WelshMedic

Then I'm sorry too, but you didn't get my message. I know these articles show us in a poor light, that was the point. It's all ultra-conservative bullcrap that you'll find on the net. It certainly wasn't an article written here.

I am also puzzled by your comment on euthanizing thousands as opposed to a few children. You're not trying to find a parallel between nazi practices and the acts of very dedicated healthcare profesionals here ,are you? As I pointed out, there is nothing "active" in the way our pediatricians act. They do not, however, believe in unnecessary suffering for the "greater good". Whatever that may be...

WM

The Netherlands has never had a hich incidence of suicide compared to other countries and we are now at a 30 yr low: www.rivm.nl

Nor are we baby killers, now we are on the subject of euthanasia. The very idea is preposterous. Look here: www.weeklystandard.com/Content/Public/Articles/000/000/012/003dncoj.asp

The Dutch suffered terribly at the hands of the nazis. Any comparison is appalling bad-taste. What dutch doctors do is resort to using supportive measures in children with no prognosis. The nazis actively killed them. Small difference there...

WM

Once again, an excellent thought provoking piece from Dust.

The mindset in question isn't exclusive to EMS, though. I can remember when I was a nursing student that we were required to turn the open-end of the pillowcase away from the door. Do you why? Florence Nightingale had done the same in the Crimean War (early 19th century) to stop the sand getting into the pillowcases and irritating the scalp of a wounded soldier.

I was a student nurse in the late 1980's!

WM

The prose is fine, it's very well written. Which begs the question: why does someone so eloquent seek to portray EMS so poorly?

WM

And when he´s done with you, Andy, he can cross the North Sea and visit us in the Netherlands. I will keep him off the pot in Amsterdam though......

WM

I'd have personally let him sign a treat and release and gone back to bed in the safe knowledge that his wife would finish the job properly in the meantime. Thus also hushing up my management of this particular patient.

WM

honey - I don't play second fiddle to anyone.

Now I definitely know you'll be alright out there, Kaisu. Remember - take no prisoners!!!!!!!!!!!!

Good luck in Arizona. I, too, wish you all the best in the sandbox (Rather you than me......phew!).

WM

The Washington Post has published a personal article from one of it's own jounalists. It is a very readable piece that has obviously been written by a very articulate gentleman. It's message, however, says a lot about volunteerism in EMS.

Read here and see what you think.

WM

Hi Riblett,

You may want to consider Holland as an option. EMS is nurse-led , you have to be an RN with critical care qualifications to be an ALS EMS provider here. The other advantage is that (almost) everyone speaks english, so that would make it really easy for you.

I am a clinical mentor for my service and specialize mentoring the nursing undergraduates. I can organize an internship for you at my station without too many problems. Send me a PM if you are interested.

WM

AZCEP,

Whilst your message is clear to me, I wonder how what constitutes " reacting favorably" in this scenario. Although this pt is clearly sick, I still stand by my conclusion that fluids are not the answer. A systolic pressure of 90 mmHg is fine in the majority of cardiac pts, as you are probably aware. I know that here the CCU uses beta-blockers to reduce pressure to a 90 mmHg level in the MI patient.

Or was it maybe that you are making a general statement and I'm only referring to the case at hand? A case of crossed wires, as it were....

WM

I also have my doubts about the atropine. I would have deemed this rate and pressure as acceptable under the circumstances. On that note, I certainly would not have started 2 IV's and run them wide open. This is almost certainly a cardiogenic cause and is therefore not helped (probably hindered) by pushing fluids to that extent.

I am a little old-school in a lot of respects. I still believe that although we should support and comfort the patient appropriately, it is not always appropriate to perform all interventions just because you can. We should realise that our main aim is to transport to an appropriate facility and not to "cure" the patient with cookbook medicine.

WM

Hi everyone,

I don't want to comment on the treatment offered to this child, I think it was perfectly adequate under the circumstances. I do, however, take issue with the comment from one of the respondents about NOT taking the parents.

I have written a dissertation on this subject for my RN. All the evidence points to involving the parents in the child's care, however critical the situation. Just remember, when a child is that sick then they need a familiar, comforting face around.

It's often assumed that that the parents will be a hinderance in such circumstances, but this is rarely the case. I think it has more to do with the perceived close scrutiny that we feel we would be under. We need to set this aside and act in the interest of our patient and it's parents.

I, personally, would not even let it happen as a parent. I would insist on travelling with one of my children, whatever the circumstances.

WM

Well said, that man!

Your title or the letters after your name are totally irrelevant in this job. It's about what you are educated to do to manage your patient and their emergency.

WM

And before someone brings it up I do understand if the abusers were not their many of us would lose our jobs. That means EMS healthcare professionals out of work as well as the support FF's that some have respond.

