triemal04

Generally speaking amiodarone can be mixed with NS or D5W without any real issues. Only catch would be if it was a mix that was going to be used over a longer period of time (hours or days, depending on what reference you look at), and some say it also depends on the concentration; I think anything over 2 or 3mg/ml in NS is supposed to be a no-no. Non-issue for EMS, even if you're dealing with a transport that lasts several hours. Of course, amiodarone also reacts with plastics and really should be kept in glass bottles for longer infusions...but nobody talks about that one...

Quick way I learned initially: (dose x kg)/25=gtts/min. Dose being where you are on that 5-20 scale. This only works with a 1600mcg/ml concentraion and a 60gtt/ml dripset, but it is pretty handy. Nice thing is, if you are using a pump, with a 60 set, drops/min is the same a ml/hr (if that's one of the settings on your pump; is on mine). Of course, this may be pretty accurate, but it is still just an estimate; if you're doing more than eyeballing it, you should try and be a bit more accurate.

Ethics and morals aside, if the responces portraying how breaks are taken in the UK are accurate, then I'm not sure why this hasn't come up before or more often. (or maybe it has and just didn't get as much media attention or the medics went to help...who knows). Unless you are taking your break away from your ambulance and out of uniform, the possibility of getting requested for a call is still there; forget getting dispatched, all it takes (as can be seen from the original example) is someone walking up and asking for your help. If that happens, you've really only got 3 answers: 1)sure, let's go. 2)nope, I'm on break, let me call you an ambulance. 3)nope, I'm on break. Right or wrong legally speaking, which do you think will cause a problem?

Funny, I don't think anybody here has said anything that you just complained about. Don't go off on one of your little rants now, ok, for once I think everyone is actually on the same page. Croaker has said it much better than I can so I won't bother trying to repeat it. What needs to be done now (by US if we want any type of credibility in the future) is to look at the systems that fail at intubations and the ones that are successful; figure out what works and what doesn't and what needs to be changed to fix the problem and then publish the results wherever possible. Anecdotaly I think everyone knows the answers allready, but until there has been a comprehensive study that proves that and has the data to back it up...change will be very, very slow if anything changes at all.

I understand that part, and yes, if a backup airway had to be used then the intubation did fail. But, this could have happened for multiple reasons, from poor prep/inexperience on the medics part to a anatomical problem that was not found during the intubation assessment. What I'm getting at is that it may have been used through no fault of the paramedic. This is not the case with esophageal intubations though; all the blame rests on whoever passed that tube. It's a bit disingenous to use both types of situations (back up airways and esophageal intubations) for the total number of failed intubations without breaking down why each backup was used; makes the numbers look worse than they allready are.

Probably the most salient points made so far. This is why studies relating to EMS should not automatically be done in areas with the largest number of incidences; yes, it will take longer to get enough data to reach a conclusion, but all to often the areas with a high volume also have pathetic EMS services. p3medic can correct me if I'm wrong, but I believe there was an internal study done in Boston awhile back that had a much different outcome as far as successful intubationspractice and undetected esophageal intubations were concerned. Appropriate oversight, QA/QI, internal/external continuing education/training, and good initial education can make a huge difference in the results of a study (depending on the subject matter anyway). The kneejerk reaction would be to limit what we can do, but if that reaction is based of the lowest common denominators...perhaps a better way would be to look at what good systems are doing and focus on bringing people up to THAT standard. And, without knowing why the authors choose to count LMA's/combitubes as a failed intubation (beyond the obvious that an ET tube wasn't placed...anyone know please share) gotta call it a BS move to include them in the total number of failed intubations; knee jerkwhile an ET tube was not placed, the airway was successfully secured beyond only using a BVM and OPA/NPA. Not ideal no, but a distinction should be made between being unable to place a tube and unknowingly placing one in the esophageus. That (12% esophageal intubations) is unacesophagusceptable any way you look at it, and should be the more important part to look at. I will note though that 10-12 years ago a similar study was published (also based out of Florida) that showed somewhere between 20-30% unrecognized esophageal intubations before the widespread use of capnography. It's still unacceptable, but things do seem to be improving (though much to slowly), and as capnography becomes more and more used hopefully that number will continue to fall...though it may be to late.

