Timmy

I see fire responding to medical calls in Australia as a growing trend. While in all states here the emergency services are government funded there still very separate services. The current tend in and around Melbourne is to send a fire truck to all cardiac arrest calls but at the same time the closest ambulance is dispatched.

I actually have no problem with fire responding to such calls as I believe the chances of survival are greatly increased with rapid response and application of AED ect. The problem I have is recently we’ve been having trouble with ambulance staffing and response times, the media reports the government to promote fire and first responder type services as the gold standard to fix there dilapidated response times. We have a very good ALS/Intensive Care paramedic service in my state, there very educated individuals but at times the recourses are spread few and far between, we really need more paramedics on the road instead of bandaid solutions like setting up fire to respond to medical emergencies.

After the fires of Black Saturday in 2009 that killed hundreds of people the government pumped the fire service with money to cover up there mistakes and to “reassure the public” that every measure had been taken to improve our response if it happened again, this pressure came from the coroners inquest, coronial enquiry ect ect.

Recently the media has been focusing on the ambulance services mortality rate due to limited resources, the government promises more paramedics but I certainly don’t see this happening in the more rural areas, in fact they’ve cut the graduate paramedic program quiet significantly. I’m sure they have increased the numbers in the metropolitan and more larger regional areas but we still have single paramedics working ridicules hours and when they get a job or go on fatigue leave there’s a massive timeframe were the smaller rural towns have no ambulance cover.

Were almost treated like second class citizens in the country, the government is closing hospital beds, we have 1 (sometimes two) ALS ambulances and 1 on call at night for 8,000 people, the ambulance service made no attempt to put on extra crews during the busy summer holiday season when the areas population can boost by 40,000 people camping along the river and our fire trucks are certainly not equipped with AEDs or dispatched to medical calls.

We don’t so much have a problem with fire taking down the education standards for paramedics, it seems using fire is a quick and cheap alternative to putting on more ALS paramedics and makes it look appealing to the media that there equipping fire to cover there ambulance response times. Oh the political games….

Thanks very much for the feedback, much appreciated. Apologies with the delayed response, things have been a little busy.

I’m just after some advice on how you guys manage a chaotic scene.

I had an incident last night involving multiple patients, I was single officer, upon arriving I found about 40 bystanders (family, friends & event officials) in mass panic, some of which were hysterical, people swamped the ambulance as I pulled up, demanding my attention, while I’m trying to assess the patients a bystander shoves a phone to my ear having already called 000, I had the clinician on the phone wanting a situation report re ALS cars/choppers, while I’m half talking to the clinician half talking to the patient I hear “I’m a Paramedic, your doing everything wrong, get collars on these people” paramedic man stands there abusing me and offering his opinion rather than assessing the other patients or helping, I had family tugging at my shoulder to come over and help there family members. Triage was difficult because there were so many people standing around I could barley move or see the other patients in the sea of panicing people.

Despite all the mayhem there was actually no one seriously injured and in the end it all worked out, we got everyone that needed transported to a hospital and everything was fine.

I’m very nursing orientated, its so easy to push the red button on the wall and have a gaggle of medical personal with me within 20 seconds, we have security officers, we can lock people in the waiting room ect. A world apart from the uncontrolled situation I had last night.

I admit, I did a crap job of scene control and there were things I defiantly could have improved on. I wasn’t panicing myself but it was so hard to get around and get a good overview of what was actually happening. I’ve dealt with anxious people and high pressure situations before but never with so many people running around in such an uncontrolled manner with no backup.

How do you guys (being experienced pre hospital clinicians) walk in, click your fingers and have everything under controlled within minutes?

Challenging indeed, a very good scenario.

Let me just go over some history. The dude has a resp rate of 32, a pulse of 118, SP02 of 51%, his in respiratory distress with the possibility of it turning into a silent airway entry (based on ‘some short burst of air’). We assume his been compliant with his regular medication which includes a corticosteroid, he has a past history of CAL, his giving inappropriate information which could suggest hypoxia, his getting tied and were 1.5 hours away from help.

The dudes working hard. I’d like to quickly consult someone more senior before I move onto the next step but in this situation I think the saying treat for the worst and hope for the best would come into play. The last thing we need is acidosis.

To take a stab in the dark I’m going to assume this is an exacerbation of CAL but until we can get him to hospital, get some ABGs, FBEs, sputum, Chest Xrays and so on I will go with an RSI and Tube. Sux, midaz and fent. I know it’s difficult to manage vent pressures, complications with extrabation and the like with CAL patients but things are only going down hill with this guy. His already tired, maybe a little agitated so a BVM may cause some combativeness as would CPAP. With on scene time and transport lets say this dude will be in hospital within 2 hours by road I think the benefits would out weight the risks of an RSI.

BUT

On the other hand, we could get a line in and push some corticosteroids, gets some bronchodilators on board and go with the non invasive ventilation BUT I still have an little alarm bell sounding, is this patient a little to sick? If I did go down this path I’d like to see an improvement within a few minutes BUT has this patient been working to hard for to long? Will our non invasive efforts be rewarded with a massive crash down the slippery slide and we ended up in respiratory arrest.

Tricky indeed, tricky indeed… I think someone with such a crappy respiratory and perfusion status the more invasive the better until we can get a clear picture of what happening. But I’d defiantly like to consult someone more senior before I’d take the invasive approach.

Control bleeding.

Cervical Collars all round.

Oxygen all round.

Methoxyflurance (inhaled analgesia, easy and effective to use for trapped pts) to who ever requires it.

Chopper can start moving based on MOI.

Any risk of crush injury?

Baseline vitals if we can.

Just BLS until we can remove patients from vehicles.

Remove patients with spinal precautions/KED.

Depending on how long extraction is going to be will depend on if I’m going to jump into the car, get lines in, get monitors on ect ect.

Until we can get these people free from the car and onto the stretcher it’s hard to examine the patients and get a good picture.

Chest auscultation?

Has he been compliant with medications?

Im very cautious of the PHX AMI at such young ages!

Lets have some 02 (10L via mask)

Id like to get a line in and run some fluids for the postral hypotention.

He has symptomatic bradycardia (poor output from the symptoms of excertion) so I wouldnt rule out giving some atropine (considering his weight Id like to give 1mg)

Im not quiet sure what non diagnostic ECG means but Im guessing there is not heart blocks.

At the hospital will probably Dig load him.

If were not responding to the atropine then consider pacing if the patient remains symptomatic and adequate perfusion is diminishing.

Is there any other information youd like to share?

You now have an Intensive Care Consultant and Intensive Care Paramedic who arrived on the chopper. The chopper has a ventilator. CVC is in. Nil imaging or pathology available. We question a spinal injury from MOI but defiantly has extremely strong and equal bilateral limb movement (takes 3 of your to hold down his arm to get the second IVC in). Reflexes were intact before RSI.

As I said, there’s a positive spin to this story. What do you want to do with the ICP?

Likewise, thanks to everyone for there support and advice over the years. I’ll use Richards analogy here, remember all those years ago when that little annoying 15 year old ‘whippersnapper’ was the perile of your worst nightmares and made you sit bolt up right at night? Well 5 years later I certainly hope things have improved dramatically!

Even though I’ve been lurking around these parts for some years I’m still the fresh faced, green 20 year old who’s hopefully on the right track to becoming a competent and educated health care professional. I hope to be the recipient of some extremely welcoming news within the next few weeks (exam results) and I hope to be completing my last year of this blasted nursing degree next year and hopefully move onto the paramedic degree in the not to distance future, which is were my passion lies.

I sometimes feel a little out of my depth on here as the Bachelor of Nursing course I’m currently undertaking is a little behind the eighth ball when it comes to acute and emergency care, while we do have a few subjects that relate to acute patient care we do have other subjects such as mental health, health promotion and it appears to be more of a general overlook of health care rather than a straight focus on emergency care like the paramedic course. Our in-depth acute and emergency care is delivered within a post graduate diploma course, so at times I find myself not in a position to contribute effectively to the discussion and certainly find myself researching information that is posted here on a regular basis.

I also continue with my first responder standby gigs as I feel it keeps my finger in the pie when it comes to managing incident scenes and providing that first line emergency care (even though were just at a BLS level) which is just something nurses are not regularly exposed to. I also got a job as an LPN in a busy, regional emergency department which is quiet exciting and I enjoy it very much. It’s very challenging and a very steep learning curve, I sometimes wonder why they employed an inexperienced, young LPN because my education and knowledge is dismal compared to the other RNs and Doctors who I work with. When things get busy I’m left to deal with some very sick patients which is extremely scary (I sometimes come home shaking) but everyone is very supportive and incredibly more than happy to answer any questions I have or go that extra mile to show me how something works. I’m very luck to be employed in such a job considering the other 3 LPNs who work there have like 30 years experience and a lot more education than me.

In conclusion I thank you guys for all the advice and at times stern wake up calls that have influenced more career decisions, answered my sometimes silly questions and motivated me through the tough times. Hopefully I can be a success story and fortunately I haven’t burnt out as many of you feared all those years ago, the spark is still well alight!

