vs-eh?

I don't quite follow...what the PULSE rate would be? Well ideally it would be the same as radial/brachial/carotid/apical/etc...Did you/he mean to say what the ballpark BP would be if you just palpated the femoral artery? If that was the case the whole 80/70/60 systolic thing is inaccurate at the best of times. I would just dig up some literature and argue it. If it was truly what rate the femoral was, then I assume you just got rattled.

Honestly it was totally a last minute thing (literally, last day to get my application in at the provincial college center and last pre-testing day for my school, it was the only school I applied for). I was studying palepanthropolgy at university and with a PhD staring me in the face in order to do any real/respected work, I quit in 3rd year. I don't remember why I actually applied to paramedic school, as none of my friends were paramedics, and none were in any type of medical field period. I was very lucky to get in (see above), very competitive 1700 apps for 60 spots. I ended up doing well, graduating with honours following the 2 years (yes, BLS is a 2 year gig in Ontario). Like Richard I am not a very compassionate person by nature. I never had any first aid/cpr/life guard/nothing prior to becoming a paramedic. I enjoy the autonomy, the problem solving, the variety, and the social interaction. Helping people is just an added bonus. In a large city like I work in you can go from pediatric struck by a car, to car door slammed on my ankle, to cardiac arrest all in one day (as was my Friday). It's a good job, and I enjoy it.

I posted this in the main discussion form to with regard to ReD's jumpkit... Let me preface this by saying we don't use, nor have I ever seen a "first responder" on the scene of a 911 call... All stuff seems excessive. You have like 8 million pairs of scissors, and a whole load of other crap.... My understanding is that as a first responder you are there to on the most basic level stabilize the ACBC. I don't know how long you are on scene for with calls that actually require critical intervention before EMS but still... Are you allowed to give those drugs as a first responder? Hydrogen peroxide? Iodine? Glucometer (as a first responder seems unnecessary) AMMONIA INHALANTS? I do not give any of those drugs on the street PO (save for asa). We are allowed to give some of those during mass special events, but they are under standing orders. Examples can be found athttp://www.thebasehospital.com/special%20events.htm . That is not my basehospital and I believe there are several more that are available but it follows roughly the same guideline. Do you have similar, or just ask allergy and give it? None of those things will be of immediate benefit to the patient, (and actually may be of detriment) which is why you are there. If I ever had worked as a first responder in the system I believe that AT MAXIMUM the largest thing I would carry would be this http://www.statpacks.com/2005/platinum2.htm Some standard BLS trauma stuff (no splints, just be taken off anyway), maybe an asherman or abdo pad. A - one of each NPA/OPA, bulb suction, maybe a V-Vac (do you guys have those in the states? They suck but in a pinch with no mech suction they're ok) B - BVM with adult/ped masks C - BP cuff maybe if room. Clinical picture, orthostatic changes, and pulse points in that role are good enough. And that is it. Certainly no drugs, no 18 scissors, no hand warmers, just the essential to grossly stabilize your pt until definitive prehospital care arrives.

This has been a point of contention recently. It is basically dogma that you check BS before administering diazepam/midazolam for seizures. Obviously a clear hx of epilepsy or diabetes would certainly query a treatment strat before hand but... You have a pt in say status epilepticus IV access is unobtainable but a glucomentry shows a BS < 4.0 mmol/L (I know normal is 3.6-6.2 but all ALS Canadian protocols I have seen symptomatic < 4.0 = Tx). No clear PMHx or whatever it doesn't matter I guess. Our options for this with no IV: a) Versed 0.2mg/kg up to 10mg dose IM Valium 10mg PR c) Give glucagon 1.0mg IM and wait until seizure potentially stops, then start IV with D50W d) Give glucagon 1.0mg IM and give either benzo option soon after before seizure actually stops. Then treat accordingly. Just curious.

Word.

*sigh* People need to read the study and see it in clinical practice, REAL FIELD EXPERIENCE, REAL PATIENTS HAVING A BETTER CHANCE, before shrugging it off... I have said this before.... Toronto EMS currently does this method (actually even LESS ventilation's *gasp*) when running an arrest be it ALS or BLS... If the arrest is UN WITNESSED by EMS/Police/Fire then CPR is initiated (barring obvious death criteria) COMPRESSIONS ONLY for 2 mins, this is then followed by 1 min of "traditional" CPR following 15:2 ratio. This is done by ALS or BLS crews as you are attaching the monitor/setting up/whatever. YOU DO NOT STOP COMPRESSIONS to even look at the rhythm. If CPR was preformed for at least 2 mins prior to your arrival and it is deemed "good" CPR by paramedics (usually by Fire/Police) then traditional ACLS can be started. The key theme here is too keep blood flowing and do not interrupt CPR for any length of significant time if possible (i.e. > 10 secs). I don't recall if the article mentions it (been awhile) but there is an exponential increase in mortality at like 10 sec intervals if CPR is interrupted. Witnessed arrests by EMS/Police/Fire follow traditional ACLS measures. Even if the arrest is witnessed (but not by above services) the same "upfront" CPR is started. Won't change? I have done it on the road and seen it work as have many others. Are all the patients discharged or those who do regain pulses not living as a vegetable? I dunno, but I can say that regaining a pulse is step one to recovery. During this trial period (approx 7 months now) if anything through the grape wine, return of pulses seems to have increased significantly in prehospital cardiac arrest.

I think what Steve was trying to say is that Toronto EMS is one of the largest EMS services in North America. Richard, I'm not familiar with the entire NYC setup but Toronto EMS is the ONLY service (plus fire and police of course) that responds to the City of Toronto 911 EMS calls. My understanding of the majority of American systems is that there are multiple private/city/hospital services that respond to 911 calls depending on the area/nature/etc....this includes NYC. There are no other services private/hospital that are allowed to respond to 911 emergency calls in Toronto (well, there are exceptions but they only involve city paramedic services from surrounding areas and usually only in times of low car count, probably like < 1% of total yearly transports). If I'm wrong I apologize. http://www.city.toronto.on.ca/ems/

I think everyone will agree that no matter how "good" a paramedic text is considered, there are always a significant number "secondary" books with any course. When I was in PCP school they used Mosby's as the "core" text, but honestly, besides looking at diagrams and procedure pics I basically never used it. We had so many other topic specific and more in-depth books that Mosby's was pretty much put by the wayside. As an example here are the current core texts for a Critical Care Flight Paramedic in Ontario. And just so ya know this is WAYYYYYYY more in-depth than the CCEMT-P stuff I have seen. CCP's in canada are pretty hardcore. American Association of Family Physicians. ALSO Syllabus. 2004. Darovic, G.O. Hemodynamic Monitoring. 3rd Ed. 1995. Garcia T.B., and N.E. Holtz. 12-Lead ECG, The Art of Interpretation.2001. Katzung, B.G. Basic and Clinical Pharmacology. 9th Ed. 2004. Mandeville, L. K,. and N.H. Troiano. High-Risk & Critical Care Intrapartum Nursing. 2nd Ed.1999. Marino, P.L. The ICU Book. 2nd Ed. 1998. Novelline, R.A. Fundamentals of Radiology. 7th Ed. 2004. OAABHP. Medical Directives & Standing Orders. 2004. OAABHP. Medication Information. 2004. OAABHP. Medical Operations Policies & Procedures. 2004. OAABHP. Medical Procedures. 2004. OAABHP. Student Handbook. 2004. Pilbeam, S.P. Mechanical Ventilation. 3rd Ed. 1998. Pagana K.D., and T.J. Pagana. Mosby’s Manual of Diagnostic and Laboratory Tests.2002. The STABLE Program. Learner Manual. 2004. Walls, R.M. Manual of Emergency Airway Management. 2nd Ed. 2004. So those, in addition to your PCP and ACP books from before equals quite a small library for the paramedic student at the top of his or her game. And as for USAF's arrogance? Meh, in this field you kinda have to be a bit arrogant. It comes with the territory.

I've heard that he is writing a critical care text that is due out in the fall.

Correct me if I'm wrong, but I believe CT can only be used on dead patients, LMAs are more flexible in that regard. CT offers identical airway protection/oxygenation/blood gases (I think, or it is high comparable) to an ETT. The main differences are cost (significant), sizing restrictions, and the fact that as it is a blind insertion with the majority entering the esophagus. It eliminates the tube as a med route if it is not in the trachea.

That can't be right... We give epi (for asthma) @ 0.01mg/kg 1:1000 up to 0.3mg or 30kg is maxed. I believe standard is that dosage up to 0.5mg SQ/IM max per dose. We can repeat once in 10 mins provided they are still in extremus. 5ml of 1:1000 epi is 5mg. That is alot of epi no matter who you are, single dosage or not, you risk a lot of cardiac irritability, dysrythmias, increase mvo2, etc....

LMA use is part of the Canadian Medical Assoc. NOCP's for advanced care and critical care paramedics. I had to "learn" how to use one in school. IMO it is as easy to insert as an OPA and offers somewhat better ventilation, though less a/w protection than an ETT. I dunno what they cost but I assume that is the limiting factor why they aren't in widespread use. In Ontario I don't know if they are used except by critical care paramedics as a failed/difficult airway option.

I don't remember exactly why it works well. I believe it has something to do with ATP and "priming" the heart to make it more receptive to defibriation. I'm sure if you emailed Toronto EMS/Sunnybrook and Women's College Health Sciences Center (our base hospital) they would be more than happy to provide the studies/why we are trialing this. Remember that in healthy people (which obviously aren't most cardiac arrest patients, but still) have a residual volume that can supply adequate oxygen for a significant amount of time provided proper CPR. Stopping CPR for x amount of time increases mortality significantly, something like 10sec interuption is 10% increased mortality, 20sec is 40%....I'm ballparking but you see the trend. If these studies do pan out I would wager that you would see changes made to how UNWITNESSED arrests are run. For a witnessed arrest (by any one with a defib) normal early defib would remain unchanged.

I have posted this before but I will say this... This method of CPR is being done by paramedics on the road. Toronto EMS, which is one of the larger EMS services in North America is doing this method currently. If the arrest is unwitnessed by paramedics or fire then you are to do 2 minutes of compressions only, followed by one minute of traditional CPR BEFORE YOU START ACLS. This includes stopping CPR to look at the rhythm, you hook them up but don't stop CPR. I will say that this method seems successful in the 4-5 months we have been using it. I have seen/heard of more ROSC's using this method than previous "traditional" methods. Don't knock it 'til you've tried it.

Same answer as twojsm.

I agree, when I saw the story today I was like, "well don't just let her starve to death". That alone opens up an easy target for cruel and unusual punishment. What do her doctors/neurologists have to say? I heard people today saying that she appears to "express" joy, sadness, happiness, etc...Are they purposeful reactions or simply coincidental neurological actions with no real cognitive effort. Either way I think you would be hard pressed to find ANYONE who is of sound mind to allow themselves to exist in a vegetative/pseudo-veg state. It always seems to be the family who forces there existence, hoping for a "miracle". The doctors should just say that she will die without the GI-tube, that neurologically she has no higher cognitive function and let the woman die with dignity. Dignity to be does not = starving to death. How do they kill people on death row? That cocktail plus some midazolam and morphine would likely equal the most humane death.

On any given day I'm sure you could go across the city and see 20 plus different uniform types. Generally it is all dark blue, with any combo of tac pants, jump suits, t-shirts, long/short sleeve, sweaters, jackets, etc... Appearance wise flexible as well. We had a new facial hair policy for PPE but beyond that... It may sound vain but I would have a HUGE problem working for a service without a decent uniform. I would be hard pressed to work in a service that required medics to wear white/light blue shirts. Thankfully I will likely never have too....

500k-600,000 per year, busiest in Canada :wink: