zippyRN

hello kyle

when you say you are starting clinicals ,I presume you will be 'third manning' rather than actively working as part of a crew ?

If this is the case, find out who you are going to be crewed up with and find out what they want from you. It might well be just to sit back and actively observe for a your first shift , so you get the feel of things, yes, you've got the knowledge from training but how much actual experience do you have with real patients ?

If you are brand new and green then any decent mentor / supervisor is going to let you get the feel of things and get comfortable with the environment and how things happen on an Ambulance , however if you are already an experienced and seasoned First responder or first aider, you have a feel for things in general and know how to talk to patients / relatives / other agencies and the new stuff is clinicla practice at your new level of training.

The other thing to consider is what are the outcomes required from this placement - is it simply to get the hours in or are you required to actually do patient care under the supervision of your mentor / supervisor , is there any other work associated with it ( probably not for a pure certification course , but if it's part of a wider training / education program there may well be .

You know Zippy, its almost time to put you into the troll catergorgy I think. I'm getting curious to see if you're even able to create a post that doesn't simply boast on your country or insult ours. Always with infantile spelling, grammar and capitalization of course.

Why am I a Troll?

- Because I challenge the received wisdom?

- Because I'm looking at a system which is acknowledged to be broken from the outside and feel no need to defend it ?

- Because I've pointed out that some problems have been solved elsewhere and 10 -20 years ago ( does that make Kiwimedic a troll for pointing out the Kiwis have been talking about field cessation of resus for the past 15+ years ?

Dwayne, your obviously an intelligent chap and care about developing Pre-hospital care and paramedic practice, if you want to start a war start it with the 'we don't need no steekin' book learnin' types rather than those who offer an alternative perspective , removed from the in country socialisation of EMS.

dwayne, have a pink icecream ...

Save the grammar fascism for somewhere it's appreciated.

Gays do not belong in the military. Why ? All queers are mentally ill, thus making them queer. We dont hand automatic weapons to people with mental illness.

I have some advice for

- hand your card in and never darken the door of an ambulance station again

- you are an utter disgrace, you need to get your issues sorted out before preaching to others

Ok, to all those who wish to play Coroner and call them in the field: Why do you load and go with traumatic arrest instead of working them for 20 minutes and then calling them dead ? A traumatic arrest has a less than 1% survival rate, much less than those cardiac arrest patients your are calling "dead", which have about a 10% chance depending upon where you live ?

And P.S.: The quality of prehospital intubation is far less than that of Anesthesiologists, but we still try. The same argument could be made for IVs started enroute.

again asking simple question questions ... ( which i note have been ignored from my previous post)

1. after 20 minutes of ALS in the field what does transporting a normothermic adult patient without " special considerations" achieve ? especially if they are asystolic despite all links of the chain of survival and enough epi/ iso to make a steak walk out the door and start mooing ... you have delivered the full range of care to this patient

2. does a traumatic arrest fall into the criteria of 'special circumstances' ... and are we talking blunt or penetrating ? and why does that make a difference ?

as for resourcing in hospital Codes - anything more than 5 or 6 people total is a cluster-feck waiting to happen

the best codes i've worked have had 4 providers hands on all of whom are ALS providers and all of whom can manage airways, defibrilate and do IVs ... and a 5th person as a runner who might get hands on for the odd 2 minutes of compressions.

in the ED we only ever had 4 or 5 people hands on - that was our rules as it kept the cluster fecks to a minimum - 2 ED nurses, 2 ED Docs ( one middle grade or senior , one junior) and the anaesthetist ( plus the aforementioned runner). that said we as a dept were known for 'throwing out' extraneous Doctors from trauma calls or making them stand in the corner behind the line and observe.

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With regard to the last paragraph quoted, I know we have a number of members on this site who serve in Marine and Army combat units. I would like to hear their opinions on this. Why and how would having a gay person in the unit hurt the unit’s ability to fight?

they are quoting the kind of bigoted claims that used to be used by the CoC as to why prohibiting homosexuals ( of either gender) from serving, as per usual the 'land of the free' is decades behind the rest of the civilised world...

Yes you should transport all of them, as it gives the family the peace of mind, that all that could be tried was tried. Does that mean you need to transport the obviouse corpse in an unsafe manner ? No.

To all those who say dont work them, I ask you what percentage of infant/pediatric codes do you call in the field ? If dead is dead, you should never transport a pedatric patient that does not respond to treatment.

in respect of the above assertions;

1a. what interventions in a normothermic adult patient with no evidence of any other special circumstances are available in the ED that aren't in the field?

1b. in 1a . above what, if any, is the evidence base for these interventions?

2a. what is the primary cause of Cardiac Arrest in the Adult (out of hospital) patient population ?

2.b What is the primary cause of Cardiac Arrest in the Paediatric patient population ?

