vs-eh?

Wait a sec...

Now people may have issue with this firefighter523 guy... And potentially for good reason...

But scaramedic called me "brilliant" I think, in a deleted post...and yes I saw that post...

I deserve all my kudos. Is "cum up pans" an actual word or phrase? Because I need that.

The extra aspirin is not necessarily going to kill the pt but you may leave the surgeon with a bloody mess that will increase the chances of the pt not making it off the table. You are right, a tearing sensation does not make it a dissection, but it should raise your suspicion for a dissection especially in the setting of other signs and symptoms. I can see that developing a differential is difficult for you since you seem to be protocol driven and unable to make clinical judgements. An aneurysm and a dissection are not the same thing. They are seperate entities and your use of them interchangably goes to show your lack of education. When you site statistics and solid numbers, you need to cite your reference (and Wiki does not count). Show us the evidence for your 26%.

Wayyyyyyy ahead of you doctor...

Cool....I'lll assess this patient...

General impression of the patient -

Hello... -

What's going on today? -

How's your breathing?

Auscultate prn-

Any pain/discomfort/funny feeling? prn (points to head chest adbo) -

palpatate prn -

"OPQRST" prn

"AMP" prn

vitals -

Witness my awesome...

vs , tearing CP doesn't mean that it is a disection. ACS can also present with tearing CP. Just because the pt thinks it might be tearing, could mean it feels more like crushing to the next person. You don't know. It is up to you if you want to withhold ASA, I do know this, ASA decreased mortality by up to 26% in MI pt's if given right away.

What if the pt already takes 81 mgs a day, and the disection is not complete yet, say it is just an anyurism right now. Is your 325 mgs really going to kill the pt , since he has been taking 81 for the past 10 yrs??? Doubt it...

Very true. Ischemic CP can present in a myriad of forms. Solid clinical assessment +/- diagnostic tools can aid in that assessment. I assume ALL of your CP aren't treated with (forgive me) MONA. All things being equal (and speaking in the context of thoracic aneurysm), I would have a greater degree of suspicion for a thoracic aneurysm than anything else. Tell the ER your suspicion base on clinical assessment (and withholding certain medications) and you're cool.

Pulling internet stats does not help your knowledge as a practical clinician...

I hope that any paramedic would have to patch (call a doctor) for that type of patient presentation. If you wouldn't have to patch, please tell me your education and your standing orders...

Good case.

ER Doc wrote: "Are you going to give ASA to a pt with a disection"?

Someone with a posible disection is usually going to present with almost the same signs and symptoms as ACS. Chest pain, pale, cool, diaphoretic.

Your answer is yes, I do not have x-ray vision. And then I would proceed to give him nitrates, to decrease his preload, and to vasodilitate, and then I would proceed to give him 2 to 5mgs of MS to decrease his pain, and to decrease preload of the possible disection! If you cant differentiate ACS from disection, you must give ASA in the field. Sorry Doc.

What are some questions you might ask a patient or assessments would you do to query a thoracic aortic dissection over say ischemic CP (myocardial)?

If your patient had certain clinical signs or say they had "tearing" CP to the back (as an example) could you (would you) withhold tx with asa given a reasonable clinical suspicion? As long as you can rationalize your reason from withholding asa (which is the ONLY drug that decreases mortality in the event you are giving it), then don't give it.

The very fact that you mention specific drug doses of say morphine, leads me to believe it has nothing to do with real clinical evidence and everything to do with what YOUR specific, by the book protocols say to do. Mine say I CAN give 2mg q 5....I generally don't...and what about fentanyl?

Second shift: In my pea brain I say "Ok, I've now started 10 IVs that I didn't think were necessary and haven't managed a single complete assessment, which I do think is necessary. This doesn't seem to be a well thought out plan. To medic "It seems like I'm trying to do too much at once, and not doing anything correctly" Medic "Well, it takes experience, and you don't have any do you?!"

Tell your preceptor this...

"I am not going to be touching the patient, outside of my assessment (i.e. ausculation, palpation), unless there is a procedure that I want to do".

There is no reason (other than mentioned) for you to be touching your patient or doing a procedure on your patient on any average EMS call. Your partner can do an IV, start oxygen, monitor, draw up medications, etc... You don't HAVE TO do these things. Proper assessment equals proper treatment, anything else uneducated cookbookedness (patent pending). Delegation and "stepping back" is as important as anything else in advanced assessment and treatment. Watch an ER doctor for reference...

Now I'm not saying don't do anything. Start an IV if you want from time to time (especially on difficult patients), obviously do critical ALS interventions (intubation, med administration, thoracostomy, etc...), draw up medications if you want, etc... But your assessment is your treatment. Don't be rushed, stand firm on this, and tell people what to do (that is your job, as long as it is within their scope). You're not a dick for telling people what to do.

Hyperglycemia = osmotic diuresis = pee pee = dehydration + hypokalemia?

His potassium was ummmm 3.1 mEq/L?

EDIT - The reason I had asked about hardcore "puffer" use before was that (s)albuterol can cause transient hypokalemia I believe on the order of reducing by 1.0 mEq/L? I don't recall...

The only real challenge I've found so far in relating to patients is the time aspect. It's difficult to get the information I want, apply the monitor, get a BGL, and start an IV (the requirements my preceptor has for me for me for about 85% of our patients.) with the 5-12 minute average transport time that we have..(This is my observation phase)

Dwayne, EMS is not a game of rushing around and trying to get procedures done within a finite amount of time, generally speaking. Your clinical/hospital time would have prepared you for the physical aspects the job. Your preceptor time should be where you start to hone your approach to the patient, assessment style and priorities and focused questioning as needed. Critical aspects include recognizing the "sick or not sick" patient. I'm not talking simple query ischemia CP patients or what not, I'm talking truly emergent, can-really-benefit-from-ALS-intervention-five-minutes-ago patients.

Take the 5-10 minutes (which 95-99% of patients can handle) and get the basic information YOU need based on what YOU want to do to aid in your pre-hsopital diagnosis or adding to your differentials. It made me cringe, and feel that you are rushing through assessments (and possibly scaring/confusing patients), because you probably are. Basic procedures can be done by others during this time, oxygen (if YOU want it), monitor (if YOU want it), etc... DELEGATION IS AN EXTREMELY IMPORTANT "SKILL" TO LEARN! The IV thing, to me is meh... In all honesty, IV's are probably started on about 20% of the patients I carry. The fact of the matter is that the actual/potential need for IV intervention (fluid or medications) for EMS patients is pretty low. A lot of people get stuck on this point, but whatever. You don't need to start a line on that patient that may need something in hospital 3 hours from now, but opinions will vary by system, and there is a fine line between laziness and practical application I suppose. I've gone off on a tangent...

If 85% of your patients truly need an IV, monitor, and blood sugar than kudos. You either must work in a system that sees many times more "sick or treatable" patients than me or you are following (your preceptor is telling you) a cook book approach that, again, is not needed in EMS. Get the information you want, develop your assessment. Tell your preceptor that you are feeling rushed. There should be no real need to feel that way. Delegate basic procedures as you see fit, develop a treatment plan (if needed) and proceed from there.

Taking his puffer a lot recently?

Is this a Hanson brother? Wasn't the elder Hason taken in for a leg pain/PE recently? Anyway...

1) Allergies/Meds/Hx

2) Prior history of same/normal level of activity?

3) Can he walk?

4) If he has been feeling shitty all week did he see his GP? Did he call just because of this new leg pain?

That's it for now.

Mmmmmm Bop...

In good 2 year Paramedic program a person could get EMT-B after 6 months, then EMT-I after 1 year. With that they could get field experience while they complete the Paramedic program. No need to stop your education get experience, then restart education.

I disagree, you need autonomous experience under your belt for the reasons I listed. Don't encompass it within your 2 year paramedic program. Learn the attributes that I listed in my initial post, attempt to hone them, and then proceed with advanced scope. You don't need to necessarily stop your education, just work on your certain aspects needed on any call prior to adding in ALS procedures and interventions.

Also, from what I understand, EMT-I is generally a mish-mash of advanced ALS procedures without adequate education for them. You don't need that. Do your BLS, strengthen those procedures and know how to do a call, talk to patients, assess patients to your skill level, and work the system. Then move on when you are comfortable. You are NOT comfortable with even the most basic scene calls until you have unobserved experience.

And before the arguement comes up (because it has and will)...

Yes, I know that physicians don't do PA or RN or paramedic prior to them becoming a doctor. I know that their isn't a mandated chain of progression from a "lower" medical profession to doctor. And I agree that you don't need it. However...

It is safe to say that medical school, residency, undergrad, etc...provides you with a substantially greater "well" of education to pull from, regardless of the years and years of "time in" you have over your average or top paramedic education. As a doctor/resident you also have (generally) at your disposal several, if not many people who have the skills (RN, RT. etc) and/or knowledge (attending physician/other MD's, etc) that are able to assist in your cerebral assessment or physically do procedures that you may need assistance with or cannot do. You have years of "guidance" with these things. Those who work in EMS (unfortunately), do not. Generally speaking ALS paramedics work alone or with another paramedic who can do said procedure or wax medically on treatment modality. They also (at absolute maximum) have 2 years education and experience to draw upon, not the years and years that physicians generally have during their education.

I won't waver from this position on the need for "real road" experience that is needed at the BLS level in EMS prior to entering ALS. This is even if you aren't doing 911 (though hopefully you are) and are simply doing stable interfacility transfers. You can still assess patients and learn the system...

This is a key point that I have made in the past regarding at least 1 year of BLS experience, prior to going ALS. While all of my US EMS information comes from this site (take that as you will), it also applies to PCP (BLS) experience here. Also keep in mind that PCP is 2 years college and includes 350-500 hours (average 400ish) preceptor experience as a PCP student prior to possible employment. From what seems to be the general consensus of 120-150 hours schooling as an EMT-B, that obviously cannot include (even above that length of schooling) a large amount of preceptor experience. I have seen numerous times people saying they have little (12-24 hours) to ZERO "road experience" prior to being available for employment.

You need at least a year of autonomous experience at a BLS level (whatever the scope may include) to learn the following:

1) Talking to patients and not seeing them as sets of numbers and a "do/don't do" list of possible treatments "by the book". Obviously the hyperventilating patient Anthony mentioned is a prime (but one of many) example.

2) Dealing with family/general public

3) Dealing with doctors/ER/the general system

4) Driving!

5) Dealing with partners and other emergency services

You gain this core experience by simply attending calls, regardless of their acuity. Now people will disagree (looking at you Dust), but when I see the average preceptor road time of most American ALS programs being 300-400 hours (plus 12-24 BLS) the above cannot happen.

My transition from BLS to ALS (and I am considered to have fast tracked by 99% of Ontario standards) was simple. Why? My assessment and the way I handle scenes that I honed from my 2ish years experience did not change. The only change was the procedures and interventions I can perform. That is it.

I think fast tracking an already grossly fast tracked and undereducated system is a silly and reckless idea. I'm sure if you look at my Australian and European peeps on this forum, they would agree.

With the implementation of the ITD, an induced hypothermia protocol, direct cath lab access, the use a the Lucas device, rapid deployment of and high availability of AED's, and an outstanding community education program, our numbers are averaging around 17% for ALL cardiac arrests. Our ROSC average is 80%+. But I digress......................

Ya, we just got re-introduced to the ITD when I did the CME. We were first shown it about a year ago (at least). I don't know what the hold up was, I don't even ask anymore.

IMHO those studies are flawed. Ours are much less as I suspect truthfully theirs are. Of course I don't count it unless they leave the hospital with a high quality of life.

I recently had my fall CME which included (amoung other things) one of our physicians commenting on the ROC study and our involvement in it. Seattle (Medic 1 or whatever), along with us and several other North American systems are involved in this study. One of the sections of the study involves the ROSC outcome amoung systems and specifically with the shock "early" or "late" study monitors.

The physician told us the reason why Seattle's numbers are so high. It is because they only include those in the study who INITIALLY PRESENTED in a SHOCKABLE RHYTHM. All other systems involved base it on the TOTAL NUMBER of cardiac arrests involved REGARDLESS of the initial rhythm. Obviously, that is going to play with the numbers. From a "survivability" standpoint alone, a patient who initially presents in a shockable rhythm (regardless of first provider contact) will likely be "fresher" with a much greater likelihood of a ROSC.

Obviously stacking the deck in your favour by eliminating PEA/asystolic cardiac arrest patients, who generally will have a significantly reduced likelihood of a ROSC (all things being equal).

Carrying on with the topic, people will know my opinion. Take a page (yet again) from Ontario's book of standards of prehospital education for BLS providers. There is your minimum folks. EMT-B and I education by comparison is a joke, and would not be allowed on an ambulance here.

NEWSFLASH!

The vast majority of EMS calls ARE non-emergent either by dispatch, call details, or actual patient complaint and treatment. Only a small percentage of 911 calls (certainly less than 20% in my opinion, likely closer to 10) absolutely see benefit from EMS transport and treatment beyond what they themselves or family could have done. Truly acute emergencies are not the bread and butter of 911 EMS folks.

Poor small town Nebraska are "bothered" by the fact that only 207 out of their 370 calls actually were deemed worthy of their great EMS prowess and attention? BOO FUCKING WHOO...

You boys are getting "burned out" by this astounding volume of calls? Try doing hundreds and hundreds of 911 calls a year that I have to attend to that are "non emergent" 911 calls...

Obviously these yahoo's had zero idea of "real EMS" and medicine in general. What a joke...

Impossible to enforce any kind of "restriction" for calling 911. Way to many what if's... But with these glory hounds it might just be better to call throw Jim-Bob in the truck and skedaddle on to the hospital yourself...

Can one really gain the knowledge they need to go out and save lives in about a month?

What do you think...

I came across this a couple of weeks ago....

http://www.emsresponder.com/survey/

Has this ever been posted before?

I was going to comment on it then, but seeing the overwhelming banal posts of people so desperate to get into chat it kind of put me off. I see now that this has kind of tapered and hopefully people in EMS who can string a sentence or two together can comment on my comments, while reflecting on their own state/province (word to run on sentences).

Theme's that often appear in these forums are: education, wages, and respect. I will leave out the "vollie" issue, because I have never encountered it. I decided to look at the survey through the eye's of those issues. In my opinion, the main point that affects all three core issues comes down to this, judging by this survey...

You have too many fucking EMS personnel in any given state.

I decided to take my home province (Ontario) and compare it to a similarly sized American state (Pennsylvania). By size I am referring to population, not area (Ontario is approximately nine times the area of Pennsylvania). The stats for Ontario seem to be accurate, at least from my general knowledge and opinion. I am going to assume that they are generally as accurate for other provinces and states. The survey itself is from 2005.

Some interesting (shocking?) numbers...Ontario will always be the first number mentioned. If addition is required I approximated.

EMS personnel - 6600 vs. 49,200 (I didn't include MD's). The numbers for Ontario anyway seem to be accurate for the number of "actively practicing" paramedics in the province. I will assume it is similar for Pen.

EMS services - 50 vs. 1,400 (Excluded air, and I know there may be some overlap with services providing two or more levels of care)

Why is there such a HUGE difference in numbers and how does this affect the three key areas of wage, education, and respect?

1) I realize that our health care systems are significantly different. Does that account for the disparity in numbers? Is it simply a money game?

2) I realize that EMS and Fire are far more tightly linked in the US than in Canada. I also realize that many FF's are cross-trained to at least the EMT-B level (I assume). This is non-exsistant in Ontario.

3) I realize that education standards are very different.

This post is already to long. I will reserve further comments until later. Seven times the EMS personnel and in excess of 25 times the number of services. That is flabbergasting to me. It typifies to me the need for more specialization for EMS from fire and the need for (again) greater education. It is pretty hard to "get respect" from the public when there are so many people for a given population who are in "EMS".

More later....

After reading EMS forums for some years now, do post's like this really surprise people?

It's just another brick in the wall the seems to permeate aspects of (mainly) American EMS. This seems especially to be the case at the basic and intermediate level, though paramedics certainly aren't excluded.

The attitude of "why can't I do this", "man, we should really have this" seems to run amok, again mainly in the US.

You can tell these people time and again the reasons why your 120 hours, or 500 hours education, doesn't "buy" you certain procedures and medications. But this attitude of medical entitlement (however little the cost) flows deep amoung far too many. People have this deluded sense of purpose of needing certain things that would be "for the patient". With these people that outlook is total bullshit, it is really for themselves.

