Kiwiology

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.

We have two. 10-9 is require urgent police assistance for patient being combative 10-10 is emergency, ambulance staff being assaulted The Dispatcher has to hear it, pick up the phone, dial the Police, wait for them to pick up, explain the situation to a call taker, the call taker has to transfer it to the dispatcher, the dispatcher has to dispatch the Police, the Police have to travel to the scene and assist. If it's busy the Police phone system will wait for I think 30 seconds then divert you to another call center and continue until somebody answers. This really annoys me because all three services (Fire, Police and EMS) here use the Intergraph system which can be linked. Fire and Police have done it but we can't seem to grasp the concept. We also don't have any stab resistant clothing or personal protection beyond our Maglite which can be seen as assault with a deadly weapon if the cops want to be pissy about it.

I couldn't agree more. Sorry I'll clarify what I said a few pages back - I am not in favor of 16 year olf EMTs to provide first running cover for exactly those reasons you said there Dust. They don't have the maturity and clinical experience. I also couldn't agree more that BLS sucks!. We have the same problem here in our smaller areas that rely on BLS by way of total volunteer crews and maybe a paid Paramedic during the day who is also on call at night. Our union takes the same approach - to Joe Layman an ambulance is an ambulance, it doesn't matter what the guys in it have the ability to do. They expect every ambulance to be able to provide what they see on TV which is ALS invariably. I am of the personal belief that BLS is an effective stopgap between ALS for true medical or trauma emergencies as I said before. They can try to keep me alive until the Paramedics arrive, I'd rather have them doing that than waiting for ALS to turn up. For example here in good ole Kiwi Land only 19% of our stations can provide ALS 24x7 while 30% capable of providing ILS 24x7 and the rest, its BLS. We are working to get an EMT-I (ILS) on every ambulance which does not have ILS or ALS already. I'd love to see a Paramedic on every ambulance, but, in the meantime if I am dying, I'd rather a BLS truck turn up first than a longer wait for ALS.

Interesting, and I agree with your point there Asys but let me look at this another way. I'm at the 14 St subway station at rush hour, my Metcard won't work and my train is leaving. I have a heart attack, er, myocardial infarction. The good people at the FDNY will dispatch an ambulance to me. The closest BLS unit is 06 Adam (CSL: 14th & 2nd Ave) so they kick off the bums who are hassling them for medical care having been annexed from the firehouse and light up the LED and speed to my locale. Wait a minute... Adam is a BLS unit, same as the 16 year old Superkids in CT. They can only pull out the AED and await an ALS unit. Closest FDNY ALS is 6 Xray at E 23rd & 2nd Ave by the FDR. Too bad 6X only works from 6am until 2pm. If I code at 3pm well ALS looks like it'll be 7 Robert from W 34th and Avenue of the Ameircas which is even further uptown. I don't see how the 16 year olds being BLS and relying on Paramedics from county mutual aid is any different than your FDNY BLS unit being BLS are relying on FDNY EMS or perhaps somebody from Bellevue or one of the other providers I've seen around the city. I understand that and I can see where you are coming from. Something is wrong at City Hall if they think providing first running EMS to medical emergencies with teenagers is acceptable. Is it better than nothing? Yes, is it as good as a professionally run, career orentaited EMS service? No. But, what differentiates them from the many other volunteer EMS (be they BLS or ALS) agencies around the world apart from thier age? Now I may be wrong, but, given that many small communities rely on the good nature of volunteer firefighters and EMTs to provide a "first running" response to fire and medical emergencies I just don't see the problem. In leiu of a professionally run and funded EMS system which may not be financially viable or practical given a low workload what else can we offer? Nothing. That sounds good! Whoops too bad if you're dying, I mean really dying, from lets say massive hypovalemic shock while blood gushes from a severed artery. Well you can wait for county ALS or a fly car to turn up but hmm that might take a while, in the meantime we could have had some volunteer EMTs turn up and apply bleeding control, O2 and those blow up MAST pants I have noticed we don't carry anymore. I know which I would rather have.

