Lithium

Oh Mr. Rid ... flight medicine is a huge upwards jump from land based EMS here in Ontario. It's such a different world, it really is unbelievable. For instance, I went from having 60+ of the most common medications available to me in the air to a little under 20, with only 4 being true ACLS meds ... Not trying to puff up my own ego, but I do appreciate the occasional pat on the back once in a while :wink: peace

Medically defend what issue? Overinflated egos and delusions of superiority are personality dysfunctions. I'm quite content that it's stated at the beginning of each protocol book that "any patient receiving symptom relief medication is expected to have high flow oxygen, continuous cardiac monitoring and a complete set of vitals pre and post administration" or something similar. This allows for justification of the cause and following trends. If I may sidestep however ... when I made the move DOWN the ladder from being a critical care flight medic to advanced care land medic, there was a huge difference in the way staff at receiving facilities reacted. The higher level of certification, the higher level of expectations and more importantly, trust, is extended to that provider. peace

Well, I was honestly trying to be sarcastic, but as I've learnt once again, emotion doesn't transfer well over the internet. And, just for clarification, I'm a practicing ACP for the past 8 years now, and use to to work as a critical care flight paramedic. peace

Why'd you think ambulances have extra wide doors? Come on now ... every paramedic has an ego :roll:

Medibrat, again, I think this discussion has been beaten to death in other threads. By allowing PCPs to have expanded scopes, it's allowing communities to arrest their citizens of true ALS care. Even Lasix has it's side effects. Have you ever seen someone develop an dysrythmia because you attempted to diurese them, not realizing they were already potassium depleted? How are you going to correct that? Wait for an arrest? I must digress ... Oh yes, and about my 2 mg IV ... come on, I was a student Hammer, a few points. First, doctor medics? Ha ... come on now, Im sure you know what its like to have 2 ACPs on scene arguing. Could you imagine what it would be like if we were all MDs treating patients in the field, then trying to hand off care to another MD 20 minutes later at the hospital? Oh boy ... No, we weren't talking about Valium. You brought up the issue that ACPs don't have antagonists to benzos (romazicon for instance), I was just trying to impress upon you that although the benzos we administer may cause apnea (among a plethora of other effects), we do have the ability to secure an airway more effectively then a PCP. Again, no, I would not contact BHP for more orders of narcan. To me, if 2 mg isn't having a response on this patient, then there's some other etiology happening, I'm not just gonna keep giving this patient more and more. This is another issue, Narcan (atleast in Ontario) is thought of as a diagnostic aid. If the patient responds to it, you can most likely suspect it was just an overdose. If the patient doesn't ... keep looking. Yes, both Narcan and IV access are good, but not for glorified PCPs. Concerning my logic, that could be a whole other issue not suitable for these forums ... Morphine my friend? No thanks ... I say haloperidol peace

Hammer; Yes, I agree with you. I'm well aware that there is always a higher level of care. This is one reason why I want EVERY ambulance to be ALS, with CCPs doing intercepts. This is purely a Canadian training thing, but still. Secondly, although I do not have flumazenil at hand to counteract the potential apnea received from one of the benzos I may elect to give, I do have at my disposal advanced airway management techniques (ETT, LMA, surgical cric to name a few) as well as a thorough and comprehensive understanding of respiratory physiology and airway maintenance procedures. Not only that, if I'm administering this medication, I can anticipate any side effects and include that in my prealert to the receiving facility. Third, as scaramedic stated, Narcans half-life is MUCH shorter that most opiates. So perhaps in an extreme case, if I'm transporting this terminal cancer patient (come on, let's get away from the stereotypical heroin junkie) who's overdosed on their morphine, purely out of a palliative attempt, and I've maxed out my protocol, I still can ensure proper airway management through intubation. Can you? And, my logic is not flawed thank you very much. My logic is as follows: "Not always right, but never unsure." peace P.S. Trust me, you're not the first to have thought of the 'morphine for withdrawal' edits: TOO many spelling errors

haha ... Scaramedic, actually, I think it was because I was pushing the narcan too fast. I'd draw up 2 mg, stick it in my IV port and try and do a slow IV push over about a minute. Both times, my patient began convulsing about 30 seconds in, and the first time I was like "what the hell!? :shock: " I admittedly went for my diazepam and the seizure broke. Second time (you would have thought I'd have leart by now eh) I was like "ahhh crap, this again". I'm well aware of the effects of an acute withdrawal. peace

