WelshMedic

Yes, this time last year as a result of a lateral MI. Luckily on the cath lab table. Have no.lasting effects. When did you qualify and what are you doing now? Feel free to PM me.

Hi all, I was attracted to this thread by a random mail. I am still around too. Has been an interesting couple of years after having a cardiac arrest over there in the States. Have now fully recovered and am back at work. Nice to see some old  names, particularly good to see that Wendy is all grown up now and a proper nurse ;) .Carl

In France too we have a very high level of education for our advanced responders who are actual physicians and nurses, and even surgeons now that we have the mobile ECMO unit

The job of the dispatcher is to assess the situation and send the required response. The problem of the seriousness of the calls isn't really an issue for the advanced response so much as it is for the first responders. The problem is that the dispatchers are now more and more afraid of prosecutions if they deny an ambulance. I know the SAMU dispatchers are keen on sending an ambulance only if really needed (otherwise they call a "city doctor" who will attend the patient's home within the hour). The Fire Dept. dispatcher are the opposite. They will deny he response only if there is really nothing relevant (eg: "My heating system stopped this morning").

I give you a blatant example: last week I attended a young woman who got her hand "burnt" by squirt of boiling oil. There was absolutely nothing to be seen. She had put her hand under tap water and called us. When we asked why she called, she said "Because I didn't know what to do..." Obviously she did because she had put her hand under water...

We reminded her of our real missions and then we wondered how the hell the dispatcher could send us on something like that...

So you see, the problem is more related to the EMT's rather than the advanced response. Why? Because to have a straight advanced unit, the situation has to be very clear and serious. Otherwise we get there first and we ask for the doc. And we better be right in our judgement, otherwise the doc will have no qualm about reminding us why he should come, or rather not come.

But of course it sometime happens that the advanced unit is called even if not really needed, because there is such a huge gap between the EMT and the physicians. For instance, a basic-LS ambulance of the fire dept. cannot transport a patient who's got an IV (from a doctor already on scene...) ... They have to call an advanced unit for transportation alone! Why? Because EMT's aren't meant to perform such gesture so they can't manage the patient once he's received the treatment.

We don't have such rules at the Civil Protection, but you see the issue.

In Germany, the EMT-B of volunteer units are trained to operate the Lifepack (ECG...) and the respirator. They can do it only on request (from a physician) and they cannot decide of any setting, BUT they're trusted to have the equipment (and not to use it outside the authorized situation) and operate it. In France, that could never happen. The day you put a respirator in a french BLS ambulance, you'll have a mob of angry nurses and physicians with pikes and torches at your doorstep.

Fab: The medical studies in France are quite special. Many student do what is called a "P0" ("year 0") during their last year of highschool, to get in touch with the subject they'll study the next year. It's a training that comes on top of your "baccalauréat" year. They do not do 1 or 2 year of "classe préparatoire" (preparatory course) like you would to get in an engineer school.

Basically all you need to get into mad school is the Bac, whatever the section (S, L, ES). YET at the end of the year you'll have an exam with a numerus closus that will allow only 10 to 20% of the student to pass on the next year. You can try twice, then you're done with med school.

The working conditions and the competition between the student make it very very hard for someone without strong wit to get through that dreaded first year.

I have tried to register for some med school in the UK but I'm afraid by academic background isn't good enough yet...

Secouriste.

I completely understand your situation. Considering your command of the english language, would it be an option to study medicine somewhere else in the world?

Carl

Perhaps mentioned on a different string, but if a medical need is there, but not requiring an ambulance, I know some jurisdictions (definitely NOT New York City) can and do send a wheelchair coach, here known as an ambulette, to effect transportation. WelshMedic, are you in one of those jurisdictions?

Hi Rich,

No, I don't work in any of those jurisdictions, I am on the other side of the Atlantic in the Netherlands. I can contact specialist cab companies that deal in wheelchair transport so I guess it's sort of the same thing.

Carl

Well, it's far from perfect (for what it's worth I think the Australians have a pretty neat system) but we are regarded as an integral part of the healthcare team and not just 'ambulance drivers' which does make it satisfying..

Carl

I'm impressed with the educational requirements being outlined here in recent posts. This is a bit of a nonsequitur, but do you find that a good percentage of the calls you run are not critical calls and could have been handled by means other than summoning an ambulance?

Well Mike, I think it's an interesting point you make there. The way that healthcare works here is that everyone is insured and so everyone has equal acces to primary, secondary and tertiary care. We have nurses in dispatch that triage calls and give appropriate advice. If an ambulance is deemed not necessary then the caller will be referrred to another pathway (usually the family practitioner but there are other channels, e.g. mental health services). If we do get called to someone that, retrospectively, doesn't need an ambulance I will refer them myself to one of the alternative pathways.

Carl

Hello both,

I am indeed Welsh but I fell in love with a dutch girl and married her. That's how I ended up here. The road to ALS EMS here is indeed only accessible via the nursing route. It's basically nursing school to post graduate critical care qualification and then into EMS. The whole process takes about 6-7 years as we also like candidates to have experience in the critical care field.

I am currently doing a teaching degree (BEd.) in order to teach nursing and EMS at college. I also run the placement program for nursing and medical students so if you are looking to hear more then I'm your man! I can also arrange ride-alongs but you'd have travel a bit far....

Carl

Hi Secouriste and Fab,

@SC: well , I think you'll find that a strong fire lobby is a common factor in a lot of countries, certainly in the US! Good to hear that although there are different services that you have training to the same standard. I wish you all the luck in getting into medical school this year!

@fab: it's in Belgium where the nurse occasionally replaces the doctor. However they are bound by very strict protocols and need to call for advice for all but the most simple calls. Here in Holland EMS is nurse-led. It's been that way for the last 30 years and so we have developed far reaching protocols which include almost all ALS interactions (with the notable exception of RSI). We do have physicians available, there are 4 on duty that cover the entire country by helicopter. They are strategically placed in Amsterdam, Rotterdam, Groningen and Nijmegen. Both Groningen and Nijmegen regularly have calls over the border in Germany. So you see, it's a small world!

Carl

Hey Welshmedic! I hope you enjoyed that very well made documentary

To answer your question I have to point out that the various services you see do not have their own number you can dial for help. What we do is we make our ambulances available for the EMS to send them on calls.

There are 2 ways, either they're in a fire station or they're "free" like in the US. If the ambulance is in a fire station it's easy: when the station is requested by the SAMU to send an ambulance, we go instead of a fire dept ambulance.

If the ambulance is parked somewhere else waiting for a call, we have people at the dispatching center who will talk with dispatchers and transfer the calls directly to our ambulances instead of the fire dept. or others.

In one fire station there is only one volunteer unit at the time so it's pretty easy.

What you see in the video is a bit different, we're covering an event so the public EMS don't have to come into play. They have HQ there and they're overwatching the situation but they don't handle it directly, we do.

I hope it's clear enough

ERDoc: Thank you! I'm from Paris itself

So, if you like, the calls come into the central 112 salle de regulation (I think that's what I heard on the video, right?) and then they send the nearest unit as it doesn't matter which organisation it is. Is that right?

Carl

See my PM.

Secouriste,

I watched the film and I noticed that the SAMU dealt with at least three different EMS organisations: you guys, the fire department and the Red Cross. Are all of these organisations involved in 112 calls in Paris and if so, who decides which organisation goes to which call?

I love Paris, by the way, have been there a few times in the past few years (I'm only about 4 hours away in Holland). It must be pretty busy there for EMS, I would have thought.

I know it's already been said, but I also think your english is absolutely amazing! My compliments!

Carl

Does being a member of the Rescue 911 fanclub count? I just luurve Mr. Shatner....

(Hi all, again! Good to be back here!)

House Officer=Intern, Senior House Officer=Resident, Registrar=Chief Resident, Consultant=Attending Physician.

Lovely place to visit but wouldn't want to live there myself. I mean, how many bungy jumps can you do before it gets boring?

Your jaw is on the floor? Not sure you want you mouth open so wide in this crowd...just sayin'.. :-)

Dwayne

Oh man, that is just inspired!!! You have made my day.

What do you have against Vanilla Ice? He gave us white boys from suburbia hope that we could be cool.

And here's me thinking this guy was your hero:

Now he was seriously cool.........

In my former service I could choose between Fentanyl, Morphine, Pethidine and (Normal)Ketamine....

