rock_shoes

It could be that was the year the unit was last inspected which doesn't necessarily indicate a lack compliance. I would check into your states inspection requirements and reporting standards before pursuing this any more aggressively. 

Damn. Two engine, two pilot, IFR rated needs to be the minimum standard across the board. Since I've started with air ambulance operations I wouldn't want to be in anything less. For the sake of my family.

Fly well everyone.

On 3/31/2016 at 6:06 PM, Arctickat said:

You getting liquid springs  too Rock?  You can follow the progress of our remount on the facebook page. I have some g-force data from my E450 type 3. When this type 1 is on the road I'll have some hard data for comparison. 

They're up for consideration in the next RFP. Knowing the usual pace of government, if they're a success they'll be at least one model year behind. BCAS is an enormous contract by Canadian standards (100+ units a year) so you can be sure Crestline and Demers will be solidly duking it out.

Welcome Sheri.

Rather unfortunate your introduction to the place was a number of armchair quarterbacks/backseat drivers. I hope you'll give the city a second chance and take the opportunity to look around while you're here.

Ed

It's a policy change referred to as presumptive coverage and it's slowly been working its way through the provinces (same concept as many types of cancer being considered occupational related for fire fighters). Alberta was actually the first and now Ontario has followed suit. Various advocacy groups in Canada have been pushing hard for this in since an independent group started tracking first responder suicides. Only those confirmed and reported are counted. Like anything of this nature the true numbers are likely higher.

TEMA Resiliency Tour Press Release

On 2/18/2016 at 10:09 AM, paramedicmike said:

This story has popped up in a couple of my news feeds over the past few days.  Thought it was interesting.

Reuters link.

Medscape link. (May require a log-in.)

Essentially, the more cardiac arrests you run the better the survival rate.  There were some limitations to the research.  It's an observational study.  It says survival to hospital discharge but I haven't seen anything about how neurologically intact any of them are.  However, some of the findings they note were interesting.  Years of experience as a paramedic didn't count.  It was observed that the more often paramedics encountered an out of hospital arrest the less the chance of the paramedic deciding to work it.  Eleven percent of the paramedics involved over the nine years of the study didn't encounter a single cardiac arrest (which makes me wonder who these folks were... admin, supervisors, people who retired/resigned early on... nothing I've seen goes into detail).

The obvious bit doesn't surprise me a whole lot. Mastery takes practice. Opportunity for skill mastery and the resultant patient outcomes are the single greatest check mark in favour of tiered and targeted deployment of urban EMS systems. The interesting piece here, is that greater exposure was corollary with a lower propensity to work any given arrest. The assertion I read from this wording is that more experienced providers are more likely to recognize both viable and non viable resuscitations. 

On 3/12/2016 at 1:20 PM, Arctickat said:

I had considered the Promaster but soon elimilimiated it. A 176HP V6 just wouldn't last very long in my organisation. I opted for the Ram 4500 4x4 6.7l Cummins with liquidspring suspension.

The Promaster might make an ok in city transfer vehicle though.

welcome  to the city.

 

 

 

 

I'm genuinely curious to see how the liquidspring technology works out. My patient's ride quality over government maintained roads is hoping it's a winner.

If the OP does return...

Why jump in guns-a-blazing? You might shoot a potential ally working that way. If something frustrates you the answer isn't necessarily leaping in and right fighting before taking the time to understand the animal your taking on. Particularly when it comes to EMS, things are dramatically different state to state, country to country, province to province. The US, Canada, Australia, New Zealand, South Africa, Mexico, UK... all have dramatically different systems for better or for worse.

If you want to enact positive change in EMS you need to study it across the board. Look at what's working in places like Canada, Australia, and South Africa (I'll give you a giant hint in that it largely comes down to significantly higher minimum education standards). Look at what isn't working in those same places. After completing your research come up with an action plan to meet the positive targets and avoid the identified pitfalls. None of it is easy. Flying off on a rant on an EMS page is easy but inflammatory and ineffective. Real change takes elbows in, skinned knee, bloodied nose labour. If you have what it takes do the labour.

