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Carl Ashman

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Everything posted by Carl Ashman

  1. Dont worry mate, we can have our own European reunion. You can tell me how Oktoberfest went. Gutted I still haven't had chance to visit.Carl
  2. I think it's fair to say that a physician in EMS will have a limited scope of practice. Of course, the OP's has other options as a native English speaker. Take a look at this. And they really are doing some cool stuff like REBOA: Presentation EMS Physician Garreth Davies Carl
  3. De laatste tentamen van het jaar net behaald. Een 9. Jippie!!!!

  4. Je moet lang wachten maar dan heb je ook wat.. een 8 voor mijn tentamen "Ontwikkelen van het beroep naar een bredere perspectief". Uncle Sam zou trots op me zijn..

  5. Fantastische dag gehad op de OK in het Radboud. Alleen nu geen treinen van en naar Nijmegen. Klotestoring.. Ach, ik zoek een studententent op en bestel de daghap met studentenkorting. We maken van een nood een deugd...

  6. I recently met a colleague that I hadn't seen for a while. He asked me: " How are things going with the degree?". I replied: "I should have started 10 years ago". His reply: "Well, it's a good thing you didn't change your mind a week before the start, just like you were going to....".

  7. You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration? Carl.
  8. (Shakes his head sadly....) Only in America! Come on people, this is just abuse of the system. They are already in an EMERGENCY room, full of EMERGENCY nurses and physicians. If they want to get taken elsewhere because of the waiting times then they take a cab. They are not going in my truck. Not that I would even get to see them because dispatch would refuse and ring the ER. Is it no wonder that healthcare in the US is so broke? I don´t normally have such strong opinions but this just goes beyond the pail to me.... Carl.
  9. I used to live on Lou Costello Street. It was around the corner from Charlie Chaplin Drive. No, I'm not kidding, It was called the filmstar neighboorhood. C.
  10. Ouch, that is harsh. This can also be a good place to learn about how other people do things. It will give good ideas for the future. One good example, I visited the US in my capacity as EMS educator more than 10yrs ago. I saw CPAP in action and was impressed. I went home and hounded my Medical Director so long that he finally relented and we now have CPAP. Don´t underestimate the power of the net. Other than that, you make good points. Prescribing is, however, a long way off, I fear. Carl
  11. An excellent, well made point there Bieber. Education is a substantial part of the answer but not the whole sum. Whilst I agree that, with better and broader (degree-based) education, providers should be given more options than taking a patient "hot" to the nearest ER, there are a number of issues. Safe clinical practice dictates that in the management of chronic illness you should be able to refer your patient to a primary care provider. Now I am not about to start a debate on the entire US healthcare system but it is fair to say that a large portion of the population don't even have a primary care physician, let alone an entire support network. Therefore, here's the dilemma: it's fine to refuse transport to the mild COPD patient, but who is going to manage his care after you've left? Carl.
  12. As far as I know I'm neither transgender nor, indeed, the OP. That was Metal Medic. Going somewhat off-topic here: I am however confusing things. I am better known here as WelshMedic. However, for lots of reasons (like being on forums on 3 different continents) I have decided to revert to my real name. So there. Sorry, now on-topic. Are you in the loop now Dwayne? Carl.
  13. Hey Rob, I've been MIA from here for a while too now.... I was wondering what you were up to, it's so quiet around here these days. Let's see if we can kick up a bit of dust (no pun intended) and let this place rock again!!! The artist formerly known as WelshMedic.
  14. And there's me wondering how I offended you.... I've never had an issue with type II, we just do everything on the right side. In fact, type II is relatively large here. Have a look how our other neighbour's do it: Yes, you really are looking at a standard Mercedes with an ambulance built on top!! Now they really are a pain to work in (even if they are very comfortable and go like the wind)
  15. Oh, AK... it really like old times here. It's good to be back........................ Where is Dust anyway? Carl.
