Paramedic Treatment of Pulmonary Embolism


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Paramedic Treatment of Pulmonary Embolism

November 7th, 2013

Any patient who presents with signs and symptoms of a pulmonary embolism should be treated as a medical emergency. As pulmonary embolisms rarely present with a clear clinical picture, paramedics must maintain a high index of suspicion with any patient who presents with shortness of breath without a clear clinical cause.

A pulmonary embolism is often caused by the formation of a deep vein thrombosis (DVT) which then breaks free and travels to the lung, causing a blockage within the pulmonary artery. Depending on the size of the thrombus, and the location within the pulmonary arterial tree, this blockage will result in a minor decrease in oxygenation of the blood through to a complete obstruction resulting in sudden death.

It is not uncommon to treat a patient who appears to have a minor respiratory problem, who on further investigations is determined to have a pulmonary embolism. Not all pulmonary embolisms are fatal, but they should all be treated with urgency.

Treatment of a pulmonary embolism first starts with identifying the possibility that a patient has one.

Signs of a Pulmonary Embolism

The following are signs of a pulmonary embolism that paramedics should be aware of:

1. Sudden increase in shortness of breath.

2. Chest pain, particularly pin pointed chest pain. Cardiac chest pain is often difficult for a patient to describe. They will often complain of a heaviness or a funny feeling over the entire chest, where as a person who has a pulmonary embolism will normally describe a sharp pain at the point of the blockage. This makes it particularly difficult for the assessing paramedic, because it is often initially identified as pleuretic pain.

3. Pain or swelling to the calf muscle.

4. Increase respiratory rate without clear clinical causes, such as asthma, COPD, CCF. Be cautious with the patient who appears to be simply hyperventilating, but denies any recent cause of anxiety in an otherwise healthy person.

5. Severely decreased oxygen saturations in a person who has clear breath sounds.

6. Tachycardia, as a means of compensation.

7. S3 and S4 gallop.

8. Cough.

9. Hymoptysis

10. Lower extremity oedema.

Associated conditions that may be the result of a pulmonary embolism or a sign of a pulmonary embolism. These can be applied to a variety of our otherwise well patients!

1. Seizures.

2. Fever – surprising a lot of patients with a pulmonary embolism have a increased body temperature.

3. Abdominal pain.

4. Flank pain.

5. New onset of atrial fibrillation.

6.  Syncope.

7. Delirium.

Remember, unless you look for it, you will miss it!

Pulmonary Embolism Key Points in History

Because the signs of a pulmonary embolism are so varied it is most commonly picked up by taking a thorough history. The following are vital signs a paramedic should consider when taking a history of any patient who has shortness of breath or chest pain, with an unexplained cause:

1. Recent travel – a study in 2012 identified as little as 4 hours travel within the past month is enough to cause a DVT which then results in a pulmonary embolism.

2. Surgery in the past 4 months.

3. Previous diagnosis of a DVT or current diagnosis of a DVT.

4. Recent trauma to the pelvis or lower extremities.

The following are key risk factors that increase the likelihood of a patient getting a pulmonary embolism:

1. Tobacco smoking.

2. Oral contraceptive use.

3. Sedentary lifestyle.

4. Obesity or large calves.

5. Varicose veins.

6. Any known clotting disorders.

7. Chronic obstructive pulmonary disease.

8. Chronic heart failure.

Upon identifying a high likelihood that a patient has a pulmonary embolism a paramedic should focus on urgent transport to a definitive hospital that ideally has cardiothoracic surgical capabilities. The patient should be oxygenated with high flow oxygen if conscious. IV access and early hospital notification should be provided, but not if it will delay the patient getting to hospital. Little research has been completed on pre-hospital use of anticoagulant therapies, but potentially these will come in future years.

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Signs of a Pulmonary Embolism

November 7th, 2013

A pulmonary embolism is often caused by the formation of a deep vein thrombosis (DVT) which then breaks free and travels to the lung, causing a blockage within the pulmonary artery. Depending on the size of the thrombus, and the location within the pulmonary arterial tree, this blockage will result in a minor decrease in oxygenation of the blood through to a complete obstruction resulting in sudden death.

As a paramedic, it is vital to maintain a high index of suspicion in any patient who presents with chest pain or shortness of breath. It is not uncommon to treat a patient who appears to have a minor respiratory problem, who on further investigations is determined to have a pulmonary embolism. Not all pulmonary embolisms are fatal, but they should all be treated with urgency.

The following are signs of a pulmonary embolism that paramedics should be aware of:

1. Sudden increase in shortness of breath.

2. Chest pain, particularly pin pointed chest pain. Cardiac chest pain is often difficult for a patient to describe. They will often complain of a heaviness or a funny feeling over the entire chest, where as a person who has a pulmonary embolism will normally describe a sharp pain at the point of the blockage. This makes it particularly difficult for the assessing paramedic, because it is often initially identified as pleuretic pain.

3. Pain or swelling to the calf muscle.

4. Increase respiratory rate without clear clinical causes, such as asthma, COPD, CCF. Be cautious with the patient who appears to be simply hyperventilating, but denies any recent cause of anxiety in an otherwise healthy person.

5. Severely decreased oxygen saturations in a person who has clear breath sounds.

6. Tachycardia, as a means of compensation.

7. S3 and S4 gallop.

8. Cough.

9. Hymoptysis

10. Lower extremity oedema.

Associated conditions that may be the result of a pulmonary embolism or a sign of a pulmonary embolism. These can be applied to a variety of our otherwise well patients!

1. Seizures.

2. Fever – surprising a lot of patients with a pulmonary embolism have a increased body temperature.

3. Abdominal pain.

4. Flank pain.

5. New onset of atrial fibrillation.

6.  Syncope.

7. Delirium.

Remember, unless you look for it, you will miss it!

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What is Hirschsprung’s Disease?

September 16th, 2013

Hirschsprung’s disease (HD) is a disorder of the abdomen that occurs when part or all of the large intestine or lower parts of the gastrointestinal tract have no nerves and therefore cannot function. During normal fetal development, cells from the neural crest migrate into the large intestine (colon) to form the networks of nerves called Auerbach’s plexus and Meissner’s plexus. In Hirschprung’s disease, the migration is not complete and part of the colon lacks these nerve bodies that regulate the activity of the colon. The affected segment of the colon cannot relax and pass a stool through the colon, creating an obstruction.  In most affected people, the disorder affects the part of the colon that is nearest the anus. In rare cases, the lack of nerve bodies involves more of the colon.

Typically, Hirschsprung’s disease is diagnosed shortly after birth, although it may develop well into adulthood, because of the presence of megacolon, or because the baby fails to pass the first stool meconium within 48 hours of delivery. Normally, 90% of babies pass their first meconium within 24 hours, and 99% within 48 hours. Other symptoms include: green or brown vomit, explosive stools after a doctor inserts a finger into the rectum, swelling of the abdomen, lots of gas and bloody diarrhea.

The relevance of understanding Hirschsprung’s disease for paramedics is relatively limited to the fact that paramedics will treat these patients for associated conditions such as abdominal pain, bowel obstructions, nausea and vomiting. Consequently, it is important to have some background understanding of the disease.

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Explosions and Blast Injuries

April 17th, 2013

Explosions and blast injuries are fortunately very uncommon in most countries. With the exception of working as a paramedic in the defence forces during active service, it is unlikely that you will ever attend a patient suffering with severe blast injuries after an explosion. Unfortunately, although very infrequent, terrorists acts do occur as well as accidents involving explosions, so it is important to have a basic understanding of explosions and blast injuries. 

It is important to understand that explosions cause significant and complex injuries to people and even a minor explosion, such as one caused by the reaction of a heated aerosol can has the potential to cause significant injuries often hidden internally.

What is an Explosion?

An explosive material is a reactive substance that contains a great amount of potential energy that can produce an explosion if released suddenly, usually accompanied by the production of light, heat, sound, and pressure. An explosive charge is a measured quantity of explosive material.

This potential energy stored in an explosive material may be one of the following 3 types:  chemical energy, such as nitroglycerin; pressurized gas, such as a gas cylinder or aerosol can, and nuclear energy, such as in the fissile isotopes uranium-235 and plutonium-239. It is also important to understand that uranium may be used in conjunction with traditional chemical explosions to create a dirty bomb.

The most common of these three types of explosions seen by paramedics today is pressurized gas explosion often as the result of burning of aerosol cans or gas cylinders for barbeques. It is important to remember that not all explosions are intentional terrorist acts.

Explosive materials may be categorized by the speed at which they expand. Materials that detonate (explode faster than the speed of sound) are identified as “high explosives” and materials that deflagrate are identified as “low explosives.” Explosives may also be categorized by their sensitivity. Sensitive materials that can be initiated by a relatively small amount of heat or pressure are primary explosives and materials that are relatively insensitive are secondary or tertiary explosives.

Mechanism of Injury of Explosions

Primary injuries are caused by blast overpressure waves, or shock waves. These are especially likely when a person is close to an explosion. The ears are most often affected by the overpressure, followed by the lungs and the hollow organs of the gastrointestinal tract. Gastrointestinal injuries may present after a delay of hours or even days.  Injury from blast overpressure is a pressure and time dependent function. By increasing the pressure or its duration, the severity of injury will also increase.

In general, primary blast injuries are characterized by the absence of external injuries; thus internal injuries are frequently unrecognized and their severity underestimated. Although poorly understood, there is a general agreement that spalling, implosion, inertia, and pressure differentials are the main mechanisms involved in the pathogenesis of primary blast injuries.

Secondary injuries are caused by fragmentation and other objects propelled by the explosion. These injuries may affect any part of the body and sometimes result in penetrating trauma with visible bleeding. At times the propelled object may become embedded in the body, obstructing the loss of blood to the outside. However, there may be extensive blood loss within the body cavities. Fragmentation wounds may be lethal and therefore many anti-personnel bombs are designed to generate fragments.

Most casualties are caused by secondary injuries. Some explosives, such as nail bombs, are deliberately designed to increase the likelihood of secondary injuries. In other instances, the target provides the raw material for the objects thrown into people, e.g., shattered glass from a blasted-out window or the glass facade of a building.

Tertiary injuries are caused by the displacement of air by the explosion which creates a blast wind that can throw victims against solid objects. Tertiary injuries may present as some combination of blunt and penetrating trauma, including bone fractures and coup/ contre-coup injuries to the brain.

Quaternary injuries are all other injuries not included in the first three classes. These include flash burns, crush injuries and respiratory injuries.

High-order explosives produce a supersonic overpressure shock wave, while low order explosives deflagrate (subsonic combustion) and do not produce an overpressure wave. A blast wave generated by an explosion starts with a single pulse of increased air pressure, lasting a few milliseconds. The negative pressure (suction) of the blast wave follows immediately after the positive wave. The duration of the blast wave, i.e., the time an object in the path of the shock wave is subjected to the pressure effects, depends on the type of explosive material and the distance from the point of detonation. The blast wave progresses from the source of explosion as a sphere of compressed and rapidly expanding gases, which displaces an equal volume of air at a very high velocity.

The severity of the blast injury is subject to the following criteria: the peak of the initial positive barometric pressure, the duration of the overpressure, the degree of focussing due to a confined space, the medium in which it explodes.

The most important things to remember when you attend an explosion or treat a patient with blast injuries are: don’t become a victim yourself, look for dangers, and get the patient and yourself out of there; transport urgently to definitive surgical care, these patients are going to have major injuries, whether they’re visible injuries or internal. Reassurance, oxygen therapy, burns dressings, IV access and analgesia should all be provided en route to hospital. Traumatic amputations quickly result in death, and are thus rare in survivors, and are often accompanied by significant other injuries – if you are on scene early enough, arterial tournequets may just save a life.

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Joint Injuries and Dislocations

April 16th, 2013

A joint dislocation occurs when there is an abnormal separation in the joint, where two or more bones meet.  A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma to the joint from a direct impact or an indirect impact from a fall. As a paramedic, our main goal is to achieve adequate analgesia and ensure reasonable distal perfusion en route to hospital. If inadequate distal perfusion is possible, the patient should be urgently transported to hospital due to the risk of ischemia to the limb.

Unless specifically trained to do so, paramedics should not routinely attempt to relocate a dislocated joint. Any joint that has been dislocated has the ability to damage surrounding ligaments, tendons, muscles, and nerves. Even in hospital, most patients who have had a dislocation will have an X-ray taken before Medical Staff attempt to reduce the dislocation.

So, what are the priorities as a paramedic treating a joint dislocation?

1. Reassure the patient – they’re limb appears to be in an awkward position, this is going to be frightening.

2. Adequate analgesia – this may mean lots and lots of morphine. Generally, these people are young, fit and healthy (and playing sports) so they can handle a lot of morphine.

3. Check distal perfusion. This means checking the colour, warmth, movement and sensation distally, as well as checking for the presense of a distal pulse.

4. Splint if this can relieve some of the pressure. Generally, a person with a shoulder dislocation will have their arm in the best position for themselves and there is no benefit in trying to adjust the arm so that it looks nice in a sling. Talk to the patient and see if what you’re doing is going to help.

5. Perform a thorough head to toes assessment. If they have had enough trauma to dislocate a joint they are likely to be injured somewhere else.

6. Take them to hospital.

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Seizure Assessment

April 16th, 2013

Paramedics attend patients who are having a seizure on almost a daily basis. Consequently, paramedics should understand the disease processes related to seizures and be confident in their prehospital management. In general, with the exception of a patient in Status Epilepticus, seizure management should be relatively straight forward.

So, what is a seizure and what causes it? Basically, a seizure is any unusually excessive neuronal firing from the brain which manifests as changes in a patient’s motor/sensory control, sensory perception, behaviour and autonomic function.

At a chemical level a seizure occurs when there is a sudden biochemical imbalance between the excitatory neurotransmitters and inhibitory neurotransmitters. The primary excitatory neurotransmitter found in the human central nervous system is called N-Methyl D Aspartate (NMDA); whereas the primary inhibitory neurotransmitter is called gamma-amino butyric acid (GABA). When there is an imbalance between these chemical mediators repeated firing and excitations of the neuronal cells occur. Depending on the area of the brain in which this occurs, the seizure will manifest as a focal seizure, sensory change, behaviour disturbance, or complete tonic and clonic muscular activity.

Paramedic Assessment and Treatment of Seizures

As a paramedic these are the steps that I take to assess and treat a patient who is having a seizure or is post ictal:

1. Position the patient on their side and remove any dangerous items from the patient. If the patient is sitting, try to assist him or her to the floor. The safest place for a person who is having a seizure is on the floor or in a bed with rails so that they are unable to fall any further and injure themselves. I try to get a pillow (if possible) to place underneath their head and keep their airway naturally open. Don’t try to place anything in their mouth to protect them from biting their tongue. It won’t help and is only likely to cause more harm.

2. Reassure their family members or bystanders. Anyone who has witnessed a seizure for the first time will understand just how frightening it can be. Particularly if you are treating a child and their parents have never seen a seizure.

3. Assess the patient’s airway for patency and respiratory rate. Most people who have seizures have only very short periods of apnoea, but some may have prolonged periods. Normally, the airway can be protected by laying them on their side and if required a nasopharyngeal airway can be inserted (but shouldn’t be required in all patients).

4. Benzodiazepines have been used as the mainstay emergency treatment of seizures. IM or IV midazolam is generally very successful in control seizure activity. Benzodiazepines increase the activity of GABA by binding to the benzodiazepine site on the GABA – A receptors, which potentiates the effects of GABA by increasing the frequency of the chloride channel opening and causing an inhibitory response in the CNS.

5. Gain an accurate seizure specific history of the patient. Ask questions such as:

– Does the patient have epilepsy?

– When was his or her last seizure?

– Did he or she take their anti-epilepsy medication today?

– Has there been any recent changes such as illness?

– Has there been any traumas to the head, such as recent falls or direct hit to the head?

– What was the seizure like today? Was it the normal presentation for this person, or was it different? If so, how so?

– Does the patient normally have subsequent seizures, or just the one?

– What type of seizure did the person have? Were there arms and legs shaking (tonic/clonic movements), or was it just a focal part of the body?

– Is the person a known alcoholic? Or, has the person been recently withdrawing from alcohol or benzodiazepine use?

6. Assess the patient thoroughly including an assessment of their: airway, breathing, circulation, disability, and exposure. Make sure to take their temperature and check their blood glucose level, because changes in either of these are known to causes seizure activity.

7. Provide oxygen therapy for all patients who appear to have had a seizure or who are having a seizure. As each cell becomes polarized and the subsequent muscles contract large amounts of oxygen is utilised.

8. IV access, where possible, should be gained prior to moving the patient, especially if the patient is known to have multiple seizures.

9. Perform a thorough head to toes assessment to check for any trauma caused prior to or as a result of the seizures. Check that the patient hasn’t bitten their tongue.

10 .Assess pupils for signs of a stroke, arm strengths, face symmetry and speech.

11. Make a mental note whether or not the patient has been incontinent of urine or faeces.

12. If this is their first seizure or they have epilepsy but have no clear cause for the seizure activity today, it is vital to transport them to hospital for further investigation.

Seizure Causes

For patients who have been diagnosed with epilepsy the most common cause of seizures are either sub therapeutic levels of anticonvulsant medications (most commonly the patient has been non-compliant in taking their medications) or there is a problem with the patient’s pharmacokinetics (such as a disturbance in their ability to absorb, distribute, metabolise or excrete the medication, most commonly seen during periods of infection).

In patients who have never previously been diagnosed with seizures the following are potential causes:

1. Alcohol or benzodiazepine withdrawal

2. Brain tumour or neoplasm

3. Traumatic head injury

4. Hypoxia

5. Drug overdose or poisoning

6. Eclampsia (pregnancy related hypertension and seizure activity)

7. Metabolic disorders (primarily hypo or hyperglycaemias, but also hypo/hyper natraemia often associated with women who start crash diets involving the consumption of large amounts of water)

8. Infections (meningitis or encephalitis)

9. Drug use

10. Hyperthermia (most commonly febrile convulsions seen in children)

Whatever the cause of the seizure activity, it is important to treat the seizure early. The longer a seizure is allowed the last the greater the potential risk to the patient that they will become status epilepticus. Never leave a patient at home who has had their first seizure ever or an unexplained seizure.

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Do Paramedics Drive the Ambulance?

February 3rd, 2013

Yes, paramedics drive the Ambulance. Paramedics both treat patients and drive the Ambulance. In general, paramedics take it in turns each day to treat or drive the Ambulance. Most paramedics enjoy their driving days because it makes an easier day for them in which they can rellax. Many paramedics argue that they only really work half the time (because all they have to do every second day is drive the Ambulance).

Can you be a paramedic and not drive the Ambulance? No, most Ambulance Services require the paramedic to be licenced and capable of driving the Ambulance. If a paramedic loses his or her licence they become unable to work and often lose their job. Many paramedics have lost their licence and consequently their job and the same time. This is why it is important to maintain a clean driving record if you want to become a paramedic.

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Do Paramedics Wear Scrubs?

February 3rd, 2013

No, paramedics do not wear scrubs. Paramedics wear a paramedic’s uniform, which provides safety from the elements (cold and heat), fire retardant, and is clearly identifiable to the public. The paramedic’s uniform is vitally important to the paramedic’s safety as it clearly identifies him or her as a paramedic and not an intruder who is comming into a person’s house in the middle of the night.

The international colour of the medical uniform is green. However many paramedic uniforms in Australia and around the world are not green. In NSW and Victoria the paramedic’s uniform is blue, in QLD paramedics wear a blue/green uniform.

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What Kind of Shoes do Paramedics Wear?

February 3rd, 2013

Paramedics wear boots because they not only look good but provide essential safety to the paramedic for the role that he or she has to play in an environment that is often dynamic and full or risk. Good leather boots provide basic risk protection towards the paramedic from environmental occupational exposures, such as blood. The boots must come up above the paramedic’s ankle in order to provide essential protection against a sprained ankle while the paramedic works on uneven ground in often dark areas.

Paramedics are usually provided with work boots from the Ambulance Service that they work for. The key safety requirements of a paramedic’s boots include protection from:

1. Needles and sharps

2. Blood and vomitus

3. Ankle injury.

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Paramedic Fatigue Management

February 3rd, 2013

Paramedic fatigue management is a vitally important aspect of the paramedic’s duty to themselves, their colleagues and their patients, as well as the responsibility of the Ambulance Service that employs them. Very little is scientifically known about paramedic fatigue and its effect on the paramedic’s health and the health outcomes of their patients. Anecdotally, stories relating to paramedic fatigue are rife within the profession of paramedics: the time I fell asleep at the wheel, made a massive medication error, left a patient at home because I was too tired to notice that he was having a silent heart attack. These are all too common stories amongst paramedics.

Given the amount of hours that paramedics work it is strange to think that paramedic fatigue management has been so overlooked until recently. The correlation between fatigue and work related accidents have been well documented and studied since the early 1980s. Even better documented is the correlation between driver fatigue and car accidents. In NSW sleep studies have shown a correlation between driver fatigue comparable alcohol intoxication. Persons forced to stay awake longer than 16 hours or have a cumulative loss of sleep of 2 hours each night over 3-4 days were found to have similar coordination with persons who had blood alcohol readings greater than 0.10.

In NSW it is illegal as a professional driver to drive longer than 10.5 hours in any given 24 hour period. Yet, paramedics across Australia work 12-14 hours shifts, which can easily extend to 16-18 or more with overtime.

Tips on Managing Paramedic Fatigue?

The following are tips on paramedic fatigue management:

1. Ensure that you have a good balance between work days and days off so that you are relatively refreshed by the time you start your set of days on and are not starting your working week already fatigued. Many paramedics make the mistake of taking on too much overtime or a second job on their days off and are consequently fatigued before they even start their working week!

2. Don’t take the job home with you. As a paramedic you deal with people in stressful positions every day it is important not to take this stress home with you. When you leave the job for the day, you need to leave the stress their too. This may be a little difficult if you are on call with work.

3. Ensure adequate meal breaks every 4-5 hours. A short 20 minute, uninterrupted meal break is usually sufficient. Many Ambulance Services fail in this respect by expecting their staff to work 12 -14 hours shifts without any break due to work demands.

4. Eat good food and long lasting food (such as foods rich in nutrients and carbohydrates). Try to avoid eating large amounts of food on night shift which then change your bowel system when you return to day shift or days off.

5. Few people are genetically predisposed to sleeping well during the day. Consequently, it is important that Ambulance Services avoid rostering systems that require the paramedic to work multiple night shifts in a row.

6. Avoid short change over shifts where you go from afternoon shift to early morning shift.

7. Sleep can be seen as a bank account. If you have plenty of sleep in the bank you are able to withdraw some of this saved up sleep during night shift. Without excess sleep in the bank account you enter negative sleep balances and this is when fatigue becomes detrimental to your health and your clinical judgement as a paramedic.

8. Avoid eating excessive amounts of sugar (lollies) or stimulants such as caffeine to get you by night shift. These may help on the occasional night shift, but become troublesome if used to regularly. It is abundantly clear that illegal stimulants have no place in managing a paramedic’s fatigue.

9. Take regular holidays (preferably at least once every 3-6 months) in order to manage the cumulative effect of fatigue.

10. Ensure that you are educated about the signs and symptoms of fatigue so that, as a paramedic, you are aware when you are experiencing fatigue and are better able to manage it. All paramedics are different and only you can identify your own fatigue and manage it correctly.

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Paramedic Carry Chair

December 17th, 2012

The paramedic carry chair is one of the most useful pieces of equipement in an Ambulance. A paramedic carry chair often effectively allows two paramedics to get just about anystandard size and weight patient out of a house regardless of their injuries and level of consciousness.

By using a carry chair paramedics are able to roll a patient through tight corridoors, around tight fitting bed spaces, toilets and if need be carry down stairs. The aim with a carry chair is to get the patient to sit still with their arms across their chest and not reaching out at everything (often trying to be helpful). Our Ambulance Service has the policy that you must use seat belt like restraints to the torso and legs to make it less likely for the patient to fall out or to reach out and grab things.

While using the chair it is important to try not to make any sudden or jolting movements. Pick your route and be purposeful in each movement. When descending a set of stairs it is often easier to lift the carry chair rather than try and let it roll down each step, which avoids any lifting but often causes a lot of jolting and potential damage to the paramedic.

The paramedic carry chair has been particularly useful in emergency settings where an exertion by the patient could be quite detrimental, but you are unable to gain enough access for the stretcher. For example, patients with chest pain or asthma.

There are a variety of carry chairs on the market of paramedic use. A purpose build paramedic carry chair has been made by Ferno. The  Ferno Compact Carry Chairs are simple, effective and lightweight for use in the ambulance and pre-hospital environments. These chairs are designed to assist in moving patients from wherever they are found.
They fold to a compact size for convenient handling and storage.

The chairs have been developed taking into consideration designs which assist with comfort and ease of use for both patient and attendant. The chairs offer support for the patient’s shoulders and feet while providing comfortable foot and head-end hand grips to enhance comfort and stability for the attendant. Each model is supplied standard with chest and
ankle restraints.

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Traumatic Amputations

November 27th, 2012

Traumatic injuries resulting in total or partial amputations of fingers, hands, arms, nose, ears, eyelids, tongue, genitalia, legs, feet or toes all require specific amputation related assessments and treatments. Unlike assessing other injuries and illnesses as paramedics, traumatic amputations generally require immediate treatment to stop the exsanguination and maintain haemodynamic stability.

Anatomy behind an Amputation

It is important to have a basic understanding of the anatomy behind an amputation. The upper limbs include the fingers (phalanges), hand (metacarpals), wrist (carpals), forearm (radius/ulna), upper arm (humerus), shoulder blade (scapula) and collar bone (clavicle). Neurovascular structures include subclavian, axillary, brachial, radial, median and ulnar arteries. Axillary, radial, median and ulnar nerves are also present.

Lower extremities include the pelvis (ilium, ischium, pubis), upper leg (femur, patella), lower leg (tibia/fibula) and foot (tarsals, metatarsals, phalanges. Neurovascular structures include the abdominal aorta, femoral, popliteal and anterior/posterior tibial arteries. Lower extremity nerves include sciatic, tibial and perineal.

Types of Amputations

Amputations can be complete or incomplete.  In a complete amputation, there are no tissues, ligaments, muscles or other anatomical structures connecting the amputated part to the body. A partial amputation is one in which an anatomical structure, such as a ligament, tendon or muscle, is still intact between the body and the amputated anatomy. Although the body part may not be functional at the time and complete amputation may appear to be imminent, the body part is still connected to the body. In a partial amputation, every effort should be made to preserve this connection. Amputations can involve proximal or distal anatomy. Proximal amputations involve anatomy that is attached closely to the body’s core, such as an entire arm at the shoulder joint or a leg at the hip joint. Distal amputations involve anatomy that is distant from the core of the body, such as fingers or toes. Distal amputations are more common than proximal amputations. A common distal amputation is cutting a finger off (through the guillotine movement of a knife) or a finger avulsion (by getting a ring finger caught while falling).

Mechanism of Injury of Amputations

Crush, guillotine and avulsion mechanisms are three of the most common forms of traumatic amputation. Crush injuries are the most common and can result in significant tissue damage and injury. Because of the injury associated with crush mechanisms, amputations resulting from these forces are less likely to be successfully reattached. In contrast, guillotine injuries involve sharp edges, resulting in less tissue disruption. As a result, body parts that are amputated by guillotine forces are likely to have better reattachment and recovery outcomes.

In general, when assessing a traumatic amputation I will assess the person’s Airway and Breathing while I approach them (by simply asking their name and hopefully getting a response) and then will resolve any problems with Circulation by applying direct pressure, raising the limb and in most likely applying an arterial tourniquet. If you do not have a tourniquet on you a BP cuff raised to 250-300 mmHg will work to stop the bleeding. Make sure to mark a T (for tourniquet) on the patient’s forehead and the time of application. Although it looks bad, in general a single traumatic limb amputation should not be a complex case for a paramedic to attend.

Once haemorrhage control has been establish priority should be given to urgently transporting the patient to hospital (remember time is closely related to success of reattachment of the limb). Oxygen therapy should be provided en route because oxygen is a potent vaso-constrictor which will assist in haemorrhage control. IV access should also be established and fluid available if the person becomes hypotensive. It should be noted that surgeons as a general rule prefer their patients to be “drier” rather than “wetter” prior to surgery, as multiple studies have demonstrated that excessive IV fluid administration increases a patient’s coagulation times and increased risk of bleeding.

How to Preserve the Amputated Limb 

Preserve the amputated part as follows:

1. Moisten appropriately-sized sterile gauze with sterile saline solution.
2. Wrap the severed part in the moistened sterile dressing, preserving all amputated material.
3. Place the severed part in a watertight container (plastic bag).
4. Place the container on ice or cold packs (if available).
5. Never freeze the amputated limb directly as this causes damage to the microvasculature and reduces the chance of reattachment.

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Assessing Limb Fractures

November 27th, 2012

As a paramedic it is common to attend a person who has a fractured limb. Whenever there is significant enough trauma to cause a fractured limb it is important not to focus solely on that injury but complete a full head to toes assessment and keep a high index of suspicion of other fractures or injuries to the person’s body. All too often a paramedic will attend a person who has a clearly deformed tibia/fibula and completely miss the fact that they have fractured their spine.

When a patient has a clearly deformed limb or compounded fracture the first thing that I do is acknowledge that I can see that they have fractured their leg, but want to assess from top to bottom to see if there are any other injuries.

What is a Fracture?

A fracture is any break in the continuity of a bone. Fractures are relatively common and as per the WHO statistics in 2012 the average person is likely to suffer a fractured bone two times in a lifetime. Like most illness and injuries bone fractures are more likely to occur in young children, who are more adventurous and have not yet suffered the consequences; and the elderly who have brittle bones.

There are multiple types of fractures and largely paramedics do not need to know the specific names of each. It is important to understand a basic background about the types of fractures and whether or not the fracture is open or closed. At a very basic level, fractures can be simplified into terms of open or closed fractures. An open fracture occurs when part or multiple parts of the bone break the skin, leading to a much greater risk of infection; whereas a closed fracture does not keeps the skin intact protecting the area from serious infection.

All fractures can be further simplified into the following two categories: displaced and non-displaced fractures. A displaced fracture is where the break causes the now separate pieces of bone to not line up straight. If there are multiple breaks in which each section of the bone no longer lines up, this is called a comminute fracture is normally much more complicated to repair. A non-displaced fracture is where a break has occurred, but the two ends of the bone have maintained their natural alignment.

The following are types of limb fractures that you see, learn about and read about in patient’s notes, but are not necessarily required when performing your duties as a paramedic:

– Greenstick fracture, which is an incomplete crack in the bone where the bone then becomes bent;

– Comminute fracture, where multiple complete breaks in the bone, causing entire sections of the bone to become fragmented;

– Oblique fracture, where the break causes the bone to form a curve;

– Pathological fracture, where a form of pathology such as cancer has caused the fracture as opposed to a direct or indirect force;

– Impacted fracture, where two ends of the bone become compressed during impact.

Steps in Fracture Assessment

As a paramedic, these are the steps that I take to assess a limb fracture and the things that I consider while treating a patient with a suspected limb fracture:

1. Complete the normal steps of assessing any patient through checking the patient’s Airway, Breathing, Circulation, Disability and Exposure.

2. Ask fracture specific history questions, such as:

– What caused the injury?

– Was there a direct or indirect impact?

– Have you ever fractured this limb injury before?

3. Perform a head to toes secondary assessment.

4. Provide adequate analgesia (normally IV morphine or fentanyl).

5. Assess the limb itself – is there obvious deformity, discontinuity to the limb, swelling, pain, discolouration, tenderness on palpation, or any loss of movement or function?

6. Is the fracture open or close? If it is an open fracture it is important to try and keep the area as clean as possible. If there is dirt in the wound (for example the motor cyclist who has broken his leg into dirt) it is important to remove this as much as possible before dressing the wound.

7.  Is the fracture in alignment or does it require realignment and traction?

8. Expose the wound and clean with saline soaked dressing if compounded.

9. Assess the colour, warmth, movement and sensation of the limb distally. Compare the injured limb with the uninjured limb. Mark the pedal pulse if the injury is to the leg so that you can easily reassess this later.

10. Splint the fractured limb to provide support and reduce further injury to the surrounding blood vessels, tissues, and muscles.

11. Keep reassing distal perfusion and the patient’s level of pain and analgesia requirements.

The following patients are more susceptible to bone fractures: people have a known diagnosis of osteoporosis, vitamin D deficiency, hypothyroidism, and people who regularly take corticosteroids.

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What Do Paramedic Do?

November 27th, 2012

What do paramedics do? Paramedics provide emergency and non emergency pre-hospital medical care to persons who require help outside of hospitals. The help that paramedics may provide can range from treating a multitude of medical conditions and traumatic injuries, through to psychiatric problems and resolving complex situational problems.

Paramedics can do the following range of activities during their day:

1. Provide a wide range of pharmaceutical interventions through injections, intraveneous injections, intranasal sprays, sublingual tablets, nebulisers, transdermally and subcutaneous injections.

2. Immobilize fracture limbs with splints.

3. Transport rapidly with the use of warning lights and sirens to assist in getting through traffic.

4. Deliver babies.

5. Look after burns victims.

6. Resuscitate cardiac arrest patients through defibrillation, CPR, intubation and IV drug administration.

7. Attend motor vehicle crashes.

8. Take people to hospital who have a welfare card and don’t want to see their own GP.

As a paramedic, it is often important to remember that your role is to help people and not necessarily with a medical problem. Often paramedics are called by people who just don’t know what else to do.

What do paramedics do on a shift?

 

Paramedics normally do a broad range of activities on any given shift. Starting with checking the Ambulance and signing out their scheduled drugs (such as morphine). Throughout the day paramedics will respond to a number of emergency and non emergency cases. Paramedics will most likely get stuck in hospital at some stage, try and find food on the run, have a good laugh with their work partner, see something completely  new and see a dozen things that you’ve seen a thousand times before. Finally paramedics will refuel their Ambulance, wash both inside and outside of their Ambulance, restock what they have used or were missing throughout the day, complete any health care records that were not completed throughout the day, sign drugs back into a safe and sign off for the night ready to do it all again!

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Bug in Ear

November 26th, 2012

All paramedics will eventually be called to treat a person with a bug in their ear. At first you may ask yourself why this is a paramedic’s problem? But the reality is, if a bug manages to fly directly into a person’s ear it can be very confronting for the patient and if you do not deal with the situation calmly and efficiently you may have a very emotionally distressed patient on your hands.

It is also important to acknowledge how painful and uncomfortable an alive bug crawling or frantically flapping its wings in the deep inner aspect of your ear may be for a patient. In reality, you do not know what type of bug it may be. There is nothing to say that it is not an ant, wasp or spider that is repeatedly stinging or biting the patient from within their head! Also, because the bug is so close the ear drum, any sound that it makes is magnified to the sensitive audio receptors within the ear drum.

How to Safely Remove a Bug in an Ear

As paramedics, with the exception of an extended care paramedic, we do not routinely carry an otoscope, so it is very difficult for us to safely remove a bug from a patient’s ear without potentially damaging the vulnerable ear drum. This does not mean that we can’t start to treat a patient with a bug in their ear.

Working as a paramedic in Australia it is not uncommon to be called to treat a person with a bug in their ear. These are the steps that I use to safely remove a bug from a person’s ear:

1. Reassure the patient that you are aware how distressing this is for them and that you will get the bug out of their ear. The need for confident reassurance cannot be overstated here. These people will be distraught.

2. Lie the patient on the stretcher with their head tilted on the opposite side to the one with the bug in the ear.

3. Pour olive oil into the person’s inner ear, while pulling the lower lobe out to allow maximum fluid into the inner ear. Olive oil is safe for consumption and does not irritate the inner areas of the ear. Olive oil should be at room temperature or slightly warmer. Cold olive oil will generally upset the balance within the middle ear and cause the person to experience vertigo. This may happen anyway, so it is important to let the patient know about this beforehand.

4. Do not let the patient move for 5 minutes. During this time the insect will usually drown. Olive oil is slippery and the bug will not be able to naturally climb out of the ear canal. If the patient can feel the bug moving wait until they feel it stop.

5. After 5 minutes (or until the bug stops moving) turn the patient over to the other side and let the olive oil and bug drain freely out of the ear. Use a cotton ball to remove the bug from the outer ear and any remaining olive oil. If the bug does not come out or the patient is still very uncomfortable and believes there is something still in the ear, transport the patient to hospital.

Warning Tips When Removing a Bug in an Ear

These are some important warning tips about removing a bug from an ear:

1. Don’t put anything inside the ear canal – you can easily damage the soft tissues of the ear drum and cause damage. Make sure the patient doesn’t have anything that he or she can use to jam into their ear as this will cause damage to the inner ear.

2. If the patient is in pain do not wait on scene with the patient to try and remove the bug. Place them on a stretcher and pour olive oil into the ear canal and then transport.

How does a bug get into a person’s ear? A bug can simply fly, fall or crawl into a person’s ear while they are outside, inside asleep or awake. During certain times of the year bugs are more plentiful and active.

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Night Shift Sleep Tips

October 22nd, 2012

Few people like night shift and one of the greatest reasons for this are that most people don’t sleep very well during the day. It is a well-documented fact that people who work regular night shift are at a greater risk of injuries, illness and generally lack of wellbeing than those who enjoy the consistency and normality of a day job. I’ve been a paramedic, a nurse and a hospital wardsperson since I left high school 15 years ago, and in that time I have only ever worked shift work that involves night shift. These are my night shift sleep tips: 

1. Catch up on your sleep on your days off. If you are already run down and sleep deprived before you start night shift your body will often find that it is over-tired and unable to sleep. 

2. Set up your sleeping environment. My wife and I both work night shift, so we have spent the extra money to have the necessities of our employment. Make it dark – really dark. We have metal block out shutters and block out curtains. If this still isn’t dark enough, try an eye mask. Make it cold. Your body naturally likes to sleep when it is cooler (this has come from many years of sleeping during the night when it is cooler). Consequently, you are better off sleeping in a cooled environment. We have ducted air conditioning. 

3. Make it quiet – if possible, try and set up a quiet room of the house, which is positioned the furthest away from traffic and outside noises. If this is not possible, consider using ear plugs. Make sure that they’re disposable and change them daily. Ear infections don’t help with sleeping either. 

4. Avoid stimulants, such as caffeine and energy drinks. Yes, I know that they help you get through the night shift, but you will regret it when you try to sleep afterwards! This goes for illegal stimulants too. 

5. Avoid using drugs or alcohol as a means of falling asleep. Prescribed sleeping pills may be fine short term or as a once off when you have been having real trouble sleeping, but long term use leads to addiction and dependencies. 

6. Try exercising daily. Exercise releases natural endorphins which help with sleeping. 

7. Don’t try to go to bed immediately after night shift. Try to unwind for an hour and then go to sleep. This is an important time in which you physically and mentally can differentiate between your “work” time and your “sleep” time. Research into Night Shift Nursing has identified that most people require a decompressive time, in which to eat, relax and watch an episode of a favourite TV show and really make the switch from work to sleep time. 

8. Avoid eating a big meal before bed. This is no different from going to bed on a full stomach in the evening. Likewise, avoid going to bed hungry, that’s just another reason to keep you awake! 

9. If you work a permanent night shift, it is a good idea to keep a regular sleep routine on your days off too. This is rarely useful for paramedics who generally work a rotating roster involving some days and some nights. If you are on a rotating roster, evidence has suggested that the body is far more inclined to move from a morning shift, through to an afternoon shift, followed by nights rather than the other way round. One benefit of a rotating roster is that you do not have to work a number of night shifts in a row, which has also been proven to have significant health risks. 

10. Try not to have a long commute to and from work on night shift. Every minute that you spend travelling to and from work is taking away from your potential sleep time.

11. Try to avoid bright lights for about an hour before you go to bed.

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Healthy Meals for Paramedics

October 22nd, 2012

Paramedics work long hours and by the very nature of their work, are rarely able to return to the station, heat up some food and sit down to a nice quiet, uninterrupted lunch break. It is for this reason that paramedics seem to have some of the poorest diets among health professionals. Many paramedics find themselves regularly eating fast food, skipping meals, eating in the late hours of the evening just before they go to bed. 

These are some of the basic healthy meals or snacks that I bring to work on a day by day basis: 

1. A variety of nuts. I usually like to mix macadamia nuts, walnuts, almonds and cashews together. All make a good snack that is full of good oils. 

2. Muesli bars. If I get a chance I’ll make a batch of homemade muesli bars on my day off before I go back to work. They’re cheap, healthy, and help you get through to that lunch break that never comes. 

3. Green beans, pre-washed and packed, for some reason seem to be an easy snack for me. They taste good, keep me awake, and are full of nutrients and fibre. 

4. Fruit is a good substitute for that chocolate bar, but watch where you store it or your work bag may become wet with crushed fruit.

5. Sandwiches are an obvious simple meal for paramedics on the go.

6. I find a salad will last most of the day in a container. If you’re going to keep tomatoes in your salad, you’re better off cutting it up just before you eat it, otherwise, the entire salad will become affected by the juices.

7. Small canned tuna or salmon are usually relatively easy to eat on the go. But I’d recommend checking with your partner first. Some people have an aversion to the smell of canned fish and no matter how much you wash up after yourself; it seems to stink out the Ambulance. This goes double for where you’re going to dispose of the can. If you don’t have a bin that’s outside the ambulance, don’t even think about opening it, and don’t dump it next to the triage nurse or you’ll never get a bed for your patient again. 

8. Pasta usually keeps quite well for a day and is easy to eat cold.

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Tips for Staying Awake on Night Shift

October 22nd, 2012

Unless you’re in that 1:1000 percentile of the population who actually prefers to be awake during the night, you will find that having to stay awake at night is no fun. Many long-term paramedics will talk about happily being a paramedic for the rest of their life, so long as they don’t have to do anymore night shifts! As a paramedic, night shift can be especially difficult because there can be long quiet periods followed by intense cases requiring your entire not so there concentration. Every shift worker is different and what works for some doesn’t for others. So, these are my tips for staying awake on night shift. I hope they can be of some help to you.

1. Get enough sleep beforehand. Okay, this seems pretty obvious, get some sleep during the day and you will stay up at night. Unfortunately it’s not that easy to sleep during the day. Sleep is like a time bank… if you only work the one night shift, you can pull through on the extra time that you have in your sleep piggy bank. Unfortunately, as each night shift combines, the cumulative effect of lack of sleep starts to kick in. This also means that if you’ve been behind on your sleep for a while, you’re going to have to catch up on your days off. Napping works for some people. It doesn’t work for me. 

2. Avoid too many stimulants. You will find a lot of paramedics get through the night on caffeine and energy drinks. This may work in the short term, but develops bad habits and a variety of problems long term.

3. Have a set amount of food to eat. You will find that some paramedics get by on eating when they’re tired. This will lead to obesity and other health related problems.

4. I use crushed ice in a cup (found at just about every Emergency Department) as a little pick me up when I’m really about to fall asleep.

5. Outside stimulants such as music and air conditioning may help, but by the time you reach this stage you are becoming dangerous on the road and really do need more sleep?

6. Take turns on driving and keeps an eye on your partner. There is no benefit to one of you sleeping while the other one is driving, this is just dangerous.

It is important to recognise that you are tired and are not performing at your best on night shift and make conscious changes to help mitigate the risks. Drive slower, talk slower, and double check your medication administrations.

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Paramedic Stress Management Tips

October 22nd, 2012

Being a paramedic can be very stressful. Stress on its own is neither good or bad, but how it affects our lives can be positive or negative. Too much stress is never good and it is important to take steps as a paramedic to manage your stress levels. Paramedics may be exposed to a higher than normal level of stress due to the following areas:

1. Paramedics work in an often intense environment where decisions can literally mean life or death

2. Paramedics don’t always have the right answers or know what to do in all cases.

3. A paramedic’s day is dynamic… sometimes it’s mundane, sometimes it’s exciting.

4. Paramedics work in a very close proximity to their partners for long hours, over a number of weeks, which all lead to an increased stress environment. I’ve seen even the happiest of friends never want to see each other again after working too many rosters together.

5. Sometimes bad things do happen. As a paramedic, you’re there because people are sick and injured. Some day’s people die.

6. As a paramedic you work through the night when your body, your hormones and your conditioning since birth have all told you that you should be sleeping.

7. Sometimes the uniquely different personalities between each paramedic clashes.

8. When things go wrong and are reviewed, hindsight is always clearer than at the time when everything appears so hurried.

Okay, so we have identified that being a paramedic is a pretty stressful occupation. How do we manage the stress?

Paramedic Tips to Manage Stress

1. Ensure that you make enough time for you outside of work completely away from work. Many paramedics get stuck enjoying the financial benefits of overtime, but quickly find that the stress levels build up. It is important to find a few days of the week to do something totally unrelated to work.

2. Exercising has long been known to increase endorphin levels which lower stress, improve cardiovascular health, and generally make you feel better.

3. Get some sleep. Inadequate sleep is one of the major causes of illness, both physical and mental. Without adequate sleep, being a paramedic will take a heavy toll on your wellbeing.

4. Find hobbies and interests outside of work.

5. Accept that you can’t help everyone.

6. When you are at the “big job” – take your time. You will see that the faster a person tries to get things done the slower it works due to an increase in mistakes. When I attend a major incident or a serious motor vehicle crash I will intentionally slow myself down so that I both appear more confident than I am, and so that while it feels like I’m only slowly doing things that need doing, I’m actually working at a normal and safe speed.

7. Avoid stimulants. You won’t find many paramedics who don’t drink tea and coffee like they’re going out of fashion, but too many stimulants will just increase your already stressed body.

8. Enjoy the job for what it is and remember why you chose to become a paramedic in the first place.

9. Have regular holidays. I know of some Ambulance Services that insist on their paramedics taking short holidays every 4 months for mental health reasons. You will find that paramedics get injured the most in the last few weeks before they go on holidays because their stress levels have reached that critical point associated with fatigue. Whereas, paramedics who have just come back from holidays are less likely to get injured and more likely to pull through the difficult cases.

10. If you are having troubles, talk to someone. This doesn’t have to be another paramedic, but you need to offload to someone.

11. Don’t continuously offload to your husband or wife – this will just drag your normal relationship downwards. If you find that you are continuously offloading to your significant other… maybe you are in the wrong profession?

12. Look at the problems at work as challenges instead of problems.

13. If you really find that the job is getting to you and you’ve tried everything else to improve the job, it is important to make the decision to get out and find a new job. It’s not the end of the world. You spend too much time at work to find it is always miserable.

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What is Congenital Insensitivity to Pain?

October 22nd, 2012

Congenital insensitivity to pain (also known as congenital analgesia) is a rare congenital condition in which a person does not feel any pain sensations. Other motor and sensory responses appear normal, but pain sensation is non-existent. Cognitive and sensory responses, including the sense of touch generally remain normal.

What causes congenital insensitivity to pain? There are currently two known causes of the disorder. These are:

Excessive production of endorphins within the brain. For this cause, regular naloxone administration has been known to produce some changes.

1. Genetic mutations and abnormalities.

2. Hereditary sensory and autonomic neuropathy is the term used to describe a variety of medical conditions that lead to an inhibited pain sensation.

The biggest problem with congenital insensitivity to pain is that without the sensation of pain, a person will often cause harm to themselves unintentionally. For example, young children with the condition are known to have severe oral damage and regularly bite off the tip of their tongue. Other people are known to have been walking around with multiple fractured bones. 

Although congenital insensitivity to pain is a very uncommon condition, it is important to be aware of it as a paramedic or clinician so that you are able to recognise the signs and symptoms in a young child who you attend who may not yet be diagnosed. It is not our job as paramedics to diagnose the condition, but it is to identify abnormalities and ensure that steps are taken to ensure that the infant or child is transported to hospital for further investigation.

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What is Cotard’s Delusion?

October 22nd, 2012

Cotard’s Delusion (also known as walking dead syndrome) is a very rare mental disorder in which the person feels as though they are literally dead. Often these people walk around believing that they are invisible, cannot be killed because they are already dead, that they have no blood in their body and that their body is rotting somewhere in the ground.

As a paramedic, is is very rare to see Cotard’s  Delusion, however, it is important to be aware of it, because some of the apparent suicide attempts that we attend are not suicide attempts at all but persons with Cotard’s Delusion who walk in front of trains, cars, or off cliffs because they literally believe that they are already dead.

These people are not necessarily depressed, but will often inadvertently injure themselves believing that they are already dead and therefore immortal.

Pathophysiology of Cotard’s Delusion

Neurologically Cotard’s delusion is thought to be closely related to Capgras Syndrome as both conditions appear to involve a disconnection between the areas of the brain that recognise faces and emotions.  Psychologically, Cotard’s delusion is often related to schizophrenia and an acute psychosis (often causes by certain drug use).

Constant reassurance in a calm and confident tone is important for these patients. Within the hospital system, treatment aims at mood stabilisation through antidepressant therapies, antipsychotic medications, and in severe cases, electro-convulsive therapy has been seen to improve the person’s condition.

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Cardiac Chest Pain Vs Noncardiac Chest Pain

October 18th, 2012

Differentiating between cardiac chest pain and noncardiac chest pain can be a difficult task and one that paramedics must make on a daily basis. How can a paramedic differentiate between cardiac chest pain and noncardiac chest pain? The truth is a paramedic in the field can’t with complete accuracy. But there are a number of diagnostic clues while assessing the patient and key triggers that should be identified when you take a person’s history, which help make an educated guess about the aetiology of the chest pain.

If in doubt, it is generally best to treat any form of chest pain as cardiac in origin until proven otherwise. However, there are some exceptions to this, where the treatment regime for cardiac chest pain may be detrimental to the patient. A good clinician should be aware of these dangerous noncardiac causes of chest pain.  

The following are all examples of dangerous noncardiac causes of chest pain: oesophageal varices,  abdominal aortic aneurism, and a tension pneumothorax.

Key history clues in order to differentiate between cardiac and noncardiac chest pain:

How long has the patient had this pain for? Did the pain come on suddenly as the result of an injury, such as a fall or hit or did the pain start for no apparent reason? Always beware of the patient who was woken from their sleep in the because of a new onset of chest pain. Does the person have any cardiac risk factors or familial history of heart attacks? Age alone is a poor determinant for differentiating between cardiac and noncardiac chest pain. I recently attended a fit healthy 21 year old who had a STEMI and required angioplasty.

Key assessment clues when differentiating between cardiac and noncardiac chest pain:

Look at the patient. Most patients who are actually having a heart attack will look sick. Their skin will be cool, pale and diaphoretic. Can the patient take a deep breath – if the person complains of a sharp stabbing pain on inspiration/expiration it is likely to be related to pleurisy rather than problems with the heart.  But there is nothing to say that a person with a chest infection who develops pleurisy doesn’t also have an underlying heart condition. Ask the patient to take one finger and point to the pain. Due to the way the phrenic nerves surround the heart and then outwards towards each arm, nociception in heart is difficult to pin-point.  A patient who can point immediately to where the pain is, is unlikely to be having a heart attack. Whereas the patient who points to an entire area of the chest is more likely to be caused by heart problems.  Assess the lungs. Congestion maybe related to a chest infection and increases the likelihood that the pain is related to pleurisy. Alternatively, crackles (generally indicating fluid in the lungs) is related to poor cardiac output and heart failure.

In hospital and in some ambulance services repeated 12 ECGs and serial blood test are taken to definitely identify if the cause of the chest pain has been related to damage to the heart or not. While 12 lead ECG interpretation is become commonplace in most Ambulance Services the acceptance of blood pathology for cardiac enzymes is relatively new and expensive, but look to be on their way.

Common heart attack imitators:

Pleurisy, chest infections, asthma, GORD, oesophageal varicies, aortic aneurism/abdominal aortic aneurism, traumatic injuries, fractured ribs, pulmonary embolism, subcutaneous emphysema, pericarditis, and most common in younger men, costochondritis.

Assessing chest pain is a paramedic’s bread and butter case, so it pays to have a thorough understanding of the pathophysiology of chest pain and well adept at assessing it. In general, if in doubt, treat the patient for cardiac chest pain.

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How Often Should an Infant’s Nappy Become Wet?

October 5th, 2012

The fluid ouput of any child will vary, but at a minimum all infants should develop a wet nappy every 4 hours. If, after 4 hours an infant’s nappy is still dry then the infant is severely dehydrated or has a renal problem.

A neonate and infant will pass approximately 1ml of urine per kg per hour. In general, a healthy infant will pass some urine every hour.

As a paramedic, it is important to incorporate the parents in our history taking process. Determining when the nappies were last changed, how often, and if they were wet or dry or if the infant passed a very loose diarrhoea like stool. Also, asking the parents if the infant is feeding and drinking normally and what exactly the infant is being fed is important.

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Warning Signs in Paediatric Emergencies

October 5th, 2012

Paediatric patients are generally in the best position, physiologically, to compensate to any injury or illness. This said, children do not decompensate very well and it is important to recognise immediately when there is a sign of a paediatric emergency.

These are the basic warning signs in paediatric emergencies:

Airway – imminent airway obstruction or new onset of stridor.

Breathing – Apnoeas, decreasing respiratory rate (often secondary to exhaustion, particularly in asthma), markedly increased respiratory rate, absent breath sounds, hypoxaemia.

Circulation – severe increase in heart rate, absent peripheral pulses, hypotension.

Disability – responds only to pain, new or prolonged seizure activity.

Exposure – fever greater than 41.0 Centegrade or hypothermia less than 34.0 Centegrade.

Fluids – significant bleeding or fluid loss

Glucose – BGL less than 2mmols.

If any of these warning signs are present the child is in serious danger and requires urgent transport to hospital and medical interventions.

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Paediatric Emergency Assessment Tips

October 5th, 2012

As a paramedic we attend a lot of paediatric emergencies. These are some of the few tips that I use every time I assess a child after an accident, medical emergency, and not so urgent event. Even the seasoned paramedic will tell you that he or she doesn’t feel comfortable assessing a critically ill child. Children are not like small adults, they compensate remarkably well, but rarely have a decompensatory period.

This is how I assess a critically ill child:

Like everything else, we start to make assumptions or determine basic warning signs as we walk through the door and get our “first impression” – is the child well or not well.

To do this, we can look at a variety of structured approaches that ultimately, most paramedics will develop as part of their gut instinct. One such structured approach that I have found useful is called the TICLS assessment tool. Where the clinician looks for the child’s:

Tone – good is a child that is grabbing; bad is a still or floppy child.

Interactiveness – good is a child that is interested in the world and smiling; bad is a child uniterested in the world

Consolability – good is a child that is easily comforted by gentle rocking and by being wrapped up firmly; bad is an unconsolable child.

Look – good is a child that looks at you and follows your movement; bad is a child that is staring or not engaging in eye movements.

Speech/cry – a child who cries or talks is a good sign; a child who is moaning, grunting or QUIET is bad!

Remember, as an adult, you appear much larger to a child and more confronting, so here are some basic guidelines for assessing children:

1. Try and involve the parents/carers as much as possible before, during and after you do anything! This may not be possible if the parent or carer is hysterical.

2. Crouch down and get down to the child’s height. I like to talk to someone at face height and I’m sure a child has no desire to look up at a giant who is asking them personal questions.

3. Speak in a slow, calm, confident tone. Children are very intuitive and will easily pick up if you appear flustered or nervous that there is something seriously wrong!

4. Use age specific examples to explain what you are going to do and why. Don’t try and play something down. If you are going to insert a cannula, it is going to hurt, let the child know, but explain that it will only hurt for a few seconds and then you can take away their pain.

5. Children are very different from adults, if you ever give a medication (particularly  an IV injection or IM injection, always cross check with your partner).

Beware of the patient who displays Paediatric Warning Signs!

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Assessing Pain in Children

October 5th, 2012

Managing a patient’s pain adquately is the responsibility of all health care professionals (especially paramedics) and adequate pain relief is the right of all patients, irrespective of their age. Just because a child is too young to tell you that they are in pain does not mean that they do not deserve good analgesia!

So, how do you assess pain in children?

There are a variety of age appropriate pain scoring techniques develloped over the years by paediatricians, paramedics, nurses and allied health care workers.

This is a list of the common age appropriate pain scoring methods that I have come across during my time on road:

1. The face of pain – which depict several faces ranging from happy smiling to severe pain and as a clinician you may ask the child to point to the face that he or she feels most accurately represents how they are feeling.

2. The FLACC pain scale, which looks more at the behaviour of the patient rather than specific numerical pain values. You look at the face and search for grimace, frown, withdrawn, chin quivering or a clenched jaw. Then you look at the legs to see if they are in the normal position, squirming or arched back, rigid or jerking. Look at the activity, lying quietly or squirming. Listen to the cry, moan, wimpers or constant scream. Assess the consolability, is the child consolable or unconsolable? On a FLACC pain scoring chart, individual numbers are related to each behaviour response. In my experience, it is a relatively useful tool for assessing if the pain is small, medium or big.

3. The linear pain scale, where you have a ruller with a numbering system of no pain through to worst possible pain and ask the child to place the ruller where they beleive they sit.

All of these pain scales have some merit, but in my experience, identifying a specific numerical value for a child’s pain is irrelevant (almost as much as it is in assessing an adult’s pain score). At the end of the day, you want to know if they are comfortable or not. If they are uncomfortable, do they want you to try and take the pain away. If I provide analgesia, I want to know if it is making the pain better or worse.

As a paramedic, I look at the visual clues to see if a child appears in a small, medium or large amount of pain. If they can understand the concept, I will ask them if it is a small, medium or big pain and after providing analgesia I will ask only if it is better or worse? I look at the child’s vital signs, which often tell you a lot more than a number ever will.

The following are physiological signs of pain in children:

1. Tachycardia

2. Tachypnoea

3. Raised blood pressure

4.Raise in blood glucose levels.

5. Restlessness

Good health care can only be achieved by adequately providing pain relief to all patients.

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Assessing Dehydration in Children

October 5th, 2012

Children are at a far great risk of dehydration than adults for a variety of reason and consequently all paramedics should be vigilent in their assessment of dehydration in children. Not only are children more likely to become severely dehydrated than adults, but they are less likely to be effectively treated early. Children have a higher metabolic rate, are more prone to gastroenteritis leading to fluid loss through diarrhoea and vomiting, and insensible fluid loss through fevers.

As a paramedic this is how I assess dehydration in a child:

1. Because children generally are uncomfortable with strangers, leave the normal routine tool based assessments until a little later when you have some trust. Assess the patient to see if they appear globally well or unwell. Are they awake? Are they interacting normally? Are they crying, but consolable? Are they looking at you and tracking your movements? Are Ask the parents or carers if they look normal, and if not, in what way?

2. Look at overall urine output. Ask the parents/carer if their nappies have been wet or dry? A normal infant will have wet nappies at least every 4 hours. If the nappies are dry after 4 hours there is something wrong and most likely the child is dehydrated or has a renal problem.

3. Assess the mucuous membranes (such as the mouth and bucal mucossa) for signs of dryness or moisture.

4. In neonates, the undeveloped cranium provides a soft fontonelle (the top part of the cranium where majority of the joins eventually come together). If this is sunken it is a sign that the neonate or infant is severely dehydrated.

5. Assess skin turgor. Normal skin is soft and easily returns to its normal position is moved. Dehydrated skin remains where you squeeze it and only slowly returns to its normal position.

6. Look at the eyes – sunken eyes, like a sunken fontanelle is a bad sign indicating dehydration.

7. Look for changes in overall perfusion, such as skin colour, level of consciousness, pule rate, blood pressure and respiratory pattern. A decreased BP is a late sign of severe dehydration.

8. Look for the injury/illness that you can’t see, such as diabetes mellitus, which will cause osmotic diuresis. Ask questions about recent injuries or illness. Has the child had any fall recently?

Always be weary when assessing children for dehydration. Children compensate tremendously well, but only provide a very minimal amount of decompensation.

Children at a High Risk of Dehydration

 

The following is a list of children who have been identified as being at a higher risk of dehydration:

1.Children younger than 1 year, especially those younger than 6 months!

2. Infants who were of low birth weight.

3. Children who have passed six or more diarrhoeal stools in the past  24 hours.

4. Children who have vomited three times or more in the past 24 hours.

5. Children who have not been offered or have not been able to tolerate supplementary fluids before presentation (don’t forget many parents through good intentions have stop giving fluids to their children in an attempt to reduce the vomiting and diarrhoea).

6. Infants who have stopped breastfeeding during the illness.

7. Children with signs of malnutrition.

Signs of Hyponatremic Dehydration

Dehydration with concurrent hyponatremia is clinically much more dangerous than dehydration on its own. The following are signs associated with dehydration with concurrent hyponatremia:

– Jittery movements

– Increased muscle tone

– Hyperreflexia

– Convulsions

– Drowsiness or coma.

These patients need urgent medical intervention. As a paramedic you must recognise the child with hyponatremic dehydration and act fast.

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Dehydration Versus Volume Depletion

October 5th, 2012

Dehydration and volume depletion are usually considered synonymously associated with overall fluid loss. At a basic level, this correct, but as paramedics and clinicians it is important to understand the key differences in the pathophysiology of dehydration versus volume depletion, and how to best treat each condition.

Volume depletion involves a reduction of the total intravascular plasma pool; whereas dehydration is caused by loss of plasma free water (which is disproportionate to the loss of sodium). Although both volume depletion and dehydration are caused by fluid loss, it is important to identify the differences because you can have one without the other and the medical treatment should differ accordingly.

For example, a patient who has cut their leg and lost a litre of blood would be considered to have volume depletion because the same amount of plasma volume and free water have been proportionally reduced. Alternatively, the patient who has developped diabetes mellitus and subsequent osmotic diuresis, will lose large amounts of free fluid in a disproportionate amount to the loss of plasma.

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Why are Children More Susceptible to Dehydration?

October 5th, 2012

Children are the most susceptible to dehydration because they are often unable to communicate effectively, their parents are often new to the world of parenting and although mean well may not adequately understand the signs and symptoms of dehydration, and because children (who are always keen to put things in their mouth) experience the most amount of gastroenteritis of any age bracket.

The most common cause of dehydration in children is gastroenteritis, which results in large quantities of fluid loss through vomiting and diarrhoea. Other relatively common causes of dehydration include poor oral intake due to diseases such as diabetes mellitus, which causes osmotic diuresis (and is generally diagnosed in childhood) and insensible fluid loss due to infections and fever. As a paramedic, we attend many children who appear dehydrated. Often, the dehydration can easily be corrected with an increase in oral fluid intake and correction of the fluid loss. However, it is important to look for the illness that you do not see. For example, check for early signs of diabetes mellitus (diabetes type 1).

If the child has vomiting and diarrhoea, check with the parents how they are replacing the child’s fluids. Too much clear fluids (tap water) will replace the fluid volume, but not the solvents (salt) and the child may become hyponatremic. This is where the plasma volume has been reduced, while the free fluid (water) has maintained its normal levels. Dehydration with concurrent hyponatremia is clinically more dangerous than dehydration on its own. Alternatively, too much boiled milk, thickened soups or incorrectly diluted infant formula will cause the child to become hypernatremic. In this case, the child will have adequate plasma volume without adequate free fluid replacement. Hypernatremia if left untreated will lead to CNS disturbances, seizures and eventually death. However, it is generally treated easily with basic IV fluid replacement. There is a potential risk of cerebral oedema if excessive free fluid replacement is provided too rapidly. 

Dehydration versus volume depletion – The terms dehydration and volume depletion are commonly used synonymously when discussing intravascular fluid depletion. In generally, this is correct, however, as a paramedic or any other clinician, it is important to understand how the two terms may vary.

Volume depletion involves a reduction of the total intravascular plasma pool; whereas dehydration is caused by loss of plasma free water (which is disproportionate to the loss of sodium). Although both volume depletion and dehydration are caused by fluid loss, it is important to identify the differences because you can have one without the other and the medical treatment should differ accordingly.

In children with dehydration, the most common underlying problem actually is volume depletion, not dehydration. Intravascular sodium levels are within the normal range, indicating that excess free water is not being lost from plasma. Instead, the entire plasma pool is reduced along with solutes (mostly salt) and solvents (mostly water) in proportional quantities. This is volume depletion without dehydration. The most common cause is excessive extrinsic loss of fluids in conditions such as vomiting and diarrhoea which is commonly seen in just about every child at some stage in their early life.

Children are often susceptible to volume depletion as a result of vomiting, diarrhoea, or increases in insensible water loss through fevers. Significant fluid losses may occur rapidly. Children may utilise more fluid than an adult and at a much faster rate because they have: higher metabolisms, increased body surface area to mass index, and higher water content than adults. Most anatomy and physiology textbooks identify average water content in the human body at  various stages of life to be 70% in infants, 65% in children, 60% in adults and less than 50% by the age of 80!

As paramedics, it is important to be particularly diligent when assessing small children with suspected dehydration. Most children will become dehydrated at some stage in their life and they will respond well to treatment. But unrecognised, the dehydrated child may continue to progress down a very steep spiral of systemic pathologies.

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What do Paramedics Carry With Them?

August 5th, 2012

What do paramedics carry with them? Each paramedic carries different equipment on their person as part of their individual “necessities” required to assist in their ability to provide prehospital care. Some paramedics carry heavy pouches full to the brim of useless equipment, while others carry only the bare essentials needed to assist in the treatment of patients. As a paramedic, this is what I carry on me:

1. In my right trouser pocket I carry specific protocols, drug dose reference cards and a blank notepad.

2. In my left trouser pocket I carry my I-phone which allows an extra communication channel with dispatch, communication with the local hospital doctors and poisons info. I also have a variety of apps as references, such as Micromedex for medication references, language translators and a medical dictionary.

3. In my right breast pocket I carry a blank notepad.

4. In my left breast pocket I carry my wallet with a small amount of cash (for when I get stuck somewhere) and my ambulance identification card.

5. On my shoulder I carry a pen torch and a couple of pens.

6. On my belt I carry a pair of trauma shears which I use every day.

7. I also carry a pair of clear protective eyewear around my neck in case the patient becomes inclined to spit or I enter a motor vehicle crash where there is a risk of broken glass.

That’s it… I don’t carry anything else on my person. I find that if you try to carry too much on your belt or in a pouch, it usually sits on the dashboard of the ambulance and not at my side when I attend a sick patient.

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What is Oculocardiac Reflex?

July 26th, 2012

The physiological response known as oculocardiac reflex identifies a unique decrease in pulse rate associated with any traction of the extraocular muscles or compression of the eyeball itself. This is particularly relevant to paramedics who are treating a patient with an injury who becomes bradycardic. The phenomenon is rarely seen out through accidental trauma and is most commonly seen during eye surgery, particularly in neonates and children.

What Causes Oculocardiac Reflex?

Oculocardiac reflex is caused by stimulation of the vagus nerve which is closely interconnected with the trigeminal cranial nerves, resulting in parasympathetic stimulation and subsequent brady-dysrhythmias.

As a paramedic it is important to consider oculocardiac reflex in any patient with a traumatic injury to the eye that may result in any traction of the extraocular muscles or compression of the eyeball itself. A cardiac monitor should be used with these patients and closely observed for signs of bradycardia.

Treatment of oculocardiac reflex by paramedics and within hospitals involves immediately removing the stimulus that is causing the pressure on the vagus nerve. This generally results in the restoration of sinus rhythm. If unsuccessful, treatment options should consider anticholinergic medications such as atropine. In very rare circumstances, severe bradycardias and assystole may result requiring external cardiac pacing (or CPR).

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Paediatric Emergency Notes

July 25th, 2012

Peadiatric emergencies are often the most difficult cases that paramedics have to attend. Ask any paramedic what the worst job that you fear attending and he or she will not doubt say – a seriously injured child or a paediatric cardiac arrest. Paediatric emergencies are profoundly difficult for paramedics to attend because of the heightened emotions associated with a seriously injured or ill children; difficulty in communication; are anatomically and physiologically very different from adult patients; and although children compensate very well, rarely decompensate as an adult would prior to cardiac arrest.

Treating children in an emergency is further made difficult by their parents. Ask any paramedic where most of their focus will be spent when treating a child (irrespective of how sick the child is) and they will reply that the hysterical parents will most likely take up most of their time. Reassurance is important for paramedics to use at any emergency, but when treating a child it is even more important. Explain to the parents what is happening and reassure them.

These are my paediatric emergency notes to help paramedics remember the basics of treating children. 

Anatomical and Physiological Differences in Children

Assessing children in general:

Paediatric Assessment Tips

Warning Signs in Paediatric Emergencies

Paediatric GCS Assessment

Assessing Pain in Children

Assessing Dehydration in Children

How Often Should an Infants Nappy Become Wet?

Common medical conditions and injuries involving children:

Croup Versus Epiglottitis

Croup

Susceptibility of Children with Dehydration

 

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Anatomical and Physiological Differences in Children

July 25th, 2012

Any paediatrician will tell you that anatomically and physiologically a child is not simply a small adult. It is for this reason that paramedics often find themselves uncomfortable treating children, because all of the normal physiological values differ and basic anatomical positioning must be changed to meet these differences. This page identifies the basic anatomical and physiological differences in children that paramedics should be aware of.

Airway Assessment in Children

A child’s airway is obviously much smaller than an adult, but the differences go further than basic size.

For example:

– An infant is an obligatory nose breather for the first 6 months, which means that a blocked nose can lead to respiratory failure!

– Infants have very short and softer tracheas than adults. This means that overextension during airway manoeuvres may result in airway collapse (not too dissimilar to kinking a narrow garden hose).

– Tonsils and adenoids grow disproportionately fast in children, making any inflammatory response more likely to compromise the movement of air. Tonsillitis can be a life threatening infection for a child as opposed to an annoyance to an adult.

– Infants have proportionately large heads, short necks and large tongues, which again, makes airway obstruction more likely.

– Both infants and even toddlers have a long and floppy epiglottis, which means more chance of airway obstruction.

Assessing a child’s airway involves looking for patency. A crying or talking child indicates at least a certain amount of patency.

Airway manoeuvres in children should primarily include the head tilt-chin lift technique and avoid overextension of the neck.

Assessing Breathing in Children

The following are important differences between an adult and a child’s breathing:

– A child has much small upper and lower airways which results in a great chance of respiratory difficulties and failure.

– Infants are abdominal breathers who rely primarily on the muscles of the diaphragm. This means abdominal distension can lead to respiratory problems.

– The immature muscles associated with respiration, such as the diaphragm, intercostal muscles and sternocleidomastoid are more likely to fatigue.

– The respiratory centre is relatively immature. This means that neonates and young infants have irregular respirations and are at a greater risk of apnoea. Many neonates will literally feed and forget to breathe.

The following is a rough guide for respiratory rates in healthy children:

Neonates: 30-60

Infants: 30-40

Toddlers: 20-40

Young Children: 20-30

Older Children: 15-20

Warning signs in children with respiratory problems include:

– Nasal flaring and head bobbing in children infants with respiratory distress.

– Chest wall recession indicates severe respiratory effort.

– Tracheal tug, which is identified by a downward pull of the trachea during inspiration.

– Sternal recession, which is associated with severe respiratory distress.

– Grunting is a sound made by neonates and associated with expiration against partially closed vocal cords is a sign of severe respiratory distress.

– Gasping is a sign of severe hypoxia and is often pre-terminal or respiratory arrest.

Remember, children have underdeveloped muscles associated with respiration and are consequently more prone to fatigue.

Assessing Circulation in Children

Children generally have very good cardiovascular health. This enables them to compensate well for circulatory problems such as hypervolemia and dehydration. There will rarely be a change in a child’s blood pressure until it is about to have a cardiac arrest.

The heart rate of a child makes a better diagnostic tool.

Tachycardia is a sign of hypervolemia, and although the heart muscle is capable of prolonged rates in excess of 200 beats per minute, if the cause of the hypervolemia is not detected and treated, the child will eventually become bradycardic and have a cardiac arrest.

Bradycardia is a pre-terminal event in children.

The following are basic heart rate guidelines for children:

Neonate: 110-160

Infant: 100-160

Toddler: 90-140

Small Child: 90-120

Older Child: 60-100.

Assessing a Child’s Neurological Status

A child’s behaviour and general appearance needs to be assessed during a neurological assessment. A child’s behaviour should be compared to what is normal for that child. Use the parents and ask them to compare the child’s presentation with his or her normal general appearance.

– An infant will normally track their eyes to follow motion.

Assessing a Child’s Temperature

Neonates and infants lose heat more rapidly than adults because the surface area on their heads is larger by comparison to their body mass. Also, young children have an undeveloped hypothalamus, which means that their ability to regulate temperature is impaired.

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Personalities for Paramedics

July 17th, 2012

There is no clear right or wrong personality for paramedics, but it is useful for people who want to become a paramedic to consider what the job entails and the type of personality that would work well in that environment.

Being a paramedic is not always exciting and about saving lives. A large part of our day is spent waiting as a paramedic and boredom can be tedious. Waiting for a job, waiting at a doctor’s appointment, nursing home, or hospital are all part of the job. When I first started as a paramedic, the job was described to me like this: 

“Being a paramedic is about being bored 99% the time and then terrified half to death while you use all of your training and experience to get you through some seriously tough time during that other 1%” -Australian Paramedic.

So, you need to consider whether you really want to be a paramedic, and if you have that sort of personality that makes you enjoy working as an Ambulance Officer. The right personality to become a paramedic doesn’t necessarily mean that you can handle blood, but, do you want to spend your day talking to old people, chronically ill people, and taking people to hospital who have been booked in for a week to have their routine urine catheter replaced… this is what we really do for a living… and every now and again, you get to have some excitement and treat someone who is critically sick or injured. Don’t get me wrong, I’ve been a Paramedic for about ten years, and I still love the job.

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What is a Reflex Arc?

July 15th, 2012

A reflex arc in human physiology refers to the physiological processes involving the afferent, interneuron and efferent neurons in response to an event that requires an immediate action. A reflex arc allows a immediate action to take place prior to the afferent neurons reaching the cerebral cortex (command center).

The simplest example of a reflex arc in practice is when a person stands on a sharp thumb tack, an afferent message will be sent from the foot to the spinal cord, where an interneuron will identify that a reflex arc is required and consequently an efferent message is sent directly to the foot to move, causing the person to jump.

What is the Purpose of the Reflex Arc?

The purpose of the reflex arc is to avoid further damage to cells while the afferent messages are sent to the cerebral cortex. By producing a reflex arc the interneurons are able to initiate the immediate reflex action required.

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June 13th, 2012

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Did The Patient Really Say That?

June 11th, 2012

As a paramedic for a number of years I have heard some incredible things come out of the mouths of my patients… These are some of the most ridiculous things that my patients have said… for your amusement…

I was treating a patient a patient with a severe wound infection and this was the conversation that followed:

Paramedic: “Have you ever had Golden Staph?”

Patient: “No, but I have a Golden Retriever” 

I was attending a 16 year old girl in labour. After asking all the normal pre-natal questions regarding previous pregnancies, check ups, family history and any other medical conditions I asked the patient “Do you know what you’re having yet?” She smiles and says “No, but I’m really hoping that they’re twins!”

I attended a 32 year old man with bleeding ears. After some minor inspection of the ears, it appeared obvious that the patient had damaged ear drums. I asked him what had recently happened to cause this. He replied: “Well, I had blocked ears… you see… and so I used a screw driver and a some tissues and tried to clean out my ears by pushing it through my head… you know… like they do in Bugs Bungy!”

While attending a patient who had obviously been deceased for some time I spoke to the relatives who stated that they hadn’t seen the patient for a few days and found him this morning dead. I discussed with them the fact that he appears to have died in his sleep a few days ago… they smile politely and said… “Okay, so how long does the treatment take to work?”

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Anaphylaxis

May 20th, 2012

Anaphylaxis can be defined as an exaggerated, life-threatening hypersensitive reaction to a previously encountered antigen. As a paramedic, responding to a patient who is having a genuinely anaphylactic reaction is one of the very few situations when your treatment as a paramedic will clearly save a person’s life in front of you. It is because of this that it is paramount for any paramedic to thoroughly understand the pathophysiology and management of anaphylaxis.

Anaphylaxis can occur after a person is exposed to any antigen such as: bites and stings, medications (medical or herbal), foods, chemicals, or plants/pollens.

Paramedic Assessment and Treatment of Anaphylaxis

Airways may be compromised due to laryngeal and eppiglotic oedeama. Good airway management is critical! This includes insertion of nasopharyngeal airways and, if laryngeal or eppiglotic oedema develop, immediate intubation, as a golden standard of airway management.

Breathing may become difficult and should be assisted with intermittent positive pressure ventilation (IPPV) if necessary via bag valve mask

Circulation may be compromised as a result of relative hypovolaemia, and should be treated accordingly with adrenaline and fluid resuscitation.

Administration of the patient’s own “Epipen” if available.

Posturing should depend on the patient’s comfort. Normally, we lie hypovolaemic patients supine or with their legs raised, but this is unlikely to be possible if the person is have severe breathing problems which is often the more likely response to anaphylaxis than the hypotension.

Drugs: 500mcgs Intramuscular Injection of Adrenaline repeated every 5 minutes until desired result. Evidence based practice has indicated that IV adrenaline has no greater benefits to the patient, but many more potentially lethal risks associated with it. Oxygen should be administered. IV fluids should be given if the patient is hypovolaemic. Nebulisers should be considered as a secondary priority in patients with severe breathing difficulties (after adrenaline administration). Nebulisers should include: salbutamol and atrovent.

Any patient given adrenaline should always have a cardiac monitor applied (in case the adrenaline exacerbates a previous known or unknown underlying cardiac condition or dysrhythmia).

Understanding Anaphylaxis Pathophysiology

In order to understand the pathophysiology of anaphylaxis it is important to review the lines of defence that the human body utilises against bacterial, viral or microbial attack. This is important because anaphylaxis is just an exaggerated response by the immune system to target a particular antigen.

Lines of Defence in the Human Body

First line – intact skin, mucous membranes and their secretions

Second line – phagocytic white blood cells, inflammation and fever, antimicrobial substances, natural killer cells

Third line – immune response, specialized lymphocytes and antibodies

First line: surface defences and non-specific resistance factors

1. Physical barriers, such as skin, mucous membranes and secretions

2. Mechanical removal, such as macrophages

3. Chemical inhibitors

4. Anti-microbial substance

5. Fever, lysozyme

Second line: inflammation

1. Metabolic changes to the injured cell

2. Cellular organelles leak and release hydrolytic enzymes, causing the inflammatory response

3. Decreased cellular energy and Na+K+ activity pump, acidosis and decreased membrane integrity (leading to oedema)

4. Chemotactic factors assist the migrating leucocytes (neutrophils and monocytes) to collect along vascular endothelial lumen

5. Localised hyperaemia develops as microvasculature dilates

6. Increased filtration pressures and capillary permeability causes fluid to pass into the interstitium (this causes oedema)

7. Leucocytes engulf, digest and destroy pathogens

8. Circulating macrophages clear dead cells and debris

9. Eventually leukocytes are lysed by the release of certain chemicals

Third line: immune response

1. Primary and secondary responses

2. Lymphatic system

3. Innate (also known as natural immunity) and acquired (or developed) immunity

4. Humoral (antibody dependent) and Cell mediated immunity
B and T cells
Lymphocytes are developed through stem cells within bone marrow. They then differentiate into two distinct classes of lymphocytes. These are called T cells and B cells.

B-cells, also known as the human bursal equivalent, (thus the name B-cells) mature in bone marrow and are essential for humoral or antibody mediated immunity.

T cells are lymphocytes which complete maturation in the thymus (thus the name T-cell) and function to produce cell-mediated immunity, as well as aiding in antibody production.

Characteristics of Immunoglobulin?

There are five immunoglobulins:

IgG – displays antiviral antitoxin, and antibacterial properties

IgA – is the predominant Ig in body secretions

IgM – forms natural antibodies

IgD – is used in the maturation of B cells

IgE – binds to mast cells and basophils, and the binding of an antigen to the bound IgE causes the release of histamine and other mediators of inflammations and allergies

For a person to have an anaphylactic reaction they must first be exposed to a specific antigen to develop type I hypersensitivity. In the first exposure, the antigen enters the body by injection, ingestion, inhalation, or absorption and activates the immune system. Normally T-suppressor cells stop B-cells from proliferating, but sometimes suppression is not sufficient. In the susceptible individuals, large amounts of IgE antibodies are produced. IgE binds to mast cells and basophils and are involved in parasitic infections, allergic reactions and hypersensitive reactions.

Then IgE antibodies leave the lymphatic system and bind to the cell membranes of basophils circulating in the blood and to the mast cells in the tissues surrounding the blood vessels. They then remain there and are inactive until the same antigen is introduced into the body a second time (This is why it normally takes at least two exposures to an antigen to cause anaphylaxis).

With subsequent exposures to the specific antigen, the allergen crosslinks at least two of the cell-bound IgE molecules, resulting in the degrannulation (release of internal substances) of the mast cells and basophils and the onset of an anaphylactic reaction.

What is released on degranulation?

The degranulation of the target cell is associated with the release of pharmacologically active chemical mediators from inside the affected basophils and mast cells. These include histamines, leukotrienes, eosinophil chemotactic factors of anaphylaxis, heparin, kinins, prostaglandins, and thromboxanes. All of which, trigger an internal systemic response, which can lead to anaphylaxis.

What does this cause?

Histamines promote vascular permeability and cause dilation of capillaries and venules and contraction of vascular smooth muscle, especially in the GIT and the bronchial tree.

The increased capillary permeability allows plasma to leak into the interstitial space (causing oedema), decreasing the intravascular volume available for the heart to pump (decreasing pre-load). The profound vasodilatory effect results in further decreases in cardiac preload, compromising stroke volume and cardiac output.

These physiological effects lead to cutaneous flushing, urticaria, angioedema, and hypotension.

What are common antigens that lead to anaphylaxis?

Any antigen can cause an anaphylactic reaction, but many common ones include:

1. Bee stings, wasps, ants

2. Penicillan, morphine, and aspirin

3. Soy beans, peanuts, eggs

4. Latex gloves

There are four types of hypersensitive reactions to allergens

Type I is an IgE-mediated allergic reaction

Type II is a tissue-specific reaction

Type III is an immune complex-mediated reaction

Type IV is cell-mediated reaction

Type One

Type I reaction, or anaphylactic reaction, occurs soon after exposure to an antigen. It occurs when the specific type of antibody (IgE) attaches to mast cells. This causes the chemical substances in the mast cell, including histamine, and slow reactive substance of anaphylaxis to be released

Type two

Type II reactions, or cytotoxic reactions, are delayed reactions that involve certain cytotoxic antibodies of the IgG class. These antibodies are capable of lysing cells and commonly cause haemolytic reactions and the destruction of platelets. This causes swelling and can lead to potentially fatal anaphylaxis and airway obstructions.

Type three

Type III reactions are usually delayed reactions described as serum sickness. Like type II reactions, specific antibodies usually are involved. These antibodies, often IgGs, bind with the antigens in the blood stream and form complexes. These complexes filter out into various anatomical locations and produce an inflammatory response.

Type four

Type IV reactions are those in which contact dermatitis is produced by topical application of an antigen. These reactions are caused by T-lymphocytes, not the humoral antibodies and usually require more than 24 hours for their signs and symptoms to manifest.

There are two types of IgE mediated reactions

These include atopic and non-atopic disorders

The term atopic refers to a genetically determined hypersensitivity to common environmental antigens mediated by an IgE- mast cell reaction

The most common atopic disorders include allergic rhinitis and allergic asthma

The term non-atopic refers to disorders that lack genetic components

Non-atopic disorders include anaphylactic reactions, urticaria and angio-oedema.

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Paramedic Risk Management

May 16th, 2012

Paramedics work in a unique environment full of risk and uncertainties. The way a paramedic manages this risk will determine how successful he or she will be at achieving their pre-hospital care objectives. So, what is risk? Risk can be defined as the ‘effects of uncertainty on objectives’ (ASNZS 2009, p.1). 

Risk can be identified as the relationship of a particular consequence of an event and the likelihood of that event occurring. Risk, in itself is not a negative thing to an organisation; more so, the outcomes of risk may be negative or positive to the organisation’s achievement of its objectives. 

It is important to understand risk as a matter of:

  1. Likelihood of an event; and
  2. Consequence of an event. 

The likelihood of an event refers to how probable an event is of occurring. It should also include how often the organisation is exposed to the risk. For example, given correct lifting techniques, the likelihood of a paramedic injuring his or her back while lifting a patient is low; however, if the policy is to lift every single patient, the paramedic’s exposure to this risk increases, and with this increased exposure, there is a greater likelihood that the paramedic will injure his or her back. 

The consequence of an event can be defined as the ‘outcome of an event affecting objectives’ (AZ/NZS ISO 31000: 2009, p. 5).  Consequences of an event can be expressed as a quantitative measure, such as the number of work place injuries per year; or, as a qualitative measure, such as minor, medium, severe or catastrophic. An example of a qualitative measure is the consequence of a paramedic being involved in a motor vehicle crash. The crash may be minor, such as small dents to the vehicle and no injuries to the occupants, or it may be severe involving complete damage to the vehicle and serious injury or death to the occupants. 

It is this relationship between likelihood and consequence of an event that establishes the severity of a risk. For example, there is a high likelihood that a paramedic will be verbally abused at work by a patient during some stage of the year; however, the consequence of such an event has only a minor effect on the objectives of the organisation. Alternatively, the consequence of a paramedic physically assaulted by a patient is potentially severe; however, the likelihood of such an event is much less likely than being sworn at. 

Risk is present in all industries, and all activities of daily life. Because of the nature of the environment that paramedics are employed, there is an increased exposure to risk. Acknowledging this fact, it is evident that ambulance services need to be diligent in their risk management practices to mitigate these risks. 

What is Paramedic Risk Management?

The field of study, known as ‘Risk Management’ is a relatively new concept. It has been described by the AS/NZS ISO 31000 (2009) as a set of ‘coordinated activities to direct and control an organisation with regard to risk’ (p.2). Based on this definition, paramedic risk management can be defined as the development of methods that will effect change in the likelihood, consequence and severity of an event towards the objectives of a paramedic, which include: the treatment of and transport of sick an injured persons. Paramedic risk management is almost an unheard of concept, and has largely been incorporated into basic legal requirements under occupational health and safety laws.

When should the risks be managed?

Ideally, risk should be managed well before an event occurs. Therefore, risk should be managed when an organisation develops its management objectives. Once these objectives are known, risk management processes should be developed in order to then manage the risks associated with achieving these objectives. Although risk management is primarily about avoiding or mitigating loss, it can also lead to the identifications of new opportunities. Because of this, it is important to integrate risk management into an organisation’s management plans and objectives.

