Kiwiology

It is not, it is a rash to the trunk consisting of rosy coloured spots and some petechiae/purpura

I think it might have been easier to just not commence resuscitation, or to have ceased. Asystole with two rounds of adrenaline ain't looking good. In the absence of such and if a definite airway was desired then whoever desired it should have performed the procedure. Curiously, what did you want? Personally, I reckon an NPA with a good jaw thrust or an LMA would suffice quite nicely

Football is for bitches, rugger is where its at, a bunch of pissed blokes going for mongrel at each other on a paddock covered in mud, no pads, no helmets, broken necks and such all around, bloody awesome!

I disagree, it is time to do like other nations in the world such as New Zealand, Australia, Canada (Alberta and Ontario more specifically) and South Africa that have removed superflorious levels , heavily up-educated and up-skilled their base level practitioners and ensured that the top level ("ALS") get sufficient exposure to crook people so they use their specific skillset as frequently as possible. It's also time to get rid of a Paramedic (ALS) on every ambulance or on every fire truck where the IAFF is concerned, and for as little as sixteen weeks' Paramedic "training" plus a couple hundred hours of "skills internship" to be acceptable. Intubation generally, I think ICP in New Zed gets about 1 tube per month per Officer, RSI is slightly less however we have consistently, for a decade now, exhibited > 97% success with (as of 2009) all failed intubations managed without cricothyrotomy. How is this possible? By having people who are extremely well educated and ensuring maximum possible on-going exposure. And no, we shouldn't be intubating, or I don't think even ventilating, primary cardiac arrest patients.

Last time I heard numbers, down here in New Zed something like up to 30% of patients have a recommendation of non-transport made

Let me clarify, I think it is a valid question from the point of view that if the practice of using an endotracheal tube or any other sort of airway (in this case an LMA) is harming patients by decreasing their chance of survival then it needs to be studied and practice changed to reflect the results. I don't think, as I have said earlier, that the device matters, I think the 100% oxygen and/or the amount that is put down it (tidal /minute volume) does.

Whilst I completely agree with what you are saying I think it is still a valid question; if what is currently practiced is somehow harming patients somehow regardless of how dead the overwhelming majority of them are going to remain then it deserves attention. I still say that ventilation is not a priority and should probably be removed from primary cardiac arrest until ROSC is achieved; I've been saying forever and a day that adrenaline is probably harmful and should be abandoned.

I agree this is a great topic and a very relevant issue In New Zed it has been decreed that regardless of problem, if an LMA is in place and working well that the patient should not be intubated (unless they will benefit from RSI and control of carboxaemia e.g. TBI) and specifically in cardiac arrest, ventilation in primary arrest is at or one above the bottom of the list, above perhaps only IV drugs from the bottom of priorities. I cannot help but wonder if a more appropriate study would be ventilation vs. passive oxygenation? I know there were some studies from Arizona that looked very promising where the patient was not actively ventilated?

I don't think there is really a role for ventilation in primary cardiac arrest at all regardless of which piece of plastic you are using. The evidence clearly shows that intubating people makes outcomes worse, and it may be the case with supraglottic airways such as King or LMA. I hypothesise that this is due to over-ventilation causing increased intra-thoracic pressure (and therefore causing venous return to fall) or the arteriolar constrictive effects of 100% oxygen causing myocardial perfusion to be lowered. Not giving oxygen to a normoxaemic patient with myocardial ischaemia / MI is all the rage now, so why suddenly when they are unconscious is it OK to cram 100% O2 down their gob with a bag mask? And as for the Japanese Paramedics (called Emergency Life Saving Technician or ELST) if memory serves me right they require a Bachelors Degree (of 3-4 years duration I am unsure which it is in Japan) and that they are, or at least up until very recently were, highly restricted in the treatment they could provide; I heard it was limited to LMA, manual defibrillation, adrenaline for cardiac arrest and one or two other small things; not unlike the original Paramedics of the late 1960s in the USA. Having said that, I did read somewhere that some were allowed to tube people (clearly that must now be the case if this study is out) and Japan already has Doctor staffed MICU Ambulances anyway.

It turns out that the house is not normally this dirty; about two weeks ago all of the students went to the coast and caught a lot of shellfish because its summer and they wanted to BBQ them; apparently only a couple of the party ate them, including the sick one, the rest did not because they did not smell "right". It was about 4 days afterwards that she became sick. They have not cleaned since because they claim to have been too busy between studies and looking after their sick housemate. The rash looks like this

Hey, hey, hey lets not be giving him ideas like he might be important Rude bastard probably won't even come over for dinner and let me sit here all alone

The water itself looks fine, the container just looks a bit suspect i.e. dirty No rodents; just a few domestic cats that are clearly not cleaned up after These are all reasonable differential diagnoses and ones that were considered. Nobody else has been sick. PEARL + GCS 13 (E2 M5 V6) No neck pain No photophobia B/L basal crackles Approx 1 L day of water input and maybe ~ 200 mL of urine output Skin sweaty with cutaneous rash and some small purpura Abdo NAD ECG ST No contact with anybody else who has been sick

This is a real case I have recently had at work however minor details have been altered to decrease any chance the patient can be identified ... not that I imagine they could be but still. It's 1pm and you are called to a small three bedroom unit (apartment) on a divided lot in a reasonably well kept neighbourhood in a major metropolitan city. The chief complaint on the magic telly box in the big white van has been listed as "feeling unwell". You arrive to find the house is quite messy and unkempt, very dirty with lots of dishes piled high in the kitchen and several cats running around inside. There is lots of newspaper laid down on the kitchen floor and the house reeks. Many Middle Eastern students in their 20s exclaim "to be coming the quickly, yes please, sick, sick!" while yelling at each other in some foreign language. In the lounge there are 3 mattresses on the floor, one of which contains the patient. A total of 8 people live in the home. The patient is a female in her early 20s, she appears very unwell. PMHx - none; is on an international student visa for last 4 months; "never sick" in home country HPI 10/7 feeling unwell, malaise, fever, diarrhoea, malena, nausea, vomiting, no hameotemesis, low appetite, abdo pain, low urine output O/E she is conscious but confused with many cutaneous spots and a blotchy rash Obs BP 90/40 PR 120 RR 38 SpO2 92 (RA) T 40.1 (104 F) BGL 4 (80 mg/dl) CR 3 The other people tell you that while she has been sick they have been feeding her "the helping curry" which is basically vegetables and rice with some curry spices, and lots of water. You notice a large plastic milk container nearby filled with water, the container is very dirty. They have not taken her to see a Doctor as she is an international student so is not eligible for publicly funded healthcare and cannot afford to pay for the Doctor (a typical non-enrolled visit fee for a 15 minute (!) consult with the GP is anywhere from $70 to $100 NZD). What do you reckon is wrong with this young lady and more interestingly, where did it come from?

Here in New Zed we used to have a Class E license (Ambulance) however this was withdrawn and although no replacement has been introduced to cover Ambulance specifically the equivalent is the P endorsement (passenger) which falls under the commercial driver license medical standards so I am using those in my opinion forming, which state 2.4 Epilepsy The Agency may consider granting a [commercial] licence for these classes or endorsements where an individual has been seizure free for five years without taking any anti‑seizure medication and a neurologist’s opinion supports the application. I believe it appropriate for somebody who meets these criteria to be capable of driving therefore employable as an Ambulance Officer; although the P endorsement is not specifically required.

Glad to hear you are alive and well, clearly those pins I have been putting in the voodoo doll are not working and I will double my efforts I may venture across the bridge next set of off-watch days I get to smother you with fluff your pillow and such, I will stock pile some extra valiumz and dopanergic antagonists for such an occasion. Actually, I have the entire house to myself for the next week, you would be welcome to come over for dinner, hmm, let me go look in the fridge, better make sure that suxamethonium has not expired.

I don't think there is a problem with people having a firearm for protection of their own home and family from harm, New Zed has some of the strongest gun control laws in the world and I think we have just taken it too far, but then again there are some states in US where you need no ID, no background check and simply the money to purchase a firearm and nobody stops you, which I think is perhaps too far on the other end of the extreme. I am not one of these second amendment bashing gun freaks but having spent enough time in US and around people who have ready access to, and use, their firearms my viewpoint has significantly changed and as I have said, sensible people should be allowed sensible access to firearms but I do not think this extends to fully automatic weapons. People with mental illnesses who are a danger to others, psychotic etc shouldn't be allowed guns that is kinda you know, a no brainer, just like a blind guy shouldn't be allowed behind the wheel of an 18 wheel Mack truck, however to say that people with "mental health problems" should not own a firearm is too broad.

... or as hairy, ew!

I hear ASNSW has "revolving door" stations where the maximum possible amount of time on those stations are spent applying to get a transfer out of them ... that can't be good!

Clearly because he is a douche face who thinks he knows more about me than he actually does, either way I find it rather amusing, but am not the left bit concerned, he has not returned and is probably a troll. Excuse me, time for my lunchtime valiumz

Lol from my understanding NZ Ambulance Association are of dubious reputation so um yeah ...

That was pretty damn good, even I wouldn't have probably gone that far, nice work Trev, have a Tim's!

I wouldn't waste my valuable urine in his cornflakes mate, I need to save that for hydration, damn flouride is out to get me so drinking water is a no go unfortunately ....

Um yeah, because its always that obvious and you are always told that such a situation exists, and the Police are always free to come help you and not 20 or 30 minutes away .... um right, sure, thats how it works I suggest you watch this http://www.3news.co.nz/Ambulance-drivers-suffer-abuse-while-saving-lives/tabid/367/articleID/185871/Default.aspx

The maximum limit for EMT-Basic of 110 hours set in 1990 was rather arbitrary too ... I know the figure of about 190 has been touted for the new "EMT" level under the NSOP. So we have increased 80 hours in 20 years and nowhere in that additional 80 hours could simple things like entonox, salbutamol, GTN, glucagon or intramuscular adrenaline be accommodated .... how very, very disappointing, Kiwi sad now. I have also figured I dislike the title of Emergency Medical Technician and much prefer Primary Care Paramedic (thanks Canada!) or maybe just Paramedic.

Nah he's probably some doucheface I wouldn't worry about him. If I eat enough valiumz, dopanergic agonists, noradrenaline reuptake inhibitors and smoother-outers he will go away and hopefully the massively debilitating suicidal depression will follow, now that has been getting a bit better I must admit, but eh .... that would be too much to ask I reckon. I might go get a snack, lets see whats in the fridge, oh look, suxamethonium ....