rock_shoes

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.

On 3/4/2017 at 6:31 AM, ERDoc said:

I miss my time on the bus (yeah, I said bus).  Maybe we make the past seem much better than it was but I would love to go back to those days.  I don't miss some of the shit that management pulled, like the guy in the Durango they hired whose only job was to sneak up on crews and find some way to bust them.

If I could talk to the young me I would tell him, "DON'T DO IT!!!  DON'T GO INTO MEDICINE!!!"  The enjoyment of medicine is being beaten out of the field by people who have no medical knowledge and have never taken care of a pt.

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).

2 minutes ago, Lili said:

Ah, okay. That is true about the PTSD part, I already have that, but it's much better... I'd sure hope to, I think it'd be a nice thing to do. 

 

How do you like it so far? 

I still love my job but it has changed a lot over the last 10 years. I started out in a rural community where the station did 700 calls a year (working as an EMR which is essentially the same as an EMT - B). Presently I'm most of the way through a Critical Care Paramedic program and working fixed wing/rotary air-evac (CCP programs are a Canadian thing involving roughly 5 years of post secondary education and a tremendous amount of clinical time). Every once in awhile I do get to be the cog in the machine with the ability to prevent disaster for someone. That part is an incredible privilege.

The give and take in this job is not to be underestimated. Paramedic education programmes are rigid/inflexible as a rule. I've missed numerous family events and important happenings as a result. The tolls that missed events, long stressful shifts (particularly nights), and in your case as a US citizen lousy pay, take on you add up. I know without question my life will be shortened as a result of my service. Think long and hard about whether the increased mental health risk, increased heart disease/stroke risk, and shortened life-span are acceptable trade-offs for doing this job long term.

On 4/18/2017 at 3:47 AM, babyrhino said:

Hello Guys I am new on this site and I hope that it will be helpful to me- I was wondering at what time (if ever) it is ok to deny PT transport to a 911 caller if the condition of the caller seems stable? 

Our service will never deny transport but patients can be triaged directly to the waiting room when appropriate (immediately freeing up the crew without them needing to speak to any hospital staff). I suspect the next step may become refusal of service but that becomes a liability nightmare.

On 3/29/2017 at 0:48 AM, Stephni said:

Hi guys! 

So I've noticed previous posts about this and have researched it for hours. Unfortunately most posts on here are rather old. I'm hoping some of you have new info! I'm currently a certified paramedic in Ontario and Alberta, looking into the process of moving to the US. Any kind of information (as current as possible) would be awesome! 

 

Thanks! 

Before you go through some long process, a couple of questions. Are you admissible to the US on some form of work visa (typically employer sponsored)? Are you aware of the average wages for paramedics in the US compared to Canada?

I can't touch on immigration law, but I can tell you paramedics on average are paid dramatically better in Canada (even factoring in our current rubbish currency exchange rate).

Agreed P_Instructor. Some of the most useful family members I've ever dealt with were grandchildren who were able to translate like a boss. No one seems to have picked up on one of the obvious ones though. Timely good quality CPR after calling 911. If nobody does CPR for 6-8 minutes before I get there odds of bringing back a brain are pretty damn low.

Pulse confirmed. Brain function... Well... it might need some work.

Too bad. I guess only the Canadian medics get to laugh at it until the content makes it to youtube.

I've never met nor assessed you medically so I really can't give advise as to your suitability to any position (never mind one in the emergency services). What I will say is this, working in emergency services is a well known precipitating factor to the development of critical mental illness (most frequently PTSD). Do you want to work in such a field when you yourself have already expressed mental illness from which you have not yet recovered?

On 3/26/2017 at 11:40 PM, Ashleychao said:

So I'm an EMT in Kenya and I'm yet to pursue my studies overseas,what are my chances of getting a job there .? 

Do you have the option of taking your paramedic training in South Africa? South Africa is well known for having excellent advanced paramedic training programs.

I'm with Ruff. I don't expect you'll go wrong with a proper pair of Red Wings.

I'm very proud of my Ottawa brothers and sisters for being awesome enough to convince a firefighter to switch teams (to EMS). Oh and welcome to the city.

At least he used his turn signal...

I personally can't get over two particular lines in this article.

"Is health care a right of all Americans?"

"Or is it a privilege for those who can afford it?"

There's a reason the US is the only first world country without some form of bare minimum socialized healthcare. If basic healthcare isn't a right in your country it bloody well should be.

More on the topic at hand, the problem isn't HEMS cost so much as it's too many providers in the market. Multiple providers all scurrying for the same damn peanut creates an unsafe feeding frenzy clearly evidenced by the HEMS crash rate. Clear and concise training for ground crews as to when HEMS is appropriate alongside controlled provision of service on the part of the state. When a ground crew makes a HEMS request that request should go to a state dispatch centre with zero affiliation to any particular service provider. The state dispatch centre selects the most appropriate air resource and they're dispatched to the call. No crew shopping period.

