WelshMedic

Start a debate on bringing back public masturbation.....?

(Oh, I'm for it, by the way)

WM

As Dwayne said, this is a very interesting topic.

I recall reading an article posted on this forum just recently, written by Bryan Bledsoe in which he discussed doing away with on-line medical control.

Our brothers with the funny accents (or do we have the funny accents?), make a very astute and valid arguement, that any well trained provider should be abe to practice their profession without permission or distraction from Medical Command.

The main difference here is education. Some of us, have been blessed with making the right decisions on which school to go to, to finish our degrees, and to work for progressive, professional orginizations. Not all of us have this, and that is where we find ourselves.

I will agree with Fiz that online med control should be available, but can honestly say that the only reason I call for command is because I have to by our policy, and not because I cannot manage my patients. I would presume, that this is the same case in a majority of the people on this Forum.

I think there is a large disparity from those of us on opposite sides of the globe, simply based on the way our educational and liceansing systems works. The fact that these systems are not only different in regards to requirements, and level. They can be further complicated by by region, state and even service. Because there is not one set standard, although a shame....we are all not craeated equally.

The bottom line here is that it is the personal responsibility of the provider to continue to learn, be compitent, and be proficient. It is the managements and Medical Directors job to set boundries, but most importantly to trust their proviers to do their jobs. If this is not the case, why are we employeeing these people?

Cheers everyone.

Hi AM,

You have made a valuable contribution to a great thread. First things first (to start off on a light note): You, my friend, have a funny accent with a twang in it. I, however, speak the Queen's english which is the only true form, my old chap!

Education, Education and Education...we can't emphasize it enough, can we? Dust commented to me (in reply to a comment about the lack of confidence in EMS):

I think that's a great observation. It is indeed a very common factor in US EMS. The original medics in the US were founded on the concept of being the so-called "eyes and hands of the physician". That mindset has persisted all these years, just below the surface. Way too many medics have never been forced to step outside of their flowchart protocols and use their heads to think for themselves. They are still living the "eyes and hands" life from the 1970s. And honestly, that's probably a good thing in most of the country.

Whilst this is undoubtedly true, I think there are other factors which perpetuate the situation in today's EMS.

1) Volunteerism: when someone is already doing 2 paid jobs and volunteering in EMS, how do they find time for professional development? They don't.

2) When a Fire Monkey is using EMS as a stepping stone then he/she also isn't going to hit the books much.

3) Educational standards need to be reviewed and reset. ALS should be the domain of someone with at least a Bachelor's Degree. It doesn't matter which country you are in, or which system. That level of critical thinking needs education.

As far as your comment on personal responsiblity for keeping up-to-date: Amen, brother!

Take Care,

WM

My guess would be with a large jolt/shock of some sort.

http://en.wikipedia.org/wiki/Pentaerythritol_tetranitrate

You'd get a bigger BANG out of the Bangkok shuffle wouldn't you?

(is that too rude for here?)

May I remind you all that it's 1 april in a few days...

WM

<HUMOUR>

Yeah Rob (Dust) is a broken down wreck, but, knowing him, it's just a ploy to get some 20 something blond live in nurse move in with him

</HUMOUR>

Seriously, he is a good bloke

Yes, he is! The live in nurse would have to be a real tough cookie to put up with him though

I can't find that reference. Can you be more specific?

Dwayne

Correct me if I'm wrong but I thought you mentioned either AK or Dust being ill and not able to post much these days?

Send me a PM if you think it's more appropriate.

Carl.

PS - And yes, I read Aaron's blog AND show it to all my students..

Hey Dwayne,

Don't apologize, I didn't take it personally because I knew I hadn't done anything wrong. As far as your mentors here are concerned, I couldn't agree more. I sometimes think that if I had half the knowlegde of those two individuals here then I'd be a bloody fantastic practitioner.

I hadn't really thought about it before, but I guess you are right when it comes to Aaron (FizNat). He is willing to admit his mistakes and that makes him, per definition, a good provider. We've never met, but I think I could trust him with one of my own.

I am left a little baffled about your comment on ilness...who did you mean?

Carl aka WM

Dwayne,

You have made some good points in your very eloquent post. So much so that you get gushing compliments from the Dust himself...so your day can't be ruined anymore.....However:

But I have to say to the non Americans that when you make the argument that, "You need med control because you're systems sucks so bad you'll likely screw the pooch without it. Someday you'll be as smart as we are and actually know how to treat patients at which point you won't need such silly things any more." that you come off as arrogant and unbelievable. I believe your training is likely Superior to most of ours, but I don't for a second believe that it's superior to your doctors. And your doctors, believe it or not, ask for advice all the time.

That is very definitely NOT what I said. I said, in fact, the opposite:\

I can't help but wonder (genuinely wonder - this is NOT intended to be an inflammatory comment) whether our US colleagues have so gotten used to being told that they are at the bottom of the chain that they have started believing it themselves?

I know from experience that there are some damn good people out there that don't need handholding. That was my point: there is nothing wrong at all with a friendly consultation in your patient's best interest. Heck, I've done it before now because I wasn't sure of the right path to take. However when it becomes mandatory before carrying out an ALS intervention, then it becomes a whole new ball-game. That's where I draw the line.

In reference to Jake's question about SOP's: yes Jake, we have a national protocols which are set every 3 years by a committee of EMS and hospital professionals. This book is then published in pocket-sized format which we are required to carry. It's an important framework, but we can and do make exceptions if in the interests of a particular patient.

WM

Med control will make you lazy. Why remember stuff when someone is on the other end of the line to make the decision for you?

Phil makes a good point here, actually. Not sure whether I would have been quite so blunt...but nevertheless....

MedCom is a way of avoiding responsibility. I'm not even really sure why, either. The people who hang around here seem to be pretty knowledgeable and committed. I'm sure most of you are more than up to the job of critical thinking in an acute situation. You don't need anyone to hald your hand for you.

I can't help but wonder (genuinely wonder - this is NOT intended to be an inflammatory comment) whether our US colleagues have so gotten used to being told that they are at the bottom of the chain that they have started believing it themselves?

I agree with Phil and Kiwi - MedCom is a cop out.

WM

I now have to admit that I did not look into the specifics of the bill before posting my comment. I realise that this is going to cost people money, in some cases a lot of money. But surely those who are very poor will get some assistance?

I still stand by my comment that healthcare is a right. It's funny, but it would only be an American that would think otherwise.

It's always amazed me the number Europeans willing to work more for the goverment's benefit than their own. I guess it comes from centuries of being subjects instead of citizens?

The above by the way....mmm....I think you'll find we had democracies long before the US was even formed. As an insult: FAIL!

Well, since the vox populi here so far seems to pretty negative about the pending Healthcare reforms then let me re-adress the balance:

I think that it's a travesty that one of the world's richest and powerful countries has waited so long to adopt decent healthcare for all, regardless od socio-economic status.

Shame on you all for opposing this bill. And yes, I'm an outsider. An outsider that pays 52% income-tax to benefit from one of the world's most developed social security systems. No, we are not going to hell in a handcart from all the those free-loading parasites costing us a fortune. I live in a prosperous, caring country.

No-one in the developed world such need to worry about a basic right such as decent healthcare.

You want a strong opinion, you got it!

WM

I was searching some drugs reactions and OD type things. I found this website that seems to be quite informative http://www.thegooddrugsguide.com/drug-guides/index.htm

I got the histamine part. Thanks!! This is good to know since I have seen histamine effects of morphine. Not horrible but itching and mild hives. A dose of say benadryl is appropriate for this type of reaction, I would say.

What I am reading is an allergic reaction to Morphine is more likely than an allergic reaction to Fentanyl. Am I under the correct assumption?

I think you'll find that a reaction to either of the drugs is fairly rare, I have never seen it in 20 years of ALS, both in and out of the hospital setting. Having said that, if you follow CH's logic then I think you made a pretty fair assumption. Fentanyl also has the distinct advantage that it's serum plasma concentration time is shorter than that of Morphine. In layman's terms that means that it is faster-acting but has a shorter half-life. This can also been seen as an advantage too, of course. Particularly in EMS. I gave a presentation last year to EMT-P students at the Montgomery County Public Service Academy in Conshohocken, PA. Although the first half is not relevant to this discussion, the slides of the second half are about pain-management strategies in EMS. Here's the link to that presentation. I hope it helps.

WM

Hello all,

This is an intersesting subject which shows the differences between different countries. Most of the salient points have been made but there is one aspect that springs out to me:

Although MedCom is generally bemoaned within the profession, it appears that our US colleagues are not quite ready to go it alone. I have been in EMS for more than 15 yrs and have contacted an MD just once in that time. Other than this one incident which involved a very complicated post transplant patient, I cannot think of a single moment when I felt the need to speak to a doctor. Not that I think I'm God but because my education and experience guides me in my patient care.

MedCom is, to my mind, delegating responsibility. You know what to do and how to do it, but insist on holding someone's hand to do so. Take STEMI, for example. 12 lead interpretation is a cornerstone of EMS. I have no problems at all with getting the cath-lab up at 3am because of an acute MI. ALthough I realise there are some potential pit-falls such as pericarditis, I am pretty sure that I have never given out a false alert. Even if it were the case: better safe than sorry!

The profession does need more education (is there such a thing as too much education?) but I also think that the profession needs to recognize the leaps forward that we have made in the last 20 years. And to stand up and be counted!

WM

Psychology is also a good class to follow. Preferably psychology of the ill person, but that's not available everywhere.

Good Luck!

WM

How about I don't care about your silly non-american systems.

Well, that says a lot about you and your contribution to this discussion.

The only way is the American Way......

Arrogance AND stupidity, you'll go far.....

WM

Note the bilateral needle thoracentesis at 3:30 in the first clip. Standard of care, even for the ground crews for chest trauma

It's also a fantastic example of a flail chest. I'm using that one in my next lecture.... (now, how did it go again with copyright? )

Scott, it's a real blast from the past, isn't it? The old bedford vans and Sierra Rapid Response (and the Met's Vauxhall Astra's). And that cell phone the mighty Dr. Davies is using, the size of a housebrick. Ah, those were the days...

WM

PS: Yes, I'm old and grey.

I think that piece is great. After being (sometimes) treated badly as a nursing student I decided I would go into preceptorship after qualifying. Making the bad good again, you know the score.

I use the points in that letter almost daily.

WM

A holistic approach is addressing a patient's needs, medically, mentally, and socially. I wasn't saying that you doubt that I am a caring professional. Yes, there are those in EMS that ignore the needs of a patient beyond the medical. But you can't tell me that there aren't those in nursing who do the same. Just because you are educated in something or taught to do something doesn't mean you do it. However, in the pre-hospital setting, you are limited as to what needs you can meet because you're only with the patient for a short amount of time. I know medics who have let dogs out, locked doors, changed a baby's diaper, etc. Yes, holding someone's hand is hardly the definition of a holistic approach, but it's more than some paramedics and nurses do.

That we can certainly agree upon!

Better educated? That's what critical care medic would be for.

Better at a holistic approach to medicine? I'll have you know that yesterday I transported a terminal cancer patient to comfort care who was sedated and, just like his daughter asked, I held his hand the whole way just so he would know somebody was there. I never lie to my patients or their families and I keep their promises. I do everything in my power to make them comfortable. Why? Because it's my job.

Better at communicating with patients? I've gone on two and a half hour transports and talked with the patient the whole way, laughing, telling stories, etc.

What would a paramedic know about cytostatic regimes? Plenty if they were taught about them.

As far as paramedics working in the hospital setting as "ER techs", you mean "go for"s and CNA replacements? Because that's all they seem to amount to over here in the states aside from the rare hospital that might let them get a little close to their scope of practice... let them put a little IV in to keep them happy and keep them from thinking they're a slave for grunt work.

My simple argument is that there is no need for pre-hospital registered nurses, or at least there wouldn't be if some places bothered to educate their paramedics.

I don't doubt for one second that you are a caring professional. That wasn't my point. I was making a comparison of the both professions as a whole. Besides, holding someone's hand all the way is not the definition of a holistic approach. That's called common decency and compassion. Oh, and I should hope you don't lie to your patients!

WM

A nurse might take the attitude that a paramedic doesn't have a god-given right to pre-hospital care, but one could flip it around and say that a nurse doesn't have a god-given right to hospital care. One could also say that paramedics may not have a god-given right to pre-hospital care, but neither do nurses, especially since there are interventions that paramedics can perform but nurses can't (unless they're a PHRN). It's convenient that nurses have been given a way to function in a paramedic role, but there is no such bridge for paramedics without becoming nurses.

As far as a reasoned argument goes, what's yours? What is the rationale for a PHRN in the United States other than putting paramedics out of work?

First of all, my reasoned argument would be that nurses are better educated, better trained to look at the whole patient (holistic approach)and better, generally, in communicating with patients (we do that class from day 1).

As far as the flip side argument goes, I agree that paramedics could work in the hospital setting. In fact they do, as ER techs, as I'm sure you know. But what would a paramedic know about cytostatic regimes on an oncology floor? Not that I can remember much either but then I didn't choose oncology. I chose pre-hospital nursing. After trying ER nursing. The clue here is that a nurse is more broadly educated, opening more doors. A paramedic is trained in pre-hospital care, and does it fantastically. But that's where the door shuts too in almost all cases.

