OzMedic

Not much more I can add to that. Sucked in poms!!!!! Had a few callouts during the night, got up at 1130 to watch the cricket and it was all over, spewing!!! You would think they would have let Warnie open the batting though

Tniuqs, I also worry about the use of adrenaline in these patients to early in the piece. It should be reserved for pre-arrest patients in my opinion, especially in older patients. If a patient is in extremis with minimal air movement I tend to stick with the high concentration oxygen via NRB and go straight to IV salbutamol (albuterol). It tends to be a bit kinder to the heart than adrenaline. I switch back to nebulised as soon as the patient starts moving some air. I also administer some IV steroids as early as practical so they begin to work sooner, not much benefit pre-hospital but will benefit the patient earlier. Sorry I realise this is not related to the original subject of this thread.

Hey Phil, Do you know why no Aussie or Brit troops have been shot lately? They are all in their tents watching the cricket.........lol!

My area also have a J.D. Gator 6WD which has been extensively modified to carry the top of a ferno 50 stretcher and 2 medics with their equipment. We mainly use it for a major annual event we have that involves 25,000 people camping out in the bush. My station also has a modified Landcruiser troop carrier that I utilise to access patients on the extensive remote beaches, national parks and large sand island that my area covers.

Could not agree more! The first lecture in my medic class was about not getting all excited about our new toys and remembering our primary function "TRANSPORT MEDICINE".

I don't get it either, whats wrong with a good old tourniquet? I thought we had worked out all that compartment syndrome stuff and how to treat it!! Thats even if it got to that point which it probably would not. Hey Dust.......I'll tell you a secret but don't tell anyone else because I don't want the surgeon to get in trouble ok? This one time in band....I mean Paramedic camp, I was in an operating theatre and the surgeon was trying to fix this guys leg...........and he put this pumpy uppy thing on his leg and................he even called it a tourniquet, aaaaand he like didn't even take it off for like an hour and a half. You would be surprised at the amount of shark attack victims here that exsanguinate for the same reason. A decent tourniquet early on would have saved most of them! Asysin, not talking about your case mate just the boogyman issue that EMS education seems to have with tourniquets.

Are you serious or just trying to have a laugh? Oh, I get it...........ok guys where's the camera?

Timmy, First of all what do you think that I am telling you to do/not to do that you are doing now? and second, what do you mean by "something were to happen"? I would never advise anybody to go against the specific training and medical direction that they work under for a start. To do so is foolhardy and contrary to your contract of employment. What I do promote is research and questioning of how we all do things. If we do think we have found a better way then there are always internal mechanisms for change. All I am promoting is my opinion based on the research and training and experience that I have been exposed to, which could very well be dead wrong! However as with most things medical you will very rarely find a dead wrong or right way. As you have seen my opinion on this issue is probably in the minority and I can honestly say that if something comes up on this board to change my opinion then I will follow it through within my organisation as I have done in the past and give credit where it is due. The question you ask is kind of irrelevant and but if you are worried about this issue then be more specific and I will try to answer you as best I can.

Dude you just supported my argument, immobilising the head is easy. It's rigid with little mass, just tape it to something and it won't go anywhere. The problem is the body. It's floppy with a lot of mass and needs space to allow for ventilation. The reason I feel so strongly about this is that I have seen airways compromised on more than one occasion under the guise of cervical precautions that probably are more likely to worsen the risk of exacerbating cervical injury anyway (i.e, taping heads). Yes you are correct I have not provided the evidence which I will do when I get around to digging up the hard copy as I have not been able to find it easily online. As someone said the whole issue of cervical precautions is being questioned anyway as there is little documented evidence of benefit for any of it. The argument I am making is which method is most likely to provide the most stabilization of the entire head and spine as a whole and still allow emergency airway care. The problem of a fully immobilised head and a partially immobilised body is worse that a partially immobilised head and a fully immobilised body (I think Einstein had a theory about this). Another theory is that if there is partial movement of the body then the head should be allow to move a little to go with it but not allowed to flop around (this is the rolled towel/sandbag theory). Or try and immobilise the body as a priority and the head as much as possible which is the point of the vacuum mattress over the backboard. Anyway there will always be different opinions and I do aploigise as my last post was placed when very tired.

Fair enough Brian! Good luck Emilea, I hope it goes well for you. Just remember to commit to becoming a lifelong learner and you won't go far wrong. There is a huge array of talent and knowledge on this site and you are lucky to be in an EMS generation where your free and unlimited access to it! Please remember though just because one, some or all on this site or text book or instructor says it, does not make it so! EMS is full of grey areas and you need to be comfortable in this arena if you want to excel. Knowledge is power and while you will have rules to follow don't ever stop questioning them in the quest for a better way. Sorry I'll get off the soap box now

lol, ouch! I was just trying to point out that we need to keep and open mind before applying hard and fast rules to when and why we administer drugs. Sorry If I was to abrupt but my original point still stands.

Emilea, just a question as I don't know the format of your scenario exams. In your plan, you go into great detail about all the questions that you are going to ask which is great but you sum up your treatment in one line "Interventions". If I was examining you, this is the area where I would be most interested as it is ultimately what is going to determine the patients outcomes! I am wondering how you are going to make these decisions as the questions you ask are only a small part of the picture. I want to know how you are going to assess the patient and what observations you are going to take, in what order and most importantly WHY? I will be happy to provide feedback if you like as well as a far more simplified assessment method. If what you are doing is just trying to tick the relevant boxes to pass a specific assessment then I probably can't help as I have no experience with EMT/basic type education and I'm sure plenty of guy's on here can tell you what to do to pass. Thats totally OK because if you don't jump through the hoops then you don't get to play or get paid but if you pass and go out on the road thinking that you need to put oxygen on every medical patient or splint every fracture on every trauma patient then that is sad for you and the EMS system as a whole.

As I said before I work normal day shifts (8-9 hours) and then are on call after hours (this is fairly typical in rural Australia). I am expected to be on-case within 3 minutes during my normal shift which is fine because I am being paid accordingly to by available for a rapid response. After hours my turnout time is extended to 10 minutes which gives you time to get changed, splash some water on your face, have a slash or whatever. I feel this is quite reasonable as you cannot live 7 days straight in a state of constant readiness to turn out within a few minutes. I try to get on with a normal life as soon as my shift is over and forget that I am on-call until the pager/mobile goes off. As for needing twice as many vehicles, that may be the case but it is much cheaper that staffing a night shift! Vehicles are cheap compared to trained paramedics.

so?

The thing I find bizarre is that you don't all take a unit home with you! I work 7 days straight and on-call at night so essentially 24/7 but all services in Australia take the units home with them when they are on call. If there are 2 of you on call then you take a unit each and meet at the job or somewhere on the way, park one of the units and pick it up later. That way you can have a normal life, go to the shops, pool, beach whatever as long as you park the unit close by.

My first two cases on new-years-eve were: "17 y/o female with stuck tampon" and "4 y/o male with foreign object stuck in his foreskin". I kind of knew it was going to be one of those nights after that!

Salbutamol (albuterol) by itself is more effective that Ipratropium by itself, however, when the two drugs are combined they are synergistic in their effect. That means combined effect is greater than the sum of the two individual responses. This is due to the combined inhibition of the parasympathetic (ipratropium) and stimulation of the sympathetic (salbutamol) nervous system. There are many quality studies documenting this effect.

I'm with you phil, I used to work for a living! The study load is getting me down but thats my own stupid fault

God this is tiring! I am so sick of answering BS responses to people that have not read all the posts or not read them properly. For a start I live in Queensland Australia so what do you think the chance is that I have extricated a patient from a ski slope? Every one of my posts has advocated the use of spine boards as an extrication device! I would consider moving a patient off a mountain an extrication. Further to that you would also of seen my advocation of a vacuum mattress for these types of patients (I believe they still work in the snow). You could even put the vac-mat on top of the backboard if it made you feel better. Your response to proper management of an airway does not make sense! If you feel that you can prevent aspiration in a patient that vomits while flat on their back while moving them off a ski-slope without log rolling the patient then please share you secret as it will definitely be a skill that I would value. As for the pre-medication I do always pre-medicate my spinal patients, however I utilise an anti-emetic that is probably more likely to prevent emesis than phenergan which is mainly utilised for nausea due to disruptions within the middle ear such as motion sickness vertigo and labyrinthitis due to it's inhibition of of signals from the vestibular apparatus to the emetic centre in the medulla. This means that vomiting due to head injury, morphine administration and many other aetiologies will still be likely to occur. I place my posts on here in the hope that the people that read them will find the information interesting (or not) and stimulate them to do further research. I am more than happy to answer any queries in relation to my posts but silly snipes such as "my protocol says this" or "what about if this?" are not constructive in this context, especially when the information is there if the person had only read the post or used some common sense and adapted the information to their context. Please feel free to give ask questions or offer different opinions/information (backed up by evidence if possible) but try to keep it constructive. This way, we can further our knowledge and recognition as professional practitioners instead of a mob of protocol monkeys taking snipes at each other.

If you read my posts again you will see that I actually say that people should not be transported on backboards, not that they should not be used! Additionally, patients should be strapped to the board for safety just not their heads. The problem being that even in ideal situations (which we rarely work in) it is almost impossible to strap a person to a board/stretcher so well that there is no movement of the spine, however when you strap their head it's not going anywhere so any movement of the rest of the spine increases the risk of potentiating injury. This has been found to be more risky than if the head is left unstrapped and excessive movement prevented with towel rolls etc. As for my medical control, it absolutely contraindicates the strapping of heads to boards or stretchers in any way shape or form. Hope this clears things up!

