krumel

Nice memo and for sure a one very well thought of... Just an observers notice: Have of the world who were using Scoops&vacuum matresses (or just scoops) by now have turned over to spineboards because they are "the good thing from the states".... I wonder what will happen nexxt... the US-Paras during to vacuum matresses?

Just one little thing: Have you thought of using a LT-Tube instead of a LMA? The "system" is the same as the LMA but there are various studies that show that the LT is easier to use and teach to group like you're trying to instruct.

Being around with mobile intensive care transports for a while I must admit I see the problem chbare is seeing. Ventilator therapy is getting more complex in our times and it is not a field that should be handeld only by the "paramedics have their hands free" perspective. On the other side there a plenty of Ventilators below the level of an full-size ICU-level transport ventilator like my beloved Oxylog3000 or the Hamilton T1. With the basic Weinmann, Draeger, etc. ventilators that basically have 3 parameters to set its a hole different story. Personally I would like to live in a world where a prehospital provider can handle a full size ICU-ventilator...But... As we all know this is not the case it might at least be a good start to go with an "easy" ventilator (by the way: Germany company weinmann is adverising an "full automated ventilator" that only needs one parameter input from the provider)... Because one thing is for sure: A mechanical IPPV will be much better than a "BVM" IPPV by a "scared" provider. When it comes to actual models(I think this was the original posters intention) I personally prefer the oxylog 3000 or the Hamilton T1 (the oxylog mainly for the "being used to it" factor, the Hamilton itself might be the better concept)...I worked with Weinmann Transport, some old Siemens&Dräger ones (Servos&Evitas, even a Siemens 900C at some point) and a few crazy creatures like the ambu...But I mostly hated them... when it comes to basic vents nothing comes over the extremly reliable Oxylog1000.... No batteries, reliable and stable as hell and light&small.

Worked for a small service in the alps for a while....Next hospital (very very basic one - The docs had to come in at night...and no surgeon during weekdays nights) was 30 Minutes, next trauma center was 2.5h hours in summer (going over a mountain pass up to 2500m...)....In winter you were screwed. Ass the passes are closed you can only get there by train..So pack the patient in the ambulance... drive the ambulance on a train...wait 45 Minutes..drive off the train... Makes 3.5h hours in total. BUT the train operates only during the day.... So at night you totally rely on HEMS (who very rarely are able to fly over the passes in winter-nights)...Or "store" the patient at the hospital...Or try to get the federal insurance commision to allow you to go to the next foreign trauma center -which is still 3h... But: We had DVD Players mounted to the roof of the ambulance so the patient that are not critical can be watching DVD and (theoretically - I've never seen it working- TV)

The german speaking world uses something called the "Maurer Scheme". This is made up by a joint comitee of EMS&Fire Dept. Bosses.... It has a "point-score", depending on the type of the event, the estimated visitors, etc. Those are added together and the final score give you a direction how many staff, ambulances, doctors, etc. you need. (Although the "doctor count" will be much higher due to system differences).

Sorry, I'm not allowed to talk about the company anymore. Sorry.

My old service used HyperHAES, which is hydroethylstarch with 7.5% NaCl for small volume resucitation and - in some very rare cases- for hypotensive head traumas. Had some good effects on the BP-side, I personally did see much effect on the neurological side.

Regarding Australia: The minimum level would be an "Ambulancer officer"... This is still more training than an EMT-B & as far as I know there is no service that hires AOs anymore (and the AO grade is only given to students, beside some older "left-overs"). (And beside that your scope of practice looks smaller than a AOs one in most services) Technically there is the chance to get a (at least temporary) visa as an EMT-B in AUS. But: Seen realistically it is impossible. There are enough people with normal paramedic-degree trying to get into the country (and failing). Seen realistically the state ambulance services (and the two state-contracted services) won't hire you. So the mining industry and the "event-medicial"& patient transport companies are left. The mining industry is strongly going for MICA-Paramedics and/or Paramedics with an double degree (nursing/paramedic) or a community paramedic-master. Personally I know a lot of aussie medics that are trying to get into the mining industry for years (or it took them years). The patient transport companies and event medic-companies would hardly be able to sponsor you as fulltime-work and a certain wage is a requirement. If you come over with another persons visa: Try it with the above mentioned (event medics and patient transport)...and get a recognized qualification (=> Uni-Degree). Regarding Germany: An american EMT-P can be recognized as a "Rettungsassistent" (the highest possible training level for "non-doctors"), the local goverment bodies (of the regions) are responsible for that. But it would mean serious deskilling as the scope of practice in Germany is reduced (not to mention the pay) and the system is (in most regions) very doctor-on-scene-based.

