rock_shoes

Our current precautions for SARS, H1N1, etc. are in line with best known practices. Isolation gown, gloves, N95, eye protection and proper don and doff procedures for medics. Surgical masks for patients. We also have the option of moving to full tyvek suits and double glove in the future if neccessary. We do have inline viral filters for the BVMs. The procedure is to notify the hospital as far in advance of the incoming patient as possible so that they can prepare a negative pressure room (assuming the hospital has such a room). Post call the ambulance gets a complete deep clean and both the medic and driver change into fresh uniforms.

With the upcoming flu season I've been thinking about things we do that become high risk when dealing with droplet transmission illnesses. The preferred method for Ventolin (Albuterol, Salbutamol, pick your favourite name/brand) administration is via nebulizer in most services I'm aware of. This becomes problematic when dealing with a suspected H1N1 patient due to the nature of how it's spread. This doesn't mean that we should fail to treat these patients however. All that said, I began to think about the possibility of IV Ventolin administration. Thus far the downsides found in my recent searches include greater risk of tachycardia, hypokalemia, cardiac dysrythmias, and elevation of BGL. Does anyone use IV Ventolin in their service? If so how effective has it been? What has the prevalence of adverse affects been like? Any links to relevant research and studies are welcome.

I have mixed feelings with regards to bringing the employers last offer to a vote. Part of me thinks a resounding no vote from the membership will be a usefull show of solidarity. Part of me thinks it's a waist of valuable time. A no vote is a no brainer for us. Voting to accept this offer would see contract clauses preventing the destruction of the service removed.

That’s really the truth of it all. BCAS’s last contract offer was for one year 3% (retroactive back to April 1, 2009). However included in the one year short term offer was the elimination of key contract language preventing the service from being “busted up” and privatized. We are actually going to have to vote on this one. Do they think we’re illiterate? Completely incapable of understanding what elimination of those contract clauses will mean? Yep. This happens all the time. It’s actually an excellent example of how a Paramedic Practitioner with the requisite education to do the job properly could save the health care system huge amounts of money. Handle the patient on scene with a referral to a primary care physician the next day for follow up care. Most of these patients don’t need hospitalization. They need a proper care plan. This brings to mind some possible variations in triage systems. This happens all the time in most BC hospitals however there are a few that are more hard nosed about the whole thing and are actually quite successful in doing it. St. Paul’s and VGH are excellent examples of an efficient ER. Any CTAS IV or V patient is actually triaged to the waiting room freeing up the ambulance crew. Once patients figure out this is the case it cuts down on the number of these calls and even the ones you do typically don’t result in crews trapped in a hospital hallway. That makes two of us. The way things are going I’m not sure how long I’ll actually continue to work on car after finishing an EMT-P (ACP) program. Most likely I’ll be applying to a PA program shortly afterwards.

None of us want to put down ambulances. It’s actually getting to the point that working above and beyond our scheduled shifts is a safety hazard to us and our patients. Just to give you an example. The other night I worked a 14 hour nightshift after which I was scheduled to be on call to staff the second car for the following 10 hours. At 0805 just after finishing my 14 hour nightshift I was paged out to transfer a patient to another hospital. It was 1800 hours by the time I finally returned to the station and was able to actually go home. This was working what I was scheduled never mind picking up anything extra. In a typical 2 week pay period I spend over 200 hours either on calls, at the station, or on a pager. I’ve been doing this for almost 2 years and it just isn’t sustainable. We have a staffing crisis that is being completely ignored. If people stop working overtime for 2 days and 30% of the cars go down things are a hairs breadth from imploding on any given day already.

Most likely the equipment in question is using the same technology as what would be used by a wireless computer network. As long as the existing pieces of equipment are not interfering with each other I don't see any reason adding e-PCR tablets would cause an issue. If they did the key would be running each of the different types of devices on different frequencies (same idea as having multiple radio frequencies for ambulance radios). Many hospitals actually have wireless networks already that just haven't been used for this purpose. We still use paper forms but one of the hospitals I take patients too actually has a "courtesy" wireless internet connection for patients and their families.

Sounds like a good techie could solve the whole thing fairly easily. Wireless networking could solve a whole host of issues. Printers don't care what software you're printing from just that you have the correct driver. If each facility provided one printer and a wireless connection all any of the services would need to do is have the correct printer driver on each of their tablets. In the service I work for all of the station printers are on a network. I could actually print something out at the station in Dawson Creek hundreds of kilometres away if I wanted to. I see no reason you couldn't do the same thing over a wireless conection.

How many units transport to any given hospital? Don't most services have more units than they have hospitals they transport too?

Who does a drunk call without at least doing a blood sugar? Investigating for possible trauma? What about drug use either by choice or by accident (some freak might have slipped grandma some GHB yah know)? How about a neurological assessment? Maybe grandma's having a CVA? Criminal negligence comes to mind here.