By managing risks early, an organisation potentially protects against significant financial, human and operational costs in the future related to poorly managed risk, such as loss of productivity, damage, and injuries. Risk management is dynamic, and requires continual monitoring and review of the risk management process to ensure that it still meets the required objectives. Proactive risk management allows for risks to be managed before adverse events occur and hindering the organisations ability to achieve its objectives.

Why should an ambulance service manage risk?

Effective and appropriate application of risk management guidelines in ambulance practice will result in the following benefits for an ambulance service:

  • Improved understanding of the potential risks in ambulance practice
  • Improved ambulance management practices
  • Identifications of new opportunities
  • Greater ability for the organisation to achieve its goals and objectives
  • Provide a safer and more cost effective ambulance service
  • Improved occupational health and safety within the ambulance service
  • Improved management of ambulance resources
  • Greater confidence in the institution from both internal and external stakeholders
  • Reduction in unforseen costs
  • Reduction in injuries at work (and their associated costs) 

What are the risks in ambulance practice?

Because of the nature of ambulance practice, paramedics work in an area of intrinsically higher risk than many other organisations. These risks encompass the following areas of risk and will be discussed in depth later on:

  • People risks
  • Organisational environment risks
  • Organisational management risks
  • Ambulance practice specific risks 

What is the Risk Management Process?

Risk management in its basic forms has been utilised in business practices for more than six decades. Like any other area of study, risk management has evolved and improved throughout this time. In 1995 the first Risk Management Standards were developed by the Australian Standards/New Zealand Standards of Risk Management (AS/NZS 4360:1995) in which a generic risk management framework was first clearly identified. This framework has regularly been reviewed and is currently identified by the AS/NZS ISO 31000:2009.

Risk is unavoidable, and risk management is a dynamic process. Therefore, continual efforts in risk management are the only measures to ensure that the goals and objectives of an organisation are achieved. It is essential to an organisations ability to achieve its goals and its overall success.

The AS/NZS ISO 31000 (2009) identifies five primary processes to managing risks.

These are:

  • Establishing the context
  • Identifying the risks
  • Analysing the risk
  • Evaluating the risks; and
  • Treating the risks

(AS/NZS 2009, p.14).

In combination with these five processes, there is the need to develop a specific risk management committee, or planning group who continually communicate, consult, monitor, review and document throughout each stage of the process. 

Paramedic Risk Management Process

The following steps identify the risk management processes and their application to ambulance practice: 

  • Step One: Establishing the Context
  • Step Two: Identify the Risk
  • Step Three: Analyse the Risk
  • Step Four: Evaluate the Risk
  • Step Five: Treat the Risk
  • Step Six: Monitor and Review
  • Step Seven: Communication and Consultation

Managing Risks in Ambulance Practice

 

Step One: Establishing the Context

This is the start of the risk management process and requires the development of a clear understanding of the organisation’s objectives, external and internal parameters to be considered when designing a management plan for risk, and identifying the scope and risk criteria to be utilised. By outlining these key contexts at the onset of the management and risk management development, an organisation is better positioned and equipped to establish an effective risk management program. Failure to adequately establish the context, may result in the requirement of multiple reviews and re-designs of a risk management program, as the result of unintentionally targeting a tangent risk or re-prioritising the objectives of the program.

By establishing a concise context, an organisation can identify its objectives and the normal parameters that the organisation must perform its tasks within to achieve those objectives. The parameters in ambulance practice often refer to areas such as:

  • Financial restraints and budgets
  • Equipment availability, such as vehicles, medical equipment
  • Human resources, including recruitment, retention and competency of paramedics
  • Timelines
  • Government regulated/agreed upon ambulance response times to medical emergencies in the metropolitan, semi-rural and rural settings.

 When determining specific parameters that an ambulance organisation must remain within while achieving their objectives, it is easier to identify what risks exist to prevent the achievement of these objectives. The management of risk should be undertaken with the full consideration of the need to justify the resources used in carrying out the risk management.

For example, it is poor risk management for an ambulance service to allocate $500,000 in the development of a financial risk treatment of medical equipment worth $100,000. In this circumstance, it would make sense to make a conscious decision to accept the original risk.

Establishing the external context

Establishing the external context requires identification of the external environment in which the organisation seeks to achieve its objectives. It is important to understand the external context to ensure that the objectives and concerns of external stakeholders are considered when developing the risk criteria.

In ambulance practice, the external context includes:

  • The social, cultural and political perceptions;
  • Legal and regulatory requirements;
  • Financial constraints;
  • Technological, economic, natural and competitive environment.
  • The key drivers and trends that impact on the objectives of the ambulance service. 

The relationship with perceptions and values of external stakeholders must be examined in order to achieve successful risk management. This is because the stakeholders’ perceptions of risk often dictate the potential risk management objectives and strategies. If the stakeholders do not perceive a threat as a result of the consequence of an event, it is hard to justify the resources allocated in managing it. 

Establishing the internal context

Internal context refers to anything within the organisation that can influence the way in which an organisation will manage risk.

In ambulance practice, the internal context includes:

  • The objectives of the ambulance service, including providing emergency pre-hospital health care and transport of patients to hospitals
  • Providing the most up-to-date and best emergency health care for patients; and
  • Promoting an image of duty, credibility, caring and trust.

 

Establishing the context of the Risk Management process

The objectives, strategies, scope and parameters of the activities of the organisation, or those parts of the organisation where the risk management process is being applied, should be established. The management of risk should justify the resources used.

In ambulance practice, establishing the context of the risk management process may include:

  • Defining the goals and objectives of the risk management activities
  • Defining the responsibilities for and within the risk management process
  • Defining the scope, as well as the depth and breadth of the risk management practices
  • Defining the risk assessment methodologies
  • Defining the way performance and effectiveness is evaluated in the management or risk
  • Identifying the specific decisions that must be made. 

Defining the risk criteria

An organisation should define the criteria to be used to evaluate the significance of the risk. This criterion should reflect the organisation’s values, objectives and resources. Some criteria can be imposed by legal and regulatory requirements. For example, many ambulance services are governed by state and federal legal requirements based on Occupational Health and Safety (OH&S) laws, which clearly define specific risk criterion. In New South Wales for example, there is a legal requirement under work cover’s OH&S laws to wear a high visibility uniform that mitigates the risk of being hit by vehicles while working on a road, such as a florescent yellow vest.

When defining risk criteria, factors be considered include:

  • The nature and types of causes and consequences that can occur and how they will be measured
  • How likelihood will be defined
  • The timeframe/s of likelihood and/or consequence/s
  • How the level of risk is to be determined
  • The views of stakeholders (this should include their perception of the risk)
  • The level at which the risk is acceptable or tolerable
  • Whether or not a combination of multiple risks should be taken into account or not. For example, in Ambulance Practice, a single risk such as entering a house at night in a low socio-economic neighbourhood may be considered an acceptable risk, but combined with a history of a recent brawl may be considered unacceptable. 

Step Two: Risk Identification

The second step in the risk management process requires the risks to be identified and the general process of risk identification, risk analysis and risk evaluation to take place. Through this process, an ambulance service is able to develop an understanding the risks that need to be managed, risks not to be managed, and where opportunities for better achievement of objectives can be realised.

 

The ambulance service should create a list of risks based on those events which may: create, enhance, prevent, degrade, accelerate or delay the achievement of objectives. Included in this, should be risks associated with not pursuing an opportunity.

Risk identification should also consider any cumulative or cascading effects of an event. For example, if a paramedic gets injured attending to a patient because he or she has not been adequately equipped to lift the patient, the consequence of that event will lead to an immediate negative consequence to that paramedic, being a back injury. The cascading effect of this event, will mean that the paramedic will not be able to attend work for many weeks, resulting in numerous costs to the organisation, including: overtime costs for other staff, inability to respond ambulances in a timely fashion, costs of rehabilitation and so forth.

Risk identification in ambulance practice includes risks associated with:

  • the organisation’s people
  • the organisation’s environment
  • organisation’s management; and
  • ambulance practice specific risks

The following provide some areas of risk associated with an ambulance service:

Risks to the organisation’s people:

  • Human resources
  • Failure to recruit and retain staff
  • Induction training and competency
  • Continued education and skills maintenance
  • Occupational Health and Safety (OH&S)
  • OH&S Management Systems
  • Equal Employment Opportunity
  • Professional Services and Conduct
  • Health and wellbeing of the paramedic
  • Threat to the physical safety of employees
  • Threat to the physical safety of other emergency service personnel
  • Threat to physical safety of the general public
  • Threat to physical safety of the patient/s
  • Hazard Management
  • Industrial Action
  • Rehabilitation and Work Cover

Risks relating to the organisational environment:

  • Natural hazards
  • Technological hazards
  • Security
  • Hazardous and toxic materials
  • Public health
  • Waste and refuse
  • Radiation/contaminated waste
  • Disasters

Risk relating to the organisational management:

  • Finance
  • Insurance
  • Ambulances, Property, Equipment
  • Public Liability
  • Legal Relationships
  • Information Technologies
  • Communications

Paramedic Specific Risks:

  • Failure to respond an ambulance to an emergency
  • Driving an ambulance during emergency procedures and (lights and sirens) parking an ambulance at an emergency site/disaster site
  • Interacting with other emergency personnel at an emergency
  • Treating patients at an emergency
  • Violence towards paramedics
  • Transporting patients to a hospital
  • Failure to maintain competent and up-to-date with ambulance practices
  • General wellbeing of the paramedic; and
  • Promoting an image of duty, competence and compassion to the community

How are risks and sources of risks identified?

Risk management committees may use a multitude of risk management tools and techniques to identify risks and their potential sources in ambulance practice. It is important to utilise people with appropriate knowledge of the industry to be involved in identifying the risks. Often, poorly managed organisations develop risk management programs without involving the front-line employees who are most likely to be affected by the risk. Without having appropriate knowledge of the risk, any management plan is bound to fail. Therefore, paramedics should be involved in the process of identifying risks and sources of risks.

These are examples of resources used to identify risks in Ambulance Practice:

  • Experiences as a paramedic
  • Historical records
  • Legislation compliance records
  • Inspections and audits
  • Interviews and surveys of paramedics, patients, and other emergency service personnel
  • Inter-Service Communication with other Emergency Services
  • Group Brainstorming Sessions
  • Review of adverse events, including route cause analysis.

Step Three: Risks Analysed

This is the third process in risk management and is utilised to analyse the specific risks that have now been identified. This process provides background information that will later be used by the organisation to develop potential treatment options. It should also provide a triaging or prioritisation process of the risks to ensure that the most significant risks to the objectives of the ambulance service are evaluated and treated first, rather than the risks in which the consequences have little or no impact on the Ambulance Service’s objectives.

Risk analysis looks at considering the cause and source of risk, their positive and negative consequences, and likelihood that those consequences can occur. Any factors that may affect consequences and likelihood should be identified (AS/NZS 2009, p.18). An event can have multiple consequences and can affect multiple objectives. Existing controls and their effectiveness and efficiency should also be taken into account.

The way in which consequences and likelihood are expressed and combined in order to determine a specific level of risk should reflect the type of risk, the information available, and the purpose for which the risk assessment output is to be used.  Through this process, a risk can be determined to be acceptable or unacceptable by an ambulance service.

Methods for Analysing Risks

The methods for analysing risk include the following types of data analysis:

  • Qualitative
  • Semi qualitative; and
  • Quantitative.

Qualitative Analysis

This method enables paramedic experience, judgement and intuition to be used in the decision making process and is therefore generally less time-consuming and less costly in terms of resources. The negative aspect of this method is the potential for risks to continue to be managed in the same way as they have always been managed and therefore the same mistakes are potentially being made time and time again. An example in ambulance practice would include an incident debrief, in which paramedics are able to sit around a room and discuss with their colleagues how they felt the risks were managed.

Semi-Qualitative Analysis

In certain circumstances an in depth quantitative analysis may not be appropriate or viable due to the time constraints, cost implications, level of risk or availability of data. In these cases, a semi-qualitative analysis may be useful, in which data is collected and analysed through experiences, judgements and intuition, but is supported by quantitative data where the likelihood and consequences may be quantified. This may include taking surveys from paramedics about incidents, events or adverse outcomes in order to determine what went wrong or what could have been done better.

Quantitative Analysis

Quantitative analysis requires the data collectors to gather data that can be quantified in order to represent the consequence and likelihood of risks.  Examples of quantitative analysis includes: reports of amount of injuries paramedics have sustained during particular events, how long they have been unable to attend work, and the specific financial costs of rehabilitation including replacement staffing (overtime costs) incurred as a result.

Step Four: Risks Evaluated

This is the fourth process in risk management and allows decision makers to determine if a risk is acceptable or not by comparing the outcomes of the risk analysis to the established risk criteria (identified in the establishing the context stage). Here, paramedics and decision makers need to determine the risks that require treatment and the priority for treatment implementation.  

Decisions made should involve the broader context of the risk, including not only the organisation undertaking the risk management, but also including the wider context of the risk, such as parties outside the organisation that are affected by the risk. This should also include identification of any legal, regulatory or other requirements (AS/NZS 2009, p. 18).

It should be recognised that not all risks, once evaluated require treatment. In some circumstances, the potential adverse effects on the objectives of the organisation are less than the cost of the implementation of risk management strategies. In these circumstances the organisation should make the decision to accept the risk by informed consent. In this circumstance, some ambulance services choose to self-insure their ambulances.

Risks Treated

The fifth process in risk management involves identifying and implementing risk treatment options in order to treat the risks that have already been identified as unacceptable during the risk identified, analysed and evaluated processes.

 

Risk treatment involves selecting one or more options for modifying risks, and implementation of those options.

Risk treatment involves a cyclical process of:

  • Assessing a risk treatment
  • Deciding whether residual risk levels are tolerable
  • If not tolerable, generating a new risk treatment; and
  • Assessing the effectiveness of that treatment.

(AS/NZS 2009, p. 19).

It was identified during step one (identifying the risk) that risk identification is a potentially limitless process and therefore effective risk management in ambulance practice often requires paramedics to develop a culture of risk management, rather than a guideline of every possible risk. The following are examples of risk treatment options available and applied to one common risk identified in ambulance practice. This risk treatment options apply to paramedics who are treating a patient who is violent:

a)      Avoiding the risk –  this could include if a patient is deemed to be too aggressive or violent a paramedic may choose to avoid the risk by organising the police to transport the patient in a locked police wagon;

b)      Taking or increasing the risk in order to pursue an opportunity – this could include increasing the financial risk by trialling mechanical restraint devices, which if successful could reduce the number of paramedics required to attend and treat a violent patient;

c)      Removing the risk source – if a patient, especially one that is violent or has a mental illness with a history of aggressive behaviour is sitting next to a knife or potential weapon, one solution can include, walking the patient outside (away from the knife) or simply picking the knife up and putting it away.

d)       Changing the likelihood – one solution here is to effectively communicate with the patient before approaching that you are a paramedic and there to help. Many patients become violent because they are unaware that you are a paramedic and not a police officer there to arrest them;

e)      Changing the consequences – one solution available here would include wearing protective clothing, such as Kevlar vests to protect against stabbing injuries or bullets (although the level of risk should never reach this stage in ambulance practice);

f)        Sharing the risk with another party or parties (risk financing/insurance) – this can include involving police for assistance while treating all patients who are potentially violent;

g)      Retaining the risk by informed decision – one example of this could include an ambulance service acknowledging the documented fact that paramedics are more likely to be assaulted during night time than the day (FEMA 2006, p.2), but accepting this risk by informed decision and acknowledging that paramedics must still respond to medical emergencies during the night.

Selection of risk treatment options

Selecting the most appropriate risk treatment option involves balancing the cost and efforts of implementation against the benefits derived. The benefits must also consider the potential legal, regulatory and social responsibility that the ambulance service may be obliged to adhere to.

Multiple treatment options can be considered, including individual, or a combination of risk management strategies. As a paramedic at the scene of a motor vehicle crash, this may include: wearing high visibility vests, parking the ambulance in such a way as to re-direct traffic and create a shield, using police assistance to manage traffic, or block the road completely. When selecting treatment options the organisation should consider the perceptions or values of the stakeholders. The perceptions of the paramedics may often differ from those of the other key stakeholders, such as politicians who make decisions on the services that will be capable of providing to a community.

The treatment plan should clearly identify the priority order in which individual risk treatments should be implemented. As a paramedic, it is paramount to identify those risks that need to be treated immediately and those that can be managed at a later time.

Risk treatment itself can introduce risks. For example, in ambulance practice, the introduction of goggles when working inside a car, may introduce the risk of temporary vision impairment due to the goggles fogging up. When risk treatments introduce secondary risks these risks then need to be assessed, treated, monitored and reviewed. If further treatment options are identified for these risks, a clear link between the two risks should be identified and the risks treated as a single process and not a new risk on its own (AS/NZS 2009, p. 20).

Preparing and Implementing Risk Treatment Plans

The purpose of risk treatment plans is to document how the chosen treatment options will be implemented.

The following information should be provided within the plan:

  • The reasons for selecting the treatment options, including expected benefits to be gained
  • Those who are accountable for approving the plan and those responsible for implementing the plan
  • Proposed actions
  • Resource requirements including contingencies
  • Performance measures and constraints
  • Reporting and monitoring requirements; and
  • Timing and schedule.

(AS/NZS ISO 3100) p. 20)

Decision makers and other stakeholders should be aware of the nature and extent of the residual risk after risk treatment. The residual risk should be documented and subjected to monitoring, review and, if required, further treatment.

 

Step 6: Continuously Monitor and Review

The continuous process of monitoring and reviewing should be maintained throughout the entire risk management process. Because risks are dynamic, a continuous review and monitoring of their management should be diligently maintained in order to achieve long term risk management success. As with every other treatment option in paramedics, a repeated evaluative process must be used to determine its continued effectiveness.

Both monitoring and review processes should be built into the entire process of risk management. It can be done periodically, based on time intervals or stages of development, or on an impromptu basis throughout random timeframes and stages of development.

Monitoring and review in ambulance practice can be achieved through the following methods:

  • Self-reporting system, such as the IIMs system in NSW Health in which paramedics are able to self-report the consequences of a risk, such as near misses or adverse events;
  • Risk management committees;
  • Work cover reports of accidents and injuries;
  • Reports of the organisation’s ability to meet its objectives, such as providing ambulances to meet the needs of the community.

Progress in implementing risk treatment plans provides a performance measure. The results in monitoring and review should be recorded and externally and internally reported as appropriate, and should also be used as an input to the review of the risk management framework.

Documenting the risk management process

Risk management activities should be recorded. In the risk management process, records provide the foundation for improvement in methods and tools, as well as in the overall process. Furthermore, documentation is often a legal requirement of many areas of risk management, such as OH&S and Work Cover NSW accident and injury reports.

Step Seven: Continuous Communication and consultation

The continuous process of communication and consultation in risk management ensures that both external and internal stakeholders’ needs are taken into account during each stage of the risk management process. This allows early recognition of potential discourse amongst stakeholders and allows early detection of potential solutions where required.

In ambulance practice, the perception of risk is likely to be different based on the type of stakeholders, management roles, and front-line employees. For example, the perception of risk that a paramedic may be ‘threatened with physical violence at work’ may vary depending on if you are asking the senior managers, who are required to provide safety alarms under the OH&S laws or the frontline paramedics, who may refuse to enter a property that they feel unsafe.

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Managing Risk in Ambulance Practice

May 13th, 2012

Risk exists in every aspect of business, and the way organisations manage this risk will determine how it will affect the organisation’s ability to achieve or exceed its objectives. The objective of an ambulance service is to provide emergency medical treatment and transport to patients within the community. The environment in which paramedics strive to achieve these objectives is dynamic, often hazardous and full of risk. Surprisingly, current paramedic education and training incorporates very little training if any at all, in the area of risk management. This paper will review the current knowledge base on the topic of risk management in ambulance practice. It will then develop a set of guidelines for applying the AS/NZS ISO 31000 Risk Management Standards to ambulance practice in order to equip paramedics with a greater understanding and application of risk management practices. 

It has been well acknowledged that risk exists in all aspects of our lives, in all industries, at home, socially, and in economics (AS/NZS 2009, p. iv; IRM 2011, p. 1). Paramedics provide emergency medical services in an emergency environment that is, by definition, hazardous and potentially full of risk. Given that this is the case, it is surprising to find that little is known about the way paramedics manage this risk. 

I have worked as a paramedic in both the Metropolitan Ambulance Service of Victoria and the Ambulance Service of NSW (ASNSW). It has been observed that although so much time is spent training and educating paramedics on areas such as anatomy and physiology, emergency medical procedures and communication, there is very little training in the area of risk management. Where some training has been provided, it has often been in the area of personal protective equipment (PPE), as a means of meeting legislative OH&S requirements, rather than providing an understanding of risk management concepts in a whole.

To achieve successful risk management in ambulance practice, paramedics must develop a culture of risk management that is incorporated into every aspect of their work, rather than meeting basic legislative requirements under work-cover law. 

Hypothesis  

Risk in ambulance practice can be better managed by equipping paramedics with training and education in risk management and the development of a risk management culture. 

Paramedics work in a unique and often uncontrolled environment in which risk in its many levels is ubiquitous. Given that this is the case, paramedics need to be equipped with a strong risk management knowledge and culture, so that they are able to achieve their objectives. The aim of this paper is to determine the current knowledge base on the topic of risk management in ambulance practice and then to develop a set of guidelines for applying the AS/NZS ISO 31000:2009 Risk Management Standards to ambulance practice. 

What is risk?

The term ‘risk’ can be defined as the ‘effects of uncertainty on objectives’ (AS/NZS 2009, p. 1). Risk exists in every aspect of society. It is impossible to achieve any goal without the existence of risk. Everything we do entails a certain level of risk that we will or will not achieve our objectives, or that we will exceed the goals of our objectives.

Risk can be further identified as the relationship between the likelihood of an event and the consequence if that event occurs. For example, there is a high likelihood that a paramedic will get a common cold and not be able to attend work for a couple days during some stage of the year; however, the consequence of such an event has only a minor effect on the objectives of the organisation. Alternatively, the likelihood of a paramedic getting meningococcal meningitis is very low; while the consequence of a paramedic getting meningococcal meningitis from a patient is severe and potentially fatal. 

All organisations are potentially influenced by both external and internal factors that have an effect on whether, when and the extent to which they will achieve or exceed their objectives. The effect this uncertainty has on the organisation’s objectives is ‘risk.’

In ambulance practice risk can be further defined as the effects of uncertainty on a paramedic’s ability to provide emergency medical treatment and transport to a patient during an emergency. If an ambulance develops a mechanical fault enroute to an emergency, the risk exists that an ambulance will no longer be able to attend the emergency. Now, if there is a second ambulance nearby that is able to respond to the emergency, the consequence of this event is not severe; however, if there is no other ambulance in the area then the consequence of this risk is potentially high.

Risk Management

The term ‘risk management’ can be defined as any process whereby a person or organisation attempts to change the likelihood or consequence of a possible event. People have been instinctively managing risk for thousands of years. In early evolutionary history, people found that they were able to manage the risk of freezing to death by covering their skin with leaves, animal hide and huddling together (Bernstein 1998, pp. 15-16). Since the 1950s many businesses have utilised risk management strategies to mitigate the potential risk their businesses face (IRM 2011, p.18). Even in general society today, we manage risk. When we get into a car, there is the risk that we may have a motor vehicle crash, so we put our seatbelt on to reduce the consequence of this and we drive cars with anti-brake-locking (ABS) braking systems to reduce the likelihood of having an accident. If the car develops a flat tyre, we have a spare tyre available to replace the first one, so that our original objective (to get from point A to point B) is not compromised. These are all attempts to manage risk through the active process of risk management.

Although risk management has been around a long time, it should be acknowledged that formal frameworks for the risk management process are a relatively new concept that only started to advance into formalised frameworks in the early 1990s. One such advancement occurred in 1995 when the AS 4360: 1995 developed a framework that clearly outlined the main processes of risk management in a standardised form. These frameworks have been regularly updated to meet the evolving needs of risk management. The most current version of this is the AS/NZS ISO 31000:2009 Risk Management Standards (AS/NZS 31000:2009, p.1).

In the United Kingdom, the Institute of Risk Management developed a similar standard and generic framework for the risk management process in 2002. This standard was made readily available to all persons for free over the internet. The organisation identified that risk management is in the interests of all persons and should be available to all (IRM 2011, p. 4). 

The AS/NZS ISO 31000 (2009) has described risk management as a set of ‘coordinated activities to direct and control an organisation with regard to risk’ (AS/NZS ISO 31000 2009, p.2). Organisations manage their relationship with risk by anticipating it, developing an understanding of it and deciding whether or not to modify it. Throughout this process they communicate and consult with stakeholders and monitor and review the risk and the controls that are modifying the risk. The AS/NZS ISO 31000:2009 describes one systematic and logical process for doing this in detail.

The AS/NZS ISO 31000: 2009 Risk Management Standards

The AS/NZS ISO 31000:2009 Risk Management Standards is a set of standards in risk management that was prepared by the Joint Standards Australia/Standards New Zealand Committee on Risk Management in order to provide a generic framework for managing risk. These Standards are not part of government, and are not laws, regulations or legal documents. Because of their rigour, they are often called up into legislation by government and often become mandatory. When this occurs, it is a decision made by the elected government and not by Standards. 

The AS/NZS ISO 31000:2009 recommends that organisations should have a framework that integrates the process for managing risk into the organisation’s overall governance, strategy and planning, management, reporting processes, policies, values and culture.

The AS/NZS ISO 31000: 2009 identifies the following framework of processes in risk management:

  • Establishing the context
  • Risk identification
  • Risk analysis
  • Risk evaluation; and
  • Risk treatment

(AS/NZS 2009, p. 14).

 Throughout this entire process, the risk management committee, key stakeholders, management, and front-line employees should maintain a regular process of communication and consultation, as well as monitoring and review as a continuous process throughout.

The Paramedic Environment  

Paramedics provide emergency medical services in physically hazardous and socially complex situations where risks are often difficult to foresee and mitigate (Campeau 2008, p.3). Paramedics respond to emergency sites, in which potential risks are endless. Rendell and Johnson (2004) identify that: ‘every situation that an EMS (paramedic) enters into carries with it a certain amount of associated risk (p.3).’

For example: a car that has crashed and rolled over may have broken glass, leaking fuel, fallen live power lines down, the potential for other vehicles to crash into it, and blood. In addition to this, there are many dangers associated with using hydraulic pressure equipment to access the patient in the car, combined with loud noises, multiple distractions and subsequently poor communication amongst emergency workers. Throughout this, a paramedic must be able to rapidly sieve out the acceptable or unacceptable risks on the scene and then implement specific risk treatment options in order to safely access the patients and provide medical assistance. 

Given that this is the case, it is surprising that many ambulance services within Australia and globally, appear to place little emphasis on the study of and practice of paramedic risk management (Campeau 2008, p. 5). These work settings provide unique challenges in terms of managing resources in order to enable the delivery of emergency patient care in a relatively safe way. Although paramedics work in this environment full of risk, the concept of risk management in ambulance practice is relatively new and there is only limited training provided for paramedics on this topic. Where training is provided, it is often in the form of basic Occupational Health and Safety (OH&S) policies which meet legislative requirements of the ambulance service they work within (Levick 2008, p. 18). Where Risk Management is incorporated into an organisation, it is only in senior management and rarely relates to front-line employees in both the development of practice and the introduction of concepts/training. 

Once a risk is identified, analysed and evaluated in the Ambulance Service, during the process of risk management, the risk treatment process looks to reduce the likelihood or consequence of the event, transfer ownership of the risk or avoid it altogether. Parker (2002) recognises that: ‘for paramedics, emergencies are routine and the unexpected the norm’ (p.2). This dynamic and unpredictable environment that paramedics are exposed to during their normal working practices increases their potential exposure to risk. As a result of this, any successful risk management policy implemented for paramedics, require a strong focus on the front-line employees (paramedics) to develop a culture of risk management. 

Campeau (2008) has developed one theory of how paramedics manage risk and identifies that  “paramedics strive to control their working ‘space’ in order to manage a scene; in doing this, a paramedic can shape what looks like a disaster site, into a safe, comfortable, working environment (p.4).” It has also been acknowledged that for a paramedic to develop this ability takes years of experience and currently has not been taught to paramedics didactically.  

Risk in Ambulance Practice 

Risks in ambulance practice can be clearly divided into the following areas: 

  • People risks
  • Organisational environment risks
  • Organisational management risks (business continuity)
  • Ambulance practice specific risks

Within these categories, paramedics must manage risks that occur in the following activities of their occupation:

Responding to an emergency;

  • Attending to a patient at the scene of an emergency;
  • Driving to hospital
  • Failure to respond an Ambulance to an Emergency
  • Driving an Ambulance during emergency procedures and (lights and sirens)
  • Parking an Ambulance at an Emergency
  • Interacting with other Emergency Personnel at an Emergency
  • Treating patients at an Emergency
  • Violence towards Paramedics
  • Transporting patients to a Hospital
  • Fatigue
  • Failure to maintain competent and up-to-date with Ambulance Practices
  • General Wellbeing of the Paramedic
  • Promoting an image of duty, competence and compassion to the community

It should be noted that risk identification is a potentially limitless function of a paramedic’s duty, and these are not the only risks that need to be identified in ambulance practice.

Why Should Ambulance Services Manage Risk?

By managing risks, Ambulance Services are able to: 

  • Achieve their objectives better
  • Decrease the cost of unforseen events
  • Decrease the consequence of adverse events
  • Improve paramedics’ health and wellbeing
  • Improve patient health outcomes
  • Provide more cost effective ambulance services to the community

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Three Collisions in a Crash

May 9th, 2012

There are actually three collisions in every crash and as a paramedic it is vital to keep all three in the back of your mind when you’re assessing the mechanism of injury of a motor vehicle accident and searching for injuries in a patient. The three collisions include: the vehicle collision, the human collision and the internal (organ) collision.

In order to understand the three collisions in a crash it is important to have a basic understanding of kinetic energy. Kinetic energy can be defined as the energy built up in a moving object. When an object collides with another object the kinetic energy must be dispersed or the original object will continue to move in the original direction. The amount of kinetic energy required to be dispersed will depend on the mass of the objects in motion and the velocity (speed) in which the object is travelling.

For example, a car that weighs approximately 1200 kgs that is travelling at a speed of 50 kms/hour will have much less kinetic energy than a truck that weighs 40, 000 kgs and is travelling at the same speed of 50 kms/hour. Consequently, the car will require less kinetic energy in opposition to decelerate and stop than the truck.

When a vehicle is travelling down a road it has a specific amount of kinetic energy (based on it’s mass and velocity). If the vehicle crashes, this amount of kinetic energy will have to be dispersed in order cause the vehicle to come to a stop. In a motor vehicle accident, this kinetic energy is generally dispersed through the vehicle/object crushing, sound waves, and the development of heat. 

The Three Types of Collisions in a Crash

In an example of a motor vehicle crashing into a solid concrete barrier these are the three types of collisions seen. As a paramedic, it is important to understand these three collisions.

The Vehicle Collision

The vehicle collision is where the vehicle collides with another object (the concrete barrier) and the vehicle frame is crushed. Fortunately, most modern cars are designed to crush well and therefore absorb the majority of the kinetic energy, allowing the bulk of it to disperse before reaching the much more fragile human occupants.

The Human Collision

As the bulk of the kinetic energy is used up during the vehicle crash and the vehicle itself starts to decelerate to a stop, the second collision occurs, and this one involves the movement of the human occupants within the inside of the vehicle. While the crushing of the vehicle’s exterior absorbs the kinetic energy, the human occupants continue to travel in the same direction at a relative velocity, until they hit an object in the vehicle that causes their forward motion to stop. For most human occupants this will likely be due to the human collision with the stationary seatbelts. However, for those occupants who are not wearing a seatbelt, the next collision is likely to be the steering wheel, dashboard, or windsheild. The unrestrained occupant will likely be ejected from the vehicle or collide with the steering wheel or dashboard. When a human body collides with a rigid object (such as the steering wheel, dashboard, concrete barrier, or tree the motion of person travelling forward will cease almost instantaneously. This will result in the sudden disbursement of the kinetic energy, and due to the softness of the human body, will most likely result in the body crushing instead. This is why unrestrained occupants have the highest risk of death during a motor vehicle accident. It is also important to recognise that, although vehicle seatbelts appear rigid they have a certain amount of stretch that allows the kinetic energy to disperse over a greater duration of time.  

The Internal Collision

Once the occupant’s body has stopped movement the internal organs of the body still remain in motion in the original forward direction until another organ or body part exerts enough energy to cause it to stop. In this case a sudden stop of a motor vehicle into a concrete barrier would cause the vehicle to crush, followed by the seatbelts to restrain the human body, where upon the organs within that body would have to potential to tear, rupture or collide with each other. This is why motor vehicle accidents that involve high deceleration forces often lead to a ruptured spleen, liver, torn large vessels (such as the aorta) and brain injuries as the soft brain continues forward while the solid skull is forced to stop suddenly.

At the end of the day kinetic energy doesn’t disappear, it has to be acted upon by an external force in order to cause an object in motion to come to a stop. As a paramedic, it is vital to have a thorough understanding of the three collisions in a crash in order to comprehend how this kinetic energy is most likely to have been dispersed. Based on this knowledge, a good paramedic will be in a better position to predict likely injuries based upon the mechanism of injury and therefore determine a better treatment and transport decision for his or her patients at a motor vehicle accident.

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Mechanism of Injury Motor Vehicle Accidents

May 3rd, 2012

Developing an understanding of the mechanism of injury in a motor vehicle accident is paramount to being a good paramedic. Attending motor vehicle accidents are a common occurrence for paramedics but usually one that requires more interventions and considerations by the attending paramedics than medical cases alone.

On top of the usual need for managing areas of concern, such as scene safety, multiple victims, multi-agency responses, communications/organisation, it is vital for the treating paramedics to recognise the mechanism of injury relating to each specific motor vehicle accident. (I acknowledge that motor vehicle accident and motor vehicle crashes have become synonymous).

In order to understand the mechanism of injury in motor vehicle accidents it is important to have a basic understanding of kinetic energy. Kinetic energy can be defined as the energy built up in an object in motion. When an object collides with another object the kinetic energy must be dispersed or the original object will continue to move in the same direction. The amount of kinetic energy required to be dispersed will depend on the mass of the objects in motion and the velocity (speed) in which the object is travelling. It is our understanding of how this kinetic energy is dispersed that allows us, as experienced paramedics, to make educated guesses relating to the type of injuries a patient may have based on the mechanism of injury in a motor vehicle accident.

How to Determine the Mechanism of Injury in a Motor Vehicle Accident

When you arrive at a motor vehicle accident (MVA) as a paramedic, what are your first thoughts about the potential mechanism of injury (MOI)?

When I arrive at an MVA I like to take a few extra seconds as I approach to “take in the accident” and consider the likely injuries that the occupants will have based on the mechanism of injury. This doesn’t mean that I dawdle over towards the vehicles involved, just that I want to look at them and grasp the likely mechanisms.

As a paramedic, these are the main thought processes that I consider when I approach an MVA in relation to the occupant’s mechanism of injury:

1. What type of MVA is it? Is it a head on collision, T-bone/lateral collision, rear collision, or vehicle roll over?  

2. Does the MVA involve one, two or multiple vehicles?

3. What type of vehicles are involved? Are they new vehicles, with built in crash zones (designed to absorb the kinetic energy during impact), or older vehicles, without crash zones? Are the vehicles of similar mass? For example, two sedans. Or, is there a large mass inequality, such as a sedan versus truck, in which I know the sedan is going to absorb much more of the kinetic energy than the truck.

4. What is the damage to the vehicle? In the many years gone past, when cars were made of built like tanks, paramedics looked at the damage to the overall vehicle to consider potential exchange of kinetic energy. Of course, these days, cars are designed to crush and absorb the kinetic energy. Consequently, outside vehicular damage is a relatively useless determinant of the occupant’s potential injuries. What is particularly relevant these days is the deformation that causes intrusion to the inside compartment of the vehicle, such as the driver’s or passenger’s compartment. Is the steering wheel intact? How about the windshield? Dashboard?

5. Where are the three collisions in the crash? These include: the vehicle impact, the occupant’s body impact, and the occupant’s organ’s impact.

6. What safety devices might have affected the exchange of kinetic energy? For example, were the airbags deployed? What type of restraints were the occupants using (if they were restrained at all)? For example, a 2 point (lap seatbelt), 3 point standard seatbelt (lap/and sash), 4,5,6  and 7  point racing harness, or a 5 point child seatbelt? Were the seatbelts worn correctly? Many people will try to loosen their seatbelt to allow them to sleep while another person drives. Was the person sitting normally, or did they have their feet on the dashboard when the airbag deployed?

A the end of the day, although the mechanism of injury in motor vehicles accidents is a good clue to paramedics about the potential injuries obtained by the occupants, they are only a guideline, and paramedics should treat the patients based on a thorough clinical assessment including vital signs and a thorough secondary survey.

Remember to always stay on the side of caution with a motor vehicle accident and stay safe.

Paramedic Assessment and Treatment at an MVA

These are the basic steps that I follow when I attend an MVA:

1. Look for the danger (there’s going to be a lot of it out there).

2. Try to mitigate the dangers. This will include wearing appropriate PPE, such as a reflective vest, helmet, gloves, and goggles (you may look silly but you will go home more comfortable).

3. Park the Ambulance in such a way that you provide the greatest amount of protection to yourself and the patient. This normally requires you to block at least one lane. If you need to, block the whole road and stop all traffic until you extricate the patient. It doesn’t matter if people get to work 20 minutes late because you inconvenienced them. If you end up hit by another car while trying to do your job, no one is going to be better off.

4. Work out how many patients you have and what you are likely to require. An early report to dispatch following an ETHANE report will make it easier for you to get the resources that you require early. ETHANE stands for Exact location, Type of Accident, Hazards, Access and Egress, Number of Patients, and Emergency Services on scene and still required. Determine if the patient is already out of the vehical or still sitting in it. Most people who can will get themselves out of the vehicle.

5. Ask the patient these basic questions:

– What happened? (You can tell early on if they had an LOC or not by their answer to this question).

– Where does it hurt?

– Can you take a deep breath?

6. If possible, perform a Head to Toes – if you can’t get to the patient’s entire body, go as far as you can.

7. Check vital signs.

8. Provide analgesia.

9. Provide spinal immobilisation if concerned about the patient’s spine. This includes: cervical collar, mannual head support, and extrication using a KED and/or spine board. Consider an antiemetic if there is a high suspicious of a spinal injury.

10. Provide basic supporting measures and transport to hospital.

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Does Hypertension Cause Bradycardia?

April 22nd, 2012

Hypertension causes bradycardia through a negative feedback mechanism. Hypertension causes the increased systolic blood pressure to stretch the baro receptors within the neck which then sends a message to the brain that tells the SA node in the heart to reduce the rate and force of contraction.

However, it is also important to acknowledge that hypertension alone is not the only cause of bradycardia.

What Causes Bradycardia?

The following are common causes of bradycardia:

1. Hypertsion.

2. Electrolyte imbalances.

3. Cerebral events/stroke.

4. Sick Sinus Syndrome.

5. Disorders of the SA node.

6. Congenital Heart Defects.

7. Underactive thyroid gland.

8. Hemochromatosis.

9. Digoxin overdose.

10. Myocardial infarction/ischeamia.

11. Pericarditis.

12.Endocarditis.

13. Hypoxia.

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Australian Paramedic

April 20th, 2012

Australian paramedics are employed to provide high quality pre-hospital emergency medical care within each of the States and Territories of Australia. Each state is funded separately, and paramedics are employed, trained, and certified by different governing bodies within each state. This unfortunately means that highly qualified Intensive Care Paramedics from NSW are not necessarily able to transfer their skills to be an Advanced Life Support paramedic in QLD or Mobile Intensive Care Ambulance Paramedics in Victoria.

In practice, paramedics are respected well from each State and can easily gain employment in different States, but usually have to apply for Recognition of Prior Learning (RPL) and at least a 6 month probationary period.

The level of training and paramedical skills differ from each state. In NSW the entire state’s public Ambulance Service is funded by the state’s health budget and provides paramedics for both metropolitan and rural areas. Comparatively, paramedics in Western Australia are only state funded within the metropolitan regions, while the rural areas are community funded and run by volunteers, who commit large amounts of time to training and providing (free of charge) pre-hospital emergency health care.

What Skills Can Australian Paramedics Perform?

Each Ambulance Service within Australia is governed by their specific protocols or clinical practice guidelines developed by their individual Medical Director. However, in general Australian paramedics can perform a variety of advanced paramedical skills.

General Qualified Ambulance Paramedics require 3-4 years training and are able to perform the following skills:

1. LMA insertion

2. Defibrillation in manual mode

3. CPR

4. IV cannulation

5. IM/ SC injections

General Qualified Ambulance Paramedics can utilise various drug regimes to treat their patients such as:

Adrenaline 1:1000, Adrenaline 1:10,000, Aspirin, GTN, Glucose Gel, Glucose 10%, Dextrose 50:50, Metoclopramide, Ondansetron, Stemetyl, Ipratropium Bromide, Salbutamll, Oxygen, Midazolam, Naloxone, Benzyl Penicillan, Ceftriaxone, Morphine, Fentanyl, and Methoxyflurane.

Most Ambulance Services also have an Intensive Care Paramedic program and these paramedics are able to perform advanced paramedical skills such as:

1. Chest decompression through thoracentesis.

2. Intubation

3. Rapid Sequence Intubation

4. Synchronised cardioversions (for patients in rapid atrial fibrilation)

Intensive Care Paramedics also have a wider range of drug regimes to treat their patients such as:

1. Atropine, Adenosine, Lignocaine, Sodium Bicarbonate, Calcium Gluconate, Ketamine, Rocuronium, Vecuronium, Suxamethonium, and Thiopental.

Australian Paramedics are considered well trained by International Standards and are well positioned to gain employment as paramedics overseas. Paramedics in Australia are also keen researchers and many Ambulance Services have their own Ambulance Research Institutes that focus on improving the knowledge base of paramedical practice and paramedical sciences.

Australian Paramedic Registration

Currently, there is no one Australian Paramedic Registration such as the National Registry of Emergency Medical Technicians (NREMT) in the USA. There has been discussions about Australia adopting a similar system, but as yet no Ambulance Service within Australia has committed to the project.

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Calling a Patient Deceased Too Early…

April 2nd, 2012

The SMH website reported a case in Victoria (Australia) on the 1st of April in which two MICA paramedics (senior paramedics) identified one patient as trapped and deceased before expediting to hospital with another patient who was seriously injured. The “deceased” patient was alledgedly later found by SES workers to still have signs of life and was transported to hospital.

Although, only a full enquiry into the event will determine what happened and what can be done to prevent a similar event, it is an important lesson to be learned for all paramedics to be certain before calling a patient deceased. This is particularly difficult and important in a motor vehicle crash, in which there are often multiple casualties. It is often difficult while treating multiple patients, or seriously injured patients in a motor vehicle crash to take that extra minute that is required to flash the torch inside a vehicle and outside and look for other patients. This is particularly difficult when you have one or more critically injured persons who need your full attention.

I remember many years ago treating a very sick mother who was unconscious and trapped in a car, when we eventually extricated her and left the scene, she became conscious and started to become concerned about her baby. None of us had seen her baby in the car. There were multiple casualties, and these were still being treated at scene. Fortunately, someone ended up finding her baby (still alive) and had been thrown through the windscreen. Another time, I remember a crew calling a helicopter off because the only patient of a high speed roll-over had no pulse and “presumed” dead. More than half an hour later, the same crew called the helicopter back stating that they had originally only felt an absent pulse in a trapped, but severed arm, and the patient was still alive.

These are very rare and extreme circumstances, but they do happen.

It is also important to note that in some circumstances, the paramedics are correct to treat a trapped person as “deceased” if they do not have the resources to save all lives. In a multiple victum situation, many emergency management protocols focus on the concept of “providing the most good for the most number of casualties” – this does not necessarily mean that you can save them all.

At the end of the day, paramedics work in a very difficult environment and do the best they can to save the people they can. This sounds like a terrible accident that could have happened to any paramedic, but will definitely be in the back of my mind the next time I treat someone as deceased at a scene.

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How Much Do Paramedics Get paid?

March 26th, 2012

How much do paramedics get paid? This depends on how a paramedic works, if he or she performs on call duties, and their clinical qualifications, years of experience and any specialty roles (such as Rescue, Advanced Resuscitation).

In general, a paramedic gets paid somewhere between $24 per hour and $36 per hour. On top of this, a paramedic will usually make shift penalties. This means that they get paid more for working night shift and week-ends. Also, there is a certain amount of overtime that is inevitable as a paramedic, and this is paid at overtime rates, which are usually much higher than a paramedic’s base salary.

How Much Does a Student Paramedic Get Paid?

A student paramedic normally gets paid about $24-26 per hour, which increases each year until they complete their internship and become a qualified ambulance paramedic, which takes 3-4 years. This makes paramedics one of the highest paid traineeships available. It is also one of the most competitive traineeships available.

How Much Does a Qualified Ambulance Paramedic Get Paid?

A qualified ambulance paramedic will normally get paid somewhere between $31-34 per hour.

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Worst Medication Error

March 11th, 2012

This is the worst medication error that I have ever seen as a paramedic. Medication errors are unfortunately a common occurence both in and out of hospitals by regularly competent (and incompetent) medical clinicians, such as registered nurses, doctors, and paramedics. The reasons for medication errors involve a multitude of events that culminate in “accidents.” When you consider the long hours and chronic fatigue that most health care workers are employed, overall stress of the job, and night shift, it is surprising that there aren’t more medication errors.

This is the worst medication error that I have witnessed:

We attended a lovely lady in her early 90s who appeared to be well and healthy. The registered nurse at the nursing home gave me the blister pack which had about a dozen odd medications which had been administered to the patient about an hour before hand. I read through the list: digoxin, captopril, slow K, a variety of anti-depressants, etc… all seemed relatively normal.

“Okay,” I say “so she’s had her medications today… what seems to be the problem?”

“Well…” The nurse looks at me a little sheepishly “Well, that’s just it… these aren’t her medications…”

So, it turns out this lady has been given a total of 12 medications from a blister pack that was not her own… to make matters worse she is allergic to ACE inhibitors (such as captopril)…

Fortunately, our patient was fine in the end… but a very simple mistake could have easily had fatal ramifications.

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Worst Nursing Home Mistake

March 11th, 2012

This is the worst nursing home mistake that I have come across as a paramedic. I appreciate that nursing homes are generally understaffed and primarily employ patient carers or care assistants and not enrolled nurses or registered nurses. That said and done, this is the worst nursing home mistake that I have witnessed.

I was called to a 104 year old with chest pain. En route I had discussed with my probationary paramedic the realities of attending a 104 year old with chest pain who ends up having a cardiac arrest. We had discussed that it would be unlikely that we would be doing anyone a favour by commencing resuscitation efforts.

When we arrived, as per usual, it took about 5 or so minutes to gain access into the nursing home. Its always difficult to get someone’s attention in a nursing home, because the staff are usually used to confused patients banging or tapping on things. Eventually, we get in and a staff member points me in the direction of the 104 year old with chest pain. As per normal, the staff member seems to have disappeared completely.

We walk into the room and find a very old lady who has been clearly dead for many many hours. She is cold to touch and had obviously died many hours earlier. I ask her room mate how long she has been like this and her room mate advises me that “She hasn’t moved since this morning… I tried to tell the nurse that I thought she was dead hours ago…”

After a while, I go looking for a staff member. Eventually, I find one and advise that their patient with chest pain is deceased. The nursing home assistant looks shocked and tells me “Are you sure, I only spoke to her a minute ago…” – I politely advise her that she must not have spoken to the patient a minute ago, because the patient’s room mate advised me that she has appeared dead since this morning!

The nurse decides not to argue with me and we start doing our paper work and organise find the patient’s local medical officer for a death certificate. About 10 minutes later we have contacted the patient’s GP and arranged a death certificate.

We are ready to leave and start making our way out the door when a nurse comes back in and advises us that “its a miracle… she’s alive again” – no, I think… I’m pretty certain she was dead.

It’s at this point that the nurse takes us to the room next to our deceased person and introduces us to our actual patient who is still alive (and now has a death certificate from her local GP!)

The staff had no idea that the lady in the next room had died many hours before hand and one of the carers told me that she “thought it odd that she was so quiet all day…”

So, that’s just about as bad a nursing home mistake as you can get… don’t forget to research a nursing home before you place your loved one in one… better yet, look after them at home (its the circle of life – be kind to your parents).

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Why Does Bradycardia Cause Hypertension?

March 4th, 2012

Bradycardia causes hypertension because the slower heart rate allows excess time for ventricular filling, which results in greater ventricular stretch and consequent increased force of contraction, as identified by Starling’s Law. By reviewing Starling’s Law, which identifies that “the greater the ventricles are stretched during diastole (rellaxed phase) the greater the force of contraction during the systolic phase” it can be seen that so long as bradycardia results in a greater filling of the ventricles, the contraction phase should be more forceful. This results in the patient having a higher than normal systolic blood pressure and often an unusually low diastolic blood pressure.

In general, patients with a signifcant bradycardia (less than 40 beats of the heart per minute), will usually have a very high systolic blood pressure as high as 220-240mmHg (the pressure during cardiac contraction), but a very low diastolic blood pressure as low as 40mmHg.

Bradycardia and Cardiac Output

Cardiac Output can be calculated by multiplying the heart rate (HR) by the stroke volume (SV). In bradycardia, the heart rate is reduced, but the stroke volume is increased. In a minor bradycardia, this can often result in hypertension (high blood pressure). However, as the heart rate is reduced greatly, such as 30-40 beats per minute, the stroke volume is higher than normal, but the heart rate is so slow that the person’s total cardiac output is much lower than normal or not effective at all.

Can Hypertension Cause Bradycardia?

Yes, hypertension causes the increased systolic blood pressure to stretch the baro receptors in a persons neck, which then stimulates a negative feedback mechanism that causes the brain to the SA node in the heart to reduce heart rate and force of contraction.

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Emergency Bariatric Equipment

February 27th, 2012

Bariatric equipment is rapidly becoming a necessity of ambulance practice and safe transport of patients who suffer with morbid obesity. As society’s obesity rates have risen to epidemic levels, medical engineers and bio-medical engineers have risen to the challenge and we have seen the invention of many new bariatric products. The following is a guide and review of common bariatric products used by Ambulance Services and hospitals alike:

The Hovermatt

The Hovermatt is literally what it sounds like. It is basically a plastic sheet that can be placed underneath the patient and then inflated so as to create a cushion of air around the obese patient and then hover, allowing health care workers and paramedics to slide an obese patient from one bed to the other. Depending on how many Hovermatts an organisation wants to purchase, they can be easily purchased and introduced into a health service for around $2500 per Hovermatt. The hovermatt is easily cleaned, safe, and has been statistically proven to reduce the amount of back injuries amongst healthcare workers.

The HoverJack

The HoverJack is a natural extension of the hovermatt concept and basically is a set of 4 hovermattresses attached to eachother. The hoverjack can be placed underneath the patient who has a BMI of 25, 35, 45 and higher! Then, as the hoverjack is inflated using a reverse vacume device, the hoverjack raises up to the height of stretcher, bed or other specified device. This makes it so that you avoid lifting the patient from ground height. The hoverjack may be used in situations where the patient is unable to get down stairs or his or her bedroom and in an emergency, may be used to literally drag the patient down using its hover-craft properties (each country has different laws regarding the safe working limits and risk management strategies for this). A HoverJack can be purchased for around $6-8,000.

Here is a video link of a HoverJack demonstration:

httpv://www.youtube.com/watch?v=l4F0hbr99cs

Striker Bariatric Stretcher

The striker bariatric stretcher has been designed to specifically meet the needs of paramedics who have to transport bariatric and super morbidly obese patietns in an emergency. The Striker Bariatric Stretcher has been designed to hold patients in excess of 1400 pounds! Striker Bariatric Stretchers usually cost around $6-7 000 each.

Mac Bariatric Lifter

The Mac Bariatric Lifter has been designed to lift a bariatric stretcher and the heaviest of bariatric patients from ground height onto the bariatric ambulance. Mac Bariatric Lifters have been designed to fit numerous models of bariatric ambulances, and commonly cost around $12,000.

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Paramedic Quiz 1

February 17th, 2012

You have been called to a 7 year old male who has fallen off his BMX bike while attempting a jump. His mother states that at first he didn’t cry, but after about 30 seconds started to cry. On examination, you find that there has been a large amount of damage to his helmet and that there is a large contusion to his occiput. He appears to be asking the same question over and over again – “What happened, where am I?”

1. What is the significance of the fact that it took 30 seconds for him to start crying after the fall?

2. What does repetitive questioning generally signify in a patient with a head injury?

3. What are your treatment priorities for this person?

Basic anatomy and physiology quizzes for paramedics:

1. What is the resting heart rate of a newborn?

2. What is the resting respiratory rate of a 10 year old?

3. What is the normal Intracranial Pressure in a healthy person?

4. Why should you not administer a hypertonic solution in a person with a base of skull fracture?

5. Where is the cubital fossa?

6. What are the 3 most used arm veins for IV cannulation?

7. How does an ACE inhibitor affect a patient’s blood pressure?

8. How much air does it theoretically take intravenously to cause an air embolism in the heart?

Basic skills quizzes for paramedics:

1. While inserting an IVC in what direction should you insert the cannula in relation to the flow of the vein?

2. What are the anatomical landmarks used to visualize correct placement of an endotracheal tube?

3. What are the correct anatomical landmarks used to perform a thoracentesis during a suspected tension pneumothorax?

4. What are the correct anatomical landmarks used to perform a 12 lead ECG on a patient?

5. What type of fracture should a collar and cuff sling be used on?

6. What type of fracture should a basic arm sling be used for?

Check back here next week for the answers!

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Cardiac Action Potential

January 25th, 2012

The cardiac action potential is what the cardiac cells utilize in order to propagate action potentials and allow cell membranes to act as a stimulus to adjacent cell membranes. Through the cardiac action potential, excited cells propagate from one to the other allowing the conduction of energy and cardiac contraction.

The cardiac action potential, as we currently understand it, can be broken into 5 well defined phases. The following are the phases of the cardiac action potential:

Cardiac Action Potential

Phases of the Cardiac Action Potential

Phase 0 is the phase of a stable resting action potential, when the cells are polarized and in an excitable state awaiting a stimulus, which will cause rapid depolarization. When a stimulus above the threshold potential strikes the cell the cell begins to depolarize. Sodium ions rush into the cell causing the electrochemical gradient between the inside and outside of the cell to rapidly move towards zero.

Phase 1 is known as the depolarization phase in which the electrochemical voltage change is so rapid that the voltage overshoots the zero potential and stops out around  +20mV. Phase 1 is a very short phase where the potential difference comes to rest near 0mV. During phase 2 of the cardiac action potential the fast sodium channels close and the influx of sodium ceases completely. While this is happening, the potassium ions continue to be depleted from the cell resulting in a small decrease in positively charged ions within the cardiac cell membrane.

Phase 2 of the cardiac action potential is known as the plateau phase where the cell membrane action potential is maintained near 0mV by the infusion of calcium ions. Calcium enters the myocardial cells, causing a large secondary release of calcium and causing contraction of the myocardium. The cell is in a prolonged depolarized state and restoration of the resting membrane potential is beginning to take place.

Phase 3 is known as the rapid repolarization phase. This phase is initiated by the closing of the slow calcium channels, which leads to an increase in cellular permeability and efflux of potassium. Repolarization is completed by the end of this phase of the cardiac action potential, and the cell is restored to its repolarized state of -90mV.

Phase 4 identifies the period between action potentials and the cell is repolarized and ready to fire again. During this phase the cell is negatively charged compared with the extracellular areas. There is an excess of sodium ions within the cell and potassium ions outside of the cell. The sodium and potassium pump is commenced and sodium is slowly pumped outside of the cell, while potassium enters the cell, raising the resting potential of the membrane so that the entire process can occur again.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Steps in ECG Rhythm Analysis

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Types of Dislocations

January 25th, 2012

The following are three types of common dislocation:

Dislocation – the displacement of a long bone from is usual position
Subluxation – an incomplete dislocation
Habitual dislocation – where the bone frequently dislocates

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Clearing a Cervical Spinal Injury in the Pre-hospital Care Environment

January 25th, 2012

Clearing a person’s possible cervical spinal injury in the pre-hospital care environment when mechanism alone indicates the potential for a spinal injury is not generally recommended for paramedics. Acknowledging this fact, there are certain Ambulance Services around the world that have protocols in place for their paramedics to clear a patient from a suspected cervical spinal injury while still within the pre-hospital care environment.

The Ambulance Service I work for does not advocate clearing a suspected cervical spinal injury in the pre-hospital care environment by a paramedic and I believe it would take a very competent (if not overly confident) paramedic to do so in any Ambulance Service.

While acknowledging this, it is still beneficial to consider how a doctor may clear a suspected spinal injury without the aid of x-ray or computer tomography. This is because it will provide you more knowledge and diagnostic techniques to identify or provide you with warning bells when treating a patient with a suspected cervical spinal injury.

If any of the following assessments are found to be possitive in the presense of a suspected cervical spinal injury based on mechanism, a patient can not be cleared of a suspected cervical spinal injury without the assistance of an x-ray or computer tomography:

1.Posterior, midline cervical tenderness
2.Focal neurological deficit
3.Normal levels of alertness/level of consciousness
4.Intoxication or other CNS depressants
5.Any painful distracting injury

As paramedcis, these should all be considered as warning bells to ensure you provide full spinal immobilisation and anti-emetic therapy (as per your Ambulance Service’s protocol or guidelines).

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Crush Injury

January 23rd, 2012

Crush injury occurs when a significant extremity or aspect of a patient has been crushed for a period of time causing either ischaemic or muscle damage to the crush injury site. Crush injury may also occur when a patient has been laying on a hard surface for such a long time that he or she has developped a non-traumatic crush injury, which inolves anearobic metabolism in the areas that are laying on the hard surface. Crush injury syndrome is a life-threatening complication of crush injuries and results in high mortality rates.

Crush Injury Phases of Mortality

 

Early (minutes to an hour) as a result of:

1. Hyopovolaemia after compressive force is realeased

2. Sudden release of potassium ions from the area distal to the compressive forces, which then travels to the heart causing fatal arrythmias

3. Sudden release of lactic accid within the circulatory system

Secondary causes of mortality following release of the crushing force include:

Delayed: (hours to weeks) as a result of the:

Release of myoglobin as a result of muscle compression at injury site and distally, leads to large myoglobin cells circulating and becoming blocking the glomerelus from filtering blood within the kidneys, this results in renal failure. This is fundamentally, rhabdomylosis.as a result of renal failure (due to rhabdomyolysis, and myoglibnaemia) and complications due to trauma, such as infection.

Monitor  ECG changes in crush syndrome for signs of hyperkalaemia such as:

1. Tall peaked T-waves

2. Absent P-waves

3. QRS widening

4. Sine wave patern

5. VF/assystole

Treatment of crush injury with ECG changes and evidence of hyperkalaemia require Sodium Bicarbonate (1mmol/kg) and Calcium Chloride 1g: 10ml over two minutes)

Crush injury – local affect: compartment’s syndrome

Crush injury – systemic affect: rhabdomyolysis

Established Signs and Symptoms of Crush Injury

The following are six well defined signs and symptoms of crush injury:

  1. Ischaemic muscle necrosis
  2. Circulating myoglobin and myoglobinuria
  3. Raised serum potassium (hyperkalaemia)
  4. Metabolic acidosis
  5. Hypovolaemic shock
  6. Renal failure.

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Pharmacokinetics Versus Pharmacodynamics

January 23rd, 2012

Pharmacokinetics is the study of the routes by which a drugs enter the body; where as Pharmacodynamics is the study of how a drug reacts with the body.

The following are the phases of pharmacodynamics:

  1. drug absorbtion
  2. drug distribution
  3. drug metabolism
  4. drug excretion

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Factors that Change a Drug’s Efficacy

January 23rd, 2012

The following factors change the efficacy of a drug within a person’s system:

1. Age (often due to a decrease in GFR therefore a decrease in drug excretion)

2. Weight

3. Condition of the patient and any previous medical illnesses or conditions

4. Individual variation

5. Idiosyncratic and allergic reactions

How a drug or medication will effect a person following ingestion or injection depends of a variety of factors. These should be considered whenever a person potentially overdoses on either a single drug or has a polypharmacy overdose when determining potential effects and treatment requirements.

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Common Microbial Agents that Cause Food Poisoning

January 23rd, 2012

The following 5 microbial agents are the most common for causing food poisoning in developed nations:

1. Campylobacter, which is common in chicken

2. Clostridium, often occurs in foods that have been warmed, then cooled then re-heated

3. Escherichia coli (E-coli) found in the lower GIT, often a sign of fecal pollution in the waterways

4. Listeria, often found in the environment, eg. soil and water. Very tough, can thrive in conditions as hot as 50 degrees and as low as 1, and causes septicemia

5. Salmonella, a common cause of food poisoning, S&S of salmonella poisoning include: stomach pain,  diarrhea, chills, fever or headache (normally for around 3-5 days)

Good handwashing and basic food preparation concepts alleviates the spread of most of these causes of food poisoning.

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What Causes Bell’s Palsy?

January 23rd, 2012

Bell’s palsy is caused by compression or damage to the facial nerve that controls the facial muscles. The 7th cranial nerve (facial muscle nerve) may be damaged by compression, swollen areas, or inflammation and this results in facial weakness or paralysis. Exactly what causes this damage, however, is still unknown.

It has been hypothesized that a viral infection such as viral meningitis or the common cold sore virus (herpes simplex) is responsible for the disorder. That the facial nerve swells and becomes inflamed in reaction to the infection, causing pressure within the Fallopian canal and leading to ischemia.  In some mild cases there is damage only to the myelin sheath of the nerve and recovery is usually rapid. The myelin sheath is the fatty covering-which acts as an insulator-on nerve fibers in the brain.

The disorder has also been associated with influenza or a flu-like illness, headaches, chronic middle ear infection, high blood pressure, pregnancy, diabetes, sarcoidosis, tumors, Lyme disease, and trauma such as skull fracture or facial injury.

Sources: National Institute of Health 2011. Bell’s Palsy Fact Sheet.

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Stroke or Bell’s Palsy?

January 23rd, 2012

The following paramedic case study identifies the difficulty in determining the difference between a Stroke and Bell’s Palsy in the prehospital care setting.

You care called to a 35 year old female, currently 21 weeks pregnant who has developed a sudden episode of slurred speach and dizziness. On arrival, you find an overweight 35 year old female in minor distress and mild confusion who states she doesn’t know what’s happening to her. On examination, you find that her skin is warm, pink dry. Her GCS is 15, although she has markedly slurred speech and is difficult to understand. She has a right sided facial droop, but good motor and sensory responses to all four limbs. She is afebrile and has a normal blood glucose level. She is monitored in a sinus tachycardia at 112 beats per minute.

Your treatment includes reassurance, oxygen therapy, and more reassurance. Your inclination is that she has Bell’s Palsy and not a stroke, but then again, how do you know?

Stroke and Bell’s Palsy Lessons Learned

1. Pregnant women are at a greater risk of a variety of medical disorders that may be causing these effects, include pre-eclampsia/eclampsia and gestational diabetes.

2. You can differentiate between a stroke and bell’s palsy by asking the patient to raise both eyebrows. If she is capable of raising both, then it is more likely to be bell’s palsy and not a stroke, if she can only raise her eyebrows on one side, then she is likely to have had a stroke.

3. Regardless of whether or not this person is having a stroke or experiencing the side effects of bell’s palsy, the patient is going to be pretty scared, so constant reassurance is vital!

4. Stroke therapy normal requires interventions within 4 hours of the onset of stroke like symptoms. Therefore, these patients should be expedited to the nearest hospital equipped to treat a potential stroke.

Learn how to differentiate Bell’s Palsy from Stroke here.

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How to Differentiate Bell’s Palsy and Stroke

January 23rd, 2012

Bell’s Palsy and Stroke both cause facial droop and can often be confused with each other during initial onset. Many paramedics treat Bell’s Palsy as a Stroke when they first attend a patient, but later determine that it is actually Bell’s Palsy. Both conditions are likely to cause alot of agitation and anxiety for the patients.

It is important as a paramedic to understand the difference between Bell’s Palsy and a Stroke.

The following methods can be utilised to differentiate between Bells Palsy and a Stroke:

1. Assess the person’s entire body for signs of weakness, if the person has a weakness to the entire body and not just the face, it is more likely to be Stroke than Bell’s Palsy, which generally only affects the facial nerves.

2. Ask the person to raise both eyebrows. If they can raise both eyebrows, but have a lower facial droop, then it is more likely that they have Bell’s Palsy. In contrast, if they are unable to raise both eyebrows and have a weakness to one entire side of their face, then they are likely to have had a stroke.

Telling the Difference Between Bell’s Palsy and Stroke

A sudden onset of Bell’s Palsy or a Stroke is likely to be very scary for the patient, and regardless of the pathology of the disease both should be considered medical emergencies in the pre-hospital care environment and treated accordingly.

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Causes of Wry Neck Torticollis

January 18th, 2012

The following are common causes of a wry neck torticollis:

1. Awkward posture during sleep resulting in wry neck upon waking

2. Minor turning of the head or sudden fast turning of the head

3. Vigorous and sudden movement or injury (most common cause of wry neck torticollis in children).

4. Any activity that involves sustained awkward positioning (paramedics, this include working in the back of an Ambulance).

5. Repetitive neck movements

6. Slipped facet joint

7. Herniated disc

8. Viral or bacterial infection may cause inflammation resulting in muscle spasm and a wry neck torticolis.

Differential Diagnosis for Wry Neck Torticollis

Okay, so if a wry neck torticollis is generally fundamentally benign and will eventually self resolve, what are the possible differential diagnosis’ that we should consider that possibly more pathological?

1. The most common of differential diagnosis for wry neck torticollis is a dystonic reaction to medications, such as metoclopramide (maxolon), certain anti-psychotic medications, and anti-depression medications. A thorough history should be taken and any medications recently administered to the patient should be taken to the hospital to identify if they may have caused the reaction.

2. Infection is the more significant potential secondary diagnosis for a person who appears to have a wry neck torticollis. Any infection that is viral or bacterial and significant enough to cause what may appear to be a wry neck torticollis should be considered dangerious. Signs and symptoms include: fever, lethargy, photophobia, and signs of systemic stress such as increased heart rate (tachycardia) and lowered blood pressure (hypotension). Also, any changes in the patient’s cognitive function (level of conscious) should be considered danagerious.

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Types of Wry Neck Torticollis

January 18th, 2012

There are two types of wry neck torticollis. These include the apophyseal and discogenic types of wry neck torticollis. The following identifies how to differentiate between the two types of wry neck torticollis:

The apophyseal wry neck occurs predominantly in younger persons up to their early thirties. It is not usually associated with radiating pain and is commonly caused by sudden movements occuring through sport and exercise. Incidentally, it has become more common in children who play exercise based computer games that require them to make sudden, unique movements. There is some postural deformity relating to the flexion away from the damaged joint.

In contrast, the discogenic wry neck can occur in persons of all ages and is more common in older persons. It progresses with a gradual onset and typically occurs upon waking from a long sleep in an awkward posture as opposed to a sudden movement or exercise. Unlike apophyseal pain, there is generally some radiating pain down the cervical and upper thoracic region.

Want to understand what causes a wry neck torticollis?

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Wry Neck Torticollis Children

January 18th, 2012

A wry neck torticollis can occur in adults, but is primarily seen in children and involves the sudden spasm or contraction of the muscles in one side of the neck (most commonly the sternocloidomastoid and trapezius) resulting in a very rigid, sometimes painful neck leaning to one side quite dramatically.

Signs and Symptoms of a Wry Neck Torticollis

Although the acute wry neck is reasonably common it can be extremely painful and quite scary for those who have never experienced it before. For the paramedic who has never seen a wry neck torticollis, he or she may think the child is playing a game or making a joke, but it is important to take the disorder seriously. The following are common causes of a wry neck torticollis:

1. Pain is typically one-sided and may be described as sharp or spasmodic (like a cramp).
2. Pain located in the neck muscles or referred down the spine, from the occiput to between the shoulder blades
3. Inability to turn the head to the painful side
4. Maybe a postural deformity (head tilted away from the painful side) due to pain and spasm
5. Inability to straighten head.
6. Anxiety and frustration may occur as the child recognises that he or she can not adjust the position of their head.
7. Vital signs should remain normal throughout.

Wry Neck Torticollis Treatment

A wry neck torticollis will usually self resolve given enough time and patience. The following medical interventions may be required or may help. As paramedics, our aim is primarily to reassure the patient and provide analgesia if required.

1. Reassurance is vital with these patients, especially if they have never had a wry neck torticollis before.

2. Manual traction in the line of the deformity (for apophyseal wry neck)

3. Manual traction away from the pain (for discogenic wry neck)

4.  Mobilisation of the joint (only for apophyseal, not for discogenic)

5. Trigger point release

6. Soft tissue massage

7. Active range of motion exercises

8. Stretching exercises

9. Exercises to improve flexibility, strength, posture and core stability

10 Ergonomic advice

11. Postural care and correction

12. Medications for pain management.

13. In extreme cases muscle rellaxant may be required.

14. Attempts to reduce muscle spasm by applying a hot or cold pack.

15. Education for both the child and the parents is vital if they have never seen this before it may appear very frightening.

Would you like to know more about the types of wry neck torticollis that occur?

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6 Ethical Principles of Drug Use

January 17th, 2012

If you are a clinician and intend on administrering drugs to your patient, whether they are oral medications or dangerious intraveneous drugs, you should considered the 6 ethical principles of drug use.

The 6 Ethical Principles of Drug Use are: 

  1. Autonomy – self determination
  2. Veracity – trust through truth telling
  3. Non-maleficence – do no harm
  4. Beneficience – prevent harm, do good
  5. Justice – equal access to resources based on health care requirements
  6. Confidentiality – not divulge information without consent

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AVPU

January 17th, 2012

AVPU is a very basic assessment of a person’s level of consciousness and is very commonly used in both First Aid and Pre-hospital care because of its simplicity and ease of use. Any LOC response of less than A (meaning alert) is a signal for First Aiders to call for professional assisstance and transport of the patient to a hospital.

For paramedics, an AVPU assessment is generally performed as they walk through the door and greet a patient, where as a more detailed and thorough assessment of a patient’s neurological response is performed through an accurate Glasgow Coma Scale.

AVPU Mneumonic

The mneumonic AVPU refers to the basic scale of consciousness and identifies the following levels of consciousness:

A – The patient is awake and alert. This does not necessarily mean that they are orientated to time and place or neurologically responding normally.

V – The patient is not fully awake, and will only respond to verbal commands or become roused after verbal stimuli.

P – The patient is difficult to rouse and will only respond to painful stimuli, such as nail bed pressure or trapezius pain.

U – The patient is completely unconscious and unable to be roused.

Case study involving AVPU

You are called to a patient who has fallen off his bike while not wearing a helmet. When you arrive you find that he is not awake and does not respond to you when you ask him to open his eyes and tell you his name. You place firm pressure on his nail bed and then squeeze his trapezius. He then squirms and tries to move away. This patient will score a P under the AVPU assessment and has a significantly lowered level of consciousness.

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Adult GCS Assessment

January 17th, 2012

The adult Glasgow Coma Scale (GCS) assessment is the basis of each clinicians basic assessment of a patient’s neurological response. It has been well recognised as the most reliant indicator of a person’s outcome post traumatic brain injury and is helpful in assessing a person’s basic overall neurolgical assessment.

The benefits of the Glasgow Coma Scale in pre-hospital care and assessment of patients is still in debate, but widely used.

How to Perform an Adult GCS Assessment

The following identifies the steps in assessing an adult’s GCS:

Best eye response (E)

There are 4 grades starting with the most severe:

 1.No eye opening

 2.Eye opening in response to pain.

 3.Eye opening to speech.

 4.Eyes opening spontaneously

Best verbal response (V)

There are 5 grades starting with the most severe:

 1.No verbal response

 2.Incomprehensible sounds. (Moaning but no words.)

 3.Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)

 4.Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)

 5.Oriented. (Patient responds coherently and appropriately to questions relating to time and place).

 Best motor response (M)

 There are 6 grades starting with the most severe:

 1.No motor response

 2.Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)

 3.Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)

 4.Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

 5.Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)

 6.Obeys commands. (The patient does simple things as asked).

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Paediatric GCS Assessment

January 17th, 2012

Most health care practitioners can accurately assess a person’s GCS without thinking about it, but bring in a child, and a paediatric GCS is often harder to perform. So, how do you assess a child’s GCS?

Like the adult Glasgow Coma Scale, the paediatric Glasgow Coma Scale is considered a reasonably reliable, observable assessment tool for documenting the conscious state or neurological response of a person post traumatic brain injuries. In pre-hospital care, there is still a certain level of debate about the overall benefits of performing a GCS on a patient versus a more basic level of consciousness assessment such as AVPU.

Paediatric Glasgow Coma Scale

The following are recognised paediatric GCS scores:

Best eye response: (E)

4.            Eyes opening spontaneously

3.            Eye opening to speech

2.            Eye opening to pain

1.            No eye opening

Best verbal response: (V)

5.            Smiles, oriented to sounds, follows objects, interacts.

4.            Cries but consolable, inappropriate interactions.

3.            Inconsistently inconsolable, moaning.

2.            Inconsolable, agitated.

1.            No verbal response.

 Best motor responses: (M)

6.            Infant moves spontaneously or purposefully

5.            Infant withdraws from touch

4.            Infant withdraws from pain

3.            Abnormal flexion to pain for an infant (decorticate response)

2.            Extension to pain (decerebrate response)

1.            No motor response

Any combined score of less than eight represents a significant risk of mortality. Accurately assessing a paediatric GCS is often difficult for paramedics who do not work in an area where they treat a lot of children and their basic diagnostic skills are often lacking. It is therefore even more important to understand the paediatric GCS tool.

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Electrolyte Changes in Heat Stroke

January 8th, 2012

The following are common electrolyte changes seen during heat stroke:

Dehydration leads to raised urea and creatinine with haemoconcentration. Excessive diaphoresis leads to low levels of Na, Mg, K, early in the illness. Hypokalaemia decreases sweat secretion and therefore exacerbates the condition.

Rhabdomyolysiss, secondary to tissue damage related to cell temperatures greater than 41 degrees celsius, results in hyperkalaemia, hypocalcaemia and renal failure may occur.

Metabolic acidosis and respiratory alkalosis common. Hyperthermia alone can cause primary hyperventilation and respiratory alkalosis, while hypoperfusion, tissue hypoxia, and anaerobic metabolism may lead to lactic acidosis with respiratory compensation.

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Pathophysiology of Heat Transfer

January 8th, 2012

Heat transfer to and from the body occurs via the following four mechanisms: conduction, convection, radiation, and evaporation. Elderly persons are at an increased risk for heat-related illness because of underlying illness, medication use, declining adaptive thermoregulatory mechanisms and a limited social support network. Underlying causes of decreased thermoregulatory mechanisms include heart disease, skin diseases, extensive burns, dehydration, endocrine disorders such as diabetes and thyroid disorders, neurologic diseases and fever.

Heat Transfer Examples

A paramedic who is standing in their underwear in a desert will result in vasoconstriction of the core vasculature, and the vasodilation of the peripheries. This leads to a shunt of the bulk of the person’s blood from the core to the peripheries, where they can cool more rapidly.

Contrastingly, if the same paramedic ended up in the snow still their underwear, their peripheries would vasoconstrict, shunting blood from the peripheries to the core, in order to maintain as much body temperature as possible.

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International Paramedic Jobs

December 31st, 2011

Many qualified paramedics consider working internationally at some stage or another during their paramedical career. Unfortunately, transferring qualifications and experience is generally difficult between countries. This is only because of minor differences in legislation and the medical directives in which paramedics are governed. With the exception of the UK, few Ambulance Services internationally have their own Paramedic Registration, like a Nursing Registration (which can be transferred around the globe).

Can paramedics work internationally? Yes, qualified paramedics can get employed internationally and they can generally claim recognition of prior learning, provided that they have more than three years of full time experience working as a paramedic. This is where tertiary qualifications become beneficial, because they provide some level of baseline qualifications that can be acknowledged and recognised internationally.

How can a paramedic get a job internationally? Paramedics generally need to follow these steps to get a job internationally:

Contact the Ambulance Service that you want to work for and confirm job requirements, such as years of experience, paramedic qualifications required, criminal record checks, driving history checks, any anything else that they require.

Identify any work VISAs that may be required. This may include an exchange position with a paramedic from another government Ambulance Service internationally. With an exchange work VISA paramedics are sometime able to work for up to one year while someone else works their position. If you aren’t able to do a paramedic exchange program with a paramedic in the country that you want to work, you will have to gain a basic working VISA. This may be possible for a limited time period depending on the relationship between your country and the country that you want to work for. Alternatively, if you are well qualified, you may be able to approach an Ambulance Service in the country that you want to work for and get a Work Sponsored VISA.

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Fly in Fly Out Jobs for Paramedics

December 31st, 2011

Paramedics are well suited to work in a variety of fly in fly out jobs. These include: working on oil rigs, mines, film sets, industrial sites, construction sites, and for a private paramedics service provider at sponsored events. Fly in fly out jobs are generally paid at a higher hourly rate to compensate for the disruption to your lifestyle and travel time.

Working as a paramedic on a fly in fly out basis has both pros and cons. The pros include: excellent rate of pay, good separation between work and home life, and generally additional leave benefits. The cons include: away from home and family on a regular basis. Unable to do anything else while you’re at work. You are completely committed to the job while away. This means that you don’t get to come home after the day’s work and generally means that you are “owned” by the company for 7 days straight.

Fly in Fly Out Paramedic Jobs Income

Paramedics who work on a fly in fly out job basis are generally well renumerated for their jobs. Paramedics are generally considered specialists by mines (not to mention a legislative requirement under the occupational health and safety act) and are paid accordingly. Paramedics make a similar hourly pay to government based paramedics, but are renumerated with living away from home allowances, disturbance allowances, meal allowances and remote area living allowances that increase the annual income well into excess of $120 000!

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Oil Rig Paramedic Jobs

December 31st, 2011

Oil rigs employ people from a range of professional and non-professional  backgrounds. Irrespective of which background a person enters into employment with an oil rig, they are usually paid well above the normal salary in their field. Being an oil rig paramedic is no different, and they are well paid and well looked after.

Because of the remote location in which most oil rigs operate, under occupational health and safety legislation, oil rigs must have an oil rig medic. This position is regularly occupied by a trained paramedic.Depending on the level of training that you have had and your qualifications as a paramedic, whether general or intensive care trained, you may be required to complete a nursing degree and become a Registered Nurse to work on an oil rig. Oil rigs particularly like paramedics to work as their medics, because of the background paramedics have with pre-hospital diagnostic techniques.

Oil Rig Paramedic Income

An oil rig paramedic can expect to earn in excess of $100,000 per year  working on a fly in fly out basis. There are always overtime opportunities if you want to make much more than a 100K per year.

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Acute Pulmonary Oedema and Salbutamol

December 31st, 2011

The use of nebulised salbutamol while treating a person with acute pulmonary oedema has been debated over the past decade in both pre-hospital care and emergency departments. In Australia, the current understanding of nebulised salbutamol and acute pulmonary oedema (APO) is that the salbutamol will worsen the patient’s condition.

The following identifies current understandings about acute pulmonary oedema and salbutamol:

Pulmonary Oedema is caused by anything that results in fluid crossing from the pulmonary artery into the alveoli and lungs. The most common cause is left sided cardiac failure, in which the left ventricle is working poorly, leading to a backlog of blood within the pulmonary artery. When the right side of the ventricles contract properly, they increase the hydrostatic pressure in the pulmonary artery, and this can force blood through the selectively permeable membrane of the alveoli and into the lungs.

Salbutamol stimulates the beta II receptors within the lungs. This causes bronchial- dilation and makes it easier for the fluid to flow into the lungs. It also increases the heart rate of the already weakened cardiac pump.

Examples of APO and Salbutamol Problems

If a patient is trying to shift fluid through a straw it will take much longer than a large hose pipe. In an example of APO and Salbutamol, the patient without salbutamol on board will have the fluid entering the lungs through a straw, whereas the person with salbutamol on board will have fluid entering through the large hose pipe.

Another example would be if you increase the heart rate while the person is in APO (which is a natural secondary effect of salbutamol on the heart), it is the same as trying to increase the RPM of an engine that is about to fail, all you do is cause it to stop completely.

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What is the Difference Between Heat Stroke and Heat Exhaustion

December 31st, 2011

Heat exhaustion and heat stroke exist along a continuum of severity caused by dehydration, electrolyte losses, and failure of the body’s thermoregulatory mechanisms.

Heat exhaustion is an excessive temperature, which left untreated will result in heat stroke and death. However, at this stage, the body’s natural thermoregulatory system is capable of maintaining a set body temperature. Once systems start to fail, such as the body loses fluid an anhydrases sets in, the body will no longer be able to respond to the excess body temperature and the person will rapidly progress to heat stroke.

Learn more about heat stroke here. 

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Heat Stroke Case Study

December 31st, 2011

You have been called to a 23 year old male with no previous medical history in the process of running a half marathon and has collapsed with dizziness. On arrival, the person is confused and combative with bystanders in attendance. On examination he is found to be conscious, but very confused. Pupils dilated and slow to react. Pulse rate 120, weak, thready. Blood Pressure: 87/45. Skin, pale, warm to touch and dry. Temperature 42.1 (tympanic).

Your immediate assessment of him suggests heat stroke.

Treatment commences with attempts to cool him down and rehydrate him. You get him into the Ambulance and get the air conditioning going. Your first priorities include: removing his clothing, applying cold packs to his axilla and back of his neck. Oxygen should be given to reduce his respiratory efforts and help remove any excess C02 produced secondary to metabolic acidosis. An ECG monitor should be applied, so that signs of hyperkalaemia and subsequent dysrhythmias may be monitored. IV access should be gained and fluids administered. He is currently showing signs of anhydrases (inability to sweat secondary to absolute fluid loss). 

Urgent transport to hospital and early notification should be provided so that the hospital is able to organise adequate cooling devices.

Enroute he starts to have a seizure. The seizure is allowed to continue for almost 6 minutes while midazolam is drawn up and given. In this time his temperature has increased to 43.1.

Enroute to hospital, signs of hyperkalaemia occur, with tall peaked T waves, followed by a sine wave formation, and eventually, Ventricular Fibrillation occurs. Resuscitation efforts commence with immediate defibrillation and continued resuscitation in the emergency department.

The person dies in the emergency department.

Heat Stroke Lessons Learned:

Heat stroke is a life threatening emergency. In some cases, heat stroke is an irreversible life threatening emergency. Therefore the less time you spend with these people the better.

Try to cool these people down as quickly as possible. Remove clothing, apply cold packs to the neck and axilla. Get them into a cool environment (no point fiddling with ice packs if they are still outside in 40 degree heat).

Don’t try to turn the air conditioner too low. All this will do is cause the person’s peripheries to constrict and shunt the blood back to the core, further heating their core body temperature. A little air conditioning isn’t a bad thing, however.

Never let a person who has heat stroke continue fitting. A seizure will further increase this person’s body temperature and will lead to their death. Midazolam or another anti-convulsant agent should be administered immediately.

Learn more about heat stroke here.

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What is Heat Stroke?

December 30th, 2011

Heat Stroke can be defined as an extreme hyperthermia with thermoregulatory failure, characterized by serious end stage organ damage with universal involvement of the central nervous system. Although there is no specific vital sign parameters that define heat stroke, a core body temperature greater than 41 degrees C or 40.5 degrees C with anhydrases and an altered mental state is generally accepted as heat stroke.

Heat stroke can be divided into exertional heat stroke and classic heat stroke. Exertional heat stroke is caused by excessive exercise, and is regularly seen in marathon runners and elite athletes who push their bodies past their thermoregulatory ability to respond to the heat produced through muscle movements. Classic heat stroke occurs more commonly in older patients or in patients with underlying illnesses who are exposed to extreme environmental conditions. In these patients, the increased environmental temperature has caused increased stress on an already weakened body system, such as cardiovascular, renal, and thermoregulatory. As a consequence, the increased temperature will cause one or more of these primary body systems to fail.

Heat Stroke Pathophysiology

Initially, with heat stroke, as a person’s core body temperature increases the body attempts to lower the core temperature through renal and splanchnic vasoconstriction with concomitant peripheral vasodilatation causing a substantial fluid shift from the central compartments to the peripheries. This allows heat to be lost via evaporation and convection. This, in turn results in an increased cardiac output of up to 3L/min per degree C and may lead to cardiac failure in patients with limited cardiac reserve.

Eventually the vasoconstriction needed to keep the blood in the peripheries fails, therefore causing cutaneous blood flow to decrease, further decreasing heat loss from the body’s core and increasing hyperthermia. This hyperthermia will then eventually cause cerebral oedema, which results in an increased intracranial pressure (ICP). This increased ICP combined with a decreased mean arterial pressure (MAP) results in a decreased cerebral perfusion pressure (CPP) and cerebral hypoxia, manifesting as central nervous system (CNS) dysfunction.

Sensible perspiration (also known as thermal sweating) is controlled by the thermoregulatory center within the hypothalamus and involves both heat and water loss through the skin. When external or internal temperature rises thermal sweating is produced. Thermal sweating results in a rapid loss of salt and therefore fluid from the body, but because thermoregulation has priority over water and electrolyte balances, sweating will continue until complete dehydration occurs. It is because of this that patients with heatstroke may present with a high temperature and hot but dry skin (anhydrases). Anhydrases is a late finding in heat stroke and is more common in classic heat stroke than in exertional heatstroke.

Tissue Damage and Heat Stroke

Tissue damage during heat stroke is believed to result from uncoupling during oxidative phosphorylation, which occurs when the temperature exceeds 41 degrees C. As energy stores are depleted cell membranes become more permeable and Na influx occurs. This causes an increased use of the Na+-K+ pump requirement to pump Na out of the cells, resulting in a cycle of increased ATP use, increased metabolic rate and therefore further elevation of core body temperature.

Eventually, the Na+K pump fails and as Na flows into the cell at a rate greater than the Na+K pump can remove it, interstitial fluid is drawn into the cell through osmosis, causes the cell to swell and eventually lyse (rupture), releasing a variety of electroyltes and toxins.

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What is Costochondritis?

December 30th, 2011

Costochondritis is a fundamentally benign, yet painful disorder that causes inflammation and sometimes swelling of the costal cartilage that joins each rib to the sternum (with the exception of the 11th and 12th ribs which are free from the sternum), resulting in chest pain and often mimicking a heart attack.

Costochondritis Symptoms

Costochondritis is considered to be the most common, non-cardiac cause of chest pain and emergency department presentations for heart attack-like symptoms. It often causes a sharp, intense pain to areas surrounding the chest, ribs, sternal and even retrosternal and can be described as a stabbing pain, crushing pain, and even tightness. The pain can be intense and people often state that they feel like they’re having a heart attack.

Treatment for costochondritis usually involves basic analgesia measures, anti-inflammatory medications and rest. In general the condition is self-limiting and resolves after rest.  In severe cases of costochondritis, corticosteroid injections may be of some benefit.

What causes Costochondritis?

A very mild amount of costochondritis may occur during later stages of pregnancy and is thought to be related to the increased abdominal pressure.

How to Differentiate Between Costochondritis and a Heart Attack

All chest pain should be treated as cardiac in nature until proven otherwise. In pre-hospital care, this is realistically impossible to differentiate between costochondritis and an acute coronary syndrome.  These are the common differences between  costochondritis and a heart attack:

Costochondritis will have increased pain on palpation, whereas cardiac chest pain will not change on palpation.

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What is the Difference Between Tietze’s Syndrome and Costochondritis?

December 30th, 2011

Severe costochondritis is referred to as Tietze’s syndrome. The two conditions were initially described separately because Tietze’s Syndrome involves swelling of the costal cartilages. It is now recognized that the presence or absence of swelling is only an indicator of the severity of the condition.

A mild amount of costochondritis is caused by inflammation of the costal cartilages, whereas Tietze  usually involves swelling of the costal cartilages. By definition, both are costochondritis, with the later, being a severe  case of costochondritis. 

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Final Episode of Recruits Paramedics

December 28th, 2011

The following is a link to watch the final episode of Recruits Paramedics for 2011: Recruits Paramedics Final Episode. Recruits Paramedic was produced by Channel Ten in combination with the Ambulance Service of NSW and show new recruit paramedics undergoing their initial training and “on road” component of their probationary training period.

This is the final two episodes of Recruits Paramedics, which show some of the more amazing footage of life and death ever publically aired. It shows Reynir’s second day “on road” and probably one of the most exciting days in his career as a paramedic. If you missed the episode on the night, I highly recommend following the link to Channel 10’s site, which allows you to watch any of the episodes that you missed.

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Asystole

December 20th, 2011

Asystole is pretty much as far down the degenerative track of ECGs that you can get… in fact, asystole is about the equivalent ECG of a rock. I thought is was therefore pertinent to leave it to the last of the ECG examples. Asystole is where all electrical impulses have ceased to propogate within the heart. In generally, very few people will ever have a spontaneous return of circulation once their heart has reached asystole.

Asystole ECG

Heart Rate: Zero
Rhythm: None
Pacemaker Site: None
P waves: absent, but may be present.
QRS Complexes: absent.

Asystole Signs and Symptoms

These people will present in cardiac arrest or decomposition.

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Torsades De Pointes

December 20th, 2011

Torsades De Pointes is a French term that literally means the “twisting of the points” seen in a rare type of ventricular tachycardia, in which the ventricular tachycardia creates a unique illusion of twisting itself around the iso-electric line (ECG baseline).

Torsades De Pointes ECG

Heart Rate: 200-500 beats per minute.

Rhythm: incomprehensible.

P-Waves: absent.

PR Interval: N/A

QRS Complexes: Irregularly shaped, pointed, and jagged.

Torsades De Pointes Signs and Symptoms

This person is very close to Ventricular Fibrillation and will most likely present as any other person in cardiac arrest.

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Ventricular Fibrillation

December 20th, 2011

Ventricular Fibrillation (VF) is another lethal arrythmia that will result in death if left untreated. Ventricular Fibrillation is caused by multiple ectopic pacemakers firing within the ventricles, causing the ventricle to fibrillate. During fibrillation, the ventricles are unable to contract in a systematic fashion, which results in a failure of the heart to pump.

Ventricular Fibrillation ECG

Heart Rate: 200-500 beats per minute.

Rhythm: incomprehensible.

P-Waves: absent.

PR Interval: N/A

QRS Complexes: Irregularly shaped, pointed, and jagged.

VF can be both coarse (thick high bizarre QRS complexes) and fine VF, in which the lines are only mildy up and down anymore. Fine VF is generally a sign that the heart has been in VF longer and the ability of the myocardium to create electrical impulse has been reduced.

Ventricular Fibrillation Signs and Symptoms

This person is dead unless you resuscitate them.

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Ventricular Tachycardia

December 20th, 2011

Ventricular Tachycardia (VT) is a lethal arrhythmia that will result in death if left untreated. As paramedics, this is where you get to do something to save a person’s life! In ventricular tachycardia, the ventricles are firing from multiple foci, resulting a fast, ventricular driven heart rate.

Ventricular Tachycardia ECG

Heart Rate: between 100 and 300 beats per minute. The faster the rate the less sustainable the rhythm is.

Rhythm: usually regular.

Pacemaker Site: ectopic ventricular pacemaker.

P Waves: may be present or absent.

QRS Complexes: usually wider (greater than .12 seconds) and bizarre.

Ventricular Tachycardia

Ventricular Tachycardia Signs and Symptoms

Any person in VT is unlikely to be conscious. They will show signs of profoundly poor perfusion, including absent palpable pulses. In certain circumstances people have conscious VT in which they remain conscious throughout being in VT. These people, given the ability to talk, would most likely feel symptoms, of confusion, dizziness, extreme weakness and a sense of impending doom.

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Paced Rhythm

December 20th, 2011

A paced rhythm is any cardiac rhythm that is driven by an artificially created electrical “paced” impulse. The most common cause of inserting an artificial pacemaker is a Third Degree AV Block (Complete Heart Block). A paced rhythm can be clearly discerned on an ECG by viewing the vertical pacemaker “spikes.”

Paced Rhythm ECG

A Paced Rhythm should be clearly identified on an ECG by viewing the vertical pacemaker “spikes.”

Paced Rhythm ECG

Paced Rhythm Signs and Symptoms

So long as the pacemaker is working well, the patient should not display or experience any signs or symptoms.

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Wandering Atrial Pacemaker

December 20th, 2011

A Wandering Atrial Pacemaker is a usually benign arrhythmia in which the pacemaker site wanders between the SA node, atria, or AV node. The wandering atrial pacemaker is commonly related to stimulation of the vagal nerve. It is most commonly seen in person who are very young, very old, or extremely athletic.

Wandering Atrial Pacemaker ECG

Heart Rate: normal (60-100).

Rhythm: mildly irregular.

P-Waves: changing in size. May change from being upright to downward.’

PR Interval: unequal.

QRS Complexes: normal.

Wandering Atrial Pacemaker Signs and Symptoms

Most people who have a wandering atrial pacemaker will  be asymptomatic. A small percentage will experience mild palpitations, but should maintain normal perfusion throughout.

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Accelerated Idioventricular Escape Rhythm

December 20th, 2011

An Accelerated Idioventricular Escape Rhythm is bizarre phenomenon in which a ventricular escape rhythm (which is usually only between 30-40 beats per minute) is accelerated to up to 100 beats per minute, but is slower than ventricular tachycardia.

Accelerated Idioventricular Escape Rhythm ECG

Heart Rate: between 40 and 100 beats per minute.

Rhythm: essentially regular.

Pacemaker site: normally from an ectopic pacemaker site within the ventricles.

QRS Complex: abnormally wide (greater than .012 seconds in duration) and bizarre in appearance.

Accelerated Idioventricular Escape Rhythm Signs and Symptoms

These people will usually appear asymptomatic unless the rhythm degenerates to a straight ventricular escape rhythm or ventricular tachycardia.

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Ventricular Escape Rhythm

December 20th, 2011

A Ventricular Escape Rhythm usually occurs when there is a conduction blockage between the atria and the ventricles. This results in the ventricle taking up the role of primary pacemaker. The ventricles have an intrinsic rate of 30-40 beats per minute, which act as a safety net, when the other (earlie pacemaker sites) fail to fire.

Ventricular Escape Rhythm ECG

Heart Rate: between 30-40 but may be lower.

Rhythm: essentially regular.

Pacemaker site: an escape intrinsic ventricular pacemaker.

QRS Complexes: wide and unusual in shape (greater than .12 seconds).

Ventricular Escape Rhythm Signs and Symptoms

These people usually are poorly perfused, but may appear relatively well perfused. In some instances, these people will have a very high blood pressure, as a result of the back-log of fluid within the circulatory system. These patients will identify symptoms such as: dizziness, weakness, chest pain, chest tightness, nausea, shortness of breath and sense of impending doom.

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Third Degree AV Block (Complete Heart Block)

December 20th, 2011

A Third Degree AV Block (Complete Heart Block) is where there is a complete conduction block between the atria and the venticles, which results in no correlation between contractions of either the atria or the ventricles. A Third Degree AV Block is a life threatening emergency, and if left untreated can result in sudden cardiac death syndrome. Treatment requires cardiac pacing through either an emergency external pacemaker or an internal pacemaker.

Third Degree AV Block (Complete Heart Block) ECG

Heart Rate: the atrial rate is likely to be normal (60-100 per minute), where as the ventricle rate is usually as low as 30-40 beats per minute.

Rhythm: the ventricular rhythm is essentially regular.

Pacemaker Site: there are two pacemaker sites. The SA node, which allows the atrium to contract, and depending on the site of the AV blockage the AV junction or ventricles will be the main pacemaker site for the ventricles.

QRS Complexes: normal or abnormal.

3rd Degree AV Block

Third Degree AV Block (Complete Heart Block) Signs and Symptoms

The person is likely to look poorly perfused. Symptoms will include: dizziness, chest pain, chest tightness, shortness of breath and palpitations.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Ventricular Escape Rhythm

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Second Degree AV Block Type II (Mobitz)

December 20th, 2011

A Second Degree AV Block Type II (Mobitz) is a more serious arrythmia than Type I (Wenckebach) because it results in a non-conducted P wave. It is almost always a disease of the distal conduction system (bundle of His or Purkinje Fibres), and almost always leads to a Third Degree Av Block (Complete Heart Block).

Second Degree AV Block Type II (Mobitz) ECG

Heart Rate: the atrial rate is usually that of the underlying rhythm, but the ventricle rate is less than normal.

Rhythm: the atria is usually regular, where as the ventricles are irregular.

P Waves: Normal

PR Interval: Normal.

QRS Complexes: abnormal and usually prolonged (greater than 0.12 seconds)

Second Degree AV Block Type II (Mobitz) Signs and Symptoms

The patient is usually starting to show signs of poor perfusion, such as mild confusion and cool, pale, clammy skin. The patient my experiences symptoms such as dizziness, chest pain, chest tightness, and palpitations.

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Second Degree AV Block Type I (Wenckebach)

December 20th, 2011

A Second Degree AV Block Type I (Wenckebach) is a relatively benign arrythmia that occurs when there is a conduction blockage between the atria and the ventricles.

Second Degree AV Block Type I (Wenckebach) ECG

Heart Rate: normal.

Rhythm: the atrial rythm is essentially regular, but the ventricular rhythm is irregular.

P waves: normal.

PR- Interval: gradually lengthening until a missed beat occurs.

QRS Complexes: usually normal.

Second Degree AV Block Type I (Wenckebach) Signs and Symptoms

The patient is usually asymptomatic.

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First Degree AV Block

December 20th, 2011

A first degree AV block (also commonly refered to as a first degree heart block) is when there is a minor conduction blockage, that causes the time between the SA node firing and the AV node receiving an impulse to be longer in duration. It is a common dysrhythmia and occurs naturally in very fit people.

First Degree AV Block ECG

Heart Rate: usually mildly slower than normal.

Rhythm: Essentially regular

Pacemaker Site: SA Node

P-waves: normal.

PR Interval: prolonged duration (greater than 0.20 seconds)

QRS Complex: normal.

First Degree Heart Block Signs and Symptoms

These patients are usually asymptomatic.

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Premature Junctional Contractions

December 20th, 2011

The term premature junctional contraction refers to any ventricle contraction that occurs as the result of any junctional pacemaker site. Premature Junctional Contractions (PJCs) are a  common cause of Sinus Arrythmia. Occasional PJCs are common occurences in otherwise healthy patients, however, if they occur too frequently, they can lead to Junctional Tachycardia or identify another underlying pathology.

Premature Junctional Contractions may occure as a single event or a set of PJCs. A set of two PJCs is refered to as Junctional Bigeminy, where as PJCs of three and four are refered to as Junctional Trigeminy and Quadrigeminy.

Premature Junctional Contractions ECG

Heart Rate: normal (usually between 60-100 per minutes), but may be accelerated.

Rhythm: irregular when PJCs are present.

Pacemaker Site: fundamentally SA node, but AV junction when PJCs occur.

P-waves: usually normal.

QRS complex: Normal.

PR Interval: Normal – 0.12-0.20 seconds in duration, but may vary between depending on when the PJCs depolarize, may appear shorter in duration.

Premature Junctional Contractions Signs and Symptoms

People who have premature atrial contractions usually are asymptomatic. If the condition is particularly exacerbated (by excess caffeine intake or stimulants) the patient may feel minor palpitations.

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Premature Atrial Contractions

December 20th, 2011

The term premature atrial contraction refers to an atrial contraction that occurs as the result of any atrial pacemaker site other than the Sino-Atrial (SA) node. Premature Atrial Contractions (PACs) are the most common cause of Sinus Arrythmia. Although little is known about the exact aetiology of the condition, it is known that a Prematuer Atrial Contraction occurs whenever any area within the atria depolarizes before the SA node has a chance to fire. In generaly, PACs are common and occur in otherwise healthy patients.

Premature atrial contractions my occure as single events or sets of multiple PACs. Sets of two PACs with the QRS complexes following coupled together is called atrial bigeminy, while atrial trigeminy or quadrigeminy refers to three or four PACs.

Pramature Atrial Contractions ECG

Heart Rate: normal (usually between 60-100 per minutes).

Rhythm: irregular when PACs are present.

Pacemaker Site: an ectopic atrial pacemaker.

P-waves: occure earlier than the normal expected P wave.

QRS complex: Normal.

PR Interval: Normal – 0.12-0.20 seconds in duration, but may vary between depending on when the PACs depolarize.

Premature Atrial Contractions Signs and Symptoms

People who have premature atrial contractions usually are asymptomatic. If the condition is particularly exacerbated (by excess caffeine intake or stimulants) the patient may feel minor palpitations.

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Junctional Escape Rhythm

December 20th, 2011

A junctional escape rhythm is when a ventricular contraction originates from an ectopic pacemaker site within the atrial ventricular junction. This can occur when the AV junction fires prematurely, or when the intrinsic rhythm fired by the SA node fails to meet the AV junction on time.

Junctional Escape Rhythm ECG

Heart Rate: 40-60 bpm

Rhythm: irregular in single junctional escape complexes, but regular in junctional escape rhythm.

P waves: depends on the site of the ectopic foci. P waves will usually be inverted, and may appear before or after the QRS complex, or they may be absent, hidden by the QRS complex. This is because the P wave represents the depolarization of the SA node, which is occuring just before or just after the AV Junction depolarizes, meaning that the P wave “appears” very close to the QRS complex or even after it and is inverted.

P-R interval: if the P wave occurs before the QRS complex, the interval will be shorter than normal (less than 0.12 seconds).

QRS Complex: Uuually normal in duration and morphology (less than 0.12 seconds).

Junctional Escape Rhythm Signs and Symptoms

The patient will commonly be unaware of their underlying heart rhythm until the rate becomes low enough to become symptomatic. At a rate of 50/minute the person my find it slightly harder to exercise, but will often be unaware of any changes. As the rate lowers towards 40/minute the patient will become poorly perfused, with signs such as cool, pale, clammy skin. They may feel symptoms such as dizziness, mild palpitations, chest pain, chest tightness, and generaly weakness.

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Atrial Fibrillation

December 20th, 2011

Atrial fibrillation (commonly referred to as AF) is a heart condition in which the atria fires off multiple ectopic pacemakers causing a fibrillation of the atrial contractions and increasing the rate of ventricle contraction. Atrial fibrillation occurs most commonly in people who have a variety of cardiac diseases, however, it has been noted in some people who have an otherwise normal heart.

Atrial Fibrillation ECG

Heart Rate: greater than 100 per minute.

Rhythm: irregular

Pacemaker Site: multiple ectopic atrial pacemaker sites.

P-waves: absent.

QRS complex. Normal.

Atrial Fibrillation Signs and Symptoms

People who have atrial flutter are likely to have the following signs and symptoms:

1. Signs associated with poor perfusion, such as pale, cold, clammy skin. Some diaphoresis may be present.

2. Symptoms such as the sensation of a racing heart (palpitations), dizziness, chest pain, chest tightness, sense of impending doom, syncope.

3. In many cases the person may have no symptoms at all.

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Atrial Flutter

December 20th, 2011

Atrial flutter is a heart condition in which the atria fires off multiple ectopic pacemakers causing a flutter of atrial contraction and increasing the rate of ventricle contraction. Atrial flutter occurs most commonly in people who have a variety of cardiac diseases, however, it has been noted in some people who have an otherwise normal heart. Atrial flutter is not a sustainable rhythm and generally either self-resolves or progresses to atrial fibrillation.

Atrial Flutter ECG

Heart Rate: greater than 100 per minute.

Rhythm: irregular

Pacemaker Site: multiple ectopic atrial pacemaker sites.

P-waves: absent, but replaced with multiple “F” waves .

QRS complex. Normal.

Atrial Flutter Signs and Symptoms

People who have atrial flutter are likely to have the following signs and symptoms:

1. Signs associated with poor perfusion, such as pale, cold, clammy skin. Some diaphoresis may be present.

2. Symptoms such as the sensation of a racing heart (palpitations).

3. In many cases the person may have no symptoms at all.

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Atrial Tachycardia

December 20th, 2011

Atrial Tachycardia is another Supraventricular Tachycardia. Atrial tachycardia is usually caused by an abnormal conduction of electical impulses fromt he atria to the ventricles via an accessory pathway. This pathway usually occurs through the AV node, and causes a premature ventricular contraction.

Atrial Tachycardia ECG

Heart Rate: ussually greater than 160
Rhythm: essentially regular
Pacemaker Site: an ectopic atrial pacemaker site.
P-waves: present and normal.
PR Interval: Norrow – 0.08-0.12 seconds in duration.
QRS Complex: Normal or slightly longer than normal in duration (greater than .10 seconds).

Atrial Tachycardia Signs and Symptoms

People who are in atrial tachycardia usually have the following signs and symptoms:

1. Signs associated with poor peripheral perfusion, such as pale, cold and clammy skin.

2. Complains of dizziness, anxiety, sense of impending doom, chest pain, chest tightness, nausea, and palpitations.

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Supraventricular Tachycardia

December 20th, 2011

Supraventricular Tachycardia (SVT) is the term used by clinicians to refer to any ECG rhythym that is fundamentally triggered by a pacemaker site above the ventricles (meaning anything from the atrial origin).

When doctors refer to a SVT, they are usually refering to Paroxysmal supraventricular tachycardia (PSVT) which is due to an AV nodal re-entrant tachycardia. Although, by definition, supraventricular tachycardia can refer to any tachycardia that originates above the ventricles, such as atrial fibrillation, atrial flutter, wolf-parkinson’s white syndrome or atrial tachycardia. Most clinicians will refer to these cardiac conditions specifically, and not by the term SVT.

Supraventricular Tachycardia ECG

Heart Rate: ussually greater than 160
Rhythm: essentially regular
Pacemaker Site: an ectopic atrial pacemaker site.
P-waves: with the exception of atrial fibrillation and atrial flutter, the P-wave in SVT is usually normal and precedes the QRS complex.
PR Interval: Normal – 0.12-0.20 seconds in duration.
QRS Complex: Normal.

Supraventricular Tachycardia Signs and Symptoms

People who are in SVT usually have the following signs and symptoms:

1. Signs associated with poor peripheral perfusion, such as pale, cold and clammy skin.

2. Complains of dizziness, anxiety, sense of impending doom, chest pain, chest tightness, nausea, and palpitations.

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Recruits Paramedics Second Season

December 19th, 2011

Will there be a second season of Channel 10’s Recruits Paramedics? The first season of the reality TV show follows paramedic recruits as they commence their initial paramedic training through to their “on road” experiences as recruit paramedics. As yet, Chennel 10 and the Ambulance Service of NSW has not indicated whether or not it will run a second season of Recruits Paramedics.

Will there be a Second Season of Recruits Paramedics?

The decision to make a second season of the reality TV show Recruits Paramedics will most likely depend both on the popularity (ratings) of the first season and on how well the Ambulance Service of NSW believes the show has effected their relationship with the general public. One of the potential benefits of the first season for the Ambulance Service of NSW would likely include: increased awareness of what paramedics do for the community, increased interest in becoming a paramedic for Ambulance recruitment, and increased awareness by the general public and when to call an Ambulance and when not to.

Recruits Paramedics Season 2

If there is a Recruits Paramedics Season 2 will it continue on with what happened to the current paramedic recruits who were followed, or will it start with a whole new set of recruit paramedics?

At this stage, we’ll just have to wait and see if we’ll get to watch a second season of Recruits Paramedics!

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Cardiac Enzymes

December 17th, 2011

Emergency Departments and cardiologists will usually assess a person’s cardiac enzymes by taking blood from any patient who has chest pain or discomfort. Through assessing the blood enzymes a doctor is able to provide a more conclusive diagnosis of an acute coronary syndrome (heart attack) by assessing a variety of cardiac enzymes.

The main cardiac enzymes include: tropinin I and T levels, creatinin kinase, and myoglobin.

Troponin Enzymes

Troponin is a protein found only in striated muscles (generally voluntary skeletal muscles and the muscles of the heart). There are three different types of troponin proteins. These are: troponin C, tropnin T and troponin I. Troponin C is found in all striated muscles, and therefore is generally irrelevant as a heart attack indicator. However, both troponin I and tropin T are mainly found in the myocardium and therefore any increase in these levels indicate recent damage to the myocardium.
There are three different types of troponin

Troponin I and T level changes can be seen in cardiac enzyme blood results within 4 hours and usually peaks within 12 hours. Troponin I and T are the most accurate, early cardiac enzyme indicators of an acute coronary syndrome. Blood results indicating tropin I levels greater than 10 mcg/L is considered indicative of recent damage to the myocardium. Blood results indicating tropin T levels greater than 0-0.1 mcg/L is considered indicative of recent damage to the myocardium.

Creatinin Kinase and Myoglobin

Creatinin Kinase and Myoglobin is found in both skeletal muscles and heart muscles. Changes in CK/Mb levels are relatively accurate in indicating recent damage to the myocardium, in the absense of recent skeletal muscle trauma. Where recent skeletal muscle trauma is suspected, such as heavy exercise or traumatic injuries, teh CK/Mb levels are irrelevant as a cardiac enzyme.

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Heart Attack Imitators

December 17th, 2011

Chest pain may be related to pathologies in the following areas of the body: heart, lungs, chest muscles (pectorals major and minor, back muscles, intercostal muscles), referred abdominal pain, spinal injuries, or psychological in nature. Chest pain may be cardiac in nature, meaning that it has come as a direct result of damage or pathology towards the myocardium (heart). Chest pain may also be related to problems with the lungs, the muscles around the chest, such as the pectorals major and minor, back muscles, spinal injuries, and a great deal of other problems.

Common Heart Attack Immitators include:

1. Costochondritis (Inflamation of the intercostal muscles), which cause chest pain.

2. Pleurisy

3. Chest Infections

4. Traumatic Injuries to the chest.

5. Asthma

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Heart Attack Symptoms

December 17th, 2011

The following are all potential symptoms of a heart attack:

1. Pain to the central chest

2. Pain to the left side of the chest

3. Pain or numbness to the left arm

4. Tingling sensation down the left arm

5. Jaw pain

6. Neck pain

7. Shortness of breath during exercise or at rest

8.Indigestion pain

9. Abdominal cramping pain.

10. Vomiting

11. Nausea.

12. Rapid pulse

13. Weak pulse

14. Anxiety

15. Tooth Ache

16. Dyspepsia

17 Raised JVP

18. Altered Level of Consciousness or Syncopal Episodes

19. Hypotension (low blood pressure)

20. Diaphoresis (sweating)

21. Skin that is cold, grey, pale, or sweaty.

22. Sense of impending doom.

23. Nothing at all.

If in doubt about the symptoms that you are feeling, it is important to call an Ambulance and visit your local emergency department as soon as possible. When it’s your heart, every second counts!

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ST Elevation Imitators

December 17th, 2011

The following are common ST Elevation imitators that often make an ECG look like there is an ST change.

1. Bundle Branch Block (BBB), in which there is a conduction delay in the bundle branches, which causes the ECG to have a prolonged QRS complex greater than 0.10 seconds. This will often lead to the appears of a raised ST segment where the S wave meets the T wave.

2. Left Ventricular Failure (LVF).

3. Ventricular Rythyms often cause the QRS complex to cover much of the ST segment making the appearance of a possible raise in the ST Segment.

4. Pericarditis, will often result in an increased level of ischaemia to the entire heart, and this will result in a mild to severe ST Segment changes to all ECG leads.

5. Pericardial Tamponade, like pericarditis, results in the myocardium being squeezed by the pericardial sack, and this will result in ischaemia to the entire heart and subsequent ST changes.

6. Certain medications can causes changes to the ST segment of the ECG.

7. A Ventricular Aneurysm may result in a variety of ST changes, both elevation or depression.

8. Benign Early Repolorization, results in the ST segment of the ECG being taken over by the R wave and consequently appears like ST elevation.

Return to ECG Interpretation page.

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Assessing Chest Pain

December 17th, 2011

The following is a good method of assessing chest pain based on the works of Newberry, Barnett and Ballard (2003, p84-5) mneumonic for assessing chest pain. Over the years there have been numerous mneumonics for assessing chest pain, including the commonly used OPQRST mneumonic used to assessing any pain type.

Chest Pain Assessment

C – Commenced when? This looks as the onset time and activity undertaken when the pain commenced.

H – History of heart disease or risk factors, such as smoking, age, sex, high blood pressure, high cholesterol, unstable BSL, obesity?

E – Extra symptoms – what other symptoms does the patient have, such as nausea, dizziness, sense of impending doom?

S – Stays or radiates? Where is the pain and where does it go?

T – Timing – when did it start, how long has it lasted? Is it continuous or intermittent?

P – Place – where is the pain exactly? Can you pinpoint the pain or is a non-specitific pain?

A – Alleviates/ aggravates – anything that makes the pain feel better? Anything that makes the pain feel worse?

I – Intensity. How intense is the pain – 0-10?

N – Nature – describe the pain – is is advised that you do not describe the types of pain, because this will likely just cause the patient to follow on with what you identify and not what he or she feels.

On top of these chest pain assessments, clinicians should perform a 12 lead ECG and assess it for any acute changes in the ST segment or arrythmias. In an emergency department, further 12 lead ECGs will be taken and blood tests will be collected to review blood electrolyte levels, creatinin kinase levels, troponin I and T levels and myoglobin levels, all of which may be elevated in the event of myocardial damage (a heart attack).

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Sinus Arrhythmia

December 12th, 2011

Sinus Arrhythmia
Heart Rate: 60-100
Rhythm: Mildly Irregular
Pacemaker Site: SA Node
P Waves: Upright in lead II: precede each QRS complex.
PR Interval: Normal

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Sinus Arrest

December 12th, 2011

Sinus Arrest

Heart Rate: 60-100/min
Pacemaker Site: SA Node
P Waves: Absent when sinus arrest occurs. This is commonly referred to as an exit block in the SA node, otherwise normal and upright in lead II.
PR Interval: Normal until SA node exit bock occurs.

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Sinus Tachycardia

December 12th, 2011

Sinus Tachycardia

Heart Rate: Greater 100/min
Rhythm: Regular
Pacemaker Site: SA Node.
P Waves: Upright in lead II, precedes each QRS complex.
PR Interval: Normal

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Sinus Bradycardia

December 12th, 2011

Sinus Bradycardia is defined as any heart beat that originates in the sino-atrial node and causes a ventricular beat of less than 60 per minute. Sinus bradycardia is generally benign and most patients are asymptomatic.

Sinus Bradycardia ECG

Heart Rate: Less than 60/min
Rhythm: Regular
Pacemaker Site: SA node.
PR Interval: Normal
QRS Complex: Normal.

Sinus Bradycardia Signs and Symptoms

In general patients who show a sinus bradycardia on their ECG will show little other signs and symptoms depending on the rate of their rhythm and any co-factors such as an acute coronary syndrome, pain, injuries, etc. Most patients will appear well perfused with good skin colour, warmth and no diaphoresis. If patients are on common blood pressure medications such as Beta Blockers it is likely that these will have artificially lowered the person’s heart rate and that their normal resting heart rhythm is a sinus bradycardia.

In general, patients who have a sinus bradycardia are not hypotensive. This is because as we learned in Starling’s Law, the slower the heart rate the greater time allowed for ventricular filling (which is passive), ventricular stretching (pre-load) and subsequent cardiac output.

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Sinus Rhythm

December 12th, 2011

Normal Sinus Rhythm

Heart Rate: 60-100 bpm
Rhythm: Essentially regular
Pacemaker Site: Sino-Atrial Node (SA Node)
P Waves: Upright in Lead II, identical and precedes each QRS complex.
PR Interval: Normal (0.12-0.20 seconds which equates to 3-5 small squares on standard ECG paper).

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Steps in ECG Rhythm Analysis

December 12th, 2011

The following steps should be used during any ECG Rhythm Analysis:

1. Look at the QRS Complexes – Are they regular or irregular? You can feel the patient’s pulse while you do this and see that the patient has a regular or irregular pulse and that this matches up with what you are seeing on the ECG or EKG if you’re in the US.

2. Determine the rate by counting the QRS Complexes in a 10 second strip. Is it fast (greater than 100 beats per minute), Normal (60-100 beats per minute) or slow (less than 60 beats per minute)?

3. Look at the P- Waves. Are they normal? A normal P wave should be upright in lead II and should be identical to all the other P waves in the ECG. A P wave should also precede a QRS Complex. If you can’t see a P-wave, the person most likely has Atrial Fibrillation – (see if this is normal for the patient, or a new condition).

4. Look at the PR interval and the relationship between the P-Waves and the QRS Complexes. A PR interval should normally be between 0.12 and 0.20 seconds in length. If it is longer than this, there is a conduction problem between the SA node and the AV node. If it is shorter than this, the SA node is firing too quickly as is the case in Atrial Tachycardia.

5. Look at the RR intervals – are they regular? Are they identical in timings? In a normal sinus rhythym an RR wave should be consistent.

6. Look at the QRS Complexes – It is normally less than 0.1 seconds in length. If this is longer, there is a conduction problem between the AV Node and the Perkinje Fibres (this indicates a Bundle Branch Block).

Steps in ECG Analysis

By following these steps, the basic ECG rhythm can be interpreted.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

The Normal ECG

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ECG Interpretation

December 12th, 2011

ECG Interpretation is a course designed by paramedics for paramedics. There is a reason why the medical profession has acknowledged the concept that ECG readings are only an “interpretation” of what is happening to the heart. There are many different types of ECG rhythms and for every additional cardiologist, there is usually another interpretation of any given ECG. That said and done, this tutorial is designed to arm you with the basic methods used to interpret ECGs and familiarize yourself with some of the more common ECG Rhythms.

It is important to recognise that ECG rhythms are rarely clear on a real patient and getting rid of the last of the ECG artefact is always difficult in the back of an Ambulance. For this reason, we have tried to include numerous examples from actual patients.

Before you start to learn about ECG Interpretation it is important to review the anatomy and physiology of the heart, so that the relevance of each aspect of the ECG can be applied to the clinical science. A strong knowledge of and understanding of the Conduction System of the Heart is required when identifying pathological abnormalities in an ECG. Furthermore, basic concepts such as Blood Flow Through the Heart and Coronary Artery Blood Flow should be understood before learning about ECG Interpretation.

As we are still collecting ECGs from paramedics, some links are missing or do not yet have an ECG as an example of that type of ECG rhythm.

Anatomy and Physiology of the Heart:

The following will help you revise the normal physiology of the heart and identify the pathophysiological basis of any abnormal ECGs:

Conduction System of the Heart

Blood Flow Through the Heart

Coronary Artery Blood Flow 

Phases of the Cardiac Action Potential

ECG Examples

The following are examples of ECGs in which the heart beat originates from the Sino-Atrial Node.

Steps in ECG Rhythm Analysis

Normal ECG

Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrest

Sinus Arrythmia
Common Dysrythmias

The following are common dysrythmias:

Bundle Branch Block

Supraventricular Tachycardia

Atrial Flutter

Atrial Fibrillation

Junctional Escape Rhythm

Premature Junctional Contractions

Atrial Tachycardia

Premature Atrial Contractions

First Degree AV Block

Second Degree AV Block Type I (Wenckebach)

Second Degree AV Block Type II (Mobitz)

Third Degree AV Block (Complete Heart Block)

Ventricular Escape Rhythm

Accelerated Idioventricular Escape Rhythm

Wandering Atrial Pacemaker

Paced Rhythm
Lethal Arrhythmias

The following are all lethal arrythmias that you must be able to immediately identify:

Ventricular Fibrillation

Ventricular Tachycardia

Torsades De Pointes (Twisting of the Points)

Asystole

Assessing Chest Pain

Chest Pain

Causes of Chest Pain

ECG Tips

The following are useful tips when assessing an ECG:

Tips for Reducing ECG Artefact in an Ambulance

ST Elevation Imitators

Paramedic ECG Interpretation Debate

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Bundle Branch Block

December 12th, 2011

A Bundle Branch Block is basically a blockage at the AV Bundle of HIS, which slows down the conduction of the electrical impulses through the bundle branches. A Bundle Branch Block is identified whenever a QRS complex is greater than 0.10 seconds in duration.

When looking at a Bundle Branch Block on an ECG you look at leads: I, V1 and V6. A Bundle Branch Block is diagnosed when the QRS complex exceeds 0.10 seconds in duration (which identifies a conduction delay through the ventricles).

Here is an image of a  Bundle Branch Block in a heart:

Bundle Branch Block

In this example, you can see the blockage in the Right Bundle Branch, causing a blockage down the Bundle Branches and subsequent conduction delays.

How to Determine Bundle Branch Block Side

If you want to determine whether or not a bundle branch block is to the left or right this is how you do so:

In V1 the QRS complex is primarily pointed upwards and this is determined to be a right sided Bundle Branch Block.

In V1 the QRS complex is primarily pointed downwards, then this is determined to be a left sided Bundle Branch Block.

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Conduction System of the Heart

December 12th, 2011

One of the more unique abilities of the cells within the heart is automaticity, the ability to create its own electrical activity, and inherent rhytmical electical activity is what allows a heart to contract with some level of rhythm. This conduction process is developed during early embryonic stages of development, in which as little as 1% of the cardiac cells devellop autorhymicity. This 1 % goes on to develop the primary pacemaker sites that form to make the conduction system of the heart.

The following is an image of the normal conduction system of the heart:

Conduction System of the Heart

(1.) The SA node is the first to fire off the intrinsic, rhythmic electrical current (that later causes the atrium and ventricles to contract). 2. This current then travels through the right atrium and triggers the AV Node (2.) to continue the conduction down the AV Bundle of HIS (3.), further down into the Left and Right Bundle Branches (4). and finally into the large branches of the Purkinje Fibers(5.).

Here is a video outlining the conduction of system of the heart:

httpv://www.youtube.com/watch?v=te_SY3MeWys

Conduction Pathway of the Heart

1. The SA Node has autorhymic fibers that are capable of initiating cardiac action potentials and setting the basic pace for the heart.

2. The Atrioventricular Node receives the action potentials from the SA Node and triggers the conduction of the Atrioventricular Node Bundle of HIS.

3. The Atrioventricular Node Bundle of HIS passes the action potentials (conduction of eletricity) through the left and right Bundle Branches.

4. The Left and Right Bundle Branches recieves action potentials from the AV Bundle of HIS and passes them onto the Purkinje Fibers.

5. The Purkinje Fibers receives the action potentials and passess them to the ventricular myocardium, which is the muscle responsible for the ventricle contraction and the mechanical pumping of the heart.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Blood Flow Through the Heart.

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Coronary Arteries Blood Flow

December 12th, 2011

Although the heart pumps blood around the body, supplying oxygenated blood to cells within the human body and removing waste products such as CO2, the heart itself is only oxygenated through relatively small coronary arteries that flow around the heart.

The following is a diagram from renowned Medical Author, Gray’s Anatomy:

Coronary Arteries

Blood is supplied to the heart during the diastolic phase (relaxation phase) of the cardiac cycle. During the systolic phase (when the left ventricle is contracting) very little blood is supplied to the coronary arteries. During diastole, the left ventricle relaxes, but the high pressures within the aortic arch allow the residual blood pressure (diastolic blood pressure) to force oxygenated blood into the coronary arteries, which branch off the ascending aorta.

From the ascending aorta blood flows into the two main coronary arteries – the left coronary artery and the right coronary artery. There is also a circumflex artery that supplies oxyenated blood to the walls of the left atrium and left ventricle.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Phases of the Cardiac Action Potential

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Blood Flow Through The Heart

December 12th, 2011

The following page discusses how blood flows through the human heart. The human heart is basically a very economical pump, designed to last you a lifetime. The heart itself can be broken into 4 main chambers, the right and left atrium and the right and left ventricles, which are designed to pump blood around the body. The right atrium and ventricle are two interconnected chambers that pump separately to the left atrium and ventricle, which are also interconnected chambers.

Here is an image of the blood flow through the heart:

Blood Flow Through Heart Diagram

1. Deoxgyenated blood, which is blood that has already released most of its oxygen to the cells to maintain homeostasis, enters the heart through the superior and inferior vena cava. From here, it enters the right atrium and flows into the right ventricle, through the contraction of the right atrium. 2. The right ventricle then pumps the deoxgynated blood into the pulmonary trunk. 3. From the pulmonary trunk, the deoxygenated blood travels up the pulmonary trunk, which divies into the right and left pulmonary arteries and then pulmonary capillaries (this is where the deoxgynated blood picks up oxygen in the lungs and loses its CO2). 4. Newly oxgyenated blood is now returned to the left atrium via the pulmonary veins and then into into the left ventricle (the larger of the two ventricles). 5. Oxygenated blood is then ejected into the body through the aortic arch and throughout the body.

How Does Blood Flow Through the Heart?

The blood flows through the heart through both pre-load (back-logged blood from the rest of the circulatory system) and through the opening of various valves within the heart and the contraction of the left and right ventricles which cause the blood to be literally pumped around the heart and body.

What is the Purpose of the Heart?

The purpose of the heart is to literally pump oxygenated blood around the body to provide the oxygenation of all cells within the tissues of the body in exchange for CO2.

 

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Coronary Artery Blood Flow

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Traction Splint

November 23rd, 2011

Traction is a process by which a limb is stretched in order to better position a deformed bone into its normal anatomical alignment, while also pulling apart two ends of a fractured bone which may otherwise result in the grating of each end of the bone (crepitus), pain, and potential neurovascular damage.

Due to the muscles of the body’s natural desire to shorten (ordinarily held at bay by the strength of the limb bones) any fracture to a long bone in the body (such as femur or humerus) is likely to result in a sudden shortening of the surrounding muscles and consequential overlapping of fracture bone structures and high likelihood of neurovascular damage.

In order to reduce these complications traction splints should be applied.

Unfortunately, traction splinting will not work or should not be attempted in all fractures. Particularly, the following injuries are contraindicated for tractioning: ankle injuries, fractured NOF, fractured pelvis, dislocation to the hip,  fractures to the distal third of the tibia and fibula, and fractures or dislocations to the knee.

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Clavicle Splint

November 23rd, 2011

A clavicle splint is a splinting device most commonly associated with fractures involving the acromioclavicular joint, middle and outer aspect of the clavicle. When the middle or outer aspect of the clavical bone is fractured the sternocleidomastoid pulls at the inner aspect of the clavicle causing it to move upwards, while the pectoralis major  and deltoid muscles  pull on the fractured aspect in a downward motion, which  causes separation or movement of the two fractured aspects of the clavicle bone and subsequent poor healing and discomfort.

By applying a clavicle splint a clinician is aiming to elevate and retract the shoulder in order to further reduce the outer aspect of the clavicle. A complete reduction of the fracture is generally impossible and the clavicle splint is aimed only at providing some reduction and proting comfort, allowing the patient to maintain his or her normal activities of daily living.

Clavicle Splint Costs

Depending on the type of clavicle splint that you require, most clavicle spints cost less than $30 and provide valuable relief to those who have had a fracture of the middle to outer third of their clavicle bone. An orthopaedic surgeon will indicate to you if your fracture requires a clavicle spint. In the majority of cases, fractures of the clavicle bone heal on their own and do not require any active interventions.

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Vacuum Splint

November 23rd, 2011

A vacuum splint is a splint made out of sealed vinyl filled with polystyrene beads that is easily pliable under normal circumstances. Once the vacuum splint is applied the air is removed through a suction device causing the ordinarily pliable splint to become rigid and support the fractured limb.

A vacuum splint is considered gold standard in terms of splinting difficult to splint fractures. Vacuum splinting is also very good for entire body splinting in patients who have a potential spinal cord injury. By utilising the entire body vacuum splint, paramedics are able to ensure the best spinal support for their patient during transport.

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Box Splint

November 23rd, 2011

A box splint is a three padded sides and a foot piece designed to be applied to a deformed limb. Box splints are relatively simple to utilise and provide excellent support for a fractured limb.

The box splint basically works by sliding the middle padded sheet under the leg or limb and then the remaining outer padded sheets should be folded in  order to produce a box around the patient’s leg or limb. If applying the box splint to the leg, the foot pad should be applied at a 90 degree angle. The Velcro straps should then be tightened to produce the appropriate amount of support and firmness without reducing circulation distally.

Box splints consist of three padded sheets, a padded foot piece and Velcro straps. This makes the box splint one of the cheapest and most reliable splinting devices available to any Ambulance Service.

Cost of a Box Splint

Box splints are considered relatively cheap compared to the rest of the splinting devices used in Ambulances. Box splints come as cardboard (very cheap) for as little as $8 each and plastic and foam for about $35 each. Either way, you wont find a cheaper way to splint a lower limb fracture.

Box splints are a basic, but used by a competent paramedic or clinician, can provide very good splinting and support for a fractured limb. Box splints do not provide as complete support as a vacuum splint, which are relatively expensive.

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Principles of splinting

November 23rd, 2011

Returning to the basics of paramedicine. Splinting is a fundamental skill required by paramedics to perform their duties in pre-hospital emergency health care. Unfortunately, with the rise of our higher medical skills, such as IV cannulation, intubation, advanced drug administration, fundamentals of the paramedic profession have sometimes been forgotten.

Splinting Fractures

So, lets return to the principles of splinting fractures:

1. Inspect the wound site and determine that the patient may benefit from splinting. If a patient is not neurovascularly compromised and is comfortable, don’t try and change it. Whatever position works for them is usually the best one.

2. Assess neurovascular status distal to the injury site prior to application of a splint (this means marking the pedal pulse with a pen in leg trauma or checking a radial pulse in a fractured arm).

3. Manage any wounds that require interventions at the site that is going to be splinted (because you may not have access once the splint is applied).

4. Pad the splint well to reduce movement of the injured limb and increase comfort. Large trauma pads are commonly used for lower limb fractures.

5. Support the injured limb from above and below the fracture site while applying the splint.

6. Consider the need for traction if the limb is out of alignment or there is poor distal perfusion.

7. Splint firmly, but ensure that distal circulation is maintained.

8. Avoid covering fingers and toes as these are the easiest indicators of good or poor circulation.

9. At the completion of the application of any splint always check for distal colour, warmth, movement and sensation (and pulses).

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Advertising Policy

November 23rd, 2011

Thank you for taking the time to look at our advertising policy.

This website, Emergency Medical Paramedic, is run by a group of volunteer paramedics who are actively involved in creating a database of real paramedic stories and lessons learned by paramedics for paramedics. Emergency Medical Paramedic actively seeks internet advertisers such as google ads and affiliate programs such as clickbank in order to fund its web hosting and more technical website development. Emergency Medical Paramedic tries to do so without affecting you, the user, by having overly distracting or “spam-like” ads.

Emergency Medical Paramedic agrees to:

1. ensure that our readers are able to easily distinguish between ads and editorial writings by using the words: ads by google, adchoices or affiliate program, clearly marked on any advertisements used.

2. only advertise using reputable internet advertising agencies, such as google or clickbank, which uphold a certain moral, ethical, and legal standard of advertising.

3. does not advertise pornography or gambling sites.

If you feel that we have failed in any of these respects please contact our webhost Chris, at our Contact Us page.

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Authors

November 22nd, 2011

Thank you for taking the time to see who contributed to this Australian Paramedic website.

Chris Cartwright – a currently practicing paramedic in Australia, with extensive experience working as a paramedic in both metropolitan and rural settings in Australia over the past 12 years. Qualifications include: Bachelor of Clinical Practice (Paramedics), Bachelor of Health Science (Nursing), and a Master of Emergency Management. Chris started this website as a means of providing a platform for other paramedics to discuss lessons that they have learned in the field and out of the field in order to improve patient care, paramedic clinical and “street sense” knowledge, and further their paramedical development.

Ian Wells – a UK trained paramedic with more than 20 years experience as a paramedic.

Maria Co Paler – Clinical Nurse Specialist in Emergency (ED) with over 12 years experience and has provided insight into what hospitals want when they receive patients from paramedics and the areas in which they perceive a paramedic has excelled or failed in his or her duty. Maria has completed both a Bachelor of Health Science (Nursing) and a Master in Critical Care Nursing.

Joe Cartwright – renowned Australian Watercolor Artist, who contributed by providing many of the the artist’s impressions of medical diagrams. You can view Joe Cartwright’s works at Painting With Watercolors.

I would also like to note the valuable assistance of the community of paramedics out there who have sent in suggestions and paramedic articles, interesting case studies, and a variety of other information utilised to ensure that this website serves its purpose in providing up-to-date information for paramedics, by paramedics.If you would like to become a writer for Emergency Medical Paramedic, or wish to submit a case study or suggestion, please contact us here, we’re always appreciative of help by paramedics.

As a group, we do not take legal responsibility for the use of any recommendations or procedures decribed in this website, but merely provide them as an adjunct to your current paramedic training and suggest that you follow your specific Ambulance Service approved guidelines, procedures, and skills. Please review our disclaimer. 

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Tips for Reducing ECG Artefact in an Ambulance

November 18th, 2011

The ECG machine was originally designed for quiet hospital settings in which a cardiologist or team of cardiologists were able to to negotiate and interpret the ECG rhythym strips for signs of myocardial ischaemia, infarction or conduction disturbances. Over the years the role of the ECG machine has expanded to include out of hospital use by paramedics to more accurately identify and interpret cardiac presentations by paramedics. Unfortunately, the ECG machine is designed to catch the most minimal sounds and movements as electrical activity of the heart, which means that, the noisy environment that paramedics generally work within is likely to cause the ECG machine to interpret many areas of the environment as artefact.

It is difficult to ever completely remove the causes of ECG artefact in the prehospital environment, but these tips for reducing ECG artefact may help.

Tips for Reducing ECG artefact in an Ambulance:

  1. Make  sure the engine of the Ambulance is turned off.
  2. Ensure  that the patient is comfortable and laying at rest.
  3. Make  sure the leads are on correctly and that all hair has been adequately  removed prior to electrode placements.
  4. Turn  of the air conditioner.
  5. Make  sure the ECG leads are not touching each other because this may cause  artefact.
  6. Make  sure the ECG leads are laying flat on the patient and aren’t  dangling/bouncing around.
  7. In  the patient who has a continuous shake or tremor (such as Parkinson’s  Disease) you may never get a perfect ECG, but should be able to get a better ECG if you perform a modified ECG with the 4 Limb leads placed on  the torso (right shoulder, left shoulder, right lower quadrant of the abdomen, left lower quadrant of the abdomen) – this is not going to  produce a perfect ECG, but may be better than nothing. As with any other changes from the norm, it is important to document on the ECG where you  have placed the electrodes if you have made any modifications. This will avoid future confusions by medical staff in hospital. If you really can’t  get a good ECG tracing, make sure you document this too.
  8. Make sure any hair has been cleanly shaved so that the electrodes have better conduction through the patients’s skin.

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Normal ECG

November 18th, 2011

Normal ECG Components. As a paramedic, given that we generally treat the elderly and persons with known cardiac disease or a multitude of medical diseases and disorders, it is very unlikely to see a perfectly normal ECG. In reality, even with younger people and genuinely healthy people, it is uncommon to see a perfect, normal ECG. But, you need a baseline in which to work with, so this page provides information about the mythical “perfectly normal ECG.”

Normal Components of an ECG

Basic ECG Graph

(Image Source: Wikipedia 2011)

P Wave

Normally precedes the QRS complex and is upright in leads: I, II, aVF, and V4 and V5. Inverted (negative) in leads II, aVL and V1 and V2. Duration of P wave is usually under 0.1 Second. Amplitude should be 0.5-2.5 mm when viewed in lead II. The normal shape of the P wave is smooth and rounded.

QRS Complexes

Regularly follows a P wave at regular intervals. 0.10 seconds or less in duration. Shape generally narrow with sharply pointed waves.

T Waves

Amplitude less than 5mm in the standard limb leads and less than 10 mm in the precordial leads.

PR Interval

0.12 seconds -0.20 seconds.

QT Intervals

Less than half the preceding R-R intervals

ST Segments

Normally flat, but may commonly be depressed or elevated but no more than 1.0 mm.

Normal ECG

 

Normal ECG Patient Presentation

A patient with a normal ECG, given no other health concerns, should present well perfused with skin that is warm, pink, dry, their level of consciousness should be normal, their blood pressure may or may not be normal, and their pulse rate should be between 60 and a 100 per minute in a fundamentally regular and strong rythym.

Return to: ECG Interpretation Tutorial.

Next page in the ECG Interpretation Tutorial:

Sinus Rhythm

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Cardiac Auscultation

November 14th, 2011

The auscultation and interpretation of cardiac sounds is infrequently utilised in the pre-hospital care setting, however, it can be of use to clinicians and is certainly utilised by doctors and cardiologists regularly. Some ambulance services do utilise this skill, and it is for this reason that I have provided a basic introduction to cardiac auscultation for paramedics.

In the normal, healthy adult, heart sounds are created by the sound of the valves of the heart closing. Cardiac valves do not make any sounds when they open. As a paramedic, or clinician, it is paramount at this stage to have a thorough grasp of both the anatomy of the heart and the physiology of its pumping abilities through the cardiac cycle in order to understand the heart sounds heard in the normal or abnormal patient. Cardiac Auscultation is considered an advanced medical skill that requires training and experience to maintain (which is why it is seldome used in pre-hospital care). Furthermore, many abnormalities are either faint or very subtle, making them almost impossible to recognise or accurately interpret in the pre-hospital care setting (which has numerous outside noises).

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3 Lead ECG Placement

November 14th, 2011

The 3 lead ECG is the most commonly used ECG in pre-hospital care and is most regularly utilised in continuous monitoring of the person who has had some form of cardiac event. This is because it is simple to use and requires a much less sensitive machine, therefore it is capable of picking up the specific electrical rhythym (or lack of rhythym) in the heart, without picking up as much arterfact (interference) as a much more detailed 12 lead ECG would.

A 3 lead ECG is considered non-diagnostic, meaning that it does not provide a clear view of the entire heart, but instead a basic view of the electrical pathway of the heart triagulated between the 3 leads.

3 Lead ECG Placement Diagram

The 3 lead ECG is usually simple to use and most brands have a standardized colour coded placement of the 3 electrode leads. Although I’ve recently discovered that the US use a different colour scheme involving the colours red, yellow and green for their electrodes. These are the most common 3 lead ECG placements:

1. Right arm limb lead is white (white goes to the right) – forearm, proximal to the wrist.

2. Left arm limb lead is black and is considered the Earth lead, and is placed at the forearm, proximal to the wrist.

3. Left leg limb lead is red and is placed at the left lower leg, proximal to the ankle.

Please note that, irrespective of the colour codings, the 3 lead ECGs have the name of the electrode, such as RA, LA, and LL. Furthermore, it is important to understand that there is sometimes a fourth limb lead (Right Leg), which is then used as the neutral lead and this leads into the basics for the limb leads used in a 12 lead ECG.

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12 Lead ECG Electrode Placement

November 14th, 2011

Great, so the 12 Lead ECG machines have finally been arrived to pre-hospital care (ambulance practice). Is the 12 lead ECG like the 3 lead ECG? No, other than the fact that it basically shows a rough outline of the electrical pathway of heart the similarities basically end there. Where the 3 lead ECG primarily looks at finding basic arrythmias, such as VT, VF and Assystole for the purpose of immediate treatment, and other more minor dysrhythmias, such as AF, SVT, 1,2, and 3rd degree heart blocks, the 12 lead ECG looks at an overall picture of the electrical pathway of the heart, for the purpose of find conduction pathway disturbances that indicate myocardial ischaemia and/or infarction. In particular, In Ambulance Practice, we are looking for acute changes in the ST segment of the ECG (being ST depression or ST elevation in 2 or more contiguous leads of more than 1 mm in the limb leads or 2 mm in the augmented leads.

12 Lead ECG Placement

Okay, so we’re looking for a STEMI (ST elevation myocardial infarction). Where do we place the 12 lead ECG leads? The regular limb leads should be placed on each wrist and each lower limb, while the precordial leads (augmented leads) should be placed as follows:

1. V1 – at the fourth intercostal space to the right of the sternal notch.

2. V2 – at the fourth intercostal space to the left of the sternal notch.

3. V3. Midway between V2 and V4 (this will make sense when you see this later).

4. V4. Fifth intercostal space, mid clavicular line (this roughly corresponds with the left nipple).

5. V5. Left anterior auxillary line at the same horizontal level as V4.

6. V6. Left mid auxillary line at the same horizontal level as V4 and V5.

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TRACEM HAZMAT

November 13th, 2011

TRACEM is an mneumonic used by HAZMAT and Paramedics in order to determine the type of damage possible from a hazardous material. This becomes particularly important when responding to incidents which include unknown materials, liquids or gasses. In some cases, paramedics have recognised the danager of a hazardous material, taken precautions to protect themselves, only to die from an un-recognised hazardous threat.

What Does TRACEM Mean?

TRACEM stands for:

Thermal: heat sources, radiant heat, burning, sun.

Radiological: nuclear reactions (fuels) by-products, and nuclear bombs (dirty bombs).

Asphixation: oxygen theft, heavy gases, carbon monoxide.

Chemical: toxic or corrosive chemicals.

Etiological: biological hazards and accidental or designed virus strains and bacteria.

Mechanical: such as trauma from mechanical sources, such as bullets, shrapnel, vehicles, and building collapse.

HAZMAT Identification Chart

HAZMAT Identifcation Chart

As a paramedic, you are likely to be the first persons on the scene of an accident involving hazardous material. For your own safety and that of others it is important to recognise the signs of a hazardous incident and take early actions to mitigate the risks. If you suspects something, evacuate the area upwind (the opposite direction to the one that the wind is flowing) and contact HAZMAT.

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Gastric Sleeve Surgery

November 13th, 2011

The gastric sleeve is safe, effective bariatric surgical solution for obesity that is becoming increasingly popular today. People who suffer with obesity and morbid obesity often have a much larger stomach than people of average size and weight. Because of this, people with obesity often need to eat more to feel full and consequently overeat and gain further excess body weight. Obesity is often seen as disease of a progressively worsening cycle, until something is either done to break the cycle or the person becomes bed bound due to their morbid obesity. This is because, the more you eat, the larger your stomach gets and the more that you will feel like you need to eat. The gastric sleeve is a specific surgical solution that combats this problem.

How Does the Gastric Sleeve Help?

The gastric sleeve helps by surgically removing a section of the stomach pouch, which therefore reduces the size of the stomach and provides the realistic sensation of feeling comfortably full after eating a smaller amount of food, and also making you feel fuller for longer periods of time. The procedure generally results in no pain or discomfort whatsoever.

 

Surgical Gastric Sleeve

Gastric Sleeve Surgery Cost

Gastric sleeve surgery costs somewhere between $5000 and $15000 for the surgery alone, depending on the coutry that you intend to have the procedure done in. On top of the cost of the surgery, there may be additional out of pocken expenses for the aneasthetist and a range of health care professionals who would assist you both before and after the gastric sleeve surgery.

Gastric Sleeve Pros and Cons

Although gastric sleeve surgery is considered relatively safe surgery and is performed regularly these days without any complications, it is still surgery and not without some risk. Gastric sleeve surgery should only be considered after all other avenues of non-surgical solutions to obesity have been exhausted. These solutions for obesity should include: changing diet, to include a low GI diet, lifestyle changes, including increased cardiovascular exercise (such as daily walking), and medical review to rule out medical causes of increase weight gain (such as diabetes and hypothyroidism).

The benefits of having a gastric sleeve include:

1. Research has shown that the Gastric Sleeve consistently achieves greater weight loss than the Gastric Band.

2. The gastric sleeve surgical procedure removes approximately 60% of the stomach, this greatly reduces the size of the stomach and the consequent amount of food you can physically put in it. Not only does this stop overeating, it also greatly reduces the sensation of hunger.

3. The grastric sleeve most consistently reduces the most significant amount of weight in the shortest amount of time. Some research has suggested a gastric sleeve can reduce up to 20-30% more excess body fat than gastric banding alone!

4. Gastric sleeve surgery is considered opperate once and leave alone type of surgery, meaning that there are no “adjustments” or reviews required after surgery.

5. There are follow on benefits for your health because of the gastric sleeve surgery and resultant weight loss, including: better controlled diabetes, lower cholesterol, lower blood pressure, and improved cardiovascular health (with a decreased risk of heart attack).

6. The risks associated with gastric sleeve surgery are similar to any other surgery, but the risk of not managing obesity are greater!

7. Gastric sleeve surgery is considered treatment of a medical condition and not cosmetic surgery, consequently, many health organisations/countries subsidize the cost of the gastric sleeve, having recognised the long term benefits of the procedure.

Gastric Sleeve Weight Loss

The cons of the gastric sleeve include:

1. The most common concern with choosing gastric sleeve surgery is the fact that it is irriversible surgery. This means that if it isn’t right for you, you can re-attached the removed part of the stomach the next week!

2. Because you have surgical removed up to 60% of your stomach, if you eat too quickly or don’t chew your food properly, there is a significant chance that you will feel sick and vomit.

3. Gastric sleeve surgery is just that – it is surgery and although it is commonly performed with a very low mortality rate, there is always the risk of post operative infection, bleeding, and because the surgery includes stappling of the stomach, there is always the risk of leakage.

4. A gastric sleeve will still allow you to drink as many liquids as you like – this means you are still capable of drinking too many soft drinks and thickshakes, which will make you increase body fat!

Here is a video of gastric sleeve surgery being performed:

httpv://www.youtube.com/watch?v=lVNmnpdo7zQ

At the end of the day, how much weight can I expect to lose if I decide to get a gastric sleeve? Gastric sleeve surgery is considered very safe surgery and obviously the risks of not having surgery, and continuing to gain weight are much greater.

Gastric sleeve surgery have been performed for many years and are considered a safe and effective way of permanently reducing weight and improving the health and wellbeing of a person who suffers with obesity and morbid obesity.

As the gastric sleeve surgery is becoming increasingly popular and a necessary bariatric surgical step in the treatment of people with morbid obesity, paramedics are required to know more and more about this procedure, its potential complications, and their treatments so that they are better able to serve patients.

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Gastric Band Surgery

November 13th, 2011

Gastric band surgery, also known as gastric banding, is considered the safest, most cost effective surgical treatment for obesity today. Gastric banding surgery is generally performed laparoscopically (through key hole surgery) and takes less than an hour to perform. This means, only minimal scarring, shorter aneasthetic times (with subsequently shorter hospital stays!) and faster recovery times. Gastric banding surgery is proven to reduce your excess body weight rapidly and keep it off long term!

It is because of these facts that it is important, as paramedics to understand gastric banding so that we are better equipped to treat the potential complications of gastric band surgery.

How does a gastric band work? A gastric band is basically a silicon band filled with saline (salty water) and inserted over the proximal (top) end of the stomach. This forms a band around the top of the stomach making it physically difficult to eat to excess. As your stomach naturally shrinks with less food, you can adjust the tightness of the band by simply adding or subtracting the amount of saline within the band. This process is done in your bariatric surgeon’s office and takes about five minutes.

Here is a video of the gastric banding procedure being performed:

httpv://www.youtube.com/watch?v=KPuThbFMxGg

Benefits of Gastric Banding

The gastric banding procedure is considered one of the most cost effective, safe, bariatric surgery solutions around today. Gastric banding is completely reversible, leaves minimal scarring, and is proven to reduce excess weight rapidly.

Frequently Asked Questions Gastric Banding

1. What happens if the band breaks and leaks? The gastric band is a hollow plastic tube, filled with salty water – salty water is considered isotonic (meaning that it has the same osmolarity as blood), which means that it will not cause any problem whatsoever to your stomach or surrounding tissues.

2. Is it normal to feel as though the gastric band is tighter in the mornings? Yes, this is because of the fluid shift while you lay flat during sleep. This is a common complaint, and if it becomes a concern to you you should talk to your bariatric surgeon, who may decide to loosen the gastric band a little.

3. How much does a gastric band cost? Gastric banding surgery usually cost around $5000 in Australia, but this can be as high as $20,000 in the US. Some cheaper alternatives may include overseas surgery in countries where the overall cost of health care is much cheaper. In many of these oveseas private hospitals, the surgeons are highly qualified, trained, and experienced bariatric surgeons, but the associated cost of surgery (such as hospital stays) are considerably cheaper. In Australia, gastric banding is considered a health requirement, and not cosmetic, which means that the government may subsidize much of the cost. Even so, it is important to remember that often the quoted price of gastric banding surgery is only the surgeon’s fees and does not include the cost of hospital stays, aneasthetists, dietiticians, etc.

4. Is gastric banding considered cosmetic surgery? No, obesity is recognised globally as one of the greatest risk factors for morbidity and mortality, and consequently, gastric banding surgery is recognised as a necessary surgical treatment option for obesity and morbid obesity.

Gastric banding is a relatively new surgical treatment for obesity and weight loss therapy. It is widely used around the world and many of our call outs to patients who suffer with obesity are likely to have had gastric banding surgery or other bariatric surgery. As paramedics, it is important to know the potential risks and surgical complications associated with gastric band surgery so that we are better equiped to advise and treat people who have signicant or minor complications or discomforts. Gastric banding is not considered cosmetic surgery, gastric banding is an important medical and surgical treatment for people who suffer with morbid obesity and have had no other weight loss options available to them.

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Bariatric Wheelchair

November 12th, 2011

One of the greatest downward trends that people who suffer with morbid obesity often face is their inability to leave their own home. As a person’s mobility decreases, they often gain weight and this further promotes a downward trend for people who suffer with morbid obesity, because they further gain weight, increase depression and therefore often eat more and become further immobile.

One of the easiest solutions to increase the mobility of a person with morbid obesity is to utilise a wheelchair and ensure that they get out of their home as often as possible. Studies have shown that for every week that a person with morbid obesity is no longer able to leave their own home, the greater risk that they have towards their health. This includes higher incidences of DVTs (deep vein thrombosis), increased obesity, bed sores, increased depression and a general feeling that they have ‘lost’ their battle with obesity.

bariatric wheelchairs

If a person can leave their house, even just for a short period each day, they are along way towards health improvements.

Bariatric wheelchairs can be expensive, however, the health benefits of improving a person mobility and ability to leave their own home outways all costs associated with purchasing a bariatric wheelchair.

How Much Does a Bariatric Wheelchair Cost?

The Cost of a bariatric wheelchair differs depending on location and general weight requirements. Furthermore, if you would like the wheelchair to be electric or not.

The cost of a bariatric wheelchair can vary between $400 Australian to $8000 Australian depending on the size and weight requirements and if you would like it to be automated (electric).

Bariatric Mobility Scooters can cost between $3000 and $10 000. Depending on the country and the weight requirements.

Where to Buy Bariatric Wheelchairs

Bariatric wheelchairs can be purchased here on-line or through most of your good local Medical Equipment Stores.

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Insulin Pump Cost

November 10th, 2011

How much does an Insulin Pump Cost? An insulin pump generally costs between $5000 and $8000 depending on the type of insulin pump being purchased. It should be noted that most countries offer a subsidy for persons who are medically required to utilise an insulin pump (such as patients with poorly controlled blood glucose levels due to bad management or complicated diabetes).

How much does it cost to maintain an insulin pump?

Once you have bought an insulin pump it usually costs between $200 and $300 per month to maintain, which is considerably higher than using the basic needle and syringe method of administering insulin. However, this offers a much easier quality of life to many persons who have diabetes.

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What is an Insulin Pump?

November 10th, 2011

An insulin pump is a relatively new medical device, built on the latest technologies avaliable to persons who live with insulin dependent diabetes mellitus. The insulin pump is a small computerised device that delivers a slow continuous level of rapid acting insulin throughout the day. It can be programmed to give more or less insulin when and if required based on the persons blood glucose levels. The insulin is delivered through sub-cutaneous cannula and is usually changed at a minimum of once every three days.

An insulin pump requires:

1. The insulin pump itself (this includes all medication adjustment controls, processing unit, and batteries for power),

2. A disposable reservoir for insulin (inside the pump) use to store insulin until it is required, and

3. A disposable infusion set, including a cannula for subcutaneous insertion and a tubing system to interface the insulin reservoir to the cannula.

httpv://www.youtube.com/watch?v=eSJz7vFSZ0Y

How Much Does an Insulin Pump Cost?

An insulin pump can cost between $2000 and $10,200 depending on the type of Insulin Pump and the country of purchase. It should be noted however, that most countries offer a subsidy for persons who medically require the pump due to unstable or difficult to manage insulin dependent diabetes. In Australia, these subsidies may be as much as $6200 if medically required.

Types of Insulin Pumps include: Animas Insulin Pump,  Medtronic Veo Insulin Pump, Accu-Chek Spirit Insulin Pump, and the Dana Insulin Pump.

Pros and Cons of an Insulin Pump

The benefits of an Insulin Pump includes:

1. Better control and management of blood glucose levels, which in turn, reduces the likelihood of secondary diseases associated with diabetes, such as cardiovascular disease, peripheral vascular disease, and blindness.

2. Improved sexual health and lebido.

The weaknesses of an Insulin Pump includes:

1. The fact that you have to continuously wear a heavy and sometimes cumbersome Insulin Pump wherever you go and during whatever activity you choose to participate in, such as swimming or sport.

2. Insulin pump malfunctions are still possible.

Overall this new technology has been accepted well in the community of people who live with diabetes. As a paramedic, it is important to understand what an insulin pump is and how it works so that you are better able to treat diabetic patients who have an insulin pump insitu or regularly use an insulin pump.

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Baxter Infusion Pumps

November 10th, 2011

Baxter is a well known brand in medical technologies and medical equipment and have been developing volumetric infusion pumps for many years. Infusion pumps are used to deliver intravenous fluids and medications to patients in controlled amounts over time through intravenous giving sets. Infusion pumps are generally utilised when the medication being administered has a very narrow therapeutic index (meaning that the difference between adequate dose, drug overdose and inadequate response is very small).

By using a mechanic infusion pump, such as a baxter infusion pump, the risks associated with administering medications such as potassium is greatly reduced.

Few ambulance services utilise Baxter Infusion Pumps in their ambulance due to the difficulty managing any infusion pump in a moving vehicle. In general, Ambulance only use Baxter Infusion Pumps for low speed, routine transfers of patients, who require ongoing IV medication administration. One common example of this is a heparin infusion for patients who are at a high risk of vascular clots.

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Weight Loss Tips

November 3rd, 2011

Health care workers are renowned for gaining weight, whether you work in nursing or paramedics the long hours, lack of sleep, poor diet, all lead to weight gain and poorer health outcomes. If you search the internet you will find about a million weight loss solutions, some work, some don’t, many include weight loss tips that just don’t work for health care workers, such as eat regularl small meals at the same time every day.

I’m not a dietician or a weight loss expert, I’m a paramedic, and I found when I was working in a remote town, was on call every night, and was almost unable to do any form of exercise, that I gained a lot of weight. These were the tips that I found helped me lose weight:

Tips to Lose Weight

1. Drink plenty of water (but don’t go overboard). Water is good for your system, and most people live in a perpetual state of dehydration. Water also helps to alliviate some of the in built desire to eat again. Don’t go crazy on the concept. People who drink in excess of 5L of water per day regularly end up with hyponatremia (low sodium levels), which leads to seizures and other bad things.

2. Eat a low GI diet (this sounds obvious, but helps in many respects). A low GI (glycemic index) diet will make you feel fuller, and stop you comming back for more food immediately after you’re finished eating. Diets with a high GI lead to glucose intolerance syndrome, which leads to diabetes and weight gain. Some of the bennefits of a low GI diet include:

– increasing the body’s natural sensitivity to insulin,

– weight loss,

– reduction in heart disease occurence,

– better diabetes management,

– improve blood cholesterol levels,

– feel fuller longer!

More information on lowering your consumption of high GI foods.

3. Perform some form of cardiovascular exercise, such as walking for at least half an hour every single day. This can be very difficult for shiftworkers, but it makes a massive difference in the long run.

4. Plan your bad food – instead of getting to that point in the shift where you “need” chocolate to get you through the last of the night, plan your bad food, and buy it before hand, so that you know exactly what you’re going to have and how much. This avoids the splurge traps.

5. When your uniform’s officer or clerk comes around and suggests ordering your new uniform one size larger so that you have room to grow… politely reply that you will make sure to stay in your current size…

Paramedic Weight Loss Benefits

The following are benefits of maintaining your health as a paramedic and losing weight if you are overweight:

1. Improved general wellbeing.

2. Reduced risk of back injury or work related injury during your normal activities related to working as a paramedic, such as performing CPR, Lifting, Dragging, and assisting patients to stand.

3. Reduced risk of cardiovascular disease.

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Cheap Health Insurance

November 3rd, 2011

Paramedics attend people who are in need of medical help every day, but what happens when a paramedic needs help? Paramedics are generally the last people on earth to ask for help, especially when they are sick or injured. Unfortunately, due to the lifestyle that often goes with the job, paramedics often have poor health and are more likely to have a traumatic injury than those who work regular office jobs. It is for this reason, that paramedics should have health insurance, and preferably, this health insurance should be provided cheap through a ambulance service subsidised fund, or in full through the paramedic’s ambulance service’s employment conditions.

Many Ambulance Services in Australia have recognised this fact, and have elected to provide group discounts to paramedics wishing to gain access to cheap health insurance.

In the US, most Private Ambulance Services offer private health insurance as part of their employment package.

Why get health insurance?

If you are young and fit and healthy, you may be asking why you should get health insurance. The reality is, you don’t know when something will happen and you need good health insurance. I broke my ankle when I was 21 and, although a public hospital could repair it, the damage was severe, and the rehabilitation phase took many months, and involved many hours with physiotherapists, and hydrotherapy. As a result, the cost of the entire process was about $4,000. In Australia, if you earn more than $80,000 and don’t have private health insurance, you have to pay a 1% excess on your medicare, which basically means, it costs the same to pay for private health insurance.

Some of the benefits of private health insurance, include being able to actually pick your doctors, as opposed to being handed the intern of the day to perform your operation, better hospital services, more comfortable hospital conditions, subsidised life-style choices, such as covered dental, physiotherapy, chiropractic, remedial massage, etc.

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The Healthy Paramedic

November 3rd, 2011

Paramedics work long hours, night shift, often eat takeaway, have high levels of stress and many, unfortunately still smoke… all of this leads to poorer health outcomes, early deaths, and poor qualities of life for those who have helped so many, when it is their time to grow old.

The following are some basic recommendations to ensure that you are one of the few “Healthy Paramedics” out there:

1. Keep the job while you still love the job and get rid of it once it starts to get to you and you find yourself hating the job. I’ve watched some people work as a paramedic for forty plus years, and loved every day of it, and then I’ve watched other paramedics who hate it after the first few years. At the end of the day, your not doing yourself any favours by staying in a job you don’t like, nor are you helping your patients who you are shot with, or your partners who find it ever harder to work with you.

2. Get some sleep – chronic sleep deprivation is the number one causes of many cancers, diseases, and immune system disorders. This means, sleep before your nights shift/ after your night shift. Sleep is like a piggy bank, you need a certain amount, and a gradual loss of an hour or two each night will result in an empty sleep piggybank.

3. Pack your own lunch/dinners – a wise person once said that the difference between failure and success is a few simple mistakes, repeated every day over many years. If you eat take away every day as a paramedic (which is common given that most places give us half price meals with extra fatty toppings) – you will become over weight and this will lead to poor health outcomes.

4. Don’t smoke – if you want to live a little longer and a much healthier life free from regular disease and illness, don’t smoke – its that simple.

5. Drink alcohol in moderation – most paramedics like a good drink with friends – that’s fine, but don’t drink to excess regularly, it takes it out of your body systems. Remember, one glass of red wine is good for the heart, a couple bottles doesn’t make it any better…

6. Drink plenty of water!

7. Eat low GI foods, fresh fruits and vegitables, and a variety of nutrient rich meals. Nutritionalists recommend high consumption of fibre, which litterally flushes out most of the toxins that we regularly put into our poor bowels.

8. Be active every day. Even just half an hour of walking every day goes a long way to staying healthy. Most paramedics think that because they’re lifting patients they have a physical job, in reality, we spend most of our time, waiting in hospitals, waiting on the couch for the “big job” and sitting in traffic – this all results in a lot of sitting and very little health benefits.

Enjoy the job and stay healthy!

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What is Calcinosis?

November 2nd, 2011

Calcinosis is the formation of calcium deposits in any soft tissue within the body, associated with a vareity of conditions and often benign.

Clacinosis are generally associated with excess calcium within the blood stream, renal problems (especially in the glomerelus) and milk/alkaline syndrome.

As a paramedic, it is not uncommon to notice calcinosis in your patient, however, on its own there is little clinical significance. Calcinosis are commonly seen in patients who have scleroderma disease, post medical equipment implantation, and a multitude of other aetiologies.

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What is Esophageal Dysfunction?

November 2nd, 2011

Esophageal or (in Australia Oesophageal Dysfunction) is a medical disorder causing a decrease in a person’s ability to swallow or regurgitate food often associated with painful spasm like symptoms of the oesophagus.

Esophageal Dysfunction is commonly associated with Scleroderma Disease, in which the smooth muscles atrophy and fibrosis occurs. This leads to a weakening of the oesophagus and decreased ability to produce oesophageal paristalsis. The motility of the oeophagus is generally only preserved by the proximal end of the oesophagus, which is primarily made up of striated muscles (left unaffected by the Scleroderma Disease).

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What is Raynaud’s Phenomenon?

November 2nd, 2011

Raynaud’s phenomenon is primarily a vasospastic syndrome, meaning that the vascularature is prone to spasm, causing vasoconstriction with increased blood pressure to a small region and potential ischaemia distally if the area that vasospasms consists only of small blood vessels.

The most common area of vasospasm seen in Raynaud’s phenomenon are the persons fingers and toes, although other areas have been reported, these are much rarer cases.

What Causes Raynaud’s Phenomenon?

Raynaud’s Phenomenon is caused by a vasospastic response, often to a persons peripheries. What triggers this response? Raynaud’s Phenomenon is usually triggered by cold temperatures, and emotional stress.

Raynauds Phenomenon is broken down into two types of disease:

Primary Raynaud’s Phenomenon, which is idiopathic (meaning that there are no known causes) and usually occurs suddenly, and

Secondary Raynaud’s Phenomenon,, which is a chronic disorder, triggered by emotional responses or cold extremities.

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Anatomy and Physiology

November 2nd, 2011

Anatomy and physiology is the study of the specific building blocks that make up the structure of the human body and the physical processes that these building blocks undergo in order to make the structures function to move and to exist.If you are venturing into the professions of health science, including medicine, nursing, paramedicine, physiotherapy and any number of other health science professions, or you have a keen interest in how your own body works, then a thorough understanding of anatomy and physiology is paramount.

Human Anatomy and Physiology

When studying anatomy and physiology it is necessary to break down the relative systems of the human body. These include:

– The skeletal System, which provides a structural framework for the human body, as well as protection from injury.

– The nervous system, which includes the central nervous system (brain and spinal cord) and the peripheral nervous system. The Nervous system is responsible for the control centre (brain) which directs all vital processes in the body, and the communication system that identifies  problems, such as pain, and sends messages to the brain to do something about it.

– The cardiovascular system, which includes the heart, lungs, and blood vessels and is responsible for the exchange of gas (co2 for oxygen) within the cells and removal of metabolic gas waste (co2) from cells.

– The lymphatic system, which is responsible for collecting excess fluid throughout the interstitial spaces and extracellular spaces, as well as performing many tasks required in the immune response to infections.

– The renal system, which is responsible for excreting metabolites and by-products in the blood through the kidneys as urine.

– The integumentary system, often recognised as the largest organ in the body, providing warmth, protection, sensation, regulation of body temperature, and many other vital processes.

– The endocrine system, which uses hormones to regulate certain physiological conditions within the body.

– The reproductive system, which is vital to ensuring the procreation of the human species.

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What is Diascopy?

November 2nd, 2011

Diascopy is the medical diagnostic test for blanchability within the skin in order to determine if a rash or lession is vascular in nature (meaning that it inflammatory) or non-vascular (nevus) in nature or haemorrhagic (such as the petechial or purpura rash assocaited with meningococcal disease).

In order to perform diascopy, the paramedic or medical clinician should apply pressure to the skin with a finger or glass. If the rash/lession blanches it is determined to be vascular. If it does not blanch, then it is most likely to be non-vascular or haemorrhagic.

As a paramedic, we regularly perform diascopy when we check a rash for blanchability as part of our clinical assessment of a person with sepsis like symptoms in order to rule out meningococcal disease.

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What is Sclerodactyly?

November 2nd, 2011

Sclerodactyly is a thickening and tightening of the localized areas of the toes and fingers. Sclerodactyly literally means hardening of the fingers and toes in Greek.

What is the significance of Sclerodactyly in medicine?

Sclerodactyly is commonly seen in patients who have the following medical disorders:

– Scleroderma Disease

– Mixed Connective Tissue Disease, and

– Multiple Autoimune Disorders

As paramedics, the most common reason for us to identify sclerodactyly is in patients who have scleroderma disease.

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What is Telangiectasia?

November 2nd, 2011

Telangeactasia is a rare disorder that affects the micro vasculature (small blood vessels) within the cutaneous and mucos surfaces of the human body. Telangiactasias are found as little white marks often seen most commonly on the face, but can be found anywhere on the body.

What is the significance of a telangiectasia on a patient? As a paramedic, there is little diagnostic benefits to searching for and assessing for a telangiectasia. As a Medical Practictioner, it may be one of the multiple signs that will used to diagnose Scleroderma Disease.

Facts about Telangiectasia:

1. It is commonly asssociated with Scleroderma Disease.

2. Telangiectasias may also be indicative of high blood pressure.

3. Because Telangiectasias are vascular, they will blanch when tested through diascopy.

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What is CREST Syndrome?

November 2nd, 2011

CREST Syndrome is an older name for what is currently known as Scleroderma Disease. The pneumonic CREST referred to the symptoms and complications most commonly associated with the disease. These are: Calcinosis, Raynaud’s Phenomenon, Esophageal Dysfunction, Sclerodactility, and Telangiectasias.

The following identify the main features of teh CREST pneumonic identifying the most common signs and symptoms of Scleroderma Disease:

Calcinosis, refers to excessive calcium deposits under the skin.

Raynaud’s Phenomenon, which causes spasms in the blood vessels, often in the hands and sometimes in the feet.

Esophageal Dysfunction, poor swollowing abilities and regurgitation (based on the US spelling of esophagus).

Sclerodactyly, which is a localized thickening and tightening of the cutaneous (skin) layers of the fingers and toes.

Telangiectasias, which are small ruptured blood vessels on the cutaneous surface.

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What is Scleroderma Disease?

November 2nd, 2011

Scleroderma Disease is a chronic systemic autoimmune disorder that primarily affects the connective tissues, causing fibrosis, vascular changes and excessive antibody production. Sleroderma Disease has been previously identified as CREST Syndrome due to the pneumonic based on its common symptoms. These are: Calcinosis, Raynaud’s Phenomenon, Esophageal Dysfunction, Sclerodactility, and Telangiectasias.

There are two main forms of Scleroderma Disease. These are: Limited Systemic Scleroderma and Diffuse Systemic Scleroderma.

Limited Systemic Scleroderma

Limited Systemic Scleroderma generally affects the cutaneous layers and clinically manifests in the limbs, back and face.
Pulmonary Artery Hypertension is a common side affect of CREST Syndrome

Diffuse Systemic Scleroderma

Diffuse Systemic Scleroderma is a much less likely type of scleroderma and also a more rapidly progressive disease process, affecting vital organs, such as the heart, lung, and kidneys.

What is the treatment for Scleroderma Disease? There is no clear medical treatment for scleroderma disease, however medical treatment options often look at treating the symptoms which manifest.

What is the life expectancy of persons who have Scleroderma Disease? The life expectancy of persons who have Scleroderma Disease are actually quite high. People who have limited systemic scleroderma usually have a normal life expectancy.

I treated a 94 year old last week who had a cough that she couldn’t get rid of – this was related to the pulmonary artery hypertesion (commonly associated with Scleroderma Disease), but lived at home, and was otherwise well. She had been diagnosed with Scleroderam Disease in early life and had 3 children and was still able to walk to the local shops!

 

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Patient Lifting Devices

October 30th, 2011

In paramedics patient lifting devices are paramount to safe ambulance practice and good risk management. Our job is and always will include some level of lifting patients, and therefore patient lifting devices must always be considered. This is irrespective of the severity of the emergency, if paramedics are going to be able to continue to perform their duties they will need to be able to use their back in the future! So, what are some good lifting devices?

Lifting devices come in two main forms: physical patient lifting devices, and mechanical patient lifting devices. Unfortunately, ambulances are still full of the physical lifting devices (in which the paramedics must still actually  life the patient themselves, but the lifting equipment makes it easier to do so).

Physical Patient Lifting Devices include:

1. Patient carry sheet – which can be rolled under a patient and then used by 4 or more paramedics to carry the patient out of a house or lift him or her onto an ambulance stretcher. The benefits of a patient carry sheet is that it allows you to twist the shape of the patient in order to mobilise the patient around a doorway. The obvious negative aspect of the patient carry sheet is the fact that you still have to physically lift the patient, and it may not be easy to get 4 or more paramedics through small coridoors or staircases.

2. Pat Slide (or patient slide) – which is basically a firm board used by paramedics and nurses to slide a patient from one bed to another (instead of lifting the patient from one bed to the other, the energy is used to physically slide the patient which is easier).

3. Patient Carry Chair – which is a small wheel chair that can be used to wheel a patient and lift a patient down stairs.

4. Scoop Stretcher – a scoop stretcher is a small scoop like board that comes apart in the middle (feathers in the middle) to allow you to place the scoop around a patient. This avoids having to roll a patient to get it underneath them, or when you have to remove it. This is particularly useful if you are treating a patient with a fractured pelvis.

5. Spine board – a spine board is basically a tough peice of plastic which can be used to slide a patient out of an motor vehicle. This helps to avoid physically lifting a patient out and instead changes the physics of the lifting to a sliding motion. It also helps maintain spinal allignment during the process.

6. Kendrick Extrication Device – the kendrick Extrication Device is a paramedical lifting device, originally designed for the military, and is utilised to imobilise a patient’s spine while in a vehicle and then allows a rescuers to lift the patient out of the vehicle, without causing further damage to the spine.

Mechanical Lifting Devices

The HoverJack is a natural extension of the hovermatt concept and basically is a set of 4 hovermattresses attached to eachother. The hoverjack can be placed underneath the patient who has a BMI of 25, 35, 45 and higher! Then, as the hoverjack is inflated using a reverse vacume device, the hoverjack raises up to the height of stretcher, bed or other specified device. This makes it so that you avoid lifting the patient from ground height. The hoverjack may be used in situations where the patient is unable to get down stairs or his or her bedroom and in an emergency, may be used to literally drag the patient down using its hover-craft properties (each country has different laws regarding the safe working limits and risk management strategies for this). A HoverJack can be purchased for around $6-8,000.

Here is a video link of a HoverJack demonstration:

httpv://www.youtube.com/watch?v=l4F0hbr99cs

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New Housos Show

October 26th, 2011

SBS has recently aired a new TV show called “Housos” on Monday evenings. The show was develloped by Paul Fenech who also created TV Parodies such as Pizza, and Swift & Shift Couriers, and is an overly exaggerated, mock, reality tv show that portrays the lives of the dumbest, lowest denominators of society, who live in housing commission houses and consider their greatest achievements to include scamming the government. The developer, managed to do so, without the aid of any political correctness.

So, as a paramedic, we attend housing commissions every day. So, is this new mock show about housing commissions similar to what we see on road?

httpv://www.youtube.com/watch?v=-ygygES6GWE

If you want to know more about the TV show please visit the SBS website at http://www.sbs.com.au/shows/housos. The new Housos show has been critisized by certain News productions for being harsh or incorrectly portraying the lives of those must stricken by poverty. Some people have even inadvertently accepted it as a real documentary, funded by the Australian government (obviously incorrect).

Housos is a politically incorrect, unabrideged, view of some of the “stereotypes” associated with people who live in Australia’s housing comission estates…

It just so happens… that are correct!

So, what are real paramedics, who consider housing commissions  as one of their most common places to attend their clientele, saying about the new Housos show?

We like it…

“I’ve attended patients who resemble almost every one of these characters over the years…”

“A Houso’s place is the only house where you can find people who haven’t eaten for a week because they are poverty stricken… but a 72 inch flat screen TV on the wall!”

Disclaimer – we do also realise that some people living in Housing Commission houses are nothing like the people from this Housos show, and are only living in Housing Commission due to unfortunate circumstances beyond their control….

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Cheap Stethoscopes

October 25th, 2011

If you are new to medicine a good stethoscope is a necessity to perfrom your professional skills. A cheap stethoscope often found for less than $15 may get you into more trouble than the dollars that it saves you.