It's taking the easy way out, but hey, I'm lazy. http://emedicine.medscape.com/article/796690-overview Between the info there, the references to where the info there came from (it's only abstracts, but better than nothing), and links to further info, you should be able to gain enough to start things moving. This is probably one of the more relevant abstracts although it is 10+ years old; though with this problem that shouldn't be a huge issue. http://www.medscape.com/medline/abstract/9794688 Little more current: http://www.ncbi.nlm.nih.gov/pubmed/19202042 Far as local protocols, generally in this area it's 1gm IVP for eclampsia and preeclampsia, with some services continuing with either a mag drip (total of 4gm in 20 minutes) or giving repeat 1gm doses IVP every 5 to a total of 4gm's. I don't know of any that cannot treat the problem before the pt seizes.

The BMI is generally not worth the paper it's printed on. Unfortunately, so are a huge number of physical agility tests, lift tests, or whatever that particular service calls them. Often the tasks that you are required to perform are not job-specific and don't give a good indicator of what you will really be doing in the field. As well, ask yourself this, if you finish the test and are barely able to walk after, or barely finish it (but still do), you have passed. But, would you still want that person working next to you? To have a good test that will accurately show how well someone will perform, it needs to contain both job-specific tasks in a realistic setting, as well as actually be HARDER than what you will be doing. Couple that with a employer sponsored fitness program (at least a free gym membership) and it's a start. Of course, then you just have to worry about enforcing the standards and firing people when they can't complete it...and then come the lawsuits...any wonder why so many EMS services don't have anything beyond an arbitrary test?

Interesting study, and while it's good that someone finally did one, the results really aren't that surpising and just confirm something that most know: we may be able to get ROSC on someone in cardiac arrest, but getting them discharged home...we suck at that. It does confirm what I believe was the original reason for the push to change to biphasic; it takes fewer shocks to convert a rhythm with a biphasic defibrillator than a monophasic. Though that'd be a good thing for someone with a perfusing rhythm getting cardioverted; be curious to see a study on that and if there was any change in the results.

Actually...the 2009 NFPA Fire Code/Uniform Fire Code now requires sprinklers in all new residential construction. Not that every city follows that code, but hey...it's out there... On topic, the best system I can think of would be a fully-funded third-service that still allows, one way or another for an adequate number of providers to be called to a scene when needed. If this means that a second ambulance is called for say, a code, then so be it (though that would mean that the system is now short a unit that could otherwise be used...unless they are over-staffed...and I know how much people hate that), or, if needed, call for an engine company from the local fire dept. Regardless, and no matter what people's personal opinions are, cooperation with the fire dept is still essential, because like it or not, both will be going on the same calls, albeit in a perfect world that number would be pretty small; MVA's, possible codes, extra manpower needed, technical rescues and the like.

It'd be interesting to see both what the schedules are like, and what the retention rates are for the higher ranked services. It looks like Boston has the highest so far, but they work a 12-hour shift (I think, correct me if I'm wrong), and far as I know don't have a lot of people leaving, whereas some of the lower ranked systems work longer shifts but have medics leaving in droves.

Does anyone even realize that this jackass likes to argue both sides of the issue over and over again? Playing devils' advocate is one thing, but constantly changing your stance just to pick fights is ridiculous and maybe indicative of a bigger problem. And moving someone to an ambulance isn't delaying life-saving care, it's delaying care period. Treat them where you find them, and then after they are awake, continue to treat them with the appropriate tool: FOOD. Idiot.

Couldn't tell you as I haven't worked for every fire department out there. I'm not sure what you mean by combined fire&EMS training. For EMS you will have to learn the system, protocols, equipment etc at each department, and each will have various ways of doing it, as well as different protocols, equipment, etc etc. On the fire side you'll have to learn...well...how to be a firefighter. And each will have various ways of doing that. If you meant training as in being taught how to be a paramedic by a fire department...not happening cochise. If you missed it, a DEGREE is REQUIRED to be a paramedic in Oregon. I only know of 1 department that will pay for a paramedic's degree. And they don't even transport...go figure. In Washington it's about the same. Tacoma Fire does or did send some of their people through Tacoma Community College to get their paramedic cert, but beyond that I don't know. Is that what you wanted to know?