At my station it's just about impossible to miss something/someone in front of the bay exit. Whoever is attending steps outside before the driver pulls out the ambulance and closes the bay door from the outside after the driver pulls out (it's a keyed open/close switch). You would have to be blind to miss an obstruction. Some people complain about the system saying an automatic door opener would be better. I like it myself because it forces someone to get out of the vehicle whenever entering or exiting the bay. Might as well back up your partner since you're already out of the vehicle right?

Unfortunately Siffaliss that probably is the plan. Make it fail, then find a buddy who owns a private EMS company whose pockets you can line. I'm watching it happen in BC right now. Mark my words; Alberta will be next if we fail to stop it here. Healthcare should never be run as a for profit business. Any profit being made over and above what's required to pay healthcare workers a fair wage should go directly towards improvement of service. This is the case in the majority of first world countries for a reason. This isn't to say things shouldn't be done to curb abuse of the system. Quite the contrary. The more a system is abused the fewer services will be available for those who truly need it. There are many places cost savings could be realized. Kicking every person with nothing more than the sniffles out of the ER would be a great start. How many of us have witnessed hospital ER’s being treated like walk in clinics?

One can only hope the upcoming release of the new NOCPs will be the kick in the rear needed for another try. The PAC might not be a regulatory body but it does set the standards by which paramedic programs are accredited. Sure sounds like something worth supporting in a quest to become the regulatory body to me. No one ever wants to make a change when the economy is strong. Then when the economy weakens and a change actually occurs the economy is too weak to really do anything. Very clear legislation regarding the responsibilities and educational requirements for such a position must come first. Otherwise it’s putting the cart before the horse all over again. True national standards first, then expanded scope operations. ACoP members must vote for the council. Who appoints the lawyers? If it’s the council I think ACoP members have chosen poorly. Yes it is. Unfortunately, as more and more of those who actually had to fight for democracy depart, fewer and fewer Canadians understand why democracy is important. They’re so busy worrying about where they will find the next “double-double” they’ve forgotten that they aren’t the only ones worth consideration. Selfishness is reaching all time highs, while family values reach all time lows. Apathetic is now the “cool” way to act. Actually caring about what happens is so passé. Apathy is one trend I’m more than happy to bow out of personally. Ah yes. Proof that it is possible to form a meaningful national organization. My dad is a member of the Canadian Association of Medical Radiation Technologists (CAMRT). Another example of a group that managed to get its fecal matter all in one pile long enough to do something worthwhile. Just an observation, but in BC RTs and MRTs belong to the Health Sciences Association of BC (HSABC). Perhaps there is a connection between unions that have bargained successfully for their membership and the formation of professional governing bodies? Might it have something to do with having time to work on building professionalism when you don’t have to spend most of your time trying to eek out a living?

So they didn't recognize the firehalls address as the call location? Maybe looking out the bay door before pulling out the ambulance might have helped?

Agreed. A national college of EMS providers would be in the best interest of patients and paramedics alike. We desperately need national standards that everyone is held to. The longer we remain in our own little fiefdoms the longer it’s going to take EMS to grow up and join the other health care professions as respected effective members of the health care team. It’s disappointing to see ACoP lose its focus like this. I had hopes this wouldn’t happen but I’m not surprised that it did. The real death knell for ACoP was divesting from the PAC. The PAC is actively seeking to set national standards with input from a broad base of providers. I believe it was only a few months ago I posted a PAC survey for paramedics seeking input for the development of new national occupational competency guidelines. Did ACoP even tell its membership why they ditched the PAC? Yup. It’s complete and blatant disregard of labour law. If they step on us hard enough we’ll just bow down and take it. At least that’s what they want us to do. This kind of rule works for awhile but in the end it always fails. Eventually some of us will put up some rusty nails for them to step on and you can bet It won’t be you or I sticking them in the ass with a Tetanus shot. I will not be taking on that kind of responsibility without the educational background required to make sound evidence based decisions. Smart paramedics will take this stance. Scope of practice hungry fools without regard for best practise will try to take on these responsibilities without demanding the requisite education to do it right. All any of us can do right now is hope fewer fools exist in our midst than it would appear do. No disagreement here. EMRs should have zero say over standards and should not be voting on professional issues. If you want say and a vote go back to school and join the professionals. I’m not against EMRs being regulated and at least held to some kind of standard though. Perhaps ACoP should be the overseeing body without allowing EMRs to vote on issues or set standards? So true, and sorry to say it, BC and Alberta are the two biggest sticks in the mud holding everything back. The people in power here in the west realize that progress costs money. What they fail to realize is that a lack of progress has a much higher cost in the end. Politicians in the west have great vision right up to the end of there noses. The sad truth of it all. What good is any of this if we don’t take care of our own first? If someone wants to come and be a productive member of Canadian society I’ll be the first to welcome them. Otherwise they can get the hell out. Canada’s a country not a charity. If you’re not willing to learn the language, get a job, and pay the same taxes the rest of us pay you should go back to wherever you came from. Just think. I’m not even that conservative. Imagine the stance a hard line right winger would take. It isn’t just a union busting exercise. It’s a public healthcare busting exercise. Campbell specifically listed the dismantling of BCAS as one of his goals before ever being elected the first time. Pushing the whole thing to the brink and watching it collapse has been his plan from the beginning. Then he can say “look it failed... but private company X can make everything better and for less money”. We are just the first step. Hospitals and long term care facilities are next. It’s no different than what’s happened with BC Hydro. BC Hydro was an incredibly profitable crown corporation supplying a number of British Columbians with well paid secure jobs. Instead of allowing this to continue Campbell hacked BC Hydro off at the knees and dictated that all new power projects be private and BC Hydro must buy power from these private producers.

