melclin

I just can't understand how you could get a scene time of 10 mins.

My scene times are routinely 30+ mins. When we're really moving that might peak under 20.

Anyone got any insight into how jobs are being run to achieve these 10min scene times?

I've had:

- ~3 male and ~4 female GPs/PCPs

- 1 male dermatologist.

- 1 female Intensivist.

- 3 male EM physicians.

- 4 male psychiatrists.

- 1 female general surgeon.

- 1 maxillofacial surgeon.

I can safely say that on average, I couldn't give 2 stuffs whether they had lady or man parts; if I feel comfortable with them, I feel comfortable with them - simple as that. For me, it depends entirely on the individual.

Paramedics have a different scope but not necessarily broader. For instance, how many can insert foleys, NGT's, titrate inotropes, infuse blood products, administer antibiotics, set up, start, run and discontinue dialysis (including CRRT), access central lines, insert PICC lines, initiate ventilator weaning protocols, manage invasive pacemakers, manage invasive monitoring lines (arterial, Swan Ganz etc)? Just to name a few "skills" beyond intubation. The majority of the aforementioned activities require some degree of "critical thinking" abilities.

2) If as a nurse you are unable to do this you won't last long in an intensive care or high acuity ER environment. Nurses don't stand around and wait for the doctor to come when a patient is coding.

True, but I think your missing my point about the fundamental focus of the paramedic vs nursing undergraduate education, which was really my original point. Most of those skills listed their are quite advanced and are not predominantly things that graduate nurses do. I keep saying, I'm not having a go at nurses and people list skills and talk about how wonderful nurses are. I concede that I was unaware of the extent of the scope of advanced practice nurses in some settings, however, that is not terribly relevant to my main point which was basically if you are looking for an affective way to educate prehospital professionals, the best way to do that is begin with prehospital qualification, because of the specific skill set required. I happily agree that good ICU/ED nurses would make great paramedics, but as I said, to require prehospital professional to be great ICU nurses before they can step onto an ambulance is an overly round about and unnecessarily long pathway to EMS (with the corollary being that a nursing undergraduate degree by itself is by no means equivalent or superior to a paramedic degree when it comes to prehospital care, which is a common argument in the states where the prehospital qualifications are inferior, and I wanted to provide a picture of a system where that was not the case).

Some of the things I said "dissing" the average grad nurse was my attempt to explain to the Americans that a BSN in Australia is not equivalent to an American BSN which is a higher qualification as far as I can tell.

3) Pretty bold statement to make based on hearsay and your own very minimal experience and limited knowledge. It actually only shows your ignorance of what it involves to be a nurse especially in a critical care unit or ER. I can guarantee you that there are many Doctors who have ignored a nurse's advice and caused harm to a patient or on the other hand listened to what a nurse said and prevented a serious event as a result. Do you think Doctors aren't human and don't make mistakes or write orders incorrectly?

Of course not, but to be far I didn't really suggest that. I have obviously touched on the a nerve that many nurses and paramedics have (students like me included) that involves raising ones temper when people assume a much lower level of practice that you actually have. It appears some of what I have said has been the equivalent of calling you an ambulance driver, and I do apologise for not being more familiar with the extent of higher levels of nursing practice. However, again, this was not fundamental to my point about the fundamentals of the undergrad education.

Also, importantly, I often make a point of the fact that I'm a student. I don't claim to be coming from a position of any particular expertise and my point was primarily about something that I am familiar with, which is the nature of the paramedic and nursing undergrad education. I do however, maintain that almost every nurse, some of them quite highly qualified and experienced, that are now doing my degree have said that it is a much different ball game - that it is much harder than they thought when its all on them and them alone, especially without the support structure of the hospital. You can take or leave my undereducated and under-experienced opinion, but that is a pretty common sentiment from people who have actually made the switch. I was also on placement with two experienced paramedics, who were originally ICU nurses and wanted to return to nursing, who were complaining angrily of the re-certification requirement on the grounds that they do more as paramedics than they ever could do as nurse. So I feel my opinions are not totally baseless, but your're right, I know very little about the nursing field, but I never really said I did beyond the graduate component.

4) Another example of ignorance since "educated clinical decision" making is the foundation of nursing. It is obvious that your whole perception of what a nurse is and does it to mindlessly follow Doctor's orders.

No it isn't. But I can see how you would think that looking back on some of my posts. I apologise for my obtuse use of language and broad generalizations.