The problems you mention are why it isn't reliable for absolute values. It's still useful for establishing a waveform, respiratory pattern, and even trending. If a patient's anatomy results in a false low for example, it will consistently do that. That means changes in values over time will still tell you if EtCO2 is increasing or decreasing. If you want actual blood values do an ABG.

I think front wheel drive is a huge no no for light industrial vehicles such as an ambulance. The Sprinter is probably the better choice for a service seeking out lower cost and or more nimble alternatives to the traditional type 3 unit.

When dealing with a soiled/fluid airway it's often better to go in DL first to clear out the offending substance(s). If you were to go straight to VL you would just soil the thing and have no advantage over DL. That said, I have definitely gone in DL, cleared/suctioned the airway, then intubated VL after ventilating them up.

Think about the typical injury patterns paramedics experience and go from there. Back injuries, shoulder/rotator cuff injuries, hip/knee injuries. For the most part all of them are joint injuries of some form or another. Now consider what exercises you can do to strengthen the muscles supporting all of those vulnerable joints. If you work to strengthen your back/core, back injuries are less likely to plague you etc.

Focus on strength training that will enhance joint stability and form when performing lifts. Cardio can be whatever you choose as long as it brings your heart rate up for a decent length of time.

Phenylephrine, ketamine, sux, consider fentanyl as an analgesic adjunct but the ketamine should do the trick. Plasmalyte would be preferred if any fluid resusc. ends up being required. TXA. Strictly talking the pharm not the technique at this point.

If you have time/equipment prior to evacuation stabilizing the femur fracture should be a priority (huge potential blood volume loss). The other two should still have a full trauma survey before going with the probable drunk/stoned theory.

I've used both the Glide scope and the King Vision. Out of the two the King Vision required the least muscle memory adaptation versus direct laryngoscopy. The Glide scope was definitely the more versatile tool due to the screen being separate from the blade (making a side on intubation possible in the aircraft). If I had to pick only one I would go with the Glide scope due to the increased versatility.

Within my service ground ALS units carry the King Vision while flight units carry the Glide Scope. This seems to have worked fairly well as ground providers never have to intubate from a non-standard position making the lesser degree of muscle memory adaptation required for the King Vision an advantage.

I suspect he's referring to the nasal end tidal CO2 sets available for use with non-intubated patients. They're good for a waveform, respiratory rate, and trending but the absolute ETCO2 numbers aren't all that useful (not a closed system so typically gives a false low). 

Based on the OP's information it definitely appears as though company policy is encouraging both fraud and unethical practice then. As others have already mentioned I would steer clear of this potential disaster, document the hell out of everything, and be prepared to speak to the appropriate authorities.

Tossing on a few monitor leads and taking a set of vitals? No big deal even if it isn't particularly relevant to the patient's complaint. Starting an IV without any clinical indication just because management said so? Big problem. That's an unjustified invasive procedure which, though pretty routine for most of us, is not without risk.

Now as to the billing side of things, I don't fully understand the relevance. I work in a provincial system. The bill is the same ($85) heavily subsidized amount whether the patient is a 5 minute transport for a stubbed toe or air lifted. Do US services charge by procedure (ie. basic transport fee plus $15 for the IV, $20 for patient monitoring, $300 for an ET tube...)?

The crew wearing appropriate PPE for the conditions was taking their own safety for granted? It was a close in shot. For all any of us know fire was performing traffic control and some inattentive jackass blew through anyway.

I'm not suggesting you replace the soft squishy thing between your ears. That's what will tell you whether or not you can trust the numbers. Having an end tidal certainly doesn't mean you shouldn't have a listen either. SPO2 and EtCO2 do however remain the only quantifiable numbers you're going to get on an ambulance anytime soon. If you have access to them and you refuse to use these well vetted and studied tools at your disposal your being a prat.

Don't believe me? Here's one of a great many papers regarding the use of EtCO2 to mitigate unrecognized esophageal intubation.

http://mastertrain.8m.com/masterimages/2013articles/The Effectiveness of Out-of-Hospital Use of Continuous End-Tidal Carbon Dioxide Monitoring on.pdf

If you have it use it. In the absence of blood gases SPO2 and EtCO2 are the only guides we have with respect to oxygenation/ventilation. We should be using them to guide our ventilation strategies.