Not sure if all of you have seen this but it is was originally a book and DVD released by the late, great James O. Page (founder of JEMS and former Captain of the first LAFD Paramedic unit). I came across the video on YouTube (watch it here) but have also got the expanded DVD edition which can be ordered from Amazon.com here 'Tis an absolute must watch and is really interesting to see where we have come from. Hope it's of use.

I used to be in the Army and I know a bit about combat medicine. One of my personal interests is the history of civillian EMS which has its beginnings with the French during the Napoleonic War if I remember correctly. The Royal New Zealand Army Medical Corps (RNZAMC) teaches our medics along the same track as our civillian Paramedics, emphasising a clinical knowledgebase and competency in emergency and trauma care. I think it's necessary to know both sides of the equation - i.e. general medicine (treating a sore tummy or foot full of blisters from too much PT) and also traumatic combat injuries. Note I said combat medicine because that is different than military medicine. I differentiate the two because on base in the military you don't get a lot of people with major trauma, gunshot wounds, ordaniance embedded in various bodily cavities etc. You can go along to the doctor and he'll take an exam, maybe take some bloods and give an Rx (and if you're lucky a day or two off PT). Out on the line there are people who have had limbs blown off, thier chest ripped open and insides shredded, who are bleeding profusely etc etc. In that situation it's (arguably) not necessary to know how to treat a medical problem such as a sore tummy because this guy who has lost 1/2 of his blood volume probably and is seriously hypovalemic probably doesn't care. All he wants is some blood, those funny looking blow up MAST pants which seem to be used less and less these days, and a spot on the chopper to a MASH. Now in saying that not every waking second of combat is er, combat. So if you've got said sore tummy in your foxhole at 2am then yes, I would want my co medic to be able to tell if I had a bleeding ulcer, appenditicis or a perforated colon due to the mystery meat we ate at chow. There is a place for both but figuring out why my tummy is sore and how to treat me when I am shot up and bleeding.

Sorry I missed that until now, I was out with the local malitia fighting the CIA installed General who has overthrown our poor third world country's Government in a coup and on the way back I had to check how the well digging was going because I am sick of walking 10 miles for water. Boy it sure does suck to live in a country that's considered in the First World huh?. *removes tounge from cheek*

Our EMT-Bs (which is a mix of EMT-I/85 and EMT- can do the following: Independant - O2 and OPA - LMA and NPA - Entonox and methoxyflurane - AED - Asprin & tylenol - Nebulized allbuterol - Nitro - IM Glucagon Authorized by medical control or a Paramedic - IM adrenaline - Nebulized adrenaline IVs: Maybe way out in the boon docks. IVs and other invasive interventions carry risks, benefits and consequences. I am studying for my EMT-I qualification here which is a combination of I/85 and EMT-IV so part of it is IV cannulation and fluids. I don't find the procedure that hard to learn and understand but you must consider the implications of a failed IV. What do you teach them to do? IM, IN etc? I am generally against EMT-Bs being given the ability to start an IV. GTN, ASA, BGL, 12 lead, allbuterol: We can do them here except 12 lead acquisition but that's not hard to teach so I don't see the problem. Naloxone: Abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures and cardiac arrest. EMT-Bs don't really have the skills to treat those (such as nausea and vomiting - they can't give metaclopramide (maloxon) or IV fluids) so I'm generally not going to support it. Maybe under the the supervision of a Paramedic they could do it. I can see the logic in including it but I'd need to do some further digging.

Yup its true. Los Angeles was one of the original Paramedic cities - along with Jax and Miami. Remember John Gage from Emergency? - John Gage comes from Jim Page who was the Captain at LAFD Station 7 at the time NBC came to do research on thier Paramedics. See this is what happens when you like EMS too much, end up full of usless information

Us Kiwi's have 5 which will soon be 4 because EMT-IV and EMT-I are being merged. FR + AED (O2, AED, Entonox) EMT-B (mix of EMT-B and EMT-I/85 (LMA, GTN, allbuterol) ) EMT-IV (0.9% NaCI, manual defib, IV cannula) EMT-I (Epi, Naloxone, D5W, Metoclopramide (maloxon) and morphine) EMT-P (NREMT-P) Any one of these can work on the ambulance.