6) I agree with Ventmedic about Paramedics having a false idea of autonomy. They all operate under standing orders or protocols (Doctor's orders! Every program has a Medical Director for that very reason). Many different units have their own version of standing orders and protocols just the same that nurses can initiate and use without having to ask the Doctor for each specific order. Autonomy exactly the same. The Doctors are not always readily available in the units either. How many medic programs have to call for online medical control to give an extra dose of Morphine over the protocol amount (just for example!). Really no difference just looking at it from a different perspective. Doctors orders and the protocols that paramedics follow are really the same thing except in the hospital they are individualized to a patient and not a broad disease category. Nurses in the ER will often triage and start treatment with standing orders before a doctor has even seen the pt. (For example with chest pain). Is that not exactly the same thing that a paramedic does? That is just one example.

Yes it is that way in America, but things are a little different here. I take your's and Vent's point about a false sense of autonomy, but I do think that depending on the extent to which you are willing to defend your decisions, we have more autonomy here than perhaps you realise. I think the point here is the difference between guidelines and protocols, while some here argue the difference is only the name, others feel that they can basically do whatever they want if they can justify it, and that is different to a lot of American systems, which is what you appear to describe. I don't of course want to start a pissing match about who can do more because it is evident that, one, I already did that without intending to and I don't want to continue it, and two, I obviously don't know enough about nursing to do it. What I will say however, is that I think the above paragraph shows a bit of a misunderstanding about some of the aspects of a lot of Australian paramedic practice. I don't know your background, so I obviously can't say for sure, but the above does sound like an odd interpretation of Australian practice if you are aware of its specifics, so I'd like to humbly and tentatively suggest the possibility that you may be more unfamiliar with modern paramedic practice here than you realise. Forgive me if I have misinterpreted your words, and that you are actually the CEO of Ambulance Victoria, which could be somewhat embarrassing on my part .

7) Actually a midwife is a nurse with further education. You can't be a midwife without being a nurse first.

I am not attacking you personally here. I am just a tad offended at the statements made when you obviously don't really know what you are talking about.

Midwives absolutely do not need to be nurses first - http://www.med.monas....au/bmidwifery/

I can see that I have offended you and, as I said, I do apologise. I was wrong about a number of points but I also think you misinterpreted the main point of my post perhaps because of its inadvertently offensive nature....This feels familiar .

Oh and the creatures remark...I just assumed that all health care professionals ate noisily from horse troughs and made abhorrent noises and gestures when displeased. Is that not the case of nurses?

I sense a little naiveness here. I don't think a Registered Nurse is any more or less educated than a paramedic, merely you're provided with industry specific education.

When I say slightly more education, here's what Im getting at: The BN is 3 years and roughly 50% on the job training, where as the B. Emerg Hlth is actually three years of classes learning theory. While you may argue about the validity of class room learning and on the jobs learning, the fact still remains, that paramedics have, for better or worse, a little more classroom time to add to their on the job experience.

The Bachelor of Nursing degree in Victoria is not based around emergency or pre hospital care,

Thats entirely the point. No arguments there. That's why I argue that while its not necessarily time wasted if its added to prehospital education, but nursing in itself is not an adequate substitute for prehospital specific learning. An ICU/ experience crit-care ED RN with added relevant training in prehospital care would be a good paramedic, but the five years of formal education plus the experience required to go and do ICU grad dips etc is an unnecessarily extensive pathway for prehospital care when it could be covered in a field specific sense in 3-4 years, so I don't believe it should be the only pathway as it is in the netherlands.

Depending on the facilities standing orders specific RNs can RSI, thrombosing, perform needle chest decompression, give front line medications and take any measure to sustain life within their scope of practice with out a medical order.

I am certainly surprised about that. I was not aware that any nurse could RSI with or without a physicians orders. I feel skeptical about it, given that metro nurses are often not even allowed to give OTC medications without orders. To be clear you're saying, pt comes in head injured, GCS 9, poor O2 saturation, and a nurse can cannulate, setup, order fluids, sux, atropine, midaz/propofol/fent, intubate, and start infusions of pancuroinium/morphine/fent/midazolam and begin a ventilation plan, all without a doctors orders? I apologise profusely if I have led everyone down the garden path on this issue.