I found the discussion about not giving pain meds for "diagnostic purpose" quite interesting as we have a completly other doctrine here...

ER Personal will get pretty mad if the patient is in pain and we don't have a really good excuse.

On the practical side I'm clearly in favor of ketamine in a multi-systems trauma....It provides quite a good pain reduction and brings (when combined with a benzo, i.e. Midazolam) to a very "calm and stable" state soon.

BP-Management is as well as never an issue as the BP will normally only go up in a 10-15mmHG range which only very rarely is a problem...

Emergence-Phenomen occour sometimes, most of the times in Patients with an preexisting mental or neurological deficit but can be controlled with Midazolam just fine. (By the way: Emergence can also occour with patients who seem asleep.... YOU can't see it..but the patient will remember it when you don't use a benzo...)

Back in Germany we used Esketamine a lot, the Racemic of Ketamine which does not bring that much side effect, i.e. almost no emergence and not that much hypertension....Quite good stuff...

But to bring up a new topic in the discussion: Experience about the combined use of Fentanyl and Ketamine anyone?

So long,

K

Krumel,

Whilst it isn't seen as a standard cocktail, I have used esketamine and fentanyl together in the past. The fentanyl hits the nocireceptors and deepens the dissiassocative effect of the esketamine by virtue of being an absolute (as opposed to relative) anesthetic drug.

I would personally only reserve it for polytrauma patients that have multi-system injuries and whereby I need to watch the haemodynamic status very closely. Having said that, for these patients, it is very effective indeed.

My initial bolus dose would be: midazolam 0.05mg/kg, esketamine 0.5mg/kg and fentanyl 0.15 mg/kg. I would titrate from there. The pain score would lead me further.

Carl.

It is allowed, and the entire section of the forum has notation that some of the humor might be...not family magazine printable.

Right on! Let's get this debauched party started then!!!!!!!!

Love it! Oh and your daughter wasn't bad either.......

Inspired my man? Did you pose for this particular piece of art? And did she make you come?

Is this actually allowed here???? :whistle: :whistle:

Intubation was not exactly prolific during the Crimean war.

Here's a personal (and entirely unrelated) Nightingale anecdote. I did my nursing course back in the 80's in the UK. On one of the internal medicine floors we had a fierce Sister (Charge Nurse/Head Nurse) that insisted that the open end of the pillowcase always faced away from the door. This was still in the time when RN's actually did mundane things like make beds and feed patients. WTF? I hear you say (nursing is great for rituals, I reply). I was a precocious student that was never content to just do as I was told so I decided to question the rationale.

After a little research I found out that NIghtingale has advocated the same during the Crimean War as sand would blow into the hospital tents and get in between the sheets and pillowcases making them uncomfortable for the wounded soldiers.

Yet more than a hundred years later there were still colleagues following her doctrine!! She must have made one heck of a mark on our profession.

Oh and I suddenly feel old by telling this story...

Carl.

Just to add to what usalsfyre's and mobey have posted, this website is quite helpful in explaining the pathophysiology and management of TBI:

http://www.trauma.or...euro/index.html

On the same website and a great fun:

http://www.trauma.org/archive/resus/moulagetwo/moulagetwo.html

See how you get on..

Carl.

I think Welshmedic would beg to differ.

Good man! But well, what do you expect from a Kiwi?

(note to Kiwi: it's the Dutch flag you dingbat! )

And Scott, thanks for the compliment! I'm very flattered, on behalf of all my colleagues, even if I'm not sure it's true. There are some pretty smart people around here too.

WM

Hi Toni,

TNCC is the Trauma Nursing Core Course. This is the nursing equivalent of the PHTLS and ATLS. The question arose because a young colleague from the ER has just completed the course and there they were very anti permissive hypotension. Everybody got 2 large bore IV's and lots of fluid.

Carl.

Hi all,

Not sure if I'm in the right place here, but here goes:

Does anybody know if the current TNCC doctrine still includes 2 large bore needles and lots of IV fluids or are have they moved onto permissive hypotension? I ask it because it's a current discussion on a Dutch EMS forum, apparently they still advocate lots of fluids there. I said I would ask here, talk about international co-operation!

Thanks in advance for the help!

WM

Welsh, don't be surprised if I come and take you up on the offer...

Oh, you are more than welcome! You wouldn't be the first, either..