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What does it come down to then? Mental disorders are only then a problem when they start affecting your ability to 'function' in everyday life. Functioning as a paramedic is a part of that. In what ways do you think OCD could affect that ability? If it affects Seth's coping mechanisms, that can be dealt with before it affects patient care. On the other hand if he is not going to be able to make appropriate decicions on a run due to OCD, that is going to harm his patients. And that's exactly what mustn't happen (and probably won't, from what I understand). Would you mind revealing your point of view? Would you mind clarifying what you mean by 'Kool Aid'. Kraft Kool Aid Country Time Drink Is that what you mean? I've got to admit, there was never a necessity of going back to powdered drinks. Maybe it's time to move on, not just from powdered drinks.

Essentially, that's what it comes down to.

Are all of you mad? EMS is the best job I could imagine, well it's definitely up there... Don't tell me you think differently. Yes, occasionally you may want to run away, but then again working in accounting would want to make me run away - every day Seth, give it a try, if you fuck up... You're still young, you'll find something else. Never regret what you did, regret what you didn't do (can't remember who said that). Excuse my French

There are currently two studies being conducted in Germany, the first one started a few years ago, basically a truck with a CT scanner in it without the ability to transport patients (Homburg). http://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2812%2970057-1/abstract The other one in Berlin with an ambulance eqipped with a CT scanner http://www.berliner-feuerwehr.de/2505.html?&L=1 http://www.youtube.com/watch?v=Ou9xr8CRnrw They've been doing fairly well, although I would imagine they come with a huge pricetag. A neurologist, a radiology assistant and two paramedics (+radiologist on stand-by who receives the images), additionally the closest ambulance would be dispatched too...

I'd actually be more interested in hearing something about admission for medicine. Is it common to do one of the preparatory courses as it would be for other studies? Is it true that everyone with Bac S (?) gets a spot and filtering is done during the first year? Do you know anything about a programme in English? I'm also thinking about joining the military, even though I have already refused military service (conscription still in place here, well not anymore but 3 years ago...) Good luck Ja, I know a few dutch girls too, congratulations I'm guessing you worked in EMS before, (in Wales? had a Welsh teacher, interesting language) so did you get reciprocity? Which province do you work in? I'll probably be in Amsterdam for a few days in May or June and I'd be really interested to learn a bit more about your system.

Hi Carl, you work in the Netherlands? How come (assuming you're Welsh)? Where do you work? I've heard good things about your system and thought about relocating either for EMS or Med School, Groningen actually has an English BA-program (medicine). But then again I'm not much of a nurse (especially considering 5 years of training required) and Holland is not really my favourite country. Maybe Switzerland, I'll have to see.

Thank you for clarifying. So what's your 'civilian' job? Actually is it possible that a nurse 'replaces' the physician in French EMS? Seem to remember that the fire department does that sometimes...

If it was closed, a BVM (or any other supraglottic airway) wouldn't do much good I guess... only once had to wait for inspiration to slip the tube in, that was on the street though (and rather due to the vocal cords being 'closed'). I did some research, interesting question really. I just tried it with a bottle of water, if you seal the bottle-opening with your lips and swallow while compressing the bottle all you do is blow out your cheeks. Whereas doing the same thing while relaxing you can actually inflate the lung... Looks interesting too...

Sorry to disappoint you mate but most had received at least 1mg of Remifentanil (syringe driver obviously still running), 1.5-2mg (per kg) of Propfol, and about .5 (per kg) of Rocuronium (and a lot of oxygen ) ... You can consider them apnoeic. No visual guidance. As I said, I was shocked. It works though. I usually visualized the vocal cords while intubating nasally, simply to get the hang of that. I very rarely had to touch the Magill foreceps, normally the tube slips in easily. I still remember my very first attempt, got the tube in but broke the cuff. That never happened again.

Bonjour Secouriste, I thought you could help me with this... I stumbled across a documentary about SAMU de Paris, really interesting and well made (even for me with the petit peu of French that I speak). The question I've got is, what's happening from about minute 8:40 onwards. What I understand is the medecin gets 'shocked' while performing chest compressions. Yet the defibrillator (looks like an LP 15 or something, are you familiar with it?) hasn't released a shock, the patient's heart converts into a sinus rhythym or at least some sort of circulation returns. Is that correct? Seems like an interesting phenomenon... http://www.youtube.com/watch?v=S06RpYWQRZc Oh, and a late welcome to the forum Bienvenue!