The Medsystem III has blood product administration sets made for use with it. I've always just used the designated blood sets or eyeballed the drip for the remainder of the infusion when doing a transfer.

CBC Canada's public broadcaster has recently started airing a series of short films surrounding paramedics and the calls we respond to. They're some of the best I've seen and intended to be funny. Just be prepared they might make you cry.

SAVE ME

Somehow I've spent 4 out of my 9 years in EMS getting more edumucated. By the time I finish my current program that will end up being 5 years out of the first 10 in EMS. After spending half of my career pursuing higher education in emergency health services my appetite for EMS  discussion during my personal time seems to have waned. Perhaps it will peak again in the future as this current program of study is the end of the educational pathway in Canadian EMS. If I go further it means branching away to other pursuits.

On 1/29/2017 at 5:11 PM, paramatt_ said:

 

That's probably one of the most horrible situations you can be in, especially with a pead. I suppose if her oxygenation deteriorated you would have been looking at a surgical airway.. It sounds like you guys did a great job nevertheless, and with a favorable outcome.

Good chance for a side question..it is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations? I'm a fan of high-flow nasal cannula with lateral positioning if possible.

I'll often insert a NPA in addition to O2, patient positioning, frontline benzo's, and all the usual assessment pieces (vitals, BGL rhythm, etc.). In the end it all come's down to suspected cause. TBI's are going to have a much lighter RSI trigger than say a known epileptic with a history of poor medication compliance.

22 hours ago, Ruffmeister Paramedic said:

Dartmouth,  I agree with their premise.  I always felt that in most ED's they are too quick to resort to the next medication before allowing the first to work.  

 

Are we causing more harm than good sometimes when we move on to the next med.  I think we found that we were in a code situation but this is promising research.   

The caveat always being ability to maintain oxygenation/ventilation. In my own experience the decision to intubate these patients prior to the 90 to 120 minute mark has nothing to do with seizure control. Perhaps Canadian ER's are a little more cautious about taking these patient's airway's? I can only speak for myself but the only time I've ever intubated one of these patients in the field was because the patient was hypoxic, high risk for aspiration, had already aspirated, or they were in ventilatory failure (air-evac transports being a somewhat different of course as that initial 90 to 120 minute may have passed before our arrival).

Emergency medicine has a bit of a "shoot from the hip" reputation amongst the ICU crowd and I think in many ways they have a great deal to learn from each other. Emergency medicine can learn that it isn't always necessary to shoot first ask questions later and Critical Care medicine needs to understand that in the initial phases of treatment morbidity/mortality can increase by failure to act decisively. ED patient's are not typically admitted intubated with initial ventilation optimization and appropriate central/arterial lines. ICU's are presented with patients where critical interventions have been completed making it easier to armchair quarterback how things were done after the fact. This is actually great feedback for the ED but it must be delivered tactfully or the message will invariably be lost.

Our air-evac crews carry phenytoin, propofol, and worst case scenario paralytics in addition to the usual benzo's. We can also make use of any second line agent a sending hospital has in stock if we need to. We use second line agents for certain categories of intracranial bleed with a propensity to seize more often than anything. Scene responses are mainly trauma patient's for us which typically respond to benzo's. Inter-facility patients are definitely where we use them the most frequently.

Second line agent's aren't terribly useful on a city ALS unit and require a pump which few ground services have. For a rural unit with long transport times I can certainly see potential value in carrying a second line agent. The further you are from a hospital the more valuable second line treatments of any variety become. The amount of gear we take with us on air-evac calls can attest to that lol.

ERDoc makes two excellent points in this case. First off, blindly following protocols can be dangerous for patients. Secondly, patient history is needed for sound clinical decision making in this case (was onset within the last 24-48 hours? do you have the option of rate control with a calcium channel or beta blocker?).

Necro-bump!

Unless it has changed since I did my EMT-P exam in 2012, written exams are still of the paper variety. The original CBT project fell flat on its face.

On 12/15/2016 at 2:44 PM, Jihadi_Jerry said:

But I have! I know it sounds crazy but it's true. I have lived in Seattle, Portland, LA, Santa Monica, San Antonio, Phoenix, San Francisco, stayed in Miami and Key West for a bit, Jersey Shore, a bit in Chicago, and New York for a wee bit. 

In Canada I lived in Vancouver, Nanaimo, Kelowna, Calgary, Winnipeg,  Montreal, and now Toronto.Everything between Vancouver and Toronto is no mans land. Winnipeg must be exciting right ???? WRONG!! 

It's true about America. You ever go to Montana, North and south Dakota, Minnesota, Ohio, Wyoming, Kansas, or most of Texas? There's NOTHING FUN GOING ON IN THOSE STATES. You would understand. There's NOTHING. 

I live in a motor home and travel a lot with my current career. However, I can't tell you guys what I do for a living, for it is of MOST SECRET 

"Everything between Vancouver and Toronto is no man's land."

You're a special kind of troll aren't you. This will be my last reply. Good luck to you in your endeavors. I'm rather confident we will never cross paths professionally as long as you maintain your present attitude.