rock_shoes

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.

Or those with the power were given high profile high paying jobs by STARS when he retired from government as a reward for assisting with their expansion.

http://www.stars.ca/news-and-events/media/news-releases/release.html?id=7

What disturbs me in this is that the Dr. Wheeler has identified the problem as a lack of education. STARS response was "But our flight teams in all of our bases have the same education." All this means to me is that the entire STARS organisation needs to be looked at because that comment is simply an admission of culpability to me, not a defense.

See this is an assumption on your part.

The lack of an inquiry does not indicate a lack of inadequacy. It also does not measure success.

STARS is such a PR powerhouse in this province, what doctor would sign his name too it?

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.

What are you using to gauge their success?

Lack of an inquiry showing failure does not indicate success.

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.

Our treatment was pretty simple. I cheated a little bit with the ECG's, the first 3-lead and the first 12 lead are 10 minutes apart, the second 3 lead was 7 minutes after that and the final 12 lead was 30 minutes after the initial 12 lead.

ASA, O2 with nasal cannula at 4lpm, 18g IV with NS TKO. I gave two 2mg doses of Morphine about 15 minutes apart being mindful of her BP which didn't change for us. This only dropped her pain to a 5/10

I really don't see this patient as a symptomatic bradycardia as the lethargy was consistent with her normal use of the sleep aid (Zopiclone). The main issue I have with using dopamine is the inotropic and chronotropic effects on the heart. I dont want to make a damaged heart work harder (plus dopamine isnt in our protocol for that) Nitro is contraindicated in this patient as per our protocols.

Pt maintained her GCS, BP and vitals throughout the transport to the recieving hospital and into the cath lab 10 minutes later. Pt had a 100% occlusion of the RCA, once cleared and stented the 3rd degree AV block resolved and the patient left the CCU into a cardiac ward within 3 days.

Thanks for playing!

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.

Thats kid of what I was trying to figure out Rock: if they have been doing this for 29 years as an organization, then what is different ???

too many unanswered questions.

OR someone has an agenda

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.

In one case, according to the report, STARS ran out of oxygen in flight, something Wheeler said “should never happen.”

Rather difficult to dispute this point.

In another case, the air ambulance crew ran out of epinephrine while transporting a severely allergic man who had been stung by a bee to hospital, says the report. The patient died.

Pretty basic stuff. Check your equipment at the start of your shift. No different than a ground ambulance crew.

“As a group, the nurses and paramedics lack adequate training and experience to work in the air medical environment,” Wheeler writes in his report.

Dr. Wheeler goes on to elaborate further regarding the issue of insufficient training.

In a section comparing other provincial helicopter ambulance programs, the report concludes that STARS Manitoba’s 10-week training program is “grossly insufficient” and “falls far short of training models in B.C. and Ontario,” where air crews must train for 12 to 24 months.

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.

STARS should redesign its training program and immediately supplement its crews with experienced flight personnel for a minimum of six months.

STARS should limit its transport of pediatric patients to trauma scene responses, and not carry out routine patient transfers between facilities, while it reviews its pediatric training. Emphasis should be on pediatric airway assessment and management.

The methods of dispatching STARS “lack co-ordination and need improving,” he writes.

Quality control must improve because “overall, an emphasis on creating and maintaining a culture of quality is missing.”

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.

whackeritus at it's finest.

Same type that wears the T shirt with

"we fight what you fear" on the back

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

Follow up 12 lead and 3 lead after ASA, Morphine, O2

Edit for Vitals: No change in vitals, pulse remains 45, BP 124/68 RR 18, SpO2 98% Pain 5/10 after 4mg Morphine IVP

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.

I did see that, just looking for a diagnosis from that.

Any further treatment?

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.

Ok, to consolidate everyones treatment

We are now enroute to the Cardiac Center, about 40 minutes transport, we have O2, a NS line, 3-lead and 12 lead, and quick combos in place. STEMI alert has been called.

Haven't seen a interpretation of the 3-lead, and no one has has actually said what kind of MI the 12 lead shows

And just you in the back, in the event that she goes into arrest, you have access to a Zoll Autopulse.

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.

ecg1web.jpg

Oh and here is the requested 3-lead and 12-lead

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).

If you're based in BC and want to work for BCAS, you should look at the JI. The JI, EMA Licensing, and the BCAS ALS residency program are becoming more and more integrated and give students a pretty smooth transition through practicum, licensing, and residency to get new ACPs out on the road and practising.

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.

I don't see how it will save time either unless they are going to be able to do it all in that one ambulance from CT to final intervention.

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.

The reason we worry about afib with a duration of >48 hours, as I'm sure you know, is the risk of post-cardioversion stroke from embolizing a clot out of the left atrium. If somebody has a history of atrial fibrillation their stroke risk is the same regardless of whether they have intermittent or permanent atrial fib. So in someone with intermittent afib, the concept of <48 hours vs >48 hours does not apply to them.

If you have a patient with known afib you should NOT cardiovert them chemically or electrically, unless they have been on anticoagulants for at least 4 weeks. Of course this doesn't apply to a patient who is hemodynamically unstable.

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.

Not all patients are on anticoagulation for atrial fibrillation, but she probably should be with her medical history. This would not be an afib < 48 hours old though, as she has a documented history of afib. I would consider rate control if you thought her symptoms were related to her atrial fibrillation, but they're more likely due to her respiratory issues.

Documented history yes. Constant a-fib not necessarily. Some patients go in and out of a-fib based on any number of things. With this patient it was likely related to both low magnesium levels and a respiratory infection. I did qualify the consideration of CCBs with ensuring the rate was not in fact compensatory (respiratory infection in this case).

They opted not to give her anything for rate control since she was already on a beta blocker. Instead they opted to treat her upper respiratory infection & also her low magnesium level. I checked on her the next morning. Her A-Fib had resolved. They increased her beta blocker, added magnesium oxide.

All sounds perfectly reasonable to me. Interesting case. Any idea why her magnesium levels were in the toilet?

During the first five minutes of transport she reports right sided jaw pain x 2 days. Her temp is 37.1

Ah, so it likely is compensatory. Scratch the CCB for the time being then. What's her dental history? Any recent trips to the dentist? Take a look in the mouth. Any sign of an abscess? It's amazing the s&s that rear their head with dental/jaw infection.