rock_shoes

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.

Where one stands with regard to the cost part of the issue is going to vary dramatically depending on the nature of the system in which they work. I for example work in a publicly funded system whereby paramedic services, hospital services, and specialty services are all funded by the province (with a portion of federal transfer money earmarked for healthcare costs). A paramedic crew assessment and discharge costs the taxpayers a few hundred dollars. An emergency department visit costs the taxpayers several thousand dollars. In short, the more closely paramedic services are tied to overall health services in an area, the greater the potential cost benefit to paramedic services providing non emergent care and discharge.

One of the best calls I ever did was for a newly diagnosed diabetic. He called because he was concerned his BGL was elevated and his family doctor had put the fear of god in him regarding the dangers of chronically elevated BGLs. Naturally we checked it for him and it was perfectly fine. Then we investigated a little further. The real reason he had called was because he didn't know how to use his home glucometer to check his BGL. He didn't know how to use his home device because he was functionally illiterate and unable to make any sense of the instructions. In a matter of 20 minutes we taught this gentleman how to use his home device and as a result he never accessed EMS services again for anything of a minor nature. That's community care and that's why EMS providers must accept that they have a valuable role to play within community care.

I can't decide if you're a troll or just naturally inflammatory. Either way I think I'm going to pop a couple of ASA before diving any further into this.

I don't see this article as a strike for or against community paramedicine. What I do see it as is a call for both appropriate education and health team collaboration. The giant culture shock that's coming for many paramedics is that they were always meant to be a health care entity. What makes us unique is the fact that we are health care workers operating in an emergency service environment.

This is a very realistic concern regarding any refugees coming to Canada also. In the end I support taking in refugees with a proper screening process but I'm concerned our own in country resources are not prepared to care for these people adequately.

To be honest I've stopped counting. I did 3 in just my last block of work (4 days on 4 days off) which is fairly common; so I'm willing to estimate a conservative 20+ this year. I work in a targeted service so I end up doing the pre-hospital intubations for an entire zone as opposed to a single unit. For those who don't have similar working opportunities, the body of evidence supporting high fidelity simulation practice and its resultant increase in first pass success is becoming quite clear. Practice, either on a manikin or a patient, breeds a higher degree of success.

Then do an IM or IN dose of an opiate to start out. An inhaled agent like entonox (50:50 mix of N2O2 and O2) is a bloody good stop gap while waiting for the IO to sit or IM/IN opiate administration to kick in (if it isn't contraindicated). If they're already in agony for whatever reason giving them one more reason to be in agony is far from a kindness. There are always options including the external jugular (assuming of course that's in your allowed SOP which I suspect it is if your doing nerve blocks and sutures).

The key is patience. Once the slow infiltration of lidocaine is complete you have to wait a solid 4-5 minutes before flushing or doing anything else. 4-5 minutes on an ambulance call seems like an eternity so very few providers wait long enough. If the patient is so crook you can't wait the 4-5 minutes you just have to accept you're going to cause significant pain. On the plus side, early administration of an appropriate benzo means the patient is unlikely to remember how much the flush sucked.

I can share my own decision regarding CCP education (the rather lengthy Canadian version of said education). I decided to go for it. The reading has already begun with the main portion of the course starting in January and running over the following 2 years. In the end it came down to desire for responsibility. My desire to take on that role and the education that goes with it exceeded my nervousness about whether or not it was the right decision. The decision to work in a targeted ALS response capacity was similar. Furthering ones education should be a humbling experience. It certainly has been for me. The more knowledge I acquire the more I feel as though I'm lacking in education.

The value of the program is entirely dependent on the content of the program. If it helps further your career in the desired direction by all means pursue it.

I've used this technique for the last year with similar results to those reported. The concept behind it is that more prolonged vagal stimulation provided by the short term bump in CVP provided by the leg raise will increase effectiveness of the maneuver.

Frankly, it seems like a waste of money when a little bit of crew education could perform the same task. If I have a crook patient I make a phone call and notify the receiving facility. If I feel the hospital needs as much notice as possible, that phone call happens before I've even left the scene. The whole concept of sending a partially completed PCR to get the hospital started seems like a waste of time. If a patient's very ill my PCR is blank when I get to the hospital and their health card is in my pocket to hand to admitting.