Simple answer from my perspective: Right for extrication (and very short transports), Wrong for transports! If you do not have a vac mat to transfer the patient on to then place them on your normal stretcher and utilise towel rolls for the head and folded triangular bandages to tie the legs/feet (together, not to the bed). While I validate what emsbrian said about padding the voids with the use of backboards, I feel that in practice it is far to inexact. How can you actually tell if you have the right amount of padding once the patient is on the board? The same goes for KED's for that matter! Additionally I also try to utilise a scoop stretcher instead of a backboard in the same way shown in your picture (they suck on the beach though). This reduces the amount of logrolls necessary when transferring the patient and allows for a more neutral spinal position.

Timmy, As I said before backboards have been shown to provide an abnormal surface for spinal support, patients on back boards are supporting their spines with the muscles in their back (if conscious) by both voluntary and involuntary spasm along the spine and around the injury site(this is a protective mechanism and the most effective form of spinal immobilisation). This will only last for so long until fatigue and especially morphine allow the muscles to relax and if on a hard flat backboard the spine conforms in an unnatural manner to the board. Also, as I said before, It has been shown with the help of CT imaging that strapping patients heads increases unnatural movement due to the fact that it is impossible to fully immobilise the body. This is if you are strapping it to a backboard which is wrong anyway but strapping it to a bed is even more wrong because you cannot logroll the patient at short notice if there is a problem with the airway eg: vomiting. A vaccum mattress is the solution to both of these problems because it does immobilise the patient in a manner that conforms to the individual patients anatomical peculiarities and allows 1 person at a pinch to safely logroll the patient. Anything less is substandard and strapping the head to a bed or board is just plain wrong! Timmy as you gather more experience throughout your EMS career you will realise that a lot of things are done for the wrong reasons, the main one being that it is past accepted practice and that is the only reason I can offer as to why things are done the way they are in VIC as you say. The best argument you can make if you disagree with me is to dig up some evidence that supports spinal immobilisation in the way you propose. Saying that so and so does it that way carries no more weight than if you show the guys down there my posts to demonstrate why you should do it my way. Bushy would be a good place to start if you are chasing the relevant studies but I can tell you now they are all pretty poor. The one factor that is becoming apparent from recent research is that is does not really matter what we do as long as we are not silly as the initial insult usually does the damage or not! Good luck with it mate :wink:

Backboards are extrication devices only and should not be utilised to transport spinal patients on! Taping/strapping the head only potentiates the problem and increases the risk of injury exacerbation and aspiration. Studies utilising CT imaging have demonstrated the inappropriateness of this approach not matter how much the patient is trussed to the board (this goes for KED type devices as well). The most efficient method of immobilisation is the full vacuum mattress, if this is not available then scoop/back board the patient onto your stretcher mattress and place 1 towel rolled from both sides under the patients head to minimise lateral movement. Do not tape the patients head in any circumstance!! Again these methods have been shown to be the most spinal friendly by the utilisation of CT imaging. Helmet removal should not be a problem when adequately trained and prepared for and I disagree totally with leaving them on for transport. The added mass of the helmet will add to the mass of the persons head and increase lateral movement. In addition a helmet will not allow a supine patient to lie in a position that does not hyperextend the spine. Airways can also turn from good to bad in an instant and you do not want to have to rip off the helmet in a hurry by yourself while in the back (when was the last motorcross event you attended that was in town and a short distance from hospital?). These patients require a slow/smooth transport (preferably helicopter) so you could be with them for a prolonged period of time. Remember cervical collars are not always going to be an option (try putting one on a rugby front rower) or for reasons previously mentioned, a poorly fitted collar is a bigger risk factor than no collar so if it's not an option then manage as I previously mentioned and use extra care and utilise manual support as practical.

The distinction that ER Doc made is very important in the context of OP or nerve agent poisoning. As already mentioned Atropine blocks muscarinic receptors sites only! It is a very simple drug when learned in that context. Organophosphates/nerve agents work by binding, and in turn inactivating acetylcholinesterase. The flow-on effect is over-stimulation of muscarinic receptors by acetylcholine for which atropine helps by it's aforementioned action. This does nothing to help the actual problem of the inactivated acetylcholinesterase. Pralidoxime is the agent we use to reverse this inactivation by OP/nerve agents. The problem is that in a matter of hours the bond between OP's and acetylcholinesterase becomes what is called "aged" which means it is irreversible even after the administration of pralidoxime. This is not such a problem when farmer joe gets exposed to organophosphate and is transported to hospital in a timely manner with atropine to reduce the symptoms and gets the pralidoxime within a few hours. The ageing process in the case of weapons grade nerve agents such as sarin and VX takes milliseconds to minutes and all the pralidoxime in the world won't help! Atropine may help reduce the symptoms but also will not solve the problem. Do you think they tell the guys in the military this stuff when they issue them their atropine/pralidoxime autoinjectors and say "there you go son, you will be ok now"? :wink: