WelshMedic

Hi all,

I realise that I'm a little late on weighing into this discussion but I wanted to tell you about my experiences with ketamine. My opening line: it is simply the best thing that has happened to pre-hospital care in 10 years.

Ketamine has been around since the 60's. It is a disassociative anaesthetic which means that it shuts the brain off to conscious experiences. You take a pt. literally writhing in pain from, let's say, a long-bone fracture and medicate them. The first thing they then remember is waking up at the ER. It's only real disadvantage is the re-emergence phenonmenon, which plays a part when the pt. is waking. It can be best described as intense nightmares and some people can wake up literally screaming. It's not all bad news though. Re-emergence can be effictively managed by co-commitant doses of benzodiazepines. My personal choice is midazolam, I find that it very effective in combatting re-emergence. To the extent, in fact, that I have not seen the phenomenon for at least 4 or 5 years.

It's obvious advantage is that it has no negative effect on hemodynamics. Whilst it can lead to a positive intotropic effect, it is very transient. I have never encountered a problem in the 10 years I have been using it.

Ketamine is safe, very effective and versatile. I would recommend that your service consider it as an option, your patients derserve it.

WM

Join in the chat and maybe Brett and I can help

Brett, you want to pop in as well?

I'm in. Hubby says he'll pay airfare anywhere I need to go.

Wish my better half would do the same... Might be difficult for me, but keep us posted and who knows... If there's one thing I have learned in the last few days, it's that life really is too short.

Carl.

I am glad that I stumbled upon this thread. A lot of the stuff that has already been said, I felt too. The sick feeling in my stomach upon reading the banner, the regret that I have about not flying down to Texas in september. But it is what it is. No-one can change that.

The best way we can remember Rob is to make the city the best educational resource on the net for EMS. There are enough of us here to do that.

Now let's go and kick a few whacker's and newbies asses. That's a proper tribute to Rob!

Take care all,

Carl.

Its been a long time since I have posted to EMT City and must admit being provoked to once again join the action by Dr. Bledsoe's message announcing the passing of dustdevil. While I didn't know Rob personally, I did "meet" him through EMT City. Rob and I didn't necessarily see eye-to-eye at first, and continued to see things through our individual lenses. I did learn to respect and admire Rob.

We had several spirited discussions within the forums and outside their confines. Rob wielded his intellect as if he were King Arthur wielding Excalibur! Those of us who found ourselves in the way of it's sharpest edge learned not to play with fire or insult Rob with pettiness, but to bring our A game to his arenas of discussion.

I can tell you I am a better person for having met him through this utility and I am so very sad to learn of his suffering and his death. It is my most sincere prayer that he find peace, comfort and rest. I only wish I could have know him better and to have had the opportunity to learn more from him!

RIP My Friend

Randy Fugate, AKA Captainstandup

Randy,

An extremely eloquent post and a fitting tribute to our friend. Thank you for that!

Carl aka WM

Stand easy and stand down, DustDevil, we'll continue from here what you started.

Damn, that one made me cry....

Let's say you honestly forgot to put something on your PCR because you were being leaned on by your dispatcher because there were multiple calls hanging. A lawyer will turn it around and say you didn't write it because you screwed up and were trying to cover the fact.

It's a sad world...

That research was done on normal people. With ER docs, you have a 5-10 sec window before our ADD kicks in and we start thinking about the next pt, pizza or the hot nurse standing next to you. If you need our attention for more than that you need to use a key word such as intubation, arrest, elevation, hypotensive or pepperoni pie with extra cheese.

I find that "fancy a beer to go with the pizza" does it for me...

We have a meeting every 3 months with our colleagues in the ER. It tends to smooth out any wrinkles. As far as scope of practice is concerned, most of the pre-hospital nurses here (we don't have paramedics) have, at one time or another, all worked in the ER themselves. We therefore, mostly, speak the same language.

WM

Hi magic. I live and work in Auckland but at North Shore hospital. DO you know our area?

Thank you all again for your posts and all are great for this project. I will follow up any patient fir any EMS crew as it's part of the learning circle

Scotty

Scott,

I've heard that NZ is a lovely place. You get funding for the post, and I'll beat you to it! :icecream:

Just kiddin'

Carl

(how's life, haven't been around here for a while...)

Well, for starters, it looks like you've already made a decision not to renew. I think that's also the best of action in your case. Your career progression into nursing will neither be helped or hindered by a recertification process. Bearing that in mind, I would leave it as it is and concentrate on being the best nursing student you can.

If you then later decide to do something in EMS, you can always pick it back up. You'd likely get a lot of concessions for your nursing qualification. IN Pennsylvania you can even challenge the NREMT exam and become a PHRN (Registered Pre-Hospital Nurse).

Go forward and don't fret about the past (or things you can do nothing about), It's a waste of energy.

Positive enough for you?

