rock_shoes

That is the point, none of us are politicians, we are health care providers. If we do not fight for what we know is right, then who will ???????? We can choose to hope that big-pharma gives us the silver bullet one day in the future, or we can work to do what we know works.

It's funny fire departments, EMS departments, and Hospitals have no problem budgeting for a new ladder truck, a new ambulance, or a bond referendum to expand facilities, but we can't seem to find the money to do what we know will save the most lives.

How many more lives would be saved by $500k of community defibrilators, versus a new ladder truck, some new ambulances, or a new outpatient center ??

This is something I can support you on. Overall more than enough money is already being spent. Spending needs to be directed more appropriately. The hospital doesn't need to fund a new entrance way. It needs to fund more OR time to deal with the orthopedic back log. The city doesn't need to fund a new ladder truck. It needs to ensure every park/recreational facility has public access defibrillators.

Studying drugs like Epinephrine, Glucagon, and Magnesium Sulfate is a little different than studying something like Amiodarone. Big pharma stands to gain essentially nothing on these drugs because they aren't proprietary. Big pharma makes its money on proprietary products. The more we can make use of non-proprietary drugs to treat patients the better.

Actually Mike, both ROSC and survival to discharge rates have improved. The amount of improvement varies significantly by service with services like BCAS (metro operations) and Seattle/King County leading the pack. One of the biggest improvements so far was the re-emphasis of timely quality chest compressions (which was in fact a throw back from the 60s).

ROSC & survival to discharge rates have waxed and waned a number of times over the years. I expect them to continue to do exactly that with a general upward trend over the long term. To say that we've learned nothing over the past 50 years of cardiac arrest management would be ignorant.

Explain to me the basic concepts of 12 Lead EKG (How do you identify a STEMI), and how Dopamine and Dobutamine works, in as few words as possible. There is a big difference in treating mostly trauma, to having to treat everything a regular Paramedic has to treat in a non-combat role. I will be waiting for your quick and immediate response since you need no further training (Its 12/12/2014; about 7:30am EST in the USA).

Did you actually read the post? The suggestion was that military medic education be brought in line with civilian medic education so that these vets did not have to start all over again when leaving the armed forces.

I am glad you think your are an adult triemal, but to discount real life experience versus what you read in a book, is not very mature. I read that Obama is an alien from mars, and that Bush was a puppet of the Luminatie. I also read that the earth is flat, and that the menstral cycle can be cured with leaches. Real life would suggest a different reality. I had far more ROSC under the ACLS protocols (not my protocols) of the 80s, versus what is offered today. If you practiced under those protocols, then please provide your real life accounts of why they were wrong.

I don't think the point being made was that those protocols were necessarily ineffective. The point was that they had little evidence behind them. Spiking glucose levels for example has been proven to be harmful in several different varieties of brain injured patients. By extension we can suspect that administering D50W to a cardiac arrest probably won't have a positive effect on that patients neurological outcome. Without, to my knowledge, having studied it perhaps glucose increases ROSC. The real question though is whether or not that's truly beneficial if the glucose cooks what's left of the patient's brain. ROSC workout neurological recovery is irrelevant to the patient and worse for the patient's loved ones.

What!? You mean if you really learn how to do something in the first place, perform it on a regular basis, and continue to train on it you'll actually become good at it!? BLASPHEMER! That defies all logic! EMS logic that is...

Sorry, I just couldn't resist. In all seriousness though, there are departments out there that work like that, and have published their data. I wish that was the message that people were actually taking home, not just the standard "don't do this" one.

Education and procedural competence. A great practitioner knows the when and what of a treatment plan in addition to being able to perform the appropriate procedure in a timely manner.

All the education in the world won't help if you're incapable of performing the correct procedure. All the procedural competence in the world won't help if you don't which procedure should be performed. The two are forever linked.

I think that what you'll see is either a intubation study (maybe, but if some groups dropped out that could, and hopefully WOULD kill that study) or one done on various doses of epinephrine. My personal opinion only on the latter but...wouldn't surprise me.

Sure you did.

I have been hearing from our ROC coordinator that an epi trial is on the radar. What exactly that will look like is the real question. Personally I'm hoping for a three pronged RCT to start (0 versus 500mcg/dose versus the current 1mg/dose).

One of the other questions is method of administration. Maybe we should be running infusions to achieve steadier levels of the drug versus the monstrous bolus doses we currently push.

In the Canadian Forces, our Med Techs take the Primary Care Paramedic course and get licensed as PCP as part of their training. CF Medics regularly do shifts on civilian ambulances during their time in the forces to keep up their skills when it comes to things beyond dealing with healthy 20-40 year olds. Makes the transition to civilian paramedicine fairly easy if that's where they choose to go.

All true. Where our CF medics end up getting the shaft is if they stay in long enough to almost be trained to the ACP level but leave prior to becoming a PA. If a CF Med Tech leaves at any point prior to PA training they are bounced right back down to PCP even though their training may be significantly more advanced. Canadian Forces Med Tech training is delivered in modules associated with rank after they complete their PCP training. The problem with the module system the Canadian Forces has developed is that it doesn't line up with the Canadian National Occupational Competency Profile.

Canadian Med Tech's would be served very well by an education unification whereby the NOCPs and CF modules were unified. IE. once you have completed module X you are allowed to challenge the ACP licensing exam.

It's something that truly matters to these vets. The average wage for a full time PCP in BC for example is $68,000/year (base salary), while a typical ACP makes $81,000/year or more (base salary). In most provinces the difference in education between PCP and ACP is quite significant so I don't dispute the difference in wages. What I do take issue with, is our failure to assist veterans in bridging into the civilian system without having to start back almost on square one (and on their own dime).

For starters welcome to EMTCity.

Now to go directly to the nitty gritty. Depending on the nature of your traumatic experience, working as a paramedic could place you in situations that will stir up old traumas of your own. I would advise you to seriously consider the ramifications of a potential severe panic attack on your life and the lives of those you care about. All that said, I love the job and wish you all the best in exploring whether or not you are suited to the work.

If you find you're still interested in medicine but don't feel you're suited to working as a paramedic, fret not. There are numerous interesting and valuable aspects of healthcare for you to pursue that don't involve situations as easily personalized.

In all honesty a good quality multi-tool will probably serve you the best. This is one of my favorites.

http://www.gerbergear.com/Essentials/Tools/Suspension-Multi-plier_22-41471

This is the newest version of the one I've carried for the last 7 years on the job.

http://www.gerbergear.com/Military/Tools/Diesel-Tool_22-01545

Unfortunately your tracings are of too poor a quality to have any real diagnostic value. A safe expeditious ride to the hospital where a CT, lab work, and better quality tracing can be obtained is in order. I wouldn't be administering ASA or nitro to this patient. IV, O2 if needed, monitor, and transport. If things change with regard to the patient's rhythm along the way treat as per ACLS guidelines or local protocol (whichever you're held too).

Here's a thought, maybe send the guy to a physician that the your service has on retainer for a fitness for duty evaluation.

After ensuring this individual is transported every time they have a hypoglycemic episode. You wouldn't want regular hypoglycemic episodes to be absent from the overall medical evaluation.

No worries. My service is heavily involved in the various ROC studies and I was wondering if enough evidence had been collected to suggest it as a new trial once we're finished with ALPS (Amiodarone Lidocaine or Placebo (saline)).

As of November 1, 2014 you can add BCAS to the list of services carrying and using TXA for major trauma patients. Funny how things work. As soon as it came out on car my trauma patients seem to have dried up. I sure could have used it in September/October.

Have you come across any follow up to this study Ruff?

ROC has been kicking around doing a randomized study looking at ETI and supraglottic airways during cardiac arrest for awhile; from what I head a few months ago it may actually be in the works after the completion of ALPS. The problem is that there are a few ROC members who will catagorically refuse to be involved in this, including some that already have both high resuscitation rates, and high first pass success rates for ETI.

A true randomized study absolutely needs to be done, but as with all studies on paramedic ETI, it has to first use services that are truly competant at intubation before it's studied in the average service. Depending on the study design, that may be hard to do.

I work in one of the services you mention. I can absolutely confirm BC ALS providers will not buy into the proposed SGA versus ETI study. We have some of the best resuscitation and first pass ETI rates in Canada. I suspect the ETI success rate in BC is largely attributable to the fact an average ALS provider can expect to perform at minimum 20 to 30 intubations per year.

The damned if you do damned if you don't part of the whole thing is that the systems you need to play ball, like BCAS and Seattle King County, are the most likely to pack up their things and go home should such a study be dropped on them.

Possible reasons for these services success rates are numerous. Here are a few of the easily identifiable culprits for anyone not familiar with these services.

1) High level of intubation experience.

2) CPR continued and never stopped during intubation attempts (This is drilled in at every opportunity. CPR does not stop for intubation)

3) Regular Airway Management review/training (BCAS uses the AIMS program)

4) High levels of cardiac arrest management experience (ALS providers can expect to work at minimum 15 to 20 arrests per year)

5) Increased venous return as a result of eliminating intrinsic peep via intubation (something that does not happen using an EGD)

The number of variables are staggering when you really start to look at it. What is best in one service delivery model is not necessarily best in another.

Hello all,

I am hoping to get some feedback from previous Siast ACP students on the program. I am attending the saskatoon campus and am hoping previous students could share some tips or experiences so I can best prepare myself. Currently working in BC but did my training at Nait.

Out of curiosity, why not go back to NAIT or consider SAIT if you did your EMT at NAIT?

my thought on drug abusers is : give them all they can smoke , snort ,shoot up or stick up their arse and they will all be dead within a few months.

No more drug addicts.

Same theory goes for fat people. Give them a spot at the counter of Mc ratmeats or at the local chinlee all you can eat buffet, and let them eat themselves senseless.