8. I'll probably like it more after completing an ALS program. Nothing more frustrating than knowing the care a patient requires and not being able to provide it.

You're not going to get any disagreement from me on this one. They literally cram 2 semesters of material into a single semester here in BC and it's far from ideal. One point to consider however is that educational time required to become an ACP is very similair across Canada. ACP's would of course be the group drawn upon to develop Paramedic Practitioner programs. The provinces with shorter PCP programs typically have longer ACP programs with the opposite being true in Ontario where most PCP programs are 4 semesters. Front loading vs. back loading the programs. Personally I lean towards front loading programs and giving BLS providers a better foundation to work from (as in Ontario). Governments have favoured back loading in the past because, at least in BC, they used to fund paramedic programs. Paid training, though I would love to have someone else pick up the tab, has held us back in many ways. Now that paid training is gone I expect to see a great many changes. One of the first things I want to see is BCIT taking over all ALS paramedic training from the Justice Institute (currently the only school providing ACP training in BC). The Justice Institute is the biggest reason I'm applying to the EMT-P (ACP for the rest of Canada) program at SAIT in Calgary(a 2 year ACP program to help make up for my PCP programs shortcomings). I should rephrase a little. Currently BC is divided into several health authorities. Hospitals and long-term care facilities fall under these health authorities. A Paramedic Practitioner program will require carefully planned integration with the health authorities. As things are currently structured that integration will be impossible without developing a close working relationship with our base hospitals. Essentially hospitals are regional while the ambulance service is provincial.

That's what happens when you go in half cocked. The reason the transition went so much more smoothly when BC went provincial was the timing. In the 1970's EMS didn't really exist in BC. Larger centers had a smattering of private services while in smaller communities the local undertaker would whip out and pick people up in the hearse. In Alberta they're trying to merge a bunch of services that are already functional. When something is already functional it takes real planning to merge things successfully. It doesn't sound like much thought went into the whole thing. Provision of service, particularly in rural areas, needs a complete re-think. Where better to develop something like a Paramedic Practitioner than a rural area where transport times are longer and many of the hospitals have to send patients out for definitive care? This will require further integration with hospitals while currently it seems like we are trying to distance ourselves to our own detriment.

Going ALS definitely enhances your mobility. No question about that. Where I'll have to disagree with you is with regards to the provincial system being the problem. Run properly the provincial system has the potential to be far superior to running a smattering of regional or municipal services. Unfortunately BCAS is currently being run by shortsighted government lackeys who are content leaving things in the dark ages as long as lord Gordon Campbell presides over our fair province.

I'm done with following the ESO myself. I'll be working my scheduled shifts and that's it from now on. No more picking up the slack when someone books off sick and no more staying late when someone out on the other car is late getting back for their first car shift. If they want to charge me with contempt of court I will not be posting bail. I'll walk down to the nearest police station and turn myself in. Have fun keeping the cars staffed when we all go to jail. By contract as long as I'm "part time" (the knee-slapper that it is when this part-timer works over 100 hours a pay period), I only have to be available to work 8 shifts per month. I'm looking forward to the contempt charges this winter when I cut back to 8 shifts a month and do some private work. The head-hunter calls have already started for the upcoming season.

Well it lasted the whole weekend. Without working overtime approximately 30% of the fleet in the lower mainland (home to approximately half of the residents of BC) was down. Some communities went without local coverage at all. In the interior the shortages on car were not as bad however staffing in the interior dispatch centre was down 60%. Excluded managers did their best to alleviate shortages in interior dispatch. The severe shortages experienced over this past weekend did not occur because paramedics refused to come into work. They occurred because paramedics stopped working extra shifts above and beyond those they are regularly scheduled. We stopped working beyond our contractual obligations for a single weekend and the whole service nearly collapsed. As a result the BC Supreme Court issued a ruling dictating that BC paramedics will work their "usual overtime" and the union (CUPE 873) will rescind its direction to the contrary. Union direction was rescinded but not immediately following the Supreme Court’s decision. The union's direction was rescinded when the employer (BCAS) elected to return to the bargaining table with third party mediator Mark Atkinson. It would appear that BC Supreme Court Justices have no qualms with ignoring labour law altogether. Good thing I live in a democratic country that doesn't support indentured servitude! BC Paramedic labour talks to resume

I would definitely have taken this patient in for a psyc evaluation. Even if the patient only admitted to taking 20 ASA that still amounts to 10 times the recommended dose. Also you found the ASA bottle to actually be empty in addition to the patient having consumed alcohol. This patient gave up the right to refuse care the moment they called for emergency services and stated they intended to engage in self harm. As for the police refusing to perform an arrest for mental health reasons that's a bit of a sticky situation. Personally I would take the officer in question aside and explain a few things. Number one. If I indicate to an officer that a patient needs to go in for a psyc evaluation and that officer refuses to make the arrest, the officer in question becomes liable for any actions the patient may take to harm themself after refusing care. If the officer still refused to make the arrest, (after explaining the liability issues I think this is unlikely) I would make contact with medical direction, explain the situation, and let my medical director have a chat with the uncooperative officer. I've never had to do any of these things myself. When it comes to patient care, all of the officers I've dealt with have been very helpful and cooperative. Did your partner or other members of the service you were out with have inter-agency issues with the PD? It seems to me like more was going on than just a lazy partner and stubborn officer.

1)Personally I don't have much difficulty switching from days to nights and back again. However, I'm also 25 years old and have done shiftwork since I was 17. Natural daylight lamps and Melatonin can be a huge help for some while others just never adapt and truly suffer for working nights. Have you ever worked shiftwork in the past? If so how did you fair? 2)For my service new hires need to be able to lift 150lbs from floor to waist level while maintaining proper form. Don't just focus on strenthening your back. You need to keep your entire core as strong as possible (abs, back, everything) and focus on proper lifting technique during every lift. Every time I do a lift, no matter how critical the patient, I take a brief moment to think through the entire lift and plan best possible allignment for the entire lift. You're not going to be able to help anyone if you destroy your back the first day. One more question. Are you looking to do this a second career or is EMS going to be more of a hobby to keep you busy as a retiree?

As of 1800hrs September 18th, 2009, job action in the BC Ambulance Service/CUPE 873 labour dispute is hitting a new level. From now on there is a ban on overtime, working secondary operators, and picking up shifts left vacant for any reason. BCAS officials have publicly stated there are no recruitment or retention issues within the service and as such BC paramedics should not be required to work any overtime to keep cars staffed. This action is in direct violation of the current Essential Service Order and as such I expect we will be charged with contempt of court very soon. Paramedic dispute could affect 2010 Olympics! BC Paramedics only to work regularly scheduled shifts.

True you are not going to see much pushing 10-20mL into a botched AC. The odds of you failing to get good flash from an AC are also very low however. If you blow out an AC altogether it's unlikely you will miss the blood going interstitial. PCP's (EMT-I roughly) in my service don't even use D50W. We use D10W in 100mL boluses until BGL returns to an acceptable range with a 50mg slow IV push of thiamine during the first 100mL bolus. In my experience it has worked extremely well for two reasons. First. Grandma's papery thin veins aren't such a big deal because you can run it through a 22 guage if need be. Second. It allows you to maintain a person's BGL on a glucose drip should there be any reason the patient will not be able to eat for any amount of time following. Personally I hate using glucagon. I will only ever use it if I can't get a line. Using glucagon depletes a person's emergency stores and running down someone's emergency stores when there is an alternative seens fool hardy to me.

Personally I've never been one to use formulae for med calculations. I've always relied on my algebra skills instead. For Example. Billy-Bob requires medication X. The weight based dose is 1mg/Kg/hour. The patient weighs 70Kg and medication X comes in a concentration of 0.7mg/mL. What drip rate should you set your pump at in gtts/min using a 10gtt/mL dripset. If you break it into parts things are much simpler. 1) (1mg/Kg/hour)*(70Kg) = 70mg/hour (for Billy-Bob with a weight of 70Kg) 2) (70mg/hour)*(1mL/0.7mg) = 100mL/hour (of this 0.7mg/mL concentration medication) 3) (100mL/hour)*(10gtt/mL)*(1hour/60min) = 16.7gtt/min If for example you are making up your own minibags for medication admin it can be worked out based on other information given but I'll leave that for another post if you find my methods effective for you. In the end go with whatever works for you personally. Sometimes half the battle is finding a method that works for you.