Kiwiology

Our protocol says a witnessed arrest gets up to three shocks at max joules before CPR is started.

Without oxygen and nutrients, the fibrillating heart will loose its electrical activity (coarse VF) due to acidosis and hypoxia and degrade to fine VF and eventually to asystole.

Research (pg. 16) has shown that 1.5-3min of EMS CPR PRIOR to defibrillation (if call-to-arrival time was 3-5 minutes or more) improves survival rates because it delivers oxygen and substrate to the heart muscle (and as said above, may convert fine VF to coarse VF) thus increasing electrical activity (and size of the VF waveform) making defibrillation more effective at eliminating VF.

Dunno about you but I found that interesting 8)

The pt has the right to refuse any treatment, including life saving treatment if they wish.

We have to transport if we do something major (defined as giving mediciation beyond tylenol) or any fluids (exceptions are febrile seizures or simple hypoglycemia)

If we feel medical intervention is not required we do not have to transport.

A lot of our funding for accidents comes from the Government hence we only get paid if we transport, so we do a lot of absolute crap transports so we get paid.

See here http://www.health.wyo.gov/Media.aspx?mediaId=3166

I was in ED the other day - its the same story, lack of beds and lack of staff. Some mystery QI/PR suit doesn't need to tell me that.

I can see this going down the gurgler when somebody dies in chairs because some jagoff mystery shopper was occupying a bed with a fake illness.

See, "mystery shopper" implies that a nice, friendly, joyus customer satisfying occasion is to be had at the emergency department, yeah right.

As the Horse on Ren & Stimpy said "no sir I dont like it!"

Weird, not sure why the BLS crew legged it but maybe they though this was a movie and the double slap was to go. But, then surely they can look out the window and see paramedics with thier gear wanting to get in or do you not have windows?

Autolocking doors eh, we don't have that but our ER does require a key code to get in thru the ambulance entrance. Really annoying when you don't have one and you just went back to get a ryhthm strip and get locked out in the cold in short sleeves!

Yep valid DNR is final here provided we act in "good faith" and "resusciatation attempts are not in the best interests of the patient".

Stewie from Family Guy coz he's articulate yet evil, blast!

GRRRR every video I try and view it says "sorry this video is unavaliable"

The BP cuff is about to burst off my arm!

I carry a basic kit (including a steth & BP cuff) in the car and on my person I always have a CPR mask and gloves.

Not to say I go looking for disasters but if I am out in the middle of nowhere and happen across a wreck its handy to have something with you.

There was a presentation at a trauma conference I saw about exactly this - some people carried all sorts of stuff in thier cars (AEDs, airway kits, O2 etc etc) I mean good on them great thinking but I think its a bit of overkill personally.

My brother's girlfriend had a tonsillectomy so she could take a size 10 ETT and er, other things, w/o gagging

Maybe I should try this on her!

Why should they? Since they are in Australia or other parts that are not in the bass-ackwards U.S. system, maybe we should try to emulate them rather than criticizing.

Nice broad strokes you are painting with there. Did you bother to ocnsider that there are a number of situations that would not respond favorably to the strong beta effects that epinephrine will exert?

The cookbook seems to be getting to easy to follow for people to actually think anymore.

It seems to me anyway, the cookbook is being rewritten from an evidence based approach (which if you read Circculation the 2005 AHA guidelines admit that randomized studies with cardiac arrest pharmacologics are few and didn't seem to show any great results)

Let's take bicarb as an example: The 1974 AHA guidelines said that along with Don McLean, Chevvy hightops (not sure if KKK-1822 was in force then) and really high gas prices all ACLS providers were to administer two 50mEq amps of sodium bicarbonate.

30 years later, we know that acidosis does not automatically occur in all cardiac arrests, so the guideline was changed. We don't use it at all (not sure how good/bad that is).

It seems to me that this is a bit of a grey area. I just want my paddles back!

All our ambulances sit at the station and wait for a call. Our maximum urban response time to "priority one" is eight minutes. We often have fly cars driving around who get to a situation first and call for transport as appropriate.

In a mixed fly car/transport system the truks generally are ILS or BLS and the fly cars provide ALS whereas in our city (~80,000 people) we run 3 or 4 trucks (two ALS and two ILS or BLS) during the day and 2 or 3 at night (2 ALS or 2 ALS & 1 BLS or ILS).

The paper pusher managers (all of who are medics) also have fly cars to go out to jobs in rather than push paper if needed.