I still remember my first day as a Student Ambulance Paramedic, when the Ambulance Service I worked for at the time provided me with a cheap, $15 Stethoscope. I took the stethoscope and tried to listen to a healthy persons’s chest and then to a brick wall – they both sounded identical. I then listened to a simmulator’s lung sounds that were supposed to describe a patient in acute pulmonary oedema and then back to the brick wall – again, they both sounded identical. I realised then and there, that cheap stethoscopes aren’t worth the few measley dollars we spend on them.

Personally, I believe that, of all the medical equipment that we eventually buy and utilise in Medicine, as Paramedics, Nurses or Physiotherapists, the Stethoscope must be of the highest quality and is the most useful to our ability to perform our day to day jobs. Consequently, I recommend spending that extra bit of money on a good quality Stethoscope such as a: Littmann’s Stethoscope, Littmann’s Cardiology Stethoscope, or Littmann’s Cardiology III.

Where to Buy Cheap Stethoscopes

Okay, so you’re still keen to buy cheap stethoscopes. Where should you go to buy cheap stethoscopes? The following are good starting points to find a good cheap stethoscope:

1. At a hospital look for medical notice boards that often advertise Medical Student’s previously loved cheap stethoscopes (which they are discarding now that they are practicing medicine),

2. Check on line at places like E-bay, Facebook, and swap sites for second hand pre-loved cheap stethoscopes.

3. You can buy cheap stethoscopes at most on-line medical supply stores from about $15, which probably wont help much if you are practicing cardiology, but should be fine for taking blood pressures and listening to basic lung sounds.

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Australian Paramedic Salaries

October 23rd, 2011

The following is a current guide for Paramedic Salaries within Australia as of October 2011. It should be noted that these are the base wages for most paramedics, and that paramedics are often on a much higher annual income due to shift penalties, specialty skills allowances, missed meals, overtime, on call allowances, call outs, and living away from home allowance for some country stations. In general, paramedics within Australia can be on salaries ranging from unpaid voluntary service through to positions exceeding $100,000 per year.

 

Paramedic Salary QLD Australia

Paramedics in QLD Australia usually earn a Salary of $45,000 -$55,000. However, penalties, often increase a paramedics overall package up to around $70,000 per year, depending on location, qualifications, and experience.

Paramedic Salary NSW Australia

If you work as a paramedic in NSW the average salary is approximately $56,000 per year, depending on experience (time in the jobs), qualifications, and any specialist qualifications, such as Intensive Care Paramedic/Extended Care Paramedic, or Ambulance Management Roles. However, once shift penalities, shifte overtime (when you get a job just before the end of your shift and have to attend), most paramedics earn an annual income of between $80,000 -$90,000. If you push for overtime shifts it is reasonable to earn an annual income of greater than $110,0o0 per year, however managing your own fatigue if you are working that much overtime may become a problem. Also, if you are willing to work in remote locations, and rural settings, which include ‘on call’ – you will be paid an on-call allowance and a ‘call out’ fee every time you are called out as a paramedic whilst not on shift (generally the night hours).  Depending on how busy the area is that you are working, you may end up making an annual income of greater than $140,000, but you will have to be available for a lot of ‘on call’ time and may not necessarily be called out.

Paramedic Salary Victoria – Australia

Paramedics in Victoria are usually on a salary of approximately $60,000-$75,000 per annum, however this is considered a composite wage, which means that it includes the rolled in average cost of penalties, and overtime. Paramedic in Victoria do not receive shift penalties, unlike many other Ambulance Services, while they do have the highest paramedic salary in Australia.

Paramedic Salary ACT – Australia

Paramedics in the ACT can expect to earn a salary between $65,000 and $74,000 per annum, plus shift penalties.

Paramedic Salary – South Australian Paramedics in South Australia can expect to earn a salary between $45,000 and $60,000 per annum, plus shift penalties and education benefits.

Paramedic Salary – Tasmania – Australia Paramedics in Tasmania can expect to earn a salary of between $65,000 and $70,000 per annum. 

Paramedic Salary Western Australia Paramedics in Western Australia are often employed on a volunteer basis, with the exception of qualified intensive care paramedics in Perth and regional areas. Qualified Paramedics employed full time in St John’s Ambulance Service of Western Australia, can expect to earn between $45000-55,000 per annum, with some penalty benefits.

Please review our Paramedic Salary page for paramedic salaries globally.

These paramedic salaries have been identified by paramedics who have worked for each of these Ambulance Services and have offered their oppinions of their salaries and actual earnings per annum, for the bennefits of paramedics interested in working in other areas. This website acknowledges no affilation with any of these Ambulance Services. If you know, or believe that any of these paramedic salaries are incorrect, please contact us via the contact us page with references to support your view. This has been compiled for the benefits of paramedics around Australia, and it is our intention to ensure that it is maintained with accurate information.

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Paramedic Salary

October 23rd, 2011

A Paramedic’s salary is dependant on a variety of factors, such as the country and even the state that the paramedic is employed, whether or not they work for a government Ambulance Service or in the Private Sector. Depending on experience and formal qualifications a paramedic’s salary will range between $72,000 through to high salaries in excess of $120,ooo per year for country paramedics.

In general, paramedics have a salary that is comparable to other medium range salaries in health, such as nursing salaries. However, it should be noted that due to the nature of paramedicine paramedics often earn large amounts of their annual salary as a direct result of overtime, missed meals, and shift penalties.  A paramedic’s salary is only a portion of their overall income.

What is a Paramedic’s Salary?

A paramedic’s salary is usually considered below average for a health professional’s job, however, once actual penalties, such as overtime, missed meals allowances, uniform allowances, and shift penalties, such as night shift and afternoon shift come into effect, a paramedic’s overall wage is quite good.

Australian Paramedic Salaries

The average paramedic salary within Australia is about $65,000. However, is should be noted that most paramedics earn a much higher annual income due to shift penalties, missed meals, location penalties, on call allowance and continuing education allowances.

Overseas Paramedic Salaries

Paramedic Salary UK  – Registered Paramedics in the UK can expect to earn a salary of 21,000 and 28,000 pounds per annum, plus shift penalties.

Paramedic Salary USA – Qualified Paramedics under the NREMT in the USA can expect a salary between $34,000 and $47,000 per year.

Paramedic Salary New Zealand – Qualified Paramedics working in New Zealand can expect a salary between $55,000 and $62,000 per year based on experience, qualifications and location of position.

Paramedic Salary Dubai –Dubai often recruits overseas trained paramedics who often have specialist qualifications in Intensive Care Paramedicine or Advance Life Support. These paramedics can expect to earn a salary of greater than $90,000 US per year (often tax free) and with numerous job benefits, such as once a year travel allowance, accomodation and health insurance.

Paramedic Salary South Africa – Paramedics working in South Africa can expect to earn about 180,000 to 220,000 Rand per annum.

Paramedic Pay

Paramedics are paid quite well in general considering the training required and the high level of stress that the job often entails. On top of the reasonable salaries associated with paramedicine, paramedics often have the ability to earn much higher amounts of money based on their decision to work overtime, which, because of the nature of the job, is regularly available. Paramedics also, work rotating rosters, which means they normally work 4-8 days on and then have 4-8 days off. On top of all this, you get to look at yourself at the end of the day and think that you have done something good and helped someone.

This website acknowledges that it has no affliation with any Ambulance Service in the world and that these average salaries for paramedics around the world is based on website user’s information only, and is liable to change regularly. As this website aims to provide current and correct information for paramedics, if you notice that any of these pay scales are incorrect, please contact me via the contact us page with the correct information and its source.

Thank you, Emergency Medcial Paramedic Team

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What is Necrotizing Faciitis?

October 21st, 2011

Necrotising Fasciitis is a rare disease in which the connective tissue of the fascia between the muscles or around organs becomes inflamed and eventually necrotic due to a sudden, widespread microbial infection.  There are two types of Necrotizing Fasciitis: type I is poly-microbial and type II is mono-microbial. Type I, poly-microbial is the more common cause of Necrotizing Fasciitis.

Why does Necrotizing Fasciitis occur? No one knows the exact causes of Necrotizing Fasciitis, however, it is well known that people who are: immune-compromised, have diabetes, chronic systemic diseases are more predisposed to the condition. Necrotizing Fasciitis has, on even rarer occasions, effected otherwise previously well and healthy persons.

One of the hypothesis about the cause of Necrotizing Fasciitis is that a person who is malnourished, in a weakened state, or immune-compromised, will cause opportunistic bacteria to try to multiple more commonly.

Signs and Symptoms of Necrotizing Fasciitis

Because the infection often occurs deep into the body tissue very limited signs are observed on the skin or surround area of the limb until the disease has thoroughly progressed. Often, by the time Necrotizing Fasciitis is diagnoses, urgent surgery and widespread intravenous antibiotics are the only solutions.

If the infection is superficial (less common presentation), then the localized areas will show signs associated with infection, such as inflammation, swelling, redness, urticaria, itchiness, pyrexia, and pain.

If the infection is deep in the body tissues, then little will be seen or felt, until the infection progresses. Then the following signs may be identified: fevers, nausea, vomiting, diarrhoea, headache, and deep muscular pain that seems excessive given the outward appearance of the limb. 

Pathophysiology of Necrotizing Faciitis

Necrotizing Fasciitis is often referred to as ‘Flesh Eating Virus’ or ‘Flesh Eating Bacteria.’The term ‘Flesh Eating Virus’ and ‘Flesh Eating Bacteria’ is an incorrect view of necrotizing fasciitis. First of all, necrotizing fasciitis refers to a syndrome caused by bacteria, not a virus and in reality, the bacterium does not actually ‘eat’ the cells. Instead, what occurs, is the poly-microbial or mono-microbial infection causes a breakdown of the cell walls within the tissues of the skin, muscles, and fascia which results in the release of streptococcal pyogenic exotoxins – which, in turn, cause the non-discriminatory activation of T-cells and subsequent widespread overproduction of cytokines . Excess cytokines cause a further release of cell mediators, breakdown of the cell structure, and clotting factors, resulting in haemorrhagic shock, such as DIC. 

 

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What is a Rapid Responder Paramedic?

October 14th, 2011

A Rapid Responder Paramedic is genrally a senior paramedic, often trained to Intensive Care Paramedic levels, who works as a single paramedic from a smaller, faster, and more agile vehicle. The purpose of the Rapid Responder Paramedic is to provide urgent advanced medical treatments, while waiting for an Ambulance to arrive and transport certain patients.

As a Rapid Responder Paramedic, you are not capable of transporting patients, but may often assist other crews in stabilising and transporting.

Benefits of Rapid Responders

The benefits of Rapid Responder Paramedics is the fact that they can allow a single intensive care paramedic to reach the critical patients sooner and back up general paramedics, who may lack the experience or the authority to perform advanced medical procedures such as intubation and advanced drug management, such as cardiac drugs.

Most Ambulance Services throughout the world now utilise the aid of Rapid Responder Paramedics.

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What is a SCAT Paramedic?

October 14th, 2011

A SCAT paramedic in NSW stands for Special Casualty Access Team and was first formed in 1986 as a means of providing a high level of medical and paramedical treatment to casualties who were in unusual and difficult to access locations, such as cliffs, remote areas, caves, and through urban search and rescue (building collapses).

SCAT paramedics have the highest level of paramedical training in NSW Ambulance Service and generally work from helicopters, however they often work rosters on road as well.

SCAT paramedics can be called out for duty during disasters or major events for days and weeks and are capable of spending multiple days in the bush, stabilizing and extricating injured patients in remote areas.

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How Long Does it Take To Become a Paramedic?

October 14th, 2011

Every state in Australia and most Ambulance Services around the world have a different training process for trainee paramedics, but generally speaking, it takes 3 years of full time study and on-road practical experience to become a paramedic at the very minimum. In Australia, you can complete a three year bachelor degree and then a twelve month traineeship (making it a total of 4 years to become a paramedic).

How Long Does it Take to Become a Paramedic in NSW?

In NSW it usually takes general entry paramedic students 3 years to complete a probationary period of 10-12 months, followed by a 2 year paramedic internship. After this they become a qualified paramedic, which is the basic level required to work as a paramedic in NSW. From here, you can gain specialty training in areas such as Intensive Care, Special Operations, and Extended Care.

How Long Does it Take to Become an Intensive Care Paramedic

If you studied very well and focussed, theoretically you can become an intensive care paramedic within 4 years of initial training as a paramedic student. However, in reality, people are usually paramedics for about 5 years before they apply for an Intensive Care Paramedic training position. Not everyone who gets accepted on to an ICP course will successfully complete the course.

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Paranoid Schizophrenia Stories

October 13th, 2011

I was called to a patient with chest pain. As I arrive I park up on the patient’s driveway. As I get out of the Ambulance, an elderly lady comes out of the house, walks right by us both, and walks around the Ambulance. I smile and ask if she called an Ambulance… “No… no, I certainly did not…” was all I got in reply. Okay… I continue to walk into the patient’s house… Before I walk through the door, I look back and see the old lady using a pencil and some paper to stencil the number plate off the Ambulance…

That was enough for me… something was wrong about this image for me…

Are you okay, can I help you? I ask her. “No, certainly not…”

You seem concerned I ask… We’ve been called to this address for someone with chest pain… do you have chest pain? She smiles… “No… I don’t”

Hmmm…

I decide the person obviously has some underlying mental illness and that seeing as she does not appear aggressive, maybe I should go inside and see if there is someone who actually has chest pain. I wonder inside and find my patient. My partner starts to treat her, and after a short while I got back out to the Ambulance to organise the stretcher.

As I’m out at the Ambulance, I find the old lady, now with a measuring tape, measuring my Ambulance for size.

What are you checking? I innocently ask.

“Who are you?” She asks.

I’m Michael, a Paramedic…

“A paramedic you say… how do I know you’re a paramedic?”

Well… I say, see this uniform – it says paramedic on it… also, I came here by Ambulance and generally paramedics drive Ambulances so therefore, I must be a paramedic (I thought I was making pretty good sense)…

She ponders all this over… “We had a paramedic here before… he was driving and Ambulance too…” she pauses for effect and the points at me as though she’s found me guilty “Two Ambulances at the same place… only days apart!”

Yes I say… I spoke to your mother inside… she said that she had a fall two days ago…

“Ahah!” She says “Two Ambulances… and they both look the same…”

Yes, they generally do, I say.

“Well… it’s very suspicious… isn’t it?”

Yes… very good… I mutter as I continue to get the stretcher ready for the patient.

By the time I’ve come back with the actual patient – the old lady has contacted the police (who have a station only metres up the road from her) and convinced them that there’s a very suspicious looking person who has entered her mother’s house and is now taking advantage of her.

 

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The ‘Special Kids’ Euphemism

October 13th, 2011

Many words are considered politically incorrect and are usually replaced by a euphemism. But, sometimes the euphemism is more demoralising than the word that accurately describes a disorder, disease, or problem.

 

The Special Needs Euphemism

I was called to a fall of a 16 year old male who had had a fall and now had a bloody nose (epistaxis). When I arrived I found a relatively normal 16 year old boy who no longer had a bleeding nose. The boy’s mother was in attendance and was very upset and concerned about the patient.  After some time spent on the scene it became clear that the mother wanted the patient to go to hospital.

As we were leaving the patient’s teacher pulled me aside and said ‘Just to let you know… he’s a “special” kid.’ Oh, I reply, in what way is he special? I ask. ‘You know… “Special”’ She says and winks a couple times at me. I mean… we’re all special kids aren’t we? I ask the direct question, does he have a medical condition? ‘No, not all… I just mean that he’s a “special” kid…

I start to leave and realise that I’m not going to get any real sense out of this teacher, for her fear of being politically incorrect. As I load the patient into the Ambulance I’m stopped by the school Principle who asks to tell me something in private. Okay, I think… maybe I’m going to get more of an understanding.  The school principle says ‘Just letting you know… he’s one of our “Special” kids. Again, I ask the same set of questions about his medical background… does he have ADHD, does he have some learning disability. The school Principle then denies everything and says ‘No, no… I just want you to know that he’s very “Special.”

I finally get to talk to the patient’s mother who appears very distressed. Does he have any medical problems? I ask. “No… no medically problems…” she says. Okay, so he’s a normal fit and healthy boy? I ask. She pauses… “Yes, he’s very fit and healthy… except…” I wait while she pauses… “except that he’s “Special.”

Okay … in what way is he special? I’m getting mildly frustrated by now…  “You know… he’s a special kid…”

Okay, what do you mean that he is special? Does he have a learning disability? I wanted to just come out with it and say “Does he have Down Syndrome?”

Finally, she pulls me close and whispers… “He has a mild global learning disability…”

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Causes of Chest Pain

October 9th, 2011

There are numerous causes for chest pain and although some of them may relate to the heart, and should be treated as an emergency, may are related to pathologies totally unrelated to the heart. So, how do you differentiate between the many causes of chest pain?

The easiest way to differentiate between types of chest pains is to assess the pain based on OPQRST questioning. The following are a list of common causes of chest pains and how to differentiate between them and cardiac chest pain. If in doubt, always treat chest pain as though it is cardiac in nature.

Chest Pain Causes

Myocardial Infarction – Onset: sudden. Provocation: occurrence at rest, with exertion, physical or emotional stress. Quality and intensity: severe pressure to the chest area ‘tightness,’ ‘crushing,’ ‘vice like,’ ‘heaviness.’ Region: Sub sternal, midline or anterior chest pain, radiating down left arm, jaw, fingers and abdomen. Severity and Signs and symptoms: dyspnoea, apprehension, nausea, diaphoresis, changes to pulse rate, decrease in blood pressure, gallop heart sounds. Often considered severe. Times: usually ½ an hour to 3 hours.

Angina – Onset: gradual or sudden onset. Provocation: Exertion, stress, micturition or defecation, cold or hot weather. Quality: Mild to moderate. ‘Stabbing,’ ‘heaviness,’ ‘tightness’ or ‘discomfort.’ Severity and Sign and Symptoms: dyspnoea, nausea, desire to void, belching, apprehension. Time: should self-resolve after rest within 30 minutes.

Pericarditis – Onset: sudden onset, continuous pain. Provocation: recent myocardial infarction, upper respiratory infection, no correlation to exertion. Quality: Mild ache to severe pain. Often more specific than a myocardial infarction, such as: ‘stabbing pain to specific point in chest’ and ‘knife life pain.’ Region: substernal pain to left or midline some radiating pain to back and sub-clavicular area. Severity and Signs and Symptoms: Precordial friction rub, increased pain with movement, inspiration, laughing, coughing, left sided pain, pain sometimes decreases by sitting or leaning forward.

Gastro-Oesophageal Reflux Disorder (GORD) – Onset: gradual, sudden, intermittent, or continuous pain. Provocation: ingestion of spicy foods, alcohol, soft drink. Quality: Squeezing pain and heartburn sensation. Region: sub sternal, midline or anterior/posterior chest pain. May have radiating pain to upper abdomen, back or shoulder tips. Severity and Signs and Symptoms: Dysphagia, belching, diaphoresis, vomiting, nausea, dysphagia, may decease with sitting or standing. Time: Often after eating.

Pleurisy – Onset: gradual or sudden onset. Provocation: Pneumonia, long term respiratory disorders, such as emphysema, COPD or severe asthma, respiratory infections. Quality: very specific pain, described as ‘knife like’ or ‘pin-point pain.’ Severity and Signs and Symptoms: Pleural friction rub, fever, dyspnoea, cough, pain on inspiration/expiration. Time: continuous.

Musculo-skeletal: Onset: gradual or sudden onset. Provocation: weight lifting and excessive exertion to the pectoral muscles, abdominal muscles, and back muscles. Quality: Soreness and muscular tenderness. This may mimic the heaviness associated with an Acute Coronary Syndrome. Severity and Signs and Symptoms: Severe pain, increased on movement. No changes to perfusion, such as diaphoresis or skin perfusion. Times: intermittent pain for 2-3 days.

Tietze’s Syndrome: Onset: gradual or sudden onset. Provocation: Common after upper respiratory infection and cool weather. Quality: mild to severe tenderness. Region: anterior chest articulations; radiation to either shoulder or arm.

Costochondritis: Onset: gradual or sudden. Provocation: common after a long term chest infection, or strenuous exertion involving the muscles of the chest wall. Quality: ‘Sharp’ or ‘crushing’ in nature. Region: retrosternal, left and right arm, sternal. Severity: 10/10 intense pain. Time: intermittent or acute.

Anxiety: stress can trigger the sympathetic nervous system’s ‘fight or flight’ response and this can mimick many of the signs and symptoms associated with an acute coronary syndrome. The easiest way to differentiate between these two causes of chest pain, is to determine what the stress is and see if the removal of such a stress relieves the chest pain. In many cases, these patient’s will have to be treated as though they are having an acute coronary syndrome first and then later have the stress managed.

Chest pains can indicate a life threatening cardiac condition, such as a ‘heart attack’ and medical assessment and treatment should never be delayed. Until the chest pains are proven to be caused by something other than than the heart, I recommend calling an Ambulance immediately when you get chest pains and go straight to an emergency department. If chest pains are caused by damage to your heart, the earlier you get treatment the better your heart will be.

The problem with waiting when you have chest pains is that if it is caused by damage to the heart, every minute that you don’t receive treatment will cause more myocardial (heart) cells to die. Once enough of your heart cells die, there is nothing you can do to fix your heart. So, with chest pains, act fast and call an Ambulance now!

For information about chest pain and heart attacks please visit the Chest Pain page.

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What is Tietze Syndrome?

October 9th, 2011

Tietze Syndrome is a benign inflammatory disorder effecting the costal cartlidges and often mimicking many of the symptoms associated with cardiac chest pain. Although the pathophysiology of Tietze Syndrome is poorly understood, it was previously thought to be associated with a viral infection aquired during cardio-thoracic surgery. However, recent studies have proven that it is possible to develop Tietze Syndrome in the absense of recent, if any, surgery.

Tietze Syndrome Symptoms

The symptoms commonly associated with Tietze Syndrome are closely related to cardiac chest pain, and therefore acute coronary syndrome treatment should be commenced until further diagnostic tests have been completed and cardiac involvement rulled out. These are the common symptoms associted with Tietze Syndrome: acute, sharp central chest pain, often radiating down one or both arms. Unlike costochondritis, which usually presents with only central chest pain, Tietze Syndrome routinely involves arm pain and discomfort. The patient will often complain about exacerbation of the pain during respiration and with movement. The patient may appear short of breath.

Tietze Syndrome is considered relatively benign in nature and should self resolve within 10-12 weeks, provided that the patient maintains good health otherwise, such as eating right, sleeping well, and maintaining normal deep respirations. One complication with Tietze Syndrome is that people will often take shallow breaths as a means of avoiding the pain associated with deep breathing. This will then lead to further infections, such as pneumonia and should be avoided.

Alexander Tietze, a German Surgeon first decribed the condition in 1921. At that time, it was thought to be associated with the surgery, but this has been disproved through further studies.

Tietze Syndrome Treatment

Tietze Syndrome itself is considered benign and should self resolve. As a paramedic, it is important to be aware of this disorder because it so closely resembles an acute myocardial infarction. In fact, it does this so well, that a paramedic, doctor, nurse and other clinicians should treat for an acute coronary syndrome until Tietze Syndrome has been unequivically diagnosed. Tietze Syndrome is most commonly seen in patients who have had radiotherapy to the chest, chemotherapy in general, previous cardio-thoracic surgery, younger persons under 18 years of age, and persons who have recently undergone serious strenuous exercise involving the muscles of the chest.

If you would like to learn more about how Tietze Syndrome compares to other types of chest pains, please visit my Chest Pain page.

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What is Agenesis Corpus Callosum?

October 9th, 2011

Agenesis Corpus Callosum is a rare congenital abnormality, in which the person has a partial or complete absence of the corpus callosum, which is the area that connects the two hemispheres of the brain. 

In most cases, Agenesis Corpus Callosum is diagnosed during infancy; however, in some circumstances it may be discovered later in life, and have no effect on the person’s health and wellbeing. The most common symptom of Agenesis Corpus Callosum are seizures, neurological problems involving difficulties sitting, walking, and balancing.

As paramedics, this is a rare disorder to see, however, it is important to have an understanding of the disorder, so that you are better equipped to manage the symptoms when you do attend a patient who has Agenesis Corpus Callosum.

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What is Guillain-Barre Syndrome?

October 9th, 2011

Guillain-Barre Syndrome is a rare auto-immune disorder in which the body’s own immune system decides to attack the peripheral nervous system, leading to sudden motor and sensory deficits in varying degrees to aspects of the body. This condition may result in minor motor and sensory deficits through to complete paralysis in severe cases. If the deficits encompass the muscles involved in respiration Guillain-Barre Syndrome may be fatal.

The specific cause of Gullain-Barre Syndrome is unknown, however, it is known that a person who is suffering with Gullain-Barre Syndrome will have both antibodies and lymphocytes attacking the peripheral nerves for no apparent reason. It has been associated with persons who have had a bacterial or viral infection recently.

Gullain-Barre Syndrome was first identified by the French Neurologist Gullain Barre in 1916, when two soldiers were found to have decreased motor and sensory responses, in the absence of spinal damage or significant trauma.

What is the treatment for Guillain-Barre Syndrome?

There is no specific cure for Guillain-Barre Syndrome, however management looks at treating the symptoms of the disorder so that the body has time to repair itself. The majority of patients diagnosed with Guillain-Barre Syndrome will survive and return to some level of normality within 3 months. Management should include: monitoring and managing the basic functions of life, such as: Airway, Breathing, and Circulation. Intubation/Tracheostomy may be required if the disease has affected the muscles of respiration. Plasmapheresis and IV Human Immunoglobin transfusions have been associated with better outcomes.

As a paramedic, you will most likely see patients who have Gullain-Barre Syndrome, but have not yet been diagnosed. The most likely symptoms will include motor and sensory deficit in the absense of spinal trauma. These patients will often appear pedantic  about their positioning and  continuously uncomfortable. This is because Gullain-Barre Syndrome often affects just the motor response and not necessarily the sensory response, so, unlike a patient who has a spinal injury and can’t feel anything below the injury site, Guillain-Barre Syndrome patient’s may not be able to move, but will continue to experience the pain and discomfort of a limb that is not moving.

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What is Essential Tremor?

October 9th, 2011

An essential tremor is the most common cause of hand tremors and idiopathic in nature and has no known treatment options. Treatable organic causes of Essential Tremor should first be investigated and treated where possible, such as: hyper/hypoglycaemia, systemic infections, and thyroid abnormalities.

Essential Tremor is often considered more of an irritating disorder or embarrassing disorder, than overall debilitation. In certain professions requiring high hand acuity may find this disorder more disabling. Personally, I have suffered with Essential Tremor all my life and found that for many years, as a paramedic, people have assumed me to be nervous rather due to the tremor. These days, experience has enabled me to insert cannulas and perform other tasks requiring higher levels of hand dexterity faster than most, but still with the same level of success.

What is the difference between Parkinson’s Disease and Essential Tremor?

Unlike Parkinson’s Disease, in which the hands usually shake most at rest, Essential Tremor causes hands to shake more during movement and use. Stimulants, such as caffeine, some Asthma medications, and increased stress all contribute to the disorder and increase the severity of the hands shaking.

Abstaining from stimulants such as caffeine, high levels of stress, and certain medications, such as Beta Blockers may resolve the symptoms of the disorder.

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What is a MICA Paramedic?

October 6th, 2011

What is a MICA Paramedic? A MICA Paramedic stands for a Mobile Intensive Care Ambulance Paramedic and was first trialled in Melbourne Australia as part of and Emergency Doctor/Emergency Paramedic team initiative in 1971, in which an emergency doctor and senior paramedic attended the most injured patients and the sickest patients. The trial rapidly showed to better health outcomes for those who were being treated by the MICA team, and as a result the introduction of the MICA Paramedic was created.

Now days, many Ambulance Services utilise the MICA Paramedic concept to provide high levels of paramedical and intensive care support on road.

The following are some of the intensive care skills that MICA paramedics posses in addition to normal paramedical skills:

1. Endotracheal Intubation

2. Cricothyrotomy

3. CPAP

4.Capnography

5. Rapid Sequence Intubation

6. Synchronized Cardioversion

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What is an Arteriovenous Malformation?

October 6th, 2011

An arteriovenous malformation is a direct meshing of abnormal blood vessels directly connecting arteries to veins in the brain. It is a hereditary condition and often goes unnoticed until later in life, when it becomes symptomatic.  An Arteriovenous Malformation (AVM) can form almost anywhere in the brain, brainstem, or spinal cord; however, the most likely position for an AVM is the cererbal hemispheres.

Diagnosis of an Arteriovenous Malformation

Unless a person has a familial history of AVM, the most likely diagnosis of an arteriovenous malformation is often after a person with AVM has a haemorrhagic stroke, resulting in further investigations (such as CT and MRI where it is first identified).

Treatment of a AVM includes surgical removal and radiotherapy.

As a paramedic, it is important to understand the pathophysiology of an arteriovenous malformation, because in a certain percentage of the stroke victims you treat, this condition will be present (although it may not have been diagnosed yet). It is also important to understand some of the common treatment strategies for AVM, due to the likelihood that you will be treating and transporting these patients on a regular basis.

 

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What is an Astrocytoma?

October 6th, 2011

An Astrocytoma is a tumour within the brain or surrounding part of the brain. Astrocytomas develop in glial-cells, which are star shaped cells within the brain known as astrocytes.

The World Health Organisation recognises 4 main grades of astrocytomas:

1. Grade I – Astrocytoma slow growing astrocytoma, with good long term survival prognosis;

2. Grade II Astrocytoma – low grade, and relatively benign.

3. Grade III Astrocytoma – anaplastic astrocytoma, which is often related to chronic seizures.

4. Grade IV Astrocytoma – glioblastoma multiform , which is a fast growing, most common malignant astrocytoma.

Unfortunately, the most common astrocytoma to be diagnosed with is a Grade IV malignant astrocytoma, although brain metastesies still have a much higher incidence than astrocytomas.

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What is a Rhabdomyoma?

October 6th, 2011

What is a Rhabdomyoma? A Rhabdomyoma is a benign tumour involving striated muscles. Striated muscles is primarily found the myocardium (heart) and the tongue, but may be found in parts of the genitals. Rhabdomyomas are generally benign, but due to there location in the heart may cause more significant problems and may need to be removed.

Rhabdomyoma versus Rhabdomyosarcoma

Where Rhabdomyomas are generally benign and affect only striated muscles, on rare occasions a Rhabdomyosarcoma may develop, which is a malignant tumour affecting the skeletal muscles.

Rhabdomyoma Treatment

Rhabdomyomas rarely require treatment, being generally benign. In some cases the Rhabdomyomas are surgically removed from the heart in infants, where the position of the tumour causes cardiac function problems.

Paramedic treatment of and experience of rhabdomyomas is unlikely, except for the purpose of transporting these patients. In some cases, oxygen therapy and cardiac management may be necessary as a result of acute function damage to the myocardium. Although, generally, these cases will be identified early in the fetal stages, and then managed prior to the new born going home.

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What is Tuberous Sclerosis?

October 6th, 2011

What is Tuberous Sclerosis? Tuberous Sclerosis is part of a group of disorders identified as Neurocutaneous Syndromes, primarily affecting the central nervous system and the skin. Tuberous Sclerosis is an uncommon genetic disorder relating to mutations in the genes TSC1 and TSC2, which genetically code for the proteins hamartin and tuberin. These proteins act as tumor growth suppressors that regulate cell proliferation and differentiation. As a result of these mutations, multiple micro-tumours within the central nervous system, skin, heart and kidneys occur.  Excess growth of normal cells occurs in many organs throughout the body and these are seen as micro tumours. As a child grows, these tumours will often calcify (leading to the term sclerosis) and as this occurs, many children affected by Tuberous Sclerosis will lead normal lifestyles after the age of 2 and almost all persons diagnosed with Tuberous Sclerosis will have similar life expectancies as people without Tuberous Sclerosis.

It is estimated that approximately fifty percent of the people born with Tuberous Sclerosis will lead normal lives with no apparent intellectual dysfunction or epilepsy.

Signs and Symptoms of Tuberous Sclerosis

The signs and symptoms of Tuberous Sclerosis include:  white patches on certain areas of the skin as a result of decreased pigmentation; red patches on the face containing many blood vessels, known as an adenoma sebaceum; raised orange-peel patches on the skin (most commonly found on a patient’s back); developmental delays, chronic seizures; and rough non-malignant tumours on the tongue.

Treatment of Tuberous Sclerosis

There is no known treatment for the disorder Tuberous Sclerosis; however, treatment options include managing the symptoms of the disorder, such as anti-epilepsy medications to control seizures.

Paramedic treatment of Tuberous Sclerosis often involves treating the acute symptoms of the disorder, including: managing the patient’s airway and seizure control with the use of benzodiazepines (such as midazolam). Often, parents of children with Tuberous Sclerosis may poorly understand the disorder, because their children may have only recently been diagnosed. Alternatively, some parents will know far more about Tuberous Sclerosis than most doctors. It is important to ask the parents about how the child is normally, and how things have changed today. Reasurance for the parents is just as important as clinical treatments for the child in these circumstances.

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Benefits of Being a Paramedic in NSW

September 30th, 2011

The Ambulance Service of NSW is a progressive Ambulance Service with an advanced medical team developing the future protocols and guidelines for paramedics to utilise. The following are some bennefits of being a paramedic in NSW:

Benefits of NSW Ambulance Service

1. Good training – with progressively widening paramedic practices.

2. Large Ambulance Service (one of the largest in the world in both numbers of paramedics and geographical coverage)

3. Good equipment and reseach. The Ambulance Service of NSW has an Ambulance Research Institute which is continuously improving the scope of practice for paramedics and the efficacy of their medical interventions.

4. Good working conditions and financial incentives, including shift penalties.

5. Normal benefits associated with any government job in Australia, such as job reliability, worker’s compensation, OH&S obligations, sick leave, maternity /paternity leave, etc.

Overall – a good Ambulance Service to work for as a paramedic.

 

This website acknoweledges that it does not have any affiliation with the Ambulance Service of NSW, but is representing some of the benefits of becoming a paramedic in NSW for prospective paramedics.

To learn more about how to become a paramedic in NSW, please visit my How to Become a Paramedic in NSW page.

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How to Become a Paramedic in NSW

September 30th, 2011

How to become a paramedic in NSW – NSW Ambulance Service is the largest Ambulance Service in Australia and one of the largest in terms of number of staff and geographical distances in the world. It covers the entire NSW land area and employees over 4000 staff! So, if you want to become a paramedic, NSW Ambulance has a lot to offer in the way of exposure to experiences, training, career paths, and employment conditions.

Become a Paramedic in NSW

So, how do I become a paramedic in NSW?

Based on the current information for Trainee Paramedic Applications in NSW there are three main entry methods for trainee paramedics wishing to gain employment with the Ambualnce Service of NSW.

These include:

One – Train on the job paramedic diploma program. In which student paramedics complete a period of study at the ASNSW Education Centre followed by a 12 month probationary period and a total of 3 year paramedic internship. Don’t worry, you will get paid during the entire process, and at the end of the day will be entitled to a dipoloma in paramedical science. This is a great option for the person who has life experience and has recently decided that they want to change careers, while not be able to or wanting to go back to university full time.

Two – Graduate Paramedic Student Program. In which students have complete a bachelor degree in Paramedical Science or a similar health science degree relating specifically to paramedics. These students then complete an examination/education period before progressing to a 12 month probationary period and qualification of a qualified paramedic. People with non paramedical, but similar health related backgrounds may be able to apply for this recognition of prior learning pathway. People who have backgrounds in nursing, physiotherapy and medicine may wish to apply through this route.

Three – Qualified Paramedic from Interstate. Paramedics who are qualified from an Australian interstate Ambulance Services or Overseas Ambulance Services should apply directly to the Ambulance Service of NSW. As a general rule, Qualified Paramedics with 3 or more years of experience are generally recognised by the Ambulance Service of NSW.

Requirements to Become a Paramedic in NSW

NSW Ambulance Service, like all good health services, seem to change their recruitment requirements regularly. These were the paramedic application requirements as of 2011, but they may change – obviously read the paramedic application package well.

– Over 18 years of age

– Full drivers licence (un-restricted)

– Criminal Record Clearance – Basically, you wont get through if you have conviction against you about child abuse, and any serious criminal offences. If in doubt, give them a call!

– Up to date vacinations based on the health requirements of health care workers – your GP should know what these are (they change quite regularly too).

– Year 12 or above completion.

On top of these, you will have to pass a medical/fitness test (not too hard), an aptitude test, and a basic skills test (maths, reading, writing) and you will probably have to pass a basic driving test.

Good luck on becoming a paramedic in NSW

Remember, they are regularly recruiting, so if you don’t get through the first time, give it another go.

This website acknowledges that it has no affiliation with the Ambulance Service of NSW and that it is only providing information on how to become a paramedic in NSW for prospective trainee paramedics or persons wanting to know how to become a paramedic in NSW.

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Paramedic Degrees

September 28th, 2011

Where can I study a paramedic degree? The concept of paramedic degrees is relatively new to the profession of para-medicine. In Australia the paramedic bachelor degree was only first introduced in 1999 and until then all paramedics were considered tradespersons who had gained their qualifications as paramedics through vocational training and on the job traineeships. In 1999 Charles Sturt University (Bathurst) opened up a bachelor’s degree in paramedic science (clinical practice). At that stage, the paramedic degree was only really reserved for qualified paramedic wishing to go into senior paramedic management positions.

Universities That Teach Paramedics

What universities teach paramedics? The following are some of the current universities that teach paramedics, however they are growing all the time:

1. Charles Sturt University (Bathurst NSW) – 3 year bachelor degree in health science/clinical practice

2. Monash University (Victoria) – 3 year bachelor degree in paramedic science

3. Victoria University (Victoria)- 3 year bachelor degree in paramedics

4. University of the Sunshine Coast (USC) (QLD) has introduced a paramedic degree in 2008

5. University of Tasmania has both an internal paramedic degree program and a distance education paramedic degree program run out of Rozelle in NSW – which fast tracks a 3 year degree into two years.

6. Flinders University (South Australia) -3 year paramedic degree

7. Queensland University of Technology (QLD)

8. Australian Catholic University (Ballarat Victoria) 4 year combined double degree in paramedicine and nursing

9. Latrobe University (Bendigo Victoria) Bachelor of paramedics and Master’s of Paramedic Practice

10. Edith Cowan University (Western Australia) – 3 year bachelor degree in paramedics.

11. Australian Canberra University (ACT) – 3 year bachelor degree in paramedicine.

Paramedic Degree Courses

What is covered in a paramedic degree? Most paramedic degrees cover the following areas in a varaity of depths:

– Anatomy and physiology

– Science/biology, chemistry, and some basic physics (don’t be too concerned here if you haven’t done these sciences at high school – I didn’t and I got to learn them at university easily enough).

– Sociology

– Medical Research

– Indigenous Health

– Clinical Practice (where you learn the trade of being a paramedic)

– Clinical placements – where you will gain hands on experience in being a paramedic. This will be your first exposure to what the job actually entails.

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How to get rid of Hiccups

September 28th, 2011

Hiccups are fundamentally caused by an irration to the diaphragm resulting in sudden spasms which cause air to be suddenly inspired into the lungs and cause a closing of the glotis (which makes the sound known as a hiccup). This page identifies multiple methodologies for getting rid of hiccups. Everyone’s body works differently, and there is no one ‘fix it all’ solution for hiccups. However, if you follow these tips there is a good chance that you will get rid of your hiccups. If you try these and hiccups continue for hours or days, please see your doctor, because you have what is known as a pathological hiccup disorder.

If you want to know more about what causes hiccups, please visit my what causes hiccups page.

Tips To Get Rid Of Hiccups

The main principles of how to get rid of hiccups is to try to allow your diaphragm to relax. This may be easier said than done. The second main principle of getting rid of hiccups includes distraction. Okay, so how do I get rid of hiccups?

These are the best steps I’ve found and used to get rid of hiccups:

How to get rid of hiccups tip one:

Take a deep breath and hold it for ten seconds – if you can do this, you have probably succeeded in getting rid of your hiccups. This may take three or four attempts. If this is the case, try and hold your breath as long as possible each time – the longer you hold your breath the more time your diaphragm has to relax and resume its normal function during the respiratory process.

How to get rid of hiccups tip two:

Try to drink an entire glass of water – this allows your diaphragm to rest and makes you concentrate on something other than the hiccups.

How to get rid of hiccups tip three:

Suddenly frighten the person who is having a hiccup ( the theory and efficacy of this practice is debated and if you are researching how to get rid of hiccups for yourself, you can hardly scare yourself now, can you?)

How to get rid of hiccups tip four:

Go for a swim underwater – evidently, if your hiccups are so violent that you keep on having them despite diving under the water, this can be problematic. However, unless you have what is known as Pathological Hiccups Disorder, diving under the water should stimulate the mammalian diving reflex, which stimulates the nerves involved in respiration, to slow the need for respiration and this will help you get rid of your unwanted hiccups.

How to get rid of hiccups tip five:

Try to do some chin ups on a bar. If you are capable of doing chin-ups, this will engage the large muscles of the lats, arms, and chest (many of which are involved in respiration), your diaphragm will often naturally want to contract as you try to pull your entire body weight upwards. This will result in a pause in your hiccups and after performing a few chin-ups you should have gotten rid of your hiccups.

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What Causes Hiccups?

September 28th, 2011

A hiccup can be defined as an involuntary spasm of the diaphragm, causing a sudden shift of air through the lungs, which causes the glottis to close abruptly and make the unique coughing sound, now known as the sound of a hiccup. What causes a Hiccup? There are multiple physiological reasons for a hiccup to occur, but at a basic level, the aetiology of every hiccup is based on an irritation to the diaphragm (the large muscles above (proximal) to the abdominal wall, which are used during the process of respiration). This irritation towards the diaphragm causes the diaphragm to spasm, resulting in a sudden influx of air into the lungs (inspiration) which causes a closing of the glottis and the subsequent sound known as a hiccup.

Causes of Hiccups

The pathophysiology of hiccups includes acute and chronic causes of diaphragmatic irriation, such as spicy food ingestion, allergies, excess laughter (yes, too much laughter may be a bad thing), beer ingestion and some soda drinks.

These all contribute to irriate the diaphragm and cause hiccups.

Spicy foods causes hiccups because it irritates the stomach and oesophagus which spasms and therefore causes a change in respiration and an irriation to the diaphragm resulting in hiccups.

Beer and soda drinks all include carbonated soda which causes excess bubbles in the stomach and lead to burping – when you burp excess air is expelled up through the oesophagus. If this occurs during inspiration, the diaphragm will interrupted, causing a muscular spasm in the diaphragm leading to hiccups.

Allergies, such as certain pollens cause a person to sneeze. If you sneeze you expell large amounts of air suddenly. If this occurs during a inspiratory phase, the diaphragm will have to change what it is trying to do and this can result in diaphragmatic irriation and the cause of hiccups.

Excess laugher is also likely to cause air to go in when it should go out and vice versa, which results in diaphragmatic irriation and one of the many causes of hiccups.

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Types of Headaches

September 28th, 2011

There are numerous forms of headaches, and each have their own aetiologies and clinical manifestations. If you are trying to determine what has caused your headache and thus treat it, it is important to consider the various types of headaches out there.

 

What are the Types of Headaches

 

These are some of the common types of headaches:

1. Generalized Headache – a general headache may be caused by a number of things, such as dehydration, infection, pain associated with the head, neck, shoulders or back. Generalized headaches are usually mild, short and self resolving.

2. Tension Headache – A tension headache is generally associated with prolonged stress levels, such as preparing for important exams, work roles, or relationships.

3. Cluster Headache – a cluster headache commences as a small pain progressively increasing until it reaches a climax of agony lasting up to 45-60 minutes. The cluster headache may continue intermittently for weeks, months and even years. It is primarily uni-lateral, meaning that it affects one side of the brain at at time. Although this side may rotate each time you have a cluster headache.

4. Migraine Headache – a migraine headache often has no identifiable causes, and is strongly related to a familial history of migraines. A migrain headache can be extremely debilitating and is reported as one of the most common causes of sick leave in both Australia and the USA.

5. Hormone Headache – a hormone headache is caused by a sudden change in certain hormones, including excess or inadequate amounts of certain hormones. Contrary to common belief, a hormone headache affects both women and men, alike.

6. Organic Headache – an organic headache is caused by an organic change within the cranium resulting in damage or complications to the brain. Examples of an organic headache include, brain tumours – both malignant and benign.

7. Sinus Headache – a sinus headache is usually caused by a build up of pressure within your sinuses as a secondary result of a blockage in the sinus. People who report regular sinusitis are prone to sinus headaches, and report experiencing pain along their cheek bones, forehead, and behind the eyes. It is also common to develop nausea and experience associated vomiting with a sinus headache.

If you would like to know more about what causes headaches, please visit my page on what causes headaches.

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What Causes Headaches?

September 28th, 2011

The common aetiologies of headaches are poorly understood and may be caused by a single pathology or multiple compounding pathologies. One common understanding about headaches is that a headache can occur when the various and multiple structures of the head and neck are irritated, such as the brain, spine, neck muscles, teeth, eyes, or shoulders.

Treatment solutions for headaches must therefore strive to treat the anatomical or physiological irritations which cause the headache, instead of the clinical manifestation of the painful headache. At the worst case scenarios, treatment options should aim to provide analgesia, therefore not compounding the original irritant which caused the headache.

 

Causes of Headaches

 

The sensation of pain felt during a headache can be caused by referred pain, meaning pain that has come from another location, but due to the nerve pathways has been felt in the headache, such as a neck strain, which is felt as a headache. Alternatively, a headache may be caused by direct pain, such as an infection or swelling of the brain causing direct pain to the head.

Stress triggers the sympathetic response and release of sympathomimetic (drugs like adrenaline that act to make the body more capable during a fight of flight response). Stress can cause a headache through the following primary methods: tightening the muscles in the neck, head, shoulders, abdomen, back and arms. Increases a person’s sensitivity to pain in order to theoretically notice and adjust to outside stimulants faster. Reduce the natural level of endorphins (the body’s naturally produced and released analgesia during exercise).

Certain diets and foods can cause a headache, especially in people with allergies.

Changes in a person’s blood sugar levels, such as a persistently high or a low blood sugar level.

Food additives, such as MSG and many food colourings cause headaches.

Excess caffeine intake or sudden reduction in caffeine intake.

Neck injuries – such as muscular strains.

Stroke – in severe cases a headache may be caused by damage to the vasculature within the head and brain, such as a stroke. Before you run off to the local emergency department certain that you’re having a stroke, keep in mind that almost 25% of Australians have reported having a headache on a regular to simi-regular basis.

Head injuries –  even minor concussions, will likely cause a headache.

Eye problems – Eye problems such as eye strain or injuries will cause a headache. If you need glasses but don’t want to wear them, you will likely end up with a headache. Alternatively, if you wear glasses when you don’t need to or if you wear contact lenses for too long, you are likely to get a headache.

Dehydration – is one of the most common causes of a headache. Most people drink too little water, or too much diuretic rich drinks, such as coffee, tea, and soft drinks, which actually reduce the fluids within the body.

Infections – resulting in an irritation of the meninges of the brain or increased temperature will also cause a headache.

Ear, nose or throat problems, such as infections, anatomical problems, and recurrent sinusitis all lead to headache.

Hormonal imbalances – which may occur during different stages of the menstrual cycle, and during menopause may all lead to the development of a headache.

Brain tumours, benign or malignant will also cause prollonged headaches.

Migraines – migraines are more common in women than men and although their aetiology is particularly poorly understood, many researchers attribute their causes to hormonal imbalances associated with various stages of the menstrual cycle and during menopause.

Persistent Hypertension – high blood pressure is considered to be the 2nd most common cause of headaches in older persons, due to the nature of excess pressure building up in the cerebro-vasculature (piping in the brain).

Jaw Problems – such as recent dental work, toothaches, abscesses, mouth ulcers, and recent trauma may all cause headaches.

Poor posture – any posture that consistently causes the spine to deviate from its natural curvature will ultimately place strain up the nervous pathways and into the brain which will result in a headache.

Post Intoxication – the typical hangover headache is caused by the dehydration which often results due to the diuresis caused by alcohol. If you don’t want the hang over headache, make sure that you drink a glass of water for every glass of beer and 2 glasses of water for every glass of spirits!

Noisy Environments – noise is simply sound waves being interpreted by the brain. It therefore makes sense that if you brain has already received too much information for the day, or is concentrating on something else, the last thing it wants is excess noise. Specifically, loud noises, a multiple noises are associated with causing headaches.

Labyrynthitis – Middle ear infections are known to cause dizziness, vertigo, and nausea, which in turn increase intracranial pressure and often result in headaches.

Certain Drugs – both prescribed and ilicit drug are known to causes headaches. Common headache causing drugs include weight loss pills, oral contraceptive pill and ironically, certain types of pain killers.

If concerned about your headache, please see your doctor for more definitive solutions.

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Paranormal Activity True Story 4

September 19th, 2011

This is one of the more concerning paranormal actities that I have witnessed as a paramedic. We were called to a child who appeared hysterical and was waving his arms but not talking to anyone. When we arrived, the child (about 4 years old), asian background, was in the middle of the stree and waving his arms about suggesting that we follow him. I tried to get him to sit down so that we could talk, but he wouldn’t listen and started to run off down the street. No one around said that they had ever seen him before or new where his parents were.

We followed him down the street (in our ambulance) and eventually he reached a house and ran around the back of it. We parked the Ambulance and started to walk towards the house. The back door was still half open and we saw the child running up the stairs. We notified dispatch of our location and what was going on, and advised that we were entering the house. Something seemed wrong – and I wasn’t sure what it was yet and had an eery feeling that something was wrong and unsafe… I wanted to get out of the house and call for police, but…then again… that would have been foolish – I mean, it was only a small child, right?

I follow up the stairs and state several times loud and clear “Ambulance, has someone called an Ambulance?”

As I walk up the stairs all three doors are closed – now I’m certain that the child is playing a game, or setting us up… for something…

I start to yell again, “Ambulance… is anyone here…”

No response…

“Hey kid… where are you? Its the paramedics… ”

I cautiously open the door, not certain of what I might find… an empty room.

I open the next one, it leads to a dark corridor, followed by a bedroom – I walk in…. when I reach the opening to the room, I find a women in her mid thirties (asian, appears to be the child’s mother), unconscious – I check for a pulse – only a carotid present. I call for my partner… and we place our monitor on her chest to check her heart rhythym – she’s in a condition called Ventricular Tachycardia – because she is young, she has enough strength in her heart to maintain this rhythym (but not for very long) – we make the decision, to treat her as though she is in a cardiac arrest, and we deffibrilate her.

Nothing – she’s still in VT.

We charge up the machine and shock again.

This time there’s a long pause (almost like assytole) and then, a normal rhythym returns.

She becomes conscious (wow, I actually got to save someone’s life!).

We start to get her ready to go to hospital and my partner starts to look for her child – he’s no where to be found.

I ask the mother about her son – she becomes frantic and starts to cry – “Why do you say this thing?”

Eventually calms down and we continue to search for her child. I tell her that she’s lucky to be alive and that she owes it to her son… She gets much more angry this time…

I try and get her to calm down and ask her what’s wrong…

“My child was murdered 5 years ago!”

He was her only child and she had never had children since…

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Paranormal Activity True Story 3

September 19th, 2011

As a paramedic I regularly attend those who are dying or have recently departed the world of the living. This has provided me with an unusual view of true paranormal activities. This is paranormal activity true story 3 and it is based on a real medical scene that I have attended.

I was called to a person who was in labour. I don’t generally like to deliver babies, I don’t do it very often, and although it generally turns out well for everone, I just don’t feel comfortable delivering babies. Furthermore, I get covered in blood – and that’s never much fun… but, on the other hand, delivering babies means bringing babies into the world instead of helping people leave it – so that’s a bonus.

Okay, so, like I said, I had been called to a women in her mid twenties who was in labour. I arrived and found a women comfortable at home and obviously not in the middle of labour pains. I spoke to the lady and was informed that she hadn’t rung 000 (our version of 911 in Australia) and that she was not currently, nor had she ever been pregnant. She then informed me that she lives alone and that she doesn’t even know of any of her neighours being pregnant. I appologize and check with our dispatch to make sure we have the right location. They confirm that I have the right location.

I ask them to call back the phone number which had been used to call for the emergency in the first place. They find the number and ring it.

Eerily, the phone in the house starts to ring – I laugh – surely someone else hasn’t just now decided to ring. The resident of the house walks over and picks up the phone -“Hello…” she pauses… “Where did you get this number?” She appears frightened, and then says “this isn’t funy… I’ll put him on…”

– its work – they confirm that the original call to a woman in labour was definitely from this phone. I ask if there are kids around or someone else who might want to play a joke on this lady. No, she lives alone and hasn’t had any visitors today.

Okay, I appologize for the confusion and tell her not to worry about it – sometimes wires get crossed somehow… we both make a comment about the poor lady who is in labour and obviously isn’t getting any help.

We leave her and start to head back to station…

About 20 minutes later – the phone rings – its dispatch – “You wont believe this… we’ve just had another call to the same address for a woman in her mid twenties having labour pains…” I inform them that there’s a mistake and that the lady who lives at that address is most certainly not pregnant and not in labour and she lives alone! “Well” Dispatch tells me “You’d better go check so we can get this thing off our screen… and clear this mess up.”

So, reluctantly, we head off to the same address..

When we arrive – we hear a woman screaming inside – the same lady in her mid twenties from before…

“I’m in here… quick” she yells…

Its the same lady from before and she is panting heavily…

“There’s no way that I’m pregnant… what the hell is this?” She asks…

I ask my usual questions, such as – when did you last have sex? Well, she had had sex around 38 weeks ago – but she was certain she had been careful – and besides, she would have felt something before now…

So, in short she has the baby – and it is healthy – in fact, it is unnaturally healthy and comes out almost looking at us as if to say, I called earlier today – you didn’t listen…

The lady promised that she hadn’t called earlier…

We took her to hospital and the baby went on to be healthy.

Why had the phone rung earlier that day? We will never know.

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Real Paranormal Ghost Story

September 19th, 2011

I’m not particularly religious and I have no idea about ghosts or spirits or anything else of such paranormal type background… However, working as a paramedic has taught me that sometimes there is more to life than the physical body… what that is, I have no idea. But these are some of my stories, that can be considered nothing but ghost stories…

Ghost story one

We were called to a 62 year old male who had apparently collapsed at home and had appeared to stop breathing…

Originally the call was considered potentially a hoax because… well… this is how the phone conversation went after it was recognised that the patient had potentially had a cardiac arrest…

“Sir, an Ambulance is on its way… now… is anyone able to do CPR?” Call taker…

“No…”

“Okay, now… I’m going to talk you through this… are you able to do this?”

“No… please hurry…”

“Sir, I’m going to tell you exactly how to do this… you can do this…”

“No… I can’t….”

“Sir, I can tell you how to do this… you just have to listen to me…”

“Please hurry, I’m all alone…”

When we arrived

The door was locked… but we could clearly see the man collapsed on the floor inside… we yelled out… but no one answered… we contacted our despatcher and got them to call the phone of the person who had rung “OOO” in the first place… The phone inside started ringing… we could clearly see it on the wall in another room… but no one came to answer it…

We made the decision to break the glass door… and came in… my partner had a quick look around the house – in case someone was there (you never know what’s actually happened in these cases)… and I started to work on the patient… he was in a VF cardiac arrest… we applied the defibrilator pads and shocked him… by the 2nd shock… we had a spontaneous return of circulation… and we transported him to hospital alive…

A few days later we met up with him again at hospital… and we asked him about who he lives with. He told us that he lived alone, and that he doesn’t have any living relatives… okay, we think… and then ask him if he had any friends over… no, he tells…. we then ask if he remembers anything about the event…

“No… not much… but I had the strangest dream…”

“Oh, what was that” – people often interpret sounds and actions into their dreams…

“I dreamt that I was sitting talking someone and saying that I’d better go… and same stanger kept on telling me -no, don’t go yet… help is on their way…”

The man denied ever calling for an Ambulance and his neighbours couldn’t possibly have seen him… The call taking records show that someone called from that house and the voice recording of the person who never identified himself, was definitely not the same voice as the man who had collapsed…

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Acute Versus Chronic Pain

September 17th, 2011

Both acute and chronic pain are discomfortable for patients, however discerning between acute versus chronic pain in a patient who presents in an emergency department or in the field when attending as a paramedic is vital for determining their treatment options.

Acute pain can be defined in many ways, but fundamentally is used to identify a new injury or illness and serves to function as a protective identifier for the patient. For example, you place your hand on a hot stove, the nerves in your hand will tell your brain that this is painful and your brain will advise your hand to move rather quickly. This is an acute pain, and as such will subside once the hand has been moved away from the stove, and once the hand is allowed to cool and the injury repaired, the pain will cease.

Chronic pain can be defined as pain that has persisted beyond the duration of the healing process. Chronic pain may result as a consequence of years of untreated pain, such as back pain and back problems. For example, a person with lung cancer may be in chronic pain, and that pain will never cease.

In both acute and chronic pain, the assessment of that pain is subjective and different for all persons. It is important to manage pain where pain exists and current improvements in treatments and drug based analgesia have made it much easier to ensure that people are able to be pain free.

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What is a Bone Injection Gun?

September 17th, 2011

What is a bone injection gun (also known as a BIG)? A bone injection gun was first produced and utilised in paramedicine and medicine in early 2000 as a rapid means of delivering emergency resuscitation drugs, such as adrenaline and atropine into the intraosseous space of the manubrium (lower part of the sternum).

The bone injection gun was designed to be inserted straight into the manubrium during active resuscitation efforts in cardiac arrest for adult patients, however it can also be used to gain intraosseous access into the tibial tuberosity.

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Female Heart Attack Symptoms

September 16th, 2011

Female’s are less likely to have a heart attack than men, however, when they do have a heart attack they are more likely to dismiss it as indigestion and therefore wait until they receive treatment, which is often too late. It is because of this that it is important to have a high index of suspicion for any woman who presents with heart attack signs and symptoms.

 

Heart Attack Symptoms Female

Female heart attack symptoms are similar to men but are often less pronounced and include:

Chest pain, tightness, discomfort, crushing pain, heaviness, pain to the neck, pain to the left arm, pain to the jaw, tingling to the left arm and numbness to the left arm, shortness of breath, dizziness, nausea, vomitting, sense of impending doom and sudden death.

 

Female Heart Attack Signs

Female heart attack signs are generally the same as men and include:

Skin cool, pale, and sweaty (clammy), difficulty breathing.

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Signs of a Heart Attack

September 16th, 2011

There a numerous signs of a heart attack – these are things that you can see in a person who is having a heart attack. All people who experience a heart attack do so differently, however these are some common signs of a heart attack.

Person’s skin looks pale, sweaty, and is likely to be cool to touch (clammy).

Person may appear short of breath or struggling to breath.

Person may have a weak or thready pulse, or an irregular pulse (often quite a late sign of a heart attack).

 

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Symptoms of a Heart Attack

September 16th, 2011

Unfortunately the symptoms of a heart attack are wide and varied. In fact, no two similar people will ever experience a heart attack exactly the same way. The following are some common symptoms associated with a heart attack.

Chest pain – generally described as a heaviness or sharp pain over the middle to left side of the chest. Rarely described as an exacting pain over the heart.

Neck pain.

Left arm pain

Left arm tingling or numbness

Left shoulder tip pain.

Jaw pain.

Shortness of breath or struggling to breath.

The pain in the chest may be described as a tightness, heaviness, stabbing pain, squeezing sensation or the patient may feel as though someone is sitting on their chest.

The patient may feel dizziness.

The patient may feel like vomitting.

The patient may feel wobbly on their feet.

The patient may lose consciousness.

The person may feel a sense of impending doom (if they are having a heart attack they will most likely feel like they are going to die!)

Their heart may stop working altogether and they may go into cardiac arrest (this is where it’s your turn to do CPR!)

And after all these possible symptoms… in as many as 20% of the population, they will feel no symptoms when they have a heart attack.

If you are worried that you may be having a heart attack, stop reading this now, and call and ambulance immediately!

If you would like to know more about heart attacks, please visit my Chest Pain page.

 

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Risk Factors for a Heart Attack

September 16th, 2011

An acure coronary syndrome (heart attack) may occur in any person without any real prior warnings or notices; however, there are some risk factors which may indicate a higher risk for having a heart attack. These include the following: non-modifiable and modifiable risk factors.

Non-modifiable (the things you can’t change) risk factors for a heart attack include:

Age, gender, family history.

Modifiable (the things you can and should change) risk factors for a heart attack include:

High blood cholesterol levels – particularly low density lipids and triglycerides (generally anything that is fried is bad for your heart)

High blood sugar levels

High blood pressure (also known as hypertension)

Smoking – it has long been proven that there is a strong correlation between smoking and coronary artery disease and a myriad of other early causes of death. If you smoke, no mater how hard it is to give up, not quiting is going to hurt more!

High stress – maybe you shouldn’t just quit you job yet, but a high stress job is a strong risk factor for coronary artery disease and chest pain.

Obesity

Sedentary lifestyles

If you want to learn more about chest pain and a possible heart attack, please visit my Chest Pain page.

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How Many Coronary Arteries are There in the Heart?

September 16th, 2011

How many coronary arteries are there in the heart? There are three main coronary arteries that provide oxygen and nutrients to the myocardium (heart muscle). These include: the right coronary artery, left coronary artery and the circumflex artery.

There are multiple smaller coronary arteries that branch off from the left and right coronary artery and even the circumflex artery.

The myocardium itself actually gets 100% of its oxygen and nutrient supply from the coronary arteries and receives no oxygen or nutrients from the blood that passes through the ventricls of the heart.

 

Coronary Arteries

The left side of the heart is fed by the left coronary artery and circumflex artery, which originate at the root of the aorta (before the aortic arch) during the diastolic phase (relaxation phase) of the heart. The left coronary artery originates from the left aortic sinus, while the right coronary artery originates from the right aortic sinus. These coronary arteries are relatively tiny compared to other arteries in the body, which is why they are prone to atherosclerosis (narrowing of the artery wall).

A very small proportion of people will have a fourth main artery (the posterior coronary artery), while an even rarer proportion of people will have only one single coronary artery that loops around the entire heart providing the only oxygenation supply.

If the atherosclerosis continues and the heart muscle is no longer able to acheive an homeostatic balance of oxygen used an oxygen received by in flowing blood, the heart muscle will start to die. This is when you will start to feel chest pain. If you want to learn more about chest pain, please visit my Chest Pain page.

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Acute Coronary Syndrome

September 15th, 2011

Acute Coronary Syndrome (ACS) is defined as a broad category of acute myocardial events which broadly fall under three categories: STEMI, Non-STEMI and Unstable Angina. The term Acute Coronary Syndrome has recently replaced  other more specific terms which have been previously used to describe problems with the heart, such as acute myocardial infarction, heart attack, transmural and non-transmural myocardial infarction.

Acute Coronary Syndrome is almost always secondary to a rupture of an artherosclerotic plaque and subsequent coronary artery thrombosis, resulting in myocardial ischemia.

Acute Coronary Syndrome falls under the following three categories:

1. STEMI (ST -Elevation Myocardial Infarction)

2.Non-STEMIO (Non-ST Elevation Myocardial Infarction) and

3. Unstable Angina

STEMI Definition

A STEMI can be defined as a myocardial infarction, in which an ECG (EKG if you’re American) identifies a raise in the ST segment of the ECG in two or more continguous leads (views of the similar apsect of the heart from a different angle). Each ST elevation must be greater than or equal to 2mm in the vector leads (augmented leads) and greater than 1mm in the limb leads. A STEMI identifies current infarction to the myocardium as a result of ischemia (most likely due to a rupture of atherosclerotic plaque with subsequent coronary thrombosis).

Non-STEMI Definition

A non-STEMI can be defined as an acute myocardial infaction, in which the ECG does not show any changes, or significant changes to the ST segment of the ECG. The reason that a Non-STEMI may not show acute changes to the ST segment of the ECG includes: infarction in an un-seen/unusual part of the heart, or complications.

Unstable Angina

Angina is common in people who have coronary artery disease and is a disease process involving long-term atherosclerotic plaque build up resulting in a reduction of less than 25% of normal coronary artery blood flow. As a result, the heart is not able to compensate for any increased blood flow requirements, due to exercise, stress or any other level of exertion. In unstable angina, this reduction in coronary blood flow has become so significant that, without the disruption of a atherosclerotic plaque, it may still cause ischemia to the myocardium and a subsequent myocardial infarct.

Here is a link to a video about Acute Coronary Syndrome:

httpv://www.youtube.com/watch?v=ZSmuilMhwvk

Acute Coronary Syndrome Management

Acute coronary syndrome management includes the following steps:

1. Reasure the patient – no point having their heart work any harder than it already is. Fear has been identified as one of the greatest stresses placed on the heart during an Acute Coronary Syndrome.

2. Place the patient at rest – this allows the patient to rellax, and not utilise as much energy (this is why we try our best to avoid walking patients with chest pain).

3. Administer oxygen – this provides an increase in inspired oxygen partial pressures, which, in theory decreases the amount the heart has to work to get oxygen. There is currently some research that suggests that oxygen is actually counter-productive in suspected acute coronary syndrome patients, because oxygen is a potent vaso-constrictor, and may cause vaso-constriction to the coronary arteries. Currently, however, all Australian Ambulance services and medical guidelines indicate oxygenation for patients with chest pain.

4. Administer aspirin (acetylsalicylic acid) – 150mg-300mg per oral, which stops platelet aggregation (makes the blood less sticky).

5. Administer GTN (glycerin-tri-nitrate) – 600 mcg sub-lingually, which causes vaso-dilation and theoretically opens up the obstructed coronary arteries. It also reduces preload to the heart, which in turn reduces the stress placed on the heart during left ventricular contractions.

6. Morphine – 2.5 mg IV increments to titrate patients pain and comfort levels.

7. 12 Lead ECG – This should be done as early as is practical and repeated regularly so that serial ECGs can be reviewed for signs of ischemia progression.

8. Bloods should be taken early to assess for troponin I and T level changes, CK levels, and recent studies have show benefits assessing elevated B-type natriuretic peptides, which are associated with the presence of myocardial ischemia. However, the accuracy of B-type natriuretic peptides does not seem to be high enough for use in clinical use currently in Australia.

9. Other causes of chest pain should be considered and ruled out.

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The Circulatory System

September 15th, 2011

The circulatory system is often refered to as the cardiovascular system. In its simplest form, the circulatory system may be explained through a process of plumbing, involving the heart (the pumpt), the blood vessels (the piping) and the blood (water).

The heart pumps deoxygenated blood (blood without oxygen) up through the pulmonary artery into the lungs, where each red blood cell collects oxygen. It is then returned to the heart through the pulmonary vein, and then pumped by the left ventricle of the heart (the main workhorse), through the blood vessels (piping) of the body, where it distributes oxygen to all the cells.

Blood Flow Through Heart Diagram

Blood leaving the heart is pumped through arteries, which become smaller and then are called arterioles, followed by by body capillaries (where the last of the oxygen is removed from the red blood cells), the blood then returns to the heart via small veins called venules, followed by veins and then re-enters the heart through the vena-cava.

The heart perfuses itself first (provides oxygen) by sending oxygenated blood into the coronary arteries off the aorta. It is also important to note that the heart gets its oxygen from blood which is pumped through the coronary arteries, and not through the left and right ventricle chambers. This is why coronary artery disease is associated with such a high mortality rate.

To learn more about cardiac chest pain please follow my link to Chest Pain.

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Chest Pain

September 15th, 2011

Chest pain is one of the most common jobs that paramedics attend. Correct assessment and treatment of chest pain by paramedics (when it is caused by an acute coronary syndrome) will determine if the patient lives and how much of a quality of life the patient will have after treatment. The management of prehospital care chest pain has improved dramatically over the past 5 years, where paramedics are now able to accurately identify a STEMI through the use of a 12 Lead ECG, commence Thrombolytic Therapy (if greater than 1 hour from hospital) or transport directly to a Cardiac Catheter Lab for Angio Stenting.

Chest pain can be classified as any pain or discomfort to an area around the chest and may be related to an underlying pathology of the heart. Chest pain may be caused by a multitude of disease processes or injuries to the chest, lungs, heart, diaphragm, neck, stomach (reflux/indigestion pain) and even the abdominal organs. If in doubt about the type of chest pain, treatment should always first be targeted at the potential cardiac causes. This treatment for chest pain can then be discontinued or modified once more evidence is gathered to identify another aetiology of the chest pain.

Types of Chest Pains

Until proven otherwise, all chest pain should be considered cardiac in nature. Chest pain comes in many forms and disguises and a good clinician always considers cardiac possibilities in his or her patients. The following are common heart attack symptoms:

1. Pain to the central chest

2. Pain to the left side of the chest

3. Pain or numbness to the left arm

4. Tingling sensation down the left arm

5. Jaw pain

6. Neck pain

7. Shortness of breath during exercise or at rest

8. Sense of Impending Doom

Cardiac chest pain versus noncardiac chest pain? Simply because a person states that they have chest pain does not mean that they are having a heart attack. The exact nature or aetiology of the pain may relate to any number of medical or traumatic problems. A thorough history, taken by a good clinician with a high index of suspicion, and many diagnostic tests are the only way to determine if a person is experiencing an acute coronary syndrome (such as a heart attack) or a variety of Heart Attack Imitators. Similarly, the absence of chest pain alone, does not rule out an acute coronary syndrome, and a clinician treating any patient should have a high index of suspicion for the many manifestations of acute coronary syndrome.

According to the World Health Organisation (WHO) ‘cardiovascular disease is a major cause of disability and premature death throughout the world and contributes substantially to the escalating costs of health care’ (WHO 2011). It is therefore paramount for a patient and a clinician to suspect an acute coronary syndrome in any patient who presents with chest pain like symptoms until proven otherwise. As a paramedic, this often means treating for cardiac chest pain until you get to hospital, where more definitive cardiac diagnostic test can take place, such as blood tests, cardiac stress tests, and angiography.

Assessing Chest Pain

Newberry, Barnett and Ballard (2003, p84-5) describe a good mnemonic for assessing chest pain which may be useful for paramedics, nurses and doctors when assessing patients who may have chest pain. The following describes a good mnemonic for assessing chest pain. OPQRST is still a useful mnemonic for assessing chest pain. The mnemonic CHESTPAIN is a very good structured approach for assessing chest pain for beginning clinicians and cardiologists alike.

Paramedics assess chest pain by performing a 12 lead ECG on a patient and assessing for signs of myocardial ischemia.

In an emergency department, serial (repeated) 12 lead ECGs will be performed to assess for any acute changes in the ST segment of the ECG, and serial bloods will be taken to assess for acute changes in Cardiac Enzymes such as Troponin levels and CK/Mb levels, which may all change if a patient has had any damage to the myocardium (such as a heart attack).

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Anaphylactic Shock Symptoms

September 15th, 2011

Anaphylactic shock symptoms need to be recognised early so that treatment can start early!

Signs and Symptoms of Anaphylactic Shock

 

Most signs and symptoms of anaphylaxis can be broken down into these categories:

1.Gastrointestinal

2.Respiratory

3.Neurological

4.Cardiovascular

5.Cutaneous

Gastrointestinal response:

GIT effects of anaphylaxis include: nausea, vomiting, diarrhoea, and severe abdominal cramping. The increased GIT activity is related to smooth muscle contraction, increased mucous production, and the outpouring of fluid from the gut wall into the intestinal lumen, initiated by chemical mediators.

Respiratory response:

Respiratory effects of anaphylaxis include: sneezing and coughing, bronchospasm as a result of bronchoconstriction, through to complete airway obstruction, secondary to  laryngeal and epiglottic oedema

 

Neurological response:

Nervous system effects of anaphylaxis include: a sense of impending doom, agitation, confusion, syncope, and unconsciousness as a result of impaired gas exchange leading to systemic and neurological hypoxia.

Cardiovascular response:

Cardiovascular effects of anaphylaxis include: hypotension through to vascular collapse and profound shock, dysrhythmias, associated with the severe hypoxia and intravascular hypovloaemia. The patient may complain of chest pain if myocardia ischemia develops.

Cutaneous response:

Cutaneous effects of anaphylaxis include: erythema and urticaria that results in well-circumscribed wheals of 1-6cm, which may be more reddened or pallid than the surrounding skin and are often accompanied by severe pruritus and pyrexia.

 

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Anaphylactic Shock Treatment

September 15th, 2011

How do we as paramedics manage Anaphylaxis? Anaphylactic shock treatment is one of the few medical treatments used as a paramedic in which you are able to clearly see that you have saved a persons life. The following are guidelines on how to treat anaphylactic shock. 

Anaphylactic Shock Treatment for Adults

Airways may be compromised due to laryngeal and eppiglotic oedeama. Good airway management is critical! This includes insertion of nasopharyngeal airways and, if laryngeal or eppiglotic oedema develop, immediate intubation, as a golden standard of airway management.

Breathing may become difficult and should be assisted with intermittent positive pressure ventilation (IPPV) if necessary via bag valve mask

Circulation may be compromised as a result of relative hypovolaemia, and should be treated accordingly with adrenaline and fluid resuscitation.

Mainstream paramedic treatment for adults in anaphylaxis includes:

Administration of patient’s own “Epipen” if available.

Posturing should depend on the patient’s comfort. Normally, we lie hypovolaemic patients supine or with their legs raised, but this is unlikely to be possible if the person is have severe breathing problems which is often the more likely response to anaphylaxis than the hypotension.

Drugs: 500mcgs Intramuscular Injection of Adrenaline repeated every 5 minutes until desired result. Evidence based practice has indicated that IV adrenaline has no greater benefits to the patient, but many more potentially lethal risks associated with it. Oxygen should be administered. IV fluids should be given if the patient is hypovolaemic. Nebulisers should be considered as a secondary priority in patients with severe breathing difficulties (after adrenaline administration). Nebulisers should include: salbutamol and atrovent.

Any patient given adrenaline should always have a cardiac monitor applied (in case the adrenaline exacerbates a previous known or unknown underlying cardiac condition or dysrhythmia).

Anaphylactic Shock Treatment Paediatrics

Administration of patient’s own “Epipen” if available.

Posturing should depend on the patient’s comfort. Normally, we lie hypovolaemic patients supine or with their legs raised, but this is unlikely to be possible if the person is have severe breathing problems which is often the more likely response to anaphylaxis than the hypotension.

Drugs: 10mcgs/ per kg of patient of Intramuscular Injection of Adrenaline repeated every 5 minutes until desired result. Evidence based practice has indicated that IV adrenaline has no greater benefits to the patient, but many more potentially lethal risks associated with it. Oxygen should be administered. IV fluids should be given if the patient is hypovolaemic. Nebulisers should be considered as a secondary priority in patients with severe breathing difficulties (after adrenaline administration). Nebulisers should include: salbutamol and atrovent.

Any patient given adrenaline should always have a cardiac monitor applied (in case the adrenaline exacerbates a previous known or unknown underlying cardiac condition or dysrhythmia).

I hope you have enjoyed this presentation on allergies and anaphylaxis.

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Alcohol Abuse

September 14th, 2011

Alcohol abuse is widely recognised as the single most expensive and detrimental drug in society. According to the World Health Organisation alcohol is directly related to 2.5 million deaths per year and 320 000 young people between the age of 15 and 29 die from alcohol-related causes, resulting in 9% of all deaths in that age group.(WHO 2011). It is therefore surprise that alcohol is the most commonly legal drug and readily available drug in society. In Australia alone, tens of thousands of people become victim of alcohol addiction or alcohol abuse, such as binge drinking. In the youth, binge drinking is seen as ‘cool’ and socially acceptable.

In 2010, the World Health Assembly approved a resolution to endorse a global strategy to reduce the harmful use of alcohol. The resolution urged countries to strengthen national responses to public health problems caused by the harmful use of alcohol.

As a paramedic, I treat more patients who have become injured or been injured as a direct result of alcohol abuse than any other person! Alcohol is associated with many serious social and developmental issues, including violence, child neglect and abuse, and absenteeism in the workplace.

If you need any inspiration to try to quit drinking, then think of this case I once attended. I was called to a women who was 25 weeks pregnant and alledgedly assaulted by her husband. When I arrived the patient appeared to have been beaten quite badly from head to toe. She later miscarried and the baby was still borne. While I treated her, she explained how her husband was a good man, but that he gets carried away when he starts to drink. She then mentioned that I should check out her daughters. She had three young girls, who had tried to stop their father from beating their mother to death. One of them had taken the full brunt of their father’s alcohol induced violence and had suffered a major head injury (resulting in a sub-arachnoid bleed).

Alcohol leads to many chronic and permanent diseases, including epilepsy, cirrosis of the liver, imune deficiencies, cardiovascular disease and multiple cancers.

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Homeostasis Negative Feedback

September 14th, 2011

What is a negative feedback mechanism in homeostasis? A negative feedback system is the most common type of homeostatic regulation used by the body. In this system, the body acts to remove or hinder any deviation from the set ‘ideal’ state. The body does this with three main components. A receptor that acknowledges that something has deviated from the ‘ideal,’ a control center, which establishes the set point in which a variable is maintained, and an effector, which is capable of changing the variable.

An example of a Negative Feedback Mechanism in the human body would be:

A patient loses blood and consequently the blood pressure is decreased. As the body’s normal blood pressure deviates lower than the ‘ideal’ the body’s receptors (primarilylocated in large blood vessels around the heart and neck) pick up this deviation. The receptors then tell the control center, which identifies the deviation, and tells the effector (in this case, primarily the heart – to start contracting stronger and faster, and the kidneys to start retaining salt and therefore fluid). This will then increase bloodpressure.

Another example of a Negative Feedback System in the human body includes the Renin Angiotensin
Aldosterone Pathway (RAA).

For more information about homeostasis, please review my homeostasis page.

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What is the Mammalian Diving Reflex?

September 11th, 2011

The mammalian diving reflex is a phenomenon that occurs in mammals when they are submerged in cool water below 21 degrees centigrade (or 70 degrees fahrenheit), in which the body’s natural cardiovascular responses are altered to maintain cerebral and cardiac blood flow. It has been hypothesized that the mammalian diving reflex has been used by mammals over centuries of evolution to enable them to reach greater depths in streams and oceans, while hunting and gathering food.

Mammalian Diving Reflex

When the face of a mammal (this includes humans) is submerged in cold water and the process of normal breathing is ceased, the following physiological responses occur in order to improve cerebral perfusion and cardiac blood flow:

1.  The larynx spasms.

2. The heart rate slows to conserve energy.

3. Blood vessels constrict in order to shunt blood through to the vital organs of the body (heart and brain).

Through the mammalian diving reflex the colder the water temperature the more oxygen is shunted (diverted) towards the heart and brain.

Mammalian Diving Reflex In Children

In children the mammalian diving reflex is more significant due to the following reasons:

1. They have a much smaller body surface area and will become hypothermic much faster.

2. Their metabolic needs are often higher than an adult.

For paramedics, the concept of the mammalian diving reflex becomes important when attempting to resuscitate a patient who has had a near drowing event. Persons who ordinarily would have been pronounced dead on the paramedic’s immediate arrival otherwise, may actually have a good chance of resuscitation due to the mammalian diving reflex.

Mammalian Diving Reflex and Medicine

The principles of the mammalian diving reflex has been used in medicine in the treatment of multiple injuries and illnesses including the following:

1. The rapid infusion of cold hartmans solutions (RICH) trial in which patients in cardiac arrests were infused with high doses of cold hartmans to reduce the patients core body temperature. Although, strictly speaking, this is not triggering the mammalian diving reflex, the principles of its benefits, are based on the mammalian diving reflex.

2. To this day, one treatment available for neonates who have a run of SVT (which is a pre-terminal event in neonates) are dipped head first in a cold bucket of water in order to artificially stimulate the mammalian diving reflex and therefore reduce the heartrate. The mammalian diving reflex is known to reduce the heart rate by 25%.

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What is the Difference Between Decorticate and Decerebrate Posturing?

September 11th, 2011

Decorticate posturing  is when the patient’s back arches backwards and flexes the arms, where as decerbrate posturing is where the patietn arches the back (like in decorticate posturing) but then extends the arms out parallel to the body.

Both decorticate posturing and decerebrate posturing are indicative of serious head injuries with significant damage to the brain. Decerebrate posturing is slightly worse and indicates significant brain stem damages.

How to remember the difference between decorticate and decerebrate?

There are a number of stories or systems in which medical students, nursing students and paramedics can remember the difference between decorticate and decerebrate posturing. These include:

1. If a person is flexing their arms upwards like they are praying that they are going to get let off by the judge, then it is decorticate (like going to court), and therefore if they are not doing this, then they must be decerebrate.

2. If a person is flexing their arms upwards towards their brain then it is decorticate (as in towards the cortex of the brain), again, if not, it is decerebrate.

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Why Do People Die From Cancer?

September 11th, 2011

Every type of cancer is different and the reason why certain people live where others die from cancer are varied.

Here are some reasons why people eventually die from cancer:

1. They die because the cancer/tumour or fast growing cells have destroyed a vital organ in the body or blocked a vital organ from functioning – examples include lung cancer, which stops a person from being able to difuse oxygen into the blood through the lungs, liver cancer, which causes so many toxins to build up in the blood that a person dies, brain cancer, which causes the brain to cease to function.

2. The pain associated with the cancer becomes to great that ever increasing doses of analgesia eventually cause the person to stop breathing. People are not at risk of increasing their chance of dying by taking strong analgesia when they have cancer, but are more likely to have a better quality of life up until the end of it.

3. They die because they accept that they are going to die.

 

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Why Do People Die?

September 11th, 2011

Why do people die? Most people will acknowledge at some stage in their life that they have considered the question, why do some people die? Others will try hard not to even contemplate the concept of death, while some accept it with alaclarity. Some people choose to explain life and death through spirituality, by experiences they have gained through life, through their up-bringing and their family beliefs, and other’s accept that they just don’t get any say in the matter.

As a paramedic, I deal with death on a regular basis and as a consequence, feel that I am in a better position than the average human being to explain why people die – but the reality is, as a paramedic, having seen people live and die many hundreds of times in the past decade or more, all I have come to understand of death is that it is inevitable and that it is different for everyone.

The following are some reasons why people die that I have identified:

1. At a clinical and physiological level the reason a person will die is that person stops eating/defecating, breathing or their heart ceases to pump, their life will cease.

2. If a person fails to see a point in their existence, a reason to get up in the morning and be alive, they will cease to exist. This is plain as day. I have seen patients who have worked hard all of their lives, only to die suddenly two days after retirement. This does not mean that you should never retire, but that you should have some purpose for living past retirement – this may simply be, to read a good book, to visit family, to travel or any number of other interesting reasons to live after retirement.

3. If you no longer have family or friends to share your life with. I have seen it litterally hundreds of times before, where a person will die within hours of their husband, wife or life-time partner dying. They do not wish to be alive anymore and consequently, cease to exist. This is also common in people who have never been married or had children, and as a consequence reach the years exceeding 80, in which most of their friends have died and now they have no one left to share their life with. Statistically, you will live as many as 7-10 years longer if you have children!

4. If you lead an unhealthy lifestyle you will increase your risk of sudden death, but many unhealty people still live to their old age. Unhealthy lifestyle habits, such as smoking, drug use, sleep deprivation, alcohol consumption and obesity are all linked to reduction in longevity.

5. Continuous high risk takers are also more likely to die earlier. This is simple statistics, if you partake in high risk activities, such as base jumping, climbing mountains, etc there is a higher likelihood that one of these things will cause your sudden demise. But, for many people the benefits that they get in life by taking these risks will actually increase their longevity, if they are lucky enough not to die suddenly from an accident.

6. Studies on centarians (people who live to be in excess of 100 years of life) have show little similarities. One of the few factors identified has been that all of their blood results have shown consistently low levels of blood sugar (BSL) and un-commonly low levels of insulin. One theory is that insulin or sugar (both generally go hand in hand) are contributing factors for cell degeneration. Unfortunately, other than eating a well balanced diet, low in sugars, people cannot change this for themselves.

After all this, why do people die?

One of the best explanations for why people die that I have identified is that having a definite end time (cesation of life), whether it is soon or far in the future, gives our lives meaning and significance. Instead of thinking that we are going to live forever and achieve things eventually, the knowledge of our eventual death gives importance to each day.

There are many other spiratual reasons that people may quote, but that’s about as good as it gets for me.

As a paramedic, I’m still confused by the concept of death. I’ve attended people who have fallen 6 stories on to concrete, only to have broken their legs, or the person who stepped in front of a slow moving train, but was so drunk that the he bent to fit underneath the center of the tracks, tearing many of his ligaments but allowing him to live. On the other hand, I have attended a young fit, healthy person, who died while reversing her car and being side-swiped at less than 20kms per hour – just the random way that she was turning with her head, and the point of impact, being enough to snap her neck and kill her immediately.

So, why do people die? People just die – everyone does.

 

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Never Run Into Any Situation as a Paramedic

September 8th, 2011

As a paramedic it is important to always think before you act. Even just a couple seconds of sizing up a scene before you start work can make a big difference to both the outcomes for the patient/s and your own longevity.

A few years ago I attended what I thought was a simple cardiac arrest. I was called to a 40 year old male who appeared blue and was not breathing. I rushed in and was ready to start doing CPR. In my head I had run through our cardiac arrest protocols and reviewed the drug regime in my mind.

As I came through the door my partner stopped me with a sudden thud. He had seen something that I had not.

He had seen the wires attached to the 240volt power point and followed over to the unconscious person laying motionless on the bed. There was a strange smell in the room, almost like cooked steak.

It turned out – this person had intentionally killed himself by attaching copper wires to his body, and then through a fish tank timer and finally to a 240 volt power socket, so that as the timer ticked over, the 240 volts of electricity flowed through his head and chest and killed him.

Had I run up and started CPR as I had intended to do, I would have been electrocuted.

That day changed my view of running to an emergency for the rest of my career as a paramedic. It doesn’t mean that I wonder, or dawdle on my way to an emergency, it just means that I stop, think about the scene and then proceed. You don’t need long, just a pause, and with experience, your instincts (built on experience) will tell you when something isn’t right. 

Lessons Learned:

1. Always give yourself an extra few seconds pause before you run into anything – especially when its an emergency and your adrenaline rush may get ahead of you, or blind you from obvious dangers.

2. Remember, your safety and your partner’s safety will always be more important than any patient you attend (no matter how sick they may appear).

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Scene Safety and Narcotic Overdoses

September 8th, 2011

You have been called to a person in respiratory arrest or potentially cardiac arrest in the street. When you arrive, you find a male in his early 40s unconscious on his back and apnoeic. There is clearly vomitus on his mouth and he appears almost blue. Your first impression is, “is he dead?”

You go over and check for a pulse – yep. You give him a strong sternal rub to no avail.

Okay, you start over again with the job…

Airway – No, he’s supine and unconscious and consequently suffocating on his on tongue. Lets roll him over and clear his airway. Good… maybe even insert an oropharyngeal airway.

Breathing – No, hmm… that’s not good for sustaining life – you’d better fix that. You ramble through those parts of the oxygen kit that you rarely use and set up a bag-valve ventilation system to provide a hundred percent 02 through a bagging process.

Circulation – Yes, good strong pulse, very tachycardic – that’s reasonable, he’s been hypoxic for a little while and the heart is somehow trying to compensate by increasing its rate and force of contraction.

Disability – Unconscious. Pupils pinpoint and not reactive (that’s because their pinpoint) – highly indicative of a possible narcotic overdose.

Exposure – Track marks up the arms and a needle still in the right cubital fossa.

You start to ventilate the patient and he starts to look a better colour (not quite so blue). No rush here, you know you want to give him some naloxone, but no need to rush at this stage, and you don’t want him to come up cerebrally hypoxic and fighting.

You give him a small dose of naloxone (say 400- 800mcg) so that he doesn’t come up too quickly. You keep ventilating him. After about 5 minutes he starts to breath on his own, but not very well. He then start to choke on his oropharyngeal airway – now, there’s two theories of practice here, you can either choose to remove it form him (so that he doesn’t vomit) or you can speak to him and tell him he just has to take it out himself. By the time that he is awake enough to listen to you and remove it himself, he is awake enough to manage his own airway.

He is still fundamentally unconscious, but slowly rousing. Here’s the choice: do you want to give him another dose of naloxone to stop him overdosing 20 minutes after you leave? Or have you given him enough to wait and see what he wants. (I’ll give you a hint… he’s not going to want it once he’s awake – and naloxone has a much shorter half-life than heroin so unless you want to come back and treat the same person twice, I’d be giving him another dose pretty quick before he wakes up).

Shortly after his next dose of heroin, he slowly wakes up.

He is mellow and a little confused, but by no means aggressive.

It’s normally about this stage you remember to put on your protective glasses in case he spits(which you should have had on all along). You do a more thorough assessment of him and take a history. During the history taking process he informs you that he is Hep C positive (which is just about as lethal as HIV, but much easier to catch). You also start to do a full secondary survey to see if he is injured anywhere. During this process, you find several needles which have been used dozens of times and left in his pockets.

You carefully check what you are doing, and decide to leave him on his merry way.

You get back into the truck (ambulance) and start doing your paper work and think about the risks that you have just taken. Nothing went wrong, but that was only because of good luck, not through your own risk management strategies and good ambulance practice.

Lessons Learned:

  1. Safety glasses are there for a reason, so use them. Especially for high risk patients and unconscious people who you are likely to be exposed to sputum and saliva.
  2. Roll a patient over on their side away from you and use your foot to support their head and knee to support their back. By doing this, they can’t wake up suddenly and hit you. Also, if they vomit, spit, or cough, they are pointing away from you.
  3. Be careful when you are assessing any person, especially an unconscious person, because you don’t know what you may find.

 

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Gastric Banding Emergencies

September 8th, 2011

Gastric banding is considered a relatively safe surgery with very few gastric banding emergencies.

I recently attended a patient who had had a gastric band inserted only weeks prior. When I attended the gentleman informed me that he had been advised to stop eating when he felt full and not to overeat. Unfortunately, the meal that he was having was too good to resist and he had multiple plates.

The problem with overeating and gastric banding is that there is literally a gastric band (filled with saline) to provide a constriction around the stomach. If you fill the stomach too much, as is the case when you overeat, then the food has nowhere else to go but straight back up. Consequently, this gentlemen had started to vomit uncontrollably.

The person was transported to hospital and I avoided giving an antiemetic, such as maxolon or ondansetron due to the fact that he physically needed to expel the excess food that was in his stomach.

Lessons Learned:

1. If you have a gastric band, stop eating when you feel full!

2. If someone who has a gastric band starts to vomit, don’t give an antiemetic, they need to expel the excess food.

 

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Can I Be Sued For Providing First Aid?

September 4th, 2011

If you witness an accident or attend an accident and want to provide first aid, do you know if you can be sued for providing this First Aid?

Depending on which country and which state you live there a multiple laws generally designed to protect anyone who voluntarily offers, or renders, assistance or first aid during a medical emergency. Many states have what is called a Good Samaritan Law, or Good Samaritan Act, which basically protects a person, who, through a voluntary basis, is providing first aid. Any person, irrespective of their normal professional standards, such as a medical physician or paramedic, is generally protected from liability, when they render first aid in good faith at the scene of an emergency.

In general, a person may only be sued for rendering first aid if it is proven that they maliciously or with wanton intent to harm, provided a level of care below the standard of a person with similar knowledge and experience in the same circumstance. This does not mean that a medical doctor should be assessed based on his or her knowledge as a doctor in a hospital, but rather as a doctor, who has no medical equipment, and is outside his or her normal location of practice.

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How to Safely Remove Gloves

September 4th, 2011

Wearing medical gloves is one important risk management technique used to reduce the risk of spreading infectious diseases. However, wearing medical gloves is only useful if the wearer knows how to safely remove the gloves.

How do you safely remove medical gloves?

To remove gloves safely follow these steps:

  1. Use only surfaces of the gloves that are contaminated on other contaminated surfaces of the glove (such as the outside of the gloves). Never touch the inside of the glove with the outside, contaminated part of the glove.
  2. Used two gloved fingers to pull the outside cuff of the glove down and outwards of the second glove. Remember, never touch the inside of the glove.
  3. Pull completely down until the glove is removed and the glove is now inside out.
  4. Use the clean inside part of the glove to pull on the inside of the second glove.
  5. Dispose of the contaminated gloves into an infectious materials/hazardous materials bin.

By using these steps in how to safely remove gloves you will further reduce your risk of infections.

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Infectious Diseases That Affect Healthcare Workers

September 4th, 2011

Infectious diseases are one of the greatest risks for healthcare workers and consequently healthcare workers should take steps to mitigate these risks through the use of good PPE, barrier control, and hand washing. This is particularly important for paramedics, who often attend patients who have an infectious disease, but are not yet aware of it themselves.

The following is a list of infectious diseases that affect healthcare workers and risk of this infection should be managed by healthcare workers:

1.Hepatitis

2. Hepatitis C

3. Acquired Immune Deficiency Syndrome (AIDS)

4. Tuberculosis

5. Multidrug-Resistant Organisms

6. Severe Acute Respiratory Syndrome (SARS)

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How to Detect a Pulmonary Embolism

September 3rd, 2011

How to detect a pulmonary embolism and a diagnosis of pulmonary embolism should always be in the back of your mind as a differential diagnosis in any patient who is hyperventilating for no apparent reason.

If you assess a patient in respiratory distress, who, on ausculatation has clear lung sounds and air entry into the bases, you must consider a pulmonary emobolism as a cause. A pulmonary emobolism is a blood clot (or thromobosis) in the lung. It can be on one side of the lung or both, and it may be lodge in the saddle of the pulmonary arteries (where the pulmonary arterieis bifurcates into the two lung fields), and there may be multiple emboli.

A pulmonary embolism is a medical emergency with very high mortality rates.

 

How do I detect a pulmonary emobolism?

The most common techniques for detecting a pulmonary emobolism include:

1. Recognising a patient is in respiratory distress;

2. Clear lung sounds and air entry to bases on ausculatation;

3. Previous medical history of cardiovascular disease, including obesity, ischaemic heart disease, high cholesterol or regular cigarette smoking;

4. Recent history of prolonged sedentary positioning, such as a long international flight;

5. Recent history of a fracture long bone, which may result in the development of a fat emobolism.

 

 

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Look For A Pulmonary Embolism

September 3rd, 2011

You have attended a patient who appears to be hyperventilating for no apparent reasons.

As you walk through the door, her husband tells you that she has been having intermittent periods of shortness of breath and looks terrified. As you walk through the door you can hear her clearly hyperventilating.

On Examination you find:

A 55 year old female who is mildly overweight. Alert. Skin pale, cool, diaphoretic. On Auscultation: chest clear. Good Air entry to bases. L =R. Inspiratory = Expiratory Phase. Speaking in single words only. Tachypnoeic at 36 resp per minute. Saturations: 84 on room air.

PMHx: High cholesterol.

Recent Hx: Flew long distance international flight yesterday.

Conclusion: most likely a pulmonary emobolism due to the obesity, poor cardiovascular healthy, and long haul flight with decreased movement for long periods.

Treatment options: high flow oxygen (although it probably wont help much) and urgent transport to a hospital that either 1. has cardiothoracic surgery capabilities or 2. heparin/thromalytic options.

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Most Horrific Obesity Story

August 30th, 2011

I’ve been a paramedic for about 10 years and during that time have seen many horrific and sometimes gruesome events, but this is the worst morbid obesity related event that I’ve ever witnessed. Given that this is the case, it may surprise you that I only had cause to actually vomit at work for the very first time recently. This story is not intended to humiliate or ridicule the patient who was suffering with super morbid obesity. Instead, it is designed to encourage people to make changes, as hard as they may be, to ensure that you never let their obesity get to this stage.

So, I received an emergency call for a person with a sore leg. The patient lived in a well-known, low sociological suburb, in which I have attended many times previously.

I arrive and find a patient who is suffering with super morbid obesity, a medical term used to describe people with so much excess body fat that they are in serious risk of death as a direct consequence of their obesity.

She is about 35, very few people suffering with super morbid obesity live longer than this, and she is lying on a three seater couch, which has been modified so that it is twice as deep as a regular three seater couch and even so, appeared to be filling the entire dimensions of the couch. My first impression is that the entire room smells of rotting food scraps and she appears to be a female version of Jaba the Hut.

The room has leftover buckets of food scraps, almost like a pig’s pen, strewn around the room, almost as though, in an emergency, she would be able to re-nibble on leftover, several week old scraps of deep fried meat.

I start to assess the patient and ask my usual set of paramedical questions. It isn’t long before I get to the point where she explains that the reason she has called for an Ambulance today is that she has pain in both legs.  She has a large sheet which she has lightly draped over her body. I have a remarkably poor sense of smell, but even I knew that this was the most disgusting smells of all time. I pull back the covers and find that due to her diabetes both of her legs have become necrotic (dying cells). Eating away the dying flesh I find literally hundreds of maggots. This patient had been unable to move for such a long time that she was no longer able to see her legs over the enormity of her girth. I explain to her what I had seen and she had no idea that she had maggots living in both her legs.

I then, regretfully ask if she has pain anywhere else.

She then points to her enormous apron (large stomach flap) – and tells me that it has been irritating her lately and has the odd tingling sensation.

I hold my breath and try to pull back the stomach flap as best I can. Maggots! More maggots were growing in the moist flap of the stomach… and then….

Eeep…. I hear….

What normal stomach anatomy makes the sound Eeep?

Mice! There are two mice squirming away in the warm undergrowth of her apron.

Please, don’t let this happen to anyone else you know! If you stop bringing them food, they will have to move to go get it! This is a self-resolving issue! Please pass this on as added incentive to anyone you know who has tried and tried again to start a diet that works!

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Homeostasis Definition

August 8th, 2011

Homeostasis can be defined as the balance in which a system, animal, country, or planet maintains a variable around an ideal normal value, or set point. Homeostasis can refer to the human or animal body, eco-system, city, planet or even a solar system, in which each system must maintain a certain balance to function. For example, Earth maintains homeostasis through a range of variables such as the global temperature. If the global temperature raises to high (above the normal values) certain animals within its system will not be able to survive, where as if it goes to low  (below the normal values) other animals will no longer be able to survive.

If you would like to learn more about homeostasis please view my homeostasis page.

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How to Become an Emergency Doctor

June 10th, 2011

If you’ve been a paramedic for some time and you are very competent in pre-hospital care you will find yourself identifying trends in your patient’s conditions and complications that you often find emergency doctors at time may overlook. It is about this time that you start to ask yourself the question, why couldn’t I be an emergency doctor?

So, what do you have to do to become an emergency doctor after being a paramedic?

To become an Emergency Doctor you should:

1. Have an excellent understanding of science, including advanced mathematics, chemistry and physics;

2. If you’ve been a paramedic for more than 3 years, chances are that you either have a degree in paramedics or at least an advanced diploma in ambulance practice. This means that you should be able to apply to study medicine as a postgraduate. This means only 4 years of study as opposed to 6 years!

3. Get some practice sitting the Graduate Australian Medical School Admissions Test (GAMSAT), which includes testing in mathematics, chemistry, biology, physics and English comprehension. This can be quite a hard test if you don’t have a strong background in sciences. You have to remember that you are competing against many people who have just completed a bachelor of medical science. However, where they will have a stronger science background, you have life experience and much more clinical experience as a paramedic.

4. Complete your medical degree. Amazingly enough, medical school is much easier to complete than the GAMSAT and the long build up of study towards getting into medcial school.

5. Complete a 12 month Medical Internship;

6. Complete a Medical Residency (like an internship, but more responsibility) for 2 years;

6. Choose an emergency specialty and apply for a training position;

7, Study a Registrar period in emergency (this can take up to 7 years)

8. Pass your Consultancy exams

9. Sit before a fellowship of peers in your chosen Medical Specialty and await their approval/ recommendation for you to become a Consultant in that area.

10. Continue to work and enjoy being a great emergency doctor!

 

Many paramedics go through this route and become excellent doctors. Many other paramedics have no desire to become doctors and this has no reference ability as paramedics.

If you would like more information about job prospects and careers as a doctor here is a link to more information about becoming a doctor.

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What is Reverse Osmosis?

June 10th, 2011

Where normal osmosis is the passive diffusion of a solute (water molecules) from an area of low solvent (mineral molecules) to high solvent levels through a selectively permeable membrane, reverse osmosis forces water molecules through a selectively permeable membrane through the use of an artificially raised hydrostatic pressure, requiring the active release of energy (such as pumps). In doing so, the small water molecules are forced through the small pores of the selectively permeable membranes, while the larger mineral molecules, such as salt are trapped in the filter and remain behind, thus leaving only clean drinking water on the other side of the selectively permeable membrane.

What are the benefits of Reverse Osmosis?

The benefits of reverse osmosis is the potential to produce clean, drinkable, water from the ocean during periods of severe draught, or in countries like Malta that have very little natural water supplies.

What are the cons of Reverse Osmosis?

1. The downside of reverse osmosis is the fact that this is not a passive movement of water through diffusion and requires the expenditure of large amounts of energy.

2. While reverse osmosis does remove all large mineral molecules, small bacteria (which are molecularly smaller than water molecules) are able to freely pass through the selectively permeable membrane, requiring desalinated water to have further refinement and treatment before it is drinkable by human beings.

3. Reverse osmosis also wastes large amounts of water during the process.

If you would like to learn more about osmosis, please review my what is osmosis page.

If you would like more examples of osmosis, please review my examples of osmosis page.

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What is Osmosis?

June 10th, 2011

What is osmosis? The term ‘osmosis’ in science refers to a process where by there is a diffusion of a solvent (water molecules) across a selectively permeable membrane from an area of less concentration of solutes (such as salt molecule) into an area of higher concentration of solutes. The process of osmosis is considered a passive movement, and does not require energy to achieve this movement of water. Although osmosis is considered a passive process it does cause the movement of water, and this does reflect some form of kinetic energy. The energy that osmosis utilises can be seen causing the movement of water, which releases kinetic energy.

What is the Significance of Osmosis?

Basically, this concept becomes important when we start to administer hypertonic (lots of minerals) or hypotonic solutions (lots of fluid). We understand that if we were to admister 100% sterile water intraveneously to patients who are dehydrated, the cells within the vasculature (blood vessels) would draw up all that fluid due to the osmotic gradient shift (this basically means that the fluid will want to shift into the cells) and this will cause the local cells to swell and lyse (rupture). This means that the red blood cells themselves will no longer be capable of carrying oxygen and serving their purpose.

Likewise, if you were to administer 50% glucose intravenously, the hypertonic solution (lots of solutes) will cause a lot of fluid to shift towards it. Now, so long as the canula is in a large vein, it will be able to draw fluid from a large area. However, if the canula is inserted in a small vein or accidentally inserted into the intersitial space and not a vein, it will not be able to draw fluid from all over, and consequently draw all the fluid from the surrounding cells. This will cause the cells to shrink (crenate) and again, become unable to sustain life. In these circumstance, patients may develop cellulitis or damaged veins.

How to Remember What Osmosis is

When trying to remember what osmosis is, think ‘salt sucks’ – because wherever salt goes, fluid will be sucked into following.

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How to Insert an Intraosseous Needle

June 1st, 2011

Inserting an intraosseous needle is another paramedic skill that you want to always be very copetent and capable of performing, but hope you go through your entire career without having ever having the need to do so.

An intraosseous needle is basically an IV Cannulae that goes directly into the bone so that you can rapidly infuse intravenous drugs or fluids directly into the bone marrow of a patient who is in complete life-threatening danger (generally reserved for cardiac arrests and very near cardiac arrest situations in paediatric patient) and there is no other way of gaining IV access. Intraosseous cannulation is generally only used in young children, because their bones are not fully developed and an adult can generally puncture the bone to reach the fluid of the bone marrow section of the bone. However, in recent years, technological advancements and equipment advancements have introduced many autimated intraosseous insertion machines that may have some place in adult cardiac arrest management. Currently, as paramedics in Australia, we only ever use intraosseous needles for paediatric patients in cardiac arrest.

How do you insert an intraosseous needle?

1. Determine the need for an intraosseous needle insertion – can I insert an IV cannulae instead?

2. Determine the location to insert the intraosseous needle – Any large aspect of bone can theoretically ‘take’ an intraosseous needle; however the proximal tibia or distal tibia are most common in paediatric patients. Insertion at the proximal tibia should be done about 1-2 cm inferior of the tibia tuberosity in the large flat surface of the the medial aspect of the tibia. Insertion at the distal tibia should be done at the medial aspect of the tibia just proximal to the tibial malleolous. In adults, the sternum has been used.

3. Prepare the skin as you would for any other cannulation (alcohol wipes) and remember that you are providing a direct access route to the bone marrow, so be certain to avoid infection.

4.  Insert the needle at a90 degree angle away from the growth plate

5. Twist the needle while placing a downward pressure until a loss of resistance is felt

6. Remove the needle (by rotating counter-clockwise)

7. The needle does not require securing because it should be firmly fixed into the bone.

 

Reasons Not to Insert an Intraosseous Needle

1. Obvious fracture to the bone

2. Prevoius attempts of I/O insertion with damage to the bone cortex

At the end of the day, if you, as a paramedic need to insert an I/O needle, the patient is in dire need.

Risks Associated with Intraosseous Needle Insertion

1. Extravisation (leakage of fluid into the interstitial space)

2.  Infection

3. Damage to the bone

4. Damage to the grown plate in paediatric patients

5. Penetration of the needle through the bone

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How to do CPR

June 1st, 2011

CPR stands for cardio pulmonary resuscitation and is the only resuscitation technique in cardiac arrest that has any scientific evidence of having an affect on the survival outcomes of the patient.

CPR was first identified as earlly as 1760, when attempts at resuscitation following cardiac arrest were documented in Amersterdam. Because Amersterdam had many canals and water ways, there was an unnaturally high level of drownings. Consequently a society of intelligent persons gathered to form the “Society for the Recovery of Drowned Persons.”

Over the years CPR has progressed and changed many times. The International Liason Committee on Resuscitation (ILCOR) was developed in 1992 and was designed to bring together the many committees and associations on the topic of best practices for CPR.

How to perform CPR based on the currently recommendations by the ILCOR:

The most simple CPR guidelines:

In the most simplest terms as a layperson or bystander, who witnesses a cardiac arrest or come across an unconscious person you should:

1. Push down fast and firmly on the center of the chest at a rate of about 100/minute.

2. If trained and confident: provide chest compressions at a rate of 30 compressions to 2 breaths. Remember, the most important thing in CPR is the chest compressions!

3. Keep going for as long as you can or until paramedics arrive and take over (if you still have strength to keep going, the paramedics may ask you to continue with the chest compressions while they provide the casualty with a breathing tube, defibrillation and cardiac drugs).

CPR may not resurrect a person in cardiac arrest, but without CPR, the casualty has no chance of survival.

Thank you for taking the time to read this. Remember, the most likely person that you will ever provide CPR to, will be a family member or close friend.

For more information on the International Liason Committee on Resuscitation, please follow this link: ILCOR

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What is Tinel’s Sign?

May 30th, 2011

Tinel’s sign is used by neurologists and othopaedic surgeons as a means of identifying irritated nerves.

How is Tinel’s test performed?

It is performed by percussing over a proximal nerve to elicit a sensation of tingling (pins and needles) in the distribution of the nerves.
In a positive result, the patient will experience a tingling sensation throughout the distal nerve branches.

Significance of Tinel’s sign

A positive Tinel’s sign is indicative of a possible neurological lession in an otherwise healthy adult or nerve regeneration in patients with partial nerve damage.

What are some examples of Tinel’s sign?

Example of Tinel’s sign in carpal tunnel syndrome. In this example, the clinician compresses the median nerve (in the wrist). A positive result of Tinel’s sign in carpal tunnel syndrome involves the presence of a tingling sensation in the thumb, index, and middle finger. Another example can include testing Tarsal Tunnel Syndrome, where a positive result can be identified by pain in the sole of the foot associated with pins and needles. If a neurologist compreses the calf, the patient will experience numbness and tingling in the toes and sole of the foot, indicating nerve damage or nerve regeneration in previous partial nerve injuries.

Here is a video of Tinel’s test being performed:

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What is Thompson’s Test?

May 30th, 2011

Thompson’s test is used as one method of determining if a patient has a ruptured Achilles tendon. The test is usually performed by an orthopaedic surgeon or a physiotherapist.

As a paramedic it is unlikely that you would routinely perform a Thompson’s test with a patient who has injured their ankle or damaged the tendon of the lower leg. However, if you have a patient who is still able to weight bear, and does not want to go to hospital, a Thompson’s test may provide an indication to the patient of the severity of the damage and importance of urgent orthopaedic assessment and treatment.

How do you perform a Thompson’s test?

A Thompson’s test can be performed by placing the patient in a prone position with the affected leg extended. Then squeeze the calf muscles to indirectly plantar flex the foot (in the healthy adult).

A positive Thompson test can be acknowledged if the foot does not plantar flex. A positive Thompson test helps confirm the diagnosis of a ruptured Achilles tendon, but is not definitive.

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Signs of Thyrotoxicosis

May 30th, 2011

The following are medical signs of thyrotoxicosis (excess circulation of the hormone thyroxine):

Dalrymple sign – (widening of the upper eyelid)

Gifford’s sign (difficulty averting eyes upwards)

Joffroy’s sign (Absence of wrinkling of forehead on sudden upward gaze)

Ballet’s sign (Weakness of at least one of the extraocular muscles)

Jendrassik’s sign (Paralysis of extraocular muscles )

Suker’s sign ( Poor fixation on lateral gaze)

Leowi’s sign (Dilatation of pupil with weak adrenaline solution )

Cowen’s sign (Jerky pupillary contraction to consensual light )

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What is Gifford’s Sign?

May 30th, 2011

Giffords sign is identifies hyperthyroidism and describes the condition in which a person develops a difficulty averting eyes upwards.

Giffords sign is one of many signs commonly associated with eye involvement with hyperthyroidism.

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What is Stellwag’s Sign?

May 30th, 2011

Stellwag’s sign describes infrequent blinking commonly associated with increased stress, calcium deficiencies, sleep deprivation and prolonged raised levels of anxiety.

Stellwag’s sign is also commonly associated with Darylmple’s sign, which is associeated with Grave’s disease.

As a paramedic, stellwag’s sign can be identified in conjunction with Darylmple’s sign as a potential risk factor for a patient who may be suffering with increased thyroxine levels. Many thyroid conditions are undiagnosed until serious cardiac dysrhythmias occur, triggering the patient’s need for medical investigation.

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What is Rosenbach’s Sign?

May 30th, 2011

Rosnebach’s sign indicates unusual tremor of the eyelids which is often associated with various diseases involving high levels of thyroxine.

What are the diseases associated with Rosenbach’s sign?

1. Grave’s disease
2. Hyperthyroidism
3. Thyroid storm

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What is Jellinek’s Sign?

May 30th, 2011

Jellinek’s sign refers to an increased pigmentation of the margin within the eyelids, often secondary to longterm sun exposure and hyperthyroidism.

What is the significance of Jellinek’s sign?

Jellinek’s sign is normally benign but may be a late sign of hyperthyroidism.

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What is Darylample’s Sign?

May 30th, 2011

Darylample’s sign is a noticeably widened eyelid due to the retraction of the upper eyelid. The palpebral (eyelid) is widened in Darylample’s sign as a result of excess thyroxin circulating in the blood. This is often seen in medical diseases affecting the thyroid gland, such as: Grave’s disease, Thyrotoxicosis, Hyperthyroidism , Thyroid Storm and iodine overdose through excess iodine intake.

What is the significance of Darylample’s sign to a paramedic?

As a paramedic, you may be the first diagnostic point in which a thyroid disease may be identified. By identifying Darylample’s sign a
paramedic may identify the need for  thyroid testing, and also an increased risk of cardiomyopathy as a result of prolonged tachycardia associated with
hyperthyroidism.

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When to Intubate a Patient

May 30th, 2011
Paramedics should start to consider intubation for any patient who is no longer effectively managing their own airway. Paramedics should be hesitant to wait until a person is completely unconscious before that start to think about intubation and getting equipement ready to intubate.

All patients with the following medical conditions should be intubated:
1. Patients who have suffered a cardiac arrest
2. Patients who have severe maxilla/facial trauma
3. Burns patients who have suffered burns to the upper airway
4. All severe cases of hypoxia in which the paramedic is unable to maintain adequate oxygenation through any other means (such as bagvalve mask ventilation and intermittent positive preassure ventilation (IPPV).
5. Persons with a traumatic or non-traumatic brain injury that become combative and are safer once sedated and intubated.
6. Drug overdoses, unresponsive to naloxone or flumazenil, such as GBH overdoses, in which the patient has intermittent periods of consciousness and complete unconsciousness.

Intubation should be performed as a last resort, but this does not mean that planning and preparation for intubation should wait until the last minute!

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eMR for Paramedics

May 30th, 2011

What is eMR? The term ‘eMR’ is an electronic medical record system that is being introduced to most public health services in Australia as a means of improving the clinical standards in health, improving the ability to manage key performance indicators (KPIs) and increased abilities for conducting health research.

eMR in Ambulance Practice

The introduction of eMR systems in Ambulance Services within Australia commenced with trials in 2005 in the Metropolitan Ambulance Service of Victoria. Since this time, Ambulance Services in NSW, QLD and Tasmania have all recently introduced eMR for paramedics, in which paramedics utilise tough computers and the Victorian Ambulance Service designed VACIS program, which was designed to allow paramedics to:

Allow better training for paramedics

Review clinical standards

Conduct pre–hospital research

Audit dispatch priority codes

Design services for the future.

eMR , like many other recent technologies in ambulance practice is often met with poor reception by paramedics(and sometimes poor introduction by the various ambulance services). Where eMR is much more difficult in ambulance practice than in nursing, medicine and other aspects of health, is the fact that paramedics work in a unique environment, such as a person’s house, motor vehicle crash, and in the back of an ambulance.

Which Ambulance Services currently use eMR?

The following ambulance services in Australia use eMR (based on the original VACIS software):

Ambulance Victoria

NSW Ambulance Service

QLD Ambulance Service

TAS Ambulance Service

eMR still has a long way to go and many future developments in both technology and software development to ensure that parmaedics are able to perform their normal pre-hospital care duties. Whether we like it or not, it is the way of the future, and certainly the way of future research and improvements to ambulance practice, so we may as well make the most of it.

The following websites have good information about eMR and VACIS:

Ambulance Victoria
eMR in NSW

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Australian Ambulance Services

May 29th, 2011

The following links provide official information about many of the Ambulance Services in Australia and other emergency management organisations which may be able to assist you in finding paramedic jobs in Australia:

 

Ambulance Service of NSW

Ambulance Service of Victoria

QLD Ambulance Service

St John’s Ambulance Service Western Australia

ACT Ambulance Service

SA Ambulance Service

Emergency Management Australia

Emergency Medical Services Protection Association

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What is Cricothyrotomy?

May 24th, 2011

Cricothyrotomy is a last resort, lifesaving, procedure for paramedics who are treating a patient with a complete airway obstruction unable to managed in any other way.

To review normal paramedic advanced airway procedures please see my How to Intubate page.

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain severe life-threatening airway obstructions.

The following are indications for cricothyrotomy:

1. Airway obstruction by a foreign body unable to be relieved through back blows, chest compression or the use of a laryngoscope and magills forcepts;

2. Angioedema;

3. Facial trauma;

4. Unable to intubate;

5. Unable to manually ventilate;

6 nasal injuries (that do not allow oral or nasal tracheal intubation)

7. Massive midfacial trauma

8 Possible cervical spine trauma preventing adequate ventilation

9. Anaphylaxis with angio oedema unresponsive to adrenaline;

10. Chemical inhalation /injuries

 

Cricothyrotomy is easier and quicker to perform than tracheotomy; howver, cricothyrotomy is not designed for longterm or definitive airway management, but lifesaving emergency treatments.

Paramedics never routinely perform cricothyrotomy – in fact, aneasthetists never routinely perform criocothyrotomy. Cricothyrotomy is for when things have gone wrong or were very wrong to begin with and is a very last resort.

Other names for cricothyrotomy include:

1.Thyrocricotomy;

2 Cricothyroidotomy;

3 Inferior laryngotomy;

4. Intercricothyrotomy;

5 Coniotomy; or

6.Emergency airway puncture.

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What is Rapid Sequence Intubation?

May 24th, 2011

Rapid sequence intubation or rapid sequence induction are the terms used when a clinician such as a doctor or paramedic intubates a previously conscious patient by providing an induction agent (anaesthetic) to make the patient unconscious, followed by a rapidly acting neuromuscular blocking agent (muscle relaxant) so that that patient becomes both unconscious and muscular paralysis occurs allowing for the insertion of an endotracheal tube (ETT).

When should you Rapid Sequence Intubate a patient?

RSI is another relatively new concept in paramedics, with ambulance services such as those in the UK, Melbourne (Australia) and in many parts of the US embracing it for use in the following circumstances:

1. Rapidly declining patients, who are likely to require intubation soon;

2. Patients with severe burns to the upper airway who are likely to develop laryngeal oedema and occlude their airway later;

3. Trauma patients, with head injuries who are deteriorating or unable to be managed;

4. Acute Pulmonary Oedema/ severe airway problems that are unable to be managed in the conscious patient to the patient’s cerebral agitation.

Rapid Sequence Intubation requires confidence on the paramedic’s behalf that he or she is capable is capable of intubating the patient and if intubation fails that there is an alternative airway solutions, such as LMA, Bag valve Mask Ventilation, and Cricothyrotomy (in desperately extreme cases).

How do you perform a rapid sequence intubation?

The following mnemonic for performing RSI should be followed when performing rapid sequence intubation:

1. Preparation — prepare all necessary equipment, drugs and back-up plans;

2. Preoxygenation — with 100% oxygen to remove excess nitrogen and allow greater time and safer intubation;

3.Premedication — this should induce unconsciousness, such as midazolam

4. Paralyze — this makes it physically possible to pass a tube through the vocal cords (such as suxamethonium or rocuronium)

5. Pass the tube —visualize the tube going through the vocal cords

6. Proof of placement — using a reliable confirmation method, such as auscultation, end title CO2 monitoring (where you can confirm placement of the ETT by showing an ETCO2 waveform;

7. Post intubation care — secure the tube, ventilate, and regularly monitor

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What is Dahl’s Sign?

May 23rd, 2011

Dahl’s sign which is also known as Thinker’s sign or Target sign is a clinical sign in which areas of hyperpigmentation are seen on the
skin of the lower thighs and elbows. It occurs in patients with longstanding severe chronic obstructive pulmonary disease.

The sign occurs because patients with COPD tend to sit forwards with their arms resting on their thighs, leading to chronic erythema of the
skin at the points of contact. Over time, haemosiderin released from red blood cells trapped in the skin is released causing a brown discolouration of the
skin.

Air trapping in the lungs of COPD patients causes the diaphragm to be pushed down and flattened, which reduces the effect of
contraction of the diaphragm during inspiration. Sitting forwards pushes the abdominal contents upwards, increasing the curvature of the diaphragm and
improving its effectiveness. This is why, when we attend patients in severe asthma, they are often in the tripod position.

The relevance of Dahl’s Sign to paramedics:

As paramedics we often attend patients who have COPD. Sometimes these patients may appear very short of breath, but are not able to
explain that they have COPD. Dahl’s sign is one way to identify that a patient has COPD normally.  It is one clinical factor, and of course not the only thing that you should rely on in your treatment decisions for this patient.

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What are Brushfield Spots?

May 23rd, 2011

Brushfield spots are small white or grayish/brown spots on the periphery of the iris in the human eye due to aggregation of connective
tissue, a normal iris element. They are common in many children of Caucasian background, but much less common in children with Asian backgrounds. They occur commonly in children who suffer with Down syndrome, although their appearance alone does not indicate Down Syndrome.

Is Brushfield Spots relevant to paramedics?

Not particularly, however it is important to recognise normal variances in eyes, such as pupil dilations, dots, etc, and determine if this is a normal variance or a pathological occurance.

In most cases Brushfield’s spots do not indicate any pathology.

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What is Dunphy’s Sign?

May 23rd, 2011

Dunphy’s Sign is a medical sign that relates to a person who has right sided abdominal pain and assocated coughing, which is usually indicative of appendicitis.

So, what does Dunphy’s sign entail?

Dunphy’s sign requires the following signs to be present:

1. Increased right side abdominal pain; and

2. Associated coughing

What does Dunphy’s sign actually indicate?

Dunphy’s sign indicates the potential for an enlarged or inflamed appendix. It is not a definitive diagnostic tool for the diagnosis of acute appendicitis; however it does suggest appendicitis and certainly warrants further test to confirm or rule out appendicitis.

Is Dunphy’s sign relevant to paramedics?

It is important as a paramedic to be able to recognise when or if your patient is suffering with acute appendicitis, because this is a life threatening emergency that needs urgent surgical interventions. Dunphy’s sign is just one tool that can be used as a paramedic to indicate a high likelihood of a patient suffering with appendicitis.

 

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What is Hickam’s Dictum?

May 23rd, 2011

Hickam’s dictum is a counterargument to the use of Occam’s razor in the medical profession.
The reason for using Hickam’s dictum as a limiting principle to that of Occam’s razor is that it is often statistically more likely that a patient has several common diseases rather than having a single, rarer disease that explains his myriad symptoms. Another key reason is that, independent of statistical likelihood, some patients do in fact turn out to have multiple diseases.

As a paramedic, I have often treated a patient who’s signs and symptoms do not match any given single condition. Later, it has been determined that the patient has had multiple ailments and not one large bizaire medical condition.

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What is Occam’s Razor?

May 23rd, 2011

The principle of Occam’s razor is often erroneous duplicated in the words:  “the simplest explanation is most likely the correct one.”  In medicine, Occam’s razor is sometimes used when a patient’s case becomes so complicated that the clinician or doctor looks to the most simplest solution.

Diagnostic parsimony advocates that when diagnosing a given injury, ailment, illness, or disease a doctor should strive to look for the fewest possible causes that will account for all the symptoms.

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What is Saint’s Triad?

May 23rd, 2011

Saint’s triad reflects the significance of identifying three totally un-related medical signs or symptoms. Doctor Saint reminded medical staff that patients aren’t necessarily afflicted with only one medical condition. Through the medical triad of Saint’s Triad which identifies the existence of three totally un-related medical conditions (1.Cholelithiasis, 2.Hiatal Hernia and 3.Diverticular Disease) that a clinician should be wary of the existence of more than one potential medical condition.

Saint emphasized the need for considering the possibility of multiple separate diseases in a patient whenever a patient’s history and the results of the physical examination were atypical of any single condition.


So what is Saint’s Triad?

Saints triad includes the existence of the following three conditions:

1. Cholelithiasis;

2. Hiatal hernia;

3. Diverticulae

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How to Insert a Nasogastric Tube

May 23rd, 2011

As with any other procedure performed as a paramedic, doctor, nurse or any other health care professional you need to ask yourself
the important question of – do I have to do this procedure? Before you start practicing your skills on them.

So, what are some reasons why you would want to consider inserting a nasogastric tube?

Gastric distension with air or fluid after near drowning or poor EAR is the most common need for inserting a nasograstric tube in an emergency setting, especially when the patient has:

An increased risk of regurgitation;

Continuous vomiting unresponsive to antiemetics;

Intubated patients who are receiving IPPV (especially
children).

How to insert a nasograstric tube:
Choose the right size tube;

Measure from the tip of the nose to the ear lobe down to just below the xiphoid process (this gives you an approximation of the length
required to reach the stomach, but it may vary, all humans seem to  be anatomically different);

In the unconscious patient, insert the ETT first and then pass the tube through the widest nostril and then down the oesophagus using a
laryngoscope to confirm that this tube went into the oesophagus.
In the conscious patient, the tube should be lubricated first and then passed through the widest nostril while encouraging the patient
to swallow. Little sips of water may assist this process.

To check for adequate placement of the NG Tube:

Aspirate with a 50 ml syringe and assess for gastric contents;

Inject 50ml of air down the tube and auscultate the epigastrium for the sound of bubbles in the stomach.

 

Secure the NG tube well.

 

Other variances of this procedure include orogastric insertion where the tube is inserted through the mouth, down the oesophagus and then into the stomach.

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How to Intubate

May 23rd, 2011

Intubation is an advanced airway management skill that should be practiced regularly and used sparingly. As a paramedic, the advanced airway skill of intubation has been used since the Vietnam war in which army doctors had no desire to go into the jungle to intubate their badly burned soldiers, and so decided to teach their medics how to intubate. After the Vietnam War, paramedics started to think, hey, if we can do it in Vietnam, why not back home on the streets? 

Senior paramedics in ambulance services all around the world have been trained and regularly use the skill of intubation to manage unconscious patients who are not longer managing their own airway, such as cardiac arrest victims and people with a GCS approaching 3.

Intubation

In the past ten years researchers have started to question the appropriateness of intubation in the pre-hospital care setting after some research has indicated worse outcomes for patients who were intubated prior to arrival in hospital than patients who were manually ventilated and then intubated in hospital.

Some of the reasons highlighted for this include:

* Trauma patients were delayed on scene while the paramedics attempted to intubate (although intubation should only take 10-20 seconds the
preparation may take much longer);

* Often unclean environments in which paramedics treat their patients may lead to secondary complications such as pneumonia and later on
difficulties weening patients off the ventilators in ICU;

* Concentration on intubation over all other issues (where a patient could be manually ventilated to hospital); and

* Incorrect placement of the ETT into the oesophagus (and not diagnosed by the paramedic).

* Patients who were intubated at the scene were more commonly at the end of their potential treatment options (such as cardiac arrests and severe trauma with airway involvement);

This said and done, intubation is an excellent skill and one that I believe well and truly has a place in the pre-hospital environment. Intubation should be considered as a gold standard of airway management and securement in any patient who is unconscious without the ability to maintain their own airway.

Intubation is particularly important in patients who have:

1. Suffered a cardiac arrest, as a means of securing the airway and providing an easier relationship between chest compressions and ventilations;

2. Suffered burns to the airway, which will likely swell and occlude the airway if left untreated.

Guide on How to Intubate

So, how do we intubate a patient?

ETT insertion follows these main steps:

Always have a back up plan in case you are unable to intubate!

Maintain normal airway management and ventilation throughout procedure;

Pre-oxygenate the patient with 100% oxygen (of course, this may not be possible if the reason you are trying to intubate the patient is due to being unable to manage the airway any other way)

Position the head into the ‘sniffing’ position, in which the head is slightly raised, tilted back slightly and the chin is stretch anteriorly into a ‘sniffing’ position

Prepare the ETT equipment, including suction, ventilator (if your service is lucky enough to have one), and LMA in case the ETT fails

Laryngoscopy and visualize the vocal cords (easier said than done)

Insert ETT and inflate cuff

Attatch bag and ventilate slow deep ventilations, while auscultating the stomach first (to listen for possible gurgling sounds if you are in the oesophagus), then both axilla to ensure that you haven’t intubated
the right or left bronchus only

Attach a CO2 monitor and assess for a CO2 wave pattern (no pattern means no CO2 and indicates that the ETT is in the wrong place)

Secure ETT if correct placement is confirmed
Regularly monitor, ETT placement, equal raise and fall of the chest, equal lung sounds, CO2 wave pattern, SaO2, Skin colour of patient, heart rate, and blood pressure to ensure that the patient is still being well perfused.

More Guides on How to Intubate

Here is a video link on how to intubate:

httpv://www.youtube.com/watch?v=Ix8i708Cv7g

Tips for the actual insertion process of intubating:

Visualise pushing laryngoscope away from patients’ nose. This avoids the natural tendency to lever laryngoscope on teeth. If you break teeth during intubating in a cardiac arrest there is the chance that a tooth may become dislodged and fall into the larynx (this is not a good thing);

Insert laryngoscope down right hand side of mouth and push tongue to left and out of the way. Gradually insert until cords are visible.
Alternatively insert blade all the way in (too far) and then slowly pull back until cords become visible. Push tip of laryngoscope into vallecula.

If an attempt is not successful within 30 seconds withdraw and ventilate immediately to minimise apnoea.

Holding your breath during laryngoscopy and ETT insertion will give an indication of when the patient requires ventilation (although it
may not help you concentrate and may add additional stress on your body);

When inserting tube, viewing the cords can become obstructed. This may be exacerbated by having laryngoscope blade and tube both being central and dominating the view. Try pulling laryngoscope across as far to left as possible whilst inserting the ETT from as far right as possible to open up view.

Tips of the trade for paramedics intubating:

If left side of the chest does not expand during ventilations you may have inserted the ETT into the left main bronchus
(although it is more common to accidentally go into the right main bronchus, this does sometimes occur) – if the ETT is placed correctly,  assess for other causes such as tension pneumothorax and treat accordingly.

Where cardiac arrest is from an obstructed airway be careful of foreign matter remaining within the trachea and being pushed further down by
the tube, Magill’s forceps are recommended.

Don’t forget to suction (I know it’s a nuisance to clean afterwards) but there’s  reason our cars are equipped with it and this is it;

If you are performing effective non-intubated ventilations then you are doing what the patient requires ;

Prolonged attempts to intubate a patient may result in hypoxic brain damage.

Hyperventilation may lead to hypocapnia (reduced carbon dioxide in the blood), also hypotension due to increased intrathoracic pressure

decreasing venous return. 

To learn more about other advanced airway procedures please review my Rapid Sequence Intubation page and Cricothyromotmy page.

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Mental Illness, or Just Bad People?

April 27th, 2011

If you or a family member suffer from a borderline personality disorder, please do not be offended by this topic…

I’ve noticed that over the last 5-10 years our attendance to violence associated with “Mental Illness” has increased drematically. In many cases these people have a genuine mental illness and are capable of being treated with medications and returning to normal and productive lives within society. However, unfortunately for people who do suffer with mental illness, there are many who either ‘fake’ mental illness, or are simply bad people.

The question however, is how do we differentiate between mental illness and just bad people?

Don’t get wrong, I’ve treated many patients who genuinely suffer with Mental Illness such as Pschizophrenia who I believe genuinely suffer with a mental illness and are good people…

However, I attend people time and time again who assault people, steal, hit, spit, puonch, etc… and are repeately taken back to hospital for treatment of disorders such as Borderline- Personality Disorders. How do we differentiate between these people and just bad people?

Here is a case…

16 year old male – found attempting to stab his sister with a fork. Called by police to treat a patient who has been diagnosed with “Anger Management Disorder” (although I can’t seem to find that in the DSM IV).

The 16 year old had litterally stabbed his older sister and was now claiming that he had a mental illness and wished to be treated. I talked to him, and he advised that he didn’t want to kill himself, but that he loses his temper and wants to kill his sister and mother regularly. When asked if he has an idea of how he is going to do this, he states: “I will stab them to death in their sleep…”

This person,first and foremost, irrespective of his potential mental illness needs to be sedated or locked up for the safety of the community and his family.

I asked the patient if he was willing to go to hospital, and he decline in no uncertain terms. He was eventually scheduled and forced to go to hospital. He was given the age old Ambulance offer of “Do you want to come in the Ambulance and behave or go with the police…” and he spat on my partners face… that made the decision clear for me. And I advised the police that they would be transporting him.

My decision was later reviewed when his mother complained that we had locked him up like a common criminal even though he was not a criminal but had a mental illness…

What does everyone else think about this?

To me, it seems clear, if you can’t behave in an Ambulance (whether this is because you have a mental illness, are in a drug induced psychosis or just a bad person) you don’t get the choice, you must be taken in a police wagon that is safe for you and for us.

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What is Reynold’s Pentad?

April 27th, 2011

Reynold’s Pentad is a collection of both signs and symptoms that a Medical Practitioner or paramedic can identify in order to determine a diagnosis of sepsis.

In acute ascending cholangitis, which is an infection of the biliary tree (usually from E-coli) the patient may have Charcot’s triad of symptoms (fever with rigors; jaundiced skin, and RUQ Abdominal Pain) and Reynold’s Pentad (Hypotension and Decreased Level of Consciousness) indicating that he or she is septic.

What is the signicance of Reynold’s Pentad to paramedics?

As a paramedic, the presence of Reynold’s Pentad should highlight to the paramedic the need to look at possible causes of sepsis and to commence early anti-bacterial therapies with IV antibiotics such as ceftriaxone or benzylpenicillans.

Reynold’s Pentad indicates sepsis as a likelly cause of the low blood pressure and decreasing level of consciousness as opposed to other common causes, such as cardiac problems, toxicologies, or cerebral events.

At the end of the day, as a paramedics, it is always important to treat the patient based on the signs and symptoms that you see, and not to focus too much on a specific diagnosis.

 

 

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What is Charcot’s Triad of Multiple Sclerosis?

April 27th, 2011

Charcot’s triad for Multiple Sclerosis identifies three medical signs which highlight possible brain stem damage or involvement:

1. Nystagmus (the uncontrolled movement of the eyes from in a lateral motion)

2. Intention tremor

3. Staccato speech

It is important to recognise that although these three signs are indicative of multiple sclerosis, they are not definitive of the diagnosis.

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What is Charcot’s Triad of Ascending Cholangitis?

April 27th, 2011

Charcot’s triad for ascending cholangitis

Charcot’s triad for ascending cholangitis is a result of ascending cholangitis (an infection of the biliary tree duct often caused by E-coli).

1. Jaundice (yellow tinge to the skin)

2. Fever, usually with rigors (shakes and tremors)

3. Right upper quadrant abdominal pain.

If the patient is hypotensive (low BP) and there are changes to his or level of consciousness you should consider Reynold’s Pentad and sepsis.

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What is Charcot’s Triad?

April 27th, 2011

Charcot identified two different medical triads. These include: Charcot’s Triad of Multiple Sclerosis and Charcot’s Triad of Ascending Cholangitis. They are both identifying very different diseases and disorders and should not be confused with one another.

Charcot’s triad for Multiple Sclerosis identifies three medical signs which highlight possible brain stem damage or involvement:

1. Nystagmus (the uncontrolled movement of the eyes from in a lateral motion)

2. Intention tremor

3. Staccato speech

It is important to recognise that although these three signs are indicative of multiple sclerosis, they are not definitive of the diagnosis.

Charcot’s triad for ascending cholangitis

1. Jaundice (yellow tinge to the skin)

2. Fever, usually with rigors (shakes and tremors)

3. Right upper quadrant abdominal pain.

Charcot’s triad for ascending cholangitis is a result of ascending cholangitis (an infection of the biliary tree duct often caused by E-coli).

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What is a Carcinoid Syndrome?

April 27th, 2011

A Carcinoid Syndrome is a medical syndrome which is caused by a malignant tumour (normally in the gastrointestinal tract) that results in the stimulation of glands which release vast quantities of various hormones.

The hormones most commonly responsible for the symptoms is normally serotonin.

What treatment is available for Carcinoid Syndrome?

Treatments for Carcinoid Syndrome are primarily palliative; however, if able to surgically remove the primary tumours, this should be done, and then secondary treatment should involve medications that control the symptoms.

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What is a Carcinoid Triad?

April 27th, 2011

A carcinoid is a type of tumour that originates in the gastrointestinal tract (GIT) and causes vast quantities of certain hormones to be produced, which in turn cause three distinct signs, which form the Carcinoid Triad. 

The classic ‘triad’ seen in a carcinoid triad of symptoms include:

1. Flushing

2. Diarrhoea

3. Cardiac problems (most commonly right-sided heart failure)

 The cause of most of these signs is serotonin.

 What is the clinical significance of Carcinoid’s Triad?

The clinical significance of Carcinoid’s Triad is that it should highlight to a General Practitioner, Oncologist, Community Nurse or Paramedic the need for further investigations, including abdominal ultrasound, CT or MRI to determine the possibility of un-diagnosed malignant tumours.

Carcinoid Tumours are usually very slow growing and many patients have been known to live for 30-40 years after diagnosis.

If you would like to learn more about Carcinoid Syndrome, please review my Carcinoid Syndrome page.

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Allen’s Test

April 27th, 2011

Allen’s Test is a test used in medicine prior to arterial blood gas collection in order to determine normal patency of the ulnar artery.

Anatomy of Allen’s Test

The anatomies evaluated in Allen’s Test include both the ulnar and radial arteries. In normal anatomical and physiological function the hand is supplied with blood (perfusion) through the ulnar and radial arteries. If one is occluded, the other provides blood to the hand and maintains perfusion. In a very small percentage of the population, only the radial or only the ulnar artery is functioning, and therefore they lack the ability to have dual blood supply to the hand.

How do you Perform an Allen’s Test?

To perform an Allen’s test:

  1. The patient’s hand should be elevated above his or her heart;
  2. The patient’s should be asked to make a fist;
  3. Pressure should be applied to both the radial and the ulnar artery until distal blood flow is occluded;
  4. While maintaining the elevated hand position, the patient should then open the hand. The hand should appear pale and have limited capillary refils;
  5. The ulnar arterial pressure should be released (while maintaining enough pressure to occlude the radial artery).
  6. The hand should return to normal colour within 5-7 seconds.

If the patient’s hand returns to normal colour within 3-7 seconds the Allen’s test is said to be negative and the patient has normal dual blood supply. If the patient’s hand returns to normal after 7 seconds, the Allen’s test is said to be negative and the patient does not have dual blood supply to the hand (or if he or she does, it is very small).

What is the Clinical Significance of Allen’s Test?

When the Allens test is positive (meaning that the patient does not have dual blood supply to the hand), he or she will often have a negative result for the other hand. Therefore, to reduce the risk of ischemia to that hand, it is important to perform the cannulation or arterial blood gas collection from the hand with dual blood supply.

What is the clinical significance of Allens test in Paramedics?

The clinical benefits of Allens test in paramedics is only relevant when you are about to attempt to cannulate near the radial or ulnar artery. It is uncommon as a paramedic to need to cannulate the veins in this region; however, in some IV drug users, or people who have been on steroids for many years, that most of their veins are damaged, and consequently these are the only veins left open to use. In this circumstance, it is important to perform an Allens test before hand to ensure that you do not accidentally damage the radial or ulnar artery on the one hand without dual blood supply.

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What is Chadwick’s Sign?

April 27th, 2011

Chadwick’s Sign of Estrogen

In medicine, Chadwick’s sign is used to identify a raised level of estrogen associated with pregnancy, and can be seen as early as 8-10 weeks after conception. Chadwick’s sign identifies a blusih discoloration of the vagina, labia and cervix, as a secondary result of the venous congestion after the female body has increased its base estrogen levels.

What is the clinical significance of Chadwick’s sign?

Chadwick’s sign is generally an interesting phenomenon seen in obstetrics and gynaecology. The clinical significance is generally more as a trigger to perform a BHG hormone test (pregnancy test) in any patient who is complaining of changes in their vaginal colours. However, this is more an interesting phenomenon than  a clinical need to know, because all patients who are experiencing these changes should have a pregnancy test performed anyway.

Is Chadwick’s sign relevant to paramedics? No, unless you’re a midwife and working for the Royal Flying Doctors, this is irrelevant to paramedics.

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What is Chaddock’s Sign?

April 27th, 2011

Chaddock’s Sign or Chaddock’s Reflex

Chaddock’s sign is similar to a Babinsky Sign, in which stimulation over the lateral malleolus causes the big toe of an adulto to reflexively point upwards, which indicates potential lessions to the pyramidal tract.

How does Chaddock’s sign differ from Babinski’s Sign?

Charles Gilbert Chaddock was originally an assistant medical officer to Joseph Babinski (the neurologist who first identified the Babinski sign). Chaddock later move to the US and published his version of the sign, which included stimulation over the lateral malleolus, instead of the base of the foot.

To learn more about the Babinski Sign, please refer to my Babinski Sign page.

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What is Carvello’s Sign?

April 27th, 2011

Carvello’s Sign of Tricuspid Insufficiency

Carvello’s Test is a medical sign used during auscultation of the heart in order to determine if a patient has a tricuspid or a mitral valve insufficiency.

In order to test Cavello’s sign a Doctor or Medical Practitioner should auscultate the sounds of the heart and ask the patient to breath in. During the inspiratory phase or respiration, a positive Cavello’s sign will increase the volume of a cardiac murmur as a result of the tricuspid insufficiency, if the sound remains the same or lessons, it usually indicates that the murmur is the result of a mitral valve insufficiency and not tricuspid.

This indicates a flow of leaking blood in a backwards direction from the right ventricle to the right atrium during the systolic phase of the cardiac cycle (this is when the left ventricle compresses in order to eject blood through the aortic arch).

What is the clinical significance of Carvello’s  Sign?

The clinical significance of Carvello’s sign is that it is a simple methodology for a clinician to discern between a tricuspid insufficiency and a mitral valve insufficiency.

Is Carvello’s sign rellevant to paramedicine? Typically, Carvello’s sign has little significance in the pre-hospital care setting; however, it is interesting to know, and may be useful if you are transporting a patient from cardiology or intensive care, because it may be seen in the patient’s notes.

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What is Carnett’s Sign?

April 27th, 2011

Carnett’s Sign – Abdominal Assessment

Carnett’s sign is recognised in medicine and paramedicine as a method of determining the likelihood that the abdominal wall is the primary source of the pain and not the internal organs or viscera. To perform a Carnett’s test a clinician should ask the supine patient to lift his or her legs off the bed (alternatively, you can ask him or her to lift their head or shoulders off the bed). A positive Carnett’s sign is identified when the patient acute abdominal pain remains unchanged or in some cases worsens during the test. If the abdominal pain decreases during the test, it is more likely that the patient has organ or visceral pain, and not abdominal muscle sheath damage.

What are some conditions that a positive Carnett’s sign may indicate?

Positive Carnett’s Sign may indicate medical conditions such as:
1. Abdominal Hernia;
2. Abdominal wall haematoma; and
3. Rib Tip Syndrome (in which the lower rib tips are hyper-flexed causing referred pain into the intra-abdominal region.

Want to know more about abdominal assessments? Please review my Abdominal Pain Assessment page.

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What is Capgras Syndrome?

April 26th, 2011

Capgras syndrome, which is also known as Capgras Delusion Syndrome, is a disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member has been replaced by an identical-looking impostor. Under the DSM IV the Capgras delusion is classified as a ‘delusional misidentification’ syndrome, a class of delusional beliefs that involves the misidentification of people, places, or objects. It can occur in acute, transient, or chronic forms.

Although the delusion is most common in patients who have a previous diagnosis of schizophrenia, it can also occur in people who have had a brain injury and those who suffer with dementia.

What is an example of Capgras Syndrome?

Here is a basic case study of a person who is suffering with Capgras Syndrome:

62 year old female lives with husband of 40 years. She has no previous medical history and takes no medications. She is involved in a car accident in which she suffers a concusion with a minor loss of consciousness (otherwise fine after the event). On her way home, her husband comes by the hospital and she is unable to recognise him as her husband. Does he look the same? Yes. Does he speak the same? Yes. Is he your husband? No, definitely not.

In this case, the Capgras Syndrome was an acute, post head injury event, and not a longterm syndrome.

How is Capgras Syndrome relevant to medicine?

Capgras Syndrome becomes relevant to medicine because it identifies other potential causes of what may otherwise appear to be schizophrenia or dementia. Capgras Syndrome can be longterm, but can also be a shortlived symptom after an event. For the diagnosis of Capgras Syndrome to be considered by a Medical Practitioner, a CT and MRI must first be performed to rule out any underlying organic pathologies.

How is Capgras Syndrome relevant to paramedics?

The relevance of Capgras Syndrome to paramedics is limited to the fact that as some stage in our career we may attend people who are suffering with this disorder. We must be wary that the condition is potentially secondary to organic causes, such as head injuries, endocrine disorders, drugs, or acute psychosis.

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What is a Nephrotic Syndrome?

April 14th, 2011

A Nephrotic syndrome is any syndrome in which the kidneys have been damaged, resulting in an increase in the amount of proteins that pass the glomerulus and into the urine.

Kindneys that are affected by a nephrotic syndrome have larger than normal podocytes (which allow lareg protein molecules to pass through).

More to come on Nephrotic Syndrome

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What are Muehrcke’s Nails

April 14th, 2011

Muehrcke’s nails are non grooved (white) indentations of the nailbed in a vertical line.

Muehrcke’s nails are also known as leukonychia striata. Muehrcke’s nails often indicate periods of metabolic stress, such as:

1. Hypoalbunimaea;

2. Chemotherapy: and

3. Nephrotic Syndrome.

Although Muehrecke’s nails are easily identified, they seldom are associated with malignant disease processes.
A Robert Muehrcke first discovered the symptom.

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What is Beau’s Lines?

April 14th, 2011

Beau’s lines are indented grooves that run from one side to the other of a person’s nail bed in a horizontal line (not vertical).

The cause of Beau’s lines are not well understood. It is believed that the following are some potential causes of Beau’s lines and are related to the nail bed’s inability to divide its cells for a certain period of time. These include:

1. Hypocalcaemia (low calcium levels);

2. Malnutrition;

3. Corronary occlusion (heart disease);

4. Trauma;

5. Prolonged hyperglycaemia (diabetes); and

6. After long periods of systemic infection, such as sepsis.

Beau’s lines were first identified by a Joseph Beau

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What is a Battle’s Signs?

April 14th, 2011

A Battle’s Sign, in medicine is technically called a mastoid ecchymosis (bruising behind the ears) that indicates a posterior basal or base of skull fracture and potential brain injury.

Battle’s Sign is usually seen post head injuries resulting in trauma to the mastoid process, leading to bruising. This sign is commonly associated with racoon eyes (the bruising around the eyes) and is most commonly found in patients with a base of skull fracture.

The first person to identify the sign is a Doctor William Battle.

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Trauma Patients – What Hospital?

April 13th, 2011

Going back as little as ten years ago, all paramedics brought all patients to the “nearest” hospital. Paramedics were given very little freedom to choose the hospital that they were to take their patient to, or determine which hospital was most appropriate for which patient. In the world of modern Ambulance Services, paramedics are aided in this decision by the adjunct of many computer systems, matrixes, hospital allocation cards and private/public patient’s requests.

However, there is now a greater emphasis on paramedics being able to be more than robots that follow flow charts and algorithyms, and actually think about what is best for their patients.

I recently attended an 18 year old male who had been hit by a car while walking across a busy road. The mechanism was car vs pedestrian 60 km/h. The patient was knocked over the windscreen and had a head injury.

On arrival, the patient was Airway: Minor Stridor/snorring (rectified with O/P airway); Breathing: Normal; Circulation: Tachycardic 132, radial pulses present, BP 102/44. Disability: Unconscious, with a GCS of 3. Exposure: Head: PEARL5mm, large haematoma to occiput with a “boggy mass”, Neck: NAD, Chest: Clear, Good air entry to bases, L=R, Abdo, rigid on palpation and appears swollen on the left side (query splenic rupture), Pelvis, NAD, Limbs: NAD (but unable to assess motory/sensory due to patient being unconscious).

Treatment on scene: O/P airway inserted, O2 therapy via a non-rebreather mask, spinal precautions including, cervical collar, sandbags, spineboard and anti-emetics.

Treatment enroute: urgent transport, IVC inserted, fluids set up, but not adminstered.

Transport decisions: There were three hospitals available to us. Two were close, but unable to provide major surgical interventions, and one was close to an hour away, but was a major trauma centre capable of providing surgical solutions (ie, for a ruptured spleen, enclosed head injury).

In the end we opted to the major trauma hospital, because it was the only place where that patient could get definitive treatment. The risks included:
1. The patient may deteriorate and require intubation and we would be unable to successfully intubate;

2. The patient may become profoundly hypovolaemic and go into cardiac arrest.

At the end of the day, it was determined that the best possible chance that this patient would have of survival required early surgical interventions, and although the closer hospitals could provide a higher level of emergency medical care, they could not treat the injuries and therefore that patient was taken to the major trauma hospital.

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What is a Bainbridge Reflex?

March 30th, 2011

Bainbridge Reflex 

A Bainbridge Reflex is a positive feedback mechanism in which there is a compensatory increase in heart rate, due to a rise in right atrial pressure. It is commonly referred to as an Atrial Reflex.

How does the Bainbridge Reflex and Baroreceptor Reflex control the heart rate and ensure that blood pressure is maintained within normal homeostatic levels? The Bainbridge Reflex is triggered when the stretch receptors in the atria are triggered – this means that there is an increased level of venous blood (not to be confused with an increase in arterial blood pressure). The Bainbridge and Baroreceptor reflexes work antagonistically, meaning that if atrial blood pressure is high the Bainbridge Reflex is dominant; however, when teh corotid artery barorecptors indicate low arterial blood pressure, the Baroreceptor reflex becomes dominant.

Why does the body do this? By increasin the heart rate the left ventricles utilise more venous blood which is currently being pooled in the venacava and atria.

Clinical evidence of Bainbridge Reflex.

Bainbridge Reflex can be seen by placing a patient on a cardiac monitor and asking him or her to breath deeply. During the process of inspiration, the intrathoracic pressure is decreased (slightly), which leads to a higher venous return, which is identified by the atrial stretch receptors, which in turn cause the Bainbridge Reflex to become dominant and cause a momentary increase in heart rate. On a cardiac monitor, this can be seen as a sinus arrhythmia (a predominantly sinus rhythym, but not entirely regular – as a result of a sudden increase in heartrate).

Who first identified Bainbridge Reflex?

Francis Bainbridge first discovered the Bainbridge Reflex in 1915 while he was experimenting infusion of saline in animals (normally dogs).

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What is Berry’s Sign?

March 30th, 2011

Berry’s Sign

Berry’s Sign is a malignant (bad) thyromegaly with an absence of a carotid pulsation as a direct result of the tumor encasing the carotid artery and muffling the pulsation.

What is the clinical significance of identifying Berry’s Sign in a patient? Berry’s sign indicates a malignant tumour of the thryoid gland, as opposed to a benign tumour in the absence of Berry’s Sign.

Who originally identified Berry’s Sign? A Thyroid Surgeon by the name of James Berry.

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What is Cushing’s Syndrome?

March 30th, 2011

Cushing’s Syndrome

Cushing’s Syndrome is a hormone disorder, resulting in a prolonged high level of circulating hormone cortisol (hypercortisolism).

Prolonged hypersecretion of cortisol and circulating cortisol leads to secondary symptoms and characteristics which are key signs of Cushing’s Syndrome. These key signs and characterisitics of Cushing’s Syndrome include the following:

– Fatness of face and trunk with wasting of extremities, this is often known as the moon face syndrome;

– Buffalo hump, this is where prolonged hypersecretion of the steroid cortisol leads to increased fatty deposits and build up around the back of the neck, literally forming a hump that resembles a buffalo hump; 

Bone decalcification, this is because a high level of cortisol reduces the production of vitamin D which is paramount in the absorption of calcium ions in the bowels. Therefore prolonged hypersecretion of cortisol during conditions such as Cushing’s Syndrome will lead to bone decalcification;

Corticoid diabetes – this is where prolonged levels of the hormone coticol produces a steroid induced insulin resistance leading to IDDM (insulin dependant diabetes mellitus).

Hypertension, due to an increased release of adrenaline and nor-adrenaline as a secondary result of hypercortisolaemia (high levels of cortisol in the blood), which in turn cause an increase in force of myocardial contraction and vascular compression.

Want more information on Cushing’s Syndrome?

I recommend Huether and McCance (2002) Pathophysiology Textbook, Mosby Inc for much more depth and clarity on the topic of Cushing’s Syndrome.

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What is Mallory-Weiss Syndrome?

March 19th, 2011

Mallory-Weiss Syndrome

Mallory-Weiss Syndrome is a syndrome in which hyperemesis (excessive vomiting) has resulted in the development of a gradual laceration or tears of the lower end of the eosophagus or stomach in a patient. This, then causes haemetemesis (vomiting of blood).

Mallory-Weiss Syndrome is often seen in patients with longterm alcholism (alcoholics) due to the acidity of alcohol. It can also be seen in patients who suffer with various eating disorders such as bulaemia (intentionally vomiting after eating).

Mallory-Weiss Syndrome rarely requires medical interventions or surgical treatments, and usually self resolves after 12-48 hours. Mallory-Weiss Syndrome should not be confused with oesophageal viracies (ruptures of arteries within the oesophagus), in which the patient will die due to profound hypovolaemic shock if not treated with surgery. In rare cases of Mallory-Weiss Syndrome, in which the bleeding is persistent, the patient may have an endoscopic aided cauterization or injection of adrenaline (which peripheral vasoconstrictor that causes minor bleeding to cease).

The condition was first identified by Kenneth Mallory and Soma Weiss, who undertook a study of 15 alcoholics.

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What is Burnett’s Syndrome?

March 19th, 2011

Burnetts Syndrome

Burnett’s syndrome is a medical condition in which a person suffers with a longterm milk and alkaline ingestion inequality that results in severe hypercalcemia (high levels of calcium in the blood), irreversible renal failure, and phosphate retention.

Burnett’s syndrome has also been associated with ectopic calcification.

People who are most at risk of Burnett’s Syndrome are older women, because they are on high dietary or supplementary vitamin intake of calcium and vitamin D, which over long term periods, cause an excess of milk/alkaline solutions in the body.

Burnett’s Syndrome is treated by decreasing dietary calcium intake and in severe cases, treatment in hospital with IV fluids to wash out the calcium.

What is the signicance of Burnett’s syndrome to paramedics?

As a paramedic, you may attend patients who have had a renal calculi, secondary to the excess levels of calcium in their blood. The main priority as a paramedic is still to treat the ABC and manage the patien’s pain. However, on top of this, it may be useful to identify the possible un-identified condition of Burnett’s syndrome.

If a patient is known to suffer with Burnett’s syndrome, it is likely that they have a decrease in renal function and possible renal failure. Consequently, paramedics should ensure that they do not use any nephrotoxic analgesias, such as methoxyflurane.

 

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What is Bergman’s Triad?

March 13th, 2011

Bergman’s Triad

Bergman’s triad is often seen when a patient suffers a fat embolism. 

Bergman’s triad includes the following clinical signs and symptoms:

1. Mental status changes;

2. Petechiae (often in the axilla/thorax – however, this is often a late sign);

3. Dyspnea (difficulty breathing);

What is the clinical significance of Bergman’s Triad? Identifying clinical signs and symptoms that indicate Bergman’s Triad of a Fat Emboli can be used to remind medical practioners and clinicians of the potential for sudden death in this syndrome and the potential need for thrombolysis treatment.

 Want to learn another medical triad? Have a look at the Waddell Triad page.

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What is Austrian’s Triad?

March 13th, 2011

Austrian triad

The Austrian triad is named after Robert Austrian who initially identified and described it and noted the high level of mortality associated with the condition (also known as Austrian’s Syndrome) in which patients regularly die regardless of aggressive treatment with IV antibiotics. 

The Triad of Austrian’s Syndrome includes:

1. Pneumococcal pneumonia

2. Meningitis

3. Endocarditis (classically aortic valve endocarditis associated with aortic regurgitation)

What causes Austrian’s Triad?

Although the specific causes of Austrian’s Syndrom or Austrian Triad are not well known or understood, it has been identified that patients who suffer with Alcoholism or IV Drug Use are more likely to develop the disorder.

What is the clinical significance of Austrian’s Triad?

The clincial significance of Austrian’s Triad is that the medical practitioner/clinician must be warry when he or she identifies a patient who meets the triad of clinical signs and symptoms ( Pneumococcal pneumonia, Minigitis and Endocarditis) due to the high rates of mortality and consider early surgical interventions and aggressive IV antibiotics interventions.

Want to learn about another medical triad? Try looking at my Virchow’s Triad?

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Ambulance Recruits TV Show

March 13th, 2011

The rumours are true that the Ambulance Service of NSW will produce an Ambulance version of the Police “Recruits” show, in conjunction with Channel 10, which will provide real life information on what it is like to be a paramedic (or a new recruit paramedic/ probationer paramedic). If the TV show goes ahead, probationary paramedics will be filmed during their early training days and on-road experience.

By the sounds of things, this will lead an increased awereness of what it is like to be a paramedic and on how ridiculous some of the “OOO” calls are, which will hopefully allow people to think twice before calling an Ambulance for minor problems, or problems un-related to medicine.

Hopefully, these rumours about a new Ambulance Recruits show are correct and this will bring about new interest and appreciation for our profession.

Having said all this, I would hate to have a TV crew filming me attending patients, especially if I was a New Recruit.

You can find more information about the new Recruits Paramedics TV show on Channel Ten’s Site Here.

Want to Become a Paramedic? If you have seen the new Paramedic Recruits show and would like to become a paramedic, please visit How to Become a Paramedic.

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What is Macdonald’s Triad?

March 12th, 2011

Macdonald’s Triad of Sociopathic Behaviour.

The Macdonald triad is a set of three behavioral characteristics which are associated with sociopathic behavior. In psychology, a combination of these behavioral characteristics are often found in the childhood histories of individuals with sociopathic behavior:

1. Enuresis (bedwetting) often past the age of 5;

2. Firesetting;

3. Torturing small animals;

 Individually, each of these characteristics are not clinically significant, but together they highlight an increased risk of future sociopathic behaviours.

The Macdonald triad is also known as the triad of sociopathy. It was first identified by a forensic psychiatrist, John Marshall Macdonald (November 7, 1920 – December 16, 2007), in a 1963 paper in the American Journal of Psychiatry titled “The Threat to Kill”.

The Macdonald triad is considered predictive of future criminal behaviour.

It should also be noted that Macdonald’s triad of sociopathic behaviours have often been correlated to early abusive up-brinings/witnesses to abusive/homocidal incidents.

If you are concerned about your child, please speak to a trained psychologist or psychologist.

If you would like to learn about more medical triads, please review my Waddell’s Triad of Trauma page.

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What is Waddell’s Triad of Trauma?

March 12th, 2011

Waddell’s triad is recognized in clinical practice as being associated with high-velocity accidents such as motor vehicle versus pedestrian, or bicycle crashes.

 Waddell’s triad consists of

1. Femur fracture

2. Intra-abdominal or intrathoracic injury

3. Head injury.

These three injuries provide significant loss of blood through internal haemorrhaging, anyone who meets these criteria for Waddell’s triad of trauma should be treated as significantly injured.

Waddell’s Triad is primarily seen in Paediatric Pedestrians versus Motor Vehicles, due to their heigh causing this type of mechanism to first injure their femurs, then abdomen/chest and finally their head.

What is the clinical significance of Waddell’s Triad?

The clinical significance of Waddell’s Triad of Trauma is that it indicates the following warning signs to Doctors and Paramedics alike:

1. If one or two of the three signs are clearly present, the clinician should be wary of the potential of the third sign, even if it has not been identified yet;

2. Large amounts of blood may be lost in the internal cavities and body spaces, therefore patients who have injuries associated with Waddell’s Triad of Trauma should be treated cautiously.

What is an example of Waddell’s Triad of Trauma?

A 5 year old pedestrian who has been hit by a motor vehicle at 60km/h (35 m/h) and been thrown over the bonnet of the vehicle is likely to have injuries consistent with Waddell’s Triad, including: fractured femur/s, abdominal injuries and head injury.

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Spinal Injuries Case Study

March 12th, 2011

Attending patients with a suspected or “potential” spinal injuries is a common case for most paramedics. We all know that most patients involved in a car accident do not actually have a spinal injury, but protocols ussually require us to place a Cervical Collar /or Brace on our patients. Furthermore, when patients do have spinal injuries, they often have other injuries,which make positioning these patients difficult.

This is based on a recent case I attended:

22 year old, fit and healthy male with a fractured clavical (compounded) and multiple fractured ribs post fall from mountain bike. Pt walking around after incident – helmet split into two pieces.

O/E Pt alert and skin warm, pink, dry. GCS 15; Pulse rate 112 strong and regular; BP 90/42; Nil distress. Speaking in full sentences; good air entry to bases; Left equals Right lung sounds. C/O severe pain at clavical site and pain on inpiration at site of ? fractured ribs. Nil other injuries detected.

Treatment included:

Thorough secondary survey and application of Cervical Collar. While attempting to lay patient supine (for spinal immobilisation) he became increasingly distressed and c/o SOB and difficulty breathing. The fractured clavical appeard to move distally and increase the difficulty of breathing as the patient layed back. This was resolved by sitting the back of the Ambulance Stretcher up ot about 20-25 degrees.

The patient was transported to hospital with the back of the stretcher at 20-25 degrees and the cervical/thoracic spine in allignment.

There were some discussions/arguments afterwards on whether or not this patient should have been transfered this way.

At the end of the day, laying him suppine increase the risk of airway/ventilation problems, while sitting him up slightly, still fundamentally maintained his spinal allignment.

Morphine 5mg IV was administered, but his pain on deep inspiration remained while trying to lay him supine. Eventually, he was transported with the back of the bed raised.

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Drug Allergy Case Study

March 12th, 2011

Drug Reaction Case Study

Have you ever given a drug to a patient and found that they were actually allergic to it? What did you do?

I treated a 45 year old female with severe back pain. The patient states it started while trying to move a bookshelf. Good motor/sensory by all four limbs. Severe pain in the lower lumber region, with associated sciatica. The Patient states only known drug allergy – Codeine. 5mg IV morphine was administered and the Patient states great improvement in pain. After 2 minutes, the Patient states severe itchiness and pain to R arm (the one with the cannula). Within another minute, the Pt developed a mildly swollen arm, widespread urticaria to the arm, and then welts following the veins where morphine had been administered. The patient’s Airway, Breathing and Circulation were unaffected. The swelling and urticaria was confined to the R arm only. The IV was flushed with saline and P/O Fenofexodine (Telfast) was given for its antihistamine properties.
This slowly reduced the allergic reaction and no other medications were administered.

Would you have considered adrenaline? What else could a paramedic have done? Would they do anything differently in hospital? Would you have considered a lower dose of Morphine because of the allergy to codeine?

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What is the DSM IV?

March 6th, 2011

The DSM IV is the Diagnostic and Statistical Manual for Mental Disorders, which is published by a group Psychiatrists in America representing the Psychiatric Community.

The DSM IV is a list of Mental Disorders that are grouped into codes, clinical characteristics, and specific  signs and symptoms that determine specific classes of Mental Disorders. The DSM IV is used by medical practitioners and psychiatrists alike when assessing or categorizing a patient who is suspected to be suffering with a specific mental illness.

The DSM IV is a complex set of criterion in which to associate patient’s conditions with specific mental disorders, so that health practitioners are better  able to identify a clear diagnoses and treatment plan. The DSM IV should not be used by people to determine if they have a mental disorder or how to treat there mental illness and should only ever be utilised by medical practitioners and psychiatrists.

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What is Virchow’s Triad?

February 20th, 2011

Virchow’s triad includes three broad categories of factors that are considered to contribute to thrombosis.

The Virchow’s triad consists of:

1. Alterations in normal blood flow

2. Injuries to the vascular endothelium

3. Alterations in the consistancy  of blood (hypercoagulability)

Examples of alterations in normal blood flow include:  turbulence, stasis, mitral stenosis, and varicose veins.

Examples of injuries to the endothelium include: damage to the veins  as a result of hypertension.

Examples of hypercoagulability includes: deficiency of antithrombin III, hyperviscosity, nephrotic syndrome, changes after severe trauma such as disseminated intravascular coagulation, burns, disseminated cancer, late pregnancy and delivery, race, age,  and whether or not the patient is a smoker

Virchow’s triad was first formulated by the German physician Rudolf Virchow (1821-1902) in 1856. However, it should be noted that Virchow never actually identified a Triad of thrombosis, but identified early concepts relating to the formation of a thrombus. It was until Virchow had been deceased for many years before modern scientists started to group the three main coagulation signs into a triad, which was later defined as Virchow’s Triad (in recognition of Virchow’s original work related to the topics).

An example of Virchow’s Triad is when a patient develops disseminated intravascular coagulation (DIC) as a result of major trauma and large amounts of both clotting and fibrin (thining) contents being released.

To learn more about coagulation, please review my Clotting Cascade page.

Want to learn another medical triad? How about Beck’s Triad?

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What is the Difference Between Beck’s Triads

February 20th, 2011

There are two different definitions of the term  Beck’s Triads which are associated with medical signs and symptoms. These Beck’s Triads include:

  1. Cardiovascular signs and symptoms and;
  2. Pyschological feelings of dispaire associated with a negative trends of depression.

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What is Beck’s Triad in Cardiology?

February 20th, 2011

Beck’s Triad  in Cardiology

Beck’s Triad of the heart includes three medical signs that indicate cardiac tamponade. Cardiac tamponade is medical emergency in which fluid accumulates around the heart and decreases the ability of the heart to pump blood. The result is the triad of low arterial blood pressure, jugular venous distention, and  muffled heart sounds. In cardiac tamponade a narrow pulse pressure is regularly observed. The cardiologist, Claude Beck, who was a Professor of Cardiovascular Surgery first identified the triad of medical signs which was later termed “Beck’s Triad.”

Beck’s Triad (in basic terms):

1. Distended Neck Veins;

2. Muffled Heart Sounds;

3.  Hypotension.

 The reasons for the cardiac causes of Beck’s Triad include the following:

1. Physiological fall in arterial blood pressure, which is the  results of pericardial fluid accumulation within the heart that acts in order to impair the ventricular stretch, thus reducing stroke volume and cardiac output. These two factors of Beck’s Triad are two major determinants of systolic blood pressure.

 2. The rising central venous pressure which is evidenced by distended jugular veins while in a non-supine position. This is caused by reduced diastolic filling of the right ventricle, due to the  pressure being exerted on it by the expanding pericardial sac. This results in a backup of fluid into the veins draining into the heart, most notably, the jugular veins. In severe hypovolemia, the neck veins may not be distended.

 3. The suppressed heart sounds occur due to the muffling effects of the sounds passing through the fluid surrounding the heart.

Although the full triad  of Beck’s is present only in a minority of cases of acute cardiac tamponade the  presence of the triad is considered pathognomonic for the condition.

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What is Beck’s Triad of Depression?

February 20th, 2011

What is Beck’s Triad of Depression?

In psychology, the term Beck’s Triad refers to a negative trend of psychological behaviours which include the patient suffering the following:

 1.The self  – for example, the self is worthless or non-existant;

.The world/environment  is unfaire; and,

3.The future is completely hopeless/ useless.

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How to Pay Online Ambulance Bill

February 20th, 2011

How to pay an online Ambulance Bill online is simple. Paying for an Ambulance Bill Online is normally easy and simple to do. Most Ambulance Services around the world now have an Ambulance Website. This is particularly common in government developed Ambulance Services. In Australia all State Ambulance Services have a Website.

If you wish to Pay for an Online Ambulance Bill these are the two methods to use:

1. Turn your Ambulance Bill over and follow the directions of how to pay Online (these are usually found on the reverse side of the Ambulance Bill and are normally very easy to follow, because most Ambulance Services prefer you to pay for an Ambulance Bill Online).

2. If there aren’t directions on the back of the Ambulance Bill on how to  pay for the bill on-line then use your search engine (such as Google, Yahoo, Bing, etc) and search for the Ambulance Service on the Bill. For example, if you are paying for a NSW Ambulance Bill, Google: “NSW Ambulance Service.” – Then, on the home page of the NSW Ambulance Service, you can clearly see a link on the right hand side of the webpage to the “Pay a Transport Bill” – if you follow this link there is a clear process of how to pay for your Ambulance Bill Online.

This process can be used to find the Ambulance Service Website and pay for any Ambulance Bill online in Australia. It can also be used to pay for an Ambulance Bill anywhere around the world.

It is important to pay for an Ambulance Bill because it is through these revenue sources that Ambulance Services are able to fund better equipment, improve training for paramedics and in general provide a higher level of pre-hospital health care and emergency health care to the community.

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What are the Signs and Symptoms of Friedreich’s Ataxia?

February 19th, 2011

What are the Signs and Symptoms of Friedreich’s Ataxia?

The Signs and Symptoms of Friedrecih’s Ataxia includes the follwing:

Muscle weakness in the arms and legs

Loss of coordination

Vision impairment

Hearing impairment

Slurred speech

Curvature of the spine (scoliosis)

High plantar arches (pes cavus deformity of the foot)

Diabetes (about 20% of people with Friedreich’s ataxia develop carbohydrate intolerance and 10% develop diabetes mellitus)

Heart disorders (atrial fibrillation, which leads to tachycardia (fast heart rate) and hypertrophic cardiomyopathy

It presents before 25 years of age with progressive staggering or stumbling gait and frequent falling. Lower extremities are more severely involved. The symptoms are slow and progressive. Long-term observation shows that many patients reach a plateau in symptoms in the patient’s early adulthood.

The following physical signs may be detected on physical examination:

Cerebellar: Nystagmus, fast saccadic eye movements, truncal ataxia, dysarthria, dysmetria.

Pyramidal: absent deep tendon reflexes, extensor plantar responses, and distal weakness are commonly found.

Dorsal column: Loss of vibratory and proprioceptive sensation occurs.

Cardiac involvement occurs in 91% of patients, including cardiomegaly (up to dilated cardiomyopathy), symmetrical hypertrophy, heart murmurs, and conduction defects. Median age of death is 35 years, while females have better prognosis with a 20-year survival of 100% as compared to 63% in men.[citation needed]

20% of cases are found in association with diabetes mellitus.

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What is Beck’s Triad?

February 19th, 2011

There are two different definitions of the term  Beck’s Triads which are associated with medical signs and symptoms. These Beck’s Triads include:

  1. Cardiovascular signs and symptoms and;
  2. Pyschological feelings of dispaire associated with a negative trends of depression. 

Beck’s Triad of the heart:

Beck’s Triad of the heart includes three medical signs that indicate cardiac tamponade. Cardiac tamponade is medical emergency in which fluid accumulates around the heart and decreases the ability of the heart to pump blood. The result is the triad of low arterial blood pressure, jugular venous distention, and  muffled heart sounds. In cardiac tamponade a narrow pulse pressure is regularly observed. The cardiologist, Claude Beck, who was a Professor of Cardiovascular Surgery first identified the triad of medical signs which was later termed “Beck’s Triad.”

Beck’s Triad (in basic terms):

1. Distended Neck Veins;

2. Muffled Heart Sounds;

3.  Hypotension.

 The reasons for the cardiac causes of Beck’s Triad include the following:

1. Physiological fall in arterial blood pressure, which is the  results of pericardial fluid accumulation within the heart that acts in order to impair the ventricular stretch, thus reducing stroke volume and cardiac output. These two factors of Beck’s Triad are two major determinants of systolic blood pressure.

 2. The rising central venous pressure which is evidenced by distended jugular veins while in a non-supine position. This is caused by reduced diastolic filling of the right ventricle, due to the  pressure being exerted on it by the expanding pericardial sac. This results in a backup of fluid into the veins draining into the heart, most notably, the jugular veins. In severe hypovolemia, the neck veins may not be distended.

 3. The suppressed heart sounds occur due to the muffling effects of the sounds passing through the fluid surrounding the heart.

Although the full triad  of Beck’s is present only in a minority of cases of acute cardiac tamponade the  presence of the triad is considered pathognomonic for the condition.

What is Beck’s Triad of Depression?

In psychology, the term Beck’s Triad refe

Beck’s cognitive triad is a triad of types of negative thought present in depression proposed by Aaron Beck in 1976. The triad forms part of his Cognitive Theory Of Depression to a negative trend of psychological behaviours which include the patient suffering the following:

 1.The self  – for example, the self is worthless or non-existant;

.The world/environment  is unfaire; and,

3.The future is completely hopeless/ useless.

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What is Meningism?

February 14th, 2011

Meningism is a term used to describe the triad of clinical signs often associated with meningeal irriation or a subarachnoid haemorrhage.

Meningism includes:

1. Nuchal Rigidity (decreased ability to move the neck and increase rigidity of the neck muscles);
2. Headache (often associated with an increased Intracranial Pressure (ICP) and irriated meninges); and
3. Photophobia (pain or discomfort associated with light due to increase ICP placing pressure on the third cranial nerve (occular motory), which stops the pupils from being able to constrict – therefore making light more painful).

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What is Brudzinski’s Sign?

February 14th, 2011

A Brudzinski Sign is an involuntary lifting of a patient’s legs in response to an examining Doctor of Health Practioner lifting the head. This is often associated with meningeal irritation, such as blood in the mininges (Subarachnoid Haemorrhage) or Acute Meningitis.

Josef Brudzinski was a Polish Doctor who has been noted for his identification of many of the signs of Meningitis.

What is the clinical significance of Brudzinski’s sign?

As a paramedic you may wish to perform a Brudzinski’s test on any patient that you suspect to have meningeal iritation, such as meningitis. A positive Brudzinski’s sign indicates meningeal iriation and is often associated with meningitis. This is a life-threatening emergency and should be treated as such by paramedics.

 

Should paramedic perform a Brudzinski’s test on all patients? No, only patients who the paramedic is concerned may have meningitis.

 

 

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What is Nuchal Rigidity?

February 14th, 2011

Nuchal Rigidity is when a patient is unable to flex his or her head forward due to an un-natural rigidity of the neck muscles.

Nuchal Rigidity is often associated with Meningitis and any irriation of the meninges, such as a Subarachnoid Haemorrhage with blood in the meninges.

Nuchal Rigidity is a primary sign of Acute Meningitis.

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What is an Opisthotonus Spasm?

February 14th, 2011

The following are basic definitions of Opisthonus Spasm:

An Opisthotonus Spasm is spasm involving the whole body in which the patient’s head, legs and back are all bent un-naturally backwards.

An Opisthotonus Spasm is often associated with a Subarachnoid Haemorrhage or Minengeal irriatation.

An Opisthotonus Spasm is also often seen in a Positive Kernig’s Sign.

What is the clinical significance of an Opisthotonus spasm? An Opisthotonus spasm often indicates a subarachnoid haemorrhage and minengeal irritation, which should trigger the clinician to order an urgent head CT, neurology review and potential need for trephination (burr holes in the cranium to relieve intracranial pressure).

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What is Kernig’s Sign?

February 14th, 2011

A positive Kernig’s Sign indicates that a patient either has a Subarachnoid Haemorrhage (with blood irititating the meninges) or Meningitis.

Kernig’s Sign can be identified when a patient with a decreased level of consciousness (LOC) bends their leg (at the hip) to form a 90 degree angle.

The term Kernig’s Sign was first identified by a German Neurologist by the name of Waldemar Kernig.

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What is a Weber’s Test?

February 14th, 2011

A Weber’s Test is a basic but effective medical test to determine loss of hearing in a patient.

The test is performed by vibrating tuning fork (sound device) in the middle of a patient’s forehead. As the tuning fork begins to vibrate the patient identifies in which ear he or she can hear the sound most easily. This test does not identify people who have bilateral hearing loss; however, it rapidly identifies people who are suffering uni-lateral hearing loss.

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What is Murphy’s Sign?

February 14th, 2011

In medicine, Murphy’s sign is a test used during an abdominal assessment which may be used to differentiate between a diagnosis of cholycystitis, pyelonephritis, and ascending cholangitis.

To assess the abdomen for Murphy’s sign:

– Lie the patient supine (as you would during any other abdominal assessment);
– Instruct the patient to breath out;
– Place your palpating hand just below the costal margin, approximately mid-clavicularly (this is just above the gallbladder);
-Then instruct the patient to slowly breath in;

A positive Murphy’s sign is identified when the patient stops breathing in due to pain – this is caused by the move of the diaphragm pushing the inflamed gallbladder into the palpating hand.

A negative Murphy’s sign is identified when the patient comfortable breaths all the way in without any pain – in this case, the diaphragm pushes the non-inflamed gallbladder into the palpating hand with nil changes in the patient’s level of comfort.

A positive Murphy’s sign often indicates Cholycystitis, where as a negative Murphy’s sign may suggest pyelonephritis, and ascending cholangitis.

Here is a video of someone assessing for a Murphy’s Sign:

Some confusions when performing a Murphy’s Test of the Abdominal Region may include:

– The patient may have pain on inspiration to both L and R sides of the Costal Margin. Always test bilaterally!
– If the examiner’s fingers are incorrectly placed the Murphy’s Test will not accurately indicate anything.

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What is Friedreich’s Ataxia?

February 11th, 2011

Friedreich’s ataxia is a congenital familia (inherited) disease that affects the nervous system, resulting in problems with speech, balance and coordination.

Friedreich’s ataxia is primarily caused by the pathogenic degeneration of nerve tissue in the spinal cord, and sensory neurons requied for directing muscle movement of the arms and legs. The spinal cord becomes thinner and nerve cells lose some of their myelin sheath (the insulating covering on some nerve cells that helps conduct nerve impulses). This results in a slowing down of the nerve impulse (messages).

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What is Ataxia?

February 11th, 2011

Ataxia is a disorder of the neurological system that affects balance, coordination and speech. People with ataxia are often unbalanced, un-coordinated and have difficulty with their speech. Ataxia is often associated with people having a stroke or cerebral event, however it can be caused by numerous other factors.

Ataxia can be caused by having a head injury or ideopathic, which means that the cause is unknown.

Is there treatment for ataxia?

Treatment for Ataxia is often associated with treating the original cause, such as drug ingestion such as alcohol, hypoglycaemia, head injury or other cause.

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What Are the Risks of Taking Steroids?

February 11th, 2011

These are the risks associated with taking steroids:

1. Increased cardiovascular disease;
2. Cardiac Hypertrophy (enlargement of the heart);
3. Increased Skin Disorders;
4. Testicular Shrinkage;
5. Increased Hair Growth;
6. Mood Disorders and Aggression;
7. Glucose Intolerance;

Steroids are used in the treatment of many disorders and diseases and if used for short term treatment they serve their purpose very well, with limited side effects. Sometimes if you require steroids long term, there may be side effects; however, you and your Doctor will consider these side effects compared with the risks of not taking them to treat your condition and determine which of the two provide the greater risk.

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What Is Steroid Induced Glucose Intolerance?

February 11th, 2011

Steroid Induced Glucose Intolerance is a condition which is caused by the use of steroids, in which the body is unable to utilise Glucose as well due to the effects of cortisol from steroids that cause the body to become resistant to Insulin.

Steroids are used in the treatment of many diseases and disorders for their ability to reduce the inflammatory response and are generally well used in medium to short term doses.

Cortisol causes the body to be resistant to the effects of insulin. Insulin is a ligand (key) that allows the cells within the human body to absorb and utilise the sugar (glucose) found within the blood. Longterm use of steroids, which act on the hormone cortisol (found naturally within the human body), can cause patients to develop type 2 diabetes. This is because their cells no longer accepts sugar as readily as a normal healthy person from their blood supply and this leads to a higher resting blood glucose level (BGL) or blood sugar level (BSL).

In addition, cortisol also causes the liver, which stores large amounts of glucose in the form of glycogen, to secrete some of its glucose stores into the bloodstream. This in turn, further increases the resting blood glucose levels and leads to type 2 diabetes.

For paramedics and emergency doctors alike, steroid induced glucose intolerance is an important concept to understand because so many patients that we see are on long term steroids to treat a variety of their normal medical conditions and consequently are at risk of developing steroid induced glucose intolerance and type 2 diabetes. This is why some patients who are not known to have diabetes, but are on longterm doses of steroid based medications, need to have the blood glucose levels regularly assessed.

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What Number to Call in an Emergency European Union

January 25th, 2011

The number to call in an Emergency in most of the countries of the European Union is 112.

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What Number to Call in an Emergency New Zealand

January 25th, 2011

The number to call in an Emergency in New Zealand is 111.

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What Number to Call in an Emergency UK

January 25th, 2011

The number to call in an Emergency in the UK is 999.

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What Number to Call in an Emergency Australia

January 25th, 2011

The Number to call for Police, Fire or Ambulance in Australia is 000.

Please save it for emergencies only!

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What Number to Call in an Emergency USA

January 25th, 2011

The number to call in an emergency in the USA for an Ambulance is 911

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What Number to Call in an Emergency India

January 25th, 2011

The number to call for an Ambulance, while in India is 108.

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Ambulance Service India

January 25th, 2011

A National Ambulance Service in India is a very new concept which commenced for the first time in 2004. However, is should be noted that India’s ability to develop such an Ambulance Service in order to provide pre-hospital emergency care to patients from a wide range of demographical and socio-economical areas of India. The Ambulance Service of India apparently attends close to 4 million emergencies per year, which makes it one of the largest Ambulance Services in the world.
The Ambulance Service of India has developed so rapidly that even Health Organisers from the United States are keenly observing India’s Emergency Call Taking and Dispatching centres as they believe that India is capable of becoming world leaders in Ambulance Practice.

The number to call for an Ambulance, while in India is 108.

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What is Maximum Inspiration Volume?

January 5th, 2011

The maximum inspiration volume is the most amount of air/gas that a person can inhale. On the average male, this is 6000 ml.

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What is Normal Tidal Volume During Respirations?

January 5th, 2011

The normal tidal volume (TV) during respiration is 500 mls; however, this may be greatly increased in times of exertion and stress.

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Is Expiration a Passive Process?

January 5th, 2011

Expiration occurs when the diaphragm rellaxes, causing the intrapulmonary pressure to raise. Therefore expiration is a passive process.

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Is Inspiration Passive?

January 5th, 2011

Inspiration requires the muscles of the diaphragm to contract and the muscles within the chest wall to widen in order to create a negative pressure within the intrapulmonary space, which causes air to be sucked in. Therefore, inspiration is not a passive process.

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What is the Normal Intrapulmonary Pressures?

January 5th, 2011

Intrapulmonary presssures (the pressure within the lung) changes during the inspiratory and expiratory phase of respiration.

During inspiratation, the intrapulmonary pressure is usually 759 mmHg or lower, which causes the outside atmospheric pressure (which is 760 mmHg) to be sucked into the lungs to create an equilibrium (balance).

During expiration, the intrapulmonary pressure is usually 761 mmHg or higher, which causes the air from within the lungs to be forced out into the lower pressure of the atmosphere.

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What is the Normal Atmospheric Pressure?

January 5th, 2011

The normal atmospheric pressure is 760 mmHg.

Although it should be noted that this is considerably less the higher you go from sea level.

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What Are Pressure Changes in Ventilation?

January 5th, 2011

Pressure changes in ventilation refers to the changes in the pressure during the mechanical process of respiration (breathing).

During inspiration the diaphragm contracts and the chest wall expands causing a decrease in the intrapulmonary pressure (the pressure of the gas within the lungs). This negative air pressure within the lungs causes air from outside the lungs (normal atmospheric pressure (generally 760 mmHg) to be sucked into the lungs. During expiration, the diaphragm rellaxes and the chest wall deflates leading to a smaller area within the lungs and therefore a greater inrapulmonary pressure, which causes air to be pushed out of the lungs and into the atmosphere. This is why the expiratory phase of respiration is normally passive, except in air flow limitations, such as asthma.

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Worst 911 Calls

January 3rd, 2011

Anyone who has ever been a paramedic will know that not all people who dial 911 or any other emergency phone number will actually be suffering with a medical emergency, or any emergency for that matter.

Over the years, I have litterally attended patient’s who have dialled emergency phone numbers because their I-phone has run out of credit and the national emergency phone number does not require credit; people who want advice on how to fix their car; because there has been a spider in their bedroom and numerous other silly reasons to call an Ambulance.

These are some of the worst 911 calls that I have ever seen:

I have never seen the been called to someone with ice on their windscreen, but I have been called to peopple with a foggy windscreen!

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The Problem With Tunnel Syndrome

January 3rd, 2011

Tunnel Syndrome is a concept ascribed to new clinicians, paramedics, nurses and doctors who seen a major problem and forget about all other potential problems to the detrement of the patient and themselves.

For example, the doctor who is so concerned about the broken leg, that he or she neglects to check the cervical spine for damage. Or the paramedic who, having seen woman crying and covered in blood runs into a situation, where he or she then gets stabbed by the orginal perpetrator.

This video link is just about the best case of tunnel syndrome I’ve seen and, unfortunately, I’ve met and even worked with a few people like this.

This is particularly funny because I have worked with orthopaedic surgeons who have wanted to operate on a femure fracture, while the patient had an inclosed head injury requiring urgent brain surgery and bur holes!

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Pseudo-Fitter

January 3rd, 2011

The first time you witness a seizure most people, ordinary people and paramedics alike, all tend to think the person is going to die – in some cases, were you not to intervene chemically with the progression of their seizure, some may die; however, as a general rule, most people who have seizures will eventually find that they self resolve. In fact in many cases, people don’t even realise that they’ve been having seizures for years until someone witnesses the event.

Okay, so what does this all have to do with pseudo fitters (pseudo-seizures)? Well, the first time you see a person have a real seizure, you think they’re going to die and when you see a pseudo fitter for the first time, you are likely to think the same thing. Some pseudo fitters will have previously had epilepsy, or had a friend with epilepsy, and consequently, can act out a seizure very well. In many cases, they will go as far as to let themselves become incontinent (wet themselves).

This is a link to a great video clip of a pseudo-fitter which I think about every time I treat a pseudo-fitter!

Pseudo-Fitter Management

The truth is, most seizures self resolve, and so long as a person is still able to manage their own airway, and keep breathing, they will be fine. Therefore, if you are concerned about whether or not a person is having a real seizure or a pseudo seizure, then these are some things to keep in mind:

1. Check persons ABC (is their airway clear, are they breathing, how is their pulse?).

2. Check their full vital signs (this should include a BSL and a Temperature). In a person having a real seizure, their pulse is almost always up around 120/min or greater, as a means to increase brain perfusion and remove lactic acid being created through the tonic/clonic movements of their limbs. A regular pulse at around 80/min is almost always a give away that a person is faking their seizure.

3. Assess their corneal reflexes (do their eyes blink when you touch their eye lashes?) – Corneal reflexes ussually only occur in conscious people, not unconscious people having a seizure (although there are some rare occasions where this is not true). Assess their pupils.

4. If in doubt about whether or not the person is faking their seizure, manage their ABCs and transport to hospital – provide them oxygen and posture them latterally. Ultimately, if you become concerned about their airway and think that they really are causing damage – there is nothing wrong with giving midazolam (it doesn’t cost you anything).

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Paramedic Rap

January 3rd, 2011

httpv://www.youtube.com/watch?v=D5fX2s_lqS0

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What is the function of blood cells?

December 27th, 2010

What are the functions of blood cells?

These are the basic functions of blood cells:

Platelet – cause blood to clot

Monocyte – promote immune defence (through phagocytosis)

T Lymphocyte – promotes cellular immunity

B Lymphocyte – produces antibodies that increase immune defence to specific bacteria and viruses

Basophil – promotes the inflammatory response

Erythrocyte – transports oxygen and carbon dioxide around the circulatory system

Neutrophil – promotes the immune system (through phagocytosis)

Eosinonphil – defence against parasites

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What are the classes of blood cells?

December 27th, 2010

What are the classes of blood cells?

These are the basic classes of blood cells:

Platelet

Monocyte

T Lymphocyte

B Lymphocyte

Basophil

Erythrocyte

Neutrophil

Eosinonphil

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What is the Function of the Endocrine Glands

December 27th, 2010

What is the Function of the Endocrine Glands

These are the basic Functions of the Endocrine Glands within the human body:

Anterior Pituitary Gland – functions as a tropic hormone to stimulate thyroid, adrenal and follicle stimulating hormones

Posterior Pituitary Gland – functions to stimulate the production of antidiuretic hormones and oxytocin, which stimulates uterine contractions during labour

Hypothalamus Gland – stimulates the thyroid gland to produce thyroxine.

Parathyroid Gland – functions to produce parathyroid hormones which cause the breakdown of bone and an increase in circulating calcium concentrations within blood

Adrenal Cortex Gland – regulates electrolyte and fluid homeostasis, stimulates libido, and stimulates gluconeogenesis during times of stress

Adrenal Medullar Gland – produces and excretes adrenalin, which stimulates the sympathetic nervous system during times of stress

Panreatic Islets Gland – produces the hormone glucagon, which promotes glycogenolyis and insulin, which acts as a ligand (key) to allow entry of blood glucose into muscle cell walls.

Ovary Gland – produces estrogens and progesterone, which promotes female sexual development and pregnancy

Testis Gland – releases testosterone and promotes the development of male sexual characteristics

Thymus Gland – promotes the development of thymus cells, which aid in immune system development and maintenance

Placenta Gland – promotes conditions required during early pregnancy

Atria – release atrial natiuretic hormone (ANH), which regulates fluid and electrolyte homeostasis

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What are the Endocrine Glands?

December 27th, 2010

What are the Endocrine Glands? Endocrine glands release hormones directly into the blood stream instead of scecreting it into a duct. The body has a network of endocrine glands throughought the body that release hormones into the blood stream to acheive physiological responses.

For example, the hormone adrenaline is released by the adranal gland during the sympathetic (fight or flight) response to an event in order to allow a person to run faster or fight harder.

These are a basic list of the Endocrine Glands within the human body:

Anterior Pituitary Gland

Posterior Pituitary Gland

Hypothalamus Gland

Parathyroid Gland

Adrenal Cortex Gland

Adrenal Medullar Gland

Panreatic Islets Gland

Ovary Gland

Testis Gland

Thymus Gland

Placenta Gland

Atria Naturietic Gland

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Body Movement Terminology

December 27th, 2010

Body Movement Terminology

These are the key body movement terms that are used during any course of study in anatomy and physiology. If you’re studying an on-line course in anatomy and physiology these concepts will be important to know:

Extension means “Stretching out”

Flexion means “Bending”

Abduction means “Movement away from the midline”

Retraction means “Movement in the posterior direction”

Protraction means “Movement in the anterior direction”

Inversion means “Turning inward”

Eversion means “Turning outward”

Rotation means “Movement of a structure, such as the head on an axis”

Reposition means “Movement of a structure to the original position that is anatomically closer to what is considered normal”

Supination means “The rotation of the forearm so that the anterior surface is facing upwards

Circumduction means “Movement in a circular motion”

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Why Do We Palpate From The Second Rib Down?

December 27th, 2010

Why Do We Palpate From The Second Rib Down?

We palpate from the second rib down because the first rib is anatomically covered by the clavicle bone and therefore difficult to palpate.

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What Are The Twelve Cranial Nerves?

December 27th, 2010

What are the Twelve Cranial Nerves? Cranial nerves are nerves which emerge directly from the brain and transfer data directly to the desired specific cells. In contrast, all other nerves within the human body emerge from the spine and then data is transfered from the spine to the brain. The first 2 cranial nerves emerge from the cerebrum, where as the remaining 10 cranial nerves emerge from the brain stem directly.

These are the 12 cranial nerves:

Cranial Nerve I

The first cranial nerve is the Olfactory nerve and serves the primary function to transmit nerve impulses from the nose to the brain in order to develop and achieve a sense of smell.

Cranial Nerve II

The second cranial nerve is the Optic nerve, which serves the primary function to transmit nerve impulses (messages) from the eye to the brain to achieve vision.

Cranial Nerve III

The third cranial nerve is the Oculomotory nerve, which serves the primary function to transmit nerve impulses from the eye muscles to the brain, to achieve eye movement (this includes dilation and constriction of the pupils.

Cranial Nerve IV

The fourth cranial nerve is the Trochlear nerve, and serves the primary function to transmit nerve impulses from the external eye muscles to the brain in order to achieve eye movements.

Cranial Nerve V

The fifth cranial nerve is called the Trigeminal serves the purpose of transmitting messages from the skin around the head all the way through to the teeth in order to achieve the sensations within the face, mouth and also in order to produce mastication.

Cranial Nerve VI

The sixth cranial nerve is called the Abducens nerve and transmits information from the brain to the eyes in order to turn the eyes outward.

Cranial Nerve VII

The seventh cranial nerve is called the Facial nerve, and as the name suggests it serves the purpose of providing contraction and movement of the facial muscles in order to achieve facial expression, as well as producing a sense of smell.

Cranial Nerve VIII

The eighth cranial nerve is called the Acoustic nerve and as the name suggests in transmits nerve impulses from the ear to the brain in order to achieve the sense of hearing and balance (as associated with the middle ear).

Cranial Nerve IX

The ninth cranial nerve is called the Glossopharyngeal nerve, and is involved in proving a sense of taste, swallowing, movement of the throat and excretion of saliva during mastication.

Cranial Nerve X

The tenth cranial nerve is called the Vagus nerve and transmits nerve impulses from the throat, larynx, and organs in the thoracic and abdominal cavities through to the brain in order to maintain many homeostatic purposes, such as parasympathetic stimulation.

Cranial Nerve XI

The eleventh cranial nerve is called the Spinal Accessory nerve and transmits impulses from the brain to certain shoulder and neck muscles in order to achieve movements such as turning and head control.

Cranial Nerve XII

The twelfth and final cranial nerve is called the Hypoglossal nerve and transmits nerve impulses from the brain o the muscles of the tongue in order to achieve tongue movement.

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Penetrating Traumatic Injuries

December 26th, 2010

Penetrating Traumatic Injuries

Penetrating trauma is an injury where an object pierces the skin and penetrates into the body or pierces an internal organ from within. The highest risk and greatest mortality rate occurs in abdominal and thoracic penetrating trauma.

A penetrating object may enter and then come out again, such as the case in a gunshot wound with an entry and exit wound. Knife wounds or any other sharp object can also cause a penetrating injury. Furthermore, a bullet, knife or sharp object may penetrate and enter a cavity and remain there either easily recognised and detected or not.

Another common mechanism for penetrating trauma includes broken bones which cause secondary injuries to internal organs. Rib fractures may cause pneumothoraxes or haemothoraxes.

Mechanisms of injuries are usually grouped based on the velocity at which they enter the body and the mount of kinetic energy that is then transferred to the internal organs and tissues. High powered rifles and blast injuries are regarded as high velocity injuries. Injuries from hand guns rifles and shotguns are considered medium velocity injuries. Where as knife and other hand held weapons are termed low velocity.

It should also be noted that the higher the density of the tissue or organ the more potential energy that may be transmitted into it – for example, the liver will absorb more kinetic energy than the fat in someone’s thighs.

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How to Assess Dehydration

December 26th, 2010

How to assess dehydration? Dehydration is a state in which a person has less fluid volume than is required to maintain homeostasis. A number of factors can lead to dehydration, including: fluid loss through vomiting, diarrhoea, fever dyspnoea, polyuria, burns and excessive diaphoresis (sweating). Decrease fluid or food intake due to poor diet, advanced age and immobility can also lead to dehydration.

Signs and Symptoms of Dehydration:

The following are common signs and symptoms of dehydration. As a paramedic, it is important to be aware of these signs and symptoms so that you can identify both the subtle and major physiological changes associated with acute dehydration. Recognising the early signs and symptoms of dehydration and correcting the dehydration is much easier than treating end stage absolute dehydration.

Looks for the following signs and symptoms of dehydration:

Tachycardia
Hypotension
Postural changes in blood pressure
Decrease Mean Arterial Pressure (MAP)
Narrowing Pulse Pressure
Dry Tongue
Sunken Eyes
Decreased Skin Turgor (the way the skin responds)
Thirst
Dry Mucus Membranes
Syncope
Decreased Urine Output; and
Inability to Sweat (due to profound dehydration).

Dehydration in Infants

The following are the most common signs of dehydration in infants:

1. Quiet baby or decreased level of consciousness

2. Sunken fontanel

3. Dry nappies

4. Decreased fluid intake 

Dehydration in the Elderly

Elderly patients are much more vulnerable to dehydration because they have approximately 10-15% less body water than a young or middle age adult. Dehydration is much more common in the elderly because of:

1. Concurrent use of medications such as antihypertensives and diuretics

2. Unstable blood glucose levels and higher resting blood glucose levels

3. Decreased mobility

4. Increased confusion

5. Current urinary tract infections.

Signs of dehydration in the elderly include:

1. Decreased level of consciousness

2. Increased confusion

3. Constipation.

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Fluid Balance in a Healthy Adult

December 26th, 2010

Fluid Balance in a Healthy Adult

Daily fluid loss and gain in a healthy adult differs depending on factors such as the person’s size, fluid intake, environment and exercise.

As a general rule a normal healthy adult will:

Lose Fluid through his or her:

Lungs (through vapour) 400 mls
Kidneys (urine) 1500 mls
Skin (Sweat) 400 mls
Intestines (feaces) 200 mls
Total 2500 mls

Gain Fluid through his or her:

Ingestion of fluid 1000mls
Food 200mls
Metoblism 2000mls
Total 2500mls

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What are Cardiac and Non-Cardiac Causes of Chest Pain?

December 26th, 2010

What are Cardiac and Non-Cardiac Causes of Chest Pain?

Cardiac Causes of Chest Pain include:

Ischaemic:

Angina;
Acute Myocardial Infarction;
Aortic Stenosis;
Hypertrophic Cardiomyopathy

Non-ischeamic

Pericarditis;
Aortic Dissection;
Mitral Valve Prolapse.

Non-Cardiac Causes of Chest Pain include:

GIT In Nature:
Gastro Oesophageal Reflux Disorder (GORD);
Oesophageal Spasm;
Reflux Oesophagitis;
Oesophageal Perforation;
Gastritis;
Peptic or Duodenal Ulcers

Pulmonary In Nature:

Pneumonia;
Bronchitis;
Pleuritis;
Pulmonary Embolism;
Pneumothorax
Pleuretic Friction Rub
Rib Fractures

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How to Insert a Jugular Vein Cannula

December 26th, 2010

How to Insert a Jugular Vein Cannula

Inserting a Juglar Vein Cannula is a serious medical procedure and should be treated as such. In pre-hospital care, as paramedics, IV insertion in the Jugular vein should be reserved to near-death situations and cardiac arrests.

This is because of the considerable risks associated with cannulating the jugular vein, not to mention the discomfort to the patient.

To insert a Jugular Vein IVC:

Explain to the patient what is going to happen (although they should probably be unconscious before you even think about attempting this in pre-hospital care);

Place the patient supine (and ideally with their legs elevated to increase the venous pooling and engorgement of the jugular vein).

Turn the patient’s neck away from the cannulation side;

Swab the site with an alcohol wipe. This is particularly important when inserting an IVC into a jugular vein due to the increase risk of systemic infection due to the size of the vein.

Prepare cannulation equipment;

Choose a cannula site. This will often being midway between the angle of the jaw and clavicle, lateral of the thyroid notch (but, at the end of the day, anywhere you can see a massive vein that you believe you can insert a large bore cannula will do just fine).

Tension the vein (this is very important in this size vein;

Insert the cannula at an angle of 15-30 degrees and with the bevel of the needle pointing upwards.

When a large flashback is observed, lower the cannula and advance the needle into the vein.

Occlude the vein proximally and remove the cannula needle before inserting the valve to the cannula;

Inject 10 mls of saline or hartmanns to ensure that the IV cannula is patent (although it’s pretty hard to miss the largest vein in the body).

Don’t forget neck is like any other limb, so you have to insert the cannula head downwards to ensure it maintains the normal flow of the venous blood. See picture (coming soon).

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How to Secure an IV Cannula

December 26th, 2010

How to Secure an IV Cannula

Securing an IV cannula is an important part of inserting an IV cannula. When a cannula falls out or dislodges prior to arrival at hospital, I often look to the clinician who inserted it and assume that it was a poor clinician’s fault (even if the patient was the one to move and dislodge it).

Different Ambulance Services, Hospitals or Health Institutions have differing policies regard taping in or securing IV cannulas and in many Health Systems, the methods are left to the discretion of the clinicians inserting them.

I currently use an “all in one” Tegaderm, which makes life convenient.

To secure an IV cannula I:

Open the Tegaderm Package;

Remove the sheet and cover the entire cannula up and to the start of the IV valve (bung), and then attach as second strip of rigid tape over the top (which I use to write the date). Remember, an IV site without a date on it, should be removed, due to the obvious risk of infection.

As a general rule, an IV should stay in situ for greater than 3 days (although this may not be possible if the patient has difficult veins and requires on-going IV therapy).

Remember, the old technique of wrapping the cannula with a loop of tape or steri-strip has been found (and proven in a randomized controlled trail) to cause an increase in infection.

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How Do I Check Drugs Before Administration?

December 26th, 2010

How Do I Check Drugs Before Administration?

Checking a drug before administration is not just a “good idea” but also a legal requirement in all states of Australia (and probably internationally).

The 5 “Drug Rights” should be performed, including:

Right patient;
Right Drug;
Right Dose;
Right Time; and
Right Route.

On top of this, I also include the patient’s “Right to refusal” – always check that the patient gives you consent to inject them or administer a certain drug.

Check that the drug is in date.

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How to Insert a Laryngeal Mask Airway

December 26th, 2010

How to Insert a Laryngeal Mask Airway

Laryngeal Mask Airways have become increasingly popular in theatres (for minor surgery procedures with low risks of aspiration) and even in pre-hospital care as a good alternative to Endotracheal Intubation.

It should be noted that although LMA insertion is easier than ET insertion it is not as stable an airway and does not protect the airway from potential vomiting. This said, LMA insertion is easier and less likely to fail.

Like any other medical procedure (even in an emergency) it is always important to prepare the patient, as much as preparing the equipment.

When I’m about to insert an LMA I like to adequately assess the patency of the patient’s airway before insertion, with simple airway manourvres such as: jaw thrust, head tilt, and chin lift. I then pre-oxygenate the patient, by ventilating with a Bag Valve Mask with 100% Oxygen for at least two minutes before hand.

I then prepare the equipment. This will include, the Laryngeal Mask Airway, syringe, lubricating gel, bite block (or oropharyngeal airway), trachy ties or tape, and scissors. I also make sure my stethoscope is handy.

I then select the size LMA. Each brand of LMA appears to have a different system. The brand that we use currently are broken down into small patients, medium sized patients, and large patients. However, it should be noted that larger patients (although technically requiring a larger LMA, sometimes, due to the size of an obese person’s neck, or a person with a particularly short, thick neck, a smaller size LMA may be the only size that actually fits. Each LMA is designed differently, so review the packaging and manufacturer’s advice on this topic.

Lubricate the posterior surfaces of the LMA (but don’t worry if you get some lubricant on the anterior side surface of the LMA, this wont affect anything).

Check to make sure that the valve depressor is inserted into the indicator bulb (this keeps some pressure in the LMA, and stops it folding back so easily).

Position yourself ideally behind the patient’s head.

Place the patient in a supine position and then into the “sniffing” position.
Use some pressure with your non-dominant hand on the jaw to allow enough room to insert the LMA with your dominant hand.

Hold the LMA with your dominant hand and insert the airway over the top of the tongue and pushing it backwards until it reaches the hard palate (back part of the oropharynx).

Advance the LMA as far back as possible.

Remove the valve depressor and insert the required inflation amount of air (often about 20-30 minutes, but may vary depending on brands).

Immediately after insertion, auscultate the patient’s lungs to ensure that you have correct placement of the LMA and that it is providing a patent airway.

Insert a bite block to stop the patient biting down on the LMA tube

Tie the LMA tube to the lip. To do this, tie a knot at the top lip. This is because the top lip does not move, where as the jaw (mandible) will likely move.

Continuously re-assess.

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How to Insert a Nasopharyngeal Airway

December 26th, 2010

How to Insert a Nasopharyngeal Airway

One of the causes of an Upper Airway Obstruction includes a backwards displacement of the tongue in an unconscious person. One solution to this, is to insert a nasopharyngeal airway (NPA).

Some of the useful situations in which I would consider a Nasopharyneal Airway over an Oropharyngeal Airway include, when the patient has trismus, is clenching their teeth, or has injuries to their mouth making an oropharyngeal airway difficult or inappropriate.

To insert a Nasopharyngeal Airway I measure it first, by measuring from the ear lobe through to the tip of the nose.

I then lubricate the NPA fully (with a water based lubricant, but each hospital or health service may have a preferred type of lubricant).

Insert it gently, but firmly through the largest nostril. Don’t forget, the nasal passage goes backwards at a right angle to the face.

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How to Insert an Oropharyngeal Airway

December 26th, 2010

One of the causes of an Upper Airway Obstruction includes a backwards displacement of the tongue in an unconscious person. One solution to this, is to insert an oropharyngeal airway (OPA).

When I insert an OP airway the patient must first be unconscious (this seems obvious), but it can also be used as a diagnostic measure, in which a patient who has a slightly decreased GCS will not actually tolerate an OP airway.

If the patient is unconscious, I generally have a few other things to consider (and inserting an OP airway needs to be done rapidly).

I measure the OP airway for a correct size, by measuring from the corner of the mouth to the ear lobe.

I then hold the flange (largest part of the OP airway, which will sit at the patient’s lips), and point the curve side down. As I insert the curved side down (so that it can get passed the tongue, I will rotate it 180 degrees .

While I do this, I’m looking for a gag reflex in the patient (and am quick to remove it if the patient starts to gag/ vomit).

I then ventilate the patient a few times and auscultate the patient’s lungs to make sure that it is doing the job that it’s supposed to and maintaining an open upper airway.

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How to Treat an Upper Airway Obstruction

December 26th, 2010

How to Treat an Upper Airway Obstruction

An upper airway obstruction is a life threatening medical emergency!

These are some methods for treating an upper airway obstruction:

Suction fluids, such as saliva, blood or minor vomit;

Log-roll if patient is unconscious;

Turn Head to the side to drain fluid;

Use fingers for solid food (watch out for the pseudo fitters, they may bite);

Use a Magill’s Forceps and laryngoscope for solids which are further down the upper airway.

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How to Assess an Upper Airway Obstruction

December 26th, 2010

How to Assess an Upper Airway Obstruction

Upper airway obstructions are partial or complete blockages of the upper airway (larynx, pharynx and mouth). Upper airway obstructions can occur rapidly and the patient can literally die within minutes, so recognition of the condition and urgent treatment is paramount.

The causes of an Upper Airway Obstruction include:

The tongue falling backwards blocking the larynx in the unconscious person;

Swelling of the nasal passages, oral cavity, larynx or pharynx due to: burns, allergic reactions, infection, trauma, cysts, or tumors;

Foreign bodies, such as fluid, saliva, vomit, blood, food false teeth, broken teeth, and just about anything people can imagine they can eat;

Laryngeal spasm

How do you actually assess an upper airway obstruction?

Look for inadequate air moving through the nose or mouth;

Listen for complete silence (in a complete obstruction), inspiratory stridor (incomplete obstruction)

Chest movement may have a see-saw type of appearance. In infants it may be possible to see intercostal recession and inspiratory in-drawing of air spaces.

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What is Insulin Resistance Syndrome?

December 25th, 2010

Insulin resistance Syndrome is a pathological condition in which the natural hormone “insulin” becomes less effective at lowering blood glucose levels. The resulting increase in blood glucose may raise levels outside the normal range and cause adverse health effects. Insulin is used by the human body as a ligand (key) that allows the body to unlock the door for glucose to enter specific cells, such as muscles in order to produce energy. Without insulin, certain cells will not allow glucose to enter.

Certain cell types such as fat and muscle cells require insulin to absorb glucose. When these cells fail to respond adequately to circulating insulin, blood glucose levels rise. The liver helps regulate glucose levels by reducing its secretion of glucose in the presence of insulin. This normal reduction in the liver’s glucose production may not occur in people with insulin resistance

Insulin Resistance Syndrome

Insulin resistance in muscle and fat cells reduces glucose uptake (and so local storage of glucose as glycogen and triglycerides, respectively), whereas insulin resistance in liver cells results in reduced glycogen synthesis and storage and a failure to suppress glucose production and release into the blood.

Insulin resistance normally refers to reduced glucose-lowering effects of insulin. However, other functions of insulin can also be affected. For example, insulin resistance in fat cells reduces the normal effects of insulin on lipids and results in reduced uptake of circulating lipids and increased hydrolysis of stored triglycerides. Increased mobilization of stored lipids in these cells elevates free fatty acids in the blood plasma. Elevated blood fatty-acid concentrations (associated with insulin resistance and diabetes mellitus Type 2), reduced muscle glucose uptake, and increased liver glucose production all contribute to elevated blood glucose levels. High plasma levels of insulin and glucose due to insulin resistance are a major component of the metabolic syndrome. If insulin resistance exists, more insulin needs to be secreted by the pancreas. If this compensatory increase does not occur, blood glucose concentrations increase and type 2 diabetes occurs.

Causes of Insulin Resistance Syndrome

Although the likelihood that you will develop insulin resistance syndrome is most commonly related to your genetic and family history, the following are considered risk factors that tend to increase your risk of developing the medical condition:

– Being physically inactive

– Having a close relative who has diabetes

– Have an indigenous background, due to the fact that your family history has not had thousands of years to grow accustomed to European food and the excessive intake of suggars.

– Giving birth to a baby weighing more than 9 pounds or being diagnosed with gestational diabetes-diabetes first found during pregnancy

– Co-existing medical conditions such as hypertension (high blood pressure), cardiovascular disease, polycystic overies, or unusually low High Density Lipid counts in your blood all have been associated with contributing to diabetes and insulin resistance syndrome.

– Having other conditions associated with insulin resistance, such as severe obesity or acanthosis nigricans.

Sources: National Diabetes Diabetes Clearinghouse (2011): Insulin Resistance and Pre-diabetes.  http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/

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What is a Panniculus?

December 25th, 2010

In a severely obese person, excess adipose tissue hanging downward from the abdomen is referred to as a panniculus (or pannus). A panniculus complicates the surgery of the morbidly obese. The panniculus may remain as a literal “apron of skin” if a severely obese person quickly loses large amounts of fat (a common result of gastric bypass surgery). This condition cannot be effectively corrected through diet and exercise alone, as the panniculus consists of adipocytes and other supporting cell types shrunken to their minimum volume and diameter. Reconstructive surgery is one method of treatment.

A Panniculus is also commonly refered as a “Gunt;” however, in medical terms, it should be identified as “Panniculus.”

What Does a Panniculus Look Like?

A panniculus can be a small flap of excess skin from the umbilicus downward, through to a large flap of excess adipose tissue and skin forming from the umbilicus downward to past the pelvis, and in extreme cases reaching past the person’s knees and onto the ground. The following is a good example of an extreme panniculus.

Panniculus

(Image Source: Donated by annonymous 2011).

Will a panniculus disappear if a person loses weight? The fatty (adipose tissues) will disappear after losing weight, but in cases where there is a large panniculus, the person will require plastic surgery to remove the excess skin.

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The Renal System

December 18th, 2010

The renal system is primarily involved in homeostasis through regulation of the following factors:

1. The maintenance of blood osmolarity (definition);

2. The maintenance of blood pressure and regulation of blood pressure;

3. Regulation of blood volume;

4. Filtering of the blood to eliminate waste products, such as urea;

5. Fluid and electrolyte balance; and

6. Acide and Base balance/regulation.

The Anatomy of the Renal System includes the following: Two kidneys (generally, but may be more and may be less), two ureters, one urinary bladder and one urethra (in both males and females).

It should be noted that the female urethra is considerably shorter than the males and this introduces the higher occurence and risk of infections, such as a urinary tract infection (UTI).

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The Lymphatic System

December 18th, 2010

In a very basic sense of the term circulatory system, the human body utilises three main types of circulatory body systems. These include:

1. The Arterial Circulatory System, which involves oxygenated blood that leaves the heart for the capilaries and individual cells that require oxygen;

2. The Venous Circulatory System, which involves de-oxygenated blood that leaves cells and travels back to the heart for re-oxygenation; and

3. The Lympathic Circulatory System, which is involved in draining excess fluid.

The Lymphatic System serves the following three purposes:

1. To drain excess fluid from various tissue spaces (normally intersitial fluid);

2. To transport dietary lipids and lipid soluable vitamins from the gastrointestinal tract (GIT) through to circulating blood. Lipid soluable vitamins, include: A, D, E and K;

3. Facilitating immune response. The lymphatic system is responsible for creating and storing lymphocytes and macrophages, which assist immune response by identifying and attacking foreign cells, such as bacteria, microbes, toxins, and cancerous cells. The lymphatic system is also responsible for releasing T-cells (also known as Thymus Cells) and B-cells (also known as Bursal Cells), which play an important part in immune response. T-cells , when released destroy invading cells, where as B-cells produce antibodies, which as specifically designed to target and fight specific bacteria, virus or foreign substances.

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The Skeletal System

December 18th, 2010

The Skeletal System provides support for the human body through a framework that allows muscles to  pull on something that is rigid.

The skeletal system is involved in:

1. Structural Support;

2. Protection;

3. Movement;

4. Mineral Storage;

5. Red Blood Cell production; and

6. Fat Storage.

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The Integumentary System

December 18th, 2010

The Integumentary System refers primarily to the skin, but can also include accessory structures, such as nails, hair, glands, muscles and even nerves. The skin is responsible for more than it is normally given credit for.

These are some of the main functions of the skin:

1. Protection;

2. Recognition and acknowledgement of stimuli, such as pressure, pain, temperatures, and sensations;

3. Excretion of fluid and electrolytes in the form of sweat and waste products;

4. Synthesis of Vitamin D, which is vital in stimulating the bones to absorb calcium.

5. Regulation of body temperature, through sweating (to cool down) and pilo-erection (hair folicles standing up straight so that the body can stay warmer).

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The Reproductive System

December 18th, 2010

The reproductive system is primarily responsible for ensuring the future survival of the human race through procreation. This system refers to both male and female organs of procreation and the organs which are responsible for creating a foetus. These include, the male penis and testes (which produce semen) and the female’s vagina and uterus.

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The Endocrine System

December 18th, 2010

The Endocrine System involves any gland within the human body, which releases or is responsible for the release of a hormone, such as adrenaline into the body, in order to have an affect on another organ of tissue within the body. This is different to an exocrine, which secretes a chemical out of the body, such as sweat glands or saliva glands.

The Endrocrine System, like the Nervous System helps to regulate homeostasis. Where the Nervous System communicates the electrical impulses or signals from and to the brain, the Endocrine System works by releasing hormones from specific organs within the human body to cause a response. For example, an endocrine system response to being attacked (known as the fight of flight response), would cause a release of adrenaline from the adrenal glands, which stimulate the sympathetic response mechanisms, such as increase force and rate of myocardial contractions, dilation of pupils, increased blood pressure, and many other physiological changes designed to increase the body’s potential survival.

Anatomy of the Endocrine System:

1. Pineal Gland

2. Pituitary Gland

3. Thyroid Gland

4. Thymus

5. Adrenal Gland

6. Pancrease

7. Overies

8. Testes

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The Nervous System

December 18th, 2010

The Nervous System, which is also known as the Neurological System works in combination with the Endocrine System to provide a micro-communication system for the human body. This system includes voluntary communication throughout the human body, such as the desire to move (from the brain) communicating with the muscles in your legs to move. The System also includes involuntary communications with the body in order to maintain homeostasis. For example, if you see a tiger, your brain will invuntarily message your heart to increase its rate and force of contraction so that you have a better chance of running away.

The nervous system is responsible for transmitting and receiving electrical and chemical signals (messages) within the body. The nervous system can also be considered the human body’s communication network. The nervous system sends messages through afferent and efferent neurons. An afferent neuron pathway or sensory neuron means nerve messagengers which send signals from the peripheries through to the cerebral cortex or command center within the brain). Efferent neuron pathways or effector pathways, send messeges from the cerebral cortex (the command center within the brain) to the muscles and various organs in the body to achieve a desired response.

An example of an afferent neuron pathway is: when a person places their hand on a hot frying pan, and the afferent neurons sends a message up the persons arm (from the peripheries) through to the cerebral cortex (command center) in order identify to the brain that the frying pan is hot.

An example of an efferent neurone pathway is: when, after the person who has placed their hand on a hot frying pan has sent the message to the brain via the afferent pathway, the cerebral cortex then sends the message via the efferent neurone pathway to the muscles within the arm, to contract and instantly pull his or her hand away from the frying pan.

Within the Nervous System there are two main areas, these include: The Central Nervous System and the Peripheral Nervous System.

The Central Nervous System includes the brain and the spinal cord. These two organs control many of the functions of the human body. The brain is the command center for the body. The brain stem (where the brain meets the spinal cord) controls many vital functions required to control life, such as: heart rate and diaphragm movement for respiration. The spinal cord is the main hub of communication signals, in which all peripheral afferent and efferent messages are transmitted.

The Peripheral Nervous System controls the messages to and from the brain and peripheries. The Peripheral Nervous System can further broken down into the Autonomic and the Somatic Nervous System.

The Somatic Nervous System is also identified as the Voluntary Nervous System, in which the person can transmit controlled messages from the Brain to the peripheries in order to control movement.

An example of the Somatic Nervous System includes: the Brain sending the message to the legs to move its arms. This causes the Somatic Nervous System to transmit a message through the peripheries through to the muscles in the arm to stimulate contraction and skeletal movement.

The Peripheral Nervous System is also called the Involuntary Nervous System and allows the brain to produce involuntary messages to cause changes within the body. The Peripheral Nervous System can be further broken into the Sympathetic and the Parasympathetic Nervous System.

The Sympathetic Nervous System causes the body to produce the “Fight or Flight Response,” in which adrenal responses such as a release of adrenaline and nor-adrenaline, cause an increase in heart rate, blood pressure, dilation of bronchioles and enhanced force of contraction of muscles within the body. This allows the human body to respond to an emergency.

An example of the Sympathetic Nervous includes: the response to a person holding a knife up to you and asking for your wallet, this results in the release of adrenal responses, which allows the person to have the best physiological ability to fight the mugger, or run from the mugger.

The Parasympathetic Nervous System is also known as the “Feed or Breed Response” and focusses on slowing the main systems of the body to aid in feeding and breeding, this includes, slowing the heart rate, lowering blood pressure, and slowing the motility of the gastro-intestinal tract (GIT).

An example of the Parasympathetic Nervous System would include: the circadian rhythym, which causes a slowing of the heart rate and a rellaxation of muscles which allow a person to sleep.

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The Neurological System

December 18th, 2010

The Neurological System, which is also known as the Nervous System works in combination with the Endocrine System to provide a micro-communication system for the human body. This system includes voluntary communication throughout the human body, such as the desire to move (from the brain) communicating with the muscles in your legs to move. The System also includes involuntary communications with the body in order to maintain homeostasis. For example, if you see a tiger, your brain will invuntarily message your heart to increase its rate and force of contraction so that you have a better chance of running away.

The nervous system is responsible for transmitting and receiving electrical and chemical signals (messages) within the body. The nervous system can also be considered the human body’s communication network. The nervous system sends messages through afferent and efferent neurons. An afferent neuron pathway or sensory neuron means nerve messagengers which send signals from the peripheries through to the cerebral cortex or command center within the brain). Efferent neuron pathways or effector pathways, send messeges from the cerebral cortex (the command center within the brain) to the muscles and various organs in the body to achieve a desired response.

An example of an afferent neuron pathway is: when a person places their hand on a hot frying pan, and the afferent neurons sends a message up the persons arm (from the peripheries) through to the cerebral cortex (command center) in order identify to the brain that the frying pan is hot.

An example of an efferent neurone pathway is: when, after the person who has placed their hand on a hot frying pan has sent the message to the brain via the afferent pathway, the cerebral cortex then sends the message via the efferent neurone pathway to the muscles within the arm, to contract and instantly pull his or her hand away from the frying pan.

Within the Nervous System there are two main areas, these include: The Central Nervous System and the Peripheral Nervous System.

The Central Nervous System includes the brain and the spinal cord. These two organs control many of the functions of the human body. The brain is the command center for the body. The brain stem (where the brain meets the spinal cord) controls many vital functions required to control life, such as: heart rate and diaphragm movement for respiration. The spinal cord is the main hub of communication signals, in which all peripheral afferent and efferent messages are transmitted.

The Peripheral Nervous System controls the messages to and from the brain and peripheries. The Peripheral Nervous System can further broken down into the Autonomic and the Somatic Nervous System.

The Somatic Nervous System is also identified as the Voluntary Nervous System, in which the person can transmit controlled messages from the Brain to the peripheries in order to control movement.

An example of the Somatic Nervous System includes: the Brain sending the message to the legs to move its arms. This causes the Somatic Nervous System to transmit a message through the peripheries through to the muscles in the arm to stimulate contraction and skeletal movement.

The Peripheral Nervous System is also called the Involuntary Nervous System and allows the brain to produce involuntary messages to cause changes within the body. The Peripheral Nervous System can be further broken into the Sympathetic and the Parasympathetic Nervous System.

The Sympathetic Nervous System causes the body to produce the “Fight or Flight Response,” in which adrenal responses such as a release of adrenaline and nor-adrenaline, cause an increase in heart rate, blood pressure, dilation of bronchioles and enhanced force of contraction of muscles within the body. This allows the human body to respond to an emergency.

An example of the Sympathetic Nervous includes: the response to a person holding a knife up to you and asking for your wallet, this results in the release of adrenal responses, which allows the person to have the best physiological ability to fight the mugger, or run from the mugger.

The Parasympathetic Nervous System is also known as the “Feed or Breed Response” and focusses on slowing the main systems of the body to aid in feeding and breeding, this includes, slowing the heart rate, lowering blood pressure, and slowing the motility of the gastro-intestinal tract (GIT).

An example of the Parasympathetic Nervous System would include: the circadian rhythym, which causes a slowing of the heart rate and a rellaxation of muscles which allow a person to sleep.

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Why is it Important to Learn About the Respiratory System

December 18th, 2010

It is important to learn about the respiratory system because this is the system that you will most likely have to consider and treat in a medical emergency. This includes everyone from First Aiders to Intensive Care Doctors.

The Respiratory System involves all the pipes and conducting airways from the mouth through to the lungs, including: mouth, larynx, trachea, right and left main bronchus (sides of the lungs), bronchioles (little branches of the lungs), alvioli (little sacs in which gasseous exchange takes place). After the respiratory system gets the oxygen to the alivioli, and gasseous exchange takes place, the circulatory system then removes CO2 from cells throughout the whole body, while O2 is delivered to all cells within the body.

Like all other piping systems, if you a pipe becomes blocked, no further flow (in this case of oxygen) will progress. In the human body, a failure within the respiratory system can lead to death in about five minutes.

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The Respiratory System

December 18th, 2010

The Respiratory System is a unique and important part of the human body.

What is the Respiratory System?

The respiratory system is the system within the human body that provides gass exchange for oxygen (comming into the body) and carbod dioxide (leaving the body).

What is the Anatomy and Phsyiology of the Respiratory System?

The Respiratory System involves all the pipes and conducting airways from the mouth through to the lungs, including: mouth, larynx, trachea, right and left main bronchus (sides of the lungs), bronchioles (little branches of the lungs), alvioli (little sacs in which gasseous exchange takes place). After the respiratory system gets the oxygen to the alivioli, and gasseous exchange takes place, the circulatory system then removes CO2 from cells throughout the whole body, while O2 is delivered to all cells within the body.

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Our Goals

December 18th, 2010

Thank you for taking an interest in our goals section of our Paramedic website. This page identifies some of our goals we had when we started creating this Paramedic Website and how they have changed. These include:

1. To improve communication and interaction between paramedics within the wider community of paramedics globally.

2. To provide an easy to access, free to use, E-learning data base for paramedics to use from home, at the station or as paramedic students preparing for exams and the paramedic profession.

3. To provide a forum, in which paramedics globally are able to exchange lessons learned from jobs.

4. To provide a stage in which paramedics can enjoy the humorous side of their jobs (through some of the black humor articles), without breaching any patient privacy or confidentiality.

5. Utilise Google Advertising to not only provide a market place for paramedic equipment and textbooks, but also fund the upkeep and maintenance of this site, so that it remains free to use.

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Submit A Case Study

December 17th, 2010

If you’re a paramedic and have an interesting case which you believe could provide certain lessons to other paramedics or even just an interesting case, please feel free to email us though our Contact Us page and we’ll post it on the Public Paramedic Case Study’s Page.

Don’t forget your patient’s privacy and right to confidentiality. If you are going to submit a case for review, please ensure that your remove any identifying factors from the case. These include: the specific age or date of birth of the patient, name, address, and location of the accident.

Thanks,

Emergency Medical Paramedic

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Suggestions

December 17th, 2010

If you’re a paramedic or training to be a paramedic and have any suggestions for our website, please send us an email through our Contact Us page.

We appreciate all the paramedic input we can get.

Thanks,

Emergency Medical Paramedic

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Disclaimer

December 17th, 2010

Emergency Medical Paramedic Disclaimer

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You agree to indemnify, defend and hold harmless Emergency Medical Paramedic, its officers, directors, employees, agents, licensors, suppliers and any third party information providers to the Service from and against all losses, expenses, damages and costs, including reasonable attorneys’ fees, resulting from any violation of this Agreement (including negligent or wrongful conduct) by you or any other person accessing the Service.
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This Agreement shall all be governed and construed in accordance with the laws of Australia applicable to agreements made and to be performed in Australia. You agree that any legal action or proceeding between Emergency Medical Paramedic and you for any purpose concerning this Agreement or the parties’ obligations hereunder shall be brought exclusively in a federal or state court of competent jurisdiction sitting in Australia . Any cause of action or claim you may have with respect to the Service must be commenced within one (1) year after the claim or cause of action arises or such claim or cause of action is barred. Emergency Medical Paramedic’s failure to insist upon or enforce strict performance of any provision of this Agreement shall not be construed as a waiver of any provision or right. Neither the course of conduct between the parties nor trade practice shall act to modify any provision of this Agreement. Emergency Medical Paramedic may assign its rights and duties under this Agreement to any party at any time without notice to you.
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6. Use of this Site.

This site has been designed, created and produced by paramedics who have desired to improve global communication among the paramedic community and in doing so enable paramedics to learn from eachother’s mistakes. All information provided in this Site is for educational purposes only and should not be utilised as medical advice. Furthermore, all educational information provided in this site is only the opinion/opinions of those paramedics who have contributed to it, and should not be utilised within your Ambulance Practice, unless they have been specifically approved by your Ambulance Service.

All paramedic stories or case studies within this Site are for educational purposes only. The authors have altered all identifying factors for the patients within, including: age, name, date of birth, and location. In circumstances where the situation was so significant that anyone reading the case, could identify the person/persons within based on the story, have had the key injuries/illness altered to further safeguard the patient’s privacy. Finally, if any of these stories, by coincidence have a comparison to an incident that you personally were involved in, then understand that this only a coincidence and no relation to facts.

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Privacy Policy

December 17th, 2010

Privacy Policy

1. Thank you for taking the time to review our Privacy Policy.

2. The purpose of this document is to explain to visitors what types of information we will collect and how that information is used. In most cases, we do not collect any information about you personal. However, some information is gathered to ensure network integrity and that we continue to provide you with the most relevant content and best possible service that suits your needs. In some cases, we are required by law to collect personal information about visitors. Except where the law requires otherwise, we undertake to protect the confidentiality of such data.

Confidentiality

3. We, at Emergency Medical Paramedic, respect our visitors privacy and the privacy of those accessing our website. We undertake to protect the confidentiality of our visitors and users including all personal information supplied in the course of participating in our services. We undertake not to sell your personal information to third parties for commercial or marketing purposes.

Collection of Personal Data

4. We, at Emergency Medical Paramedic do not routinely collect, store or distribute your personal information or information about visitors to this websites. This website does however, use Google Analytics, which is a free tracking program designed to provide us with information that can improve our website, but is not sensitive in nature. This information includes data about: the way people find out website, the country that they have accessed this website from, and the main pages and average time that they have spent on the site. We, at Emergency Medical Paramedic agree that this information is only to be used to improve our website and ensure that we are better able to provide the information that is being sought by our visitors. We agree that any information gathered through this website has been used for this purpose only, and will not be used to “spam” or sell this information to a third party. This data is stored with an encrypted password to ensure that any personal data that is gathered, is not disclosed to a third party or used in any other  means than is previously stated.

Use of Personal Data

5. The only specific personal data we collect is a visitor’s email address when he or she chooses to contact us through our contact us page. This is only for the express purpose of responding to the person’s question or original email. These email addresses will not be used by Emergency Medical Paramedic to sell, rent, disclose or “spam” information or products.  We will not routinely email you. This information is only stored long enough to respond to original emails.

6. Emergency Medical Paramedic may collect and share aggregated user data with business partners, sponsors or other third parties for the purposes of developing content and ensuring relevant advertising and content, such user data will never be used to identify individual users. These business partners and affiliated companies do not have any independent right to share this information.

7. Emergency Medical Paramedic may log the websites you visit; collect IP addresses and information about your operating system and the type of browser you use for the purposes of network/system administration; to report aggregate information to our advertisers, and to audit the use of our site. This data however will not be used to identify individual users who will at all times remain anonymous.

8. Any information Emergency Medical Paramedic collects from you through correspondence with us, whether via e-mail, telephonically or by written letter, will only be used to address the matters within that correspondence. If this requires referring such correspondence within Connecting Up Australia or to a third party to ensure customer service, your personal information will only be disclosed to the point necessary to address your query or concerns, and will otherwise be kept confidential.

Public Space

9. Any information that visitor disclose in a public space, including on any bulletin board, chat room within Emergency Medical Paramedic, is available to anyone else who visits that space. Emergency Medical Paramedic cannot safeguard any information you disclose there. Furthermore, Emergency Medical Paramedic cannot vouch for the validity or confidentiality, of any information “posted” by a visitor in a public space. Emergency Medical Paramedic cannot be held responsible for any information “posted” by a visitor on our chat site or paramedic forum. If you believe that someone has “posted” something that is inappropriate, abusive, or breaches someone’s privacy or confidentiality, we appreciate you contact us through our contact us page and we will remove it.

Site Linking

10. Emergency Medical Paramedic  may contain many links to sites that belong to third parties unrelated to us. Emergency Medical Paramedic cannot be held responsible for any use of your personal information arising from you disclosing personal such information on third party sites. Emergency Medical Paramedic  cannot protect any information you may disclose on these sites and recommends that you review the privacy policy statements of those sites you visit.

Minors

11. Emergency Medical Paramedic will not enter into a service subscription contract with a minor. Emergency Medical Paramedic undertakes not to contact minors about promotional offers or for marketing purposes without a parental consent.

Reservation of Rights

12. Emergency Medical Paramedic reserves the right to disclose information about website visitors where required in good faith, to do so by law or to exercise our legal rights or defend ourselves against legal claims.

13. Emergency Medical Paramedic further reserves the right to share information with law enforcement to investigate or prevent illegal activities being committed over our network.

14. Emergency Medical Paramedic reserves our rights to disclose your personal information where you have given us explicit legal written consent to do so. Although this unlikely to occur

15. Emergency Medical Paramedic reserves the right to monitor user and network traffic for site security purposes and prevent any unauthorised attempts to tamper with our site or cause damage to our property.

16. Emergency Medical Paramedic reserves the right to make changes to this privacy policy or update it. Where a major change is made, visitors will be informed through a notice on our website. Visitors of this site bear the responsibility to ensure that they have read the changes or updates as the case may be.

17. I take this time to again thank you for reviewing our Privacy Policy and hope you enjoy the work that we are trying to achieve in contributing to the wider community of paramedics around the world.

Notifying Us

18. If you are concerned that we may have breached or are breaching any aspect of the above Privacy Policy, we welcome you to contact us via the Contact Us page, and we will rectify this situation as early as possible.

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Should Paramedics Use GPS?

December 8th, 2010

Through the past few years the technology and the prevalence of the GPS for every day use has increased dramatically. In some Ambulance Services, such as the Ambulance Service of NSW, all paramedics are issued with a GPS, and given the liberty to choose when or if they need to use it.

However, with all these technological improvements, there come some pros and cons and for every paramedic who loves to use a GPS, there appears to be another paramedic who refuses to even look at the thing. There is still a strong culture in Ambulance, that if you can’t read a map, you shouldn’t be a paramedic (obviously, map’s haven’t lost their place in Ambulances yet, and if you really can’t read a map, you probably shouldn’t be an Ambo).

These are some of the pros to paramedics using a GPS:

1. Entering a location in a GPS is generally faster than looking it up in a street directory

2. A GPS will provide you with street numbers and should, ideally be able to take you to the front door of a house

3. Even if you aren’t actually using the GPS to find an address, a GPS can provide the names of the streets surrounding you (which will make life easier if some kid has ripped down all the local street signs)

4. A GPS can be much faster to use if, as a paramedic, you are out of your regular area

5. A GPS can help take out the stress of finding an address – even if it is longer by a few minutes, you know that you will generally get there and won’t have to take multiple wrong turns

6. You can scroll through, as text, the route the GPS is trying to take you – this way can choose the fastest route that you know to get to the local area, and then let the GPS guide you in through the little residential streets.

The cons of paramedics using a GPS include:

1. Sometimes the battery fails enroute to a job or the clouds block the satelite transmission (usually on the most important cases) 

2. The GPS may take you a longer route than normal

3. A GPS wont provide you with information about what is comming up ahead of you (such as schools, busy intersections, etc).

4. A GPS may take you a wrong way – or it will take you on a long loop, just to do a u-turn.

Obviously, there are pros and cons with using a GPS; however, as a paramedic, who has learned the job of paramedics well before the availability of GPS for private use, I believe that they can be a useful adjunct to normal navigation -so long as the paramedic is capable of using a streed directory if the GPS system fails.

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Anticoagulant Pathway

November 28th, 2010

Although there are numerous clotting factors continuously circulating within the blood system, blood is fundamentally liquid. This occurs through the bennefits of two main anticoagulant pathways.

Smooth Endothelial Lining, which prevents thrombin frombinding to the TF III within the collagen and prevents commencement of the clotting cascade.

Negatively charged ions within the preteins of the endothelial cell walls, which repel many of the similarly negatively charged platelets and clotting factors.

To learn more about the clotting cascade, please review my Clotting Cascade Page.

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Disseminated Intravascular Coagulation

November 28th, 2010

Disseminated Intravascular Coagulation (DIC) is a pathological condition in which the normal haemostatic mechanisms are disturbed leading to an uncontrolled and pathological activation of the clotting cascade as a result of profound states of shock. Most commonly as a result of Septic Shock (but can occur in traumatic Hypovolaemic Shock).

During normal homeostasis, the body acutely regulates blood coagulation and fibrinolyis in order to maintain normal circulatory function. However, in Disseminated Intravascular Coagulation (DIC) the process of coagulation and fibrinolyis is deregulated as a result of the body’s attempt to combat profound states of shock. This results in the body developing multiple micro-clots at the same time producing excessive amounts of fibrin, which attempts to break these clots further producing the need for more clotting factors. This produces a systemic circulatory state of micro-clots, micro-bleeds, which often lead to multiple organ failure and death. The mortality rate of patients suffering with Disseminated Intravascular Coagulation is close to 50%.

To learn more about the clotting cascade, please review my Clotting Cascade Page.

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Hemostasis

November 25th, 2010

Hemostasis, like homeostasis refers to maintaining systems within the body within normal, pre-determined ranges, and in the case of hemostasis, it specifically refers to maintaining a stable flow and level of blood within the circulatory system.  Mechanisms of hemostasis include: plateles, blood proteins, and vasculature.

The basic sequence of clotting includes the following steps:

1. Vasoconstriction (in order to lesson the area in which the blood can leave the vascular system – this is also known as a vasospasm);

2. Development and formation of a platelet plug (a whole bunch of platelets aggregate “join together”  and develops a plug to block the hole/wound);

3. Activation of the clotting system (the clotting cascade). If you want to learn more about the complex process of the clotting cascade, please review my Clotting Cascade Page.

4.Formation of a complete blood clot (involving more than just platelets);

5. Clot retraction and dissolution (this involves fibrinolysis/breaking up of the clot).

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Anatomy and Physiology Online

November 21st, 2010

Human Anatomy is the study of specific physical parts which make up the human body, where as Physiology considers how these parts function in order to achieve a desired goal or goals, such as walking.

An example of Human Anatomy would include physical structures of the human body, such as: the skeleton, brain, teeth, heart, etc.

Where as an example of Human Physiology would include: studying how the heart circulates blood around the circulatory system or how the lungs exchange the gasses oxygen and carbon dioxide within the alvioli.

If you are just starting a new career in health or are currently studying some form or health science, such as: paramedics, nursing, medicine, radiology, physiotherapy or speech pathology, you may wish to look at my Anatomy and Physiology Materials for Download section on the right of this webpage, which allow easy study of human anatomy and physiology at home and online.

If you wish to learn more aboud individual aspects of anatomy and phsyiology please follow this link to my Anatomy and Physiology Page.

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Anatomy and Physiology Definition

November 21st, 2010

The terms Anatomy and Phsyiology can be defined as the science of the structures of the body (anatomy) combined with the science of the functions of the body (physiology).

In broad terms, anatomy looks at physical parts that make up the body, including, the skeleton, the skin, the brain, teeth, etc; where as the term physiology looks at how these structures function to achieve the goals of the human body.

Therefore the definition of anatomy and physiology is “the study of the parts that make up the structure of the human body and how these parts function to achieve the goals of the human body to exists.”

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Medical Signs

November 21st, 2010

Where did the medical signs come from?

The Rod of Asclepius was the first well documented and easily identified medical sign or medical insignia. It included the image of the snake and the staff and is beleived to have originally signified the Ambiguity of Medicine and the Benefits of Drugs – they either worked well, and made the patient get better, or they didn’t and made the patient get worse and die.

The Medical Caduceus is more common these days and is often mis-interpreted as the Rod of Asclepius. It involves two serpents entwined by a rod and a set of angel wings and represens the Roman God “Hermes” and identifies the trade  (of Medicine) as being associated with or near to God.

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Paramedic Courses

November 21st, 2010

Paramedic Courses can be found in Australia through the following education institutes:

– Australia College of Ambulance Professionals

-Australian College of Paramedical Services

– Charles Sturt University, NSW

– Queensland University

– University of Tasmania

– Some Private Paramedic Training Providers

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Paramedic Story

November 21st, 2010

“Car 116, we have a report of a single car rollover…” – initial report…

On arrival at the scene, it was determined that the single car that had rolled over had in fact rolled over the barrier wall and down a steep/cliff like ravine… and had been carrying 7 people (only 2 who had been restrained).

It took us a little more than 20 minutes to find a path down to where the car had rolled down the ravine…

When we got there we found 2 patients deceased, 2 patients unconscious and 3 patients with only minor injuries.

The next two hours of adrenalin fuelled work in treating, extricating and transporting these victims was where we, as paramedics, earned the money our pay for all the many days that we had spent at station without any call outs.

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Paramedic Courses Online

November 20th, 2010

Paramedic courses are routinely provided in a didactic fashion, meaning that you must attend a course and be instructed through a face to face teacher/student interaction method. This is primarily because of the hands on nature of paramedicine. For instance, it is hard to teach how to immobilise a patient’s spine without physically getting the equipment out and using it.

Most Ambulance Services around the world provide initial training and then on-the-job training; however, due to the competitive nature of the profession, it is often a requirement or necessity in order to be competitive for a student paramedic position to have completed some prior course.

Many universities in Australia offer full time internal student (meaning you actually attend the university) 3 year paramedic courses. However, most will offer Distance Education or On-line completion of the final year of the course. Also, if you have a previous degree, or a background in Nursing, you may be able to get credits for some of the subjects, and then complete the degree through On-line distance education.

The University of Tasmania does offer a 3 year Part Time Associate Degree in Paramedics which can be completed Online course via Distance Education.

If you just wish to improve your paramedical knowledge in order to better provide emergency pre-hospital health care to your patients, or sit an Intensive Care Exam with better success, please review the Anatomy and Physiology and Patient Assessment Links on this website.

Alternatively, if you are looking to improve you knowlege of the human body, you may wish to review the Anatomy and Physiology Study Course or Study Materials available for download.

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Medical Diagnostic Signs

November 20th, 2010

Babinski Sign

The Babinski Reflex is  a normal response in infants up to the age of 2, in which the big toe extends upwards and backwards, while the other toes fan outwardly; however, in adults a positive Babinski Sign is pathological and often indicative of severe damage to the central nervous system.

In order to test for a Babinski Sign or Babinski Response: firmly rub the lateral aspect of the sole of the foot with a firm (but blunt) instrument, such as the back of a pen. The pen should be rubbed from one end of the sole of the foot over the curve and through to the toes. This will elicit the following three potential responses:

Extension of the big toe, in which the big toe extends upwards, while the other toes curl outwards. In infants up to the age of 2 this is a normal primitive response and is associated with the under-developed or immature central nervous system. With an Adult however, this is a pathological response, indicating severe damage to the Central Nervous System.

No Response: Indicates damage to the peripheral nervous system, muscles, or tendons within the region.

Flexion: the toes all curve inwards. This is the normal response produced in healthy adults with a fully developed and functional central nervous system.

Comparison of the Babinski Sign in Adults and Infants

In adults the Babinski Sign can indicate upper motor neuron diseases, such as lesions, which affect the corticospinal tract. The cause of this damage can be varied, however, a Positive Babinski Sign will often be the only indication of upper motor neuron disease, and will cause a Neurologist to consider other neurological investigations, such as Lumbar Punctures, MRIs and CT scans to determine cause and treatment.  In infants, an extension response, or Positive Babinski response  is common because the corticospinal pathway is not fully myelinated, which means that messages are not conducted through the neurological pathway as rapidly, and consequently, the primitive reflex is not inhibited by the cerebral cortex. The extensor response changes to a flexion response during the first 1-2 years of life, depending on natural development of the central nervous system.

Cushing’s Triad

Identifies significant indication of raised ICP, often a late sign. Includes: Respiratory changes/ Irregularities, Widened Pulse Pressure, and Bradycardia.

Kehr’s Sign

Kehr’s sign is the presense of shoulder tip pain associated with abdominal pain and often relates to refered pain from organ injury or damage within the abdomen.

Posted in Patient Assessment | Comments Off on Medical Diagnostic Signs

Babinski’s Sign

November 20th, 2010

The Babinski Reflex is  a normal response in infants up to the age of 2, in which the big toe extends upwards and backwards, while the other toes fan outwardly; however, in adults a positive Babinski Sign is pathological and often indicative of severe damage to the central nervous system.

In order to test for a Babinski Sign or Babinski Response: firmly rub the lateral aspect of the sole of the foot with a firm (but blunt) instrument, such as the back of a pen. The pen should be rubbed from one end of the sole of the foot over the curve and through to the toes. This will elicit the following three potential responses:

Extension of the big toe, in which the big toe extends upwards, while the other toes curl outwards. In infants up to the age of 2 this is a normal primitive response and is associated with the under-developed or immature central nervous system. With an Adult however, this is a pathological response, indicating severe damage to the Central Nervous System.

No Response: Indicates damage to the peripheral nervous system, muscles, or tendons within the region.

Flexion: the toes all curve inwards. This is the normal response produced in healthy adults with a fully developed and functional central nervous system.

Comparison of the Babinski Sign in Adults and Infants

In adults the Babinski Sign can indicate upper motor neuron diseases, such as lesions, which affect the corticospinal tract. The cause of this damage can be varied, however, a Positive Babinski Sign will often be the only indication of upper motor neuron disease, and will cause a Neurologist to consider other neurological investigations, such as Lumbar Punctures, MRIs and CT scans to determine cause and treatment.  In infants, an extension response, or Positive Babinski response  is common because the corticospinal pathway is not fully myelinated, which means that messages are not conducted through the neurological pathway as rapidly, and consequently, the primitive reflex is not inhibited by the cerebral cortex. The extensor response changes to a flexion response during the first 1-2 years of life, depending on natural development of the central nervous system.

What is the significance of a positive Babinski’s sign for paramedics assessing a patient?

An adult patient who is exhibiting a positive Babinski’s sign is likely to have severe damage to the central nervous system. However, as a paramedic, this is just one means of highlighting this fact, but should not change a paramedic’s treatment of the patient. However, it is important to document its presense so that it can be reviewed by a neurosurgeon in hospital. A neurogsurgeon may also take a positive Babinski’s sign into account, in conjunction with many other factors and tests, when determining possible end of life decisions in intensive care.

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Anatomy and Physiology Flash Cards

November 20th, 2010

Anatomy looks at the specific structures that make up the human bodym where as phsyiology identifies the and examines the way in which the body achieves is physiological goals and objectives. It serves very little purpose studying one topic without the other. Although anatomy as a subject requires rote memorization, the topic of phsyiology often necessitates some serious though and understanding.

Depending on your individual style of learning flash cards may be a useful adjunct to your study and exam preparation. Human anatomy and physiology is a complex field, which can only be thoroughly grasped as the result of many hours of disciplined study and, unfortunately, rote memorization does have a large part in this. For the purpose of rote memorization, anatomy and physiology flash cards can be very useful.

The on-line anatomy and physiology course provided on the right side of this website, provide “Anatomy and Physiology Flash cards” which I found useful when I was re-sitting my last Paramedic Exams.

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Paranormal Activity True Story 2

November 16th, 2010

This is the second paranormal activity true story that I have experienced since I first became a paramedic almost 10 years ago. Whether you’re religious or not… anyone who has seen a dead person can tell you that there’s something missing, something that’s just not there – and I’m not talking about good colour, rise and fall of the chest, a heartbeat and a good strong pulse. I mean, even if you watch a patient who is in intensive care and is being ventilated, you can tell that there’s something different with them when they die (even if the ventilator keeps mechanically breathing for them)…

This is a true paranormal activity story that has happened to me… and although I have talked to many people about it, I still haven’t really come to grips with what has happened…. but this is my true paranormal story…

I'[m a paramedic… and we were called to  a 49 male who had developed chest pain and dialled  dialled “OOO” for an Ambulance. My partner and I were the first Ambulance on scene to treat a patient with chest pain. By the time we had arrived the man had collapsed and had stopped breathing. We assessed him and found that he was in cardiac arrest. We applied a monitor and found that he was in assytole (the line which means that there is absolutely no electrical activity – and is ussually a sign that the person has been in cardiac arrest for a while, and has little hope of survival). We called for back up and commenced CPR and the rest of the cardiac arrest drill, including intubating the patient and administering IV adrenaline. Our back up arrived shortly and we continued the resuscitation efforts. 

We ended up working on the patient for 20 minutes without any change. One of the senior paramedics said “Okay, what do you guys reckon? Shall we call it?” I was working with a new probationer (Rookie Paramedic) and said, “No, he can use some more experience with CPR, lets run this until we finish the assystole protocol all the way through” (at that stage, included 30 minutes of CPR). The senior paramedic laughed and said, “Hey, if you want him to get more experience in CPR, there’s a maniquien back at the station, he’s got just as much chance resuscitating it than this guy…”

Almost as though the out of body person had heard that and decided, hey, no I don’t want to die just yet… we had a miraculous spontaneous return of circulation (this virtually never happens – and patients still rarely live long term after this much down time). We expedite him to hospital. Two days later we found out that they had stented his heart and that he had been extubated and was neurologically intact in cardiac ICU. No way, we think – good for him!

That was the last we really thought about it… and probably would have been the last we ever thought about him… if it wasn’t for the knock at our station door one early morning…

“Hi… Frank…” The man looks at me “My name’s John… I believe we met a couple months ago…”

I look at him… and try and work out when I treated him and what for – usually, its previous patients who are telling me that they met me a few months ago and often assume that because they had a life-threatening injury they would stand out in my memory… they don’t always… but I did remember something about this guy… I just couldn’t place it?

The man sees my confusion.

“Last time we met my heart wasn’t working… in fact, they tell me it had stopped completely…”

Now I know who he is…

I invite him in and we get chatting…. and find out about how he’s doing. Finally he turns around and says.. “I want to thank you for giving me an extra 10 minutes of CPR… even if it was only so that your rookie could practice CPR…”

“Sorry, I say…” instantly aware of how close this man was to dying because we were going to quit early…

“I was there… you see… I saw the whole thing… and I remember Jack saying that he wanted to ‘call it’ and you saying that your probationer needed extra work on his CPR anyway, so you may as well keep going…”

I’m shocked and fascinated at the same time…

“Really… what else do you remember…”

“Well, I remember that the other paramedic suggested that there would be just as much likelihood of resuscitating the manequien back at the station as resuscitating me…. and it was about then that I realised that this was serious and that if I wanted to live… I was going to have to get back in that body… and the next thing I know… I’m in hospital a few days later…”

I called the other paramedics who I had done the job with… those who weren’t working today… and they all came around to hear this story…

The lessons of this story is this – always do your best as though someone is watching (because sometimes someone is watching), never say things about dead people that you wouldn’t say to them if they could actually hear…)

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How to Assess Abdominal Pain

November 12th, 2010

Assessing Abdominal Pain – Abdominal pain is a very common paramedic case and, although many paramedics develop good diagnostic techniques and are capable of developing a fair idea of what is wrong with the patient, generally, it does not differ their treatment. Our main role in treating abdominal pain is to treat the pain – not diagnose the problem. Even good doctors, will still require other diagnostic tests, such as ultrasound, urinalysis, stool sample, etc to definitively confirm their diagnosis.

Assess Abdominal Pain Characteristics.

Palpate the area and determine where the pain is. Like all other forms of pain assessment, it’s a good idea to follow some form of pattern. I like the pneumonic OPQRST (but understand that there are many other pneumonic out there). So check the onset, provocation, quality, region/radiation of the pain, severity, and time of onset and any treatment prior to paramedic’s arrival, and if this has helped or not.

When palpating the abdomen, ensure that you gently apply pressure with your fingers so that you can feel any rigidity, guarding, mass, or spasms. This does require you to place a certain amount of pressure on the abdomen. You may assess the regions of the abdomen into 4 quadrants: right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant or you may use the nine subdivisions system for more detailed descriptions, such as: right hypochondriac region, epigastric region, left hypochondriac region, right lumbar region, umbilical region, left lumbar region, right iliac region, hypogastric region and left iliac region.

Assess for asymmetry, scars, fullness of the abdomen, and any pulsations (query abdominal aortic aneurysm AAA).

Assess any associated conditions

1. Has the patient had nausea and been vomiting?

2. Has the patient had any trouble urinating today or recently? Pain, Stinging (dysuria), Difficulty, Lack of urine? Blood in the urine (haematuria)?

3. Has the patient had any trouble opening their bowels? Bloody stools, diarrhoea, pain constipation?

4. Anorexia

Assess Relevant past medical history.

Look for things such as:

1. Abdominal surgery or injuries

2. Colycystitis

3. Diverticulitis

4. Inflammatory bowel disease

5. Crohn’s disease

6. Appendicitis

7. Diabetes

8. Currently pregnant – how many weeks?

Assess Recent Events

1. Have they been travelling lately? Any chance of parasitic causes, such as tape worm?

2. Menstrual cycle? When was their last menstrual? Any chance they could pregnant? Any chance they could have an ectopic pregnancy?

3. Genitourinary – do they have a current UTI?

Assess their general appearance?

1. Are they acutely ill, or chronically ill?

2. Do they look malnourished? Do they look healthy?

3. Consider their positioning:

– Patients with a bowel obstruction appear restless and constantly moving to attempt to get comfortable.

– Patients with kidney stones or kidney infections (nephrolithiasis or pyelonephritis) – appear restless.

– Patients with peritonitis: often lie very still. These patients are very sick.

Assess bowel sounds:

1. Silent Abdomen – very bad, means paralytic bowel or surgical bowel, and needs immediate surgical interventions

2. Hyperactive peristalsis – diarrhoea

Return to paramedic notes page.

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Stroke Assessment

November 12th, 2010

The term “Stroke” refers to any form of cerebral-vascular event that reduces blood flow to the brain, either through cerebrovascular haemorrhage causing and increase in intracranial pressure (ICP),w hich results in a decrease in cerebral perfusion, or cerebrovascular ischaemia, in which a blood clot or thrombus in the cerebral arteries causes a blockage, which results in poor perfusion distal to the blockage within the brain. The term “Stroke” used to refer to TIA and CVAs (Trasient Ischeamic Attacks – or mini strokes and Cerebral Vascular Attacks – big strokes); however, in Australia and most countries globally, the term has been simplified to just “Stroke.”

A Stroke or Stroke like symptoms in patients is a very common job for paramedics to attend to and early recognition and treatment at a definitive care institute, such as a hospital with the ability to perform a Computer Tomographic (CT) sccan and Neuro-surgical capabilities is paramount to the expected survival and longterm rehabilitational abilities of these patients.

In Australia, the FAST assessment has been adopted as an excellent tool in assessing a patient for the potential of having a stroke; however, it is recognised that many other methods are available and utilised globally.

The FAST assessment includes:

Face – looking at the person’s face for signs of symmetry or assymetry. You can ask the patient to smile, which will identify the symmetry or lack of symmetry in the patient’s facial muscles.

Arms – assess the strength of both the motor and sensory response in the patients arms and legs. Sometimes a patient who has had a stroke will only have movement on one side of their body. This is why it is so important to assess all four limbs for normal or abnormal motor or sensory responses.

Speech – assess the patient’s speech. Is it slurred? Does it sound like the patient is intoxicated? Is this normal – ask someone who knows the patient if this is how he or she normally speaks?

Time – time of onset of these symptoms should be assessed. Time to definitive treatment is the greatest predictor of longterm outcome and rehabiliation outcomes.

Other concepts which should be considered and assessed by a Paramedic attending a suspected stroke victim includes:

Assessing a person’s GCS

Assessing a person’s Vital Signs – high blood pressure may be indicative of a potential cause of the stroke.

Assessing the person’s Pupils for size, reactivity, equalness or un-equality.

Assessing the person’s blood glucose levels (BGLs/BSLs), because this may be another cause of very similar manifestations of a stroke.

Obtain an accurate previous medical history and current history of the events leading up to this situation.

Identify if there was any chance the patient has taken any drugs or alcohol (legal or ilicit).

And finally, make sure to transport these people urgently to hospital.

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Scene Management

November 12th, 2010

Emergencies, by their very nature are complex and dangerous environments. It is for this reason that the role of scene management during an emergency is given to the most senior paramedic on scene. Most emergency incidents require other emergency service agencies, such as police, fire, and rescue. Each of these agencies perform a specific role independently, and may or may not involve or communicate with the multiple agencies on scene.

The following are general concepts that paramedics must take into any emergency scene:

Maintain Safety

At any emergency scene, safety should be paramount for the paramedic, other emergency service personnel, bystanders and patients. This starts well before you reach the scene. Personal Protective Equipment (PPE) should be donned, including: reflective safety vest, helmet, gloves, protective eyewear and supportive boots. As much information about likely dangers on scene should be obtained prior to arrival through the dispatch operators. This may include information about power lines down, violent patients, weapons on scene, fuel, explosives, or structural collapses. As the paramedics approach the scene, both driver and treating paramedic should be alert and vigilent for possible dangers. Park the Ambulance relatively close to the patients, but provide enough room to allow other emergency services through if required, and ensure that the Ambulance is parked in such a way to make rapid egress possible if the an unexpected danger presents itself.

Maintain Communications

Review of many critical incidents or major incidents highlight the value of good communication between the paramedics on scene, command posts, other agencies and dispatch. An early scene assessment and scene report should be the first paramedics on scene’s priority. In Australia, this involves an accurate ETHANE report. The mneumonic ETHANE stands for:

1. Exact location of the event. This should include street location and cross street if known.

2. Type of event, such as “car into truck.”

3. Hazards on scene, such as powerlines down, building or structural collapse.

4. Access and egress, this means best way to enter the scene, and possible areas for egress (how to get out).

5. Number of patients – if this is a large incident, such as a disaster, a basic head count should suffice for first report. Preferably, if possible, patients should be tagged using the recognised disaster tagging system in your area.

6. Emergency services on scene and required. Basic emergency services already on scene should be acknowledged and those still required should be identified.

Establish Command

Initial command should be determined by each agency prior to an emergency event as part of their disaster planning. For example, senior paramedic in first Ambulance to take the role of scene commander. Command must be established immediately!

Paramedics should aim to provide the most good for the most number of people. This is why in a major incident, where resources are scarce, paramedics may not be able to work on all patients, but should aim at treating the patients who are most likely to survive provided your basic treatment.

Managing the scene of an emergency, even for paramedics who are percieved to attend emergencies on a daily basis, often find scene management a difficult role and the most important role at the scene of an accident, emergency or disaster. It is important to take your time, look confident (even if you don’t feel it) and ask for help… you can always cancel resources later, but get them comming until you’re certain that you don’t need anymore.

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Circadian Rhythm

November 12th, 2010

The Circadian Rhythm is basically a 24 hour clock within the human body that regulates the wake and sleep cycle of the human body.

The Circadian Rhythym regulates physiological, behavioural and biochemical response within the body to ensure that a person maintains an adquate amount of sleep. This is why shift workers often find it so difficult to sleep during the day, even though they have been awake all night.

As a result of the Circadian Rhythm, a person’s heart rate, blood pressure and overall muscle relaxation will be slowest at approximately 2-3 am.

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Chronic Renal Failure

November 12th, 2010

Chronic Renal  Failure is a long term progressive deterioration of glomerelus filtration (decrease kidney blood filtration), if left untreated will result in acute renal failure and death.

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Acute Renal Failure

November 12th, 2010

Acute renal failure is a sudden decrease in renal filtration, if left untreated, will lead to death.

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Anatomy and Phsyiology Courses

November 12th, 2010

Where can I study anatomy and phsyiology?

Anatomy and physiolgy is probably one of the most interesting aspects of studying medicine, paramedicine, nursing, physiotherapy and an entire myriad of health science professions.

Anatomy looks at the specific structures within the human body and physiology looks at how the body achieves its goals through the physical function of cells within the body.

Although anatomy and physiology is likely to be one of  the most interesting topics studied as part of a health science degree, it is also likely to be the most complicated and difficult topics to grasp. This is partially because the complexity of some of the concepts in anatomy and physiology, but also the enornous breadth of data on the the topic.

You can improve your ability to understand anatomy and physiology through studying the many anatomy and physiology links from this page, or by downloading a specific on-line anatomy and physiolgy course.

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Funny Paramedic Video

November 7th, 2010

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Inside an Ambulance

November 4th, 2010

What is inside an Ambulance?

Every Ambulance Service has a different set of medical equipment and paramedic equipment to ensure that its paramedics are capable of providing the best life-saving interventions while enroute to hospital.

Most Ambulances in Australia have at a very minimum:

– A deffibrilator 

– Drug kit

– BP cuff and sphygnometer

– Oxygen

-Gloves and a range of other personal protective equipment (PPE)

– Syringes, Needles, Cannulaes, Intra-nasal kits, alcohol wipes and other tools required to administer drugs

– Paper case sheets (although these are slowly being phased out with most Ambulance Services turning to electronic patient heath care case sheets)

– Stetcher (for the patient), spine board, carry chair, scoop stretcher, carry sheet.

– Splinting equipment, such as cardboard splints, traction equipment, and inflatable splints

-Maternity kits

– Burns kits

Here is an image of the inside of an Ambulance

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Greenland Paramedics

November 1st, 2010

Greenland does not generally have paramedics throughout the year; however Greenland does have paramedics employed privately to provide medical and paramedical support for researchers and adventurers while in Greenland.

Paramedics are also utilised in Greenland during the “Big Ice” ski race across Greenland, in which participants can race solo or in groups of 3-6 particpants over a 590km horizontal route across the rugged, cold lands of Greenland.

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Funny Morbid Obesity Story

October 31st, 2010

I’m a paramedic and many of the changes in todays society have lead to an increase in morbid obesity. Morbid obesity is associated with an increased risk of most diseases such as coronary artery disease, chest infections, strokes and general debility.

This is one funny morbid obesity story that I can relate, but also acknowledge the severity of the sitution.

I attended a morbidly obese patient (who weighed in excess of 350kgs) and needed to go to hospital to be assessed for various skin conditions commonly associated with poor health and morbid obesity. After a long battle with several paramedics and some firemen, we eventually managed to get this patient to hospital.

At the hospital the patient advised the assessing doctor that she feels as though there is something under her apron (the giant fold of fat that draped over her legs), As the doctor worked around the patient to assess her, the doctor organised a couple nurses to help lift her appron. Eeach time the doctor poked and prodded, she told him that there was something else there… something very uncomfortable…

There was some mould and the nurses scrubbed this off…

But still the patient complained of something larger and insisted there was something uncomfortable inside her fat…

A Jordan Lifter (lifting device) was brought in and utilized to lift her apron.

As the lifter was raised, new parts of her stomach became visible – what was found?

An old sandwich and the remote control for the TV were both identified and wedged inside the fatty folds to the point that the skin had started to absorb the foreign bodies and engulf them.

While everyone gasped in shock, the patient said turned around and said: “Wow, I thought I’d lost that remote control weeks ago!”

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Morbid Obesity Story

October 31st, 2010

I’m a paramedic and over the past ten years I have become very concerned by the increase in morbidly obese patients who I have been attending. Most of these patients are very young, and suffering from illnesses, such as heart attacks and strokes in their early twenties, which are normally reserved for people in their late forties.

This change has brought about the introduction of bariatric transport ambulances in many Ambulance Services in Australia and around the world.

I attended a patient a few years ago who weighed 425kgs (that’s a lot of pounds) – he had developed chest pain and was unable to leave his bed due to his morbid obesity. When we arrived and started to treat him for a heart attack, it became apparent very quickly that he was not going to be able to fit through the doorway (even if we were capable of lifting him).

Over the period of some hours, we had a structural engineer arrive on the scene and determine how to remove part of the wall so that a cherry picker (crane) would be capable of lifting the poor man out of his house.

The emergency process, which would ordinarily have taken us less than 20 minutes to take a patient to the nearest hospital for definitive cardiac treatment, ended up taking us more than 5 hours, and eventuated with in a half demolished house. The patient lived, but died some months later in hospital due to complications such as bed sores. The poor man was in his late 30s….

I understand that losing weight can be difficult and that there is often a genetic of physiological reason for a person to become prone to morbid obesity, but as this morbid obesity story indicates, not making the changes which are necessary to improve your health will be much worse.

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Exciting Paramedic Story

October 31st, 2010

Paramedics often spend majority of their day performing routine tasks or transporting routine patients from their nursing homes to the hospital for check ups; however, every now and again, a paramedic gets to see things that most people will never see in a lifetime…

This is a story about one of those rare times in my paramedic career, when I can say that I had a really exciting day as a paramedic.  I love my job, and I am constantly learning new things, both medically and just in my ability to control a difficult scene, but like all paramedics, I do particularly enjoy the exciting times.

We had spent most of the morning restocking the truck and performing the weekly drug checks and equipment checks (to make sure that everything was in date and in working order). The phone rang, and we had the first job of the day… a 34 year old male who had crashed his motor bike during a dirt bike race. When we arrived, we found that he had missed the landing for a major jump and had landed on both his legs on the pegs of the motor bike, but without landing on a down ramp, the force had been enough to fracture both his femurs… we managed his pain and immobilised him in case he had a spinal injury, and he was then flown out to a major trauma hospital by helicopter.

No sooner, had we cleared from this job, than we got another call over the radio to attend a 19 year old female who had rolled her car at high speed and was possible unconscious. It was a road not too far from where we had just left the helicopter. We arrived shortly afterwards, and found a few people trying to get into this car that had rolled and was currently on its roof. I found a female, laying upside down (with her seatbelt still on) who wasn’t responding to my voice (query unconscious).

Normally, we wait for a rescue agency (such as Firebrigade, SES, VRA or Ambulance Rescue) to gain access to the patient, but because I was working out in the country at the time, and the nearest Rescue Agency was more than 50 minutes away, I made the decision to use a crow bar and delicately break into the car with the help of some of the bystanders. This is more difficult and dangerous than it used to be, because with the introduction of airbags standard to most modern vehicles, the risk of damaging one of the compressed air cylinders during the process is high (if you have not been trained in Rescue) and this can lead to danger to the Rescuer and to the patient/s. We eventually got this young patient out of the car, and called for the second helicopter that day to assist with a medical team on board. The patient ended up having an enclosed head injury and a heamopneumothorax, which required urgent decompression.

After we cleared this time, we managed to get almost back to station (having mentioned to dispatch that we were running out of stock) before we got the message to attend to a woman who was 40 weeks pregnant and currently experiencing contraction pains. When we arrived, she was already in the bath and her husband was yelling “Its comming its comming” – I think we made it just in time to catch the baby and clean him up.

In that single day, I had the more paramedic excitement than I probably had in the whole previous month put together.

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Paramedic Stories

October 31st, 2010

Paramedics are highly trained emergency medical technicians or clinicians, who are trained and capable in medically treating patients who have suffered injuries or illnesses outside of a hospital. Because of the nature of the work paramedic often attend to, paramedics often deal with extremely stressful environments and unusual situations (car accidents, heart attacks, out of hospital deliveries of babies) which for most people would be considered very strange and intense; however, for paramedics, this is just a part of their daily routine at work. Don’t get me wrong, paramedics still have many hours and days spent performing routine tasks and taking regular patients from nursing homes to hospitals for check ups; however, in between all this monotony, paramedics earn their money by dealing with trauma and severe medical emergencies, such as cardiac arrests, seizures, meningococal disease and other medical emergencies.

Check out the following links to some of the better paramedic and medical stories based on real cases that I’ve attended to as a paramedic in Australia:

http://emergencymedicalparamedic.com/stories-frome-a-rookie-paramedic

http://emergencymedicalparamedic.com/home-birthing-stories

http://emergencymedicalparamedic.com/humorous-ambulance-paramedic-stories

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Paramedic Analgesia

October 30th, 2010

Most Ambulance Services in Australia and around the world use a different set of clinical practice guidelines or protocols to govern the types of analgesic options available to paramedics treating a patient who is in pain.

In Australia, Paramedic use Methoxyflurane, Ketamine, Morphine, Fentanyl, Ibrufen, and paracetamol to manage most types of pain for their patients. Each state has a preference for major pain relief and analgesia, such as Morphine, Fentanyl or Ketamine.  

 

This is an academic paper on the comparison of the benefits of morphine versus fentanyl in pre-hospital care management of pain.

What is a good analgesia for paramedics to use in pre-hospital care? 

This paper will compare and contrast the use of morphine and fentanyl as pre-hospital analgesia.

Pharmacokinetics and pharmacodynamics of fentanyl.

Administration and absorption

Fentanyl can be administered intravenously (IV), subcutaneously (SC),intranasally (IN), as a transdermal patch (TD) and as an oral transmucosal lollipop (OTM) (MIMS 2003, p 4-359; Bryant and Knights 2003, p. 247). IV administration has the most rapid onset of action, followed by OTM, IN, SC and TD being the slowest. Unlike most other opioids, which have to be primarily administered parentally, fentanyl can be administered via both the parental and enteral routes, without any major reduction in bioavailability as a result of a first pass metabolism within the liver (Galbraith, Bullock, and Manias 2001, p. 366).

IV and SC administration may be useful when analgesic requirements makes oral dosing impractical as well as patients who require rapid titration of opioids for pain relief. Medications may be given as repeated intermittent bolus doses or by continuous infusion (Bryant and Knights 2003, p. 247). IV administration provides ‘almost immediate analgesia where as SC may require up to 15 minutes for full effect’ (MIMS Annual 2003, p. 4-365). Bolus IV dosing provides a shorter duration of action than other routes, while continuous infusions provide steady blood levels (Weiner 2002, p. 482). Because of its high affiliation with lipids fentanyl is readily absorbed via the skin.  Bryant and Knights states that: ‘fentanyl is highly lipophilic making it easily administered TD’ (2003, p. 247). Plasma levels rise slowly over 12-18 hours after transdermal patch placement and slowly fall off 20-24 hours after removal (Oh 1998, p.681), making it very easy to use, and ‘practical for chronic pain disorders, especially cancer’ (Galbraith, et Al 2001, p. 366). 

When fentanyl is administered in the oral transmucosa, in the form of a lollypop, it acts in a ‘combination of an initial rapid absorption from the buccal mucosa (parenteral absorption) and a more prolonged absorption of swallowed fentanyl from the gastro-intestinal tract (enteral absorption)’ (Loeser 2001, p. 98). Both the blood fentanyl profile and the bioavailability of fentanyl will vary depending on the fraction of the dose that is absorbed through the oral mucosa and the fraction swallowed. Fentanyl is metabolized primarily in the liver and intestinal tracts which would suggest that any enteral administration of the drug would be ineffectual due to a first-pass mechanism. However, according to Evan, Kharasch, Whittington and Hoffer the ‘first-pass metabolism has little effect on fentanyl’s bioavailability from oral transmucosal fentanyl’ (2003, p1). Furthermore the buccal absorption, bioavailability, and permeability of fentanyl are markedly increased as the pH of the fentanyl solution becomes more basic. This is because of ‘an increase in the fraction of unionized fentanyl’ (Streisand, Zhang, Suyi, McJames, Remco, Pace 1995, p. 759). Intranasal fentanyl is an alternative route when the oral route is unavailable.

The IN route provides for rapid absorption and onset of action. According to Striebel, Kramer, Luhmann, Rohierse-Hohler and Rieger: ‘intranasal fentanyl seems to be a promising, non-invasive and rapid-acting new mode of opioid administration that is especially suitable in acute pain syndromes’ (1993, p.1). Acording to Hill ‘intramuscular injections should be avoided because injectionsare painful, inconvenient and absorption is erratic, meaning that the benefits do not out way the negatives’ (Hill 97, p. 3).

Distribution

According to the MIMS Annual the ‘distribution time of fentanyl is 1.7 minutes, redistribution is 13 minutes and the terminal elimination half-life is 219 minutes’ (MIMS Annual 2003, p. 4-359). According to Weiner ‘fentanyl is highly lipid soluble, causing it to have a rapid onset of action with a large volume of distribution and a relatively short duration of action’ (2002, p. 482). The mean volume of distribution at a steady state is 4 L/kg (MIMS Annual 2004, p.4-359). The analgesic effects of fentanyl may appear before the adverse effects, when administered IV. According to MIMS annual: ‘the onset of action may be immediate when administered IV; however the maximal analgesic and respiratory depressant effect may not be noted for several minutes’ (MIMS Annual 2003, p. 4 –359). 

A proportion of all drug molecules entering into the blood stream bind to proteins to form drug-protein complexes. ‘Acidic drugs bind mainly to albumin, while basic drugs bind to acid glyco-proteins contained in the blood’ (Bryant and Knight 2003, p.108). Because of the size of the molecules formed by plasma protein drug complexes, drugs which are bound to proteins cannot pass through the plasma membrane of the vascular system, and are therefore unable to cause their desired effects on their target cells or organs. Galbraith et al states: ‘the stronger the protein binding, the less of the free drug that will be present in the plasma and the longer the drug will remain within the vascular system increasing the drugs ½ life’ (1998, p.1081). Therefore, one would determine that because fentanyl is highly plasma protein bound at 85% it would remain within the vascular system longer than morphine, which is only 35% protein bound (MIMS Annual 2003, p. 4-359). However, due to its highly lipophilic nature and the fact that it has a pKa (ionization) of 8.2 its rate of distribution and onset of action is more rapid than morphine, causing its half-life to be considerably shorter (Streisand et al 1995, p. 759).

Metabolism

Fentanyl is highly metabolized by the liver, decreasing the effect of any orallyadministered but not leaving it ineffectual. Fentanyl is primarily (more than 90%) eliminated by biotransformation to inactive metabolites (MIMS Annual 2003, p. 4-359).

Excretion

The metabolites are mainly excreted in the urine while fecal excretion is lessimportant. The total plasma clearance of fentanyl is 0.5 L/hr/kg (MIMS Annual 2003, p. 4-359). The terminal elimination half-life after OTM administration is about 7 hours. Approximately 75% of an IV dose is excreted via the kidneys in urine as metabolites with less than 10% representing the unchanged medicine. Approximately 9% of the dose is recovered in the faeces, primarily as metabolites (MIMS Annual 2003, p. 4-359; Bryant and Knights 2003, p. 244-5).

Pharmacodynamics

Similar to other opiates, fentanyl acts as an agonist to bind with specific receptor sites in the brain, spinal cord and many other tissues, called opioid receptors. The body’s endogenous opiate receptor sites are known as ‘delta, epsilon, kappa and mu’ (Galbraith et al 2001, p.336). These are inhibitory neurotransmitters, which suppress pain messages to the CNS from the periphery. Fentanyl exerts its primary effect on the central nervous system (CNS) and organs containing smooth muscle. Effects include: ‘miosis, respiratory stimulation followed by depression, bradycardia, hypothermia, and a decrease in nociception’ (Loeser 2001, p. 99). There are high concentrations of receptors for the body’s natural opioids such as the endorphins and enkephalins in many areas of the CNS, particularly in the ‘grey matter of the midbrain, the limbic system and at the interneurons in the dorsal horn areas’ (Bryant and Knights 2003, p. 235). These areas are known to be involved in pain transmission or perception.

Fentanyl acts by binding to the mu and kappa receptor sites and in doing so blocking the transmission of the theoretical substance P (pain) through a variety of inhibition processes. According to Loeser the opioid receptor is ‘a gene-protein- coupled (G-protein) receptor that can work via a number of effectors and second messengers to influence a variety of neuronal processes’ (Loeser 2001, p.101). This leads to an inhibition both presynaptic and postsynaptic of transmitter release, and hence a decrease in nociception. Through G-protein coupling, opiate receptors can ‘activate potassium (K)channels, close calcium (Ca) channels or both’ (Loeser 2001, p. 102). In doingso, they cause a decrease in intracellular cyclic Adenosine Monophosphate (cAMP)levels and therefore result in a ‘reduction of chemical transmitter release and hencea blockade of synaptic transmission’ (Munson 1998, p. 408). Opiate receptors can also act on the O and I alpha G-protein subunits to inhibitadenylate cyclase and thus reduce the production of cAMP from adenosinetriphosphate (ATP). This, in turn, causes an inhibition of cAMP-dependant proteinkinase (PKC) and the transmission of substance P (Appleyard 1998, p. 14; Galbraith et al 1997, p.335). Decreased cAMP levels lead to a decrease in ‘neuronal excitability leading to inhibitory effects at cellular level; effects that appear to be excitory are actually due to the suppression of firing of in inhibitory neurons’ (Bryant and Knights 2003, p. 245).

At the spinal level fentanyl stimulates the ‘opioid mu receptors in the dorsal horn of the spinal cord’ (Galbraith et al 2001, p.362) and thus inhibits the release of substance P from the dorsal horn neurons. At supraspinal levels ‘opiates act to close the gate in the dorsal horn, thus inhibiting afferent transmission of the substance P’ (Bryant and Knights 2003, p 245). It is also capable of altering perception and emotional responses to pain because opiate receptors are widely distributed in the CNS, especially in the limbic system, thalamus, hypothalamus and midbrain (MIMS Annual 2003 p. 4 –433). When pain perception is inhibited the analgesic effect of an opioid is enhanced.

Fentanyl rarely causes a clinically significant histamine response such as morphine. Because of this, adverse effects such as hypotension are not as likely, making it a more suitable drug for patients who are haemodynamically unstable. OH states that ‘fentanyl has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680).

Contrasting the pharmacology of fentanyl and morphine

 Fentanyl absorption Fentanyl can be administered IV, SC, IN, TD and as an OTM (MIMS 2004, p. 4- 359; Bryant and Knights 2003, p. 247). Unlike most other opioids, which have to be administered parentally, fentanyl can be administered via both the parental and enteral routes, without any major reduction in bioavailability due to the first pass metabolism within the liver (Galbraith et al 2001, p. 366). Morphine absorption Morphine can be administered via ‘SC, IM, IV injection and as an oral tablet; however due to the fact that it is highly metabolism by the liver, its first pass mechanism reduces its bioavailability to all but 40% of the ingested dose (MIMS Annual 2003 p. 4-433).

Fentanyl distribution According to the MIMS Annual the ‘distribution time of fentanyl is 1.7 minutes, redistribution is 13 minutes and the terminal elimination half-life is 219 minutes’ (MIMS Annual 2003, p. 4-359). According to Shoemaker, Ayres, Grenwick and Holbrook, ‘fentanyl is approximately 500 fold more lipophilic than morphine’ (2000, p.300), which is the cause for its rapid onset of action. The plasma protein binding of fentanyl is 80-85% and the free fraction of fentanyl increases with acidosis. The mean volume of distribution at a steady state is 4 L/kg (MIMS Annual 2003, p. 4-359). The analgesic effects of fentanyl may appear before the adverse effects, when administered IV. Fentanyl reaches its peak effect in 2-3 minutes, which not only brings very rapid pain relief, but also allows safer titration. Morphine distribution Morphine is not particularly highly protein bound at ‘35% being bound to plasma protein’ (Bryant and Knights 2003, p247) and is relatively hydrophilic when compared to fentanyl, so it crosses slowly into the CNS. Because of this, its distribution time is relatively long. Approximately 20 minutes post IV administration (MIMS Annual 2003 p. 4 –364). Plasma half-life is achieved between 2-3 hours after administration (MIMS Annual 2003 p. 4 –433). IV morphine does not reach its peak effect until about 15 minutes, meaning that pain relief is relatively slow, by comparison to fentanyl, and the chance of opioid overdose through poor titration is more likely.

Fentanyl metabolism Fentanyl is highly metabolized by the liver, decreasing the effect of any orallyadministered fentanyl but not leaving it ineffectual (MIMS Annual 2004, p. 4-359). Morphine metabolism Morphine is metabolized by the liver to form ‘morphine-3-glucuronide (M3G) and morphine –6-glucuronide (M6G), which are both inactive metabolites’ (Bryant and Knights 2003, p. 249). 

Fentanyl excretion The metabolites are mainly excreted in the urine while fecal excretion is less important being less than 0.01%. The total plasma clearance of fentanyl was 0.5 L/hr/kg. The terminal elimination half-life after OTM administration is about 7 hours. Approximately 75% of an IV dose is excreted in via the kidneys in urine as metabolites with less than 10% representing the unchanged medicine. Approximately 9% of the dose is recovered in the faeces, primarily as metabolites (MIMS 2003, p. 4-359). Morphine Excretion Morphine is primarily excreted via the kidneys, and small amounts are excreted as bile and faeces (MIMS Annual 2003 p. 4 –433). Because both fentanyl and morphine are principally excreted via the kidneys any decrease in the glomerulus filtration rate (GFR) due to young age, old age or nephological disease may result in ‘maintained  higher serum levels and a longer duration of action than intended’ (Sanders 2001, p.261).

Fentanyl and Morphine pharmacodynamics

Fundamentally, because both fentanyl and morphine act on opioid receptors as their primary mechanisms of action, many of the pharmacodynamics between the two drugs are similar. Both fentanyl and morphine act as an agonist to bind with specific receptor sites in the brain, spinal cord and many other tissues, called opioid receptors. The body’s endogenous opiate receptor sites are known as ‘delta, epsilon, kappa and mu’ (Galbraith et al 2001, p.336). These are inhibitory neurotransmitters, which suppress pain messages to the CNS from the periphery. However, where fentanyl and morphine differentiate is by the specific opioid receptors that they bind with, and how much of a reaction they cause. Specifically, fentanyl stimulates the mu receptor sites +++ and the delta receptor +, with no effect on the kappa or epsilon receptors. Morphine, however, stimulates both the mu and delta sites similarly to fentanyl, but also acts on the kappa receptors sites + which may be the cause of some divergent pharmacodynamics as a result of choosing between the two forms of analgesia (Rang, Dale, and Ritter 1999, p.593).

Fentanyl and morphine exert their primary effect on the CNS and organs containing smooth muscle. Effects include: ‘analgesia, drowsiness, alteration in mood (euphoria), reduction in body temperature, depression of the respiratory drive, cough suppression and miosis’ (Hollinger 1997, p. 384). There are high concentrations of receptors for the body’s natural opioids such as the endorphins and enkephalins in many areas of the CNS, particularly in the ‘grey matter of the midbrain, the limbic system and at the interneurons in the dorsal horn areas’ (Bryant and Knights 2003, p. 235). These areas are known to be involved in pain transmission or perception. Although the delta, epsilon, kappa and mu receptor sites have all been associated with producing nociception, the mu receptor site is the most prominent in the reduction of pain. It is primarily the mu receptor sites that both fentanyl and morphine act upon to produce analgesic effects. By binding opioids to the mu receptor sites the transmission of the substance P through a variety of inhibition processes occurs.

According to Loeser the opioid receptor is ‘a gene-protein- coupled (G-protein) receptor that can work via a number of effectors and second messengers to influence a variety of neuronal processes’ (Loeser 2001, p.101). This leads to an inhibition both presynaptic and postsynaptic of transmitter release, and hence a decrease in nociception. Through G-protein coupling, opiate receptors can ‘activate potassium (K)channels, close calcium (Ca) channels or both’ (Loeser 2001, p. 102). In doingso, they cause a decrease in intracellular cyclase Adenosine Monophosphate(cAMP) levels and therefore result in a ‘reduction of transmitter release and hencea blockade of synaptic transmission’ (Munson 1998, p. 408). Opiate receptors can also act on the O and I alpha G-protein subunits to inhibit adenylate cyclase and thus reduce the production of cAMP from AdenosineTriphosphate (ATP). This, in turn, causes an inhibition of cAMP-dependant proteinkinase (PKC) and the transmission of substance P (Appleyard 1998, p. 14;Galbraith et al1997, p.335). Decreased cAMP levels lead to a decrease in ‘neuronal excitability leading to inhibitory effects at cellular level; effects that appear to beexcitory are actually due to the suppression of firing of in inhibitory neurons’ (Bryant and Knights 2003, p. 245). 

Although both fentanyl and morphine act on the mu receptor sites fentanyl rarely causes the clinically significant histamine response seen in the administration of morphine. Because of this, adverse effects of hypotension are not as likely and may be more suitable for patients who are haemodynamically unstable. Oh states, that ‘fentanyl has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680).

Because both fentanyl and morphine act on the mu receptor sites they cause a decrease in gastric intestinal motility and an increase in the desire to vomit (Rang, Dale, and Ritter 1999, p.593); however, according to the MIMS Annual ‘fentanyl appears to have less emetic activity than morphine’ (2003, p. 4-359) which may be very beneficial in patients in the prehospital care setting who may already have unstable airways, and have not fasted. Fentanyl may be the drug of choice to avoid the risk of the likely emetic results stimulated by such analgesia as morphine. The exact probability that a molecule will be protonated or deprotonated depends on the pKa (ionization) of the molecule and the pH of the solution. Fentanyl has a pKa of 8.2 where as morphine has a pKa of 7.9 (Sansom 2004, p.284). Therefore, by having a higher pKa (and a greater affiliation with lipids) fentanyl crosses over the plasma membrane more rapidly than morphine. Investigating the risks and benefits of fentanyl for analgesia in thepre-hospital care setting  Risks Like all opioids the major adverse effects of fentanyl are respiratory depression and sedation.

Fentanyl causes ‘a diminished sensitivity to CO2 resulting in a depressed respiratory drive’ (MIMS 2003, p. 4-359). Because of this, the use of fentanyl as analgesia in patients with limited respiratory reserve, such as those with chronic airway limitations (CAL) or chronic obstructive pulmonary disease (COPD) should be tentative and with close monitory of the patient’s conscious state, effectiveness of respirations (rate and depth), O2 saturations, skin colour and HR to ensure adequate perfusion is maintained.

 According to the therapeutic goods administration, due to its ‘cholinergic stimulation’ fentanyl may ‘produce bradycardia and possibly asystole’ (TGA 2003, p.2). This resultant bradycardia may be treated with atropine; however, ‘fentanyl should be used with caution in patients with cardiac bradyarrhythmias’ (MIMS Annual 2003, p. 4-359). This is a result of possible cholinergic stimulation, which is why atropine may be used in its treatment. According to the TGA ‘the inclusion of atropine or other anti-cholinergic agents in the pre-anaesthetic regimen tends to reduce the occurrence of bradycardia and other unwanted cholinergic effects (TGA 2003, p.1). According to the TGA ‘severe and unpredictable potentiation by MAO inhibitorshas been reported with opioid analgesics and the use of fentanyl in patientswho have received MAO inhibitors within 14 days is not recommended’ (TGA 2003,p.2). One of the more common adverse effects when administered with MAO inhibitors is a hypertensive crisis leading to cerebral vascular accidents (CVAs) and death (Jarvis 2005, p. 2).

Fentanyl is an synthetic opiate derivative, and therefore may cause physiologicaland psychological dependence commonly associated with the use of opioids (Galbraith et al 2003, p. 350-2; Oh 1998, p.679-83). However, judicious use of fentanyl in the treatment of actual pain should not be withheld due to an inherent risk of physiological and possible psychological dependence. ‘Patients on chronic opioid therapy or with a history of opioid abuse may requirehigher doses to achieve an adequate therapeutic effect’ (TGA 2003, p.2). Because 75% of fentanyl administered IV is metabolized by the liver and primarily excreted by the kidneys, its dose must be decreased to compensate in patients with hepatic disease or renal failure who fail to metabolize and excrete fentanyl as rapidly as healthy patients (MIMS 1998, p. 4 –359). Myasthenia gravis (MG) is one of a group of neuromuscular diseases. Neuromuscular diseases effect how your nerve pathways communicate with your muscles. With MG, the muscle does not always get messages to move parts of your body. According to MIMS Annual fentanyl ‘may cause muscle rigidity in patients with myasthenia gravis’ (MIMS 1998, p. 4-359). Alcohol and other CNS depressants potentiate effects, making it possible for overdoses, leading to respiratory failure and death.

Benefits

Fentanyl rarely causes a significant histamine response, as seen in the administration of morphine (Marik 2002, p. 706), therefore does not have such adverse effects as hypotension and may be more suitable for patients who are haemodynamically unstable. According to Oh, fentanyl ‘has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680). Fentanyl is unlikely to provoke nausea and vomiting. According to the MIMSAnnual ‘fentanyl appears to have less emetic activity than morphine’ (MIMS 1998, p.4-359). This is specifically beneficial in patients with trauma, head injuriesand an unstable airway. By avoiding drugs with the high likelihood of emetic results, one avoids vomitus blocking the airway, the possible raised intracranialpressure (ICP) caused by vomiting, and the unnecessary use of anti-emetic agents such as metoclopramide and their potential adverse effects (Marik 2002, p. 702-7).

According to Weiner ‘due to fentanyl’s lipid solubility, it has a rapid onset,large volume of distribution and a relatively short duration of action’ (Weiner2002 , p.482). This may be very beneficial because it allows for rapid onsetof analgesia and safer titration. Because it is an opioid it may be antagonized rapidly with the use of naloxone,which acts by ‘competitively blocking opioid receptor sites’ (Oh 1998, p. 681). Therefore, any overdoses may be rapidly corrected. Special Forces medics administration OTM fentanyl during operation Iraqi Freedom to 22 patients with trauma and in that time found that ‘oral transmucosal fentanyl is an effective analgesic with a rapid onset, and limited adverse effects’ (Kotwal, O’Connor, Johnson, Mosely, Meyer, Holcomb 2004, p.1).

What analgesia would work best for paramedics in providing prehospital care?

According to Lord: ‘it’s crucial for members of the health care team to acknowledge and support the expansion of the paramedic’s role as a frontline pain manager’(Lord 2004, p.52). In order to do this successfully more rapid and effective methods of analgesia must be available for pre-hospital care (PHC) workers. Drugs such as IV, IN and OTM fentanyl should be made available to PHC workers and their educational and training levels brought up to a level that they know exactly how to use it effectively without fear limiting their use of it. To this day, apprehensions about adverse effects arising from analgesic use and the influence that administration of analgesics may have on the diagnostic process have been indirectly implicated. According to the National Health and Medical Research Council, evidence that the ‘relief of pain may actually enhance the diagnostic process refutes the contention that opioids mask symptoms andcomplicate the diagnosis’ (NHMRC, 1999). Therefore the only way to decrease such fallacies is to promote education and training so that PHC workers feelcomfortable in administering the type of drugs and enough of them required toactually treat the pain.

References:

Appleyard S. 1998, Agonist Dependant Desensitization and Opioid ReceptorsPhosphorylation: a Potential Role in the development of opioid tolerance.Universityof Washington Doctoral Thesis, Seattle

Bryant B and Knights K 2003, Pharmacology for Health Professionals, Mosby Medical Textbooks, Sydney Australia

Conyers V & Hamilton L, 2001 Foundations of Paramedical Science 2 – Module 4, Learning Materials Centre, Charles Sturt University, Bathurst, Australia

 Evan D. Kharasch R. Whittington D. Hoffer C.2003, Minimal Influence of Hepatic & Intestinal CYP3A Activity on the Acute Disposition & Effect of Oral Transmucosal Fentanyl (OTFC), American Society of Anaesthesiologists,

Galbraith, A. Bullocks S. Manias E. 2001, Pharmacology 3rd Ed, McPherson’s Printing Group, Sydney, Australia

Hill, C. 1997, Guidelines of the Treatment of Cancer Pain, 2nd Ed, Texas CancerCouncil, Texas, USA

Hollinger M. 1997, Introduction to Pharmacology, Taylor and Francis Publishers, Washington, USA

Kotwal R. O’Connor K. Johnson T. Mosely D. Meyer D. Holcomb J. 2004, A Novel Pain Management Strategy for Combat Casualty Care. Annals of EmergencyMedicine. Vol 2.

Loeser J. 2001, Bonica’s Management of Pain, Lippincott Williams and Wilkins, Philadelphia, USA

Lord B. 2004, The Paramedic’s Role in Pain Management: A vital component inthe continuum of patient care, American Journal of Nursing, Volume 104 Number11, USA

MIMS Annual 2003, MIMS Australia, Sydney, Australia Munson P. 1998, Principles of Pharmacology – Basic Concepts and Applications,Chapman and Hall Publishing, New York, USA

National Health and Medical Research Council 1999, Acute Pain Management: Scientific Evidence. Canberra: Commonwealth of Australia

Oh, T.E 1998, Intensive Care Manual, 4th Ed Reed Educational and Professional Publishing Ltd, Jordan Hill, Oxford

 Rang H. Dale M and Ritter J 1999, Pharmacology, 4th Ed. Churchill Livingstone, Philadelphia, USA

Sanders M.J. 2001, Paramedic Textbook, Mosby’s Inc, St. Louis, Missouri USA

Sansom L. 2004, Australian Pharmaceutical Formulary and Handbook, 19th Ed. Pharmaceutical Society Australia, Sydney, Australia

Shoemaker, Ayres, Grenwick and Holbrook 2000, Internal Medicine, W.B Sounders Printing Company, Philadelphia, USA

Streisand J. Zhang J. Niu S.  McJames S. Natte R. Pace N. 1995, Buccal Absorptionof Fentanyl is pH-Dependent in Dogs, American Society of Anaesthesiologists,Inc. All rights reserved. Published by Lippincott Williams & Wilkins, USA

Tintinalli J. Kelen D. and Stapczynski J. 2000, Emergency Medicine 5th Ed, McGrawHill Publishing, Sydney Australia Weiner R. 2002, Pain Management – A Practical Guide for Clinicians, 6th Ed,CRC Press, London

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Fitness Test To Become a Paramedic

October 27th, 2010

Different Ambulance Services or Paramedical Services (such as Mines Rescue) require varrying level of physical fitness and as such have different fitness test requirements for employment. Interestingly enough, although almost every Ambulance Service within Australia has a Fitness Test to Become a Paramedic, not one Ambulance Service in Australia (that I’m aware of) has a Yearly or Routine Fitness Test to Continue as a Paramedic.

What is likely to be in a Fitness Test to Become a Paramedic?

Most paramedic fitness tests involve three areas of fitness: Cardio Fitness (how well your heart responds to exertion); Physical Strength and Flixibility (mainly designed to rule out previous back injuries that may impact your ability to work as a paramedic).

Paramedic Cardio Fitness is tested by a small time on a cycling machine (10 minutes or less); walking on a step (ussually less than 15 minutes) and or a running “beep” test which involves running backwards and forwards up a set of lines to the cadence of a recorded “beep.”

Paramedic Physical Strength is tested by 10 push-ups, 20 situps and sometimes an ability to carry items approximately 12.5kgs in each arm up 3-4 flights of stairs (the same weight as a paramedic oxy-viva and drug kit or defibrilator). Some Ambulance Services will make you carry a heavily weighted “dummy” down a flight of stairs or drag an unconscious “dummy” somewhere. These are often called Paramedic Work Related Testing.

Paramedic Flexibility is tested by getting you to sit with you back straight and your legs straight and see how far past your feet you can stretch your arms. If you have ever had a serious lower back injury, it will likely show up here, and if not, then it probably isn’t serious enough to cause you any difficulties in doing your job.

As well as these three main areas of paramedic fitness testing, some paramedic entrance fitness tests also include miscellaneous fitness issues such as: Body Mass Index (BMI); Review of Previous Injuries; Referals for specialist testing and performing CPR on a manniquin for a period of time (usually 10-20 minutes, but I have heard of some services making its applicants do up to 30 minutes of CPR).

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What is the Function of the Pineal and Thymus Glands?

October 16th, 2010

The Pineal gland acts to:

– inhibit reproductive function

– co-ordinate sleep/awake cycle

The thymus gland aids in immunity regulation.

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What is the Function of the Pituitary Gland?

October 16th, 2010

The pituitary gland functions to coordinate:

– the other glands of the endocrine system

– metabolism

– growth and development

– fluid balance

– childbirth

– sexual function

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Acute and Chronic Renal Failure

October 16th, 2010

Renal failure can be divided into Acute and Chronic Renal Failure.

Acute renal failure refers to a sudden interruption of the renal function and can be caused by an obstruction at the glomeralus, or poor systemic circulation and renal circulation. The kidneys require a systolic blood pressure of at least 80 mmHg to function and maintain renal perfusion.

Chronic renal failure refers to a progressive loss of kidney function, often as a result of high sodium intakes and low fluid intakes, but may also include congenital defects, infections, and trauma.

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What is the Function of the Thyroid Gland?

October 16th, 2010

The thyroid gland regulates the body’s metabolism, including tissue growth and decreases calcium within the blood.

The parathyroid gland regulates an increase in calcium within the blood.

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What is the Function of the Adrenal Gland?

October 16th, 2010

The adrenal gland is divided into the adrenal cortex and the adrenal medulla.

The Adrenal cortex coordinates fluid balance, sex drive in females, and assist in the proccess of anti-inflammatory responses.

The Adrenal Medulla secretes adrenaline and nor-adrenaline.

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Mechanisms of Heat Preservation

October 16th, 2010

The human body maintains homeostasis of the body temperature through the following heat preservation mechanisms:

1. Vasoconstriction

2. Pilo-erection (goose bumps, where the hair stands on its ends)

3. Shivering

4. Behaviour protection.

All of these methods, are regulated by the hypothalamus.

Hypoglycaemia will reduce the body’s ability to continue to shiver, and hypothermia will rapidly occur once the body is no longer able to maintain its own heat preservation techniques.

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What are the types of Hypothermia?

October 16th, 2010

There are two types of hypothermia.

These are:

1. Wet (emersion) hypothermia; and

2. Dry hyopthermia.

Causes of hypothermia include:

– cold environments

– Decreased mobility

– Severe infection

– Near drowning

– Hypoglycaemia

– Decreased metabolism

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What are the Types of Snake Venom?

October 16th, 2010

Venom is a biological toxin that is injected into the body to cause a reaction (often in order to protect the snake, or as a means of killing the snake’s normal prey).

The main types of venom include the following toxins:

1. Neurotoxins – which target the nervous system

2. Myotoxins, which target the muscles and cause rhabdomyolisis

3. Nephrotoxins, which damage the kidneys

4. Haemotoxins, which target the blood.

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What are the Types of Poisons

October 16th, 2010

A poison is basically anything that can cause harm to a person.

Poisons can be classed in the following contexts:

1. Corrosives and Non-corrosives

2. Pesticides

3. Solvents

4. Drugs

5. Noxious Gases

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High Risk Fractures

October 16th, 2010

All fractures are potentially life-threatening and should be treated accordingly. It is unlikely that a fractured arm will result in death, but a failure to treat it appropriately with adequate splinting, pain relief, and eventual surgery will result in potential fat emboli and this will result in pulmonary fat emboli.

However, it is safe to say that certain types of fracture involve much greater risks of complications and death. These include:

1. Skull damage, due to the underlying importance of the brain that it is protecting

2. Jaw, due to the increased risk of airway involvement

3. Ribs and Sternum, due to the risk of pneumothorax, haemopneumothorax, flail segment, pericardial tamponade and difficulty breathing.

4. Pelvis, due to the high likelihood of profound hypovolaemia

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What is a Hypoxic Drive?

October 16th, 2010

During normal respiration in an individual with healthy lungs, the body identifies the need to stimulate increased respirations by monitoring changes in the carbon dioxide (CO2) levels in the peripheral chemoreceptors. These changes are very minor and occur very early if the person is experiencing any hypoxia.

The hypoxic drive however, is a late homeostatic system designed to increase respiration rate and depth (tidal volume) when the body’s arterial oxygen levels (SaO2) decreases significantly. This is why patients who are somewhat dependent on an hypoxic drive to breath normally only saturate at around 90-92% oxygenation.

The hypoxic drive only accounts for a very minimal amount of the body’s desire to breath (approximately 10-15%) and generally, this is so low, that most people would literally become unconscious before their body’s hypoxic drive will trigger the need to increase tidal volume and rate of ventilation.

However, in patients who have chronic airway limitations (also known as chronic obstructive pulmonary disease), their body is continuously surviving on a much higher than normal blood CO2 level, and the body eventually “gives up” attempting to correct this diversion from normal homeostatic CO2 parameters within the peripheral chemoreceptors.

It should be noted however, that currently theories regarding the need for the hypoxic drive in patients who have had prollonged periods of high CO2, such as those with chronic respiratory diseases/ or disorders, under the headings of COPD and CAL are currently under review and there is some discourse on the topic amongst medical professionals and scientists alike.

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Paramedic Science

October 16th, 2010

The following page identifies the most common paramedical science and scientific laws used in the practice of paramedicine. Although many of the names of these laws are rapidly forgoton after sitting one’s final paramedic exam, the laws themselves, and the relationship of the laws to a patient’s condition and pathophysiology is required on a daily basis.

Boyles Law

For a fixed amount of an ideal gas kept at a fixed temperature, P [pressure] and V [volume] are inversely proportional (while one increases, the other decreases).

Basically when talking about a gas pressure and volume are inversely proportional. Increase the pressure equals a decrease in volume. Increase the volume, decrease the pressure on the gas.

For a practical paramedical example:

This means that if a SCUBA diver holds his/her breath at a depth of 10 metres of water (which doubles the pressure exerted on the air in the lungs) the volume of the air in his lungs will be half that at which it would be at the surface. This becomes important, because if the diver was have taken a deep breath and filled his lungs with air at a depth of 10metres, and then held his breath as he returned to the surface – the volume of air would have doubled as the pressure halved, and because he lungs cannot hold this much air, something would have burst.

Henry’s Law

At a constant temperature, the amount of a given gas dissolved in a given type and volume of liquid is directly proportional to the partial pressureof that gas in equilibrium with that liquid.

Basically, the amount of gas disolved in a liquid (ie: oxygen in the alvioli) is equal to the partial pressure (percentage) of that gas.

For a practical paramedical example:

This basically means that if a patient is receiving normal air, which has 21% oxygen into his lungs the partial patial pressure of oxygen which is being diffused across the alvioli is only 21% of the overall partial pressure. Now, however, if you change this equation to 100% oxygen, the full partial pressure of oxygen can be exerted to difuse across the alvioli. This is why we treat patients with shortness of breath with high concentration oxygen.

Dalton’s Law

The total pressure exerted by a mixture of gas is equal to the sum of the partial pressures of each individual component in a gas mixture. (P1+P2+P3) equals the pressure of the combined mixture.

Therefore if the partial pressure of oxygen in air equal 5, and nitrogen equals 85 and Co2 equal 5 – the total pressure of air equals 95.

For a practical paramedic example:

The concentration of dissolved gas depends on the partial pressure of the gas. The partial pressure controls the number of gas molecule collisions with the surface of the solution. If the partial pressure is doubled the number of collisions with the surface will double. The increased number of collisions produce more dissolved gas. Therefore, if the patient receives a higher level concentration of oxgyen, therefore increasing the partial pressure of oxygen concentration, there will be a geater amount of oxygen that can diffuse across the alvioli membranes.

Partial Pressure

The pressure that one component of a mixture of gas would exert if it were alone

Kinetic Energy

KE = ½  MV2

This means that Kenetic Energy (K/E) equals one half times the mass time the velocity squared.

In a practical paramedic sense: this means that a patient who weighs 80kgs (Mass in Kg) is travelling at 3 metres per second on a bycycle (Velocity is metres per second) hits a brick wall – this patient will have to disperse a total of 80kg x 3 squared x ½ = 360 joules of kinetic energy.

This can become important as a paramedic when you consider that man on a bycycle with an overal KE of 360joules collides head on with a car which has an overall KE of 12000 joules which must also be dispersed to make the car stop – you can understand how injured the patient on ht bycycle will be. Admitedly, you could also just look at your patient to realise that he’s been hit by a much bigger object.

Starling’s Law

The greater the blood volume (BV) entering the heart during diastole, the greater the BV ejected during the systolic contraction of the heart.

Cushing’s Triad

Identifies significant indication of raised ICP, often a late sign. Includes: Respiratory changes/ Irregularities, Widened Pulse Pressure, and Bradycardia.

Kehr’s Sign

Kehr’s sign is the presense of shoulder tip pain associated with abdominal pain and often relates to refered pain from organ injury or damage within the abdomen.

Cardiac Output

Cardiac Output can be calculated with formula: CO= HR (heart rate) x SV (stroke volume).

Pulse Pressure

Pulse pressure can be calculated by measuring the Systolic BP – the Diastolic BP.

Mean Arterial Pressure

The MAP represents the average pressure within the arterial system. MAP can be calculated by the formula: MAP = Diastolic BP + 1/3rd Pulse Pressure.

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Funny Paramedic Mnemonics

October 15th, 2010

These are some funny paramedic mneumonics – some of them aren’t politically correct… but some of them are funny.

If you actually want to learn real paramedic mnemonics please see my Paramedic Mnemonic Page.

I don’t take responsibility for all of them… I’m just posting them for your laughs.

FITH Syndrome – Fu#ked In The Head Syndrome – for those particularly bad patients who just don’t get it…

ABCs of Private Ambulance Service: Ambulance Billing Credits

DWPA – Died With Paramedic Assistance

Star Jumpers –  relatives and bystanders who like to jump up and down and wave their arms in the air like starjumpers so that the paramedics (who have clearly found the patient already) can see.

TFBUNDY – Totally F*&ked But Unfortunately Not Dead Yet

PITA – Pain In The Arse

DSS Dying Swan Syndrome

Code 18 (deceased) Signet – this represents a dying swan syndrome where the patient (who is clearly not dying) starts to pretend that they are dying or that they are in terrible pain, even though they have just cut part of their finger…

Tontine Therapy – this is pillow therapy for certain patients who really aren’t going to get better through any other means…

Exacerbation of F&*kwititis – for patients who are just bad people

Pensioncarditis – when the patient has a pension card and recognises that they can and should call an Ambulance at least once or twice a day, so that they can have a check up or at least have a cup of coffee made for them…

ICU – ABCs – for the ICU nursing staff – Airway, Bedsheets (don’t get the sheets messy – can the Doctors please manage to cannulate without spilling half the patient’s blood on the sheets? Everyone else is capable of this…), Circulation

SCAT – Silly C&nts Acting Tough – No disrespect to these people who really are tougher than I am!

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What is the Function of Eyebrows, Eyelids and Eyelashes?

October 15th, 2010

Eyebrows function to protect the eyes from perspiration and provide shade.

Eyelids function to protect the eyes from foreign objects and sunlight.

Eyelashes function to protect the eyes from foreign objects, produce sebum (a lubriant that the eyelids) and acts as protection for the eyes from tears.

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What is an Antigen and an Antibody?

October 15th, 2010

An antigen binds to an antibody in order to stimulate a specific immune response.

An antibody however, is a protein found in plasma responsible for immunity and binds specifically to an antigen to release a specific immune response. Antibodies take time to develop. This is how vacinations help improve your ability to treat a particular disease.

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What is Meningococcal Meningitis?

October 15th, 2010

Meningococcal meningitis is the inflamation of the meninges due to bacterial or viral infection:

Signs and symptoms include:

– Severe headache

-Neck pain

– Fever

-Fatigue

– Stiff or painful neck

– Photophobia (sensitivity to light, caused by an increase in ICP placing pressure on the 3rd occular motory nerve, which keeps the pupils from constricting)

-May result in death or permanent disabilty

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What is Meningococcal Septiceamia?

October 15th, 2010

Meningococcal Septiceamia involves the following pathophysiologies:

– Bacteria in the blood stream

– Bacteria multiples rapidly within the blood stream uncontrollably and releases toxins which damage the walls of the blood vessels, and therefore cause the purperic rash (indicating haemorrhage)

– Can rapidly lead to death.

-Purperic rash is a late sign

– Rash does not usually blanch (fade) under pressure.

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What are the Signs of Meningococal Disease in Babies?

October 15th, 2010

The signs of meningococal disease in babies include:

– Poor feeding

– High pitched cry

– Blank/ starring expression

– Dislike in being handled

– Lethargic

– Bulging fontanelle

– Laboured breathing

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Morbid Obesity Definition

October 15th, 2010

The definition of morbid obesity greatly differs depending on the country in which the term is being used. Primarily, any level of obsesity that greatly increases your risk of illness or death is termed morbid obesity. However, on the basis of this, even as little as 10kgs excess body weight could be considered “morbidly obese.”

Many health practitioners within Australia believe that morbid obesity can be defined as anyone who has an excess body weight of greater than 20% of their normal body weight. Others, also include the definition that morbid obesity applies to anyone who is more than 30kgs overweight.

The World Health Organisation (WHO) defines morbid obesity as anyone with a Body Mass Index of greater than 40; although this definition is greatly debated on the basis that the benefits and the accuracy of the BMI system is falable.

If you want to learn more abotu morbid obesity and solutions to morbid obesity please follow this link morbidobesitysolutions.com

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Morbid Obesity Emergency

October 15th, 2010

The rate of morbid obesity within the western worlds is dramatically becoming an emergency. In the past ten years, health practitioners have seen the introduction of a new wave of medical emergency pandemics involving morbidly obesity.

What is a morbid obesity emergency?

Most emergencies involving people who suffer from morbid obesity involve chronic problems, but do occasionally involve acute medical emergencies.

Chronic probelms involving morbid obesity emergencies include:

1. Decreased mobilty

2. High blood pressure

3. Cardiomyopathy (enlargement of the heart)

4. Increased risk of type II diabetes

5. Increased risk of coronary artery disease

6. Increased damage to joints due to morbid obesity applying excess weight to the joints.

7. Pressure area sores

8 Back problems due to difficulties sleeping

Acute medical emergencies involving morbid obesity include:

1. Acute Coronary Artery Syndromes (such as a heart attack)

2. Falls

3. An inability to ambulate, resulting in prolonged times on the floor after falling. This can result in pressure area sores and in severe cases non-traumatic crush syndrome.

4. Any normal medical emergency, in which the paramedics have had an increased delay transporting the patient to hospital because he or she has morbid obesity, and consequently they have had to organise a bariatric truck or a fire truck to assist in transporting the patient to hospital.

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Bariatric Emergencies

October 15th, 2010

The incidence of bariatric emergencies is currently raising globally. This has introduced unique medical complications and phenomena associated with bariatric size patients and morbid obesity.

These are some of the common bariatric medical emergencies:

1. Inability to aid oneself after a fall. Due to decreased mobility issues related to morbidly obese people, the risk of falling is not only increased, but the potentially much more lethal risk of being unable to ambulate afterwards is possible. In a house with other people this problem is easily rectified; however, if you live alone and are morbidly obese, you may not be able to ambulate (move or get up) once you have fallen over. In serious cases of this, barriatric patients have sometimes spent days laying on the floor before anyone has noticed or they have been able to call for help. If the floor surface is hard, such as tiles, or even wood, this prolonged time spent on the floor may result in pressure area sores, and in serious cases non-traumatic crush syndrome.

2. The risk of pressure area sores is greatly increased due to increased weight and pressure on any one aspect of the body.

3. The risk of hypertension is greatly increased.

4. Left heart failure and cardiomyopathy (increased heart size) are common complications of morbid obesity, due to the fact that the heart has to pump a lot more blood around a much larger area.

5. Type II diabetes is a common side affect or risk factor in bariatric patients because of the inability of the pancreas to produce enough insulin to meet the sugar intake demands.

6. In car accidents or motor vehicle crashes, bariatric patients (morbidly obese) are 8 times as likely to develop a serious injury because of the increased kinetic energy. Kinetic Energy (KE) is basically the amount of energy that is required to move or stop an object from moving and is calculated by the formula KE = Mass x Velocity Squared/ 2 . With bariatric patients, the Mass factor is increased and this results in an increased amount of Kinetic Energy being dispersed during a motor vehical crash and increased risk of damage to vital organs.

7. Increased risk of having a motor vehical crash. Studies have shown that bariatric patients or morbidly obese drivers are more likely to have a motor vehical crash. Although more investigation needs to be identified on this topic, it has been hypothesized that this is because of their inability to easily turn their neck and check for their blind spot.

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Divisions of the Nervous System

October 13th, 2010

The nervous system is responsible for transmitting and receiving electrical and chemical signals (messages) within the body. Each division of the nervous system plays a vital part in the functioning of the human body. The nervous system can also be considered the human body’s communication network. The nervous system sends messages through afferent neurons, efferent neurons and interneurons.

An afferent neuron pathway describes neurons (messengers) that send signals from the peripheral nervous system (arms and legs) through to the spinal cord and onto the cerebral cortex or command center within the brain. Efferent neuron pathways send messages from the cerebral cortex  to the muscles and various organs in the body to achieve a desired response.

The following describes the actions of the afferent, interneuron and efferent responses to an event:

When a person places their hand on a hot frying pan causing the hand to burn afferent neurons send a message up the persons arm through to the spinal cord that something has gone wrong. At the spinal cord, interneurons (which act between the afferent and efferent neurons) identify that an immediate action is required resulting in a reflex arc (immediate action). Through this pathway, interneurons send a message via the efferent neurons to cause the muscles of the hand to move away from the frying pan.

Within the Nervous System there are two main areas, these include: The Central Nervous System and the Peripheral Nervous System.

The Central Nervous System includes the brain and the spinal cord. These two organs control many of the functions of the human body. The brain is the command center for the body. The brain stem (where the brain meets the spinal cord) controls many vital functions required to control life, such as: heart rate and diaphragm movement for respiration. The spinal cord is the main hub of communication signals, in which all peripheral afferent and efferent messages are transmitted.

The Peripheral Nervous System controls the messages to and from the brain and peripheries. The Peripheral Nervous System can further broken down into the Autonomic and the Somatic Nervous System.

The Somatic Nervous System is also identified as the Voluntary Nervous System, in which the person can transmit controlled messages from the Brain to the peripheries in order to control movement.

An example of the Somatic Nervous System includes: the Brain sending the message to the legs to move its arms. This causes the Somatic Nervous System to transmit a message through the peripheries through to the muscles in the arm to stimulate contraction and skeletal movement.

The Peripheral Nervous System is also called the Involuntary Nervous System and allows the brain to produce involuntary messages to cause changes within the body. The Peripheral Nervous System can be further broken into the Sympathetic and the Parasympathetic Nervous System.

The Sympathetic Nervous System causes the body to produce the “Fight or Flight Response,” in which adrenal responses such as a release of adrenaline and nor-adrenaline, cause an increase in heart rate, blood pressure, dilation of bronchioles and enhanced force of contraction of muscles within the body. This allows the human body to respond to an emergency.

An example of the Sympathetic Nervous includes: the response to a person holding a knife up to you and asking for your wallet, this results in the release of adrenal responses, which allows the person to have the best physiological ability to fight the mugger, or run from the mugger.

The Parasympathetic Nervous System is also known as the “Feed or Breed Response” and focusses on slowing the main systems of the body to aid in feeding and breeding, this includes, slowing the heart rate, lowering blood pressure, and slowing the motility of the gastro-intestinal tract (GIT).

An example of the Parasympathetic Nervous System would include: the circadian rhythm, which causes a slowing of the heart rate and a relaxation of muscles which allow a person to sleep.

This is a diagram of the basic divisions of the Nervous System.

 

 

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Renin Angiotensin Pathway

October 13th, 2010

The renin angiotensin system (also known as the RAA Pathway) is a complex process that the body uses to maintain fluid, sodium and blood preasure homeostasis in the human body. If you want to learn more about homeostasis in the human body, please review my homeostasis page.  Through the complex RAA pathway, the body maintains homeostasis through the use of renin, angiotensin, aldosterone and how these affect body systems such as the patients vasculature, kidney functions, and release of vasoconstricting hormones such as adrenaline.

Definitions of the enzymes, hormones, and peptides  involved in the RAA Pathway and their purpose:

Renin is an enzyme that is produced by the kidneys as a negative homeostatic response to a decreased intra-renal pressure in the juxtaglomerular due to insufficient blood flow and blood
pressure. Renin is also released when the glomerular cells detect insufficient levels of sodium ions indicating a decrease in overall fluid balance.

Angiotensinogen is a peptide produced by the liver. When Angiotensinogen combines with renin the enzyme angiotensin is produced.

Angiotensin. Angiotensin is an oligopeptide found in the blood, which is capable of causing vasoconstriction, which in turn causes an increase in systemic blood pressure. Angiotenisn also
causes the adrenal cortex to release aldosterone, which is a hormone known to increase thirst (dipsogen) and reduce renal release of sodium ions, therefore increase water retention.

Angiotensin II. Angiotensin I is converted by an angiotensin converting enzyme (ACE) into angiotensin II. ACE is found in capillaries throughout the body, however, due to the high amounts of capillaries found in the lungs, the lungs have the highest concentration of ACE. Angiotensin II, III and IV increase blood pressure through a variety of biological mechanisms that
effect: the kidneys, vasculature, and hormones.

Angiotensin Converting Enzyme (ACE). ACE is an enzyme found primarily in capillaries (particularly in the lungs), which convert angiotensin I into angiotensin II. Many blood pressure medications target ACE in order to artificially regulate a person’s blood pressure. Many blood pressure medications known as ACE inhibitors block the body’s ability to produce ACE,
and therefore the body is unable to convert angiotensin I into angiotensin II, which will cause a the human body to increase its blood pressure.  One of the unfortunate side effects of ACE
inhibitors is that they may reduce the moisture in a person’s lungs, and therefore increase the risk of respiratory infection and the presence of a non-productive cough.

Here is a flowchart of the RAA Pathway in action:

 

Renin Angiontensin Pathway

Angiotensin Effects on the Body

Angiotensin I

Angiotensin I has limited known effects on the human body, other than being a precursor to angiotensin II. However, angiotensin II, III
and IV have profound effects on the human body and a regulatory role in controlling a person’s blood pressure.

Angiotensin II

Angiotensin II acts to increase blood pressure through the following mechanisms:

–     As a potent direct vasoconstrictor, constricting arteries and veins and increasing blood pressure. When cardiac cell growth is stimulated, a local anngiotensin
system is activated in the cardiac myocyte, which stimulates cardiac cell growth through Protein Kinase C. The same system can be activated in smooth muscle cells in conditions of hypertension, atherosclerosis, or endothelial damage.

–     A1 adrenoreceptor stimulation causing vasoconstriction.

–     Thirst sensation (dipsogen) through the subfornical organ (SFO) of the brain, decreases the response of the baroreceptor reflex, and increases the desire for
salt. It increases secretion of ADH in theposterior pituitary and secretion of ACTH in the anterior pituitary.

–      Angiotensin II has a direct effect on the proximal tubules to increase Na+ reabsorption. It has a complex and variable effect on glomerular filtration and renal blood flow
depending on the setting. Increases in systemic blood pressure will maintain renal perfusion pressure; however, constriction of the afferent and efferent
glomerular arterioles will tend to restrict renal blood flow. The effect on the efferent arteriolar resistance is, however, markedly greater, in part due to
its smaller basal diameter; this tends to increase glomerular capillary hydrostatic pressure and maintain glomerular filtration rate. A number of other
mechanisms can affect renal blood flow and GFR. High concentrations of Angiotensin II can constrict the glomerular mesangium reducing the area for glomerular
filtration. Angiotensin II as a sensitizer to tubuloglomerular feedback preventing an excessive rise in GFR. Angiotensin II causes the local release of
prostaglandins, which, in turn, antagonize renal vasoconstriction. The net effect of these competing mechanisms on glomerular filtration will vary with
the physiological and pharmacological environment.

Angiotensin III

Angiotensin III has mild vasopressor capabilities, but almost 100% of the aldosterone producing effects on the adrenal cortex. By stimulating the adrenal cortex,
angiotensin III causes the adrenal cortex to release aldosterone. Aldosterone is a hormone that causes the kidneys to retain sodium and lose potassium.
Elevated plasma angiotensin II levels are responsible for the elevated aldosterone levels present during the luteal phase of the menstrual cycle

Angiotensin IV

Angiotensin IV is believed to help mediate vaso-constriction, but the causes of this effect is widely unknown. 

What is dipsogen? Dipsogen is a medical term referring to an increased thirst sensation.

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Differences Between Emphysema and Chronic Bronchitis

October 13th, 2010

Emphysema and Chronic Bronchitis present very similarly and are both chronic disorders of the lungs, which are associated with constant dyspnea. These are some differences between the two presentations:

Emphysema

–Pink puffer

– Over ventilator

– Barrel chested and tripod stance

– Exertion based dyspnea

– Under weight

Chronic Bronchitis

-Blue bloater

– Productive cough

-Excessive bronchial secretions

-Shortness of breath

– Wheezes and crackles may be present

– Cyanosis and hypoxaemia

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Differences Between Croup and Epiglottitis

October 13th, 2010

Croup and epiglottitis both present very similarly. In western worlds, croup is much more prevalent than epiglotitis, because the virus that causes epiglottis has been almost wiped out of most first world countries. These are some of the differences in presentation.

Croup

– Slow Onest

– Barking Cough

– No drooling

– Hoarse Voice

Epiglottitis

-Rapid Onset

– No Coughing

-Drooling

– Muffled voice

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What are the Five Rights of Drug Administration?

October 13th, 2010

The five rights of drug administration are:

1. Right Patient

2.Right Drug

3. Right Strength and volume

4.Right Route

5.Right Time

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Where are Chemoreceptors Found?

October 13th, 2010

Chemoreceptors are used by the body to detect changes in pH and CO2.

Chemorecptors are primarily found in the carrotid vessels and arotic vessel.

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What is Crush Syndrome?

October 13th, 2010

What is Crush Syndrome? Crush syndrome is a set of overall clinical pathologies that occur when a significant compressive force has been applied to a person for any duration, which results in ischaemia and muscle damage to the site. Crush Syndrome may also occur when a patient has been laying on a hard surface for such a long time that he or she has developped a non-traumatic crush injury, which inolves anearobic metabolism in the area that is compressed against the hard surface of the floor. Crush syndrome is a life-threatening complication of crush injuries and results in high mortality rates.

For example, if a heavy concrete building structure crushes a person’s abdominal region the person will most likely remain alive and potentially conscious until that compressive force is released. Upon releasing the compressive force, lactic acid and K+ ions from damaged cells will be released, potentially leading to sudden death from arrythmias.

Crush Syndrome Mortality

Mortality related to crush syndrome occurs early after the removal of the crushing force or in the weeks afterwards due to secondary injuries.

These are the most common causes of immediate mortality following the release of the crushing force in a patient with crush syndrome:

1. Hyopovolaemia after the compressive force is realeased

2. Sudden release of potassium ions from the area distal to the compressive forces, which then travels to the heart causing fatal arrythmias

3. Sudden release of lactic acid within the circulatory system

Secondary causes of mortality following release of the crushing force include:

1. Release of myoglobin as a result of muscle compression at injury site and distally, leads to large myoglobin cells circulating and becoming blocking the glomerelus from filtering blood within the kidneys, this results in renal failure. This is fundamentally, rhabdomylosis.

Established Signs and Symptoms of Crush Injury

The following are six well defined signs and symptoms of crush injury:

  1. ischaemic muscle necrosis
  2. circulating myoglobin and myoglobinuria
  3. raised serum potassium (hyperkalaemia)
  4. metabolic acidosis
  5. hypovolaemic shock
  6. renal failure

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What are the Signs and Symptoms of Crush Syndrome?

October 13th, 2010

The signs and symptoms of crush syndrome include the following: a clearly demonstrated history of  a compressive force on a limb or large area of their body which  has been there for a period of time (ussually greater than 30 minutes) or a patient has been laying on the ground with a hard surface for some time (ussually greater than 8 hours).

1. The patient is ussually haemodynamically stable while the compressive force is insitu.

2.  Absent pulses, pale, cold, no movement, no sensation distal to injury site/compressive force.

3. Rapid onset of hypovolaemia on release of compressive force.

4. Dysrhytmias after release due to influx of Potassium Ions.

5. Signs of hyperkalamia, such as tall peaked T waves, formation of a Sine Wave, VF, and eventually assystole.

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Monitor and Review Risk Management Strategies

October 11th, 2010

Even the best thought out plans need to be monitored once implemented. Sometimes the solution to the problem can cause further problems; this would never be identified unless monitoring occurs. Organisations need on-going review in order to maintain their set goals – just because one risk is solved, it does not mean that this solution will not create a new risk. Even the solution to the problem may cause further complications or introduce new risks to the organization.

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Risk Treatment

October 11th, 2010

At this stage, an organisation must have reached a point the RM process, in which the ‘perceived risk’ has now become a risk that is unacceptable. Options are put forward and plans are drawn in order to combat or severely reduce the identified risk(s). This process can have positive or negative outcomes.

Positive outcomes include reducing the likelihood, reducing the consequences to the organisation, possibly sharing the risk with other stakeholders in order to have the problem rectified sooner (this can include utlising other emergency services, or outsourcing the consequence, as in the case of insurance), and sometime avoiding the risk altogether.

Negative outcomes include changing the risk in order to have it fall into a different severity category; this is done by not totally fixing a problem, just reducing the incidents severity or likelihood of occurrence or even bypassing the risk altogether so that the likelihood of occurrence is reduced or even stopped.

For example, in Ambulance Practice, paramedics were found to be assaulted on occasion while waiting at the scene of a violent patient for police. One risk treatment that was put forward, was that Paramedics who are called to an assault, never attend the scene without police being in attendance first. The secondary risk that this risk treatment may introduce is the potential for the patient will then deteriorate while the paramedics are waiting for police.

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Risk Evaluation

October 11th, 2010

Risk evaluation looks at the comparison from what has been perceived through risk analysis and compares those findings to pre-established criteria. It is through this comparison that the organisation decides about the prioritisation of the ‘perceived risk’. Some companies may decide that the risk has an extremely low impact on the company or its employees and has a likelihood of occurring on rare occasions, while other risks can have fatal consequences and have a moderate to a high likelihood of occurring. These risks are vital to rectify immediately. In Ambulance Practice, ‘perceived risk’ can be further disseminated to identify risks to the paramedic, their ability to respond to an emergency, other emergency responders, bystanders, and the patient.

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Risk Analysis

October 11th, 2010

Risk analysis identifies areas that may hinder the organisational goals. This is done by sorting risks into likelihood (the chances of an incident occurring) versus consequences (the potential outcome to the organisation). Risks that can have severe detrimental outcomes to the organisation can involve one or many people, they can have a high or low possibility of occurrence and can be costly or quite cheap to rectify. Most companies feed this type of information into a risk analysis matrix, to see if fixing a ‘perceived risk’ is viable for the company.

In the Ambulance Service of New South Wales (ASNSW), this process is achieved through an Incident Information Management System (IIMS) which is a NSW Department of Health initiative, and according to Travalglia and Braithwatie (2006) has been designed to ‘disseminate lessons learned from an incident which has had a potentially negative consequence to the patient or the healthcare worker’ (p.24).

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AS/NZS ISO 31000:2009

October 11th, 2010

The AS/NZS ISO 31000 was prepared by the Joint Standards Australia/Standards New Zealand Committee of Risk Management as a revision of AS/NZS 4360:2004. It provides a generic framework for establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risk (AS/NZS ISO 31000:2009, p.14). It is also considered one of the most important documents regarding Risk Management available globally. 

The standards and information provided in the AS/NZS ISO 31000: 2009 is not part of government and are not laws, regulations or even legal documents; however, because of their rigour, they are called up into legislation by government and often become mandatory. This is a decision made by the elected government at the time, and not the AS/NZS ISO 31000: 2009. The standards are developed regularly and can be incorporated into legal documents. 

The Australian Standards/New Zealand Standards International Organization of Standardization 31000: 2009 is one of the most widely used and well encorporated Risk Management Standard around the world and has been adopted by 163 countries (currently, as of 2010). 

The AS/NZS ISO 31000:2009 was developed in order to supercede the AS/NZS 4360 2004 as part of the International Organisation of Standardization committment to maintain currency of its Standards in Risk Management. Many of the concepts found within the AS/NZS ISO 31000: 2009 are directly taken from the AS/NZS ISO 4360:2004;  however, there have been some improvements and additional clarifications. 

Where can I find the AS/NZS ISO 31000:2009?

The AS/NZS ISO 31000:2009 can be purchased on-line through the SAI Global Online Store. I believe it costs about $100 to download and an additional $15 to be mailed out in booklet form (although, this was how much it cost me previously, I cannot be certain how much these cost currently). 

How Does the AS/NZS ISO 31000: 2009 Compare to Standards in Risk Management Overseas?

The AS/NZS ISO 31000: 2009 is the most published Standard on Risk Management, with over 163 different countries adopting the Standards as the best practice in Risk Management at last count. There are other Standards available on the topic of Risk Management. AS/NZS ISO 31000 in many ways. The risk management process along with all the contributing factors are tabled and explained. The IRM document explains the risk estimation procedures and provides clear tables of easily understood information on the probability of occurrences, threats and opportunities (IRM 2009, p.2). It categorises these factors into risk categories ranging from Low, Medium and High (IRM 2009, p17). The Australian documentation section provides similar information, but in many ways is more readily understood. This is because the IRM document needs to refer to legal requirements for policy statements due to the fact that these documents are not legislation, but may in time become legislation. The IRM document also focuses heavily on the role of the internal auditing process (IRM 2009, p.4). The IRM Risk Management Standard is more readily available to all organisations and individuals because the IRM is a non-for-profit organisation, and provides this product free to download.

The South African Bureau of Standards (SABS) is a body that was established in 1945 as a direct result of an act of parliament and continues to update current standards (SABS 2010, p.1). SABS has members appointed by the Minister of Trade and Industry and have many objectives. These include the issuing of National Standards and obtaining membership of Foreign and International Bodies that have similar objectives. A large difference in this format and other standards found globally is the involvement of public enquiry in its design. For example, a new draft Standard is made available for public comment both nationally and internationally, during a period of public enquiry. A comment period of sixty days is normally required and a thirty-day comment period applies in the case of adoptions. The comments are received and then are reviewed. If no comments are received, or technical changes needed, the standard is deemed to be approved and is forwarded to the Standards Approval Committee for ratification. After ratification, the document is released for publication. With this focus on health, safety and the environment the basis for legislation is provided (SABS 2010, p.15). 

The American system and documentation of standards is written more as a strategy and a long term plan that looks to the global future than just a focus on risk management today. The United States Standards Strategy (USSS) is a revision of the National Standards Strategy for the United States (NSS). The first NSS reaffirmed that the United States (U.S.) is committed to a sector-based approach to voluntary standardisation activities, both domestically and globally. It established a standardisation framework that was built upon the traditional strengths of the U.S. system, such as consensus, openness and transparency. It also provides additional emphasis to speed, relevance, and meeting the needs of public interest constituencies (USSS 2010, p. 8). 

The South African Bureau of Standards (SABS) is a body that was established in 1945 as a direct result of an act of parliament and continues to update current standards (SABS 2010, p.1). SABS has members appointed by the Minister of Trade and Industry and have many objectives. These include the issuing of National Standards and obtaining membership of Foreign and International Bodies that have similar objectives. A large difference in this format and other standards found globally is the involvement of public enquiry in its design. For example, a new draft Standard is made available for public comment both nationally and internationally, during a period of public enquiry. A comment period of sixty days is normally required and a thirty-day comment period applies in the case of adoptions. The comments are received and then are reviewed. If no comments are received, or technical changes needed, the standard is deemed to be approved and is forwarded to the Standards Approval Committee for ratification. After ratification, the document is released for publication. With this focus on health, safety and the environment the basis for legislation is provided (SABS 2010, p.15). 

The American system and documentation of standards is written more as a strategy and a long term plan that looks to the global future than just a focus on risk management today.

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Paramedic Risk Identification

October 11th, 2010

According to the AS/NZS ISO 31 000:2009, risk can be defined as the ‘effect of uncertainty on objectives’ and is often characterised by the ‘combination of the consequence of an event and the associated likelihood’ (p.1). During this process, an Ambulance Service identifies potential risks that may have an effect on the ability of its paramedics to achieve their desired goal. For the purpose of this paper, this goal has been identified as the ‘ability to effectively respond to an emergency, medically treat a patient, or patients, and transport that patient to hospital.’ The main categories of risks identified for paramedics include the following areas:

  • Driving to an emergency under lights and sirens
  • Parking an Ambulance at the scene of an emergency
  • Attending a Scene
  • Communication with other emergency personnel, dispatch and bystanders
  • Treating a patient while at the scene, and
  • Transporting the patient to a hospital

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Risk Management Process

October 11th, 2010

The Risk Management Process

The AS/NZS ISO 31000:2009 identifies five main risk management processes that should be utilised within a chronological order and two main processes that should be continuous tasks. The two processes in Risk Management (RM) that should be concurrently performed include: Communication and consultation as well as Monitoring and review. Communication and consultation with external and internal stakeholders should take place during all stages of the RM process in order to ensure complications, solutions, and future plans are addressed at the earliest stages. Monitoring and review should take place concurrently with the other main stages of the RM process, to ensure that the project is developing how it is supposed to, and any problems are identified and resolved at the earliest point. The following Five RM processes should occur in chronological order and represent the main processes of RM (AS/NZS ISO 31000 2009, p. 14).

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American Risk Management Standards

October 11th, 2010

The American system and documentation of standards is written more as a strategy and a long term plan that looks to the global future than just a focus on risk management today. The United States Standards Strategy (USSS) is a revision of the National Standards Strategy for the United States (NSS). The first NSS reaffirmed that the United States (U.S.) is committed to a sector-based approach to voluntary standardisation activities, both domestically and globally.

 It established a standardisation framework that was built upon the traditional strengths of the U.S. system, such as consensus, openness and transparency. It also provides additional emphasis to speed, relevance, and meeting the needs of public interest constituencies (USSS 2010, p. 8). The article asks Governments (at all levels in their consideration of policies and legislation), to recognize the societal benefits of standards development organisations and their role in public health and safety. Public Law 104-113, which is the National Technology Transfer and Advancement Act (NTTAA) remains the cornerstone at the federal level for promoting the use of voluntary consensus standards for both regulation and procurement within the US (NTTAA 1995, p.1).

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The UK Standards

October 11th, 2010

The UK Risk Management Standards

In the United Kingdom, many of these documents focusing on risk management, stem from the Institute of Risk Management (IRM). This document compares with the AS/NZS ISO 31000 in many ways. The risk management process along with all the contributing factors are tabled and explained. The IRM document explains the risk estimation procedures and provides clear tables of easily understood information on the probability of occurrences, threats and opportunities (IRM 2009, p.2). It categorises these factors into risk categories ranging from Low, Medium and High (IRM 2009, p17). The Australian documentation section provides similar information, but in many ways is more readily understood. This is because the IRM document needs to refer to legal requirements for policy statements due to the fact that these documents are not legislation, but may in time become legislation.

The IRM document also focuses heavily on the role of the internal auditing process (IRM 2009, p.4). The IRM Risk Management Standard is more readily available to all organisations and individuals because the IRM is a non-for-profit organisation, and provides this product free to download.

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The South African Bureau of Standards

October 11th, 2010

The South African Bureau of Standards in Risk Management is an equivalent Risk Management Standard in Africa to the Australian Standards in Risk Management.

The South African Bureau of Standards (SABS) is a body that was established in 1945 as a direct result of an act of parliament and continues to update current standards (SABS 2010, p.1). SABS has members appointed by the Minister of Trade and Industry and have many objectives. These include the issuing of National Standards and obtaining membership of Foreign and International Bodies that have similar objectives. A large difference in this format and other standards found globally is the involvement of public enquiry in its design.

For example, a new draft Standard is made available for public comment both nationally and internationally, during a period of public enquiry. A comment period of sixty days is normally required and a thirty-day comment period applies in the case of adoptions. The comments are received and then are reviewed. If no comments are received, or technical changes needed, the standard is deemed to be approved and is forwarded to the Standards Approval Committee for ratification. After ratification, the document is released for publication. With this focus on health, safety and the environment the basis for legislation is provided (SABS 2010, p.15).

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AS/NZS ISO 31000:2009 Compared to Equivalent Standards Globally

October 11th, 2010

About the AS/NZS ISO 31000: 2009 and Equivalent Standards Found Globally

The ISO enables a consensus to be reached on solutions that meet both the requirements of business and the broader needs of society. Many of ISO’s members also belong to regional standardisation organisations. ISO has recognised regional Standards Organisations representing the Middle Eastern Countries, Africa, and the areas covered by the Commonwealth of Independent States, Europe, Latin America, the Pacific area, and the South-East Asian nations. This has made it almost impossible to write a specific Standard that meets the legislation and documentation needs of each country, due to the vast differences in laws throughout the world. The following regional bodies are currently committed to adopting ISO standards as their National Standards for their members:

  • African Regional Organization for Standardization (AROS)
  • Arab Industrial Development and Mining Organization (AIDMO)
  • European Committee for Standardization (CEN)
  • Pan American Standards Commission (COPAS)
  • Pacific Area Standards Congress (PASC)

(ISO 2010, p.1).

In the United Kingdom, many of these documents focusing on risk management, stem from the Institute of Risk Management (IRM). This document compares with the AS/NZS ISO 31000 in many ways. The risk management process along with all the contributing factors are tabled and explained. The IRM document explains the risk estimation procedures and provides clear tables of easily understood information on the probability of occurrences, threats and opportunities (IRM 2009, p.2). It categorises these factors into risk categories ranging from Low, Medium and High (IRM 2009, p17). The Australian documentation section provides similar information, but in many ways is more readily understood. This is because the IRM document needs to refer to legal requirements for policy statements due to the fact that these documents are not legislation, but may in time become legislation. The IRM document also focuses heavily on the role of the internal auditing process (IRM 2009, p.4). The IRM Risk Management Standard is more readily available to all organisations and individuals because the IRM is a non-for-profit organisation, and provides this product free to download.

The South African Bureau of Standards (SABS) is a body that was established in 1945 as a direct result of an act of parliament and continues to update current standards (SABS 2010, p.1). SABS has members appointed by the Minister of Trade and Industry and have many objectives. These include the issuing of National Standards and obtaining membership of Foreign and International Bodies that have similar objectives. A large difference in this format and other standards found globally is the involvement of public enquiry in its design. For example, a new draft Standard is made available for public comment both nationally and internationally, during a period of public enquiry. A comment period of sixty days is normally required and a thirty-day comment period applies in the case of adoptions. The comments are received and then are reviewed. If no comments are received, or technical changes needed, the standard is deemed to be approved and is forwarded to the Standards Approval Committee for ratification. After ratification, the document is released for publication. With this focus on health, safety and the environment the basis for legislation is provided (SABS 2010, p.15).

 

The American system and documentation of standards is written more as a strategy and a long term plan that looks to the global future than just a focus on risk management today. The United States Standards Strategy (USSS) is a revision of the National Standards Strategy for the United States (NSS). The first NSS reaffirmed that the United States (U.S.) is committed to a sector-based approach to voluntary standardisation activities, both domestically and globally. It established a standardisation framework that was built upon the traditional strengths of the U.S. system, such as consensus, openness and transparency. It also provides additional emphasis to speed, relevance, and meeting the needs of public interest constituencies (USSS 2010, p. 8). The article asks Governments (at all levels in their consideration of policies and legislation), to recognize the societal benefits of standards development organisations and their role in public health and safety. Public Law 104-113, which is the National Technology Transfer and Advancement Act (NTTAA) remains the cornerstone at the federal level for promoting the use of voluntary consensus standards for both regulation and procurement within the US (NTTAA 1995, p.1).

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The International Organization of Standardization

October 11th, 2010

 

About the International Organization of Standardization (ISO) 

The ISO is the world’s largest developer and publisher of International Standards. ISO is a network of the National Standards Institutes of 163 countries (currently), comprising of one member per country (ISO 2010, p.1). ISO is a non-governmental organisation that forms a bridge between the public and private sectors. Many of its member institutes are part of the governmental structure of their countries, or are mandated by their government.

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Standards Australia

October 11th, 2010

About Standards Australia

Standards Australia was first established in 1922 through a memorandum of understanding with the Australian Government as a non-government set of standards developed in Australia (Standards Australia 2010, p.1). It was determined that all information developed and incorporated into the standards must be of a high quality and conform to the standards Australia guidelines.

The Standards Australia has adopted the AS/NZS ISO 31000:2009 standards for risk management as the benchmark and standard for risk management within Australia. The AS/NZS ISO 31000 was prepared by the Joint Standards Australia/Standards New Zealand Committee of Risk Management as a revision of AS/NZS 4360:2004. It provides a generic framework for establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risk (AS/NZS ISO 31000:2009, p.14). Standards Australia is not part of government and they are not laws, regulations or even legal documents; however, because of their rigour, they are called up into legislation by government and often become mandatory. This is a decision made by the elected government at the time, and not Standards Australia. The standards are developed regularly and can be incorporated into legal documents.

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Rural Paramedic Stories

October 11th, 2010

These are some rural paramedic stories that I’ve put together from my time posted out to a small outback town in Australia as a Rural Paramedic. So, if you’re soon to be posted to a rural area as a paramedic, these are some stories to get you ready for what you’re in for. At the end of the day, enjoy the experience, people are friendly and appreciate the work you do, get used to having your showers/baths interrupted (and your sleep) – many patients will even know where you live and turn up in the middle of the night if they have a problem. But, you’re generally well compensated for this both financially and by town respect/and appreciation/job satisfaction.

Anyway, these are some of my rural paramedic stories.

I live by myself on a farm-house on top of a hill with 360 degree views down the various fields and mountains… I share my land with some 300 head of cattle and a little over 2000 sheep (no comment there)… My house is an old, rustic place, with an outhouse (toilet) and a small axe next to the toilet because the snakes often come into the outhouse in search of water (or so they tell me)… It’s hot, really hot here… Yesterday, I had all the air conditioners on in the house… all night and then all day… at about 2pm I was sitting in my nice cool air conditioned house with a thermometer reading 38 degrees inside the house. I went for a swim last night and at 8pm the ambulance’s ambient temperature while parked under the shade of a large tree, read 41 degrees…(where the heck am I!!!) of course, early this morning the weather completely changed and I woke up at three am to the sound of hail plummeting down around the house.

Back to the house… it was fully furnished when I moved in with furniture which must all be antiques… and I’ve had some fun looking through the cupboards and finding interesting wood carvings and other odd things… Of course I opened one box a few days ago, which was delicately engraved with what appeared to be Latin writing… only to find that there were the remains of someone inside… that’s right, they left… someone’s urn in an antique box in my house… a little odd…. but not particularly out here…

We don’t have a garbage truck in town, so everyone just takes their rubbish down to the garbage tip (about 30kms out of town)…

Now, about the community…

I went to the general store on my 2nd day here to get some basic groceries.  I asked when they’re open, and a nice lady explained to me that “we’re open every day of the week dear, from 10am to 1pm!” She boasts, “everyday except Tuesdays and Fridays…” I reply, “Wow, so you’re open on the weekends…” to which she says… “Oh no, of course not dear…”

I then end up meeting every single person in the store, who automatically recognises me as being the “new Ambulance driver” in town. Someone asked where I was living and after I explained where I was living… this total stranger who I had just met in the isle tells me “oh, it was so sad how the previous residents who lived up there died, wasn’t it?” and then a really sad story was explained to me that the previous residents of my house didn’t pay attention to the sign in town which says, in small letters on the side of the road, “please give way trains” and husband and wife were killed by the train that comes once every six months… I have now had that story retold to me by 12 completely different people who I have met around town… who all want to tell me about how sad it was…

The community people really are lovely… even if, at times, slightly different than what I’m used to.  Everyone here knows everyone by name… I’ve made a list of people I know/have met, and have almost met the entire town. I got a membership at the swimming pool and was given a key to the door. My work partner and I went to the local (and only) café/newsagent/hardwarestore/ videostore/ restaurant in town. Its owned and run by two lovely people Paul and Marie (fictional names)… they’re lovely… but Paul’s… um … not the best café owner… we asked for a coffee yesterday at about1030… and Paul shook his head and said “My paper hasn’t arrived yet…” my partner replies… “bummer, say, can I get a coffee?” to which Paul replies crankily “I said I don’t have my paper yet… no one gets served until I get my paper in the morning…” to which his wife, looks over and says to my partner, “that’s right sweetie, you know how Paul is, no one gets anything until he’s had his morning paper…” we then come back at 1230 to find Paul at the counter… Paul shakes his head and tells us that his paper’s not here yet… at 1pm he calls to tell us that we can have a coffee now, because his paper’s arrived. We decide to eat lunch at the restaurant. I had a fantastic beef burger with THE LOT… my partner asked for a cheese sandwich without butter. She gets, a cheese sandwich with lots of butter. She asks Paul if there’s any butter on the sandwich. Paul says “yep, lots of butter…” she says “oh, Paul I really didn’t want any butter…” Paul says.. “I know, I’m not deaf, I heard you say that you didn’t want butter..” we both pause… okay… Sonya asks “next time I get a cheese sandwich can I get it without butter?” Paul says “No, gotta have butter…it’s a cheese sandwich and its gotta have butter… says so in the menu over there..”  Sonya says, “right, but just for me, can you not butter the bread… just everything else the same, but leave out the butter… thanks” Paul replies shaking his head, “No, no, you’re not listening, the menu says butter on the bread, its gotta have butter…otherwise it would be a completely different sandwich, wouldn’t it?” He then walks off shaking his head…

How’s work? On my first shift, I didn’t get a single job until 3:50 when we got a emergency transfer for a patient from one of our local hospitals with abdominal (currently without any staff) through to Wagga Wagga Base (approx 500kms round trip). I got 6 ½ hours of over time for that one job. Then got a cardiac arrest while leaving Wagga Wagga… but we don’t actually have a map of Wagga Wagga (so that was a little difficult), but we fortunately found a highway patrol man to flag down and made him take us to the address… where our old man died in the middle of his grand final lawn bowls match….

Yesterday I did my first and only job in the town itself… it was in a pretty dodgy house… okay, a very dodgy house. I knew it was pretty dodgy when I saw that they had a wood/petrol fired cooker in the house… by this, I mean in the living room this guy had a 130 gallon iron drum  filled with wood and was cooking meat in it in the living room of his shack… this guy (35y/o) was completely toothless, had underwear on and nothing else, and was complaining of  R sided abdo pain. We took him to hospital and I recommended he get some clothes to take with him, and we’ll meet him out the front. He then meets us out the front of the house, still in only his underwear, but carrying clothes… Now keep in mind that this person doesn’t have a pension card… he apparently works somewhere down the road… and apart from his appearance is fairly pleasant and sociable… I’m driving and my partner’s treating. At the hospital we unlock the hospital with a key and then call the nurse from the phone there, who then drives to the hospital and meets us there in about half an hour. My partner then gives the following hand over to the nurse:

 “This Mr ____ he’s 35, and is generally fit and healthy. Today has developed a sharp R sided pain to his abdomen. Nil rebound tenderness. C/o some nausea and vomiting. And Has been incontinent enroute.”

It was the incontinent enroute that made think what? This person’s totally normal otherwise, and has been stating NAD to passing urine/bowel movements, and now his incontinent to urine… that’s um, pretty weird. But then he get’s off our bed and I notice that my partner wasn’t talking about urine incontinence…. This man shat on our bed… he pulled down his underwear and shat on our bed! And then at the hospital was going to get on the hospital bed and the nurse said, “do you still want to go to the toilet” and he says, yeah, don’t worry about it, I’ll just do it in the bed… I’m not embarrassed… she recommends he walks to the toilet, which he eventually agrees to and then he says “You gotta pay phone around here… I gotta let the boss know I wont be in today…” that’s really weird, even by an ambulance view.

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New Rural Paramedic

October 11th, 2010

This is a story from about 9-10 years ago now, when I first took a job (okay, was posted) out to a very remote part of rural Australia as a newly qualified paramedic…

Okay, so I leave rainy Sydney and have a lovely drive out in the country (about 9 hours into the area of my new employment). That is, a lovely drive, until my car overheats and I find myself stranded about 100 odd Kms outside of my new town… with the outside temperature being 46 degrees that day… I try and find a tree for shade. Non- whatsoever to be seen. I fortunately have water. The car quickly becomes too hot to sit inside… and everywhere outside is riddled with those red bull ants that attack you the second you’re within a mile of them. So I find myself in the scorching sun, middle of nowhere, walking up and down the deserted road trying not to stand still long enough to be bitten by these bloody painful ants… 

But good news… I call NRMA (our road side assistance), and they tell me that the NRMA man for the entire area happens to be driving up the road that I’m on anyway and will stop by in about 15 minutes!! Fantastic… he stops sorts out my problem (a broken hose, which he replaces)… and I’m back on the road again… unfortunately, the same pipe falls off and literally 3 minutes later I’m on the side of the road again calling the NRMA… unfortunately, now the NRMA man’s phone is out of reception range and I am told that they will keep trying him… unfortunately, about an hour later they call and still haven’t reached him and I get a phone call from someone in Hay (about 3-4 hours away) who end’s up explaining to me what to do over the phone… which fails miserably… and I’m told he can get there within about 4 hours…or I can try slowly driving the car and then stopping until I get to the service station approximately 5kms up the road (ended up being 40kms). So over a three hour period I got my car to my new paramedic rural posting … where the town mechanic assures me he will work out the problem and fix it over the next week or two… maybe a month… (I mean, in a town with less than 300 people, how busy can a mechanic be?)

