rock_shoes

So much for this thread being a good fit for the "funny stuff" forum! That said I do think it's still salvageable. I think we could have some truly beneficial discussion over the subject of "Lifeline Calls". I'll start. Not too long ago I took a lifeline call at 0300 for a diabetic patient. On arrival we quickly discovered the patient was not experiencing any kind of immediate life threat. This particular old-timer was concerned his BGL might be too high or too low. He had recently acquired a new glucometer and, being illiterate, could not figure out how to make the machine work. For the sake of being a thorough provider I completed a set of vitals including BGL. Having put the gentleman's mind at ease regarding his BGL he promptly refused transport. Do you know what I did instead of leaving immediately after receiving a patient refusal? I programmed the patient's glucometer for him. Then I showed him how to use it. It took me a whole ten minutes and guess what? We haven't been back to this gentleman's residence for anything but real medical emergencies since. Sometimes reducing the number of non essential calls your service does is as simple as spending an extra ten minutes with your patients to make them informed users of the service.

So far public health in BC hasn't made any attempt to use paramedics for H1N1 inoculations. I guess they would rather spin their wheels with far too few public health nurses available to provide the mass inoculations needed. It doesn't make any sense to use 3500 capable paramedics to provide vaccinations enmass does it? Why use the very crews you would call should someone have an adverse reaction? There's no way paramedics could possibly vaccinate nursing home residents in their homes is there? Paramedics couldn't possibly visit schools for an afternoon to provide vaccinations? Ah hell most of BC's paramedics haven't been inoculated themselves yet. Providing care in someone’s home doesn't put you at any kind of exposure risk does it? Just last week I treated a possible H1N1 patient. 39 y/o female, hx. of asthma and fibromyalgia. She had just come home from the hospital 20 minutes before where she had been treated for SOB with Ventolin (Albuterol) and Atrovent. Her initial room air SPO2 was 77%, with wheezes throughout, poor entry to the bases, and course crackles up to the mid lung fields. She had a fever @ 39 deg Celsius, chills, and diaphoresis. I took precautions before getting within 20 feet of the patient wearing an N95, eye protection, and the usual gloves. My partner, an old timer who was convinced this is all a hoax so drug companies can make a killing, did not take any eye or respiratory precautions. Not wanting to contaminate the ambulance, I treated this patient with 5mg Ventolin in 5mL NS by nebulizer on scene. Guess which one of us, myself or my partner, is now isolated at home with a nasty case of the flu. This is the real thing and the only way I know of to stall the spread is mass vaccination. Every deployable resource needs to be put in play and I have yet to see it.

700 000km? Our units are usually retired before they reach 350 000km. Maybe you guys should check out the BC government auction site if you're looking to replace a unit on a budget. One of our retired units would only be at half its service life by those standards.

Wouldn't the ethnicity connection support the premise that there is a genetic component to bad driving? More study with a larger sample size may be in order!

The character "Chuck" is a nerd who inadvertently ended up with a host of government secrets trapped in his brain. The show is about Chuck and the adventures he (and his government handlers) end up in as a result of the secrets trapped in his brain. That's the quickest "Coles Notes" version I can come up with at 0100 hours anyway.

That’s my take on it. Only degree paramedics would be suitable for education to a physician extender level. Paramedics from “monkey see, medic do” type programs will not have the background knowledge or, I suspect in most cases, critical thinking skills needed to function at such a level. Rural healthcare is an intriguing challenge that most fail to give the credit it is due. Rural practitioners have to be able to function in a “tag you’re it” type of environment where the next person available to tag could literally be hours away. Personally, I love the challenge. I would rather have one long call where I really had to think and apply every resource available to me than 10 short transport calls where you barely have time to take a set of vitals, never mind formulate an evidence based treatment plan. Unfortunately, the way things are currently running in my home province, the more I increase my education level the less likely I am to be able to work in a rural setting (ALS (Advanced Care Paramedic) providers are only in certain designated cities with most rural areas being served by either ILS (Primary Care Paramedic) or BLS (Emergency Medical Responder) providers). Maybe I’m biased because I’m from a rural area, but I believe that rural people deserve to have this level of care available to them. Some might turn up their noses at such programs. I’m not one of them. These programs are brilliant concepts that now need to be followed by careful, evidence based, implementation. I find developing care plans for critically ill or injured patients to be fascinating. I also enjoy interacting with patients in a way that betters their lives. A well developed Paramedic Practitioner program will teach its students to do both. The prospect of say, touring through the local nursing homes providing vaccinations, then leaving to provide for a critically ill or injured patient when needed is one I find very exciting. You can interact with the community on a daily basis and then step up into a more involving role whenever needed. This type of role is about best serving a rural community not feeding your own ego at all times. Ed

Yup. You speak the truth. The use of D10W in BC (for the PCP-IV level) was initiated for exactly the reasons you describe. ACPs still have the option to use D50W if they feel it is warranted (ie. the more severe hypoglaecemic episodes squint mentioned). Fortunately for our patients it has turned out to be a sound practice. This is one of the few areas where BC’s extremely conservative practices have worked out for the better. How Thiamine managed to sneak into the BC protocols is beyond me, but I’m sure glad that it did. I’ve never done a med push into an interstitial line myself but I certainly see your point. The biggest reason for using D10W versus D50W is the lower risk of tissue necrosis. No diabetic has papery thin easy to blow veins right? It’s easy to push syrup through a 22 isn’t it? A long time ago, way before my time, BC was actually considered progressive. Now we’ve slipped so far back we’re at least 10 years behind. An excellent visit BTW. We’ll have to budget more time next go around. Unfortunately this last road-trip was a bit of a blitz trip only having 3 days and 2000Km of driving to squeeze in. The sad thing is that many PCPs probably don’t even know why we bother with the Thiamine push. We have finally moved to using “Treatment Guidlines” vs. protocols which should reduce the incidence of doing without understanding, but until the big upcoming retirement bubble goes through many will “just follow the protocol”. This isn’t meant as a slight against them in any way. These medics come from an era when any deviation from protocol, even with good reason, was met with harsh discipline. Thinking on your feet was dangerous to keeping your job in some ways so these medics learned to survive as best they could. This makes it extremely difficult for them to accept and implement changes now (ie. strong movement towards more evidence based practice). Glucagon is in my SOP but I’ve never actually used it. So far, fingers crossed it stays that way, I’ve been able to gain IV access whenever I needed it in hypoglaecemic patients. I understand how it works and why it’s a good option. I’ve just haven’t had the opportunity to put it into practice yet. One important thing to remember with Glucagon is that giving a second 1mg SC or IM dose is extremely unlikely to have much if any effect if the first dose didn’t work. Glucagon essentially breaks down the bodies “emergency stores” (glycogen, the greatest portion of which is stored in the liver). This process (gluco-neogenesis) restores the patient’s blood glucose levels temporarily. If the first dose of glucagon is ineffective the patient’s glycogen stores are already depleted making further doses useless. I prefer not to use glucagon because it means I was able to restore a patient’s BGL without tapping into their emergency reserves. I wish we carried Ringers on car here. It’s in my SOP just not in our cars. We had a burn patient a while ago who would have definitely benefited from Ringers over NS.

Having used Crestline ambulances built on both Ford and Chev chassis I vote in favour of the GM products. The duramax has far better pick-up on the bottom end, the chassis feels tighter, the steering is sharper, the brakes are more linear, and the ride is far smoother. Over all I've found the Chevy (2009 we took delivery of this spring) to be better in nearly every aspect. Perhaps the new ford diesels are worth the wait. I can't say as I have yet to drive one. The Ford Crestline (roughly 90000Km) we have sitting in our second bay by comparison has had the entire injection system replaced twice under warranty already. It rides like a lumber wagon, and the 6.0L diesel in it is so loud when the cooling fan kicks in you should be wearing hearing protection to meet WCB regulations (never mind when the siren is engaged). The only thing I like better about the Ford is the mirrors.

I've run transport times that where anywhere from 5 minutes to 2 hours working out of a single station. I would expect Kiwi has faced some of the same type of challenges. Coverage areas can be enormous for some of us.

I can get you the BCAS patch and probably a couple of collar pins if you don't already have them. Just PM the address and they're yours.

