BushyFromOz

You know mateo, i wrote this nice reply to your long winded and at times completely of base rant, but i lost the post and really have lost my care factor to replying to you. But its quite clear the mental health patient your talking about and the violent non compus mentus psych im talking about are two different animals, so ill break it down to some dot points, i might even answer some of the questions you should have asked before you pulled your civil liberties speech on me.

• At no point did i say restraints are used in isolation as the only method of management
• Patients here are scheduled i.e "committed" for transport to a mental health facility in the field. In order for this to happen they must have among other things, bizarre behaviour and thought process, lack of rational thought and be a danger to themselves or others. They are extreme cases to be committed do not have a right of refusal and they do not have the right for autonomy, so your attempted civil libertarian intellectual bitch slap has failed.
• The very fact they have lack of rational though and bizarre behaviour and violence makes it absoluetly appropriate, not required, appropriate for restraint

• The very fact these patients are not capable of rational thought makes communciation strategies limited because, well, they are not capable of rational thought!

• We do not schedule (re "committ") people for "having a bad day"
• Restraint here is soft cuffs that enable a degree of movement but not enough to strike me or untie the restraints
• Yes i do talk to these patients, i even explain the necessity of them needing to be applied, and by and large those that can comprehend agree
• No i do not restrain everyone with a mental illness, I used the specific example of violent/previously violent and unpredictable because of the nature of their presentation makes it appropriate
• Your smug comment is, quite frankly, horse crap. US providers, that is, people who work in the states routinely, almost daily, comment about the lack of underpinning knowledge in the EMTB curriculum. I didn't attack your system, i defended the guy from new jersey when a lack of knowledge comment was levelled at them. You cant expect the guy to know about the ins and outs of therapeutic communciation, legal, ethical and moral obligations when you freely admit the the level of education is flawed. I dont really care either way because im not in the states, but either its adequate or inadequate, you cant have it both ways to suit your argument here mateo.
• Restraint is not therapeutic and at no stage did i say it was

And then there is this..... highlighted for your convenience

Placing patients and personnel in situations that are dangerous and make the requirement of the most extreme measures necessary as the primary intervention in lieu of not being the most appropriate treatment.

Perhaps you should tell me what is the most appropriate intervention for a paranoid schizophrenic, or any mental health patient who is scheduled, under the law i have described, which displays abnormal and bizarre behaviour, not competent of rational thought, who has already seen to be violent and aggressive without warning and is being forced into care as they no longer have the capacity for rational autonomous thought and therefore have no right of refusal, tell me again, if soft restraints is not part of appropriate management, what the most appropriate treatment should be?

What do you think i do, walk around crash tackling 16 year old depressed kids to the ground who are having had a bad day, give them 10mg of midazolam, then strap them to the stretcher prone, with a spine board on their back?

Off my soap box, i suggest you get off yours too.

No, I think you should become a good EMT to become a good paramedic

I didn't have to be an emt at all to be a good paramedic.

I fact many people here argue that there is little to no advantage in EMT before paramedic, so purely as a pre requisite for a proper program, i dont see an issue with it.

I would have though if it is only as a pre-requisite to a proper paramedic program you guys would be cool with it?

I did not make that assumption. I know very well that it will not always work, but an honest effort should be made first. I have seen some very violent and volatile situation diffused with effective communication skills.

I understand your desire to maintain a safe environment in the back of the ambulance, but really, restraints shouldn't be a first option. I have seen some otherwise calm and collected patients become agitated and combative when placed in restraints. How would you feel if just because you had lost your temper, then calmed down and became compliant, just to be tied up "just in case". I would be pissed and do everything I could to get out of the restraints.

Of course you did. You bashed the vollie from NJ up with your therapeutic communcations speech and then slapped the guy with a "you dont know how to communicate" comment. The forums are full of how limited EMS education is over there, how much of that would be covered in your average EMTB course? I bet this guys isn't the only one with a shortfall in knowledge... system error much?

My desire to maintain a safe environment in the back of my truck comes from a compliant psychaitric patient attempting to bash my head in without warning to obscond from the vehicle between hospital and the recieving facility. The very fact these people are deemed no longer competent through abnormal behaviour and thought process to make their own decisions makes this more than "losing your temper". Im not talking about the run of the mill depressed person with suicidial idealogy, I'm talking about the paranoid pschizophrenic who 5 hours ago was a raging storm and is now compliant. Once in a vehicle and its just you, the patient and your partner it becomes almost impossible to get restraints on if they arc up, so they get restrained or the don't travel with me "just in case"

Its legal and my safety trumps their need to feel loved every time.

Your reasoning is Sound Bushy.

does my explanation make more sense?

Yeah brother, no problems

There is a reason why so much has to be documented in a hospital setting and many steps must be taken before restraints are put on. In EMS many providers use restraints as a crutch or a first resort rather than a last resort to deal with psych patients.

And i would be one of them

Any hint of aggression of violence in this acute presentation, even if it was before my arrical at scene for transport then they get restrained, and this includes interfacility transfers.

I will not put my self at risk of a patient returning to their former aggressive self when its just me and my partner driving down a freeway in a shoebox, they get soft restraints.

You make the assumption that therapeutic communication skills always work, and that a patient intially responsive and co-operative will remain so

I absolutely agree with the statement that there is nothing worse than a crazy guy in the back who gets a little to upset with you. Even the best communication strategies can fail and calm patient can beceme very agitated and agressive without provocation or warning. Unfortunatley, it part of the parcel for some mentally ill people, but i dont condone lying

I liken it to two wet cats fighting inside a shoebox going down a slippery slide.

. I just want to get my certification as fast and cheaply as possible, since I need to have it before I start paramedic school in January.

Oooohhh..... i was getting anoyed then you ended with that... if thats your motivation then im cool with it.

But i live in australia, so i cant help you with your question

Welcome to the city

When i had it, the information we were given was that in cold weather the two gasses would seperate in the cylinder, but anecdotally i would say (after providing more than just anaglesia on a couple of occasions) that the cylinder sitting for any period of time lets it seperate, so i always made a point of shaking it up before any use, not just cold weather

CPR said the thing about self administration.

I have never seen it on a side effects sheet but my experience is that many people devlope a thumping headache, similar to post GTN

Decompression sickness and bowel obstruction were a contra for us - never bothered to look up the bowel obstruction one.

You need both the demand valve with face mask and that little whistle thing atachment as well for it to be flexible enough to work in most situations

Not sure, some of us didn't need the extra practice

Ooohhh! Smackdown

The garcia book is fantastic.

I think there is also a companion book with more ECG examples in it, is that right doc?

Back to the GCS thing, there is 2 parts to this for me. The first is that we perform the assessment as intended by jennet and teasedale when the situation requires it (granted, its for more than just head TBI) And this is for a couple of reasons. GCS 9 is the trigger point of some advanced interventions (RSI, IFS) and so making the request for additional support or performing the intervention requires GCS to be performed properly. Now that i said that we use it, we also (most of us anyway) fully understand the limitations of it as a tool, but in the absence of another easily applied assessment tool that is repeatable by all of our staff (over 3 thousand) it is i think appropriately used. I dont know if there are other / better tools, this is just the one we have.

The next is the use of GCS informally, and i dont really know how to explain this without sounding like a knob, but its kind of a broad statement that lets another ambo get a 'feel" for what you are looking at. An example i guess would be calling another car for assistance and instead of saying "respiratory failure and an altered conscious state", saying "respiratory failure and a GCS of around 7" just seems to enable peoples intuition and "gut" feeling to come into play, giveing them a slightly better idea of what you are looking at without having to go into all of the observations and vital signs and is particularly handy when im pressed for time. I think this "estimation" is very important.

Having said all that, because its part of our practice to use it both formally and informally is almost cultural so i guess its almost intuitively understood after 20 years

We all like making cool things like o2 tube in paper cups when kiddies get scared of masks, but if they are happy to use it then they are happy to use it. I dont get what your crew chiefs issue is.

I live in an all volunteer area. everyone has a dash light and two grill lights at least. My little setup here is nothing compared to most members of my squad. For instance, my friend has this setup: Star High-Intensity StarBurst Phantom

Whelen Avenger Dual

(6) SNGL 3 light heads

SNDL3 Deck light

Yea, so if my dash light and two grill lights is too whackerish for y'all, then don't reply to the post in the first place.

No bro, your reply is fairly whackerish though.

And all this time I've been sitting over at [another site - edited by Dwayne] waiting for you to come back, lol. Good luck in your studies!

Is this directed at me?

Classic

I think most of you are missing the point of what the original post is about. Is the current system supporting the communities it is supposed to be supporting adequately and appropriatley. The answer is no.

Root cause analysis would say the complexity and the politics of a volunteer system raises issues that are avoided simply by paid providers essentially having a contract to be on duty available to respond, with a minimium level of resources available and not pick and choose what they will and wont attend.

simple.

Setting aside economics for a moment I want to ask why volunteer?

Please don't say, "Because I want to give back to my community". You can do that picking up trash, serving meals at the soup kitchen, putting time in with Meals on Wheels, be a Big Brother/Big Sister volunteer and more.

Why do people so insist on volunteer EMS?

Same reason i volunteered for fire for a few years

Its a selfish motivation. Yeah, i helped the community, but thats not why i went there. I went there for someting to to do an meet new people. Riding a red truck was pretty cool and i learned new things.

It was all about what i could get out of it, not what i gave.

That's okay. Won't hold it against ya, bud.

hehehe.... sure thing

:D

I still cant get it out of my head that some people realy believe that of you recieve a paychek your somehow less dedicated than someone who does it for free.

i must have missed the point where anyone said anything about going against medical direction or protocol.....

No one advocating using it for A/Fib, the point of my question was to flesh out what clinicians would do in the event of a rhythm that is difficult to differentiate from AVNRT / AVRT or Atrial fib, not about figuring out if its worth trying on a "funky rhythm".

If i extrapolate you post out, if i am presented with said difficult rhythm and a decompensated patient, do i sit on my hands because i cant decide to revert it with adenosine or amiodarone, or, do i wait for them to declare themselves and either better or get worse, and if they do deteriorate and hope they sync cardiovert successfully?

Just putting it out there.

Thanks for the feedback guys.

Patient was stable but had the most "calssic: Iischaemic cardiac chest pain symptoms, i finally found one with retrosternal, heavy radiating to L arm and neck for the first time in 5 years and slightly hypotensive but not not crook enough to be in the sync cardiovert guideline.

Spoke to the ER doc afterwards, he basically said "when i cant figure it out, i beta block first" which is an answer I suppose.

The clinical department basically said that that adenosine for this patient given the story and the "in between" ecg is the correct course of action.

The Atrial Fib as a contraintidication appears to be more about making sure some dont try and use it on decompensated rapid Af instead of syncing them.

As it turned out, we wanted this guy on the stretcher instead of propped on the kitchen stool like he was, and he valsalva'd himself while we were doing that.

Thanks al

Thanks mike

This issue for us i guess is the "is it AVNRT or Af" when your looking at rates in excess of 200 and the rate is regular but not metronomically regular (as in the rate will have slight variation over a period of time, say a minute) as a true AV nodal re entrant should be, and i cant see any reason why you would not manage them as SVT as the insanely short half life makes it relatively safe if it is in fact atrial fib. Indeed i have seen several time in hospital of patients who are unsuccessfully beta blocked given adenosine as an almost diagnostic test of sorts.

But for us atrial fib is an absolute contraindication for adenosine, and i cant seem to find any supporting evidence of that, so the issue of is this SVT or really fast and regular atrial fib that much more of an issue for us.

3 days and only 106 views and 1 comment? Boy, this place has really slowed down over the last few years....

I believe Midnight Oil tried that as a song title... but it just didn't have the ring to it they wanted.

This works much better.

You know peter garrett is a federal politician now??