zippyRN

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4mg costs more than 10mg?? Not questioning the by numbers being correct, just dont know why more costs less?

probably based on the volume they sell

while it seems some people are wedded to doses that i'd consider ' won't touch the sides' like 2 mg being the total dose rather than the initial bolus .. and others will use 10 mg and titrate .. which might leave 4mg out in the cold volume wise as the actual cost ofthe drug is probably small compared to the cost of the prefilled device like a carpuject ...

speaking of multiplexed control systems , this is the kind of thing most kit in the Uk is being fitted with

http://www.carnationdesigns.co.uk/18way.html

or the very similar Woodway optilink

http://www.woodwayengineering.co.uk/top.html ( click on control )

now i'm not suggesting you should even consider the two above ( unless Whelen will support the opti-link as Woodway is the UK Whelen main agent/ type approved assembler) but multiplex doesn't mean pain in the ass - also could some of the touch screen systems not be installed/ programmed with custom 'frontpages' which replicate the functions of something like an optilink with big clear 'respond' 'scene' 'leave scene' 'arrive' 'clear' etc 'buttons'

as cost is all ways an issue you might not go with touch screens but it doesn't mean that multiplexed isn't an option if you chosen builder can provide you with a simple® control panel or 2 for the cab and saloon and door-way repeater panels for lights / steps / ramps and panic alarm.

I know I mentioned livery in my first post but people have been quite since - how much 'passive' warning via livery does your existing vehicle have and would you be open to looking at a livery with more passive warning capability. Even if it were just chevrons to the rear rather than the whole battenburg cake deal increasingly common in Europe ?

Tarascon Pharmacopoeia 2011 priced Morphine at $$$$ which is greater than $100 but less than $200. Fentanyl is $$$$$ which is greater than $200 but $$$$$ is the highest notation of cost in the book. Chemotherapy costs for one treatment is $$$$$ and it costs thousands of dollars. So Fentanyl is more expensive & in the Pr-Hospital setting; the service will not carry both; if there's an option. It just makes financial sense. Unfortunately, heathcare must make financial sense for the institutions and patients is foremost than the care. Well at least in America. All the best....

do you know what the actual price, as in cost to produce, of morphine is ?

well under a dollar ( US, Loonie or Upside Down it doesn't matter) for a 10 mg ampoule ...

Thank you all so far for your replies, one of the other nurses and I in the department have been talking about having ride along time as a mutual agreement time between us and the ambulance service. We want to see more of the ambulance officers world and they see ours. And work it into our technical competencies to maintain ER nurse credentials. Mainly in the aspect that to understand things like MOI, further develop our IV skills *like majority of us can cannulate bloody well in the ER, but work on enhancing them out in the patients home*, acute coronary presentations in patients homes etc.

It's also an aim to strengthen relationships between medics and RN's and move out of our comfort zones. I would love to achieve ECP status one day as an NP working on the rapid response units with the advanced paramedics and nurses and Medics working together to get patients stabilised and perhaps with the NP scope of practice, doing things in the homes to minimise ER admission and patients can be followed up by distric nurses etc.

Look forward to more input, thank you all again

Scotty

Has a certain person being praising the Army (TA) and Johnner Nurses of his acquaintance ... and their flexibility , willingness to do transfers and their all round rugged charms !

Has the same person been praising the relationship between the ED and the Ambulance staff at his previous place of work as well ?

ECP ( Emergency Care Practitioner) works the biggest boundary in the UK has been the obsession with the A8 response time which lead to ECPs being used as overpaid responders ( to the point I know of people who voluntarily 'demoted' themselves back to an ambulance line as a band 5) or alternatively being BONGOs as the sector controllers were too busy playing catch up on the A8 target to think aobut deploying the ECP to ECP able calls

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Speaking from an international perspective the "less levels with higher education and scope of practice" is certianly the trend; Canada and Australia have already done it (can't speak for the NT/WA systems at all there), New Zealand is moving towards such a system over the next little while and well I'm not sure what to make of what the UK has done with the "Emergency Care Assistant" thing.

Emergency Care Assistant roles, especially the band 3 roles were a management bloody nose to the 'uppity' Techs who thought they should get band 5 pay same as a paramedic, in a few services they did get band 5 e.g. the London EMT4 role and the Yorkshire AS 'TWAT' role ... it was done to prove a point and for a cash saving

Band 4 Assistant practitoners is another cash saving idea, they are what techs 'should' have banded at and what some services banded their techs at- their job evaluation score is kept down by removing the creep of extra decision making that got techs into band 5.