Court challenges are definitely in the works. The courts work at record pace when the government wants things done then slow to a standstill when another party challenges government legislation. There is definitely more to come on that front. The public is only beginning to understand how dire the situation really is. Just to add a little more fuel to the fire. Did you know that over half of the already too few ALS providers in BC are eligible to retire in the next five years? On the note of reaching burnout here is a letter I sent in to various papers in BC about a month ago. I really appreciate the support Squint. You get it. This isn’t just about BC. It’s about paramedics being treated fairly everywhere in Canada. Hell it isn’t even just about paramedics anymore. It’s about showing a dictator that this is still a democracy and not his own personal fiefdom. As for heading north I think I’m more likely to go north of 60. I’ve always been fascinated by the territories and I think a change of scenery would do me good. Ed

Whistler isn't a designated ALS community anyway. The only time you will see an ALS provider in Whistler is if they are there for a pick-up as a flight crew or are in as "Special Operations". ALS coverage in BC is abysmal at best with the north having the worst coverage of all. The last ALS unit as you head north in BC is in Prince George which is actually in the centre of the province.

Damn Squint. It looks like the Republik of British Columbia is spilling its rhetoric east faster than Stelmach and Campbell can cash their well deserved raises. Just don't all go on strike while I'm going to school next year . It's just about impossible to complete practicum requirements with everyone on strike. Saskatchewan is too flat for me and I'm allergic to newfie screech so heading too far east is out of the question. I say the entire west goes on strike. Shouldn't be more than a week before the entire canadian economy grinds to a halt.

It's good to see I'm not the only one who writes all over my exams. The last thing I care about when I'm writing an exam is saving trees! Some might think it's silly, but going for a long workout the night before always helps me. I never study the night before. I find going out with some friends (make it an early night you still need a good sleep), and doing something completely non-related to the subject of the exam is very effective in reducing my stress levels. I'm a fairly low stress individual at the worst of times though, so what works for me might not help you at all.

I've been having the same problem finding more recent research. The shorter length of hospital admission this particular study shows with aminophylline is promising but definitely in need of longer study before any final conclusions can be made. This article does an excellent job of illustrating how modifying care provider opinions can be a huge part of the battle. I have very little experience with MDI+spacer use. It just isn't the currently used standard of care in my area. Based on clearly proven results MDI+spacer use is getting an undeserved bad rap. I think one of the reasons nebulizers seem to get all the glory is because it looks like you're doing more. Nebulizers are also really easy for a care provider. Put the medication in the bowl, apply the mask, and set the flow rate to run the neb. Where I think nebulizers still have an advantage is that they allow a provider to give humidified oxygen concurrently.

I think your right. Terbutaline is just the first medication that I started to look at in greater depth. There's more to come for sure. Again, absolutely true. If past flu's are any indication I expect a huge portion of patients requiring hospitalization and or presenting in respiratory distress will have underlying pulmonary history exacerbated by H1N1. Excellent point. I think this really strikes at the heart of the matter. Flu patients could easily be hypokalemic already. Giving such a patient medication with significant potential to cause hypokalemia could concievably have drastic negative effects on the patient's condition. I'm with you in thinking filtered administration devices will be the better solution. This has really turned into a good exercise in research for me which is why I've continued to gather information. Given the increased risk of adverse effects which is proven, I think IV administration would have to prove to be more effective (which has yet to be shown in most cases). I think this is the reason IV administration thus far has been reserved for the more severe exacerbations where the patient's airway is so far shut down inhaled administration is not viable. What would be interesting is a comparison between IV Ventolin and administering enough epi for inhaled routes to become viable in the event of status asthmaticus. Interesting study. Looks like IV Ventolin should remain on the docket for further study based on those results.

We do the same thing using D10W. Hypoglaecemic patients start with a 100mL bolus of D10W with a slow 50mg IV push of Thiamine. If the first 100mL bolus doesn't bring the patient's BGL up enough they get another 100mL bolus. Afterwards the patient is kept on D10W at a 100mL/hr maintenance rate until they are either under the hospitals care or have eaten sufficiently. It has worked extremely well in my experience. The maintenance rate is adjusted up and down based on the size of the patient and subsequent BGL checks.

Typically people spend 2-3 shifts as a third before being turned loose to attend. Junior people are paired with more senior people as much as possible and new hires (less than 6 months seniority) cannot work together. Driving is a bit of a different story. All hires must go through a one day ambulance operations program before they can drive at all. After the ambulance operations program new hires can only drive routine without a patient until completing a driving preceptorship with a qualified experienced driver. There is also a new hire package that must be completed during the probationary period. It includes all of the radio codes used by the service, WHMIS, incident command structure (ICS 100), and several other things that slip my mind at the moment. In addition there are a number of continuing education day courses that must be taken during the first year of employment.

I think a strong case could be made for choosing D5W over NS in this circumstance. If for whatever reason you are unable to "feed" your patient after administering the D50W to restore BGL, using D5W would allow you to employ a "glucose maintenance rate". D50W is "used up" by the body quickly. Maintaining a stable BGL with D5W would be preferable to the "shock and awe" of pushing more D50W in my opinion.

Well I've started into the reasearch. So far it's actually looking like Terbutaline might be a better option for IV administration than Albuterol but still reserved for the more severe cases. Here are some of the studies I've come across so far. Comparison of inhaled and intravenous terbutaline in acute severe asthma. Continuous intravenous terbutaline for pediatric status asthmaticus Continuous intravenous terbutaline infusions for adult patients with status asthmaticus. Comparison of nebulized and intravenous terbutaline during exacerbations of pulmonary infection in patients with cystic fibrosis The dose-response effects of terbutaline on the variability, approximate entropy and fractal dimension of heart rate and blood pressure The N95 is going to be an absolute must for treating these patients over the next while. Provided it is fit properly and the provider follows proper don/doff procedures the N95 and other isolation precautions should be adequate for the provider. One of the problems that still persists is the degree to which a standard nebulized treatment allows virus containing droplets to spread throughout the ambulance. That's an awful lot of surfaces to clean with a high likelihood something will be missed during the cleaning process. Any standard nebulized treatments will require the ambulance to go through a "deep clean" which will put the car out of service for 1-2 hours. This becomes a big problem in a service like the one I work for because some of the serviced communities have only one ambulance with the next closest car stationed more than an hour away.

Just at a quick glance it appears as though most of these studies involve inhaled routes of administration with the odd look at either IM or SC epi. I'll dig a little deeper through them and see what I can find. I think the filtered O2 therapy masks (which also allow for filtered nebulized med admin) Squint managed to find might be even better. At a unit price of $6.99 canadian based on a box of 50 they are actually pretty cheap. Knowing what we pay for our Salbutamol nebs I think it would be more cost effective than a new MDI for each of these patients.

Very true. Monty Python however, makes no bones about being a parody. Trauma is pretending to be serious which will not help our case with the public. The lay public will have no idea what aspects of the job are being sensationalized on the show (from what I've seen thus far everything). Unfortunately it's hard to promote a professional image when we have many whackers in out midst content with low educational standards. The one positive aspect of the "Naughty Nancy" character is that she is supposedly well educated. Thank you Dr. Bledsoe for posting the link. It was absolutely hilarious.

While we're at it. What about the possibility of using other beta agonists? Terbutaline and Levalbuterol come to mind. Perhaps a different drug would be more optimal depending on method of administration? I suspect that few studies have been done regarding alternate methods of administration due the fact that nebulizers are typically highly effective.

I don't recall it ever being that high. I've never run a nasal cannula at a rate greater than 5 lpm. The normal range I've used is 1-5 lpm. Wouldn't a flow rate that high dry out a patients nasal passage excessively? That would be my take on why it isn't advisable.

I think this will likely be a more appropriate solution for the time being. I wonder if the greater incidence of adverse effects with IV ventolin is due primarily to the IV administration, the severity of illness in the patients this delivery route is currently used on, or some combination of the two? What about a single IV push versus a continuous infusion? So many questions and I suspect the answers won't come soon enough to be of much use dealing with H1N1. I would be interested in knowing the results in Parkland as well. Hopefully Parkland has kept close tabs on the results of using IV ventolin as I'm sure the information would be valuable. Common sense says no valved exhalation for the patient. Of course that could just be me. We actually carry several sizes and types of N95s. Some valved some fold-flat etc.. Did AHS purchase all of these Newport Transport Ventilators without ensuring they could be sterilized or are there not enough trained people to sterilize them properly?