And there we have the answer in a nutshell. I don't deny anyone their right to make a living. However it is a fact that, certainly in urban EMS systems, there is a level of overkill. Look how many crews there are in any given city. Just to put this into perspective:

Putnam County has a population of 70,000. They utilize 10 ALS ambulances 24 hrs a day. My region has the same number of inhabitants and uses just 3 ambulances during the day and 1 at night. Why? Well we have well organized primary care and a no-send policy in dispatch. Should a "BS" rit still slip through, we would refuse to transport. That is why we can do the same job with less than a third of the vehicles.

I don't think EMS can be directly blamed, by the way. They are only operating under the first law of economics: supply and demand. The solution to this problem? Well, it's a complex one; investing in decent primary health care for all would be a good start. Prevention is always cheaper than cure at the end of the day. I don't hold my breath just yet though, not with all the healthcare insurance companies more interested in dividends than healthcare. It's a travesty that anyone in a first world country can be denied access to health insurance for whatever reason. Socialist medicine suddenly doesn't seem that much of a bad idea after all, does it?

Rant over.....

WM

We have a PCI policy for all our STEMI patients. Prior to arrival at the cath lab they are given Plavix 300mg, aspirine 500mg and heparin 5,000 i.u.

Plavix had the disadvantage that it only comes in tablet form, that means that it's not always possible to give to nauseous and/or actively vomiting patients.

WM

Using a formula is difficult with a BVM. What you need to do is ensure that know the size of BVM you are using and what it's total volume is. I also subscribe to the opinion that ventilating just enough so that the chest wall starts to rise is sufficient. Barotrauma is a very real possiblity in kids.

WM

That said, is it prudent to decline all offers of help? I agree that it is primarily your responsibility. However, is it really necessary to send someone away when they are helpful and , more importantly, appear to be competent?

I have had this happen to me in the past, I was at the central railway station in Amsterdam when I noticed 2 police officers doing BLS in the bookshop. I went over to see if I could help, but was turned away by a third officer. I did leave because, as a professional, I did not want to make a scene - those that do make a scene, by the way, rightly get turned away.

Not saying you're doing anything wrong, but it is food for thought.

WM

Yep, can only second the above. The mortality rate over a 2 year period for anyone over 75 with a #hip is 80%

WM

Thanks too, chbare, from me. You have given a lot to think about in this scenario, especially me.

Although I was only able to contribute in the initial stage of this scenario, I have enjoyed the subsequent entries. A real puzzle. I knew where we were going at the point where mom stated that he was having trouble getting around. DMD is a genetic disorder that is, bizarrely enough, more prevalent in the area of Wales where I grew up.

My next door neighbour and best friend had it too. He saw him go from being my football buddy to wheelchair bound and spoon fed. Then one summer he went into hospital and never came home again. I cried for what now seems like a year. I still miss him now as I type this behind the PC. He would have loved the internet, he was always into gadgets and stuff.

Sorry for the melancholy, and thank you for indulging me.

WM

Tim,

Intubating a child is not quite as scary as you might imagine. Their anatomy tends to be slightly more straightforward than an adult. No, the problem is intubating a child with bronchospasm. ET intubation tends to exacerbate the problem as well as putting the child in danger of a barotrauma. Continuous nebs with salbutamol (yes, you were right...) and ipratropium (anticholinergic) seem to give a better outcome than early intubation and ventilation. The consideration we have to make in EMS is whether it is safe or not to transport before performing particular interventions. Intubating a child on the roadside in less than optimal circumstances could lead to more complications. This is the balancing act we perform on a daily basis.

WM

This is a primary ventilation problem that needs adressing emergently because this child is obviously starting to struggle. He is currently compensating, but will shortly be decompensating without adequate treatment. I'd also like to know how his ABG's are, by the way.

My proposal: arterial line (primarily for the ABG's but also monitoring)

parenteral beta2-adrenergic agonists (as long as the HR can take it)

parenteral corticosteroids

If all else fails, intubation and mechanical ventilation with low tidal volumes

and a lengthened expiratory time to prevent barotrauma. Sedation with

ketamine should be considered because of it's positive effect on

bronchodilation (morphine should not be considered due to histamine release).

Magnesium can be considered due to it's effect on the smooth muscle, but

this will more likely be considered at the facility.

WM

I'll give you an internship here in the Netherlands. It's a long way, but certainly worth the journey. Let me know if you are interested.

WM

My god, an american that has an understanding of european politics....well done my friend!!

Now, onto the order of the day: why has the country that benefited the most from EU investment now just rejected it's treaty?

A bit ungrateful, don't you think?

WM

Man, you seriously need a no-send policy for this sort of stuff. It is tragic that such a nice person is addicted to her pain medication. It is, however, not an EMS problem.

WM

Anthony,

The way I learned was anterior/posterior for pacing and anterior for defibrillaton. I've never really questioned it, to be honest but I wil do some googling of my own this week.

WM