I love our dispatches, they always make me laugh, here's an example

Us "Comms, we're clear on a one alpha one (or whaterver the AMPDS detrement is)"

Dx "Roger, return station"

Like we're gonna go anywhere else? That would burn gas, something that costs money, money our company doesn't seem to have! They even took our intubation manakin!

We don't use vasopressin so no comment there. It seems our protocols have been change a lot recently: no more atropine or bicarb, only epi and we still have ETT drugs for some reason.

I remember back in the day standard cardiac arrest included lidocaine, epi, bretylium, atropine, maybe bicarb and Mg SO. Seems times have changed.

For United:

AUTHORIZED USE

... Medical Kits all require Captain’s consent to be released to a medical professional after their credentials have been verified. If credentials are unavailable, the equipment may still be released at the Captain’s discretion

CONTENTS

Atropine 10ml 0.1mg/ml 21ga x 1 1/2” (1)

Atropine 1ml 1mg/ml (1) 3ml w/o needle (1)

Dextrose 50% 50ml 500mg/ml 18ga x 1 1/2” (2)

Benadryl 1ml 50mg/ml (2) 12ml w/o needle (1)

Epinephrine 10ml 1:10,000 21ga x 1 1/2” (2)

Epinephrine 1ml 1:1,000 1mg/ml (3)

Lidocaine 2% 5 ml 20 mg/ml 21ga x 1 1/2” (2)

Lanoxin 2ml .25mg/ml (1)

Sodium Bicarbonate 8.4% 50ml/ 50mEq 18ga x 1 1/2” (1)

Metoprolol 5 ml 5 mg/5 ml (1)

Foley Catheter (1)

Naloxone 1ml 0.4mg/ml (2)

Tourniquet (1)

Inhalant Nubain 1ml 10mg/ml (2)

Albuterol Inhaler 17g (1)

Phenergan 1ml 25mg/ml (2)

Airway, Small (1)

Acetaminophen tabs (4) {Nonaspirin}

Calcium Chloride 10% 10ml 100mg/ml (1)

Airway, Large (1)

Aspirin 2 pack 325mg (2)

Diazepam 10ml 5mg/10ml (2) {Valium}

Clonidine Tabs 0.1mg (2) w/22ga x 1 1/2” needle; 3ml syringe (2)

Diphenhydramine tabs (4)

Furosemide 2ml 10mg/ml (1)

Stat Kit Reference Guide (1)

Nitrostat Tabs 25 tabs 0.4mg 1/150gr (1)

Procainamide 10ml 100mg/ml (2) w/21ga x 1 1/2” needle; 12ml syringe (2)

Solu-Cortef 250mg 125mg/ml act-o-vial (1) Treatment Tag (1)

18ga x 1 1/2” (1)

20ga x 1 1/2” (1)

25ga x 1 1/4” (1)

25ga x 5/8” (1)

0.9% Sodium Chloride 500ml (1)

Endotracheal Tubes w/stylets 1 x 3,5,7mm

Alcohol Sponges (2)

I.V. Set with 2 Y-connectors (1) Gauze Sponge 3 x 3 (2)

I.V. Catheter 18ga x 2” (2) Gloves, Nitrile, Non-Sterile (12)

I.V. Catheter 22ga x 1 1/4” (2) Gloves, Latex Free, Sterile (2)

Laryngoscopes x 1 ea. large and small

Hemostat (2)

Monitoring Equipment Needle Holder (1)

Aneroid Sphygmomanometer (1)

Scalpel (1)

Stethoscope (1)

Light Source (1)

Scissors (1)

Thermometer, oral strips (2)

CPR Microshield Plus (1)

Sutures, Prolene (1)

Sutures, Vicryl (1)

Miscellaneous Equipment Tape, Hypoallergenic (1)

Contamination Bag, Blue (1)

Thumb Forceps (1)

If we can, we perfer to get the patinet into the ambulance as quick as possible because its easier than lugging all the gear around.

When that's not the best option I personally like to take O2, Lifepak 12 and trauma bag.

The only time I'd take the drug and airway bag (ie ALS kit) is for things like arrests, severe asthma, anaphalyxis etc.

happened a couple times here, we had one in my city stolen from ED by an escaped mental patient which was quickly apprehended and returned.

I'm thinking a complete tox workup on this guy. If naloxone didn't work maybe some charcol?

Guessing he's either diabetic or has some form of poisoning.

Testicular torsion. Been there, done that, got two tylenol at ED for it (I protested and asked the sleepy looking resident for something stronger!) and it went away on its own. Mwahahah no surgery for me!

Maglite

Long spine board (shield)

Oxygen tank (club)

Stretcher (ram or block)

Disinfectant spray for cleaning the cabinets (mace)

Any of those work well

Oh why oh why is the wait at ED so long? Why are there no ambulances to respond to my heart attack? Why I wonder, same old story, people abusing the system.

If you go to ED here you don't have to pay so while we do get the problem of people who can't pay the $20 (or whatever) to see thier Doc turning up, its mainly people with cut fingers, colds, sore throat etc

I've never waited more than about 30 minutes to be seen in the emergency department (I've waited longer in my Doctor's waiting room reading stale old magazines) and from data our Ministry of Health publishes, it would seem that 100% of people needing immeadiate treatment are treated straight away.

I am not sure what this article means by "heart attack" - I doubt it means somebody who is in VF on the floor not breathing. I would make an educated guess here and it could mean everything from somebody with chest pain to a post resuscitation admission. I'm not saying they should wait longer than they have to, but, I don't see the problem with placing somebody with a massive hemmorage who has lost half his blood volume ahead of somebody who has been resuscitated and thrombolysed who might have to wait 10 minutes longer.

An ER Doc told me "if you are breathing and not bleeding, we don't want to know about you" and I hate to play devil's advocate but that's what the emergency department is for.

Same goes for EMS - people dial up 111 and say "oh I need an ambulance for a cut finger" or "a broken toe" or "my cat is sick". I can't tell you how mad these bullshit calls make me.

The public bitch about wait and response times for ED and EMS, well, its simple, don't abuse the system and you won't have any problems!.

I got 66% on the pre-test with no formal education in the subject.

Um, I understand a little of that but that's just scary

I think we should remove EMTs from EMS and just go with Paramedics. The scope of practice is severely limited from what I have seen, and we can sit here and argue the appropriateness of EMT-Bs intervention ability in servere medical and trauma emergencies until we are blue in the face.

From what I know, I don't think it is appropriate in many situations and really feel bad for those rural communities who must rely on BLS only services (many of whom are volunteer) because they don't have the call volume to get ALS resources.

If we staff every ambulance with two Paramedics then how do we account for those services who get very few calls?

I hate to play devils advocate, but, injecting the required funding to put Paramedics on ambulances out in the boon docks where they might get one or two calls a week does not really seem sensible.

We have one service that uses the title "Paramedic" for all EMTs and "Intensive Care Paramedic" for EMT-Paramedics.

While it is true that all EMTs are "paramedics" (ie they work outside of the hospital) some are not "Paramedics" in the industrial sense of the word - i.e. an EMT-P.

I think caution is needed to both get away from the old mindset of "driver" but must not elevate public expectation so much that it gives them a false impression of what you are able to do.

Example: Here in New Zealand we have five levels of EMT. The lowest two are equivalent to CFR+D and EMT-B but both can staff an ambulance. The media has a negative infulence in that on TV you will see EMTs and Paramedics but they often do not differentiate between the two so the public gets a distorted perception of what care can be offered. If you live in a rural area here and have say. a heart attack, the first running ambulance that will turn up will probably be a BLS unit which has no authority to do anything more than CPR, oxygen and AED.

That's not what the public see on TV, they see three or four people turn up at least one of whom is a Paramedic and adminstering advanced life support. TV does not show that some ambulances are staffed with clinicians who have no authority to deliver IVs, drugs, manual defibrillation, intubation or any of the things you see on TV.

I had a family friend who got impailed on a pitch fork (they live out in the sticks). The mother asked the EMTs if they were going to adminster some better pain relief because the entonox wasn't working. Much to her dismay, the EMT had to inform the mother that he was not qualified to deliver any drugs or fluids and they would have to wait another half an hour until the helicopter with an Advanced Paramedic arrived so that they could do it.

I am all for EMTs and Paramedics getting the proper recognition that they are not "drivers" or "attendants" but we must be careful not to give the public unrealistic expectations.

The way I see it, to the older generation of laypeople EMTs and Paramedics are simply "ambulance drivers".

We have the same problem here - all levels of EMS clinicians are called "Ambulance Officers" as a collective but the title will vary. Most people below the Paramedic (EMT-I) level are simply called "ambulance officer" while Paramedics and Advanced Paramedics (EMT-Ps) are called by thire auctual title.