Again, I will reiterate from a post I just posted in ... I agree with nsmedic. BLS personnel should not be doing ALS interventions. peace

Alright, this really doesn't seem to be going anywhere ... here's my two cents. Brat, I don't agree with you on this one. For one, to my understanding, North Bay has ALS providers available. I realize they're few and far between, and only in the city, but still, they're still there. That's what this whole debate was about, was for services without ALS allowing their EMT-Is to give this drug. You have ALS available, therefore although you may not be able to give it, the patient has a chance of receiving it prehospitally. nsmedic, I would disagree with you as well. As much as I am about the ABCs, if I can reverse a problem, I will. When I was in ACP school, I failed 2 scenarios because I kept giving Narcan through the IV. I then realized what my instructors were trying to impress upon me ... there is other routes available (IN, IM or SC). So, I began titrating through IM, and no more failed scenarios. I've seen and administered narcan in various routes, and above all, I prefer giving 0.4 mg IM q 2min PRN. We're capped here in Ontario at 2 mg anyways, but that's okay. If they need more then 2 mg, I would rather them receive it in a more controlled setting then the back of my ambulance where it's me and maybe a firefighter or student. Dustdevil, YES! I say we eliminate the PCP provider. I'm all for an ALL ALS system, but that's a far ways away. However, to clarify for you ... Ontario has a provincial set of protocols for PCPs and ACPs. Each service and base hospital usually adopts those with limited (and in some cases no ... haha hammerpcp) changes. In certain cases, some services have added their own protocols to meet the needs of the community (which I'm completely for). These services Base Hospitals then provide additional teaching and CE points for whatever additions they've made. The problem with this, is it prevents certain opportunities from becoming available in the long run. Oh well .. that's the way the system works. Hammerpcp, I agree with you to a point. I'm all for developing protocols to meet the needs of the community, however, if they want ALS interventions, they should design a system to support ALS medics. (yes, my dream one day would be to have ACPs on every car, and CCPs doing intercepts for those high profile CTAS 1s and 2s ... haha i know, im nuts). When it comes down to it, I personally don't feel PCPs should even be starting IVs. (let the flaming start!) Paramedicine is not a perdiem industry. IV initiation and maintenance is a very invasive procedure, and the way services are justifying it scares me. "well, our pcps do IVs so they can give D50" pardon me? Have you actually ever seen what happens when D50 extravates? Yes, if given correctly, it can be a lifesaving intervention. But, what are you gonna do if that IV becomes interstitial, you didn't know and you just pushed a whole tube of go-go juice? Watch the guys arm fall off ... nice. Now, I'm not saying there's more I can do for that, EXCEPT we do have access to pain control .. do you? So now the justification is to add morphine or fentanyl or perhaps a benzo, just in case. Just like Dustdevils argument (which I loved) ... "I want Narcan just in case." "Narcan causes seizures? Well then I want Valium, just in case!" "Valium causes apnea? Well then I want Romazicon, just in case! "Romazicon causes arrhythmias? Well then I want ACLS drugs just in case!" It should be all or nothing, and if communities, municipalities, districts and the MoH can't see that ... WE need to enlighten them.

Better idea ... let's get the narcotics off the streets, then we'll no longer have the need for narcan Oh my bad ...preventive medicine thinking here, and this seems to be poor in EMS ... :roll:

Because, writing and passing the AEMCA does not make you a paramedic of any level. The same as this new provincial ACP exam, it doesn't allow you to practice ALS skills/therapy, it just makes sure you know the provincial protocols. Challenging the AEMCA and successfully passing it is the way the MoH ensures ambulance service employees have the required knowledge as determined by them. Previously, it was known as the EMCA certificate, then when community colleges started teaching the symptom relief and defib programs, the MoH changed it to AEMCA, to incorporate those ADVANCED life support skills. Never kid yourselves ... PCPs are simply BLS medics performing ALS interventions, similar to the EMT-Is in the states. However of course, the PCP knowledge base is a bit thicker, but that's neither here nor there. You are only a paramedic when on active duty on an ambulance, and your certification is active with a base hospital. As soon as your shift ends, you are no longer a paramedic, just a person holding a ministry certificate. (very simplified version, but that's how it is). This is why the OPA is pushing for a College of Paramedics, because that way, you are always a paramedic, regardless if you're working or not. We won't go there though ... peace

First of all, where is the proof that the MoH has allowed these changes? I'd be interested on reading more about it and why they decided to do that. Secondly, people will whine and complain, but when it comes down to it, a health care professional is a healthcare professional. If a doctor REALLY wants to give up his doctor job, then so be it, although I think they'd have a hard time adjusting with such a culture shock. Same thing goes for RNs. My first problem would be is that these people have not undergone the training process paramedics have. I'm sure when it comes to the theory portions, both physicians and RNs would have no problems, but it's the practicals that would scare me. I can't tell you have many times I've been speaking to RNs at hospitals, and they all say the same thing ... "once the patient is in the back of the ambulance id have no problem dealing with him/her, but its getting to the back of the ambulance that scares me." Let me tell you, it really does take some skill and finesse when you're trying to extricate a restrained driver from their overturned vehicle in the middle of the night while its pouring down rain. This is the biggest difference I could see. Don't get me started on scope of practice, because well honestly, hands down, we have it better then the RNs around here ... peace

Hmm, interesting points vs, but realize to that since you work for the centre of the universe ( ) that a lot of the situations are specific to Toronto. I'm well aware of TEMSs 'level 2', and quite honestly, I think that should be the minimum level of care on any transport ambulance in the province. The only difference I've been able to find between those level 2s and fully certified ACPs is their ability to use advanced airways and administer medications. Beautiful system, I love it What services do you still consider to be 'provincial'?

Now come on akroeze, let's not go overboard here Remember there's enough studies out there trying to disprove the value of ALS services. ALS has its place, it's configuring it to the needs of the communities that's the trick ... peace

Oh yes ... and I know I'm going to be flamed for this, but experience is irrelevant. There's too many variables that come into play. Who do you think is the better medic? The guy who works for Toronto, does 8 calls a shift, but never sees a truly acute patient? Or the medic who works for Thunder Bay, does 1 call every 3 or 4 days, but every patient is at least a ctas 2? Secondly, most people develop poor habits on the road because it's easier, or quicker. So those sloppy habits translate to sloppy training. It bugs me to no end about people who always mention "the real world versus the scenario world". There's a reason why the MoH has developed those BLS standards, and that's what they expect to be the MINIMUM on every call.

Unfortunately, learning to 'assist' ALS skills is a complete waste of your education. A proficient ACP or CCP would not require assistance with such things. The best PCPs are those who can think independently and do the menial 'no-glory' grunt work on calls. Setting up the stretcher, applying the cardiac monitor, getting a COMPLETE and ACCURATE set of vitals and their parameters (BP, pulse, respirations, skin temp, pupils, GCS and CBG). Even better is the PCP who can do their own complete assessment quietly, interpret the findings and talk to me about what they think is going on. If the patient is genuinely ill, you can bet that I will be the one asking most of the questions, but if you're listening, there's no reason why you can't be thinking about what's going on. I honestly really like it when PCPs take the initiative to do physical assessments (lung sounds, neuro exams etc), because it shows you really want to be a part of what's going on without overstepping your bounds. Trust me, I've been doing this for a while, and I really don't need help with cutting pieces of tape for the IV. If you want to assist with ALS skills, goto ACP school and learn to do them properly, not through a crash course. You're only cheating yourself by thinking your helping the ACP on scene rather then perfecting your own assessments and scene management. peace