I'm merely a RN Endorsed Division 2 (shock, horror what would I know). I work casually in a small rural setting as well a regional hospital to support my way through my degree and I can tell you it's no walk in the park. I mostly work weekends and nights were we have limited contact with a doctor. Sure I need to have a doctor's order (direct or indirect) to give a medication or perform an invasive procedure but I can assure you the young intern/resident who has no interest in general medicine or surgery because they've been shoved out in the sticks as part of there rural cohort training and mope around all shift grumbling about not being at the Alfred or RMH, they makes quiet a number of mistakes and I need to know what's going on in order to prevent being dragged in front of the coroners court. Most of the time they just okaying what I've suggested is best for the patient based on my clinical observation through out a shift, 9 times out of 10 they wont even come back to the ward to R/V the patient because there too busy waiting around for the next MET call.

All the nurses in my degree including crit-care qualified ones all say that its a whole other ball game when you actually have to take responsibility for it yourself. Obviously I've never been in their shoes, and I'm only a student and all, but I'm hearing this off nurses who have become paramedics: the difference between, knowing what you need, asking for it, and having it okayed, all in a controlled environment is a lot different to being presented with a pt lying on the ground and going from knowing absolutely nothing about them to performing some of the interventions we've talked about, all on your own back. I really can't say anymore, because I don't have the experience or knowledge to be making any further claims, so we'll have to just leave it at that I think. That's just what I've heard. I will go an talk to one of the ICU nurses at uni about their scope, because I may have been mistaken about their scope of practice.

In certain ways nurses have a greater scope of practice, even though doctors must prescribe a medication I'm still responsible and accountable for giving it, this means I must be aware of the pharmacokinetics, pharmacodynamics, adverse reactions, interactions, contraindications – equally must a paramedic. The difference being you guys have… 40?? Drugs in your bag of tricks but we have a whole room full of medications. We can catheterise, deal with central/PICC lines etc etc were a paramedic would not know were to start. But on the other hand, as you say paramedics have greater flexibility in prescribing your own medications and doing what you like, per say.

In conclusion please don't short sell nurses because we all have our place and our speciality,

Like I said, I really wasn't having a go at nurses, and maybe things are that dramatically different out in the country, but in my (admittedly limited experience, including rurally) I have never seen or heard of anything like the level of scope. You certainly must have one special deal going on.

VENT: Its important that to me that you and everyone else in this thread not think that I was having a go at nurses. In saying that I don't think they are educated to make certain kinds of decisions, I just mean that's not where I believe their expertise lays. As I say above. The critical care nursing you mention is quite different from intensive care nursing here as I understand it but I may be wrong. That's why I added the caveat about nursing appearing to be different here than in the states. Nurse in all fields do seem to have rather a lot more direct medical oversight here than they do in the states. But I'm no expert in nursing.

Also, I'm certainly not saying that its impossible for nurses to be able to made clinical decisions, from what I've seen of chbare's posts I'd prefer him/her (?) treating me than most paramedics, nurses or doctors I've met. So at the higher level of CCT nurses, that may be a different issue. What I'm getting at it that if you have a field that requires not just the best (you CCT nurses in this example) but all practitioners, straight out of uni, to be making these decisions, you have to ask yourself, do you want a person who has been taught from the word go how to make autonomous decisions in the prehospital environment, or someone who's education is very general, focused on observation, advocacy and carrying out treatments ordered by others? Eg: You take the ~300 paramedic grads at the end of this year and compare their ability to make sound autonomous decisions in the prehospital environment to that of a nurse graduate. If, after uni the graduates then complete equal postgraduate formal education, the Intensive care paramedic is still above the Intensive care nurse in terms of the percentage of their education and experience that is devoted to autonomous decision making in the prehospital environment.

What part of nursing do you think is unnecessary? Community health is expanding and with the patient care experience a nurse has for the physical, psycho and social needs of the patient, their education is spot on. Also, remember that only a small percentage of EMS calls are codes and traumas. Most are medical, either chronic or acute, and not all require the EMS specific services of a Paramedic trained only in prehospital emergencies.

