WelshMedic

Wow, LOT of ASSumptions in this statement

I couldn't agree more on that statement. Admittedly this was not a clever thing to do, but everyone here should first take the time to research the politics of meal breaks in the UK before shouting their mouths off.

Some people here are just determined to qualify my preconception of Yanks and their big mouths. Luckily, they are in the minority.

WM

i saw this on Good Morning America this morning (yeah, i was up in the middle of the night)

I mean why was this thing in the air anyway?? Earlier in the story, the MCA the patient was involved in happened because of heavy rain and low visibility, and its the middle of the night. I dont understand why a helicopter was saent to this job, based on the story anyway. And can someone tell me, what exactly is a "Shock Trauma Center" ???, or is it just another fancy name?

Cheers

GMA Story

I'll hava a go, Bushy m8:

1) Helicopter services are run as private enterprises, no flights, no money. It even gets to the point where people helicopter shop until they find a crew willing to fly, whatever the weather.

2) Baltimore Shock Trauma is a leading trauma unit in the US, (some would say the world) set up by the famous R Cowley Adams. He was also responsible for the Golden Hour. Colleagues of mine from the Netherlands visited last year during JEMS and were stuck in a corner and basically ignored by everyone. So in my book it is not that great!

Hope this helps...

WM

He's altered if he's telling 2 different stories of the accident on-scene. So yes,yes and yes.

(Not mentioning the fact that the elderly are an entirely different patient population that are extremely vulnerable, and you should have a lower index of suspicion with them).

WM.

How many accidents have happened because of these "dry runs?"

What about secondary accidents, the crew may not have witnessed behind them, or at cross roads?

How is the liability covered when the people inconvienced/hurt by these "dry runs" find out there was no emergency?

How many accidents have been caused by the stressed out newbie with red mist syndrome on the way to a BS call?

Let 's face it, you are never going to win this argument on that basis. It's just done differently in the UK. Not better of worse, just different.

WM

The abdo pain example reminded me of something I heard recently while listening to the podcast of the Merck Manual of Patient Symptoms on Abdominal pain. (not the most scholarly source, nor particularly easy to reference I know) In it, their speaker a Dr. Robert Porter (whose credentials on the Merck site are listed as "Clinical Assistant Professor, Department of Emergency

Medicine, Jefferson Medical College") states that (paraphrased):

While it was once thought that pain medication would mask abdominal signs, and some clinicians may still feel this way, that it seems clear that moderate doses of IV analgesic (50-100mcg fentanyl or 4-6mg Morphine) do not hide paretineal signs. In fact the decreased anxiety and discomfort in the patient may make examination easier.

I listened to this section of the podcast again just to be sure since I can't post the exact source. Anyone have anything more credible to back this up or even protocols that allow for pain meds in cases of abdominal pain?

Denying pain medication to a pt. with abdominal pain is something still from the dark ages. There is a plethora of studies that disprove this opinion. Not even mentioning the fact that, with today's medical imaging capabilities, it makes no sense whatsoever.

If your pt. is in pain, then they deserve pain relief.

WM

Well, I think it's safe to say that Holland and Sweden are very similar. Here we are RN's with a post graduate critical care qualification and a year's training in prehospital care.

I think Australia has more in common with the Uk though, ALS providers that are university educated, but not necessarily RN's.

WM

Liz,

Welcome to the sit here. First of all let me congratulate you on deciding to join EMS, it's a decision that you are likely not to regret.

I think you need to be a little more specific with your question when it comes to druga and their dosages. Also remember that there any number of sources you can consult on the net. You will also find that a particular dosage varies from region to region, depending on the current opinion of your medical director.

Having said that, feel free to pose a specific question here, I'm sure there will be someone willing to help.

WM

The too noisy for interpretation means that the machine thinks there is too much artifact for the automated analysis to proceed. Usually this means that it is too noisy for you to analyze it also, but sometimes if you get the "artifact- press 12 lead to accept" message and you press the button, you can get a clean looking 12 lead that still says "ECG override/artifact" or whatever at the top. I figure you get this message because the machine WAS seeing a lot of noise before you pressed the button ("to accept"), but then the artifact cleared out and you get a clean strip.

In general I have no problem using any 12 lead that looks clean and has a nice isoelectric line, even if the automatic interpretation had some trouble. Usually I will try and print out another one for confirmation after that (sometimes I get my cleanest print as we're just stopping at the hospital), but for the most part just because the machine thought it was too noisy doesn't mean it actually is.