Umm ... first of all, level of certification does not equate to quality instructional skills. Why does it matter that if you are taking a PCP course that your instructor is ACP or CCP? I know plenty of variable levels of medics who are genuine instructors, as they've developed those skills of being able to relate the material to the learner. Quite the contrary as well ... many paramedics who get frustrated teaching because some people can't apply it fast enough (myself included). peace

I still say Ontario needs to catch up with the times and give us better vents, preferably with CPAP or atleast BiPAP and better PEEP control. And VS, I'm disappointed ... are you not undertaking ACP training? You should know those ACLS provider manuals inside and out! peace

So is this similar to those alternate methods of CPR as previously recommended in ACLS? Such as 'interposed abdominal compression CPR' or 'active compression-decompression CPR'? Sounds like the same idea to me ... just remember to watch your I:E times when venting ... peace

Good advice from those so far. I really do understand, as I was never a scenario person, atleast the way they run scenarios in school. Mainly, I don't like the fact that you have to verbalize everything. Yes, I realize that repetition builds memory, and memory is crucial for those high-stress moments when everything around you is falling to pieces. However, I want to be working with people who can think clearly under pressure and not revert to an automatic-pilot-mode "Oxygen, Monitor, Vitals" crap ... now what!??!?! I disagree that you need to verbalize everything in school. Clearly, if you're tearing the flynn kit apart, you're gonna be putting the patient on oxygen, or sticking in an airway, so why do you need to verbalize that? Your evaluators should have enough road experience to see where you're taking things ... Talk to your instructors, because I feel that you really need to learn how to multi-task. When you're riffling through the flynn and you're verbalizing out-loud "im searching for the bvm, here it is, im now going to bag the patient at one breath every 5 seconds for a total of 12 breaths per minute", it conditions you subconsciously to be doing the same on scene. So when you're actually on a call doing this, your silent for that time period because you weren't taught to do anything else. (This would be one of those school world vs. real world things) I believe it would be more prudent to learn how to search and apply equipment simultaneously while acquiring relevant scene and medical history from your patient and bystanders then blatantly stating what you're doing. peace

Well, this can be simply answered by ... where do you want to work when you're done? If you want to work for Durham EMS, then goto Durham. If you want to work for Simcoe EMS, goto Georgian. If you want to work for Toronto EMS, goto Centennial. Although every person will have their biases towards individual colleges for whatever reason (just look at the new private CTS program, it's having higher first-time success rates and scores on the AEMCA then most community colleges, but the graduates are still being ostracized from services), it's all up to you where you want to work. The community colleges are just that, community based. They serve the communities they are located in, and have very close ties to the EMS system in place in that region. So, should you fancy Durham, Simcoe or Toronto, goto the school in that city. If you don't care where you work when you're done, then listen to the opinions of others. It's your choice! peace p.s. congrats on getting accepted, it's dog-eat-dog for PCPs right now in Ontario.

Actually, Dust devil is right. MedicMal (and any others wishing more information about the practice of paramedicine in Ontario), this is EXACTLY the reason why the Ministry of Health changed the title of the provincial exam from EMCA (emergency medical care assistant) to AEMCA (Advanced EMCA). The AEMCA exam now includes scenario questions regarding the use of medication administration and defibrillation, and the ministry was smart enough to figure out that yes, this changes everything. As BLS providers, you're allowed to perform advanced life support skills, hence your symptom relief and defibrillation program. Even though these are thought of as BLS drugs, they certainly are not. As you advance yourself in your profession, you'll come to realize why things are set up the way they are. Ever wonder why ACPs are allowed to give first time nitro, or administer Epinephrine EITHER SC or IM and you're not? Symptom relief has only been around for 10 years now, and defibrillation about 15. The medical directors of the various base hospitals are still getting comfortable with letting PCPs giving these meds. Defibrillation in and of itself is still a controlled act, and since you're not technically licensed to practice the same way as your ACP or CCP counterparts are, this is why your defib algorithms are the way they are. Basically, you put on the pads and press analyze and let the machine do the thinking. ACPs and CCPs interpret the rhythm and choose how they want to proceed. peace