rock_shoes

1) Why is this posted in "Funny Stuff"?

2) Who made any of us judge, jury, and executioner? When someone calls in emergent medical distress, my job is to answer that call not engage in social judgement as to why that person ended up in a particular situation.

3) Previous forms of "3 strike rules" have been complete, epic, failures. Why should this particular line of thinking be allowed to prevail?

Sorry to hear. Rest and healing to his family and loved ones as they work through this.

All of healthcare in British Columbia has mandatory vaccination. At this point anyone who has not received at least dose one has been placed on leave without pay. There are exemptions in place for those not medically able to be vaccinated.

Personally I don't have a problem with it. I had to provide proof of the standard schedule of vaccinations just to be allowed into my education programme (never mind to be employed). What reason would I have to expect anything different with respect to vaccination during a pandemic?

Sad news. Rest and healing to his family and loved ones.

On 4/27/2020 at 11:21 AM, Jim Squire said:

Rock_shoes,

First, thanks for  the response.  I appreciate the time people with experience like you take to answer questions from people like me who are in the process of starting out.  I have no idea why I find all this so fascinating, but I do.  

Unfortunately, I'm not sure I understand your point - I'm still just a student without a single ride to my name yet searching for a class that's open during COVID without much success.  Can you check my analysis below and tell me if I'm right?

The Monro-Kellie Doctrine (which was a new one for me; thanks!) says that if any one of the 3 volumes of brain, blood, or CSF increases then another volume must decrease and ICP will rise.  That makes sense intuitively to me, and is why an intracranial bleed 2/2 head trauma would cause an rise in ICP.  But why is morphine contraindicated here?  I would think morphine would decrease BP, therefore decreasing cranial blood volume proportional to the brain's arterial compliance, therefore decreasing ICP, and therefore improving things.  So from that, morphine is good.

Cerebral perfusion pressure (yet another thing I hadn't heard of before; thanks!) says the greater the differential between the MAP and ICP, the greater perfusion.  Also makes sense intuitively.  From that I see that the drop in BP from morphine combined with the increase in ICP if there is a brain bleed or post-traumatic swelling would be bad; it would decrease the pressure gradient and therefore decrease neural cellular respiration. So from that morphine is bad.

Combining those two things, the takeaway is that, in practice, the damage that morphine does from decreasing cerebral perfusion is worse than the improvement it does by reducing ICP, so don't use it.  

Is that right?

I love it when a plan comes together. The heart of the concept is minimizing cerebral oxygen demand while maintaining a sufficient cerebral perfusion pressure and flow for tissue oxygenation. Assuming an ICP of 20mmHg, it would take a MAP of 80mmHg to maintain a CPP of 60mmHg (I bet MAP guidelines for the management of TBI are suddenly making more sense). Some sedative/analgesic medications balance those considerations better than others. This brings in the concept of flow metabolic coupling (Propofol is particularly good at this as sedative agents go). Agent's with good flow metabolic coupling such as Propofol reduce cerebral oxygen demand in balance with the amount they reduce cerebral blood flow. Agents such as Morphine or Midazolam do a poor job balancing the two considerations and reduce cerebral blood flow relatively more than they reduce cerebral oxygen demand.

On 3/28/2020 at 3:37 PM, Just Plain Ruff said:

When I went out due to developing a fever and was told to stay home for 14 days which was shortened to 7 days due to not having further symptoms, I was told that I could either use PHO's or not get paid.  How's that for fun times.  

PHO? I'm guessing that's what your service calls banked time?

All evidence continues to support taking full droplet precautions with suspected COVID patients. This one's the real deal. The numbers out of Italy tell the story as to what will happen if we don't take this seriously soon enough. My service switched our sick leave (75% pay) to general leave with pay (100% pay) to discourage employees from potentially infecting colleagues. 

http://www.vch.ca/about-us/news/news-releases/vgh-leads-the-way-in-traumatic-brain-treatment

Very long story short, look up the monro-kellie doctrine, and principles of cerebral perfusion pressure.

On 2/22/2020 at 10:49 PM, Matak96 said:

Hey guys I have a question on how to become a flight nurse. So I already have an EMT background completed. I tried to apply for a bachelor in Nursing but I didn’t get in. And now I don’t know what to do. There is a school near me to become an RN and there’s another school that offers the paramedic program. Which route do you guys recommend I take? I also have the other option of trying to apply again to the school of bachelor in nursing but it will take a year until I find out if I get in or not. What do you all suggest I do? Should I wait to hear back from that school again or should I go for paramedic or just get my RN then do a bridge to paramedic to be a flight nurse?

From what I know of the US system I would suggest getting your RN and doing some form of Paramedic bridging program. Take that with a grain of salt however as I've come up through the Canadian system where working your way to the Critical Care Paramedic (CCP) level is the best way to gain entry to air ambulance work (1 year PCP education, 2 year ACP education, 2 year CCP education). As you can see the path is roughly 5 years of post secondary paramedic education in Canada, which you'll find is markedly different from the US path.

It's barely possible to justify ultrasound on most units never mind an X-ray generator. Big expense with marginal applicability to practice.