For the love of god ventilate them first is all I ask. For you and your partner's safety. Other than that, fill your boots. I don't care if I never bring around another opiate overdose because the PCP/EMT/FR did it prior to my arrival.

The part about this whole debate that makes me laugh (at least in western Canada) is what brought it about. BC and Alberta have been experiencing a rash of overdoses involving Fentanyl (either directly or laced heroin). As a result of the increased number of overdose deaths public outcry has pushed the agenda. The funny bit is the dosing. The doses given either with home kits or by responding FR's/EMT's/PCP's are too small to be effective in a true fentanyl overdose. The doses these people are giving will rouse the average heroin user who took 2 points instead of the usual 1; not a fentanyl overdose. Dealing with true fentanyl overdoses I've been having to use in excess of 6mg of naloxone to bring them around to an effectively breathing state. Many of these patients end up on a continuous naloxone infusion while the fentanyl runs its course.

This my friends is exactly what I'm getting on about with one small difference. I would advocate the development of a Paramedic Practitioner group along the lines of what has been done in the UK as opposed to a PA/NP model. It might seem far fetched state side were paramedic education varies wildly; in countries like Canada, Australia, New Zealand etc. where paramedic education involves a significant post secondary commitment, it's merely a natural progression of the profession.

Interestingly enough PA programs are just starting to come to life on the civillian side of things in Canada (currently there are two producing practitioners). Presently the overwhelming majority of accepted applicants are paramedics with a smattering of RN's and RT's tossed into the mix. I can't think of a better pool to draw from when implementing a pilot program.

At no point would I ever suggest putting paramedics into such a role without education/training to match the scope of the position. Paramedic education varies wildly around the world with programs ranging from 6-12 months to 3-4 years depending on the level and country. Suffice it to say the successful programs around the world have involved providers from the more educated end of the spectrum.

As I've already mentioned a large part of the role would involve directing patients toward the correct care as opposed to providing that care directly. Ie. referring the patient requiring social work directly to the social worker or referring the home care nursing patient directly to a home health assessment team. Directing patient's toward the correct care doesn't require a practitioner to be able to provide that care. It requires a practitioner to recognize when that care is required.

As far as upping the educational anti is concerned, all I can really say is it's about bloody time.

For example.

http://kssdeanery.ac.uk/sites/kssdeanery/files/Paramedic Practitioner Presentation.pdf

I'm not talking about a pack of untrained monkeys. I'm talking about educated professionals who are prepared to provide such services.

Whether you or I believe these people should be calling for currently existing home health services instead is becoming increasingly irrelevant. They're calling EMS wether we like it or not because few of them know how to access those services appropriately. The end goal shouldn't be for EMS to take over such services rather to redirect people into them as appropriate. Granny calls because she is weak due to poor nutrition (no longer cooking for herself). Rather than just toss the poor old girl on the bed, we should probably be leaving her home (provided she checks out medically) with a referral to a mobile meal service for seniors (and a sandwich until they show up). That isn't taking over another service. It's creating a new route to the appropriate service by marginally changing our assessment and referral pathways from the traditional "you call we haul."

EMS has become a gateway to the health system for patients who don't know how to access the most appropriate service. Further to that, we have always been an extension of the emergency department.

Little Johnny fell off his bike and needs a few stitches (no other injuries presenting). Should you as an EMS provider clean it up and toss in a few sutures with instructions to see his family physician for removal (costing the system a few hundred dollars)? Should you haul little Johnny off to the ED so a physician can provide the same service (costing the system thousands of dollars and using that physician's time for a minor task when he could be otherwise occupied with higher acuity patients)? Your total patient side time is likely going to be far less with the first option because we all know little Johnny is probably going to the back hallway to wait when you get to the ED (if you even manage to get triaged in a timely fashion).

As for the paramedics making scheduled home health visits you mention, those programs typically exist in areas that don't have any other home health programs. Those will not come to be in a place like Chicago or Vancouver where home health programs already exist. Where they will come to be is in rural areas where call volumes amount to 2-3 calls a day. In between calls they can be making these visits and if a call comes in they will either leave the current visit or reschedule any visits they miss during the emergency call. The point is they won't be replacing anyone. They'll be providing a service that wouldn't otherwise exist instead of sitting on their collective ass' watching youtube at the station.