  16. Only in as much as you will find it harder to meet the demands of school versus home life. But you will get through it at the end of the day because you are determined and keen for knowledge. Besides, a little life experience can be a very positive advantage in our line of work. Try, by the way, to aim as high as you can when going to school. Nothing less than an Associate's Degree as this provides the absolute minimum in critical thinking and reasoning skills that you will need to be a practitioner that is tuned into the individual needs of your patient. Which is the opposite of a cookbook medic. Carl.
  17. Looking at it from your point of view I would be appalled too. My personal safety is of paramount importance, always. However, we work differently to you guys. The code is worked onscene according to protocol. Then, a decision is made to transport if the patient falls into the trial category (<75yrs and no other medical conditions that contraindicate) The service in question then uses an automated compression device and a transport ventilator (as opposed to a BVM). The drugs would have been drawn up before hand and would be given whilst in a belted, sitting position. The monitor is also so positioned that it can be used from a sitting position. Organ donation is not the primary aim, by the way. Of course we are far more focused upon making a save but we also realise that we can't save them all and so try and make the best of a bad situation. Here's a pic of the inside of the vehicle for you to understand a little better what I mean: Carl
  18. Hello Paramagic, Thanks for talking the time to reply. I am aware of the problem in children, that's why I tend to steer away from ketamine in this patient group. My opinion was based upon administration to adults. I have never taken part in a study, so my evidence is anecdotal, but I have never seen a serious form of re-emergenge phenomenon in subjects that have been given supplemental midazolam in the 10 years I have been using it. I have, however, seen it in patients that were given just ketamine. Carl.
  19. Morning all, Well, this has turned into a great discussion on myths in EMS. FIrst of all, Here's the link about automated compressions in PCI (not exactly convincing results, but it's a start). To adress some other points that have cropped up during the discussion: I already touched on this, potential organ donation is one issue. Well, actually, the jury is out on this one. There is a body of evidence that would suggest there's no benefit. One of the inital problems is that paracetamol is often used incorrectly by parents in terms of dosages. Sponging the child has proven to work faster than paracetamol but the effect of the drug lasts longer. However it's benefit lies within symtomatic relief, something which you would hard-pressed to deny a child. As EMS providers we would nood see the long-term benefit of sustained administration but it is not necessarily bad practice to iniate it. As far as anti-pyretics are concerned in sepsis, I agree, there is little benefit as these pts need far more aggressive therapies like parenteral antibiotics and fluid monitoring and management strategies (basically an ICU bed). Ketamine is a great drug and I am so glad to have it in my arsenal. However, it is not good practice to give it stand-alone. Ketamine works differently to other analgesic/anesthetic agents. It's a NMDA receptor agonist. It only shuts down those receptors that are responsible for conscious thought but not all senses. It can lead to intense dreams or nightmares and the so-called re-emergence phenomenon. This is where the patient literally screams his or her way back into consciousness. However, there is good news, this effect can be greatly reduduced by a co-commitent dose of a benzodiazepine. My personal choice is midzolam. I have recently been trying new options in pain management strategies (I have a very liberal protocol with lots of room for manoeuvre and a willing Medical Director). I recently attended an MVA with a young adult with multiple fractures. With a combination of ketamine 0.5mg/kg and fentanyl 0.01mg/kg topped off with a 2mg bolus of midzolam the pain score went from 9 to zero in less than a minute. Without snowing the patient under, either. She remained reasonably stable throughout the whole process. As far as I am concerned, ketamine has a great future in EMS. Carl.
  20. Yep, got to say, I really think it's the dog's bollocks. Your patient is one minute writhing in agony and snoring gently the next... C.