Perhaps try organizing your reporting into a systems based structure.

Neuro

Cardiovascular

Respiratory

GI/GU

MSK

Other (Obs/Endo/immune)

On 10/14/2019 at 4:17 AM, Jamien said:

hi i'm Jamien i just finished the EMT-B training for New York in september. i am planning to start medic school next fall. my long term goal is to work as a flight medic. anyo advice or tips would be appreciated!!

thanks 

Good luck to you sir. I work flight in British Columbia, Canada and love the job. The US air ambulance safety record scares the living daylights out of me. Enough so I wouldn't be willing to work air ambulance in the US.

On 10/15/2019 at 11:15 AM, Jim Squire said:

I'm learning to become an EMT, so be easy on me for asking this newbie question, but it points to something about O2 adminstration that I don't understand.

Virginia's health department posts a bunch of scenarios for EMT training like this one:

http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/M003.pdf

In it we find a young adult diabetic patient with a Rx for insulin, able to speak but not feeling well, alert and oriented x3 but "sluggish to respond" and a CC of "not feeling right".  He has an O2 sat of 95 and respiratory rate of 14, no mention of cyanosis, vitals normal except for low glucose.  Why does the grading criteria call it a critical fail to not provide O2?  As a not-yet-certified EMT student with no field experience, I'd think this pt doesn't seem to be in any sort of respiratory distress; he just needs some glucose paste and continued monitoring enroute to the ER (and probably doesn't even need the ride, but I understand we are always supposed to transport everyone unless they sign waivers since there are problems that require more skill/equipment than we have to Dx.)  Are we supposed to automatically provide O2 for everyone (except those in hypoxic drive), regardless of O2 sat?

Just when I think I'm starting to get a handle on this... 

Without more information, I'm willing to wager this is likely a matter of local protocol not evidence based practice. Based on the information provided the patient doesn't have an oxygenation problem.

On 4/17/2019 at 6:28 PM, 1EMT-P said:

Should EMS abandon the use of Fentanyl in the field? Based on the fact that it’s a highly abused and addicting substance. It’s not like we don’t have alternatives. Please share your thoughts.

Almost every controlled drug in my daily carry has significant abuse potential in the wrong hands. Why should best practice patient care be compromised because someone might abuse it? What opiate would you suggest a service carry instead when all opiates, benzo's etc. have abuse potential?

On 3/6/2019 at 6:52 PM, jakemedic said:

So is this website still relevant?  30 yr paramedic here.  Not much shaking here.

Be safe Out There!

Jake

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.

12 minutes ago, Just Plain Ruff said:

Well, I got a tentative job offer same day, but he wanted to talk to the crews and also see what HR had to say.  I was hoping for a phone call today.  

I'm patient.  We shall see.   

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?

On 5/26/2018 at 9:05 AM, Arctickat said:

Why do we use a verb for aggressively grabbing something to describe someone who is having a seizure?

To Seize is to grab something.

To Seizure is an active convulsion due to illness or trauma.

I have actually had doctors confused when I stated the patient was seizing because their interpretation of the word was that the patient was grabbing for stuff. Now we use "Seizuring" to avoid further confusion.

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).

On 11/5/2018 at 9:18 AM, AussieTimmy said:

Hi All,

Some of you may remember me as ‘Timmy’, the annoying and overly enthusiastic 16 year old cadet from Australia.

It’s definitely been a number of years since I’ve been on here but I’ve gown up, done a few university degrees and working in the real world now – thanks to the support of some people on here, back in the day.

I recognise a few names from all those years ago, hopefully I can get in touch with a few of you.

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.

On 11/1/2017 at 3:44 AM, BushyFromOz said:

So after 3 years and no post, I've successfully resurrected 1 dead thread and started another....

 

Anyway, Methamphetamine has become a big story here over the last few years, (the jokers would say we don't have Methamphetamine problem because everybody has it)

. And unlike you Heroin epidemic of the late 90's, to late 2000's where they were nice and peacefully asleep and a little bit cyanosed and they would generally wake up with some oxygenation and some Narcan and be pretty OK with things, these mongrels are often wound up like spring, especially the polypharm OD's and sometimes even the synthetic Marijuana user. It became such a problem we are now giving high dose IM ketamine to knock them down as Midazolam was ineffective,

Just interested to hear whats happening in other places,  are you dealing with it, and are you seeing secondary problems such as serotonin syndrome/rhabdo/renal failure/MI often?

 

There.. my contribution for the next 3 years

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.

On 11/6/2017 at 4:52 PM, BushyFromOz said:

We have had some interesting results since we swapped to Ketamine as our primary induction agent with our status patients. Where previously they were unresponsive to Midazolam, they often cease seizing on induction. As we do not routinely paralyse our status patients unless their seizure activity prevents their oxygenation, so the tube is maintained with sedation alone.

Previously when our induction was Fentanyl/Midazolam, you would get brief periods where the patient would cease seizing but then recommence and you were often bolusing midazolam during transport on top of you sedation.

I love Ketamine so much, can't remember life before ketamine (I don't want to remember it either)

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.