Absolutely they are not mostly trauma and codes, but you asume the paramedic degree is predominantly about that, when in fact it is not (we have returned to our old problem of the difference between the American and Australian systems). One out of twenty of my units was trauma based, and code related components have been spread across about 3-4 of those units. The others are very much about community health and well ballanced understandings of many medical and psychosocial problems. Far more so than the nursing degree I believe. For example, among other things, this semester, I have to evaluate a community based disability support project using our previous book learnins in public health and using techniques for health project evaluation, I also have to design an education package regarding a issue of special needs in the geriatric population along with a plan for its implementation and target audience using our established knowledge of public health and epidemiological fundamentals. Unless you chose to undertake subjects of that nature, the nursing degree tends to be quite specific and it is fifty percent on the job experience, which, while useful, does not help you get a broad and formal education in way that a university subject does. Compare that to the wide range of community, ambulance, hospital (obstets, emerg, psych, ICU, theatre) and disability placements we have to do on top of actual three years of formal education. In our degree, roughly 45% people already have degrees, often in health fields (AnP, human movement, nursing, one girl even has a masters in public health).

I wouldn't consider any skills learned in the nursing degree to be useless per se, but they focus on particular ideas more than others, while ignoring many issues that are important to prehospital care, let alone ignoring the much discussed skills portion of being a paramedic. Many nursing grads man learn to identify breath sounds only if they are in streams that are emerg specific, none can perform a patient assessment in the same way a paramedic can. The average nursing graduate cannot, for example, cannulate , its not part of the degree. I hope this just gives you a bit of an idea of why our nursing degree is less than you would be familiar with and why our paramedic degree is much more than you may have in the states. I have to qualify this all by saying, I'm not an expert in the nursing eduation system, I go by what I hear from double degree students who are undertaking both degree simulatneously over an extended time frame, from what I've read, and the classes I've shared.

Here are some links to the nursing, paramedic and nursing/paramedic bachelors, that might be more informative (and accurate) than me.

http://www.monash.ed...urses/0727.html - nursing

http://www.monash.ed...urses/3892.html - nur/medic

http://www.med.monas.../structure.html - medic

Should you have to do a nursing degree to become a Paramedic? Whole-heartedly not! You should however get an appropriate amount of education in the things you speak of and not just the "emergency" stuff especially as the ability and need to do things other than take the patient to the hospital grows.

I can see what Melclin is saying in that Bachelor of Nursing graduates are not appropriate people to be used as Paramedics and they should not expected to be. The Bachelor of Nursing should not be the required Paramedic qualification but an appropriately educated and experienced ER or ICU nurse would make a great Paramedic if they are able to become familiar with the differences in operating modality.

Precisely. I do think most ICU and ED nurses would make great paramedics with a little top up to their educations as far as prehospital specific stuff goes. I do not however, agree that this is the best or only pathway.

That is why Australia/NZ are developing (I beleive Aus. already has them) a one year post graduate conversion program for RN to Paramedic (not Intensive Care (ALS) but our base level). Should they wish to do ALS (Intensive Care Paramedic) they would have to do additional Post Graduate ALS qualifications.

Depends where you go. I think ACU have a one year course. At Monash, all nurses are required to go through the accelerated entry program which is two years, although depending on their nursing speciatly, they may gain recognised prior learning for some of the subjects in that two year block, but it still takes two years.

However, the discussion is not necessarily revolving around your specific system or experience, therefore your views regarding nurses may not even apply to the situation at hand. While we do not know what system we are dealing with definitively, would you continue to have the same opinion assuming we are in fact dealing with the Dutch system?

Take care,

chbare.

Well, no, but what else have I got? There seemed to be a 'paramedics aren't educated enough, so using nurses would obviously be better' vibe going on and I thought I'd present a view from a place where your average paramedic actually has slightly more education than the average nurse, not to mention that the entry requirement for a paramedic degree are much higher.

Specific to the dutch system, they clearly have a system that works well, but I do think they are requiring unnecessary amounts of nursing specific education for ambulance professionals. If you go back to the question of should I have a nurse or EMT based service and you live in the Netherlands, then it would make more sense to have nurses given they don't appear to have paramedics in the same sense we do. I was commenting on what I thought to be the ideal, rather than what was practically the best idea for someone for example wanting to staff ambulances because I think the conversation has moved significantly beyond giving advice to a general discussion of pathways to EMS.

I would say though that I can't really make these assertions with any confidence without knowing the educational systems intimately. I do, however, know a little about the Australian bachelor of nursing degree, and I know what its students/graduates are like, I go to school along side them after all, and while they may have many talents I don't, I wouldn't want to see them in the back of an ambulance. Its by no means derogatory. I couldn't be a nurse with a paramedic degree, and I don't think you can be a paramedic with a nursing degree, and I especially don't think you need to have nursing degree and experience before gaining paramedic qualifications.

I have to say I don't like the idea of using nurses in the prehospital setting.

Here at least, a nurse and a paramedic are very different creatures. Paramedics have a greater scope and almost complete autonomy. They also have slightly more education than nurses although the more important point though is that it is different education.

Paramedics here tend to be taught along the lines of diagnosis. Critical thinkers who can problem solve and apply their knowledge appropriately to figure out whats wrong with a patient and treat accordingly. In this sense, our training in more in the spirit of medicine rather than nursing. It has to be that way, because we don't have medical control: we sort of have to be watered down doctors. Nurses are the educated eyes, ears and hands of doctors, and while in practice, they are much more, their training is still based entirely around the idea that they are part of a team that necessarily involves direct medical oversight. Take away a nurse's support structures, other nurses, doctors, fancy gear and I think you've got problems. I've often heard nurses saying, well the doctor should be doing this and that and the other thing, but I wonder how confident they would be if the decision to paralyze and intubate or thrombilyse over PCI, decide on the amount of fluids that post-severe haemorrhage pt should get, leaving a pt at home after deciding that they aren't sick, actually rested on their shoulders.

Most of my degree is about educated clinical decision making. When it comes down to (and correct me if I'm wrong), clinical decision making doesn't lay at the heart of nursing.

(I have nothing at all against nurses, I'm just saying the fundamentals of their education are not suited to the requirements of autonomous care. I think it is also important to mention that nurses in American appear to have more education, a greater scope, and a slightly different role than nurses here).

Also, I think prehospital care is different enough for it to be its own qualification. It would be a pain in the arse if I had to do a nursing degree and, sit on a ward for 3 years, do my ICU grads, and then start learning about prehospital care. You don't have to be a nurse first to be physio, or an OT or a midwife, because while they are related in some ways, they are different enough to have separate qualifications - so is paramedicine.

I gotta say, for what its worth, I think the script is getting better.

"Mmmmmm hot and nasty".

"Yeah, just like my men".

I was just reading up on the Fentanyl/Morphine post. Without bringing it back to light. I have a few questions.

I am an NREMT-B so please bear with me. I know fentanyl is a quicker acting pn med. Morphine is a longer acting drug.

What other than what I have just stated above is different about them?

Why would you give someone one or the other??

What would your Criteria be? ie b/p, resp rate, MOI/NOI

Is it a personal choice or is it a Med Dir thing?

Also what is the difference between the 2 mentioned above and Demerol?

I ask because these are the most commonly talked about narcs available to EMS personnel? This is not related to any study I am doing just personal knowledge. Thanks for taking the time to respond. I hope I have asked these questions in a manner that is easy to understand. It is late here and I am getting sleepy.

I only skipped through this thread, but there are also some arguments out there that suggest that Fentanyl is better for certain types of pain than morphine and vice versa, but I think evidence for this is largely anecdotal.

The criteria for analgesia is pain. End of story. I can't stand seeing some of these guidelines you blokes have over there..."if pain score >7 contact medical control for 2mg of morphine".

Something worth mentioning about fentanyl is that it is highly lipid soluble and can be absorbed through nasal mucosa. So in the event of a difficult/delayed/impossible IV access, atomizing fentanyl up the nose is a good option. We have that option here, largely because we created our own evidence base for it. One of those professional things, building a discipline specific evidence base and all .

Also on the list of uses, is in break through pain in chronically painful conditions..cancer etc.

It can also be given in anesthetic doses without the haemodynamic effects of an equivalent dose of morphine for procedural sedation/analgesia (Synchonised cardioversion, RSI etc).

Demerol I don't know anything about. Its use is very limited here because of some nasty interactions and we certainly don't use it.

"It has no proven advantage over other opioid analgesics and there is significant potential for iatrogenic problems with its use."

Hi all

i am currently studying my Diploma of paramedical science, through first response Australia. I need advice Guidance on what would be my best employment option once i complete the course.

1.Do i apply for a state ambo service and ask for recognition of prior learning or apply for Graduate entry in QAS.

2. Work for a private ambulance company or try for a medics job at one of the mines or oil rigs.

Any guidance or advice would be much appreciated as i am unsure how highly regarded the Diploma course is. I am willing to work anywhere in Australia and would join any state Ambulance service I just want to learn and work.

You course appears to be recognised (by state education authorities - that means you can use the credit to transfer around). That's a good start - some aren't.

I had a look at the course materials though and they are a bit misleading. There is no such thing as an EMT in Australia. Not in the sense that that it is an officially recognised position. If a person wants to read the wikipedia page on first aid and buy themselves a uniform that says EMT, they can. More correctly if a private first aid company wants to piggy back on the popularity of American TV and call their employees/trainees EMTs..they can. Its doesn't mean anybody employs "EMTs". That said it seems that QAS recognise you qualification as a minimum level of entry into a Patient Transport Officer role. Thats something.

Also, I understand QAS still take people out of highschool and train them entirely within the service. They might look favourably on someone who had gone to the effort of doing such a course as you mention and you may even be able to get some RPL, but there are no guarentees. The only way you can know for sure is to ring someone from QAS and tell them exactly what you doing and ask them what your options are.

You best bet is probably QAS, because those diploma type things are quickly becoming obsolete in most other states. If you go off and play first aid on an oil rig for a while, you may come back to find out you can't use your diploma in an Ambulance service anymore.

The cop ruined it by his facial expression. I just don't fricken get it. I mean, I get it, but I see no humor.

That's the whole point. Its the deadpan delivery that makes it so funny.

I want one of those always blow on the pie t-shirts.

"Oh and when I said he had no complaint, I meant to say that he fell down a flight of stairs and when I said resting comfortably I meant he is unconscious, I already promised the family that they can go to their local hospital which does not have trauma services"

What a LOL!!

I wonder, was the pt in asystole, or persistant V-Fib when they transported to the hospital? I assume that since you mention amiodarone, he was in V-Fib. So, it could be argued that the pt may be potentially salvagable, although quite a long shot at this point. The paramedic may have been reluctant to call a pt that wasn't presenting with PEA or asystole. Not being familiar with your system, I don't know what medications you have on truck. I suppose the hospital would be able to perform an ultrasound of the heart to determine if it is contracting at all.

As far as the issue at hand goes, I would agree that your paramedic didn't perform as prefectly as he could have in this situation. A couple mins of CPR between intubation attempts would have been ideal. Better yet, if he was considering transport, intubation in the ambulance would have been ideal. That said, I would also ask you what was done before he tried to intubate. How long had CPR been in progress? How many shocks had been given at this point? How many rounds of Epi had been administered? Was the V-Fib coarse or fine?

That said, it might be a good idea to ask the medic in question why he did what he did, see if he knew some facts that you didn't about the situation.

Yes, persistent VF. Stayed the same way as he presented until shocked into asystole later in hospital. We cannot call patients who are in anything but asystole. Which is why I think that the transport occured simply because they figured it was a done deal and needed someone to call it.

I'm not sure he was necessarily considering transport when he intubated. I think someone else suggested it, which harks back to another issue I had with the management of he scene, but that is not the issue and it was not this particular medics fault. In his defence, he was not on duty when he got the call and agreed to respond POV because he lived nearby. Why, the dispatchers even bothered, I don't know, we (with another MICA medic) were not far away and he didn't have any MICA gear anyway so I'm not sure what use they thought he would be. Anyway...when we arrived with another MICA medic and MICA gear, the pt had already received 2-3 x epi, 5-6 x DCCS. We arrived with the gear but our medic didn't intubate, it was the bloke who had already arrived who intubated after two more rounds of compressions and one more DCCS (making a total of 6-7 at that stage). I think in total the pt had 5 rounds of adrenaline, but I don't recall the specifics on that. I think i mentioned the times a little earlier.

I asked about the amiodarone, and it seems it was simply forgotten. The transport, I didn't and I won't get a chance to ask anyone who was there. It was a long way from home, and even if it wasn't, the uni and the service are completely separate entities for the most part, there is no way I could really get in contact with him.

White board sessions...they're fantastic. Either with friends or by yourself, you pick a topic, idea or set of things to remember and then you teach the person you're with (preferably someone for class so its useful for them. Also then they can ask questions and expose cracks in your knowledge) or even just pretend u have a class (I do this with disturbing frequency) and teach "them" the concept. Understanding the idea well enough to teach it raises the level of understanding you yourself have and it exposes weaknesses in your knowledge when you realise you thought you knew something but can't really explain it well when you "student" asks you too expand.

Also, because its interactive, its much easier to get through large amounts of material without blanking out like you do if you sit down to read a textbook, when you'd prefer to be doing something..anything..else.