WM

So this particular pt had vitals all within normal ranges. I did mean 12 lead by the way. Got several of them on the way (while stopped). there was no other abnormal findings on that.

Her history was somewhat troubling. she had an aortic anyerism (spelling?) that was being monitored, 3 MI's and a long list of other things. after debating wether or not to treat, I decided to be more conservative due to there being no other changes in her status (monitor changed...pt did not change). The thing that kept ringing in my head was the list of things that make PVC's dangerous....the list i learned in school 5 years ago. Multifocal PVC's, more than 6 a minute, R on T, runs of V-Tach...she was sure having more than 6 a minute. Oh and FYI, she was being treated for CP and SOB with O2, IV, ASA, Nitro and of course the EKG. other comments....................I have had several pt's like this and Im still trying to form a general idea of wether to be more aggressive or not.

My general advice to you would be to treat the patient and not the monitor. Imagine, if you will, that you were part of a BLS crew treating a SOB pt. Would you have treated the pvc's then. NO, of course not, because they were asymptomatic and so you would have had no notion of their presence.

That list of yours will stand you in good stead, I was going to post on VT salvo's but you already have the heads up there.

Relax, enjoy the ride and be good to your patient. Give them what they need, not what your cookbook says....

WM.

PS the word is aneurysm.

Thank you..I think.

I'm specifically referring to EMS in the United States. In the United States, PHRN serves as nothing more than a way for nurses to obtain paramedic skills, come into the field with authorization to use more drugs than a paramedic, and take paramedic jobs. Instead, I say give that qualification and education to a paramedic and make them a real critical care paramedic with an actual expanded scope of practice. I'm a firm believer that paramedics belong pre-hospital and nurses belong in the hospital... two different worlds, two different mindsets.

Of course you would defend your profession, you are a medic student and therefore competing with a PHRN. However, a blanket statement like nurses belong in a hospital doesn't help your case. Have an argument but make sure it's a reasoned one.

Maybe that's why nurses are paid and respected more

No, strike that; it's unkind. I'm sorry. However, the point I am trying to make is that a paramedic does not have the god given right to pre-hospital care. There are other models that work just as well.

WM

Wow, my mind is full of thing to write. I wish I had time to write it all. I will later hopefully. I have not leared much of EMS outside of the US. Is it really that different? Gotta say im impressed. I wanna hear more.

Mark,

Here is a copy of the presentation I gave in 2008 to the paramedic students at the Montgomery County Public Safety Education Campus in Conshohocken, PA.

Here

Don't hesitate to mail me if you want to know more....

WM

PS: the cautionary tale mentioned at the end is

3. Do away with PHRNs and instead create a REAL critical care paramedic level (a bachelor's)

Whilst I have no objection to the creation of a Batchelor's qualification for EMS personnel, I do wonder why it's necessary to abolish the PHRN. PHRN's do have a role in EMS, albeit a different one in the US.

Here in the Netherlands we are all RN's in EMS. We are not in some kind of Utopia because we have our issues too (pay and retirement benefits being just an example). However because we hail from a far older profession we are accepted as fully paid up members of the healthcare team. Autonomy to practice is essential to the development of any profession. How do you acheive that? By education.

One of the nice things about my job is the fact that we aren't just looking to transport but arranging the most appropriate care pathway for our patient. Taking the elderly and/or vulnerable into a hospital ER teeming with all sorts of bacteria isn't always the right thing to do. However, in order to acheive this, I need to have a good system of primary care that can be relied upon to look after my patient after I've left. In order to do that those patients need to be insured for healthcare. Which is why it disappoints me to see that the US healthcare reforms are looking likely to strand.

Sorry for making this a little political, but my point is that in order to modernize EMS (at least in the US) factors outside of EMS' sphere of influence also need to be adressed.

WM

Well, it does have some flaws. But it's better than "Diagnose me", "I'm gonna hurt myself", "I'm sitting in the ICU next to myself", "I died", "I could never be an EMT, et al, but have a fetish for it and only play WOW while living with my 90 y/o grandma".. Chat.

That's not familiar at all.............

It's a time thing I guess. 10pm EST is for me 4am GMT+1 (Holland).

Oh, I feel so lonely.. I need a hug.

Welsh

Hello all,

I'm no stranger but Í didn't know where to put this otherwise...

Every time I log in (which is not often, lately, admittedly) there's no-one to chat with. Is the whole paid chat project an abject failure or is there some other explanation?

Good to be back,

WM