His ICP is 28mmhg.

Nil further injury noted apart from ?spinal injury and clearly a sever head injury.

BGL: 6.4mmol

ECG: NAD

ETC02: 37mmhg

Its estimates he weighs 70kg.

RSI as follows:

Fent 100mcg

Midaz 7mg

Sux 105mg

I can give you his ICP if you wish to dabble with the associated pharmacology.

The posturing can indeed indicate a head injury (just depends on what his ICP is up to and were the bleed is) as well as a spinal injury.

Unknown gag reflex, tristmus is preventing us getting to his airway.

IVC is intravenous cannular.

You’ve got him to the local ER, old doc is a little hesitant to RSI and will wait for the chopper (can hear them approaching).

Now for the ALS guys… You’re in the ER, with the chopper gear… Go for it.

There’s actually a positive outcome to this case.

You have a 14g insitu on the right CF

NACI running

10mg metoclopramide IV

NSR on a 3 lead

Still have tristmus, NPA not recommended due MOI and trauma to head.

In the car he projectile vomits about 1.5 litres of content

You stop the car to maintain airway with suction and pop the patient into lateral position, IVC in and to recheck BP

You attempt to get another 14g in, in response to a painful stimuli the patient then sits up with eyes closed, no verbal response, still has decorticate posturing (noted flection in both arms and hands) then lye’s back down. The straps on the board have been removed in response to the patients airway needs, risk of aspiration and the patient has been placed in the lateral position, collar still insitu with cervical support as best as we can.

Patient is unresponsive to sternum rub but responses to peripheral stimuli.

Will give him a GCS of 5.

BP: 164/73 – P: 52 – R: 47 – SP02: 96% with intermittent 100% 02.

Right pupil is still dilated.

What is the location of the body?

The position that you found him in?

Before touching him, what is you initial impression of the person and the scene?

Going slow so that many can participate...

Dwayne

Sorry Dwayne, I completely missed your post!

The mechanism is the rider went over the tabletop jump, became air born at high speed, landing on the back of his head (head took all the impact), patient was found supine, was log rolled by first responders who removed the chest armour and helmet, onto scoop with collar and packaged, the patient has been moved onto a stretcher but remains track side.

First impression, the dude looks really sick. The rapid, swallow and noisy respirations are noted at first as well as decorticate posturing. Apart from dad being a little ansy about cutting the gear the scene is clam, everything is in control and running as smoothly as possible. The race is stopped and there are no dangers.

I have no problem with getting ALS involved. There is an ALS paramedic on scene and a first responder is an ED nurse in there day job.

Are we going to stay and play or scoop and run?

Only down side, the ALS paramedic can not RIS single officer.

Still having some airway troubles.

Nil CSF, raccon eyes.

Bilateral airway entry is good and equal.

Nill JVD

Chopper is on the way with a doc and intensive care paramedic, ETA one hour.

You’ve got the kid loaded, it’s not suitable to land chopper at the track. You can make it to the local hospital which has one ED bed, on call general doctor (who may or may not feel like tubing) within 20mins. The hospital has a chopper pad. Police are on scene and are happy to keep dad company for a bit.

You arrive to find the St John crew (standby first responders) have a packaged patient with a GCS of 8 (initially a GCS of 3 but improved slightly with 100% 02), decorticate posturing, tachypneic/shallow respirations sitting around 52 breaths a minute, right pupil is dilated, failed OP airway insertion X 3 due to trismus, having trouble maintaining a patent airway due to trismus and increased production of secretions.

Just to make things interesting the fathers become aggressive over the first responders cutting his motocross gear and refuses to let you cut any more… You have the chest exposed and the helmet was removed by first responders with cervical support for airway management. The helmet is smashed.

The first responders have completed a secondary assessment which is NAD.

Vitals:

BP: 183/115

Pulse: 92

Resps: 52

SP02: 95% with 100% 02.

Nill past history or medications, a very fit and healthy 16 year old in a whole lot of trouble.

G’Day Guys.

Just a little scenario we had happen here on the weekend, just after some different opinions on how you’d manage this patient.

You’re a single paramedic in a small country town, could be classified as a remote area.

Your called to the local motocross track (about 20 mins out of town) for a 16 year old male, unresponsive post high speed ejection from his motor bike during a race.

What would you like to know?

We use an Australian brand call “Neann” Long Spine Board and “DHS Aussiscoop” Scoop Stretchers.

I do agree with Dwayne, Scoops are great for limiting movement and immobilisation. I haven’t had much experience with spine boards so I can’t really comment on there performance. I sometimes come to grief with the scoops when we have a pelvic fracture or the crew decided to scoop a spinal injury instead of log roll when were doing motocross, dirt track or snow type standbys. Many times we’ve scooped a patient only to have dirt clog the clips at either end or you’ve scooped up a whole heap of dirt under the patients back.

I have had some trouble with the silver ferno scoops because the immobilisation strap space is quiet limited and it’s harder to immobilise the head compared to the DHS scoop, they seem to be a tad wider and more user friendly. I’m also a fan of using a few rolled up towels and some tape to immobilise a patients head, I find the various head blocks that are available on the market are time consuming, don’t fit scoops, expensive and don’t live up to the same level of immobilisation as a good old towel roll and some tape.

Its quiet an advantage the scoop divides in half, it makes it so much more easier to transfer patients from bed to bed were they can remain supine instead of rolling around. The down side to a scoop is it’s only a lifting device, not designed for transporting over long distances. We run into some trouble with this at the motocross when your knee deep in mud and can’t get an ambulance onto the track and have to walk the patient a few kilometres up a muddy hill. I get around this by having at least 5 people supporting either side, the weight is greatly reduced and if someone slips over in the mud there’s always someone who can take some extra weight. It’s probably not best practise but it’s the only way we can adapt to the situation.

In conclusion, I think a spine board is a spine board… You really can’t add many features to a flat peace of plastic but I’m certainly not the best person to consult on this issue.

In EMS we were taught to always keep the BVM away from the patient when shocking. I don’t think there is an extreme risk of the oxygen combusting but I guess the risk is still there. I’ve never seen a defib emit a spark but I guess it’s always possible.

I wouldn’t be removing the BVM from the ET tube because of the associated risks.

I guess the best advice anyone can give is just do what you’ve been trained to or what your policy dictates, that way your covered either way.

So… I’ve missed this thread but to be truthful I’ve never actually heard or seen Ammonia Inhalants used, certainly not current practise in Australia (either that or I’m living under a rock). To me, if you mention Ammonia it’s tripping alarm bells and the ‘holly crap’ factor from my HAZMAT course, it’s not uncommon for an orchard cool room were I live to have an Ammonia leak which is quiet bad news (BA, splash suits, decontamination areas ect). But obviously there are different chemical compounds and consecrations if you guys are using these chemicals on unresponsive patients.

To be truthful I really can’t recall seeing any patients ‘fake’ unresponsiveness. At work were pretty aggressive with treating unresponsive patients, it’s not uncommon for 5 or so people coming at you with shears, airway management gear (OPAs, LMAs, ETTs), bag valve masks, suction, monitor dots, sticking for blood glucose, getting a line in, getting bloods, catheterising ect… If you have a GCS of 3, to 8 all this would be done within 5 to 10 minutes and we’d probably have you on the way to medical imaging or surgery depending on diagnosis or what ever track further investigations are heading. I’d guess we’d soon know if you were faking or not.

I like to work with the KISS (keep it simple stupid) principle (must be the Australian in me, were all pretty laid back), benefits outweigh the risk, less invasive the better ect ect.

The risk of osteomyelitis (greatly increased in the pre hospital setting), the grumpy OD who wakes up swinging then walks off into the sunset with the IO still insitu and all those further risks are very real, why do we need to put a patient at risk when a less invasive procedure is just, if not more effective than jumping to battle stations.

It’s a bit like watching the surgical and medical registrars ‘debate’ patient care, very amusing, indeed, anyway…

In my very limited experience and exposure to such events I’m probably not the best person to give feedback…

I think IO is gaining in popularity and seems to be seeping into more and more practitioners scope of practise, fantastic tool when things are going down hill quiet rapidly.

I think we need to paint a better clinical picture here, was gaining a peripheral or central line not available at the time? Poly pharmacy overdoses can sometimes dehydrate quiet quickly making peripheral cannulation quiet challenging. Every case is different and I wasn’t on scene but if the patient is ?maintaining a patent airway or even had adequate perfusion with ventilation and had an output, I think I’d be more incline to go with an IVC or CVC and use IO as a fallback. I’ve only witnessed IO used as a last restore in a resuscitation case were peripheral access was challenging secondary to sever dehydration, I’m also aware IO may be indicated and the access of choice for paediatrics patients in some strife.

IO is quiet out of my depth and I really haven’t researched it much but I’m guessing the onset and peak of medication though an IO may be slightly faster than a medication administered through an IVC due to direct diffusion into the medullary canal and coming into contact with the red blood cells, of course Naloxone is hepatically metabolised so it may just be faster to give the medication into the venous supply.

Not much you can add to this… Pretty sad and sick. You Americans seem to have some pretty bizarre people working emergency.

A little off topic but I find it sad how people have this increasing inappropriateness to use there phone in silly circumstances. The girl sitting next to me at nursing graduation was on Facebook seconds before we were called to the stage and completely ignored all the other graduates being presented before us, the doctors who answer there phone in the middle of a consultation or rounds, I’ve seen paramedics on Facebook while there partner is treating the patient, nurses carry there phones around while on shift and you find them hiding in the corner Facebooking and generally people playing around with there phone instead of socially interacting or concentrating on the task at hand! Surely there are more pressing matters than a status update or general chit chat… I understand some calls are important and need to be answered immediately but on the whole I think people have this increasing urge to use there phone inappropriately and in inappropriate circumstances.

You only have to look at 90% of the videos on Youtube to think people have nothing better to do than stand there and pull out there phone to ‘capture the moment’.

As for the above situation, it actually doesn’t surprise me. I mean… what else is there to do at a car accident with a timed critical patient?…. After all, good quality patient care, a bit of compassion and good communication skills is to hard these days…

In Melbourne the State Ambulance Service has a program with the Metropolitan Fire Brigades called ‘Emergency Medical Response’. Pretty much encumbers a few pumpers in and around Melbourne who have an AED, 02 bag, collars and first aid kit who respond when the ambulance service have limited resources. On the whole there only called to cardiac arrests but sometimes turn out to other medical calls. The program is pretty much based around making targeted response times and making things look groovy on paper, I think it’s just putting a bandaid solution to a bigger problem…. But that’s another kettle of fish! I will admit there training is pretty good as far as basic life support is concerned.

Certainly in the country we have nothing like this, due to the OH&S regulations all fire appliances carry a first aid kit, picture a large fishing tackle box with basic supplies. First aid training is a little dilapidated, we’d be lucky if one in fifteen had a first aid qualification that hasn’t expired (there’s about 50,000 volunteers). Never the less, the paramedics are never far away and the powers at be are pretty good at getting a first aid crew from St John or Red Cross to hang around if it looks like a long job.

In Australia were lucky everyone sticks to what there names entails i.e. ambulance = medical, police = law enforcement, fire = fire suppression, rescue = rescuing people, hospital = doctors and nurses etc etc… Rarely is there a cross over…

Hey buddy. Everyone deals with death in there own way. Im 20 as well and have dealt with quiet a number of patients who have passed away, fortunately most of which were palliative care patients but unfortunately I have been involved with death at motor vehicles accidents, sudden death in ED and so on.

Theres no easy way about it but in the end everyone has to die, its a fact of life, some die young, some die old. No one can stand here and tell you how to feel, how you will react or how to deal with your feelings because everyone is different.

Unfortunately living in a small community your more than likely going to know or know of most of the people who die so it makes it a little harder. I was involved in the care of an adolescent patient who was transferred from a tertiary facility in the city for palliative care management post failed excision of a brain tumour which had metastasised. He arrived at us fully alert and orientated, for pain and symptom management, he was with us for 4 weeks, in that 4 weeks I became pretty close with him and his family (being a similar age I guess it was easier to bond and get along). He ended up being on infusion of morphine, metaclopramide and midazolam. I ended up having to give him so much medication he was pretty sedated and unresponsive which was extremely hard for his family. We he past away we just supported the family, offered reassurance and what not… When I got home I spent 2 hours sitting on the floor of the shower crying, just my way of dealing with it I guess.

Youll never get use to death but you develop ways to deal with it both at the scene and once the situation is over. Theres nothing easy about seeing people who have past away in car accidents, helping the ambos extricate the body, patients who come into ED and crash and even palliative care patients who are expected to die.

Youll always remember the first deceased person you see. Its easy to forget about your welfare and state of mind, sometimes it takes a while for the adrenaline to wear off or youre busy looking after everyone whos around you and forget about what your feeling and when you get home it all hits you at once. Its important to talk about what youre feeling with someone you trust, work colleges or peer support and look out for symptoms of PTSD.

I wouldnt recommend crying in front of everyone, sometimes youre the only one who isnt hysterical and people really appreciated someone of sound mind hanging around to offer support. Of course you tear up on the odd occasion but breaking down into a complete crying fit would not be recommended.

EDIT - I forgot to mention anger! After some jobs you doubt your self and you often find yourself flashing back on how you could have improved or done something different. This is such a common occurrence for us, on the odd occasions I’ve beaten myself up over things I could have done better. The fact is sometimes little mistakes happen but what done is done and you live and learn. On some patients there injuries are just incompatible with life and despite your best efforts things don’t always have a positive outcome.

Hope this helps