3. when transporting the patient in cardiac arrest how good is the standard of CPR likely to be without additional technology? and what is the evidence basis , both absolute and in cost effectiveness terms for such equipment and technology ?

I remember in Mobile Intensive Care Officer class way back in 1994 being told that transporting cardiac arrests has no value ...

*checks calander, hmmmm

in the civilised world of EMS the idea of not transporting unless you get ROSC or there are clinical reasons pointing to special circumstances ( hypothermia, drowning, paeds , strong clinicla evidence of something which is correctable but not in the field) has been floating about for about that long.

So in my system we don't have the units to or practice "dual dispatch." We have about 15 BLS and 35 ALS units and the dispatch protocol goes like this. ALS Dispatches will go to an ALS unit if one is within 2 miles, if not it goes to closest unit. BLS dispatches will go to BLS units within 5mi of a call, if no bls then closest. Trauma runs...closest. Code Blue...Closest and ALS if one is within 2 miles.

Now the topic at hand. Our dispatch protocol states a "ONE seizure, with history of and patient is breathing normally" is a BLS call.

Thoughts? Comments?

breathing normally = not actively seizing ,

hx of seizures = the top 2 diagnoses

-1. someone with a seizure disorder or

- 2. an alcoholic who who is suffering from ETOH deficiency.

if someone is not actively seizing what the treatment from any EMS provider whether first responder or a full blown Field Physician + Paramedic / PHRN ? supportive care and offer transport to the ED to be checked out

end result = none emergent transport for evaluation or discharge at scene depending on service / state protocols / guidelines and patient preference ...

To expand on the topic, "Abdominal Pain" 35 years or older is an ALS dispatch. Now I haven't met many abdominal pains I work up, but I guess its because over the phone abdominal pain can be vauge and acutally be so much more.

rule out AAA or atypical presentation of acute MI

while it's only two patients

parent or grandparent or a paed patient taken ill while you are treating the little 'un ...

tests the providers not only on patient care but working together as a time and the psychological care of the patient

given the presentation and history , the worst case scenario has to be assumed

sepsis of unknown origin possibly viral haemorhagic fever ...

which means the full three ring circus and a retrieval by an appropriately trained crew and a high security infectious diseases team

http://www.royalfree.org.uk/default.aspx?top_nav_id=5&tab_id=453

mental capacity and competence are the keys to whether any refusal / self discharge is valid.

If you are unsure about a patient's competency or capacity make it someone else's problem there and then , a supervisor, a police officer or the patient's primary care practitioner ( i.e. Doctor or Nurse Practitioner)... in most settings supervisors and/or the police are most easily accessed.

Partial refusals are an interesting issue , some people maintain they can't exist and it;s 'my way or the highway' ... an example there would by the patient who has mechanism for a potential spinal injury, and you can't / won't fulfill the criteria or a selective immobilisation guideline / aren't allowed use one ... but the patient is adamant they are not going on a long extrication board and do not want the 'cheese wedges' claiming they are claustrophobic...

the 'my way or the highway' camp would say they sign the refusal and don't get transported , the 'partial refusals exist' camp would collar the patient , place the patient careful on the trolley, use sandbags or rolled towels/ blankets to provide the 'reminder' immobilisation and document to hell and back ...

'young people' can be an interesting area to deal with i.e. teens under the age of majority - and it depends on what the law says where you are, for us in the UK it's the Fraser and Scarman rulings in the Gillick case ...

http://en.wikipedia.org/wiki/Gillick_competence

also the stuff around the concept of the 'emancipated minor' and whether it requires a legal course of action to establish the young person as legal competent or whether like the gillick case, competence can be determined 'on the fly'by the practitioner...

No those are credit hours, so to get 128 credit hours it would take a full time student taking 12 hours a semester around 4 years to complete. This would include summer sessions

credit hours are 10 :1 actual hours and it seems about 2 credit hours = 10 UK 'credit points'- as 'full time' in HE in the Uk is 60 credits / semester , 120 credits / year

The team has no bearing whatsoever on how good you are. They can make you look better, but they cannot make you better. And making you look better is a false sense of success. It's a crutch that dooms you to mediocrity. I don't care how good my "team" is. I only care about how good I am, and how well the team listens to me and follows my directions.

If it has no relevance explain the day we (Student Nurses) spent running round the peak district doing a 'treasure hunt' .

If it has no relevance explain the reason we set 'ridiculous' scenarios as part of CPD and then artificially restrict the assistance available ( no HART/SORT , No Helimed , no fire+rescue) to make people think out the box rather than just say ' call for help '

there is no 'I' in team , but equally TEAM stands for Together Everyone Annoys Me ! there is a balalnce to be struck between the provider who cannot function without their team to back them up and a paragod who rejects the value of the team ...

a lot of the key factors are emerging

what does the 12 lead say , is this actually asthma or is it 'cardiac asthma' as a symptom of failure

is the patient beta blocked ? and what does that mean if you want to give him Salbutamol ( Ventolin is a trade name).

high flow ? or high FiO2 ?

just be glad you aren't in the UK

you are effectively uninsurable for the 10 years a Drink or drug driving conviction remains on your licence.

Your BC is showing . The clamshell most of us from BC refer to is a FERNO ScoopEXL. Excellent piece of kit and one of my personal favourites for many reasons.

as in the nice newish plastic bladed jobs

http://www.ferno.co.uk/product/scoop-65-exl

... they are pretty swish and address quite a few of the issues with metal scoops

12 leads are not an option with us yet. Been trained, still waiting for the updated equipment.

has this post been stuck in the ether for 10 years ?

Well they were all wrong. There is no criteria in any accepted c-spine clearance protocol that considers how long a person has been walking around. It doesn't matter if the injury was yesterday, we should be backboarding these patients in the field.

if you cannot apply the criteria for selective immobilisation then appropriate immobilisation is indicated , and as fiznat points out no 'clinical clearance' or selective immobilisation guideline includes time since the incident as a factor.

If a physician tells you he took an x-ray of the spine and is recommending that the patient be secured to a long board for transport, just do it. I don't see what the issue is here.

the initial issue is a red herring - if the providers at that ED can't or won't clear the neck then the patient should be immobilised for transfer to a facility that can provide the further care.

the question actually is

what (if any ) method (s) of immobilisation are best for the patient on this transfer , especially if it;s a transport of several hours duration.

my own opinion is that neither the long(extrication)board or the scoop stretcher are appropriate for the job and that they pose as many problems as they solve in a secondary transfer scenario.

the gold standard would be to scoop onto a vac mattress and transport that way ideally with a proper C-spine immobilisation collar (i.e. an Aspen or Vista) rather than an extrication collar, there is a school of thought that well strapped onto a stretcher with collar and head blocks is adequate, the principle problem there is 2-fold - its a 4 or 5 person roll if they vomit rather than one or 2 for someone well secured to a long extrication board or in/ on a vac mattress and the issues related to crash suvivability in a vehicle without a CEN compliant trolley and locking system and extra straps to replicate the strapping on a long extrication board ...

The consensus opinion given in the likes of JRCALC on how long someone should be on a long extrication board is less than 30 minutes, although the practicalities of transporting to the initial recieving facility may make that hard to achieve, I certainly would not advocate placing someone back on a long board as a routine matter for secondary transfer especially if the journey is going to be more than 20 -30 minutes , but equally if their neck or back is not yet cleared and immobilisation is indicated due to actual or potential unstable spinal fractures they must be appropriately immobilised for that secondary transfer.

the long board is the wrong device for this scenario - vacuum mattress please TYVM...

As a Registered Nurse, I'm already bound by the rules and regulations of the NMC, I adhere to those rules and to my Code of Professional Conduct and I'm proud of my practice. One of the reasons I left St John was because they were restricting my practice (being told not to touch any cardiac patients at a major event but to, instead, wait for the Drama, sorry, Trauma Squad to arrive was in clear breach of my Code of Conduct. I'm trained in ALS, PLS and ACLS, but was not allowed by St John to use those skills, even though I volunteered to come off duty in order to treat a patient. I couldn't have my professional hands tied behind my back like that. Really, I suppose though, I should be very grateful to St John. Despite being a charity, it charges for its services and we've picked up a lot of work when St John have cancelled duties at short notice because volunteers decided they couldn't work on the day.

I don't recognise any of that from the last 10 - 15 years in SJA which represents my adult service with the organisation and my involvement with operational and clinical management activities, the only concern I have from a professional practice point of view with SJA has been a reluctance to explore routes of making more medications available to suitably skilled RNs and ODPs, despite the apparent hypocrisy it has displayed over medicines legislations and IHCD technicians .... however this is down to the hard work of volunteers and paid staff in the counties I routinely work with and whom NHS and Private Sector event medical management teams are happy to contract work to.

As for "despite being a charity it charges for it's services" I think your understanding of Charity law is a little lacking, AS giving money, goods or services to another charity is not a charitable aim of SJA as lodged with the charity commissioners it is required to charge 'at cost' services it provides to another charity , although this can be offset by an exchange of services. A charity cannot enter a loss making arrangement with a for-profit organisation , therefore charges to 'for profit' organisations must be at or above 'at cost' where a not for profit organisation is not a registered charity and where the charitable aims of the organisation can be demonstrated to be met then work can be done for less than cost praice.

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Think yourself very lucky you have the support of a voluntary organisation. If you come out into the real world and try to work in the private sector you'll find life much harder. Many of us have wanted regulation for many years - it's ludicrous that anyone can buy an old ice cream van, put a few stickers and a couple of lights on it and call themselves an ambulance service. Thankfully, we don't run ambulances any more, that's one less thing to worry about, especially as we don't receive them free from people like the Masons - unlike our local St John.

To be honest the biggest block to regulation was the NHS ambulance service in the closed shop days, as they simply did not acknowledge the existance of providers other than themselves and the VASes

Do I see a little green eye d monster peeking out here ? the fact Organisations who have as their charitable objectives raising money for the benefit of Charities choose to donate to SJA, the major (national) donation by the Mark Master Masons was over 10 years ago, if lodges or localities have donated since that is a lodge / locality decision and not a national one.

In some cases grants or being the subject of a fundraising campaign is down to effective relationship building and not necessarily down to the names involved, i'm aware of an independent event cover organisation who recieved the donation of a fully equipped ambulance from an NHS Acute Trust which had used it for critical care transfers and had purchased an new vehicle for that role....

St John can obviously afford the extortionate fees but for small, independent partnerships like ours (and there ARE good services out there) it will be difficult. £1500.00 just to register is way above what many will be able to afford, on top of the annual fee they're going to charge.

The fact is the regulatory need is the same and reading the CQC guidance SJA will be registering on at least a county basis and in some cases may be registering on an area basis depending on county structure, so that will be 30 something lots ( excluding the none England 'counties' in PoE+I ) and should similar legislation come in covering Wales SJCW will be registering on a regional basis rather than nationally i suspect.

Have regulation by all means, but make it fair and make it affordable and STOP moving the goal posts - we received a letter from the CQC this week to say we now have to register in December, rather than in April.

the registration has from the outset been BY April 2011 i.e. all organisations would be registered before

Although the regulations only specify that records should be kept securely (I HAVE read the regulations), the CQC are insisting that we can no longer work from home because they don't want records stored in private houses so, instead of having records securely locked away at home, where there is almost always someone present, we now have to find premises (with all the attendant costs) where we will only be present for a few hours a day and where we'll still be using the same, secure storage units. Perhaps the CQC should look at some of their interpretations.

perhaps they should, or perhaps it needs to be queried as there are other registerable activities which could concievably be run from home or in an office attached to a home

Huh?

the moral of the tale was DEFG

don't ever forget glucose

How many providers is not the issue assuming there is appropriate audit, assessment and enforcement of the providers to ensure a reasonable standard of care is provided by all the providers...

The key has to be how the system as a whole is integrated and communicates - it doesn't matter if you have 1, 2, or 23 provider organisations as long as they appear to the 911/999 system as a single entity providing cover across the service area - this also means that provider organisations have to be able to fulfill their commitment in providing the cover they have allocated to them to provide to an acceptable level. This fits with the model of separation of 'production' of 'unit hours' i.e. physically having crewed resources in the right place at the right time with the right skill mix and 'distribution' of these 'unit hours' (by control /comms ...) ...

DEFG

that is all

The scenario states that weather won't allow for air transport. Your only option is ground.

won't allow helimed to fly in a operating to VFR 1 pilot + two Aircrew trained flight medics MD900 / EC135?

or

won't allow a 2pilot + radar op + winchman S61, S92 or AW101 to fly under IFR with NVG and a nitesun ? one advantage of the Uk being 'long and thin' is that the landmass is double covered not only by Helimed but by the HMCG / military SAR aircraft as well

A lot of it is attitude of both crews and management and also system design

If you have a system which sets a response standard with a tight time frame for all calls there is a pressure to gain every second, especially if funding is dependant on meeting the response standard ( as seen i nthe Uk with the Orcon standards where failure to meet the time standards regardless of clinical outcomes attracted 'fines' from the commissioning body )...

At this point the AMPDS wallahs will come in and say that AMPDS has it's place here - which to some extent it does in that you can triage some calls down to a less pressured response - such as the 30 min or 1 hour standards that some places in the UK have for the AMPDS codes that fall into Orcon cat C ... - this is where the marginal differences in response time but substantial risk profile changes can come around ... exactly how far can you drive from station in 8/10/ 15 minutes under normal driving conditions ?

At this point the SSM wallahs are also jumping up and down with their powerpoint presentations of predicting where the next call is and response isochrones from standby points and 'order of merit' of standby points ... SSM has positive impacts but equally the ssystems where SSM is implemented on the cheap i.e. standby points which are literally a pin in a map you upset crews, local populations and the treehuggers ...

This is all response side issues the next issue is to risk assess the benefits of transporting patients under emergent conditions, there are some occasions in which this is arguably a clinical necessity but in other scenarios is this the case ? what is the clinical need for the rapid transport ? why are crews transporting dead bodies on lights and siren for the ED doctor to call in in the back of the vehicle or after a curory round or two of ALS in the ED ....