Ok. Sure. Not going to dispute that it couldn't happen. Or that other factors may have been involved. Or that if they where "circling the drain" they might be getting transported as well. But I am curious though, since you are such a proponent of rectal D50, did you do that with all your hypoglycemics? After all, starting an IV takes time (and in your case you might have to pray that you remember how to start one), you have to sometimes search for the veins (and may not find one, in which case you just wasted some time), and the D50 may still cause damage to the veins. So wouldn't it be easier to just pop that ET tube up their ass each time? Faster and safer, which is the way to go. Right?

I suppose. Granted I don't have all the experience you do your majesty, but I have yet to see a pt that was "circling the drain" because of hypoglycemia.

Whoah now...unless you think that the west coast is ONLY southern Cali, you really need to check yourself. As well, don't lump Oregon (and Washington...those lazy bastards) in with ANY part of California when it comes to EMS. There is a vast difference in the educational standards, available treatments, use of OLMC and general quality of care from the southern end to the northern. Put simply, people outside your area are expected, and taught how to actually treat their pt's on their own.

Worth repeating I suppose. I don't see what the problem is with the country "going the other way" and only allowing uneducated and untrained providers to perform minimal interventions. Fact is, that's entirely appropriate. Just as the EMT-I (or whatever the hell it's called in various states) is an inappropriate thing to have. For instance, in Oregon it is possible to go from nobody to EMT-I (which has a huge scope of practice...not a lot less than a paramedic) with only 260 hours of education. Think that's appropriate? Think that's a proper education for all that they are now allowed? The fact that people are starting to wise up to that fact and remove EMT-I's is great. If you are a basic and want to do more of those fun things you can't now then suck it up and go to paramedic school. Don't look for a short cut. As someone has already said, the proper education for even starting an IV in EMS is a paramedic's education. Live with it. And Dust...actually, in Oregon, where a degree is required for a paramedic, the majority of ambulances are run by fire departments. Take out the volunteer services and non-ALS services (and by non-ALS I mean without paramedics) and it's still the same. Couldn't tell you for sure, but I think that before an Associate's was required there where actually MORE private/third service ambulances than there are now. Said it before and I'll say it again: make the minimum for a paramedic a degree, and people will either fall into line or get out of the way. Win win either way.

Were these jobs within the US, or outside in more of a remote-medic type situation? I'd guess the latter (though it'd be awesome if I was wrong) which makes sense; from what I know of those types of jobs (granted, not a huge amount) the people are much more involved in clinical medicine, long-term care, on-site training and occmed than the average paramedic here. So it'd make sense that the employers would want a higher level of education. Kind of surprised it didn't happen sooner. ***this in no way advocates the average paramedic NOT having at least an Associates degree; should be the bare minimum***

Can't really argue all that much here. In my part of the world the work is available for those who want it, (which means for those who are willing to relocate within the state) but there are far, far to many people that I've seen and dealt with who's only pre-hospital experience was their paramedic internship which concluded somewhere between 6 and 12 months before. Skills and knowledge both atrophy if not used...this is recognized in most every other field...why not in EMS? I think part of the problem that we face with newly minted "paramedics" lacking true field experience can be blamed on the insistence that the standards for EMS have not progressed past the 70's; all that is required by the NREMT (which way to many states base their standards off of) is a 200 hour internship...fine if all you're doing is starting an IV or maybe intubating someone who's already dead...but try cramming everything that we are expected to know into that amount of time now...ridiculous. As is the idea that every service has a well thought out training program for their new medics...hell, just look at some of the threads here and you can see the fallacy in that! I do have to argue a bit with the spending enough time in the field for competency part...at least a bit. To really get to the level of being a truly competent and experienced paramedic will take much longer than even a full year...somewhere around 5 is what I've always figured (and is fairly accurate from my perspective). Spend enough time during the educational process to be well-rounded and acceptable, absolutely, but there does come a point that you need to be able to move on. Don't know...guess the bottom line is that what we are expected to know is so much more than it was when paramedicine first was thought of, and the tools we have are so much more advanced (which means that they will tell us more, which means that we need to know more) that it's asinine to think that it's possible to learn all that's neccasary in the field. Or in the classroom.