Since 1973 the LAFD has run EMS in LA City and unlike the FDNY I believe all Paramedics are also firefighters.

No breath sounds, ok, so this guy is obviously not breathing. That's my main issue. If he has COAD or asthma or some other resp disorder / allergy he's going to have to meds or a medic alert bracelet or something of that nature. I would start on O2 at 8 lpm and check out ETCO2/chest rise & fall and re-evaluate breath sounds with a view toward BVM if he's not improving and requires manual ventilation. I am thinking this is one of the following: 1. airway obstruction: laryngascopy and remove with McGills forceps or push the endotracheal tube right down to dislodge the object. 2. asthma or COAD: 0.5mg IM adrenaline and get an IV line, if not improving intubate and start infusion of 1mg epi/hr in a litre of NS with epi boluses of 0.01mg IV as required q1-2. 3. allergic rection / anaphalyxis: 0.5mg IM adrenaline, if not improving intubate and start infusion of 1mg epi/hr in a litre of NS with epi boluses of 0.01mg IV as required q1-2. I would be interested to see how this turns out: I don't think its poisioning or a sting or some kind because I'd suspect he would have mentioned it to the EMD. What about environmental: gas leak or something?

New Zealand's fleet is making the transition to Merceedes Sprinters from Fords and Chevvy Silverados. I dont like them, they are not purpose built ambulances and are really, really crappy. They are bought mainly to proivde the highest possible degree of resale value simply because our funding is not sufficent to buy proper Type III ambulances. A picture of the interior of what I believe to be an ILS or ALS capable ambulance is below. You will note two stretchers (which is a historic inclusion and never went away), no cabinets and the fact the patient stretcher is right up against the wall. The Lifepak 12 up on the left hand side either stays there or on the spare stretcher (on the left) so its prone to sliding around. The orange trauma kit down at the bottom left is the same, it will slide around. We have long spine boards and the like in an exterior locker by the passengers side door. Note what I believe to be the ALS jump kit on the left hand front beside the passenger seat. All the drugs and stuff are in there. Even that is problematic as you have to dump all your gear on the spare steretcher to use it. The Paramedic's seat is really only useful for intubating or procedures on the top half of the pt. and therefore rarely used, they'll just sit on the spare stretcher. Can somebody PLEASE get us a good Ford E450 with some wall side cabinets and a proper interior with only one stretcher?

Most of the ER/surgical docs I know think highly of medics. If they get on your case, offer them a seat in the truck on a Friday night, I bet you they decline real fast. I know some who wouldn't touch the street unless it came through the ER doors - oh they say its too dangerous. Our medical students do ONE 12hr shift with EMS for the entire 4 years they are in medical school! Our Paramedic degree guys do placements for the entire 3 years of thier degree. Not sure where this high and mighty mentality comes from, after all, doctors like Eugene Nagel and William Grace, not to mention all those pre-1980 ACEP members invented EMS. If they get too uppity remind em that it was physicians who came up with the idea of prehospital ALS, so they are jumping up and down about a program THEY invented, that should shut up em up Oh, and if it makes any difference, our protocol says: SEIZURES 1.5mg midaz IV q 3-5 max 15mg 5-10mg midaz IM max x2 q20 15mg midaz IN q20 max x 2

Sounds like some of the guys I know, they can't comprehemd being told what to do or follow instructions.

Well now we cant have you looking like a firefighter now can we, thats a "promotion" - *tounge in cheek* - what a crock, I feel sorry for you guys who aren't even allowed in the house and get dumped at some CSL where the crazies can badge you. Far as uniform, I like the dark blue or green jumpsuit (like the Londoners wear) with the SoL all over it or something like ours, just a shirt and pants. I know one or two places that use total white - I wonder if they have a Superior ambulance with the yellow lights and glass IVs too! We don't even have the Star of Life on ours - we used to but not any more, and our protective clothing is a hard hat and a reflective vest. I sure could go for the thick bunker coat those FDNY guys stuck at ther CSL's have. I think for safety medics need to be "nuteral" ie not look like a cop so that the nutters don't confuse the two. Bring on the jumpsuit!