Our current dispatch system does have the ability to flag addresses. Dispatch seems to be fairly good at flagging addresses with violence potential but quite lax in flagging addresses with CBRNE potential (possible TB, carbon monoxide, etc.).

Students force you to either remain up to date or become a lousy preceptor. For myself I find it re-invigorates my appetite for the job. It's also a wonderfully variable experience figuring out how to best assist any given student in the learning process. Some are academically strong and skill weak while others are the opposite with any combination of the above possible.

As of January 2 all of us will belong to provincial programs with class beginning on the 4th. It should be the most rewarding period of education in my career so far with an incredible amount of ICU time and a guaranteed 3:1 student:instructor ratio. Semester 1 is primarily about equipment management in the non attending role (pumps, vents, etc.) while semesters 2 and 3 really get into the medicine. The majority of the didactic portion of semesters 2 and 3 will actually be taught in hospital by ICU docs which will allow for immediate reinforcement of the concepts during ICU rounds. If it's an option for you I highly recommend applying. That calibre of educational experience, especially in a paid education format, is nearly unheard of for paramedics. Even if you were to decide on PA school after, the experience would be valuable without costing you anything financially.

At first I noticed this thread and thought to myself nope, not me. Then I looked at my profile and realized it's been over 8 years since my first post. A lot has changed since then. I joined as an EMR (think EMT-Basic) looking for work. Now I'm an ACP (think EMT-P) working targeted ALS and about to start another 2 years education to become a CCP (any number of variations on the theme exist. In Canada it amounts to about 5 years post secondary education). As my education has steadily increased I would like to think my opinions have re-shaped themselves appropriately. I can certainly say that characters like Dustdevil and Tnuiqs helped shape what I've become.

http://www.ncbi.nlm.nih.gov/pubmed/17229343 Nerve tissue abounds in the marrow space. The pressure from infusion Kat mentions causes extreme pain as a result. A very slow infiltration of lidocaine prior to the 10 to 20cc rapid flush to create an infusion "pocket" will help to numb the nerve tissue and dramatically reduce pain of infusion.

Those are not the conversations that will benefit you the most in your chosen career. Knowledge, leadership, procedural competence and professionalism will forever be the cornerstones of sound practice at any level. The conversations that enrich any or all of those factors will be of the greatest benefit throughout your career. Arctickat said it well. Eventually those one-up-manship stories will be your nightmares. Not because they grossed you out, but because as you age you realize there are human lives attached to said stories. Oh and welcome to the city. Hopefully our crusty selves haven't deflated your enthusiasm. Most of us really do still love our jobs.

Seems everyone is in agreement. We want more information so that we can proceed.

Let's bump up the FiO2 to 1.0 if it isn't already. Paralyze. Nebulize Ventolin/Atrovent into the vent circuit. Dial her rate back to 12. Looks like she's probably hyper-inflated. Continue with some fluids at this point. Titrate in norepinephrine to a MAP of 70 if necessary. Methylprednisolone 125mg IV. What does her EtCO2 waveform look like? Surely they've done some labs on this girl. The chest tubes are in position but are they kinked or otherwise blocked off preventing relief of a pneumo?

ABC's Has the tube buggered up? Are the chest tubes bubbling away like they should or have they gone awry and she's tensioning out? What are the vent settings? Short term a fluid challenge and a push pressor while we start getting things sorted would seem reasonable. The only infusing medications you've mentioned are the Fentanyl/Versed. What are they set at? Allergies? Meds? PMHx.? History of the precipitating event? Any recent lab values available?

Putting the "Labour" in Labour day weekend. Day shift Saturday/Sunday, nights Monday/Tuesday.

Was the patient taking his insulin correctly? I know of several IDDM patients who would use the wrong length needle and end up depositing insulin between layers instead of into the subcutaneous layer. As a result the insulin would sit in pockets instead of being properly absorbed at the time of injection. The patient would take increasing amounts of insulin to control their BGL not realizing what was happening. Seemingly at random these "pockets" of insulin would absorb and the patient would end up having profound and sudden drops in BGL.