If they still want to attend the hospital, we tell them that they are free to make their own way there as they don't require an emergency ambulance. 9/10 they don't bother. The trouble is, a lot of crews take the easy road and walk the patient on to the vehicle and off again at the ED, doing only minimal obs. They'd rather pass the book to the ED than use their clinical skills and judgment. If that is all they are going to do, then we may as well just employ taxi drivers to ferry these people to hospital and save a fortune. Let's be honest, we are pretty well paid nowadays earning a basic of £32,000 ($64,000 US) pa, let's start earning it! I do agree that we should be able to levy a charge to the timewasters though.

I didn't say it was impossible, only very difficult. I have spoken the the recruitment team directly when they were at Ambex last year. I was told it was straight forward for SrPara's as skills matching had already been done - you can go over there and work pretty much as soon as you arive. Help would be given with the visa and help towards relocations fees is available. For an EMT, you would have to arrange your own visa and pay your own relocation fees then apply directly once you are there. Skills matching takes a long time. There's also no guarantee of employment once you get there.

Unfortunately, this is the way of the world and for almost any job. It happens here in the UK....many of my friends left uni with a degree and found it really hard to get work. I chose to go the vocational route and gain experience and joined the Royal Marines at 19. I joined the Ambulance service at 27. I've just finished a Paramedic course after my 2 years as an EMT and will be doing a degree at uni come september. My experience and current qualifications means I get accreditation for prior learning so I only have to do the final year of a 3 year degree and it's all paid for by my employers Expect to see me applying for an Aussie visa towards the end of next year.

I know exactly what you mean! I passed my entrance tests exactly a year ago. I have been planned on 4 courses in the meantime which have all been canceled. Now in week 2 of Para course so don't let 'em grind you down Good luck, all good things come to those who wait apparently.

Unfortunately, you'll find it very hard to to gain employment in Aus with just the EMT qualification. It is far easier to get yourself on the next Paramedic course in the UK then look to make the move. HPC registered Paramedics are already skills matched in Queensland.

It's simple really....it's much easier and cheaper to recruit fully qualified and experienced staff (from abroad or otherwise) than to take on a relative "unknown". It's called building up a skilled workforce and is a wise move for any employer and good business practice. I am on a Paramedic course here in the UK at the moment after 3 years as an Advanced Technician. Once I get my ticket, I'll be looking to move over there where I'll skills match straight in at Advanced Paramedic (Queensland). Once there, they'll assess my extra skills over and above that of Advanced Paramedic (IO access, ET intubation, 12 lead ECG, needle cricothyroiotomy, needle thoracocentesis, Ext Jugular vein cannulation, thrombolysis etc).