What I love: Storage - Everything is there..Always. The last two services I worked for where quite lazy when it came to storage-handling..So I often ended up with a "shit, only 4 infusions left and the new delivery will not come before monday"-Situation..Here...You want it - you get it...No matter if its a 20-cent Saline flush...Or a new ambulance. Support - The "support" we give each other on the "frontline" is great...By far the best I saw so far. And even the company-support itself goes far beyond what most other services can offer. Development - We are not the best service in the world...But currently probably the one which develops fastest. What has been introduced/changed within 2 years..Is enough for other services and 20 years. The change is simply impressive.

Used Haloperidol (very rarely), Diazepam (rarely) and midazolam (most of the times) for sedation. Personally I prefer the Midazolam due to it's ability to give it IN and the fact that it wears of much faster...Which makes it much easier to control, especially if you don't know what else the patient did take....

@J306: Your post shows a big knowledge gap in the pathology of back injuries. Almost every study regarding the development of back injuries demonstrate that building up muscles can prevent certain kinds of back injuries (especially those from single capacity overload) but not all kinds of back injuries. Those developing by repeated load to a certain percentage can not be prevented by muscles...... But back to topic: Personally I try to let "as much as possible" patients walk to the ambulance. Not because I'm lazy but I want to see how the patient reacts to walking. Especially in neurological patients this gives a huge diagnostical benefit. Of course spinal-immobilized, (real) chest pain and those who are "really" sick get the stretcher/chair...But they are very rare...

WA has a pretty decent one for it's flight paramedics.... And some parts of switzerland as well..

That's sad:( condolences from the other end of OZ.

Personally I totally follow aussiephil...Never.... My management (which is not involved in the hole thing.... afaik) is 100% sure that November 2013 will be the date.... So.... Yeah.... Sure....

I worked for a service that did routinly check the patient body temp. in an trauma...And can just support chbare's post...quite a lot of patients we saw were (mild) hypothermic. Coming back to the "microwave" myth: Interestingly we heard this myth in Europe, too. A mail to one of the "big brands" revealed the following: According to them there is a certain (small) hazard as household-microwaves warming fluids tend to have a very "dissimilar" heat intake. Own experiments of the company did show that some ares might get "hotspots" where the temperature does exceed the limitations the plastic bag can stand. This may cause a "washing off" of certain flexibilizers.

First I have a very strong feeling that I know the nurse your talking about... Give me a PM.... And I guess I know the school of the "young one" as well....As I once (yeaaaaaaarrrrrsss) ago went there to I asked back then whats the scientific base for this thesis...And there simply is none.... But back to topic: I definitly go the way croacker described in his post.... Consider the fact that something made people call EMS.... You (normally) don't get called for an known epileptic patient who is known to have 20 seizures a day.... You may see those patients in a transfer...But you then will know before.... When you get called usually something already went wrong.... Which means a known and medication-controlled epilepsy patient is having "a bad day" and has seizures again or something else made people not to exspect a seizure.... When you then consider the fact that you as an EMS Provider need some time to arrive on scene.... By then it is for sure a "status" or "intervention-worth seizure"... And as far as I know the worlwide common oppinion (beside some nurses) is: a status/ongoing/longgoing seizure needs fast intervention... and in case of a hypoxia (which normally is the case) some O's..

I actually used Flumazenil a few times (four or five times I think), in one case in a "CV/CI" situation after we a Ketamine+midazolam+suxamethonium RSI. We have no real protocols regarding Flumazenil but we try to titrate it to a dose that does not make the patient "wake up" but reduces your A/B problem. Same thing here with naloxone..We try to use only minimal dose of both drugs to prevent the side effects... During my internship at a toxikology-ICU I once saw an patient going totally psychotic after Flumazenil+Naloxone administration given after a massive overdose. The patient broke his own arm trying to get out of the restrains...They tried to "chemical restrain" him with other drugs but this happend before the drug started working....

