vs-eh?

I'll respond to this post from an Ontario perspective. Unfortunately, I don't think (I could be wrong) that there are any people here in this situation, but I digress.

While I still don't fully understand the semantics of 911 vs "emergency tranports" vs "80 F doing for dialysis goes bad" in certain contexts. I'll say this...

Ontario has a system where there are truely emergency (EMS) vs. non-emergency (transfer) ambulances (non-EMS).

EMS - keep in mind these are several of many legal obligations

- All are staffed with paramedics (PCP, ACP, CCP) who have provincial certifications under the Ontario Ambulance Act to practice. As well as been unde a service and hospital scope of practice.

- Are under employment with a municipal service

- Have to complete provincial ACR's on every call

- Respond to 911 calls, although all levels can and will do transfers as scope is needed.

- Can run L+S (prn)

These a several very basic aspects of the job...For comparison

Non-EMS (transfer services). I don't think are under any "real" legal obligation, beyond those listed below.

- Can be a random person who at least has a "G" License (keep in mind all paramedics, regadless of scope have "F" class).

- Can have "certs" from FA to foreign MD, to paramedic student to actual provincial cert. (those may not be yet hired as per competition).

- All of these services are private, FOR PROFIT. No municipal 911 service is for profit.

- No vitals of any kind are required, or really even need given what they are supposed to transfer.

- Have non-standard to irrelevant paper work. Meaning they will never be formally audited and "really" held for anything.

- Do not EVER respond to 911 calls EVER. They are not legally allowed to and besides, don't have access to any kind of 911 dispatch. If they have a patient that (goes south) or are picking up a patient that "doesn't look good", two of many examples, they must call 911. They don't go direct to the ER or OR, or any kind of emergency situation.

- It is illegal for them to go L+S.

I hope this makes it (somewhat) clear how this argument works here. Do some of these people still wear stethoscopes around their necks? Yup, and I hope they are paramedic students. Are there ambulances that still say "paramedic" on them? Yup, and that one kills me. It's rare, but it kills me.

There are probably about 60'ish (I'm guesstimating) EMS service in Ontario for 13 million'ish.

Transfer services are maybe half that'ish.

It's called the internet people, grow a pair. In the end you could be dealing with a person with big dreams, a simple mind, yet fast hands (like referencing medicine on google people, god, get your minds out of the gutter).

I've been on this forum for a while.

I don't ever recall "boo-hooing" about a response to a post I have ever made. It is either a response with a laugh, a response, a "ya, ok, I was wrong", or my head exploding that people can't comprehend things.

I think there are too many people on this forum that think certain members have "immunity" from critique (my self included). And I kind of chuckle when those retort to "virgin posters" with something to the effect of "Hey there buddy, this guy has been here a while and has built a rep".

Whatever, just think about what you are posting. Have some adult structure and grammar to it. And realize that people will critique it (beyond what their "rep" is).

PS - I do realize that I am a terrible "grammar" and spelling poster. I have never tried to hide that. However spell check and reading a post over works wonders...

So, why don't you come over here, get into a leadership position, and do something about it? Fostering change is so much better than bitching about it from the other side of the border.

Gladly,

I'll come down there to explain that to do a (what on many many many levels) appears to be an EMT-B's job, but requires 2 years full time post secondary education and one that (I'll provincially generalize) is a 10% chance to get into school.

Most schools also have a fairly high attrition rate.

Then I'll tell them that provided they make it thorugh 2 years they have a low (again, provincially generalizing 33%) chance to get a job.

But once you get a job (which requires a 6 hour exam that upwards of 50% fail) and get accepted into a service (which requires more testing that you have too pass).

Don't worry you'll be making $27/hour easy.

I have a crazy requirement that might perhaps eliminate this problem before it even begins...

A high school diploma and perhaps (gasp!) required courses that average Joe Highschool doesn't necessarily have to take!

EDIT - See this is a reason why EMS is general is such "nicety" to people.

"Oh don't worry, this nice young (wo)man will take you down to the hospital."

"Oh, fluid on the lungs? Ya, that's what I thought too."

"See, I told you it was nothing, you shoulda (sic) just stayed home."

This is what destroys EMS as a profession, shit like this. This is why you see people that think they can do EMS, and be a medical "professional". People (in this thread) say stuff like "what we see", gimme a fooking break. You see nothing, small town EMS throwing out shit likes this bothers me. Start treating and diagnosis a complex medical call without 18 of your buddies around (at least 4 per car according to this vid). People see trauma and cardiac arrest = EMS. People see this stuff on TV, on youtube, in People magazine (on that post53.org or whatever), and in the New York Times (also mentioned).

I am tired of it.