Overall the UK is now closer to a Paramedic on every Emergency Ambulance than it ever was before because of 2 main factors

1. more direct recruitment to planned out 'Student Paramedic' pathways i.e. where there is a 'course' in place from the beginning rather than sending people on a tech course + driving and then saying you have to keep applying for para courses as they come up ...

2. ECAs and APs to backfill techs being abstracted to attend Paramedic training ( whether that's 'quick and dirty' IHCD courses or seconded out to HE based Diploma/ foundation degree), as this was one of the issuesi nthe past with releasing people for Paramedic courses.

Not seen them used in the field here, however dropped them in at work. Not seen it routinely done for intubated patients either. We use charcol here and its not used that much, but still use it time to time. Had a run of three days where I was giving charcol and there are some nurses been there longer than me haven't yet given it. One was for an anti-depressant OD that we caught early enough, *like took the pills, called 111 and then had vomited most of them up so was within 30 mins* and so gave her a big ol cup of charcol to swig back and she did it like a trooper.

I am going to ask about NG though in arrests, and also about OG's as haven't used or seen one of those.

Scotty

an NG or OG tube on anyone intubated is great idea esp. if they've been ventilated with pharyngeal or no adjunct - this is one of the things which hacks me off slightly about those Anaesthetists or Resus Officers who oppose supra glottic airways on hospital crash trolleys - it's not instead of the anaesthetist dropping an ET when they are there it's stop the ward staff and/or the medical SHO from distending the patient's belly in the initial stages ...

an NGtube on an a patient with bloated , belly from gas or gastric stasis who is distressed because of it is a good measure, randomly putting NG tubes down any surgical patient is ritualised care and doesn't take account of the damage you can do with an NG tube

We put one in the other night when this drunk chic chewed a bottle of xanax right in front of us...but the crazy thing is hospitals in our area are steering away from gastric pumping and lavage...cause its so messy...that's crazy if you ask me...but they say it ain't killing them...they can just sleep it off...blew my mind!!!

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rarely indicated vs charcoal in recent ingestion and very very risky if performed on the unanaesthetised patient alternatively the issues of anaesthetising the patient and the risks and resource implications that brings ...

Dwayne and Bieber have posted a lot of relevant and spot on stuff here

there are a number of things you need to address

1. what is the purpose of your placement, are there specific competencies to be signed off ?

2. do you have a named mentor / preceptor for the placement ? is this a requirement for the programme ? are you routinely working with your named mentor?

3. what 'extra' do you want to learn from your placement

Don't over think the medic- nurse issue in the 'getting in the way' issue, having a student of any profession can be a real pain in the behind for the mentor ... especially if you are relatively limited in what you can be set off to do with reduced supervision - when you've got 'senior' students or supernumerary preceptees the student can be an effective 'force multiplier' but if you aren't in a position to do that you can 'slow things down' and if the pressure is on workload wise it;s unsuprising you feel 'in the way'

another thought with respect to the OPs personal situation - is it common for people where you are to go straight from EMT class to paramedic class without Any ride time ?

if this is rare then you might find that it's harder work for your mentors as they aren't used to this ... All my new crewmates in my EMS role are all experienced Events first aiders and/or community first responders so have got a certain level of skills in various areas of practice and it's more about shifting up a gear thinking like crew and adding in the extra decision making and psychomotor skills rather than looking at the whole package from rookie status ...

firstly congratulations on your appointment

potentially with the relatively wide open spec you've got you could innovate depending on the willingness of the organisation and the flexibility of the suppliers

livery ( i.e. passive high visibility), moving and handling , crashworthiness ...

not a lot to add to the above three posters except, i find IFT and Doctor's urgents (admissions) to be a wonderful training ground for breaking new crews in, far better than events or doing low priority emergency calls where the patient walks on and walks off

as others have said consider it a Hazmat scene , and that the patients need decontamination before transport .... which means a proper decontamination set up - which means either activating your equivalent to HART or that Fire respond if they do decon at scene.

the recieving hospital needs to be informed in case they want to decon again before the patient comes into the department, you and the vehicle may also need decon - decon at hospital is a valid option for the crew.