I have just a very vague knowledge about the hole HIPAA Thing so I will answer from my current european perspective.. My former service had no problem with a medic dating a patient. Happend a few times, a few marriages and baby were created this time...(Basically you can almost date everyone as long its not your student... this may even bring you to jail here,no matter how old they are) BUT: A medic would definitly be fired for getting the phone number from a patient record. It is okay to ask a patient for a number,e-Mail or a date during the call as long the patient care is not affected, the question ist well mannered (this i.e. means the medic ask once and not till he gets a positive result), the patient sane and in a stable coniditon and the question is asked in a way that it's easy to be recognized as a private question. This means "What's your phone number" is wrong..As the patient may think this is related to official duties... But..He may ask "I like to ask you out for a date, may I get your phone number?".

MD900 is a pretty cool Helo and has definitly enough room for critical care transport. I "tested it" once and quite like it..BUT: It's not that common in Central-Europe due to some issues MD has with it's replacement parts....

We use Midazolam for years now and are pretty happy with it... You can administer it in almost every way...i.V., i.O., rectal, i.m., i.n.... And it works always fast, "potent" and proper. I can only remember two incidents were I had severe problems with midazolam... Both were related to alcohol... One was a 110kg female Patient found in a public park "somewhere in the Bush"... Massive convulsions, not possible to gain i.V. access. Gave 2.5mg Midazolam intranasally... Patient stoped breathing a minute later. We found ourself in a "can not ventilate, can not intubate situation". Had to use flumazenil to bring us out of this situation. On ICU they monitored a 4.2 promil alcohol blood level...Problem was: Due to the heavy smells on scene we did both not smell the ethanol...and no other obvious signs of alcohol consumption were visible. Another patient, 79 year old female, former alcohol addict, had some kind of paradoxical reaction. A significantly increased dosis helped managed it... Key point: Be aware of the danger of Midazolam in combination with alcohol... The effects are bigger in comparison with valium.

Remembers me of a patient with two broken femurs and about 9 other fractures (fall from 12m) who choose to wait in front of his house for us...standing.....

I asked this question as most colleagues at my former service were pretty scared of mixing drugs. Personally I used this combination for dislocated shoulders as Fentanyl is working quite a bit longer than Ketamine.... Especially in situations were the main source of pain is movement or the "Reposition" of limbs it is a pretty good combo I think....

In my former service I could choose between Fentanyl, Morphine, Pethidine and (Normal)Ketamine.... I found the discussion about not giving pain meds for "diagnostic purpose" quite interesting as we have a completly other doctrine here... ER Personal will get pretty mad if the patient is in pain and we don't have a really good excuse. On the practical side I'm clearly in favor of ketamine in a multi-systems trauma....It provides quite a good pain reduction and brings (when combined with a benzo, i.e. Midazolam) to a very "calm and stable" state soon. BP-Management is as well as never an issue as the BP will normally only go up in a 10-15mmHG range which only very rarely is a problem... Emergence-Phenomen occour sometimes, most of the times in Patients with an preexisting mental or neurological deficit but can be controlled with Midazolam just fine. (By the way: Emergence can also occour with patients who seem asleep.... YOU can't see it..but the patient will remember it when you don't use a benzo...) Back in Germany we used Esketamine a lot, the Racemic of Ketamine which does not bring that much side effect, i.e. almost no emergence and not that much hypertension....Quite good stuff... But to bring up a new topic in the discussion: Experience about the combined use of Fentanyl and Ketamine anyone? So long, K

My (since yesterday) former service did 1800 calls a year.... 12h shifts with additonal 12h "standby-service". Average call load is 3 calls per 24hours... I broke the record this year with 19 calls...

The 3-seated aircrafts (although also on the EC135 a 4 person crew is possible and this is a good choice if you're doing critical care transport) are not that adequate for critical care transport. This is one of the reasons (together with the "more space"-point) that most critical-care helos in GER use EC145, BK117 or Bell's...