We have a fellow that has been basically imprisoned in an ICU double room at the hospital because he had gotten up to well over 1100 pound of stinking festering blubber laying on a pile of 4 mattresses on the floor in weeks worth of his own waste.

Now he hadn't been out of that room for months until the fire dept with assistance of a towing company removed him.

They have managed to slice almost 400 lbs off him on a STRICTLY controlled diet over 6 months and not allowing anyone in the door with food. This is a slob who was consuming 25,000 calories a day as a warm up snack to getting down to serious eating.

Do I have any sympathy for people like that???

NOPE

used it all up many years ago.

going back to the autoinjector issue :

the new users of the medical device will receive a 20 minute class on how to use them.

They will not have a background knowledge of the pharmokinetics , or the possible problems involved with aspiration or sudden reversal of the OD pt.

They won't have the knowledge or ability to respond to manage those dangerous side effects they can cause with narcan administration.

Good grief island. I was almost flame kissed just reading that post. The key here is empathy not sympathy.

Where I do agree with you is regarding the legalities of addiction. Stop turning people into criminals because they happen to abuse a substance on the list of things that are illegal to use. Stop waisting money on forcing people into court mandated treatment (only offer it and allow people to enter when they are ready to actually make a change). If we do just those two things millions of dollars will be saved.

In the short term we need to provide critical interventions to give these people the opportunity to seek out recovery. It is not any of our place to refuse life saving treatment simply because a patient's own actions lead to the circumstance in which we find them.

Regarding the naloxone auto-injectors, it's my understanding they are pre-loaded with a relatively conservative dose. Conservative dosing (0.8 to 1 mg IM) should eliminate the majority of issues with respect to someone coming off the nod too quickly. Yes ideally these patients are ventilated and pre-oxygenated, but a little confused/hypoxic is better than dead.

Let's pop in an OPA if the patient takes one, ventilate the patient, and reassess. Get the Levophed flowing if his BP is still crapped out, and intubate if time/circumstance permit.

Hello,

I had a great reply and I lost it. =(

Ok, iStater, she has been on these setting for around a day. I can not comment too much on the waveforms (not my strongest area). However, I can say they look like normal shark-fin like volume waveforms without any auto-peep. You work out her ideal body weight lung volume and lets say it is 450cc.

The red spot is from the needle decompression after she developed a tension pnx from a central line attempt. Now, when you push down on it the air leak stops in the chest tubes. Also, when you push on it the turbulent noise stops. Very odd.

Here is a question for you. I know that ARDSnet like small tidal volumes. Now, for the small peanut sized patients is there a point that you just can not cut the VT? Otherwise, the way I see it, the dead space will eat up most of your VT.

Rock Shoes: Good idea, you push Tyl 1gm down her NG

Thanks...

Well let's seal that sucker off with some tegaderm or occlusive dressing of choice and see if that solves our problem for the time being. The patient already has two chest tubes in place so a full occlusive should suffice just fine.

How about acetaminophen 1g suppository before we cook her brain completely, I know we should still be below critical high for an adult patient but she's already so far up you know what creek dropping her temperature a little probably isn't going to hurt.

Sorry if it has already been posted but what are all the vent settings?

You're about 4 minutes out. His heart rate returns to about 86bpm and he starts seizing again.

If he's still actively seizing reach for your benzo of choice (whatever your service happens to carry for this purpose, midazolam 5mg IV would seem reasonable). How's the norepinephrine working as a pressor?

At this point the patient is unable to provide any additional history. The patient and his family indicated that his only known medical history was hypertension. Anything is possible, but nothing else is suspected in his history.

Fair enough. Any chance you managed to capture a strip or 12-lead when he went into the bradycardia?

Psych history and renal history please and thank you. Any possibility this patient is on a TCA? Anything in the rest of the patient's history to suggest a possible hyperkalemia?

64/40 (MAP 48) isn't going to cut it. Start a second 500mL fluid fluid challenge and switch to a NRB for the time being. What do you have available to you for pressors Chris?

What's the patients heart history? Specifically do they have any history of valve incompetence/replacement?

Here's hoping the receiving hospital has ECMO available. They might need it to buy enough time to give this patient a shot at surviving this episode.

I'm well familiar with the process. That being said, if you're going this route it should be because you can't get a peripheral IV started. If you need access this badly do you really have time, more importantly does your patient have time, to wait the 6-7 minutes for this whole process to take place?

In the scenario outlined by the OP you'd be at the hospital faster than it would take to get an IO set up and actually infusing.

Firstly, if the patient crumps you're going to cardiovert immediately and how painful the procedure is is superseded by the patient's care needs.

Secondly, not all of us work 10 minutes from hospital. I don't know if you noticed but the people who suggested considering an IO are from Alberta. One hour plus transport times are not uncommon there. Personally I would probably consider going to the external jugular with this patient before IO but IO is perfectly reasonable deployed appropriately.