  21. Morning Bieber, Well, I must say that you are very ambitious. One thing you'll have to remember is that Rome wasn't built in a day. If I were you then I would pick out 2 or 3 of these subjects on focus on changing those first. My choice would be c-spine clearance, standing orders for pain management and a reappraisal of dosages in the pediatric patient. You have plenty of other relevant "burning isuues" but these would be my priority. Yours may differ, I don't know. I'll give you my take on the rest: MOI in trauma is a good indicator of the types of injury one might expect. Don't forget that if someone does not intially present with symptoms then it's not to say there's nothing going on. There are many cases of particularly splenic and liver injuries with late on-set presentation. Elimination on restrictions on EKG/IV application. What do you mean? EKG/BP/Spo2 montoring of patients that have received narcotics or sedatives is good, safe practice. Why would you want to change it? The subtle signs that monitoring shows may alert you far more quickly to a impending problem. Eliminating transporting Code Blue patients: Here I tend to agree, to a point. We all know the importance of BLS and that massage in a moving truck is pretty ineffectual. However, there is a progression towards automated compression with a Lucas or Zoll. This changes the rules somewhat as there is a growing body of evidence that suggests PCI (angioplasty) in cardiac arrest may have some effect. Also, we are currently trialling a new protocol which indicates transport in potential organ donors. Cardioversion as a standing order: Agreed! Clinically unstable patients that do not respond to pharmacological agents need treating stat (God, did I just say, STAT? Shoot me..). I would however advise an adjunct protocol for the administration of a benzodiazepine. Cardioversion without Versed on board..Oww!! Pain management: agreed! Multi-system trauma should not be excluded. If anything, they have more right to be medicated. Pain is a disabilatting factor that leads to higher mortality. Pijn management protocols should be linked to the individual pain score. My personal favorite is a combination of ketamine, midazolam and fentanyl.. NSAIDS? Mmmm.. I have limited experience of these drugs in EMS. The only real benefit I saw was with diclofenac in renal colic patients. Wouldn't be my first choice. Also, there really are not many patients by which opiates are contra-indicated. O2 therapy only to those who need it: I agree wholeheartedly! By now we all know about the effect of 02 generated free radicals in the MI patient, don't we? A protocol for febrile patients is actually quite easy: cool em' down and give IV/rectal paracetamol titrated to weight/age. Treat and release options: One of the problems in US EMS is that most of the ground rules are based on the lowest common denominator. Whilst you come across as being a very engaged practitioner that is hungry for new knowledge, that can't be said of everyone. Can a part-time medic with a certificate from a paramedic mill school be trusted to make that decision? EMS needs to pull up it's boot straps nd make a degree mandatory before we take that route. (Or be a nurse-led profession, but I wouldn't want to offend anyone here..) Here is the link to a presentation I gave in Pennsylvania last year, there is a relevant section on pain mangement in the middle. You have my blessing to reproduce, should you wish... https://docs.google.com/present/edit?id=0Adxb-ZUzuZENZGdkendqcG5fMThkenJnZDZkMg&hl=en Good luck with your crusade! Carl Edited to include link
  22. We have a program where we take BSN students on for an internship of 6 months. In that time they learn all about EMS (EMS is nurse led here) and undertake a clinical research project. I think it really raises awareness of the job. The group I'd personally like to see ride-along is the dispatchers. They'd then get for more understanding of their own job too. Currently they are required to do just 1 day during their initial training and that's it. Carl.
  23. I agree entirely. There is a very important role for EMT's in the First Responder role. But that isn't to say that they should replace paramedics because of cost issues. That's the issue, to me, that needs fixing. Carl.
  24. Finally someone who turns this call around to see it in perspective. Of course this lady doesn't need to go to hospital (where, at her age, she would signifcantly be at risk from all soorts of hospital-based pathogens), she needs helping up and a cup of tea. And some help and advice to the carers about preventing falls. Yes, even in this case, there is a role for preventative medicine. Carl.
  25. Yes, but why is your nearest medic 30 miles away? Because your community does not see the value in ALS. Maybe that's not the best starting point...? Once again, I have no wish to banish Basic's but I don't think they should have sole responsibility. That's why I think this amendment might not be a bad thing. Carl
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