I'm guessing that we are talking about the LP12 here, right? It's something that is a recurring problem here too. I find myself overrriding more often than not. For the most part, it doesn't stop you diagnosing STEMI though.

WM

I think it's a sad indication of the state of EMS in the US that we even have this discussion. Before we go any further, I would like to state that it is NOT my intention to bash all things american. My participation on this website is enough proof of my interest and, to a large extent, my admiration for US EMS. Having said that:

There is no way on earth any educated professional should be working this poor woman. To do so, would, in my opinion constitute assault. If I was family then I would hang you for it too.

Please, please people can we get some perspective here. This poor woman has suffered enough. Do you think she likes being frd through a tube and being changed every few hours. I have never heard anyone say that they find that an acceptable state whist they were still fit and healthy.

We have made great advances in medicine over the last 40 years, it's just a shame that we still don't always know when to stop.

Leave your monitor and airway kit in the truck. Let this woman die with a little dignity, something which she has sorely lacked in the last phase of her life.

WM

Thanks, Novisen, for your input here.

From the name I 'm guessing you are somewhere in northern europe, right? I'm from Holland and so I know we don't differ that much when it comes to ALS. I'd like some propofol, though.

WM

I'd like to add my perspective here as an ALS provider in mainland europe.

First of all, it's wrong to make blanket statements about Europe as a whole. Europe is a group of entirely independent countries, not states. Each one has its own form of EMS. IN the southern half of Europe ALS intercepts from hospital staff are used widely, in Germany there are trained EMS physicians that respond from a central location.

That's not the whole of the story though, in most of the scandanavian countries and the Netherlands (where I am) EMS is nurse led. We are critical care trained nurses that have a great deal of autonomy, I really can tell someone that they are not getting into my ambulance without having to refer to any sort of higher power. We also have no form of medical control. Everything is also standardized within national protocols.

I would certainly hope that there are NP's and PA's here in the Netherlands. It would certainly make my Masters in Advanced Nursing Practice, that I'm starting in September, otherwise obsolete. We actually have a new breed of nurse practitioner here that is trained in EMS and primary care. One minute you could be suturing an elderly patient at home, the next sedating and intubating a head-injury patient. (something akin to the ECP in the UK).

Last but not least, education is the key to advancement. We refuse transport, advise on alternative pathways and treat at home because we are trained to do so. We are degree level entry, no if's or but's. And have been for the last 10 years. If the pursuit of knowledge isn't enough motivation, then try this: $62,000 a year for a 36 hr week and 7 weeks paid holidays a year.

Now who's up for that BSN?

WM

http://www.nbcphiladelphia.com/news/local/...3-Year-Old.html

This tragic accident must be our collective worst nightmare. My thoughts go out to everyone invollved.

(Please take time to read the comments underneath the article..they are enlightening).

WM

Google Perfalgan and you'll find it all....(in Dutch )

Last time I saw Acetaminophen was in jam, strawberry to be precise

No, that was Aspartamine.

That's a shame, it really does work!

WM

Paracetamol IV is used to top-up the effects of opiates resulting in lower dosages being necessary.

WM

Lack of pain relief

Above is evidence that the problem is not limited to EMS.

And here a relevant quote from the Merck Manual of Geriatrics:

[quotePain management in the elderly has been addressed in clinical practice guidelines by the Agency for Health Care Policy and Research and by the American Geriatrics Society and in reports by the American Society of Anesthesiologists and International Association for the Study of Pain. Adequate pain management may improve cardiovascular and pulmonary function and, by preventing the stress response to postoperative pain, may lower the incidence of postoperative myocardial events. Decreased ventilatory function after thoracic or abdominal surgery is caused mainly by surgical trauma and by splinting due to postoperative pain. Pain management cannot restore ventilatory function but can help prevent splinting by enabling patients to breathe deeply and cough, thus improving mucus removal and avoiding atelectasis. Prevention of atelectasis reduces the postoperative risk of pneumonia and hypoxia.

Generally, adequate postoperative pain management helps patients walk sooner and improves functional status, hastening their return to the community. Pain management also enables patients to be discharged earlier, thus reducing medical care costs.

P3,

I'm not suggesting that we would cut mortality in half by decent initial pain management. However, I do think that it could play a role in reducing the figures. Poor pain management, whether it be pre-hospitally or otherwise, leads to poor wound healing, longer stays in hospital and extended revalidation periods. All of this has been researched, by the way, and is not just my unfounded opinion.

What I would therefore suggest is that EMS takes a leading role in providing decent pain management. Take the following example:

Doris, 80 yrs old, has taken a tumble in her kitchen. She is BLS'd (= no pain relief) into her local ER where she is put onto the corridor as a multi-vehicle MVA has just occurred. After an hour she is written up for opiates as pain relief by the ER attending. That therefore means that Doris has now gone almost two hours without any decent form of analgesia since her fall, but well, she doesn't like to complain because the nurses are so sweet, but oh so busy. Those busy nurses then leave Doris another 45 mins before they get around to administering the Morphine because of the back log of work.

Doris is finally given her pain relief almost 3 hours after her intial fall. She is ever so grateful and thanks everyone for their help before going up to the floor. It's just a shame that she was given such a poor standard of care. Now, we can all see why that happened and would be at pains not to point the finger at anyone. The fact, however, remains that she was left to lie in agony for three hours before her pain issues were adressed. You can bet your a$$ that it has affected her morbidity significantly in the long run.

All of you that have been in EMS for any length of time will recognize the above. It's fictitious, but let's face it, it could happen anywhere.

None of this need have happened, if Doris had been properly managed pre-hospitally then she would have a far more comfortable wait on that gurney. That's why we need to take a leading role.

WM

I would not agree with removing the patch is this case. The patch provides a baseline analgesia that can be continued. Any further pain relief can be titrated to the pt's pain. Just remember that anyone in a lot of pain will need a lot of analgesia.

Using set protocols and medication dosages just boils down to cook book medicine. I have been known to give a pt 25mg of Morphine without problems, if thet need it, they get it. Period.

WM

I guess I am a little late in answering this poll. My excuse is that I have just spent a week sampling lovely Bavarian beer in Germany. Now the guy/gal that comes up with effective pain relief for a hangover will win my vote for the Nobel prize for Medicine!

Pain relief is a subject close to my heart. One of the problems in EMS is that not enough time is spent on the subject during training. Those of us that have nursing backgrounds tend to have a more thorough understanding of the subject. Pain is a devastating mechanism that can even affect mortality and morbidity, particularly in the long term. It should be avoided at all costs! Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure.

My own preference:

For the initial treatment and/or extraction of the patient: Ketamine in combination with midazolam

For ongoing treatment: in the elderly it's Fentanyl, in the young it's Alfentanyl (it's great stuff, but tricky to dose in the elderly).

All supplemented with iv paracetamol because it reduces the the amount of opiates the patients need in the medium to long term.

WM

I guess I am a little late in answering this poll. My excuse is that I have just spent a week sampling lovely Bavarian beer in Germany. Now the guy/gal that comes up with effective pain relief for a hangover will win my vote for the Nobel prize for Medicine!

Pain relief is a subject close to my heart. One of the problems in EMS is that not enough time is spent on the subject during training. Those of us that have nursing backgrounds tend to have a more thorough understanding of the subject. Pain is a devastating mechanism that can even affect mortality and morbidity, particularly in the long term. It should be avoided at all costs! Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure.

My own preference:

For the initial treatment and/or extraction of the patient: Ketamine in combination with midazolam

For ongoing treatment: in the elderly it's Fentanyl, in the young it's Alfentanyl (it's great stuff, but tricky to dose in the elderly).

All supplemented with iv paracetamol because it reduces the the amount of opiates the patients need in the medium to long term.

WM

The one time that I decide not to let my annual US trip coincide with JEMS, you get together. I hate you all................................. :twisted: :twisted: :twisted:

WM

(PS - don't forget to go to the Wharf Rat opposite the conference center and drink a pint of real "ale"...)

http://www.thewharfrat.com/

Which is why I suggested titrating

Arrest scenario- Well, it depends upon whether it's a shock or no-shock situation. I don't think we need to go into the exact specifics here, I'm sure we are all familiar with the ERC (or whatever the governing body is in Aussieland) guidelines. I think there should be some attention to the 4 H and T's here though.

Was the arrest run any differently because of the patient's history?

WM

Ahhhh.....gotcha..!