The post that ERDoc linked I'm sure will continue on for many pages, but the simple fact is that you will never change the mind of this type of EMS provider. It typifies the "blue patient" gets the "blue bag" type attitude that unfortunately is the all to common conception of US EMS (again, I'm generalizing).

In Ontario, PCP's (BLS) can administer NTG spray (chest pain and/or CHF), given a proper assessment, certain vital sign parameters, and medication restrictions (previous NTG use and no ED meds x 48 hours).

There are only a handful of services that allow PCP's to start IV's. We also carry all the drugs we administer, there is no "assisting" with drugs here.

A couple of days ago I administered NTG spray to an unstable angina patient prior to starting an IV (hypertensive post self NTG admin, but ALS can obviously administer without prior use).

Proper assessment is key for both BLS or ALS nitro administration, with BLS knowing they don't have that "life line" should the patient become grossly hypotensive. Proper education and discretion that the PCP possesses may lead them down the NTG route or to perhaps just stick with ASA and oxygen.

I don't know if 120 hours gives you that education or discretion...

oh and gud post asys. 8)

PS - This is to get my post count up, so I can get into chat! *crosses fingers*

Sorry, what medications is she on?

Bilateral BP please...

Take her BGL with her glucometer. I realize FDNY does not have them (why on earth), but use her's before treating anything else (ABC aside). Treat hypoglycemia if indicated.

On the surface it would appear the classic case of the inferior MI with right ventricular involvement. But it probably isn't...

Sorry, she is a GCS of 5 but gross neuro assessment is "better than good"? Hmmm... I assume that was her initial GCS? What is it as you are talking to her/assessing her?

Big one's to me are CVA/TIA, MI, hypoglycemia, or OD (beta blocker, Ca++ blocker, or cholinesterase inhibitor - I've seen this believe it or not).

Since it's probably not the obvious as presented I'll go with OD and you could have used a "reversal" medication/treatment instead of pacing.

I got my aeromedical certificate from OAABHP (before Ornge, like 3 years ago) without doing this. The program does look like it has changed slightly though.

I also don't have the provincial exam. Probably better to get everything in order.

Perspective, it takes two years of school to get a JD (jurors doctorate) law degree...

Ya, two years postgrad...

You are looking at likely 6 years post-secondary education, plus one or more professional graduate examinations/licenses...

I'm not saying that lawyers aren't necessarily a dime a dozen, but with 6+ years of invested education they aren't exactly in the same ball park in comparison with EMS. If that is what you were looking at...

I'm pretty sure that they are referring to physicians in your highlighted sentence, not a 120 hour EMT or 6 month paramedic...

Critical care paramedics (CCP) are very very rare in Canada. Let's assume there are (and I'm really ballparking) 20,000 paramedics (PCP, ACP, CCP) in Canada. Out of that 20k, I'd say there are 500 recognized critical care paramedics. Alberta seems to be slightly different regarding CCP designation as their ACP's seem to encompass a lot of CCP scope but anyway...

CCP's in Ontario are generally only in the aeromedical environment. CCP's operate with the provincial air service and are available from that single service for the entire province. Toronto is the only ground service in Ontario that does critical care transports with CCP's (and that's basically all they do, very very little 911). Toronto did a one time job call about 10 years (?) ago and basically that program will disappear with attrition.

That being said there is a significant difference between a critical care paramedic in the US and in Ontario (and I assume Canada in general). The US critical care paramedic program (I believe) is a 2 week-ish course. It seems to be more of a cert. course. Ontario has the only CCP program in Canada that in accredited under the CMA (essentially the national standard). Here is the link...

http://www.ornge.ca/edu-programs.html

Obviously quite a bit different. A new person wanting to be a CCP in the end, starting today, will spend about 4 years in education and quite a bit of cash (2 year PCP + 1 ACP + 1 CCP - assuming that the ACP is flight).

The provincial flight service providers (ornge runs the entire province, but they contract out to preferred providers) to my knowledge still supplement educational costs to an extent if you work for them and wish to enhance your scope. No land service pays for critical care education, because, well, currently it is basically only in the air.

CCP's make in the low-mid $40/h range here though... Not bad...