All of this brings down my profession. And people just shrug their shoulders. I didn't spend 3 years in college, and neither did hundreds of other professionals and (dare I say) thousands of others across North America, to see this shit.

I'm getting really tired of it.

How many people see, and/or actually do this?

EDIT - Sorry, I mean actually opening the book and reading them.

Man, it's been a while since I created a post...

Anywho... Just wondering how often you guys decide (or need to) set up what is generally called here a "run". This happens pretty rarely, and I only recall being invloved in 2 or 3 (2 of them being pediatric arrests).

A "run" is basically allied services (mainly police, but fire I have seen get invloved), blocking intersections for EMS in a "run" (not a silly run, but a slower brake run) to the hospital. This is a large urban city BTW.

Now fair enough, we only have three municipal services for EMS, Police, and Fire so maybe it makes it easier. Just wondering if you guys do it on occasion and how well it has worked...

I have to say in the 2-3 occasions I have used it, it went very well. Impressive all things considered...

Are there actual people that can be driver's and are not allowed to take part in care?

I'm also interested. Bill Bryson made a good arguement for Australia. Just wondering as well...

anyone have info on this? Would like to know as much as i can before i make a decision

Yes, WendyT is an obvious authority here. Everything she posts is chock full of information and is 100% rational and lucid.

Anywho...

Listen dude...

1) Stay in Canada

2) I would generally recommend to go to school in the province where you want to/plan on working. It just avoids further costs/issues with reciprocity.

Ontario has the longest duration of schooling to get into the paramedic field at two years. All other provinces are less schooling (1 year or less) for PCP, and Ontario doesn't use EMR's (like they do in say Alberta or BC) in the 911 EMS system. Ontario also has some of the worst prospects for jobs for the primary care paramedic.

You sound like you have mobility, and want to get out of Ontario. Go to Alberta (lots of jobs) or BC. Get your EMR, make a bit of cash actually working, and then do your PCP in whatever province you choose.

The US educational requirements are generally low compared to Canada and other countries.

My experience with IM midazolam has not been great. I find that basically all patients that I have administered it (or seen it administered) to don't acquire the properties you would like them to :wink: . I basically limit non-IV versed to IN (via MAD), which I find is a much more rapid onset and more predictable action. I would imagine that the versed admin was not the cause of the termination of the seizure activity (given it onset IM). Prophylactic actions are obviously of benefit though...

That being said, 5mg of midazolam (especially IM) isn't THAT much medication (especially if they are chronically on benzo's for their seizure disorder). Certainly not enough to warrant flumazenil administration, especially given the presentation and the fact that now you are eliminating benzodiazepines as a treatment. From the scenario that you presented, it sounds like there are bigger issues here and that the symptomatic status seizure is part of a much more serious problem that would account for the patients need for intubation. In my opinion there is no way the 5mg of versed somehow "bought" this guy a tube.

I would have asked the doctor what he would have done, if the patient simply remained post-ictal in the ER and began seizing say at triage. Ten bucks said he would have administered a benzo...

Any further info/hx on this call? PMHx, Meds, etc...

I'll offer this reply as one of the only ACP's that post on this forum (remotely regularly) and the only one that is in the same province as you and has done similar education.

I took the 2 year PCP program and I started ACP less than 2 years after working full time.

Eliminate any comparisons people may draw from the US viewpoint of going straight to ALS after BLS (or asap) especially with Ontario's 2 year PCP program. There is no comparison.

Your questions...

1) I would wager that the majority of people since the advent of the 2 year program would like to do ACP (and maybe CCP). I would assume that most would like to do so within 3-5 years of working as a PCP. School dependent, PCP encompasses 85% of the ACP schooling (in my opinion). The move (at least from an educational standpoint) is not that difficult.

2) I too had "excellent" grades in my PCP program. While it influenced my (relatively) faster move into ACP, it didn't override the need for experience at the PCP level.

3) Yes, it is difficult to get work as a PCP in southern Ontario. It is hardly the part-time PCP, part-time McDonald's employee that you exaggerate with. I think the $30+/hour you'd be making as a PCP would easy negate wasting time in fast food. Also, Alberta and BC are hiring PCP's. Maybe not the same cash as in Ontario, but it is an option.

4) ACP/CCP does give you more freedom to work nationally, however... You would be basically wasting your money on ACP if you did not go to a CMA accredited ACP program. To my knowledge there are only four currently CMA accredited programs: Toronto EMS (in house only basically - 5-6 years+ seniority as PCP needed working in Toronto), Durham, Conestoga, and Ornge. Even if you decide to go to a unaccredited program (big mistake) I believe basically all ACP programs REQUIRE working as a PCP prior to enrollment (anywhere between 6months - 2 years as I recall). The only one that doesn't (as I recall) is Durham. As a person who has who has applied out of province, CMA is the gold standard.

1) You should. I'll explain in a sec...

2) Another reason you should work BLS first.

As you are probably aware it is EXTREMELY rare to non-existent for someone to go straight from PCP (AEMCA) right into an ACP program within minimal or no PCP work experience (I'm talking < 1% and I have never heard of anyone doing it). The reason being:

1) In house/contracted colleges usually require X time in/seniority to get into a class.

2) Only recently have more colleges cropped up that do ACP/ are letting "external" PCP's enter a class.

3) The cost issue

4) This is pretty big... Not a lot of service's are going to be willing to hire a new ACP who has little to no autonomous road experience in a municipal EMS service. Even as a PCP, at least you gain "standing" within your respective base hospital and are "known" to be able to practice sans preceptor. Base hospital's will chat when hiring paramedics from other services, they certainly will be looking at one who is ALS. If you have no prior service at any level, it may raise a few flags, right or wrong.

Listen, I appreciate your desire to go to ALS. Trust me, I shared that desire only a few short years ago coming out of the PCP program. Working autonomously is a hell of a lot different than preceptorship (regardless of the freedom they give you). The cliche of "BLS before ALS" from an Ontario perspective is one that is basically forced to be put into practice. My assessment and basically core of all my own paramedic practice has had only minor minor changes after honing it as a PCP. In all honesty the move to ALS only added an enhanced scope and procedures, nothing more.

In Ontario, the deck is stacked against you big time for what you want to do. Follow my advice, give it a year or two as a PCP, make some money, and then move on to ACP.

I'm not entirely getting what you're asking here. I certainly would not deviate from a recognized "standard of care" that is currently recommended by your service by what people on this forum suggest. Same goes for reading about a "new standard" in a journal that may differ from your current treatment modality.

While there are generalized global standards of care regarding most situations, in the end the physician that dictates your practice can "do whatever they want". If you have a concern regarding your "protocols" then bring them to the attention of your service and medical director. I would recommend not "doing what you want, just because it doesn't actually go against 'protocol'".

Some examples -

My service started doing the "up-front" chest compressions (and new compression ratio's) for unwitnessed arrests quite a while prior to them being "standards of care". I (and others) found that it lead to a significant increase in prehospital ROSC. I would not expect people on this forum to institute that modality until it is recognized by their service/physician.

I don't have any standing orders regarding treatment of a hyperkalemic patient. So, should I come across a renal patient in a wide complex bradycardia say, I can't simply administer sodium bicarbonate and salbutamol (the only medications we carry that are in the standard treatment) without calling a doctor first. Even though they are "standards" and I'm not going against "protocol" (because there isn't one), I still have to have a chat with the doctor.

Same goes for the oral administration of D50W that was talked about on this forum. Just because it can be administered by that route, I doubt that very many people have this option spelled out in their orders. Therefore you are giving a medication by a route not specified and must call for administration. A similar example is midazolam. Initially we didn't have IN as a route available, and even though it is an accepted route, you cannot simply do it. Unless you have something in your orders to the effect of "administration may proceed by all acceptable routes per drug insert" (or something), you can't simply do it.

I can give morphine to a ischemic chest pain patient, but I don't have to. I have read some journal articles questioning morphines efficacy in this setting and personally refrain from it. People do administer it though, but I find most patients prefer not to have it. Same goes for the subjective nature of treating a chest pain patient in itself, you may treat, where I wouldn't. That is the beauty of having guidelines rather than have-to-do's.

Again, if you are questioning certain treatment guidelines that your service does, based on new information, approach your service/physician first before you take things into your own hands.

The last VF arrest I did (keep in mind witnessed by medical personal with CPR, patient was young, and we were on seen quickly), the hospital applied the ROC study hypothermia treatment to them within minutes upon arriving to the ER.

It looked promising.

If I shake their hand, I'll let you know.

Ya, I don't know where the author of that article got their information from. Toronto does not provide vests to employees in general. Tactical paramedics are provided vests (I don't know if they are individually issued or not), but there are only like 30 (?) of this type of paramedic in the city. Also, generally speaking, they only wear them on ETF calls, which are uncommon at best.

Now, there are people who are on "normal" paramedic duty that wear vests. These people (I presume) paid for the vest themselves. Again, these individuals are certainly the exception, rather than the rule. Maybe 2-3% of "normal" paramedics wear/have a vest (my assumption).

This issue gets brought up every now and again, and it still might be in the works for standard issue. I have not heard of it in a while.

Yes

Enough religious lessons. I only mentioned the scripture to give the OP insight into why tattoos have been looked down on for so long.

I do highly suggest that anyone getting tattoos do so in places that will be covered at work.

Professionals need to carry themselves as such. If a patient is nervous about you based on your appearance you will find it tougher to gain their confidence, to have them view you as a professional, which can and will hurt your ability to treat as they will not speak as freely with you.

I think it's safe to say that body art has been around for far longer than today's dominating monotheistic religions...

http://magma.nationalgeographic.com/ngm/04...line_extra.html

But I digress...

It is totally based on where you work and what the culture/religion is (though I work in a vastly more multicultural/multireligious community then well, any of you). I have never heard of, nor seen an issue come up about piercings or tats. I have mentioned this before, I have 2 unconventional visible (though subtle) ear piercings that have probably been brought up a handful of times (and I can't honestly recall when the last time was).

A lot of my co-workers have visible tats and piercings that many of you would cringe at. The population that I serve (read the former) have no issue with it. I have never heard of an issue from my most "tatted" friends.

Here we go again!!

I know we've had this discussion before. Actually, Christians believe Jesus brought a new covenant and the old rules were set aside. Christians don't sacrifice goats, can eat pork, cheeseburgers and never have to sit Shiv'ah.

Peace,

Marty

So God, who's son is Jesus, but Jesus is also God...Anyway...

So God, somehow made a mistake in its initial rules. Amazing how an omniscience, omnipotenent, omnipresent being can simply "make an error". But then...

Meh...

I do intend on getting a tattoo at some point, but I would not place it where it would be inappropriate for work (such as exposed arms, chest, neck, face)

(the tat i want is going on my lower back.)

Ummm Beegs, I don't think God is specifying body placement here. You're probably a sinner for even thinking of it. Repent soon...

Read the verse, you decide.

So laws and rules to live life as per Leviticus, are good to live by?

Did you know that tattoos were pagan religious symbols and that God forbade them on his people?(Leviticus 19:28)

Might consider the view of someone higher than those of us here on the site.

That was a joke right?

Still like the 1 that I stopped at a mvc motorcycle out of province where the medic were ass's (BLS) and pushed me aside and i offered ALS support iv. ett i said tramatic cx trauma I got we got it.......till they lifted back the sheet and this heart lungs were looking back and the cocky medic passed out........so he went in the 2 nd rig and I came the primary medic. So stop and assist but stay in your scope.

Again, a tremendous story there. I thought I had read something similar before...

http://www.emtcity.com/phpBB2/viewtopic.ph...sc&start=30

Stopped at a mvc motorcycle saw the pt with two ladies, asked if they needed help, I am a Paramedic ACP they said "no they are RN's " Noticed the pt was on his stomach ,heard snorring respirations!!!!!!!!!!! I Went down and told them they must gain airway control HE'S BREATHING THEY SAID :twisted: :twisted: :twisted: I said thankyou for your help, I now need Your assistance. With all the c spine logged rolled and his helmet was chacked in half beside him ................rn's nicely removed it before I arrived, he had massive head trauma. Had my wife get my medical kit out the back as we where heading back from Sudbury Ont and suctioned him Airway was contolled, did abc's proceeded to remove clothing noticed a Hells Angles tat and patch GREAT he had 2 femur fx, 2 radial/ulner fx and when I opened the shirt 1 Rn passed out there was 2 lungs and a heart doing a bradycardic beat........his ribs were sticking lt/rt. Covered the cx the ambulace arrived I had 2 14g IV's in and they where BLS. THE LOOK OF HORROR ON THERE FACES I had my ACP TAG with me and went with them,intubated and he coded in hospital.

Yes it is nerdy to have a kit with you if you use it be prepared to go, have your tag with you, but the hospital was impressed with our scope of practice.....got a thankyou from the Hells Angles :shock: and the RN woke up after her friend pulled her out of the bullrushes.

Looks like some of the details of the story changed, maybe you just forgot. I'm sure it still happened...

You also never answered any of the questions that I posted regarding your ability to practice in Ontario on that call. Maybe you can answer them now in this thread.

She is fairly skinny.

Is it C. diff?

C. diff....

How fat is this kid. Hyperglycemia could explain her symptoms...

Considering the relative rarity of pre-hospital childbirth and the general unwillingness of paramedics to deliver pre-hospital (i.e. run for the hospital), it seems pointless.

Concentrate on properly assessing duration and frequency of contractions, getting a decent history, noting crowning, recognizing (potential) life threatening complications (placenta previa, abrupto, etc...), and be up on NRP. These are more improtant than assessing for cervical dilation.

Again, why add such non emergent physician procedures to an already under-educated system? I don't get it...

Transport to the hospital with maybe a mask.