While certainly not best, 'blind' nasal intubation still remains common practice. I've done one of my clinical rotations in the anaesthesia department of a maxillo-facial surgery unit where most ETIs were done nasally. I was shocked (on my first day) to see the senior anaesthetist simply 'shove' the tube down the patients nose without even touching the laryngoscope (and stethoscope for that matter). Still, I haven't seen any of his intubation attempts fail... Some of the other consultants used the same technique. Trick is not to tilt the head backwards, basically get it into a Jackson kind of position. Mind you, these guys had 10+ years of experience doing exactly that day in, day out. I'm fairly certain none would attempt it in a code situation. Now the interesting question is, why was the jaw clenched??? Any kind of trismus would cease during arrest, possibly the clenched jaw was due to surgery or radiation therapy? To be honest, Spock is probably right.

What do you need the chase car for then? Sound like you need a BLS-ambulance and an ALS one. What do you mean by ALS-interfacility? Anything near critical care? How about something like this http://www.ambulanzmobile.eu/brand/en/latest-items/models/emergency-ambulances/otaris.html and this as chase car

Does anyone have access to the whole study, since it's hard to judge a study simply by the abstract. Do we know anything about their approach, say: if BVM fails --> supraglottic airway, if that fails --> ETI... which would explain the results. Assuming ETI is as good as BVM in delivering oxygen to the patient, why would there be a difference in outcome? Do we know enough about the (patho-)physiology? All we are doing is guessing. Interestingly survival with good neurological outcome is as low as 2.9% in this study. Whereas in other systems it's as high as 10%...

Tell me and I will forget is a good one, I've recently stumbled upon one about a hospital in Southern Johannesburg (serving a population of 2-3 million!) called Saving Soweto. There is another one about London's HEMS. The best ones are porbably Australian A few military ones There are a few French, German, Swiss and Austrian ones but you probably won't find them with subtitles. http://www.youtube.com/watch?v=XFpnYth9mA0 http://www.youtube.com/watch?v=jXtIikh5Lvc http://www.youtube.com/watch?v=kMcGkBXoLvk

I actually considered studying in Estonia, to be honest I still do... To answer your question: 1. BLS-Ambulance (patient transport, sometimes used as first responder on emergency calls): EMT-B (2 months training) + EMT-I (4 months) ALS-Ambulance (responds to 911-calls): EMT-I + Paramedic (2-3 years) physician's chase car (responds to critically ill, severly injured patients): Paramedic (additional training concerning mass casualty incidents) + physician MICU (critical care, interfacility transport): Paramedic + Critical Care Paramedic + Physician (consultant, experienced in intensive care) neonate ambulance: Paramedic + Critical Care Nurse + Physician (nurse and physician experienced in neonate intensive care) HEMS same as physician's chase car (the doctors there are usually more qualified and experienced) 2. everything you could possibly need... propofol, sodium thiopental, etomidate, ketamine, fentanyl, morphine, succinylcholine, vecuronium... here's the neighbouring state's drug list: http://www.google.de/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=0CFMQFjAE&url=http%3A%2F%2Fwww.aelrd-rlp.de%2Faelrd%2Fcontent%2Fcommon%2Fdownload%2FNotfallmedikamente_Rheinland-Pfalz.xls&ei=72TgUJCEGY6RswbYroGQDQ&usg=AFQjCNGTSo1IjWRm2z5unZDlmhqgmEVFMA&bvm=bv.1355534169,d.Yms http://en.wikipedia.org/wiki/Paramedics_in_germany a paramedic's scope of practice is defined nowhere. Some medical directors have started giving out guidelines, but that's about it. 3. It would be unusual to call a doctor since you can have one physically present in a reasonable amount of time 4. paramedics: manual defibrillation, iv access, intubation, needle decompression, repositioning / physician: basically anything within sound clinical reasoning

Please do so, it's been a great scenario so far. To be honest what I would do is keep on guessing and rush to hospital, intubate at some stage and rush again. Anaphylaxis? Edit: Anterior wall infarction? Paralytic ileus with massive toxine spread? Probably deteriorating too quickly...

