rock_shoes

Years ago I found this site as a brand new provider. It helped shape where I am now and put me in touch with mentors I am forever indebted to. Site activity has been quite low for some time now so It's difficult to say if it would serve a new provider the same as it did me.

I'm going with a probable welcome back to the field. Sometimes it's nice when what's old is new again. I spend most of my time flying now but still enjoy the occasional shift working a street car. I like the reminder as to where I came from and why I decided to move into my current area of practice.

Wow. 11 year old thread resurrection. Impressive!

Employment status update?

Do you perhaps deal with physicians from outside of North America? Other parts of the world use different descriptors for the same condition ("fitting" is a common descriptor in many places for what we would call a seizure in North America).

I know the feeling. A little more than a decade ago I started here as an EMR (EMT - B equivalent for the US folks). Now I've done an additional 5 years of post secondary along the way and work as a Critical Care Paramedic responding to the sickest folks in the province of BC by air/land/water. Funny how the more you know, the less you feel like you know.

Unfortunately Ruff is right on the mark. If you haven't been assaulted on the job as a paramedic you're probably about 2 days into your career.

The Bledsoe textbook is a decent primer to critical care. I'm not too familiar with the US CCEMT-P education requirements but I know Bledsoe's text is just scratching the surface by the Canadian Critical Care Paramedic standard. I would dive significantly deeper if you want to be good at it. UpToDate is an excellent resource with regular evidence based practice updates. It isn't cheap but worthwhile resources rarely are.

We're essentially walking the Ketamine path right along with you. Big dose IM Ketamine for this indication is starting as a trial in one of our urban zones now and will likely be extended to the rest of the service by the end of the year. We've used Ketamine for all kinds of indications in air-evac for a long time. It's new to street level ALS practice in BC.

1) Ketamine 2) Epinephrine 3) Ancef 4) ASA 5) Benadryl If I only get 5 they better be flexible in their use.

Ditto regarding the maintenance of paralysis in our service. We avoid it if at all possible with these patients. I've found Ketamine/Propofol for maintenance of sedation (plus or minus a loading infusion of phenytoin) really give any further seizure activity the old one two punch.

Working in the Vancouver area I've seen a number of these overdoses. Management isn't really any different than any other opiate overdose. The only real differences are how long it takes to get the correct amount of naloxone on board and the probability the patient has aspirated. There are two main issues to keep in mind. 1) Always oxygenate and ventilate before naloxone to prevent wildly swinging hypoxic patients who come up angry (they probably still won't like that you've ruined their high but at least they're not taking a swing at you). If you're unable to get the patient oxygenated with good quality BVM ventilation and an FiO2 of 1.0 within 5-10 minutes of treatment, naloxone is no longer your friend. In these cases the patient has likely aspirated significantly and you're typically better to leave the patient down for intubation/ventilation. 2) If you're dealing with fentanyl or carfentanyl it will take boatloads of naloxone compared to what you typically expect. Instead of 0.4mg to 0.8mg IM or IN it may take in excess of 8mg IV. If that's the case setting up an infusion after bringing them around may be your best bet if you have the option. Expect to need roughly the amount it took to bring them up per hour immediately post rousal.

This particular study tells us absolutely nothing about inferiority/superiority. I don't see any confounding factors accounted for such as intubator skill level or cause of arrest, nor does the study have sufficient overall numbers to draw any conclusions. The study arms are broken in to "initial management with ETI" and "initial management with BVM". What's the time scale here? Does initial management with BVM mean the first 10 minutes of the arrest or the entire arrest management period? Does initial management with ETI mean at some point early on when other more important interventions have already been started or essentially when the crew first walks in the door? This study leaves far more questions about it's own validity than it does about the harm vs. benefit of early ETI in cardiac arrest.

Funny. I probably would have told my younger self to suck it up and go into medicine instead of becoming an over educated paramedic who's job doesn't exist in any country but Canada.

Nobody works in EMS as part of a get rich scheme, but making enough to be able to participate in the lifestyle you desire outside of work is certainly of value. EMS workers in countries like Canada, Australia, and New Zealand are afforded a different level of pay/respect than that received by most US providers. As much as pay and respect can't be primary motivators, those two things have a powerful effect on career longevity. If you choose EMS as a career the most disastrously unhealthy thing you can do is allow it to become your everything. Your non-EMS friends become a lifeline to the outside world. Don't let them go. Whatever your other passions are maintain them. As for helping ourselves, frankly we're lousy at it as a group and certain risk factors will never be avoidable. Night shifts will always exist, paramedics will always be placed in stressful situations, and schedules will always make healthy diet/exercise habits difficult (but not impossible).