Kiwiology

How long ago was her bloods last done at the hospital? They were all normal i.e. no leukocytosis or other biochemical signs of infection such as increased ESR, bands, segs, monocytosis etc? Temperature? What is she like to touch; warm? hot? any cutaneous erythema? After four litres of fluid this lady should be pissing like a racehorse but the fact she is not is very concerning; she probably has some massive vascular or renal dysfunction so all her fluid is being lost into the extravascular compartment rather than being retained and pee'd out. I would sedate her a bit with 0.5 mg/kg of ketamine and see if she can tolerate passive ventilation through a tight fitting bag mask with PEEP of 10 cmH2O. If she can great, if not then I am going to RSI her. I'd give 2 g ceftriaxone IV, balance of risk is in favour of giving it.

There is surprisingly little math involved in being an ambo down here in New Zed as all of our paediatric drug dosages with associated volumes are listed in the back of the Clinical Practice Guidelines so that's really duh simple so even a muppet with nothing more than Proficiency Ambulance Aid from 1991 could use them. We don't do any drips except adrenaline and amiodarone; adrenaline is 1 mg in 1,000 ml of 0.9% NaCl given at 2 gtt/s and titrated to patient condition from there, amiodarone is 150 mg in 500 ml of D5 given over 30 minutes. The hardest part of Kiwi ambo math is counting down the numbers between the day after pay day and the next pay day

Jesus H Fuck! Looks like my malpractice premiums just went up a lot ....

I will assume you are being facetious

We have a sprauge in the big green pack but honestly I don't like them, never have. The Classic II SE is great, its inexpensive (mine cost me $100 or there abouts), as Trev said it fits snugly and provides very clear sounds with both the bell and diaphragm, and it looks good too (unlike its user!)

My intrathoracic pressure increased transiently as my diaphragm moved superiorly but it feel short of a laugh Sorry bro

You're an idiot, you realise that? The DOT did a study some years back and the main reason people failed to complete the Paramedic (ALS) program according to its research was lack of basic math and English ability. Not only that but seriously? seriously? I can't even begin to describe the multiple levels of fail .... for starters all of your patient report forms are legal documents that must stand up in court and that any good medical malpractice lawyer and expert witness can make you look like a bigger incompetent muppet than you already are with ... If I continue I am going to have a haemmorhagic stroke so excuse me while I scoff down some clexane and ACE inhibitors and leave it at that. Dude, you said you liked me!

Then I might not need to watch COPS no more?

If she is still hypotensive after two litres of fluid I'd start a very slow adrenaline infusion. Because our time to hospital is so great, I am considering giving her 2 g ceftriaxone IV as well.

Trev please, have you been into the ketamine again, what's a pension?

Are you kidding me right now? Here is what you need to get into the BHSc (Para) Must be capable of meeting HPCA Act requirements and provide a police clearance; Applicants with a Certificate in Health Care Support, or with a previous or partially completed degree .. must have achieved a minimum of a B grade average; Applicants over 20 without previous tertiary qualifications must supply a CV and references; 14 NCEA credits at Level 3 in Biology, Chemistry, Physics, or Mathematics with Calculus and 14 credits at Level 2 or higher in English or CIE English and 14 credits at Level 2 or higher in Biology, Chemistry, Physics and Mathematics and/or Health or Physical Education. And yes, this is the only route now to a paid job in Ambulance, the ab-initio days are dead and by 2015 the Ambulance Service will only employ graduates (as it bloody well should!). So um yeah, about that "C" average of yours ....

Sorry to break it to you mate but you're just a body to me too, I no longer love you and have filed for divorce I would recommend you start with a thorough foundation in chemistry and biology, anatomy, physiology, English and then take a very important class called "Avoiding Kiwi and Everything It Says 101".

Sure mate, I mean the education requirements and level of complexity have not substantially changed since 1984 and are probably the lowest in the developed world (excluding the UK ECA but that is different) so can't be that hard right?

This varies greatly by jurisdiction. In some, it is the near sole job of the lower qualified Officer to drive, while in others driving is shared. It is my firm belief driving should be shared by both Ambulance Officers. Anybody who tells they do not really like to drive or that they don't want to do it is majorly full of shit; there is nothing better than driving on the wrong side of the road in the rush hour with lights, siren and air horn screaming. If anybody who tell you different is mental. Having said that, driving is one of the most dangerous parts of the Ambulance Officers' job and while getting to drive the ambulance and make lots of noise and whatnot quite nicely meets some sort of raw primitive instinct you have to be sensible about this sort of thing cos if you are a complete muppet and go to everything on a one willy nilly eventually you're gonna fuck up and waste somebody, perhaps yourself. Down here in New Zed to be able to drive you have had your license for a minimum of 2 or 3 years and have had no tickets or points in a reasonable timeframe and have had no driving convictions like you know, ever. The driving course has an online pre-class component including passing a test, then two days in class, then driving round some cones and around town for a bit with a driving instructor then you get a logbook to fill in as you build up experience that takes a couple weeks to get filled in and signed off then you are qualified to drive urgent. The other ambulance service splits non-urgent and urgent driving out even more, requiring 3 days in class plus a road test for non-urgent driving and 40 hours of experience behind the wheel built up before going back for the class and road test for urgent driving. I much prefer this approach. I would also welcome bringing back the old Class E ambulance endorsement we used to have.

Welcome onboard, keep your hands and feet inside the vehicle at all times, tray table folded upright, no flash photography and please, listen to your tour guide, even if he is destroyed on valiumz No CPAP here in New Zed (sigh!) so best we can do is a tight fitting face mask from a BVM and PEEP of 10 or 15 cmH2O

I have a Classic II SE and it's great for lung, bowel and heart sounds, can hear them all really clearly even through clothing and with noise. Note: Do not, under any circumstances, for fear of death at the hands of Kiwi, listen to sounds through clothes, this is pointless and lazy.

Thanks for the suggestion dear I've seen no less than 11 shrinks, counselors, therapists, psychologists, psychiatrists, social workers and most other variants of noggin people since the year 2000 and it hasn't done nothing. The one thing that did help fell to bits and just put me further into the mental black hole To do anything medically related you have to be slightly deranged, I guess I'm good at it because I exceed said criteria? I tell you what, as fucked in the head as I am would I take being normal if somebody offered it to me? hell no, normal people scare the shit out of me!

Mmmm num nums, thermoregulatory valiumz So my doctor thinks I eat too my valiumz and wants me to go to counselling for "mental health problems" like whatever, valiumz are cheaper and less you know, no talking or group hand holding involved ... Jeebus H Fuck, just the thought of that makes me need some more valimz!

It is so hot here I think I am having a spell .... Clearly I need to call an ambulance right?

If I make it across the border will you give Jose Benjamin Juarez Ambulancia del Kiwi consideration without asking any of those "work visa" questions?

Do we have her temperature? Any signs of an infection in her blood chemistry e.g. leukocytosis, increased ESR, bands/segs? I am thinking either a PE or sepsis but cannot think of an aetiology for either? I'd give her another litre of fluid and if that does not improve her BP then I'd be keen to hang an adrenaline drip Harry my friend, step a bit harder on that gas pedal mate

They are both manufactured by a company called Pacific Helmets here in New Zed I like the old ones because they have a face shield and look a bit more normal, plus they have AMBULANCE very conspicuously marked on them which helps. I do not know why the change but I bet the budget had something to do with it ...

We have two styles here in Kiwi (1) the good old style back from the regional ambulance service days (2) the piece of shit new ones Old style on left, new style on right The majority of the the time they are used at road crashes but really are used anytime when they might be needed

Could be a slowly developing pneumothorax or lung contusion; does the CXR reveal the fractured ribs or are they evident visually or upon palpation? If it's bilateral consolidation makes me wonder if it might also be respiratory tract infection - elderly people are known to get pneumonia pretty easily and this would seem to fit the bill aetiology wise. I definitely agree with Harry that her symps are suggestive (but not specific for) PE however I am unsure if a PE would "suddenly develop" out of thin air without some significant underlying pathology such as a DVT. Titrate oxygen therapy and analgesia and transport nice and slow, Harry you can drive.