WM

Hi all,

It would appear that the threat of litigation is the reason why everyone should be writing a novella on every patient, however mundane. Whilst I can see why that would be necessary, it seems a shame that your putting all the effort in for the lawyers and not the colleagues. Believe me, in a busy ER, no-one is going to take a second look.

Now, as far as verbal reports are concerned, that's a different matter. They need to be short and sweet. Past research has indicated that the recipient will listen for about 30-40 seconds before their attention starts to wander. Thus, you have a 30-second window of opportunity to get your message across. Mmm.. when I come to think of it, the best of us could switch jobs and make millions in advertising

We use e-PCR's which are a godsend, you don't really need to think much at all, everything is prompted. My verbal reports follow this structure:

Mechanism of Injury: what happened?

Injuries found or suspected: the findings of your physical exam. (In medical patients I would also refer to the appropriate history).

Signs: the vital signs ( and whether or not they are pathophysiological in this pt.).

Treatment: What did I do and what effect did it have?

The above is all that is required for the radio report, when doing the handover at the ER then I will supplement with SAMPLE and information over the next of kin.

WM

I am sitting here, numb. It's been a while since I have been here but I was in contact with Rob. I knew about his illness, we have been mailing each other outside of the forum since 2008. I just wish I could have seen this coming. I was in the States 3 weeks ago, I am so so sorry I didn't get an internal flight and go and see him on my trip.

Rob, you inspired many here, including me. The birds have stopped singing here and it's getting dark. Now I know why..

Sleep well brother..... we will miss you!

Carl.

I am a little more seasoned than you guys and have more than 12 years EMS experience at ALS level. Here's some good news: it does get better!

You learn from each and every call you do, even the seemingly insignificant ones. That experince then translates itself into a calm. professional attitude.

A few points to remember:

If you feel things aren't going the way you'd like. Stop, take a deep breath and reappraise the situation. This may cost a little time but your pt will benefit from it.

You are going to someone who having the worst day of their life. You can't afford to panic, because that will make them panic and the buck stops with you.

If you don't know something, don't be afraid to ask someone who does. Following that, never be afraid to call for back-up if you feel uncomfortable in a situation. I'll let you into a secret: the people who do that in our profession aren't the wusses but the consumate professionals.

Whenever entering an incident, take the time to register your first instinct, have a plan ready and don't be afraid to fall back on your ABC's if you're not sure what's going on. Try not to get distracted by external factors such as distressed family members.

And perhaps the most important: when in between calls, don't watch Home Makeover or play on the Nintendo, but learn your protocols. A sound knowledge base removes a great deal of stress.

Take Care,

WM

Yep, it's synergetic with opiates which then leads to less of the opiate being required. Particularly good in the elderly without a history of hepatic disease.

WM

Hello all again,

I've been a stranger around here for a while again. I was shocked to see the the city is facing a law suit. We have to stand up to these bully boy tactics to protect not only the city but all such fora.

I have justed donated the $150 and it was money well spent.

Carl Ashman aka Welsh Medic

Biz,

There are no statutory agreements within the European Union when it comes reciprocation of qualifications amongst EU member states. Nor is there any reciprocation of US qualifications.

Greece is not going to be easy as it's currently in a very deep financial crisis (in fact it has just been shored up with a $110 billion loan from the other member states of the EU to stop it from efectively going bankrupt.

The little I know of Greek EMS is that BLS is largely voluntary and ALS is hospital-based.

This might help: Here

Good Luck!

WM

Well that's easy enough. It takes a month or less of ambulance-specific training to make a nurse a competent pre-hospital practitioner. Learning to use ambulance-specific devices, like portable respirators, portable suction, stretchers, extrication boards and collars, etc... as well as the situational awareness to recognise your surroundings and how they contribute to the patient's condition and your care. Beyond that, ALS training is ALS training, and is really no different pre-hospital than in-hospital. Nurses already have the foundation to build upon, unlike any other lay person you could drag into the job to use instead.

By not being able to afford it, I assume you are talking about the costs of the educational system, and not administration of the actual EMS system itself? Obviously, setting up an education system from the ground up is no small task. Do you have medical and nursing schools there, or do your physicians and nurses come from the mainland or other countries?

Dust,

I think Harold is talking about nursing graduates without critical care qualifications, making the transition into ALS somewhat more difficult. (Correct me if i'm wrong, Harold..)

WM

There was mention that Nursing and Paramedics are very different in regards to clinical environment, approach and support mechanisms – this is very true. How do we overcome this? More than likely with clinical supervision and guidance from an experienced practitioner in that particular speciality but at the end it all comes down to time and experience.

Hi Timmy (and everyone else of course),

You make a good point here.

I am one of the EMS clinical supervisors you mention above. I have been mentoring new colleagues for the past 10 years. Apart from the obvious aspects that need to been taught like scene management and safety, what also strikes me is that, although most of these people are already reasonably experienced CCRN's, they still need to be helped in certain areas. Not about which drug to give or how much but whether or not it's clinically safe to leave a pt. at home with an alternative care pathway. If that is the case with this level of student, what will it be like with young paramedic students without the necessary experience.