This is not necessarily what I want, but it is what is needed to ensure the survival of our industry:

1. Medical Directors should be held liable for the mistakes of the company's employees. Once they have that fear in place, real training will occur.

they and the employing ageny are vicariously liable anyway, what you actually need is increased accountability of the providers in the field to a professional regulator i.e. 'proper' Health Professional Status

2. We need to go to a mandatory tiered system. The current economy will not support double medic trucks, it is a tremendous waste of resources. There is no reason to have EMT-B's, they should be banned from ambulances.

the whole ALS/BLS split thing is peculiarly USAn way of thinking especially as you point out that EMT-Bs have so little preparation for practice

3. I see no reason to mandate college degrees, it just makes more money for the colleges. To those who think it brings respect, would you respect a plumber with an associates degree more than you would one that has no degree but has 10 more years experience ? Our job is a blue collar job, park your ego, and deal with what we are. Be a good EMT/Pmdc skill-wise. An AKC registered dog's shit smells the same as a mutt from the pound. Paperwork does not make you better.

odd then that elsewhere in the World , paramedics ARE Health Professionals and earn the same or more than the 'Bedside' Registered Nurse ( for Same example the UK where both jobs start at AfC band 5 , for same or more the Dutch -Scandinavian model where the 'Paramedic' is an Nurse practitioner

4. All ambulance models should be crash-tested and brought up to car standards, airbags in the box, better restraints, more crash worthy in a rollover.

something which has been in existence in Europe as a 'voluntary' but effective compulsory CEN Standard for 10 or more years ( though not with airbags in the salloon as far as i am aware) , along with better manual handling practice as well

5. Any shift longer than 12 hours should be banned. If a longer shift is still permitted, you should not be allowed to work the shift immediately following, at any provider.

yep agree with that - again effective health and Safety / employment law should make that a complete no-brainer

6. No one under the age of 21 should be allowed to work in our industry. I am sorry, but if you have 1-2 years experience driving a car, are you really competent to drive an emergency vehicle ? Wonder why you dont see any 16 year old 18-wheeler drivers ?

symptom of driver training ( or lack thereof ?) and the way in which some localities have their driving licence structured , if you make ambulances vocational licences either specifically or by weight / mass and then require proper driver training , not just a 16 hour classroom course ...

7. You should have to pass a real "skills test" atleast once per year, where failure means you come off the truck until you prove your competency (every drug, every skill).

effective skills audit through field based assessment by properly prepared Team educators and lectuer practitioners ?

8. You should have to dress like a professional (no tshirts, no polos).

why ? especially given that polo shirts are an increasing staple in Emergency services uniforms around the globe ... now if you said 'stop looking like plastic policemen ' with shiny badges and arms full of boy scout badges ....

9. Each department should reflect it's community in minority make-up in employees and financial budget. We have been too "white-male" for too long, where the money goes to supplement the pensions of old white guys who make decisions that help the future old white guys. If your population is 70% hispanic, your workforce should be 70% hispanic, which means you have less white chiefs, and use that money to produce scholarships to medic school.

2 main issues one easily solvable one much harder without a backlash

1. resolve or minimise cultural bias in recruiting and retaining ,

2. changing viewpoints among populations both inside and outside the profession, as has bee nseen with certain south asian ethnicities and Nursing i nthe UK - if the members and leaders of the ethnic group consider the role to be 'below' members of the group as it is dirty or demeaning - then they can't expect to see the profession matching proportions in the wider community ...

10. Your system should be profitable, or atleast break-even financially. The tax payors should not have to waste money on your chief's EMS Kingdom, full of too many non-productive work hours (hours not running calls), expensive trucks, too many personnel for call volume, not enough cheaper BLS trucks to handle the majority non-ALS calls. To do this, private interfacility transport services should be banned, all ambulance transport that occurs in a companie's "borders" should be handled by the licensed 911 provider. If you are not good enough to be a 911 provider, you should be in the wheelchair van business.

part of the problem is the fragmentation and too smallness of the services - this is apparent in many US fire services and EMS services where the service is stand alone around a relatively small centre of population rather than serving populations of millions and areas approaching State sized ...

Can anyone confirm or deny if this is just in Canadian areas, or if this is more international in scope?

occasionally floated in the UK but never seems to happen, sometimes Hospital Resuscitation ( training and audit) Officers are Paramedics and they will come to crash call in the hospital or trauma calls in the ED and work as part of the team if needed

other ROs are Nurses or ODPs and do exactly the same.

some ECP schemes rotated ECPs of whatever background through Comms, on the road and ED / minor injuries units

Its all a joke, the only thing that saves cardiac arrest patients is immediate CPR and defibrillation. Until we start doing our jobs and educating the community to CPR and have the vehicles to deliver a defibrillator in 4 minutes or less, we are wasting our time. Pour the whole drug box in them everytime, you still will have less than 10% that walk out of the hospital.

as the sums from in hospital arrests show ... I think i'm doing well with a 66% ROSC and 33% 6 month survival on my last couple of years of in hospital Cardiac arrests ( make it 75% and 50% if you include the guy who never quite made it to peri-arrest thanks to my my colleague and a switched on locum Doc... and us spotting his hyperkalaaemia and low Mg...

ROsc from pre-hospital arrests generally relies on the first 3 links of the chain of survival being in place and being there in seconds to minutes ... which is why the figures in hospital can seem good as drop to shock in all the places i've worked has been routinely 30-90 seconds

the easiest way to make a Small Fortune from Ambulance Operations is to begin with a Big Fortune ...

A key question in curriculum design is the clinical placement structure and the duration of of the course , placement and didactic phases

From the UK perspective a Pre-Registration Nursing Course must have 4600 program hours split 50/50 between didactic and clinical and a minimum academic content of a level 5 award (Diploma of Higher Education = 2/3s of a Bachelors degree) although there are plenty of 'advanced diploma', Degree even Masters pre-reg programmes as well as graduate entry Postgrad Diploma.

The College of Paramedics recommends a minimum placement experience of 1500 hours for paramedic pre-reg programs and the HPC currently accepts 'equivalent to' Level 4 academically - which is the 'traditional' IHCD course , most of the University based courses are level 5 ( either Diploma of HE or Foundation Degree) are level 6 Bachelors degrees.

None Medical Health professional courses in the UK nearly always include aspects of 'early patient contact' as do a lot, but not all, Medical Degrees, which some of the proposals outlined above seem to ignore ... i'd be interested in the rationales people have against early clinical exposure or whether this exposure would be there in the courses in the modules suggested just not as specific units of study until later in the course.

There is no clear cut answer as it varies from service to service and some may require all of which you listed and some may require none.

and to truely mess things up I'd been doing Command roles at events before I was crew qualified - and doing 'command support' roles since I was a teen.

do you take mastercard? Visa? American Express? Just swipe your card and go.

What's next, taking chickens in lieu of payment like the old country docs used to do.

I actually have a physician friend who treated an amish boy for a fractured hip from a fall from the roof of the barn he was helping build. You know, an Amish Barn Raising.

The Amish community pitched in and built the physician a new detached garage. He saved 20K on building costs and the amish family saved the entire cost of the medical procedure.

that's a 'cash equivalent' transaction at the end of the day ...

the issue with pay before ride is as has been pointed out

1. A crew deciding something is minor and it actually being serious , regardless of whether the person travels or not

2. creates a fear of activating the service for calls that are serious incase people are charged

3. public disquiet over what is an isn't considered 'life threatening' i.e. indigestion in an over 35 year old - could be an MI .... and should be getting a 'free' ride' where a broken arm might not be getting a ride especially in an area where BLS has no analgesia options

I'm with Kiwi and Dartmouth Dave on this ... in that we've got someone with 2 lots of depressants on board ( the Booze and Morphine) and a I doubt the Gabapentin is helping either, who is likely to be acidotic because of what's happened and what he's got on board ( the Aspirin) . the Glucose stuff definitely bears consideration as well.

HBEMT - DTs ? from an opiate - especially in acute overdose I'm not sure where you are coming from if you mean DT as in delirum tremens or other withdrawl symptoms ... or do you mean DTs as in something else

Thanks to the internet and smart phones, many soldiers can be posting on facebook or surfing the web and 30 minutes later be in a firefight with the Taliban.

because the CoC does have the cojones to run Op. Minimise ? despite the opsec and persec risks to uncontrolled use of phones with out of theatre IMEIs ....

But these accusations are a typical left wing response- either you agree with our opinion or you are a racist/bigot/homphobe/xenophobe, etc. That is a logical fallacy and a false choice.

the Logical Fallacy is that sexual orientation has the slightest bit of relevance to effectiveness in doing a job. It is those who support baseless discrimination that need to address their issues rather than the standard for the USA ad hominem of calling anyone who isn't somewhere to the right of Attila the Hun a Communist .

At the end of the day the people with the problem about this are those who cannot or will not see beyond arbitrary descriptions and place a lesser value on human life because of these arbitrary descriptions... Plenty of Militaries have abandoned these arbitrary restrictions recognising that banning gays or DADT is;

1. pointless because sexual orientation has no impact on the ability to do a job there's not even the 'provable' physiological factors that can be used to justify sexist or racist policies...

2. a PERSEC risk which increases the risks because of covert behaviour or the threat of blackmail.

That does it. He's a troll. Post reported.... time for you to crawl back under the bridge...

AOL (me too!)

Zippy RN

Sorry, Doc, but on my list of priorities for this country right now, the issue of gays in the military comes in at around 250 out of 250. I also would NOT consider this a basic human right, as defined by the UN.

so you support the imposition of arbitrary requirements based on the bigoted ideas of others ?

straight or gay vanilla or kinky makes no difference to combat effectiveness ...

I heard a number that said since DADT was initiated, 14,000 soldiers have been discharged because of sexual orientation. Me being the cynic that I am- I wonder how many of those folks who were "outed" were actually gay, and how many were looking for a way out of their service. Whatever. So, let's add up what percentage of the total fighting force this actually comprises? I'd guess it's probably statistically insignificant.

and how many dedicated and competent soldiers/ sailors/airmen were disciplinary discharged for nothing more than a pathetic excuse?

I am not a soldier, so my opinion of this is completely irrelevant. I've seen polls of soldiers giving completely opposite opinions on this issue- depending on who is doing the asking. Whether it's good, bad, or indifferent to the military, is NOW- while we are still actively fighting in Iraq and Afghanistan- really the best time to repeal this? Is even the potential for such a distraction to our soldiers a good idea?

the only people who are 'distracted' by this issue is people who are gay or bi but won't admit it themselves, it's complete none issue for for people who are secure in their orientation or secure that questioning your orientation is Ok ...

ty for the post link and i dont have any experience with patient care, Im taking this as a high school class (stat regulated class) so i have not taken a first responder class and i dont realy get what you mean by public facing, do you mean dealing with family and such

'public facing '

anything where you deal with the public e.g. working in a shop , running a stall at a fair or fete , reception duties at school ... stuff where you have to deal with strangers ...

They want us to do alot of hands stuff at the end of the clinical the superviser fills out a sheet that says how much observing do we do, how much hands on stuff. (divided into many things like vitals) and if we are not doing alot of patient assessment our teacher will want us to work on that. Yes but our teacher stressed this is not a third rider thing this is hands on you will be dealing with real people and real lives. thank you for the information

Excellent extra information there Kyle - this makes it easier to give you more advice.

You need to make sure who you are crewed up with is aware of what you need and what you want to get out of your placement and what you need to be signed off on, don't run before you can walk though , what (if any ) experience in patient care and /or public facing roles do you already have ?

Underdawg's post is good and there's a thread looking at it from the other side at the minute as well, ok it's called precepting new 'medics' but a lot of the principles apply regardless of the level the new person / student on placement is at.

http://www.emtcity.com/index.php/topic/19280-precepting-new-medics/page__p__251090

Homosexuality is a mental disease. As far as the military goes, do women and men who are in the military shower together ? No ? Why not. duh for the obvious reasons. You may enjoy a shower where a homosexual is checking you out, I would not. And if my life is on the line, I do not want someone who is mentally ill beside me.

you really haven't got a clue have you ...

as for mixed showers ... well there's a few tales that could be told ...

the land of the free as long as 'free' is bigoted and sexually repressed it appears ...

lots and lots of good ideas in this thread there is not a lot I can add extra,

I'd echo what Dwayne and paramaximus have said about respect and treating your preceptee as an equal and peer - because after all once they are signed off that is exactly what they will be.

there are 2 reasons to intervene in another practitioner's care

1. they are going to harm the patient.

2. they are going to harm themselves or another member of the team.

personally i'm a fan of 'hot debriefs' and getting the preceptee to relate the rationales for treatment decisions while it;sstill nice and fresh , but without turning it into the Spanish inquistion