You tube is an under utilized resource. If there is a concept you don't understand, plug it into youtube and there is a fairly good chance you'll find some wonderfully educational video that explains things better, or just differently (because often all you need is a slightly different perspective) and helps you to understand things much better. There are many videos for things like the development of an atherosclerotic plaque, cardiac electrical systems and mechanical function, muscle contractions and endocrine/biochemical topics. Basically anything that involves a dynamic process (something that occurs over time) is better described with a video than a picture in a text book.

Don't be afraid to ask guidance from wikipedia. Don't ever take anything it says as gospel truth, but I don't care what anyone says, it is a helpful tool for quickly gaining an brief and simple overview of topics related to what you're working on but that you don't necessarily need to know in detail and would require literally hours of pouring through text books to find and understand. The online Merck manual is also good for this, searchable through google, and can be taken as gospel truth as much as any textbook.

I have a copy of a number of helpful free e-books which are particularly useful because they are electronically searchable unlike their hard copy counterparts. PM me if you're interested and I'll figure out a way to get you a student copy.

There are a few potentially exciting studies out about ACEI's and acute CHF treatment. The results show rather substantial hemodynamic improvements over traditional modalities such as nitroglycerine. I am talking class III and IV CHF. While the base of evidence is still rather small, I suspect this to become very popular with subsequent studies of large numbers. Perhaps large studies now exist? ACEI's are also very popular for AMI salvage type therapy. Even more so than beta blockers. In fact, beta blockade is being somewhat emphasized as an immediate core measure in the ER management of the AMI patient. The evidence is so compelling, my medical direction and clinical gurus are looking at a possible ACEI guideline to be integrated into our practice.

That's interesting, I'll have to have a look at some of that evidence base.

I agree, the pressor debates are all over the place and I am not sure I would consider a pressor or adrenergic based agent with any of the given blood pressures. I guess if you really had a hardon for increased B1 effects for the patient with a systolic B/P in the 90's, you could look at dobutamine; however, I am more of a conservative fella. Yet, the argument of augmenting inotropic activity and perhaps augmenting coronary perfusion is valid when considering dobutamine or even variable doses of other agents such as dopamine.

Take care,

chbare.

I agree with you. This guy is just not sick enough to need pressors in the prehospital environment. If a consultant EM or intensivist reckons its a good idea with considered assessment then maybe, but Charlie doesn't need me to mess around with those kinds of things in the 15 or so minutes I'm with him.

I'm not sure that dopamine is a good idea given its chronotropic affects and I don't think its worth the risk - the pt isn't ill enough to warrant dopamine in the prehospital environment. I don't think he's at the blood pressure at all cost stage yet and I wouldn't be comfortable giving a drug that affects his heart significantly, while not knowing exactly whats wrong with his heart. Is dopamine indicated for endocarditis/mycarditis? I would have thought you'd want all inotrope and no chronotrope for that sort of thing.

Maybe if we had noradrenaline.

I would move up to CPAP only if I couldn't get good oxygenation from ~100% and frusemide is best left for when fluids I/O and electrolytes can be monitored and managed, if at all. As for GTN, I don't feel like killing a man today, so I'll keep that safely tucked away

The MD, did he ever find those chest films?

Please clarify something for me. Charlie's temperature is 38 point 5 degrees? Either he is hypothermic, as the temperature is below 80 degrees, normal being 98 point 6, or someone forgot to indicate Fahrenheit versus Celsius.

Sorry, I'm used to working with the Fahrenheit scale.

I think you can reasonably assume that it would be Celsius. Other than the fact that pretty much everywhere in the world uses Celsius, I would imagine a patient with a temp of ~3 degrees C (38.5F) would probably not be 'complaining' of anything.

Seeing as though, I've seen this on another thread, I won't give away the answer - but these were my first thoughts when it over at the Life.

The apparent sepsis, minus a tachy and with an ECG showing me a heart in a bad mood - I thought one of the carditis' or maybe pneumonia causing some kind of secondary ischaemic heart troubles (as with secondary UA).

I would consult for appropriate use of ceftriaxone although I don't think he's sick enough to warrant it in the pre-hospital setting. Other than that I would load and go with a couple of liters depending on the pulse ox I reckon.

Who asked for salbutamol? That seems like a silly thing to do.

National curriculum or not, this is unacceptable. 30 Seconds is a long time, and I think that the medic should know in a few seconds if the airway will be difficult or not. A rudimentary assessment could possibly clue him in to that before he even gets into the hypopharynx, and maybe allow him into being a bit more prepared.

See now that's what I thought. We have a failed intubation drill that involves the use of an LMA which can be inserted in a matter of seconds with little cessation of compressions. I don't like to criticize the workings of the MICA mind but I feel this would have been a much more prudent option once it became apparent after a few seconds that it was difficult going.

I would also say that maybe just an OPA and bagging could benefit this patient more, in refractory VF as you state, as well as potentially allowing a more beneficial treatment..ETT is certainly in the plan, but if the airway is open and patent with a more basic airway, then other interventions take priority; i.e. compressions, defib, and meds...

There was good compliance and air entry, skinny bloke, no obvious abdo distension after 5 or so minutes of resus by paramedics and ~7 mins of bystander CPR (except after one very obvious whoopsie on the part of the same medic, when he gave a mighty ventilation in the middle of my compressions with no warning, and the pts stomach blew up like a balloon), continuing with an opa seemed fine to me.

I stand by my assertion that a cursory assessment could predict the airway troubles and dictate perhaps different prep, more assistance, or postponing the ETT for a bit....Simply some armchair quarterback, but this is how I try to approach a situation such as this..

I think that a longer period of compression/oxygenation should be allowed before a second attempt..Was any monitoring of the SaO2 possible while doing this?? Just curious and I am still not sure how accurate this would be...

Not that I'm aware. It was a crowed (6 or so medics/students), small and messy room, and I had other things to concentrate on, like staying out of more important people's way , so I can't be sure. But I think its a pretty good guess to say no. I wasn't aware it have thought it would be worth having on a patient in full arrest - poor circulation and so on.

All in all I thought it was a poor effort, the first attempt seemed doomed from the beginning because of the patients position precluding the medic from visualizing the airway properly. But thats something that should have been remedied before hand. We get crucified for not moving the pt to a more suitable position for airway management and CPR at uni during pracs, so its certainly not beyond a MICA paramedic.

The pt didn't receive any amiodarone, because it seems, the medic simply forgot. To make matters worse (IMHO) after about 15 mins they (not my crew) transported to hospital, CPR in progress, and we all know how good for the pt/safe that is. I can see no proper clinical reason why that would be and I was quite surprised to hear everyone on scene agree with it when someone suggested it, maybe I missed something. The hospital did nothing we could not do except call TOD (pt have to be in asystole for us to call it), and I suspect that may have been the reason.

Anyway, whats the go with tubing with compressions in progress? (Ben, do you blokes pause for LMA?) It seems to make good sense to me, or at least to do as much as possible and just cease for a few seconds to do the difficult bits, what ever that may be. I've never tubed a real person, so I wouldn't know if this is rubbish or not, but I've heard of it being done.

Posting from work so I must be brief. More info on request.

To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable.

This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube.

I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

I am all for harm minimization, although I'm sure of the efficacy of pamphlets specifically.

I listened to a couple of speeches recently. One by Dr Alex Wodak and another by Norm Stamper. Both on the uselessness of the "war on drugs" (seems likes its been a popular topic on ABC radio of late) and the supposed benefits of the legalisation and regulation - it seems solid to me. They've got my vote.

People will always want to have sex, get wasted and seek various other thrills. Simply trying to stop them doing it is short sighted and unrealistic. Chastity this and promise ring that, prohibition, banning condoms, zero tollerance drug policies...none of these things ever seem to work. You may as well accept that people will always want to be involved in this kind of behaviour and try and minimize any harm that comes from it.

Must just be a different phrase than what you're used to. By "secure the airway," I mean (basically) make sure that it is clear and that air will get in. Does that clarify it?

Sure does. I gotcha now

Might be a tautology, the American's use the phrase "secure the airway" rather liberally from what I've heard.

Ah yes I see now that it was "secure the airway". I read it as "secure the airway adjunct" for some reason (I was imaging tying some tape around an OPA to hold it in place). I'm still curious by what exactly medichopeful meant by "secure the airway" though.

All Kangaroo's look good in the cross hairs.......

But, they got nothing on the drop bears

They look even better on your plate covered in BBQ sauce.

But don't even mention the drop bears. Those things are bloody vicious.

Nasty as Bob Brown's wife I reckon.

OP I'm still kind of curious about this. Did you secure the airway before ventilating?

Since when do you secure an OPA/NPA?

Is this not high school chemistry in the states?

I sure hated it at the time (electron shell filling patterns and I did not get along) but I'm glad as hell I did it.