I agree that a degree trained medic is more than up to the job of treating and transporting. I do, however, have my doubts about accepting the level of autonomy and responsilbilty with Dutch EMS in it's present form.

WM

I sort of agree with what Melclin is saying; however the main reason nurses are used is I believe because civillian Paramedics do not exist in the nations where they are used. Israel for example uses MICN/doctor/ and a civillian paramedic on thier MICUs whereas (and WM can correct me) but in the Dutch system they do not have civillian Paramedics.

My opinion is that if we take the best of nursing education and the best of Paramedic education and combine the two then you're on the right track to not requiring a nurse on the ambulance.

I do, indeed, agree. The paramedic role that has developed in anglo-saxon countries (for want of a better term) never really took off in mainland europe. I think the OP was looking for arguments in favor of changing the system, although I can't be sure due to the lack of reply.

One thing we must recognize is that it's not about titles but education and experience. With these comes extended scope of practice and more autonomy. I am sure that a degree trained paramedic is more than capable of doing the job in EMS very competently. However, when you get into community-based paramedicine like we do, it may fall somewhat short.

Bearing in mind here that we are talking about the Dutch system, which is unique and doesn't necessarily translate well in other settings. There are just 1600 ambulance CCRN's in the whole of the country.

WM

WM

Your post was a hunch, so I do not have anything definitive to go on at this point. If your hunch is indeed correct, it would seem the current system may serve as somewhat of a model; however, the OP has yet to make additional comments.

Take care,

chbare.

My hunch would be beter called an "educated guess". The OP should reply though, you are right there.

WM

I think we are getting a little ahead of ourselves. What country are we talking about? What system, what services are provided by this system, what is the education of "EMT's" and nurses in this country, how does the current system work, and what is the rationale for new changes? Its inane IMHO to discuss a concept without knowing any of the details.

Take care,

chbare.

Did you read my post?

We are talking about the Netherlands, where EMS is nurse led (Bachelor's degree with critical care post-grad). EMT's are trained to US EMT-D level, don't independently treat. EMS at ALS level provided. The current system works very well and is often quoted internationally as good practice: Look here

Rationale for change: current system expensive, shortage of CCRN's. Making the profession accessible to larger portions of the population (which, to me, says dumbing down; but heck, I'm biased).

I think you'll find that all of the above has been mentioned, but the above is a short recap.

WM

Biggest plus to staffing with under educated emt's is they work cheap.

Too true, mate! You pay peanuts, you get monkeys...

Hi all,

Although I can't be absolutely sure, I have a hunch that the OP is here in Holland. There is a discussion going on here whether CCRN's on all ambulances aren't a very expensive option (and in short supply). One of the iniatives is a feasibility study into a 4 year Bachelor's degree that has a 2 yr common core followed by either 2 years in either ER or EMS. The problem is that the practitioner that rolls out of this programme would, not yet, have a recognized title. They are neither nurses or medics.

Whilst we recognize that change isn't necessarily a bad thing, our concern is that the programme will not prepare the student for the broad role that they will fulfill in EMS here. We are far more community based than the US. We treat and refer patients ourselves rather than necessarily transporting everyone.

Anyway, there's a bit more background info for you...

WM

OMFG WHO CARES!!!!!!!!!

*pulls hair hair out in clumps

Have you taken your medication yet today?

WM

Paramedics Investigated After Boy Handed Emergency Radio

I can see where this would cause some un-needed confusion with dispatch and other people listening. Would you do the same thing? Would the 11 year old even be in the front with you?

When I go and do a talk at one of the local schools I will usually get one of the class to do a test report to dispatch (of course, I've pre-arranged it with dispatch). Does that make me a potential subject for inveestigation?

This is such a non-story. What they did here was try to calm a frightened young man down by involving him in the process. I see no harm whatsoever.

As far as riding up front is concerned, it's not ideal but maybe there was no-one to look after him. Depending on his grandmother's condition then I would have preferred to have him back with me and his grandmother. Simply because I could explain things and reassure both of them.

WM

I can relate to this topic. We used to have tagged everything, jumpbags, airway kits, the whole lot. I hated it because I was never really sure what I was going to find upon opening them. Usually I did it at the start of a shift but on one occasion we were paged out BEFORE the shift had actually started. We went to a chest pain patient who didn't get enough pain relief from nitro so I decided to give him fentanyl. Well, that was the plan until I discovered it missing. Luckily this was at the doctor's office so I could borrow some from him (great advertisement for my service, NOT).

Back in the mess room later that morning I was bemoaning the situation to an EMT-colleague. He laughed bitterly and said: "Oh, that's nothing! I opened the airway kit last week at an arrest and there was no BVM!"

Suffice to say that tagging didn't last much longer after that.....

WM