Frickin' aussies...first you come out with the huge cans of beer and now you come out with a solid way to teach paramedics... :toothy7: I should have said that it'd only be mandatory in the US in a dream world.

Actually, he's kind of right. And kind of wrong too, but go figure. Actually working in the field and being able to put into practice all the things that you have learned in the classroom will definitely help you really understand them, and at the same time you will be learning a whole lot that is never covered in texts or the classroom. So I'm all for extending the amount of time that is required for a (paramedic) internship. Of course all that time doesn't matter if there isn't some kind of foundation of knowledge for you to rely on; it doesn't matter if you are able to run a 12-lead if you aren't able to fully and accurately interpret it and integrate that interpretation into your pt care. So cutting class time is ridiculous; extend it for the love of god! Before you ever enter the field you should already know all you can about the human body and as much medicine as possible; the field is just where you put that knowledge into practise. But it's pointless to do that if you never had the knowledge in the first place. In a perfect world I'd love to see the internship (following a 18-24 month period of classroom and clinical rotations) be something similar to a doctors internship or residency, albeit on a shorter timeline. Say 12 months of full-time work on an ambulance as the third person. By the end of that the potential paramedic should not only have a good medical education but a wealth of field experience to go with that. Win win situation. Course that'd only happen in a dream world...

Why is this hard for you? If it is, how did you make it through paramedic school? I'm not trying to be insulting, but I'm honestly curious. You're giving 150mg mixed into a 250ml bag over 10 minutes. So you're giving 250ml over 10 minutes, or 25ml per minute. 25 times 20 gives you a drip rate of 500 per minute. See how easy that is? (of course 500gtt/min is a bit hard to set...maybe you should get a different dripset, a pump, change the concentration, or use lidocaine.)

Something like this should not cause you to change your career. Something like this should, most absolutely, definitely, positively, should cause you to change where you spend your career. Bottom line for this comes out to be that yes, there where things on that call that you screwed up on. Period. But how much of that comes from being a paramedic with 2.5 months of experience being put into that situation on your own (and yes, you were most definitely on your own there)? Any service that allows something like that to happen is not where you need to be.

Gosh, that would mean no more volunteer's (at least no more volunteer paramedics). That would be awful. Terrible. Honest. :roll: There is far to much to know as a paramedic to think that some halfassed 3 or 6 month crash course is acceptable. 2 years should be the minimum, and 3 or 4 wouldn't be to much of a stretch. If people aren't willing to put in the time and effort to reach this level then that's just to bad. The comment about all the new technology and "toys" that we have caught my eye and relates to this. Yes, there are a hell of a lot of things out there now that weren't out even 5 years ago, and they can do/show you a lot of good info. If you know how to use them. As has been said (kind of) the increased amount of technology we have should be causing the educational requirements to INCREASE, simply because we now have access to info that we didn't in the past, and thus need to be able to understand it and fit it into our treatments. Unfortunately, the opposite seems to be true; because of all these new things, standards are, if anything, decreasing, because, after all, the machine tells you all you need to know. Crap. The amount of things that we can do or check is increasing (sort of...that may stop soon unfortunately), which means that the amount of knowledge we need to have is also increasing, which means that the length of our education is increasing. Or should be anyway. Maybe someday it will.

That's only half right though. Yes, if an EMT-I is the highest level on scene then they have the responsibility for the patient, and will be held accountable if something goes wrong (as it should be...for every level). But, the level of education they have is still very low compared to a Paramedic or other medical professional. The argument can easily be made that because of that, they have less responsibility to alleviate the patient's problems, and the treatments available will (probably) be less than what a paramedic can do. So while they will both be liable for when something goes wrong, the amount of time it may happen to a paramedic is much higher. Think of it this way: a paramedic with the ability to perform a crichothyrotomy or surgical trach runs on a patient where that procedure is needed. They don't do it and the patient dies. Did they screw up and should they be punished for it? Yes and yes. Now, take an EMT-I and the same patient...they can't perform that procedure, so they don't, and the patient dies. Did they screw up and should they be punished for it? No and no. Both are responsible for the patient's care, but only one will have any problems because of the higher level of care that is expected to be provided. Trust me, that issue is in full swing (back in full swing apparently) here.