rock_shoes

In a narcotic overdose situation Narcan is a life saving rescue intervention not a band aid. Think of it like giving an epi pen to someone anaphylactic to peanuts or some other common allergen. The side affects you mention are extremely unlikely when you take into account the dosage and route of administration for these public access kits are restricted. Administration is either intra-nasal or via IM auto-injector. The doses are 0.4 to 0.8 mg. I absolutely agree with you these patients require education and mental health. The problem is, they will never be able to access those things if they die of an overdose. This is an opportunity to reduce the number of overdose deaths. The next step is making the education and mental health services these people require available when they're ready to accept them.

Bingo! BC was actually one of the first places to take on this harm reduction tactic when they began allowing PCP (think EMT- I/85) level providers to administer naloxone to suspected overdoses. The downtown east side of Vancouver is a world class city's dirty little secret. It's the poorest neighborhood in all of Canada with incredibly high rates of drug addiction (heroin in particular).

If these chassis are anything like small car hybrids they're more of a gimmick than anything. An equivalent size diesel vehicle will achieve better overall fuel economy with a proven power train (particularly when moving heavy loads AKA a 14,000 pound ambulance). A diesel powered hybrid might be worth a trial, but gas seems like a poor choice.

The plot thickens. That, Arctickat, is a very interesting and relevant circumstance. I'm 100% with you in regard to the training situation. If the Alberta and Manitoba operations are using the exact same training program it seems it took a less STARS struck Manitoba eye to take an objective look at operations. Mobey, I'm with you on the STARS PR ridiculousness. As I said, I'm no more a fan of the organisation than you. I just refuse to throw the medics/nurses under the bus without seeing the evidentiary review.

29 years of operation without such an inquiry rearing its ugly head should be considered a success of sorts. I'm no more a fan of the big red PR monster than you are, but the amount of expansion from inception to now indicates those with the decision making power have considered them a success up until this hiccup in Manitoba.

Good call Quakefire. You can only work within your services guidelines. I'm inclined to agree with you regarding the bradycardia. No need to flog an already compromised heart when it's still providing adequate output. I might have been a little more liberal with the morphine. AHA guidelines are 2-4mg IV per dose. If I'm not pushing nitrates with these patients I lean toward the heavier handed end of the dosing and push 4mg at a time.

It's always possible someone has a secret agenda, but in this case I'm having a difficult time figuring out who that might be. ORNGE already has its hands full cleaning up the Mozza mess, BCAS has far too many financial/staffing struggles to even consider taking over services, and I'm not aware of any private for profit rotary services in Manitoba. Truth be told I have to question even running rotary transports in Manitoba. By scale most of Manitoba would probably be better served by fixed wing and ground ALS. The only name that springs to mind for me is Medavie. Medavie is the dominant player in the Atlantic provinces and also has a few of the Ontario contracts. http://www.medavieems.com/en-us/OperatingCompanies/Pages/default.aspx

The aspect of this whole thing that truly baffles me is that STARS has operated successfully in Alberta since 1985. I’ve never seen anything like this regarding a Canadian air ambulance program before. What is going on in Manitoba that’s so different? Is the training program in Manitoba less involved than the one in Alberta? Does the Manitoba division have a less developed/stringent selection process for staff than the Alberta division? I have many questions regarding this entire thing. I hope Dr. Wheeler’s report answers as many of them as possible. STARS is rather unique in Canada for two reasons. Firstly they use a nurse/paramedic combination where other Canadian rotary operations use a two Critical Care Paramedic model. Secondly they are a publically sponsored, private, not for profit (not that the provincially run programs in BC and Ontario pull in any profit).

http://www.cbc.ca/news/canada/manitoba/manitoba-s-stars-air-ambulance-slammed-in-draft-provincial-report-1.2542471 Let’s pull some of the relevant pieces out of this article shall we. As a point of reference regarding the report’s author, Dr. Stephen Wheeler is the medical director of B.C. Air Ambulance and Critical Care Transport. Dr. Wheeler was commissioned by Manitoba Health to write it and is in no way affiliated with any of the affected families, STARS, or Manitoba Health (with the obvious exception of being commissioned to write said report). BC air ambulance programs have no inclination to take over rotary operations in Manitoba. Rather difficult to dispute this point. Pretty basic stuff. Check your equipment at the start of your shift. No different than a ground ambulance crew. Dr. Wheeler goes on to elaborate further regarding the issue of insufficient training. Keep in mind Dr. Wheeler is not seeking to have STARS ousted. His recommendations are entirely about remedying the issues raised. Damning as this whole thing sounds he’s actually trying to help them be successful. Here are some of the key interim recommendations he has made. The last one listed in particular is critically important.

http://www.cbc.ca/news/canada/manitoba/manitoba-s-stars-air-ambulance-slammed-in-draft-provincial-report-1.2542471 This particular article probably sheds the most light so far. The final report from Dr. Wheeler should be rather telling.

Good on you for finding the ability to self reflect. It will be one of the most important skills you have going forward both in life and EMS.

Give the young fellow a break. He didn't write this diatribe. He's just trying to say thank you in his own way.

Looking at your second set of strips I'm looking at a 3rd degree block with a junctional rhythm. Just based on the first rhythm strip it looked like a huge 1st degree but reviewing the original 12 lead it was probably always a 3rd degree. Oh the advantages of folding and holding to the light. How did your patient make out going forward? Successful cath I hope.

I'm going to simplify this for you.If you truly have the passion to be a paramedic you say you do, you'll find a way to meet the requirements.It is neither uncouth or unreasonable for a school to expect you to have completed the courses you have mentioned. I wish you the best in your endeavors. The industry needs passion, but it also needs education to guide it.

ASA, O2 if required (titrated for sats greater than 95% and less than 100%), Gravol if she needs it, Morphine, Nitro (very carefully and only if your service advocates a trial with inferior MI). Everything of course done with the provisio the patient is not allergic or has contraindications to any of the preceding (ie. ED drugs for nitro, morphine allergy etc.). Personally I won't touch nitrates with these patients if I get a hit on V4r, and I'm still extremely careful with nitro even if I don't. As long as she continues to mentate with a reasonable perfusing BP I wouldn't get overly wrapped up in treating the bradycardia. Don't "fix" what's managing to perfuse at the moment.

Sinus bradycardia with a rather significant first degree block. ST changes in II, III, aVF along with reciprocal changes in the precordial leads are indicative of an inferior MI. A 15 lead including V4r, V8, and V9 would be prudent (especially prior to even considering any nitrates). Nitrates in the event of suspected inferior MI are controversial with some EMS services advocating very careful administration and other services considering it a contraindication.

Quakefire, Are you guys doing pre-hospital fibrinolytics out in Saskabush when you're too far out to make a cath lab window? In the mean time, initiate transport as soon as you have a line in place, start a fluid challenge (500mL checking lung sounds and vitals every 250mL), prep your dopamine (might just need it here), put on the pads, and get moving to the closest cardiac receiving hospital because there isn't a thing the little community hospital is going to do you can't consult a cardiologist and do on route (unless of course they can push fibrinolytics and you don't in your area).

Attending the JI is without question to the detriment of your education. The future of paramedicine in Canada will include acquisition of a bachelor degree. Credits from the JI are like monopoly money. They're only good at the JI. No matter where you choose to go make damn sure your credits count toward completion of a degree at a recognised educational institution. I could ramble on about the JI further, but sitting at my computer institution bashing won't help anyone. With regard to ease of transition into a BC ACP position, I can confirm that attending an outside institution was in no way to my detriment. If anything it was a tremendous benefit.

Thanks Ruff. Looks like an interesting article. It should round out my between call reading at work tomorrow.

Unless I misunderstood the good doctor, I believe that is the intention. Identify, intervene, and transport. I would like to know what the staffing model will be for this unit. Two paramedics and a CT tech with radiology/neurology physician consult prior to lytics?

Tim's final thank you. http://www.nsnews.com/news/remembering-tim-jones-1.802132

Someone's personal experience with Tim. I remember watching this particular event unfold on the news. It helped shape my future as a paramedic. http://m.flickr.com/#/photos/32327761@N06/12110169923/

Tim Jones, British Columbia Ambulance Service ALS Paramedic and North Shore SAR leader has died. He was an incredible man who will be missed by all. His influence on both paramedicine and SAR will continue for many years after his passing. http://globalnews.ca/news/1093238/north-shore-rescues-team-leader-passes-away/

If I'm truly unsure as to a patient's sex I ask two questions. Do you identify as male or female? Genetically are you male or female? Be simple and direct about it. Just be prepared to explain why it's medically relevant (Moby's abdominal pain example comes to mind). As far as gender specific language goes, refer to them as the gender they choose to identify as. Provided you are respectful, very few transgender individuals will take any offense to either of these questions.

Great information. I'm with you in finding it rather odd this patient was not anticoagulated. Are these criteria not modified based on frequency? For example a particular patient goes into a-fib 1-2 times a year and is succesfully cardioverted each episode within 24 hours. Is that patient really considered the same risk level as an intermitent a-fib patient who is in and out of it every other day? Both of these patients should likely be anticoagulated, but based on exposure it would seem the higher frequency a-fib episode patient would be at higher stroke risk than the lower frequency a-fib episode patient. In my own experience these patient's know their INR, and they know how stable their INR is within the accepted range. They might not know why their INR is significant, but all of them seem to notice how interested every doctor they see is in it.