Ruptured spleen? some sort of anphylaxis (any other signs for that?) To sum it up, he may be having some sort of inflammation, he's running right towards schock, massive, diffuse abdominal pain, diarrhoea. How is he neurologically? Especially leg movement, reflexes. He didn't actually lose control over bowel movement, simply couldn't hold it anymore? Consider spinal cord damage... although infarction or inflammation in that area seems fairly far fetched. Endocrinological changes, wouldn't really explain abdominal pain. How does he react to norepi or whatever you've got. I've actually had a patient with massive gall stones presenting with those kind of symptoms... What does the stool look like? Prior to giving him catecholamines, I'd risk pain management, how does he react?

You're probably right about Afghanistan, but we can all agree that the level of homicides and violent crime is unseen in any other developed nation and comparable to that in many third world countries. Especially striking, considering how much money you spend on the police force, intelligence services, homeland security etc. DFIB, don't you think that you wouldn't need a weapon if their availability wasn't as high as it is? Don't you think you could actually provoke a situation in which your opponent himself may feel the need to use lethal force against you? Which he wouldn't if you weren't carrying a gun? I can understand not wanting to become a victim. I myself wouldn't hesitate even one second to do what's necessary if I saw my family in danger. Damn, you actually found something supporting that kind of reasoning. Maybe this is about consistancy in both directions, either ban firearms alltogether or make them available to everyone... Restore balance. http://www.unodc.org/unodc/en/data-and-analysis/homicide.html http://en.wikipedia.org/wiki/Number_of_guns_per_capita_by_country http://bjs.ojp.usdoj.gov/content/glance/tables/viortrdtab.cfm http://en.wikipedia.org/wiki/Crime_in_the_United_States It's probably too much of an emotional discussion...

Why not make it obligatory to carry arms? Wouldn't that be wonderful, imagine all of the teachers armed, the school kids... How far would he have gotten? Come on, how can you defend gun ownership and put many lives at stake eyes wide open? Just answer one question: why do you personally need to carry a weapon? Anyways, I guess these mass murders are simply the tip of the ice berg, they only account for a small percentage of homicides. But it's quite funny to see that Afghanistan has a lower homicide rate than the States. It does make you wonder. Surely it's not only linked to the high number of weapons and lax laws, but changing those two parameters could have a great impact. Saydly that's probably the only fact we can agree to.

Do you still remember times when you used Alupent during cardiac arrest? And noone cared for compressions?

I agree to some extent. Yet ET tubes are improving, reducing the numbers of VAP massively (by up to 70%). Does anyone have first hand experience with tubes such as Tyco's Hi-Lo Evac? I've also heard of one using a different type of cuff which prevents secrete from passing through. All in all I would still consider them the gold standard (especially in EMS) with the only disadvantage being the extent of training needed to insert them successfully.

When you considered something a treatment, for which you would be crucified nowadays I've always loved listening to the stories the old-timers told, sadly (certainly not for the patients) most of them are hitting retirement age. Anyone here who started off as an 'ambulance driver'?

Morgagni-Adam-Stokes, sorry for that... Had the patient collapsed before, any relevant cardiac history?

Have you considered MAS-syndrome, av block? The elevated ammonia levels may be misleading and could you clarify which unit you are using. I think most causes of hyperammonemia apart from hepatic failure are quite rare and looking at that you'll also see many other metabolic (and electrolyte) disorders which may have lead or contributed to the asystolie. But (as you said) that seems unlikely since the patient would have stayed in cardiac arrest until that cause had been removed. Was his heart rate still at 30 bpm before he coded? Did you do something about the low rate, how was the output? When did you get the 12-lead (before or after asystolie)?

Captain, I see your point and it's your decision. It's fairly easy over here, everything invasive means breaking the law so I've done it quite often. Then again, (as Kat pointed) you breached your scope too... would you do that again? What if your procedure had gone wrong? What if that paramedic had succeeded with his? How many doctors fuck up massively and don't have their license to practise revoked?