On a nicer side, the two people who passed my broken down car during my 3 hour’s of waiting in the middle of nowhere both stopped, offered me assistance…and after being told that I was waiting for NRMA, both of them insisted on leaving me a bottle of water so that I would be safe… isn’t that nice… also the people I’m renting my house from offered to come tow me back when to the town when I first called to say that I wouldn’t be meeting them to pick up the keys because my car broke down… they also left half a case of beer in the fridge with a note “To cool you down after the drive…”

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What are the Characteristics of Muscle?

October 10th, 2010

There are four main characteristics of muscle tissue.

These are:

1. Contractility, which is the ability to shorten forcefully

2. Excitability, which is the capacity of muscle to repsond to stimulus.

3. Extensibility, which is the ability to stretch muscle tissue beyond normal resting length and still be able to contract.

4. Elasticity, which is the ability of muslce to recoil to ist original resting length post stretching. This is why patients develop rigor mortis, after they die, because the muscle naturally want to recoil back to their original lengths.

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Primary and Secondary Muscles Used in Respiration

October 10th, 2010

Inspiration

The primary muscles used in inspiration include diaphragm and external intercostal muscles.

The secondary muscles used in inspiration include the sternocloidomastoid and scalini

Expiration

The primary muscle involved in expiration is the diaphragm.

The secondary muscles involved in expiration include the internal and external intercostals, external oblique, internal oblique, transverse abdoninal and rectus abdominis. These are the muscles which become fatigued in the severe asthmatic patient.

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What are the Types of Joints?

October 10th, 2010

What are the types of joints in the human body? There are 3 main types of joints and it is important to know about all three as a paramedic so that you are better able to understand the pathophysiology and the treatment methods of common dislocations.

There are three main types of joints.

These include:

1. Fibrous Joint – which includes two bones united by fibrous connective tissues, and often involve little or no movement.

2. Cartilaginous Joint – which involves two bones united by either hyaline cartilage or fibrocatilage, with little or no movement.

3. Synovial Joint – Joint that contains synovial fluid and allows considerable movement between articulated bones.

What are the Types of Joints Found in the Human Body?

The fibrous joint, cartilaginous joint and synovial joints are the three types of joints found in the human body.

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What is the Difference Between a Sprain and a Strain?

October 10th, 2010

A Sprain involves an injury to the muscle and tendon resulting from violent contraction or excessive stretching.

A Strain involves an injury to the ligaments of a joint.

The treatment for both sprain and strains involve RICE.

Rice stands for:

Rest

Ice

Compression

Elevation

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What are the Nine Abdominal Regions?

October 10th, 2010

There are Nine Abdominal Regions within the human body.

These are:

Right hypochondriac region

Epigastric Region

Left Hypocohondriac region

Right Lumbar Region

Umbilical Region

Left Lumbar Region

Right Iliac Region

Hypogastric Region

Left Iliac Region

Please see image (* coming soon*)

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Voluntary Versus Involuntary Muscles

October 10th, 2010

Skeletal muscles are the only voluntary muscles within the body, which means that they are used through the voluntary choice of the person in control. The only exception to this for skeletal muscles is reflexes, in which a skeletal muscle is activated on an involuntary basis.

Smooth muscles and cardiac muscles are involuntary muscles, and act involuntarily (meaning the person doesn’t decide when or how to use them).

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Synergist Versus Antagonist in Muscles

October 10th, 2010

The term synergist refers to muscles that work together with another muscle to achieve a desired goal. For example, the biceps and the brachialis work concurrently (or synergistically) in the movement of the elbow during flexion.

the term antagonist referst to muscles which act in opposition to eachother. For example, the bicept and the tricept work in opposition of eachother.

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What are the Types of Bone Cells?

October 10th, 2010

There are three main types of bone cells:

These are:

Osteoblasts, which are used in the formation of bone.

Osteclasts, which are used in the breakdown of old bones or damaged bones.

Osteocyte, which is a fully mature bone cell.

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What is a Complicated Fracture?

October 10th, 2010

A complicated fracture is any fracture in which the bone or bones which have been broken causes damage to other organs or structures, such as the lungs, kidneys, major blood vessels, spleen or liver,

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What is the Location and Function of Smooth Muscle?

October 10th, 2010

Smooth muscle is non-striated and forms many aspects of the gastro-intestinal tract, blood vessels, glands, skin, and major organ walls.

The function of smooth muscles are to produce: peristalsis, vasodilation and constriction, bladder control, and pupil size.

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What is the Pathophysiology of Abdominal Trauma?

October 10th, 2010

Abdominal trauma causes specific injuries and introduced the possiblities of specific pathophysiology related to abdominal trauma. These are some main concepts to keep in mind if you are treating someone with abdominal trauma:

1. Any injury to solid or hollow organs may lead to hypovolaemia

2. Damage to hollow organs may lead to rupture and risk of peritonitis

3. More than one mechanism may be involved.

4. Full organs may rupture, as opposed to hollow organs. For example, a full bladder versus an empty bladder.

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Striated Versus Non-Striated Muscles

October 10th, 2010

Striated muscles are muscle which are formed by parallel fibers which are formed together to make muscle, where as non-striated muscles are made up of one single unit of muscle tissue and not parallel fibers.

Skeletal muscles and cardiac muscles are striated

Smooth muscles are non-striated, such as the muscles in the bowel and sphincter.

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What are the Four Types of Bones?

October 10th, 2010

There are four main types of bone shapes in the human body.

These are:

1. The Long Bones – such as the femur in the thigh

2. The Short Bones – such as the carpals and tarsal bones

3. Flat Bone – such as the rigs, sternum, capula

4. Irregular Bones – such as the vertbrae and facial bones

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What is a Fixator Muscle?

October 10th, 2010

A fixator muscle is any muscle that acts to stabilise the orgin of the prime mover.

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What is a Prime Mover Muscle?

October 10th, 2010

A prime mover muscle is any muscle that has a major role in movement,.

For exampe, the brachialis muscle in the elbow is a prime mover muscle during flexion.

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What is Kehr’s sign?

October 10th, 2010

Kehr’s sign is the presense of shoulder tip pain associated with abdominal pain and often relates to refered pain from organ injury or damage within the abdomen.

A example of Kehr’s sign would include right shoulder tip pain associated with right upper quadrant abdominal pain in a person with cholycystitis.

Another example of Kehr’s sign includes violent left shoulder tip pain post abdominal trauma, which often indicates damage to or a ruptured spleen.

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Intrinsic and Extrinsic Heart Regulation

October 9th, 2010

The rate and force of myocardia contraction (heart rate and force) are dependant on two primary factors: intrinsic factors and extrinsic factors.

Intrinsic factors

* No neural control or hormonal control, such as the intrinsic rate of the Sino-Atrial (SA) Node.

*Normal regulation of the heart

Extrinsic Factors

*Neural and Hormonal control of the heart

* Sympathetic stimulation causes increased rate and strength of contractions

*Parasympathetic stimulation causes decreased rate and strength of contractions

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What is the Treatment of Eye Extrusion?

October 9th, 2010

An eye extrusion can be a very difficult job to attend as a paramedic, because the patient is likely to be severely distressed.

The main processes that a paramedic should be considering are the following:

* Never try an push the eyeball back into the socket (not only will this be uncomfortable for the patient, but it will also lead to potential damage of eye structures and introduce infection).

* Support the eye with a moist (preferably saline soaked) dressing.

* Constantly irrigate the eyeball with sterile saline to keep it from drying out.

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What are the Structures and Function of the Aqueous and Vitreous Humor?

October 9th, 2010

Aqueous Humor

The Structure of the Aqueous Humor is in front of the lens and serves the function of maintaining intra-occular pressure and refracts light.

Vitreous Humor

The vitreous humor is structured behind the lens and serves the function of maintaining intra-occular pressure, maintaining shape, and retracts light.

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What is the Structure and Function of the Optic Disc?

October 9th, 2010

The optic disc  is where the retinal aqueous and vitreous humor enter and exit the eyeball and where the optic nerve enters and exits the eyeball.

The optical disc has no photoreceptors, and therefore marks the blind spot of the eye.

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What is the Structure and Function of the Retina?

October 9th, 2010

The retina forms the inner layer of the eyeball.

The function of the retina is to provide a neural layer that responds to light and contains rods and cones.

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What is the Function of the Blink Reflex?

October 9th, 2010

The blink reflex, which is also known as the corneal reflex is the reflex that is designed to ensure that your eyes do not get injured and occurs when soemthing rappidly approaches teh eye causing the rpaid oppening and closing of the eyelids.

The corneal reflex is driven by the autonomic nervous system and is not controlled by the human desire/thought process. This means that the spasm/ corneal reflex is involuntary, and will occur no matter how much a person is trying not to.

The corneal reflex is a good method of determining if a patient is  “faking” a seizure or not.

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What is the Function of the Lacrimal Gland?

October 9th, 2010

The lacrimal gland produces lacrimal fluid (tears), which moisten the surface of the eye, lubricate eyelids and wash away foreign bodies. Tears contain lysosomes, which are capable of breaking up bacteria and foreign bodies.

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What is a Touch Potential?

October 9th, 2010

If a live power line touches the ground it will form a pool of electricity in the local vicinity (on the ground). Depending on how much power was running through the wire in the first place, this pool of electricity may travel as far as 20+ meters. The further out of the pool of electricity the less the voltage. It is this voltage gradient that becomes a concern for attending emergency service personnel, because of the risk of electrocusion (as a result of the voltage gradient).

The touch potential refers to the voltage gradient between where you touch and where you stand – if there is a gradient difference between where you touch and where you stand, you will get electrocuted.

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What is Step Potential?

October 9th, 2010

Step potential refers to the electrocution risk based on the possible amount of voltage running through the ground. For example, if a power line falls down and touches the ground, it may be able to cause a pool of electricity for 10 meters (hypothetically); for every meter out from the initial pont of electrical contact to ground, the voltage may be lower. Consequently, if a person is standing at 9-10 meters from the intial live wire point – the variance between each leg may be up to 1000 volts, which will then try to travel through the person’s body.

This is why it is important for paramedics to keep their legs together when they are near fallen powerlines.

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What is the Function of Vitamin D?

October 9th, 2010

Vitamin D is when skin is exposed to light.

Skin exposed to the sun (UV light) producs inactive Vitamin D which is modified in the Liver and Kidneys to produce active Vitamin D.

Vitamin D stimulates the uptake of Calcium Ions and Phosphate which stimulates Calcium release from the bones and decreases the Calcium Ion loss from the Kidneys.

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What is a VQ Mismatch?

October 9th, 2010

A VQ Mismatch in respiratory pathophysiology is a problem with either the Ventilation (air going in and out of the lungs) or the Perfusion (Oxygen and Co2 diffusion at the alvioli and the pulmonary arteries). VQ ratios compare the amount of air reaching the alveoli to the amount of blood reaching the alveoli.

Ventilation Problems include: inadequate rate or tidal volume during respiration. For example, the person has an adequate rate of respirations (say, 18 breaths per minute), but the tidal volume is insufficient). This would be considered a V/Q mismatch relating to a problem with the V side of the equation.

Alternatively, you may have a perfusion problem. For example, excess pulmonary dead space,such as: emphasema, bronchitis, pneumonia, atelectasis, low pulmonary artery pressures, RVF, lack of haemoglobin availability (as a result of haemorrhage or Carbon Monoxide Poisoning).

Extreme VQ Ratios

The following are extreme VQ Ratios:

An area of no ventilation (VQ ratio of zero) is called a shunt;

An area of no perfusion (VQ ratio approaching infiniti) is called physiological dead space. 

Examples of a VQ Mismatch

The following are examples of disorders that result in a VQ Mismatch:

Patients who have COPD (chronic obstructive pulmonary disease) have a high ventilation rate, but a poor perfusion level at the alvioli due to damage alvioli. This results in a high V/Q ratio.

Patients who have a pulmonary embolism have an adequate ventilation rate, but the oxygen getting to the alvioli is ineffective because it is unable to perfuse the blood which has clotted in the pulmonary artery. This results in a high V/Q ratio.

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What is PEEP?

October 9th, 2010

PEEP stands for Positive Expiratory End Pressure and refers to the measurement of pressure within the alvioli at the end of the expiratory cycle. By increasing the PEEP, the alvioli are forced to remain open, allowing greater difusion of oxygen and Co2 at the point of gas exchange (the alvioli).

PEEP is often used during mechanical ventilation to ensure that the patient is getting the greatest amount of gas exchange in patients with severe respiratory disorders, such as ARDS, Pneumnia, and any other common cause of a V/Q inequality (a problem with ventilation and perfusion).

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What Forces Oppose Lung Collapse?

October 9th, 2010

The following two forces oppose lung collapse:

1. Surfactant – which breaks the hydrogen bonds which maintain surface tension of the alvioli. Some babies who are born immaturely or prematurely will have undevelloped lungs, or may not yet developed surfactant; consequently, the surface tension (due to hydrogen bonding at the alvioli) causes the alvioli to collapse.

2. Intrapleaural Pressure (the pressure in the lungs) which causes the alvioli to remain open. This is why Bipap, C-pap and PEEP (possitive end expiratory pressure) works, because it forces the alvioli to remain open allowing a greater exchange of gas (O2 for Co2).

2.

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What are the Layers of a Blood Vessel?

October 9th, 2010

These are the main layers of a blood vessel wall and what they basically do:

1. Tunica Adventia – which is the outer layer of the vessel and contains connective tissues

2. Tunica Media – middle layer of the vesssel wall and contains smooth muscle

3. Tunica Intima – Inner Layer of the blood vessel wall and contains the endothelium.

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What is Starling’s Law?

October 9th, 2010

In medical science, the term Starling’s Law refers to a theory, which states that “the greater amount of blood volume (preload) into the ventrical of the heart during diastole (the relaxed phase) the greater the amount of blood volume ejected out of the heart during the systolic(contraction phase).”

This becomes clinically significant when a patient does not have enough fluid/blood circulating and as a result the patient’s heart is not being stretched very much as it fills with a limited amount of blood, which results in a proportionately smaller amount of blood ejection fraction (amount of blood ejected by the left ventrical of the heart).

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What is Cushing’s Triad?

October 9th, 2010

Cushing’s Triad is a set of three primary signs that often indicate an increase in intracranial pressure (ICP). These signs include the following:

1. A change in respirations, often irregular and deep, such as cheyne stokes

2. A widening pulse pressure (the difference between the Systolic and the Diastolic BP)

3. Bradycardia (slow heart rate).

Cushing’s Triad was originally identified by a famous Neurosurgeon by the name of Harvey William Cushing.

Cushing’s Triad is an important, but late sign of raised intracranial pressure that doctors, paramedics and nurses must be on the look for with patients who have had a recent head injury, brain injury, neurosurgery, or anyone with a sudden altered level of consciousness.

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What is Intracranial Pressure?

October 9th, 2010

Intracranial Pressure (ICP) is the total pressure within the cranium at a given time. The ICP is the accululative pressure that the vasculature or blood, brain and cerebral spinal fluid (CSF) places on the inside of the cranium. Resting ICP is generally around 5-18 mmHg in the normal healthy adult at rest and supine; however, this pressure normally decreases up to negative 10 mmHg in a patient who is vertical.

ICP is important for paramedics who are treating patients who have had a head injury. This is because any trauma to the head may cause changes in the brain, such as internal bleeding, which will increase the ICP. If the ICP is allowed to continuously increase, it will force the brain tissue downards, damaging the brain stem, and eventually cause the brain stem and other apsects of the brain to be forced downdwards and through the foramen magnum (the big hole that the spinal cord uses to enter the cranium). This will lead to severe brain damage and death.

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Signs of Raised ICP in Children

October 9th, 2010

Signs of raised ICP in children are fundamentally the same for adults, with the following addional signs. These include:

1. Children become quieter than ussual

2. Baby’s stop tracking movement with their eyes

3. In young children, their fontanelles (undeveloped sutures in the cranium) appear swollen and bulging

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Signs of Raised ICP

October 9th, 2010

ICP stands for Intracranial Pressure and refers to the amount of pressure within the cranium at any one time. Although ICP fluctuates on a daily basis, if allowed to increase severely, it will result in long term brain injury and death. Common causes of a severe raise in ICP includes: traumatic head injuries, drug use (particularly amphetamines), cerebral infections, and stroke.

Early Signs of Raised ICP

These are some common signs and symptoms of a raised ICP

1. Headache -particularly bad, and prollonged

2. Nausea and vomiting

3. Blurred vission

Late Signs of a Raised ICP

4. Pupilary changes (as a result of increased pressure on the 3rd occular motory nerve which changes the size of pupils) – this will result in uneven pupil sizes, fixed dilated pupils, any many other irregularities of pupils.

5. Respiratory changes, include cheyne stokes

6. Widening Pulse Pressure

7. Bradycardia

8. Swollen fontanelle (in young children)

9. Signs of Cushing’s Triad:  Bradycardiac, Widening Pulse Pressure, and Respiratory Changes, which indicate late signs of raised intracranial pressure.

Signs of a Raised ICP in Paediatrics

Signs of raised ICP in children are fundamentally the same for adults, with the following addional signs. These include:

1. Children become quieter than ussual

2. Baby’s stop tracking movement with their eyes

3. In young children, their fontanelles (undeveloped sutures in the cranium) appear swollen and bulging

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Home Birthing Stories

October 9th, 2010

Home birthing occurs much more commonly than most people in western society would believe. The reason for this prevalence is based on a variety of causes. This includes: people choosing to have a home birth, early deliveries, preference, and just bad luck at times… these are some home birthing stories that I have attended during my time as a paramedic.

I attended a patient with lower back pain who was currently 34 weeks pregnant. She had had 5 children before her, and seemed very confident that she wasn’t have uterine contractions. I believed her – after all, she was the one who had had 5 previous births. However, as I got further along in the assessment areas, I soon realised that she must be about to have her baby.

She tried to tell me that I was a fool and that she must have injured her back…

I oftered her Nitrous Oxide to inhale for pain relief.

As we arrived at hospital, the triage nurse recommended we go straight to the maternity unit. The maternity unit was on the 10th story (who puts a maternity unit on the 10th story?) – we got half way up and the elevator stopped. Precisely at this time, my patient turned around in her stretcher and said to me.. “I feel… I mean… I think I can push now…” – it was all over in the next 10 seconds…

It then took almost 25 minutes before we were rescued from the elevator. We hadn’t taken our maternity gear into the hospital with us, expecting not to be alone with the patient long enough not to use it…

Mum and bubs was fine in the end… but we had some explaining to do with the Midwife on duty…

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Paramedic Mneumonics

October 9th, 2010

For some reason Ambulance Services and Emergency Services love mneumonics. Sometimes I think paramedic students spend more time memorizing the mneumonics than the actual reasons behind them. These are some of the paramedic mneumonics that I’ve come across over my time as a paramedic – and yes, there are many interpretations of them all…

If you would like to read non-serious (but funny) mnemonics, please see my Funny Paramedic Mnemonics Page

AEIOU TIPS – to assess causes of an altered level of consciousness mneumonic

Alcohol

Epilepsy

Insulin – high or low BSL

Overdose

Uraemia – (this has to do with poor renal function)

Trauma

Infection

Psychosis

Stroke

DRABC -Basic First Aid Mneumonic

Danger

Response

Airway

Breathing

Circulation

AVPU – Basic Level of Consciousness Mneumonic

Alert

Verbal

Pain

Unconscious

OPQRST – Pain Assessment Mneumonic

Onset (at rest or during exercise?)

Provocation – what makes the pain worse/better?

Quality – sharp, crushing, heavy

Region/radiation – where does it her, can you point with one finger to the pain? Does the pain radiate anywhere else?

Severity – 10/10 or 1/10, Mild, Medium Worst Pain Ever

Time/treatment – When did this start? Have you ever had this pain before? Has it been continuous since the time of onset? Have you taken anything for this pain?

SPINAL – High Risk of Spinal Injury/unable to clear a spine because of this medical mneumonic

Suspicious Mechanism of Injury – High speed MVC, roll over, patient ejected, fall, pedestrian, etc

Pain or bony tenderness around the spine

Intoxication with medications, alcohol or elicit drugs

Numbness or tingling distally (below the area of injury)

Any distracting pain

Level of consciousness altered

SERIOUS Assessment in patients with suspected meningococcal septiceamia mneumonic

Serious concern

Extremities cold and painful

Rapid onset of illness

Illness recently

Other flu-like symptoms

Unresponsive to medications

Skin abnormalities (such as purperic rash that does not blanch).

GUTPAINS assessment for abdominal pain mneumonic

Gastritis, gallbladder, gynaecological, excess gass

Urinary problems, ulcerative collitis

Trauma, think hollow organs. Think spleen, liver

Pregnancy (ectopic or normal), pancreatitis

Abdominal aortic anneurysm, appendicitis

Ischeamia of the bowel, intesitinal obstruction

Neoplasm or other cancer

Splenic rupture, or any spasm of the eosophagus

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Dementia Stories

September 30th, 2010

This is the best feel good dementia story that I’ve witnessed in my time as a paramedic.

Dementia is often defined by a progressive deterioration of cognitive function, such as memory, judgement and concentration as a result of an organic disease or disorder involving the person’s brain. However, it should be noted that many people who suffer with a progression of dementia, still have a perfectly good memory of experiences from their early childhood and young adulthood.

This is a story about a patient I recently looked after who has a very late stage  form of dementia, but still lives at home with his wife, is still capable of helping on the farm that he has owned and loved for more than 50 years, and although his cognitive function has deteriorated dramatically, his life long gregarious, steadfast and self resolve nature still holds true.

It goes without saying that the names, addresses and locations of this patient have been made up for the sake of patient confidentiality, but the actual dementia story itself is true…

Fred is a 92 year old man who has owned and lived on a farm in the outback of Australia with his wife Jeanette. Almost 15 years ago he was diagnosed with a progressively worsening disease called dementia. He has difficulty recalling where he is, what he should be doing at present, and the names of family and friends – although he still recalls his wife of 50+ years, and has a fond (if a little vague) recollection of his children and many grandchildren… he has little inclination of who most of the people around him are. But he has always been a gregarious sort of person, and happy enough to get along with a stranger as much as a dear friend, so he is well suited to this.

He’s been running the farm for more than 50 years, and although he can’t remember much about today, he recalls perfectly the work that he was performing 40 odd years ago as though it was yesterday; and that which he can’t seem to remember how to do, he is more than capable of using his dogged obstinance and steadfast determination to work it out.

Fred had his drivers licence revoked more than 15 years ago, before he was diagnosed with dementia, due to the fact that he was regularly having falls and although he hadn’t yet been diagnosed with dementia, he was unable to provide the reasurance to his wife (and the Roads and Traffic Authority) that he was safe to drive. Because of the dementia, he would regularly forget that he was not supposed to drive, and after a few ‘accidents’ – his wife took to hiding the car keys.

However, there were multiple half dilapidated cars around the paddocks – all of these had had their starter motors unplugged so that Fred couldn’t accidently drive off…

And here is where our story starts…

Jeanette has driven to town for a couple hours and left Fred at home by himself. Fred isn’t as mobile as he used to be, and is quite happy just to wonder around his paddock (which no longer has much livestock)…

When Jeanette got home, she found Fred was missing… she looked everywhere and eventually realised that the old Ford out the back was missing… she’s surprised because she recalls removing its starter motor herself. She contacted the police and because our Ambulance Station was closer to the area, they contacted us and asked if we could go help look for this gentleman.

We drove out… and along with the several volunteer emergency services, spent some time searching for Fred. After about two hours, we returned to the house to find fred returning with his truck and the trailer attached.

He came bouding up the driveway in his truck very distressed by all these emergency services around and said “Is my wife alright? Tell me – what is wrong with my wife!”

He had no  idea who we were or any of the other volunteers in the area were (all of whom had known him for years), but he recognised his wife and was relieved to hear that she was alright, and then made her promise him that she wouldn’t scare him like that again.

When asked where he had been, Fred responded that he had taken a bunch of stuff to the garbage tip that he had been meaning to do for years…

Although Fred had no recollection of fixing his truck… it was determined that in his old dogged and obstinate way, he had worked on the truck for a while trying to get it started… before eventually lifting the bonnet and noticing that the starter motor was unplugged.

To this day, Fred lives with his wife, Jeanette in a beautiful farm over-looking some mountains and a small valley…

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Am I Eligible For Compensation?

September 30th, 2010

Am I entitled to compensation because someone hasn’t done their job, or if I have been injured as a result of someone elses negligence or incompetence? Sometimes you’re sold something that doesn’t match the description, or doesn’t perform how it was supposed and by the time you eventually get what you were promised, it has taken you the better half of the year worth of phone calls, letters, visits to the ombudsmand, or your lawyer before you ever get what you paid for and were entitled to!

So, it hardly seems fair that after all the hours and trouble that you have gone through to actually obtain the original (correct) product, you find yourself asking, am I eligible for compensation? Is it really enough that I am finally now given the product I bought? Does this seem fair? Well, in some cases, unfortunately, you may not be eligible for compensation. A good company will often provide you with a “gesture of good will” – which will be a small financial benefit, such as providing the product cheaper, or for free, or in the case with phone bills, electric bills and numerous other bills which are regularly miscalculated and charged at a much higher rate, they may provide you three, six and even twelve months free phone connection as a measure of good will – which is basically them acknowleging that you are eligible for compensation or entitled to compensation, without having to formally admit it or acknowlege fault.

Depending on the company or the person who you are dealing with, this may be all that you can or will end up getting.

However, sometimes, its not even about the financial compensation. Sometimes its about making sure that a company provides the correct product or delivers the service that it is required to deliver. You have to remember, for small things, such as phone bills, one personal law suit may be insignificant, but if you feel that you have been badly treated or that your compensation is unjust, it is reasonable to believe that there are many others out there like you. What companies are most afraid of is a group of people (the consumers, such as yourself) who know that they have been wronged, and the more people who stand up to the company and file legal claims to compensations, the more likely that it will eventually become profitable for a large compensation law firm to band together and fund a class action law suit.

This really scares companies, because, apart from the massive legal costs (lawyers cost money) that this will impose on them (even if you aren’t successful) it will also be publically scrutinized and this will lead to negative company images and result in a decrease in their profits (something CEOs don’t like). Companies, especially big companies, spend a fortune on teams of lawyers to ensure that they are doing what they should be doing legally, so that they avoid massive court costs and legal fees.

So, how do you determine the answer to the question: am I eligible for compensation?

These are the steps that I would take:

1. Write down on a piece of paper exactly what I would like to be compensated with (be reasonable, but be fair).

2. Contact the company’s complaints department and discuss your grievance – if it is a small matter, many company’s employ complaints officers who have the authority to remove bills and offer small financial compensation for their mistakes.

3. State exactly what you would like to be done. Sometimes this is all that you need to do to resolve the problem (sometimes it isn’t).

4. Contact your local Department of Fair Trading or Ombudsman to determine what you are legally entitled to (these people work for the government to ensure that you, the consumer are treated fairly; however, they aren’t usually lawyers, and they aren’t there to ensure you get massive pay outs- even if you may be entitled to them).

5. Contact a lawyer – if you can’t afford a lawyer, try to find a no-win-no-fee lawyer who will work on a no win no fee basis (there are some contact advertisements for no-win-no-fee lawyers on this webpage). Discuss with the lawyer what your options are. A good lawyer will tell you what you’re entitled to or what type of compensation you may be eligible for and why. If they can’t tell you why you are eligible for a certain form of compensation, then they wont be able to tell the judge or jury why either (you may have to get a better lawyer then, or accept that you’re not entitled to compensation).

6. Have your lawyer send the company a letter of demand, clearly stating what has happened, what you have done about it, and clearly what you demand in terms of compensation. Often, if a company is in the wrong, and they will know it if they are, this is about as far as this whole process will go. The company will provide a settlement pay out figure (which will avoid going to court and save you and them large amounts of money – also, it provides them with the benefit of avoiding public scrutiny and bad publicity).

7. If the company still will not meet your demands, the final option is to go to court. Your lawyer will advise you of how to do this and how much it will cost you, regardless of whether or not you win your law case.

Remember, legal and financial compensation may take years to achieve, but if you are certain that you have been wronged, and a good lawyer can advise you whether or not you are eligible for compensation, then a good lawyer should be able to get it for you.

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Paramedic Chat

September 30th, 2010

The paramedic profession is still in its infancy, having only really been developed during the 1970s and is still very much a dynamic vocation, where entry requirements, training, skills and overall job descriptions are being changed regularly. It is often hard to follow where the goals posts are for the paramedic profession.

If you follow the links on the right, you can find paramedic articles, paramedic stories and a paramedic chat site where paramedics can discuss paramedic issues, complaints, interests, and just about anything else related to paramedics.

Cheers,

an Australian Paramedic

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Paramedic Guidelines Development

September 29th, 2010

Paramedic guidelines are developed generally through a group development process involving a paramedic guidelines or clinical practice guidelines committtee involving Senior Medical Officers (who are ultimately providing paramedics with the authority to admister drugs), actual Paramedics who provide input into the development and practicality of a new skill, protocol or pharmacology, Nurses, Research Officers (who can ensure that the Guidelines reflect current best practice) and Senior Management and Finance Officers (who can determine the financial feasibility of the paramedic guidelines being developed).

It is often missunderstood why paramedics are or aren’t allowed to perform a procedure or use a drug in one Ambulance Service and not the other – often it does not reflect the abilities and training of paramedics, but the cost of implementing such a drug or skill into the regular paramedic guidelines and practice.

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Paramedic Temperament

September 29th, 2010

Because of the highly stressful situations that most people find themselves in when they call an Ambulance Paramedic, it is important that paramedics have a calm and competent temperament, which is able to be conveyed to the patient, rellatives and bystanders. Even if a paramedic doesn’t normally have this rellaxed paramedic type of calm temperament, it is important to at least “look” and appear outwardly as being so.

These are some good personality traits of a paramedic with a good temperament:

1. Rellaxed

2. Competent

3. Easy to talk to

4. Genuine

5. Thoughtful

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Pregnant and Didn’t Know It

September 28th, 2010

I attended a 42 year old lady with severe abdominal pain a few years ago…

As part of my normal assessment of abdominal pain I palpated each quadrant of the abdomen. It was immediately clear to me that this lady didn’t have a gastric problem, but was pregnancy and her uterus was contracting regularly and forcefully – she was having a baby…

“Is there any chance you may be pregnant…” – I ask, tactfully… (if there is such a way to do this)

“No, I mean… I’m 42 there’s no way I could be pregnant… right?” – She responds…

“Hmm… if you look here… this is the top of your uterus… see how it is contracting with the pains that you’re having… I think you may be pregnant…” – I say, as sheepishly as a male paramedic telling a woman that he thinks she may be pregnant can be….

“No, that’s ridiculous… I mean, I’ve had 5 babies before… I think I’d know, don’t you?”

I went along with this… there was nothing more for me to do anyway… she still needed to go to hospital, and there, I’m sure a Doctor with more guts than me could explain to her that she was pregnant and having a baby…

We didn’t end up making it as far as the hospital, before mother nature decided to show herself…

“Something’s wrong… I can’t stop it… something’s coming out…”  – she says, almost in hysterics, as though an alien has decided to emerge…

Before she had time to pull her pants down the baby’s head had come out…

 

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What is a Phantom Pregnancy

September 28th, 2010

A Phantom pregnancy is a non-medical term of Pseudocyesis, which is a disorder that affects a very small number of women of child bearing age, and refers to a false sensation of being pregnant in a woman who is not. In mammals pseudocyesis is called pseudopregnancy; however, in humans, it is termed Pseudocyesis.

In clinical Pseudocyesis, the female reproductive system will mimic that of a normal pregnant woman, and many endocrine changes will occur.

It is still not determined what causes Pseudocyesis (or Phantom Pregnancy) but is has been associated with endocrine  disorder and psychological disorders; however it has not been identified which area triggers the other.

It is however, recognised as a definite disorder that does occur in a small number of woman.

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What is Pseudocyesis

September 28th, 2010

The term Pseudocyesis refers to a false sensation of being pregnant in a woman who is not. In mammals pseudocyesis is called pseudopregnancy; however, in humans, it is termed Pseudocyesis.

Pseudocyesis is often associated with clinical and sub-clinical signs and symptoms associated with a normal pregnancy.

Pseudopregnancy is common in mice and some other mammals and much less prevalent in humans.

It is still not determined whether or not Pseudocyesis is primarily caused by endocrine problems, or purely psychological in orgin.

It is however, recognised as a definite disorder that does occur in a small number of woman.

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Unknown Pregnancy Stories

September 28th, 2010

These a true stories about patients who I have treated who have been pregnant or delivered a baby while not previously realising that they were pregnant…

Unknown Pregnancy Story 1.

Dispatch: “Car 714… we have a 25 year old female with severe abdomen pain and suspected food poisoning… currently located in the public toilet at…”

Car 714: “Copy that, on case…”

We arrived and entered the public toilet, which was located in a public park. We instantly heard the sound of a baby crying… I paused and suddenly had a bad feeling that we had been given the wrong information about the job that we were attending.

I paused at the toilet door and asked if she was okay…

“I’m okay, but I’ve got the worst diarrhoea in my life… and… I’m bleeding…” She says… very distressed…

“Can I come in…” – I ask, hesitantly…

I’m greeted to come in…

As I open the door… I’m shocked to find the young lady still bearing down… and I could clearly hear the baby crying in the toilet…

“Can I get in there… and help your baby out…” – I ask in a calm voice that I really didn’t feel…

The patient appeared to go a further shade of white…

“What baby… I’m don’t have a baby!”

This, I wasn’t expecting…

“You’ve just had a baby…” – I inform her… almost in disbelief that she hasn’t realised that she’s just had a baby…

She then broke down crying… repeately saying… “How can this be… I wasn’t pregnant… no… I’ve just eaten something I shouldn’t have…”

As she calmed down and eventually started to get over the shock of it all (or at least start to accept that she had just had a baby) we cleaned her baby and found that everything was surprisingly well…

Then, as we took the woman and her baby to hospital… she started to explain to us that she had been on a serious diet, and her Dad had kept telling her to stop drinking beer because she was starting to get a real beer gut…

Both Mum and baby were okay in the end…

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Home Birth Stories

September 28th, 2010

Home birthing is becoming more commonplace in western society, either by accident, or through careful planning, paramedics are delivering more and more babies at home. These are some true home birthing stories from the babies that I have delivered out hospital, often in strange places (sometimes at various people’s home).

Home Birth Stories…

Dispatch… “ Car 383… we have a 32 year old female who states her waters have broken and she is about to have a baby”

Car 383… “Copy that… on case…” – we both knew that it was fairly unlikely that we would end up delivering this baby out of the hospital, but like all good paramedics… we’d really rather be sure that we didn’t get stuck with our baby catching mittens on… so we ran, lights and sirens to this job.

When we arrived we were met by the expected mother at the front door of the house, who invited us in and told us that she was ready to have her baby…

I looked at her… she was still fully dressed… and didn’t appear distressed at all… I started to think maybe braxton hicks contractions… but told her straight away, that so long as she was already up, we may as well get going, so that the doctor and midwife can look after her…

She smiles at me, and responds… no… I’m about to have the baby now… 

I smile and explain that we’ll get everything ready… if she wants to lay on the stretcher, we’ll start heading to the hospital…

She smiles back again… no,  I’ve had four babies before this one… they all come out within 5 minutes of my waters breaking…. she then walks inside and starts to take her pants off…. then she asks if I can support her while she is squatting…

Literally, as she takes her underwear off… the baby’s head starts to crown.

She then litterally pushes this baby out in one go….

After this… she passes the baby to me and tells me that she’s off to get cleaned up… while I tidy the baby up…

Baby was born perfectly normally, with an APGAR score of 10… the mum, unperturbed by the whole thing, and wonders off to tidy up…

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Inspirational Paramedic Quotes

September 28th, 2010

These are some inspirational paramedic quotes that I have heard during my time as a paramedic.

“My role as a paramedic isn’t always to save a life… sometimes it is to simply make their transition comfortable” … Australian Paramedic – Inspirational Paramedic Quote.

“Being a good paramedic means being able to do as much as you possibly can to save a life… and knowing how to accept it, when this is just not enough” – Paramedic – Ambulance Service of NSW – Inspirational Paramedic Quote

“Never complain that a patient wasn’t having an emergency (when they genuinely felt that they were) just because you knew how to deal with their medical problem… this may appear like a routine case for you, but to them, it may have been the greatest emergency they have ever faced in their lives” … Paramedic – Metropolitan Ambulance Service Victoria. Inspirational Paramedic Quote.

“If you think you can’t achieve something… you probably can’t… if you believe you can achieve something… you probably will…” – some bright paramedic somewhere… Inspirational Paramedic Quote

“I don’t need to save everyone’s life… just so long as I can save someone’s” – Paramedic of 36 years. Inspirational Paramedic Quote.

“This is a brilliant job… just don’t get involved in management or politics” – Just about any Paramedic…

 “You can only fix one thing at a time… so don’t try and solve everything at once”  – a good Paramedic

“Don’t just look at the patient’s machine observations… look at the patient… and then determine the treatment” – a Paramedic who has learned not to be machine orientated.

“Let perfusion determine treatment” – an Intensive Care Paramedic (QLD)

“Try to save the lives that can be saved… and accept those that can’t” – Paramedics

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Can I Wear Glasses as a Paramedic?

September 28th, 2010

If your eye sight is poor and you need to wear glasses to drive or read case sheets, check drugs, etc, then you may still work as a paramedic. Wearing glasses should not affect your ability to perform your duties as a paramedic. However, at some events (such as car accidents) where you are normally required to wear plastic protective goggles or glasses, you may have to wear specially fitted protective eyewear to cover your own glasses.

If an Ambulance Service attempts to refused your employment on the basis that you have to wear glasses, then they are likely breeching equal employment and opportunity laws.

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Postpartum Haemorrhage

September 27th, 2010

In postpartum haemorrhage, there are two main types of bleeding:

1. “Primary” bleeding occurs within the first 24 hours of delivery and usually occurs as a direct result of uterine atony (loss of tone in the uterine musculature) and this leads to an inability of the uterine muscles to contract and compress blood vessels.

2. “Secondary” bleeding occurs after 24 hours and is generally due to retained placenta or tissue from the placenta and the secondary infection that this causes.

Treatment of both types of postpartum haemorrhage includes:

1. Assessment of ABCs

2. Inspect the vagina and perineum – if the bleeding is clearly from the perineum and not from within the vagina, use a trauma pad and apply direct pressure to the perineum.

3. Massage the uterus to stimulate contraction (it should be noted that this is often quite painful and the patient may require pain relief). Uterine massage will usually have to be maintained until you arrive at hospital. To massage the uterus, basically press straight down where approximately at the point of the belly button. If you can feel something that is firm and tight (like a small fist in the abdomen) then the uterine wall is already contracting and this is not necessary; however, if it is soft, uterine massage may help.

4. Let the mother breast feed if she or the baby is up for it. This will not hurt the mother, and if anything, it will stimulate the release of more oxytocin this will lead to greater uterine contractions.

5. Treat hypovolaemia if required.

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Antepartum Haemorrhage

September 27th, 2010

Antepartum haemorrhage occurs between 20-40 weeks of gestation in the pregnant woman (if it is going to occur at all) and generally is first noticed in the form of PV bleeding. However, it should be noted that more bleeding may be occuring internally.

As a paramedic, you should:

1. Assess ABCDEs and vital signs comprehensively and particularly identify any signs of hypovolaemia. These patients will often complain of severed abdominal pain, pelvic pain and tense or tender uterus.

2. Treat hypovolaemia if required

3. Avoid palpating the uterus

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Eclampsia

September 27th, 2010

Eclampsia is the term used to describe a seizure that occurs in a woman who is greater than 20 weeks pregnant as a secondary result of increased proteinuria and hypertension (diastolic greater than 90 mmHg).

Common problems to be reviewed as a paramedic treating these patients include:

* Hypertension

* Altered Level of Consciousness

* Fitting

Midazolam should be considered if the patient is continually fitting.

Assess for other causes of altered LOC if the patient doesn’t regain consciousness.

Monitor BSL and Temperature, because both will be affected by the seizure activity.

Remember that your treatment here is potentially going to affect mother and un-born child as well.

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Pre-eclampsia

September 27th, 2010

Pre-eclampsia is defined as hypertension with a diastolic BP of greater than 90 mmHg and an increase in protinuria after 20 weeks of gestation in a pregnant woman, and can occasionally occur in the postpartum period. If this continues, this can cause the mother to have a seizure (when this occurs it is called eclampsia).

Paramedics should consider:

1. Treating hypertension

2. Fitting

3. Altered LOC

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Prolapsed Umbilical Cord

September 27th, 2010

A prolapsed umbilical cord is when the umbilical cord is compressed as a result of either the baby getting entangled with the umbilical cord as it comes out or comming out in an unusual position (breech birth). As the umbilical cord is compressed foatal hypoxia occurs.

1. Posture the mother in a lateral position with her buttocks elevated aboe the level of the uterus using firm pillows, blankets or anything else available.

2. Gently attempt to replace the cord into the lower part of the vagina

3. If unsuccessful after one attempt, do not continue to handle the cord due to risk of further agitation

4. Place a pillow between the knees of the mother to prevent further compression of the cord.

5. Provide 100% oxygen to the mother to increase the availability of oxygen to the foetus.

6. This is one of those times when you drive as fast as possible to the hospital!

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Supine Hypotensive Syndrome

September 27th, 2010

Supine hypotensive syndrome often occurs only in mothers who are greater than 20 weeks pregnant and results as the gravid uterus obstructs the inferior vena cava, which in turn, reduces venous return and blood preassure. In severe cases, this may lead to hypotension and syncope.

If the patient is rolled or positioned laterally, he or she should regain consciousness.

If the patient does not regain consciousness after positioning laterally, a paramedic must look to other potential causes, because supine hypotensive syndrome should be reversible rapidly after lateral positioning.

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Miscarriage

September 27th, 2010

Miscarriages usually occur spontaneously and result in the foetus being delivered before the 20th week as a result of, abdominal trauma, increased stresss, infection (including some severe UTIs), maternal stress or severe systemic medical complication, and in some circumstance, for no apparent reason whatsoever.

As a paramedic I treat the following complications as a result of a miscarriage:

1. Support to the patient.

2. Treat hypovolaemia if present

3. Pain management

4. Atropine if the patient has become bradycardic as a result of vagal stimulation during the miscarriage.

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What are Obsteteric Emergencies?

September 27th, 2010

Obsteteric emergencies are medical emergencies that occur to a mother or baby while the mother is pregnant or in the process of delivering a baby.

These are some specific obsteteric emergencies that most Ambulance Services train their paramedics to treat:

1. Pre-eclampsia or eclampsia (unnusually high BP as a result of pregnancy and can lead to eclampsia which is a pregnancy related seizure)

2. Miscarriage

3. Supine hypotensive syndrome

4. Antepartum haemorrhage

5. Postpartum haemorrhage

6. Prolapsed umbilical cord

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How to Deliver a Baby

September 27th, 2010

How do I deliver a baby? As a paramedic you may never deliver a baby or you may deliver a number of them, but you will most certainly look after many women who are pregnant. This is why it is important to understand basic obstetrics.

The first thing that you have to remember is that woman have been delivering babies for thousands of years (before doctors, midwives and hospitals were ever around) – and the baby will come out or it won’t come out, irrespective of anything that you as a paramedic can do while out of a hospital. So, relax… (Or at least look relaxed for the expectant mother’s sake).

Review the mother’s history:

Gravidity and Parity

Gravidity – number of times a woman has been pregnant.

Parity – number of times a woman has given birth to a viable foetus (normally greater than 24 weeks).

Expressed as G2, P1 – which means a woman has been pregnant twice but only carried one baby through to delivery.

1. Assess the mother’s ABCDE and make general observations of the mother’s vital signs (ensure you take a systolic and diastolic BP to rule out risks of pre-eclampsia or eclampsia).

2. Although oxygen does not need to be routinely administered to a mother. High levels of oxygen to the mother should be administered if the mother is having an obstetric emergency, such as:

* Miscarriage

* Antepartum haemorrhage

* Postpartum haemorrhage

* Prolapsed umbilical cord

*Pre-eclampsia or eclampsia

*Supine hypotensive syndrome

3. Monitor maternal contractions – time both the duration of the contraction and the length of time in between contractions

4. Position the mother laterally to avoid the possibility of supine hypotensive syndrome. But ensure that you are governed by the mother’s choice and comfort, what is comfortable for one mother may not be for another.

5. Consider pain management if required. Avoid all opioids such as morphine or fentanyl, due to the risk of that this will affect the baby’s respiratory effort post birth. Consider methoxyflurane or nitrous oxide, due to the fact that neither drug will cross over through the placental barrier and both wash out of the mother’s system rapidly.

6. Help make the mother comfortable as much as possible during the birth. Consider letting her place her feet on your hip and her husband/partners hips, allowing her to get leverage while she pushes (you would be surprised how much easier this is for her – although you may end up with bruises to your hip).

7. Let the baby come at its own rate – the only interventions that you may be required to do is to gently pull the baby’s shoulders down (one at a time) so that it can squeeze through the vaginal opening; however this shouldn’t be required during a normal birth.

8. If the baby has a lot of mucous membranes around its nose a mouth – you may suction this with a bulb suction device (see picture).

9. Clamp the cord at approximately 10 and 15 cms from the baby (I like to put a third clamp at 20 cms just to be safe) and then cut in-between. Don’t forget to ask Dad if he wants to cut the cord (this is disgusting, but some Dad’s seem keen).

10. Once the baby’s out, dry it thoroughly and wrap it up in a blanket. One of the greatest risks to a newborn baby is to become hypothermic and hypoglycaemic as it attempts to keep warm. So keep him or her well wrapped up, and close to mum.

11. Calmly take this mum and baby to hospital for further tests.

12. Don’t forget to take an APGAR Score.

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Emergency Birth

September 27th, 2010

Pre-hospital and emergency births are more common than most people think. Sometimes this is because the baby has come prematurely, there is a confusion as to the expected birthing date, or because the mother and father have elected to have a home birth and something has gone wrong. At any case, paramedics are often the first line of emergency care to provide aid in an emergency birth.

So how do paramedics deliver a baby out of hospital?

The firs thing you have to remmember is is that woman have been delivering babies for thousands of years (before doctors, midwives and hospitals were ever around) – and the baby will come out or it wont come out, irrespective of anything that you as a paramedic can do while out of a hospital. So, rellax… (or at least look rellaxed for the expectant mother’s sake).

1. Assess the mother’s ABCDE and make general observations of the mother’s vital signs (ensure you take a systolic and diastolic BP to rule out risks of pre-eclampsia or eclampsia)

2. Although oxygen does not need to be routinely administered to a mother. High levels of oxygen to the mother should be administered if the mother is having an obsteteric emergency, such as:

* Miscarriage

* Antepartum haemorrhage

* Postpartum haemorrhage

* Prolapsed umbilical cord

*Pre-eclampsia or eclampsia

*Supine hypotensive syndrome 

3. Monitor maternal contractions – time both the duration of the contraction and the length of time in between contractions

4. Position the mother laterally to avoid the possibility of supine hypotensive syndrome. But ensure that you are governed by the mother’s choice and comfort, what is comfortable for one mother may not be for another.

5. Consider pain management if required. Avoid all opioids such as morphine or fentanyl, due to the risk of that this will affect the baby’s respiratory effort post birth. Consider methoxyflurane or nitrous oxide, due to the fact that neither drug will cross over through the placental barrier and both wash out of the mother’s system rapidly.

6. Help make the mother comfortable as much as possible during the birth. Consider letting her place her feet on your hip and her husband/partners hips, allowing her to get leverage while she pushes (you would be surprised how much easier this is for her – although you may end up with bruises to your hip).

7. Let the baby come at its own rate – the only interventions that you may be required to do is to gently pull the baby’s shoulders down (one at a time) so that it can squeeze through the vaginal opening; however this shouldn’t be required during a normal birth.

8. If the baby has a lot of mucous membranes around its nose a mouth – you may suction this with a bulb suction device (see picture).

9. Clamp the cord at approximately 10 and 15 cms from the baby (I like to put a third clamp at 20 cms just to be safe) and then cut inbetween. Don’t forget to ask Dad if he wants to cut the cord (this is disgusting, but some Dad’s seem keen).

10. Once the baby’s out, dry it thoroughly and wrap it up in a blanket. One of the greatest risks to a newborn baby is to become hypothermic and hypoglycaemic as it attempts to keep warm. So keep him or her well wrapped up, and close to mum.

11. Calmly take this mum and baby to hospital for further tests.

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Home Birthing Pros and Cons

September 27th, 2010

Home birthing is becoming popular for the first time in many years in western society. As with everything else during the whole pregnancy experience, the mother and father must make personal choices as to whether or not home birthing is the choice for them. These are some of the pros and cons of home birthing to help you make your own personal choice:

Pros of Home Birthing

1. The ability to deliver your baby in the comfort of your own home

2. The ability to have your own choice of caregivers, from Doctors, Midwives, Caregivers, Lay-Midwives, Birth Facilitators, and Birthing Physiotherapists.

3. Home is safe, warm and rellaxing

4. You don’t have to listen to the poor lady in the room next to you who is having a difficult birth

5. Less preasure to “have the baby now”

6. Children can be present if desired (although this may turn them off )

7. No separation from mother an infant

8. Much quieter environment

9. Increased ability to have water births if desired

10. The “spiratuality” of the birthing experience may be emphasized

Cons of Home Birthing

1. If something goes wrong – you are not in a hospital and it may take time to get you there for definitive solutions

2. Although you will be having it in the comfort of your own home, the mess will be in your own house, sheets, bed, carpet…

3. Some insurance companies will not pay for home birthing costs

4. Not all obstetricians will support and be involved in home birthing

5. Filling for a birth certificate may be more complicated

6. Complications may occur if the caregiver is not experienced or trained in birthing complications and birthing emergencies.

At either case… I wish you luck, and fulfilment in this experience whether having a home birth or a hospital birth.

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Home Birthing

September 27th, 2010

Delivering a newborn baby at home is one of the most amazing (if a little disgusting) things that a paramedic can do in his or her career. Home birthing is still a very common occurance, whether by choice or accident. As a paramedic, I’ve delivered 11 babies in the past 5 or so years.

Fortunately, women have been having babies at home for many thousands of years and they really don’t require much help from us to make sure that the baby gets delivered.

Home birthing has become more popular lately for reasons of personal choice and comfort. If you are going to have a natural birth, and your obstetrician doesn’t forsee any complications, there are very little reasons why you can’t have a home birth, which will allow you to deliver your baby in the comfort of your own home. However, the downside to this is that you will be making a mess of your own sheets… and, if there are un-forseen complications with your delivery, you will not be in hospital with all the normal resources of a hospital.

As with everything else in birthing, it is a personal choice.

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What is an APGAR Score?

September 27th, 2010

An APGAR score is a basic observation of how well a baby is when it is born – long term, this means absolutely nothing to your baby, but is a useful tool to paramedics, midwifes and obstetricians to determine if they need to provide any interventions to help your new baby settle in to his or her new world.

The APGAR score is often taken at 1 minute and then again at 5 minutes.

The APGAR Score assess 5 observations of the baby with a score of 0-2 for each observation and a maximum of 10.

A- Appearance

Cyanosed/pale =0

Body Pink, Cyanosed Extremities =1

All Pink = 2

Pulse Rate

Absent = 0

<100 per minute = 1

>100 per minute =2

Grimace

None = 0

Grimace =1

Cough, Sneeze or Crying = 2 (babies are supposed to be upset when they’re born and crying is good)

Activity

None =0

Some Flexion =1

Active =2

Respiration

None =0 (don’t let this worry you too much at first, sometimes it takes a while for a newborn – just remember lots of tactile stimulation through drying the baby firmly with a towel)

Slow/ Irregular =1

Fast, Regular =2

And don’t forget, all babies look terrible when they’re born – they’ve just undergone significant trauma, but don’t worry, he or she will improve!

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What is in a Paramedic Maternity Kit

September 27th, 2010

For most paramedics… the paramedic maternity kit will only be seen when the sterile, sealed packet is exchanged for a new (in date) one. However, every now and again, some poor paramedic somewhere, has to open the maternity kit and help deliver a baby…

So, what’s in this magic paramedic maternity kit, that will actually let me deliver a baby?

First of all, remember, you’re not going to deliver the baby, the mother is, and all you have to do is rellax, look like you’ve done this before (although you probably haven’t), apply clamps to the umbilical cord and help clean/dry the baby afterwards. The baby will or wont deliver irrespective of all your best efforts. So rellax – you’re not the one delivering the baby.

This is what is in the average paramedic maternity kit:

1. X-ray gauze

2. Sterile scissors

3. Umbilical clamps (you really hope the maternity kit has these and that they haven’t fallen out)

4. Bulb aspirator (to mildly suction the baby’s nose and mouth if required – birthing can be such a dirty process)

5. 20 cm x-ray combines (to pad the new mother’s vagina if there is bleeding afterwards).

6. New born disposal nappy

7. Yellow gowns (this is for you to wear so you don’t get too dirty)

8. Some for of blanket for the baby (hope you can remember how to wrap a newborn baby)

9. Sanitary napkins

10. Plastic bag (for all that rubbish)

11. Newborn singlet (don’t worry about this too much, the baby will normally be wrapped up around mum anyway)

12. Self sealing plastic bag  (for that disgusting placenta)

13. An APGAR Score Card – (after all those exams in which you have had to memorize the APGAR score, they generally provide you with a nice, easy to read, APGAR Score Card in the Maternity Kit anyway!)

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What to do After a Head Injury

September 27th, 2010

So, you’ve had a head injury and the paramedic or doctor has told you that you should be alright and you can go home… now what? Well, generally, if you’re at this stage, you should be fine, however, these are some key points to remember for the next 24-48 hours just to be on the safe side:

1.Rest and avoid strenuous activities for at least 24 hours

2. Use paracetamo or paracetamol/codeine for headache and avoid aspirin or other non steroidal anti inflammatory drugs (NSAIDs) which may increase the risk of a cerebral bleed.

3. Avoid sport for at least 24 hours

4. Don’t drive for at least 24 hours – its bad enough that you may have a head injury, no reason to accidently cause another person to have one too (if you lose consciousness at the wheel)

5. Don’t drink alcohol – I know it’s just what you want to do to take the pain away, but its not good for you when you have a head injury, and if you do deteriorate, no one will notice whether this is because of the alcohol or the head injury.

6. Don’t take sleeping tablets! Like alcohol, these will distract or hide any signs that your head injury is deteriorating.

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Head Injury Warning Signs

September 27th, 2010

These are some common head injury warning signs that may indicate greater problems neurologically.

1. Acting strangely

2. Saying things that you wouldn’t normally say

3. Fainting

4 Increased drowsiness or an inability to keep your eyes open

5. Vomiting on more than one occasion after a head injury

6. Amnesia (difficulty remembering events)

7. Feeling clumsy or having difficulty moving any body part

8. Blurred vission

9. Slurred speech

10. Bleeding or fluid leakage from the ear or nose (this may be CSF – cerebral spinal fluid)

11. Unable to recognise friends or family

12. A constant headache

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AEIOU TIPS

September 27th, 2010

This is a common medical mnemonic designed to (remind you or jog your memory) of potential reasons why your patient may be unconscious. There are multiple different versions out there and there are obviously many other causes of a decreased level of consciousness too. According to one clinical training officer I worked with, “There are over 176 known causes of a syncopal event, and unless you’ve ruled each and everyone of them out, you have no reason to suspect that the patient has just had a benign syncope.”

A – Alcohol

E – Epilepsy with seizure activity

I – Infection

O – Overdose

U- Uremia (excess uremia in the blood as a result of kidney failure or inadequacy)

T – Trauma

I – Insulin (high or low BSL)

P – Poisoining

S – Stroke

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How to Assess a Head Injury

September 27th, 2010

Head injuries are common accidents for paramedics to attend and they are also some of the most potentially significant injuries. The only determinant of how significant a head injury has been is time. All head injury patients need to be monitored! It is so easy to leave a patient with a mild head injury at home – in some instance this may be fine, but you must ensure that they have someone around them for the next 4 hours who will be able to watch them and make sure that their neurological condition does not deteriorate!

Head injuries may be caused by an isolated injury or as part of a systemic mechanism of trauma. You can have a primary injury (the person is hit with a baseball bat in the head and receives an immediate injury to the brain) or a secondary injury (person’s heart stops for a short period, and consequently, there is no blood reaching the brain, and the patient’s brain develops a hypoxic brain injury).

How do Paramedics Assess a Head Injury?

1. Thoroughly examine the patient’s ABCDEs – ensure that these people have a clear airway, adequate ventilation (rate and depth) and good circulation. A failing in any one of these will result in secondary damage to the brain due to hypoxia. Thoroughly assess their disability (neurological status) – GCS and AVPU, Pupil sizes and reactivity, and Motor/sensory response by 4 limbs. Assess environmental causes and expose the patient (to look for rashes or other significant causes of a decreased LOC).

2. Consider spinal injuries (remember, if they have had enough trauma to render them unconscious, it is conceivable that they may have damaged their cervical spine). Consider spinal immobilisation with a C-collar, sandbags, and straps.

3. Assess other causes of decreased LOC such as the pneumonic AEIOUTIPS – Alcohol, Epilepsy, Infection, Overdose, Uraemia (problems with the kidneys resulting in too much uraemia in the blood), Trauma, Insulin (high or low BSL), Poisoning and Stroke.

4. Provide oxygen, cannulate, and urgently transport these patients to a hospital with definitive treatment! There is no point taking someone with a bad enclosed head injury (with obvious signs of an increased ICP) to a hospital without neuro-surgical capabilities.

5. Reassess everything!

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How To Measure a GCS

September 27th, 2010

The Glascow Coma Scale (GCS) is a tool used to assess a patient’s neurological deficit, often used to assess the severity of a potential brain injury in patients who have sustainted some form of head injury. Paramedics often use a GCS to identify how conscious a patient is and the severity of a head injury. However, the GCS tool was initially designed from a hospital Neurologist’s point of view, and specifically targets areas relating to patient recovery post head injury or brain surgery. For paramedics, this tool doesn’t generally signify much more than a basic AVPU score (where a paramedic assess a patient as being A- alert, V – responding to voice, P – responding to pain, and U – for a completely unconscious person. However, most Ambulance Services still use teh GCS in their paramedic patient assessment so you’d better know what it is…

The Glascow Coma Scale assess three areas of patient’s nervous system response in an attempt to clearly document changes to their neurological state. These three areas include: Eye Opening, Verbal Response, and Motor Response. Each category has a certain maximum and minimum score, which are added together to produce a cumulative score ranging from a minimum of GCS of 3 and a maximum GCS of 15.

Eye Opening

4. Spontaneous

3. To Voice

2. To Pain

1. Nil

 Verbal Response

5. Orientated

4. Confused

3. Inappropriate Words 

2. Incomprehensible Sounds

1.Nil

Motor Response

6. Obeys Commands

5. Localises to Pain

4. Withdraws from Pain

3. Flexion to Pain

2. Extension to Pain

1. Nil

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Can I Be A Paramedic If I’m Color Blind?

September 27th, 2010

If you are color blind you should still be able to work as a paramedic. However, some Ambulance Services require that you meet a certain criteria if you are color blind. As a general rule, if you are legally allowed to drive a motor vehicle in the state that you want to work, you should be allowed to drive an Ambulance as a paramedic.

However, some Ambulance Services still maintain a complete block for persons who are color blind (on the erroneous belief that they will misinterpret traffic lights, even though, this is not the case for most persons who are color blind, and not at all the case for any person who is color blind, but meets the standards to drive a motor vehical under state laws.

If you fall under this category, and the Ambulance Service that you wish to work for refuses to accept your application on the basis that you are color blind, I would recommend that you argue the point that this is descrimination under the Equal Employment Opportunity Act (in Australia) and that, unless they can prove how this disability directly affects your ability to do the job, they are legally bound to offer you the same chance of employment as anyone else.

If you still have no luck here (and can’t afford a lawyer) and you still want to be a paramedic, I’d recommend looking into another Ambulance Service, because most of them now accept paramedics who are color blind.

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Parmedic Personality

September 27th, 2010

Although little evidence has clearly demonstrated that paramedics must have a particular personality trait or be a particular personality type in order to be successful as a paramedic, it has often been hypothosized that paramedics are generally a certain “type” of personality.

It has been believed by so many that this golden “type” of personality that all paramedic must inherently have, that many Ambulance Service around the world select trainee paramedic candidates on the basis of a 4-6 hour personality test/psychometric evaluation. If you are about to apply for an Student Ambulance Paramedic position and you are about to undergo psychometric evaluations/personality tests, you may wish to review my Passing Paramedic Personality Tests page.

So what are the “ideal” paramedic traits?

1. Honesty

2.Integrity

3.Desire to help people

4. Confidence

5. Strength in oneself (whatever that means)

6. Altruism (the desire to do good)

7. Determination

8. Mechanically minded/ trade orientated

9. Able to follow authority

10. Willingness to change

What are the actual paramedic traits that most paramedics who appear to last in the job have?

1. Risk taking personalities (most Ambos will either ride motor bikes, climb mountains, or do some other form of high risk taking activity on their days off)

2. Enjoy excitement and easily bored (I know, it seems to go against most of our work-load that is very mundane and routine, but most paramedics have a tendency to search fo excitement, and find that they get bored easily if they do too many similar things in a day).

3. A genuine desire (or at least willingness) to help others and do what is best for their patients  

4. Ability to fake confidence (you don’t have to be confident, so long as you can appear confident, that will do fine)

5. Discipline and ability to get up at all hours and do the job (irrespective of how much you want to roll over and go back to bed in Winter).

6. Ability to follow a set path or “way of doing things” – if you genuinely want to change things, you understand that you need to change things for the future (and are willing to wait, instead of going against protocols or procedures on the spot) – this will see you in coroners court rather quickly.

7. Ability to reasess a situation and think laterally about how problem solve (at a very basic level, we, as paramedics are problem solvers for those who just don’t know where else to go – generally this is medical based problems, but can often include a range of non-medical problems.

8. An ability to do things, even if they disgust you or you find them difficult. You will find that many paramedics (especially paramedics who have been around for a long time) will be digusted by the sight or smell of blood, but are willing to focus and do their job when the need is there. Paramedics don’t have to like what they’re doing, just as long as they are capable of still doing it. I personally hate blood, but am able to overcome this disgust, by focussing on my job and looking after a patient when I attend a bad trauma.

9. Be capable of learning things by rote (the process of doing a skill numerous times until it becomes second nature, even if you don’t understand why you are doing it). As a paramedic, it is good to know why you are doing skills a certain way, however, it is important to know how to do the skill (by rote) so that, when you attend a bad scene (which, inevitably, you will) you are capable of still rendering the medical asssistance required.

10. Take pride in what you do – most paramedics will (deep down) admit that part of the reason they do what they do, is because of the pride that they get from doing the unique job that they do and… occasionally, saving lives…

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Paramedical

September 27th, 2010

Paramedics are emergency medical clinicians with strong medical training in pre-hospital care, specialising in the emergency management of the patient’s ABC (airway, breathing and circulation); but not limited to this emergency treatment. Paramedics are not doctors, however they do have very strong knowledge base and skills in topics such as:

Airway management – they can Intubate and inser LMAs

Ventilation – they can provide mechanical ventilation through Bag Valve Mask ventilation, Oxylogs, expiratory assistance (for patients with severe asthma) and in some Ambulance Services CPAP or BiPap for Acute Pulmonary Oedema.

Circulation – they can cannulate and provide fluid resuscitation for patients who are dehydrated or have lost fluids through burns or injuries, provide a multitude of inotropic drugs or cardiac drugs which improve circulations, such as adrenaline, amiodarone, and atropine for patients in bradycardia. They can also defibrillate patients who are in VF or VT.

Disability – paramedics have a wide range of skills and knowledge in the assessment of a patient’s neurological state, stroke assessment and spinal injuries.

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How to Avoid Getting an Ambulance Bill

September 24th, 2010

If you have received an Ambulance Bill and you really don’t want to pay for it… these may be some of your options:

1. Find that you are entitled to free Ambulance Cover through one of the many options, such as: being a Pensioner, having a state organised Ambulance Levy (such as electric bills levy), Ambulance Insurance or Private Health Insurance which covers Ambulance, currently be on a Welfare Program, Unemployed, or Returned Serviceman/woman (Veteran’s Affairs)

You don’t fit into any of these categories… hmm, lets see…

2. You can make someone else pay for the Ambulance Bill. This would include Workers Compensation cases, where you were injured at work, Motor Vehical Accidents, where the motor vehical insurance should cover your Ambulance Bill, or the old fashioned method… you can attempt to point the finger of blame at someone else or an organisation which was negligent and attempt to Sue for compensation and Ambulance Bill payment.

3. At the time of requiring an Ambulance, you may give the paramedic your wrong address and contact details. However, I wouldn’t recommend this method (not just because it is illegal) because it will often result in an inability to locate relevant previous medical records that may be used to treat you (and even save your life)…

At all circumstance, we recommend that if you need an Ambulance in an emergency, call an Ambulance… the Ambulance Bill should be a secondary thought, and any financial problems can be solved afterwards.

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Bariatric Transport

September 22nd, 2010

The transport of bariatric (obese) patients in Ambulance Practice has become more frequent and poses numerous risks and complications (for the patients and the paramedics).

Most Ambulance Services globally have introduce the use of bariatric or megalift trucks (Ambulances) which are designed to transport bariatric patients.  These bariatric trucks often have hydrolic lifters that are designed to lift patients onto the back of the truck. They also specially designed beds and wheelchairs for patients who do not fit into the normal Ambulances.

However, bariatric transport poses many more risks than simply driving these patients to hospital. Bariatric transport has the additional complications of extrication from their house, car, or whichever location they may require the aid of an Ambulance.

These complications include:

Getting bariatric patients through walls or doors, which they are no longer capable of fitting through. Assisting these people down stairs through the use of mechanical or robotic travellers. Often, these patients require Fire Brigade assistance to extricate from their homes.

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Fat Patient Stories

September 22nd, 2010

This page is dedicated to the innovative skills and resolve of the paramedics, firemen (and women) and other emergency service personnel who have been involved in the often difficult extrication and transport of the obese patients of this world. This page is not designed to ridicule obese patients, but instead as a tribute to the hard effort and difficulties that these patients place on emergency service personnel.

If you are obese and take offence to this page, please, I encourage you to make changes (as hard as they may be) to improve your own health. Obesity is a major problem globally and massively increases your risk of just about every single cancer or disease known on Earth. If you read the following stories, you will note that not one of these obese patients were above the age of 32 – this is because obese people do die much earlier. However difficult it may be to change your lifestyle, not changing it will be worse.

Fat Patient Story One

I attended a 32 year old female who was alledgedly fitting for the first time at home. When we arrived, we treated her as a Status Epilepticus (continuous fitting) with midazolam (a muscle rellaxant). We were told that she had come home from a 4 week stent in ICU after having gastric banding inserted (stomach clamps that litterally involve wire banding that stops your stomach from physically being capable of opening too much). She was an obese lady (approximately 400kg) – she had come home, and even though she had been advised not to eat too much, she had a family member pick her up 22 Quarter Pounders (and no, I don’t hold McDonald’s responsible for this – I like Maccas just as much as the next person – but even I know not to eat 22 Quarter Pounders).

Long story short, she was febrile and it became clear that she was majorly septic. We tried to rush her to hospital, but there were delays in extricating her due to her size. Eventually, she died before we got her to hospital. After the autopsy, we were advised that her gastric banding had litterally caused her stomach to rupture, which caused her to become septic, and die of multi-organ failure in a very short space of time.

Fat Patient Story Two

I attended an 18 year old male who was complaining of chest pain. When we arrived, his mother came out and told us to hurry, because her son had just collapsed. When we found him, he was uncouscious and had no pulse. We attached the monitor and found him in VF (all those squiggly lines) and after three attempts at shocking him, he remained in a refractory assystole (that long flat line that basically says you’re dead).

As I tried to ascertain more history about the patient, before I was happy to call (cease CPR) the patient, I asked his dad if the patient ever took drugs, or had been unwell lately. I was then advised by the Dad that his son was really healthy and had never needed to see a Dr before. If it was not for the severity of the situation and the sadness of losing an 18 year old to a heart attack, I would have found it hard to keep a straight face at the concept that this person thought his 350 kg son, was a healthy person!

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Fat Patients

September 22nd, 2010

The state of the average person’s inactive and sedentary lifestyle, combined with the sheer volume of foods (generally fast foods) available to the general public today has resulted in what has recently been defined as an obesity pandemic. Almost as though it were a dangerous virus spreading throughout society, and not a wave of laziness or gluttony.

This has provided paramedics with patients from a multitude of health problems as a secondary result of obesity, including:

Diabetes Type II

Heart Disease (including cardiomyopathy, which is an enlarged heart)

Back Injuries (for the patient and the paramedic)

Pressure Sores (due to immobility problems)

And many more emergency health problems.

This has also introduced new complications to the role of paramedic, which often involves innovative solutions for transporting and extricating obese people from their dwellings.

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What are the course requirements for First Aid

September 20th, 2010

First Aid is designed to be taught to anyone with the willingness to render First Aid to someone who is in need. To successfully complete a Senior First Aid course you do not need to be academically minded, or exceptionally bright, you just need to have a willingness to learn.

Most Government Acredited First Aid courses in Australia require about 7 hours of face to face teaching over one to two days and both a practical exam (involving CPR and some splinting) and a little written exam. However, it should be noted that First Aid is designed to be taught to everyone and that you will never find a First Aid Instructor who goes out of their way to fail you.

We want all people to be capable of providing first aid!

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Where Can I Do A First Aid Course?

September 20th, 2010

First Aid courses in Australia are provided by a number of private, government, and volunteer organisations.

If you follow any of the advertised First Aid Course links on this webpage, you will find a list of local First Aid course instructors near you, as well as information on pricing and requirements.

Alternatively, you can look up First Aid Courses in your local paper, phone book, or internet directory.

If you have a volunteer Ambulance Service, such as St John’s Ambulance in Australia, you may wish to contact them, because they regularly provide First Aid training and First Aid courses.

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What is taught in a first aid course?

September 20th, 2010

First Aid courses in Australia cover the following topics in First Aid:

Structured Responses in First Aid (DRABC)

First Aid Treatment of Fractures, Sprains, and Soft Tissue Injuries

First Aid for Spider Bites and Stings

First Aid for Snake Bites and Stings

First Aid for Help

Calling an Ambulance

CPR for First Aiders

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First Aid Courses

September 20th, 2010

“To be able to render First Aid and comfort to one who is sick or injured provides a wellness of being unlike any other pleasure” … St John First Aid Volunteer.

First Aid courses are generally pre-requisites for many vocations which have a higher than average risk associated with its, such as mine work, most trades, and all jobs in health. For those who are not required by their work to have a current First Aid Certificaate, they will still find the benefit of have knowledge about first aid when they or someone they love are injured or unwell.

First Aid Courses cover areas of First Aid on topics such as structured approaches to emergencies (DRABC), Basic Fracture and Soft Tissue Injuries, CPR, Burns, Stings and Bites, Eye Injuries, and many other aspects of First Aid.

In Australia, many organisations teach both Junior First Aid (for those children under 12 who want to learn to provide a basic level of First Aid ) – which is very useful for kids who live on a farm or may require the need for basic First Aid, and also, Senior First Aid (for those over 12 who wish to be capable of providing as much First Aid as possible if required).

If you are thinking about doing a First Aid course, as a paramedic, I highly recommend it. Just remember, the next life you save may just well be your own or a loved one. In Australia, statistically, the most likely person you will ever provide CPR to, will be an immediate family member!

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What is ARDS?

September 20th, 2010

Adult Respiratory Distress Syndrome (ARDS) is a secondary response to a severe lung injury. ARDS occurs when the inflammatory cytokines damage the epethelium and the endothelium of the lung tissue. Some of the common causes of ARDS include:

Septic Shock

Aspiration of Gastric Juices

Severe Trauma to the Lungs/Pulmonary Contusions

Pregnancy

Multiple Blood Transfusions

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What is Bronchitis?

September 20th, 2010

Bronchitis can be both a chronic condition involving the inflammation of the large bronchiole airways in the lung, and also acute inflammation of the large bronchiole airways.

What is Chronic Bronchitis?

Chronic bronchitis is the result of long term damage and inflammation to the large airways. This results in an increased sputum production and chronic lower airway infections.

What is Acute Bronchitis?

Acute bronchitis is a sudden onset inflammation of the large airways, often secondary to an infection, bacteria, virus, fungi, parasite, or pollutant. Treatment includes supportive measures, such as rest, oxygen therapy and bronchodilators, such as salbutamol.

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What is Pneumonia?

September 20th, 2010

Pneumonia

Pneumonia is an inflammatory condition of the lung as a secondary response to infection, bacteria, fungi, parasites, or antigens/pollutants. This often results in a filling of exudate (inflammatory fluid) in the alveoli, which then results in increased sputum production.

 

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What is Emphysema?

September 20th, 2010

Emphysema

Emphysema is a chronic disorder as a result of damage and inflammation of the alvioli (air sacs,which are used in the defusion of oxygen and CO2 from the pulmonary arteries and the lungs). This disorder is often secondary to longterm smoking. The damage and destruction of the alvioli results in a decrease of surface area available for oxygen and CO2 diffusion. These patients often rely on a hypoxic drive to breath.

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What is Croup?

September 20th, 2010

Croup is a severe upper respiratory infection (often viral) which although it can affect adults, only causes clinically dangerous manifestations in infants and young children (who already have a very narrow upper respiratory tract). The inflammation to the upper respiratory tract causes swelling to the larynx, trachea and large bronchi. This swelling results in a “barking cough” or “seal like cough” and a stridor (inspiratory airway obstruction). The clinical risk and potential affect on the infant or child is often worsened by severe crying (due to the increased work load on the body and decrease in oxygenation). It should also be noted, that in patients with croup, a suddent lack of stridor occurs as the patient decompensates and the condition worsens.

When Does Croup Occur?

Croup is most commonly seen in winter months when the air is often cooler and drier. Croup is a common airway disease that paramedics attend to. If treated early, croup is not serious; however, if left untreated croup can be potentially fatal in a small child. If in doubt, call an Ambulance immediately!

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Lung Cancer

September 20th, 2010

Lung Cancer

In these cases, lung tissue cells have over proliferated, resulting in lung tumors and lung tissue damage. Lung tissue cells are some of the fastest growing/replicating cells in the entire body. Consequently, lung cancer often results in very short life expectancies. Treatment is often based on chemotherapy, radiotherapy and supportive measures such as home oxygen, bronchodilators, and pain relief.

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Acute Pulmonary Oedema

September 20th, 2010

Acute Pulmonary Oedema

Acute Pulmonary Oedema is the result of an increased fluid build up in the alvioli space, which then increases the space in which 02 and CO2 diffusion must occur. Common causes of APO include increase infection, left sided cardiac failure (resulting in a backlog of fluid in the pulmonary artery), fluid overload, saltwater drownings, and ARDS (adult respiratory distress syndrom).

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COPD

September 20th, 2010

Chronic Obstructive Pulmonary Diseas and Chronic Airway Limitations are both synonymous categories of airway disorders that encompass chronic airway disease, such as emphysema and chronic bronchitis, with the long term complications related to a narrowing of the bronchial airways. Both terms are interchangeable. These are chronic diseases, and generally un-reversible. The diseases are generally sub-acute but may have periods of exacerbation as a result of pollutants in the air or respiratory infections. Treatment for these patients often target holitic solutions aimed at preventing a worsening of the disease, through regular vacinations, imunisations, cessation of smoking, or removal of irritants and pulmonary adjunctive treatment options such as salbutamol and oxygen during periods of exacerbation. Some patients with COPD may develop what is known as a hypoxic drive, in which they become used to living with a very low level of blood oxygen saturations, and (unlike a normal healthy person), require a change in the CO2 levels (a much later change than oxygen saturations) to cause the body to recognise the need to increase its respiratory rate or depth. Consequently, some of these patients, if given high concentration of oxygen, may find that they litterally forget to breath as a result of the low CO2 levels in the blood. This, however, should not prevent a paramedic from administering high levels of oxygen in a patient with severe exacerbation of COPD and shortness of breath.

 

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What is the pathophysiology of asthma?

September 20th, 2010

Asthma is a very common respiratory disorder that paramedics attend and are particularly capable of making difference to the health outcomes of a person suffering a medical emergency. In young male patients severe asthma is one of the most common medical causes of sudden death and it is for this reason that paramedics must be diligent when attending asthmatic patients.

What is the pathophysiology of asthma?

Asthma is a disease that leads to a  chronic disorder involving inflammation of the bronchial airways as an allergic reaction to a pollutant or irritant, which may be both internal (stress) or external (pollutant). During the normal progression of asthma, the inflammatory response causes a narrowing of the bronchial airways which allow a decreased amount of airflow. During the expiratory phase the exhaled air naturally causes the bronchial airways to close, and can be heard in the form of a wheeze. In severe cases, a wheeze may be heard on the inspiratory phase as well as the expiratory phase. This results in an increased difficulty getting rid of the pollutants (often which caused the problem in the first place) and therefore great inflammation. This leads to increased mucous production and increased formation of a mucosal plug.

In an attempt to resolve all of this, the body may develop a broncho-spasm, which further narrows the airways and results in an audible wheeze. This results in a difficulty in getting rid of the air that a patient has inhaled. If the patient is young and otherwise healthy, he or she should still be able to compensate well up until this point. However, as the course of asthma progresses the patient will no longer be able to compensate. As the muscles of respiration become fatigued (such as the diagaphram and accessory muscles: sternocloidomastoid, pectoralis major, intercostal muscles) the body will start to decompensate and will eventually result in the patient suffering a respiratory arrest. This is a life-threatening emergency and should be treated as such because of the risk of sudden decompensation leading to respiratory arrest and death.

Treatment includes preventative medicine such as avoiding irritants and pollutants in the first place which stimulate the inflammatory response, bronchodilators (such as salbutamol), anticholinergic bronchodilators (such as atrovent) cortico steroids (such as hydrocortisone), and a very good asthma care plan.

As a paramedic, reassurance is paramount for these patients because they will literally feel as though they are suffocating. A calm, competent response by paramedics is the best reassurance available.

In severe cases of asthma (asthmatic in extremis) I/M or IV adrenaline is the front-line treatment. This is because nebulised salbutamol will not be able to reach the bronchioles where they can cause bronchodilation and effect a change. Consequently Adrenaline should be used as your first line of treatment in severe asthma. Don’t forget to get help running on the way (you will most likely need help extricating these patients as they will not be able to help themselves). Don’t wait on scene for the patient to get better, get going to hospital.

Return to paramedic notes page.

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Emergency Respiratory Disorders

September 20th, 2010

These are a basic overview of emergency respiratory disorders that paramedics regularly attend:

Asthma

This disease is a chronic disorder involving inflammation of the bronchial airways as a result of a pollutant or irritant. During the normal progression of asthma, the inflammatory response causes a narrowing of the bronchial airways which allow a decreased amount of airflow. During the expiratory phase the exhaled air naturally causes the bronchial airways to close, and can be heard in the form of a wheeze. In severe cases, a wheeze may be heard on the inspiratory phase as well as the expiratory phase. This results in an increased difficulty getting rid of the pollutants (often which caused the problem in the first place) and therefore great inflammation. This leads to increased mucous production and increased formation of a mucosal plug. In an attempt to resolve all of this, the body may develop a broncho-spasm, which further narrows the airways and results in an audible wheeze. This results in a difficulty in getting rid of the air that a patient has inhaled. If the patient is young and otherwise healthy, he or she should still be able to compensate well up until this point. However, as the course of asthma progresses the patient will no longer be able to compensate. As the muscles of respiration become fatigued (such as the diagaphram and accessory muscles: sternocloidomastoid, pectoralis major, intercostal muscles) the body will start to decompensate and will eventually result in the patient suffering a respiratory arrest. This is a life-threatening emergency and should be treated as such because of the risk of sudden decompensation leading to respiratory arrest and death.

COPD or CAL

Chronic Obstructive Pulmonary Diseas and Chronic Airway Limitations are both synonymous categories of airway disorders that encompass chronic airway disease, such as emphysema and chronic bronchitis, with the long term complications related to a narrowing of the bronchial airways. Both terms are interchangeable. These are chronic diseases, and generally un-reversible. The diseases are generally sub-acute but may have periods of exacerbation as a result of pollutants in the air or respiratory infections. Treatment for these patients often target holitic solutions aimed at preventing a worsening of the disease, through regular vacinations, imunisations, cessation of smoking, or removal of irritants and pulmonary adjunctive treatment options such as salbutamol and oxygen during periods of exacerbation. Some patients with COPD may develop what is known as a hypoxic drive, in which they become used to living with a very low level of blood oxygen saturations, and (unlike a normal healthy person), require a change in the CO2 levels (a much later change than oxygen saturations) to cause the body to recognise the need to increase its respiratory rate or depth. Consequently, some of these patients, if given high concentration of oxygen, may find that they litterally forget to breath as a result of the low CO2 levels in the blood. This, however, should not prevent a paramedic from administering high levels of oxygen in a patient with severe exacerbation of COPD and shortness of breath.

Acute Pulmonary Oedema

Acute Pulmonary Oedema is the result of an increased fluid build up in the alvioli space, which then increases the space in which 02 and CO2 diffusion must occur. Common causes of APO include increase infection, left sided cardiac failure (resulting in a backlog of fluid in the pulmonary artery), fluid overload, saltwater drownings, and ARDS (adult respiratory distress syndrom).

Lung Cancer

In these cases, lung tissue cells have over proliferated, resulting in lung tumors and lung tissue damage. Lung tissue cells are some of the fastest growing/replicating cells in the entire body. Consequently, lung cancer often results in very short life expectancies. Treatment is often based on chemotherapy, radiotherapy and supportive measures such as home oxygen, bronchodilators, and pain relief.

Croup

Croup is a severe upper respiratory infection (often viral) which although it can affect adults, only causes clinically dangerous manifestations in infants and young children (who already have a very narrow upper respiratory tract). The inflammation to the upper respiratory tract causes swelling to the larynx, trachea and large bronchi. This swelling results in a “barking cough” or “seal like cough” and a stridor (inspiratory airway obstruction). The clinical risk and potential affect on the infant or child is often worsened by severe crying (due to the increased work load on the body and decrease in oxygenation). It should also be noted, that in patients with croup, a suddent lack of stridor occurs as the patient decompensates and the condition worsens.

Emphysema

Emphysema is a chronic disorder as a result of damage and inflammation of the alvioli (air sacs,which are used in the defusion of oxygen and CO2 from the pulmonary arteries and the lungs). This disorder is often secondary to longterm smoking. The damage and destruction of the alvioli results in a decrease of surface area available for oxygen and CO2 diffusion. These patients often rely on a hypoxic drive to breath.

Pneumonia

Pneumonia is an inflammatory condition of the lung as a secondary response to infection, bacteria, fungi, parasites, or antigens/pollutants. This often results in a filling of exudate (inflammatory fluid) in the alveoli, which then results in increased sputum production.

 

Chronic Bronchitis

Chronic bronchitis is the result of long term damage and inflammation to the large airways. This results in an increased sputum production and chronic lower airway infections.

Acute Bronchitis

Acute bronchitis is a sudden onset inflammation of the large airways, often secondary to an infection, bacteria, virus, fungi, parasite, or pollutant. Treatment includes supportive measures, such as rest, oxygen therapy and bronchodilators, such as salbutamol.

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Speed Versus Efficiency

September 16th, 2010

The importance of speed only when it can be done efficently is important to a paramedic in an emergency.

This is a story that my very first training officer told me about the importance of being efficient, not trying to speed in an emergency.

When he was very young he went to a Karate class and one day his Sensei told him and all the other kids to take off their shoes and then race to tie the shoe laces up again, as a way of testing everyone’s speed. All the kids raced and some made some reasonable times too. Afterwards, he asked them to all take their shoes off again and untie the laces. The Sensei then said, “actually, don’t worry about that, put your shoes back on and we’ll go for a run instead.” Now, none of the kids rushed, but just tied their shoes like they normally would. Because they weren’t rushing, they were very efficient in the way they tied their shoes, and didn’t get their hands caught on things while tying them. As a result, afterward, the Sensei (who had been secretly timing them on both occasions) pointed out that every child had been considerably faster in tying their shoe laces, when they weren’t trying to race, than when they went as fast as they possibly could.

The moral of this story is that you only have two hands and one mind. You can only do one thing at a time efficently (you can try to do lots of things, but it probably wont get you anywhere faster). As a paramedic this is a good lesson, because it identifies the fact that when you attend a major medical emergency (and your first instict is to do 20 things at once), you must take one thing at a time and slowly get through it all.

After telling me that story, my training officer said to me everytime we attended a major incident and he could tell that I started to race too much, he would say “Shoelaces” and this would remind me of the story and force me to slow down and do each thing correctly.

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Emergency Plastic Surgery

September 16th, 2010

Emergency plastic surgery isn’t about getting bigger boobs, or removing fat. Emergency plastic surgery is common after trauma and burns, which require delicate plastic surgery to repair. Plastic surgeons are also capable of repairing severed fingers, through the use of delicate microsurgery and plastics.

I recently treated a young 14 year old girl who had had her face badly bitten by a dog. Through the expertise of an emergency plastic surgeon, and 8 hours of emergency plastic surgery involving 248 micro-stitches, this young girl made a virtually full recovery, and her scars are almost un-noticeable by people who didn’t know that she had had such an injury.

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Plastic Surgery Emergency

September 16th, 2010

Plastic surgery is becoming an increasingly popular option for people who are particularly pre-occupied with their personal image and outward asthetics and beauty. However, plastic surgery can sometime result in medical emergency and medical complications.

Some of the plastic surgery emergencies that I have seen during my experience as a paramedic include the following;

1. In older types of breast enlargement procedures plastic surgeons used to use a silicone based gel to develop the shap of the larger or more shapely breasts. The risk of emergencies as a result of this was the possible potential of the silicon gel to leak, causing potentially lethal imune responses, allergies, sepsis and in some cases anaphylaxis. This are life threatening emergencies.

2. In Europe, an oil based breast enlargement gel had been developed (although this procedure has not been approved in the US currently. The risk of this procedure is that if the oil ever leaks and is absorbed into the circulatory system, it has the potential to cause a fat/oil based embolism (which if can lead to sudden death if the embolism occurs in the pulmonary arteries).

3. All plastic surgery, like any other surgery has the potential to introduce infection into the body. With patients who are having cosmetic plastic surgery for cosmetic augmentation after a mastectomy, they are generally doing so after chemotherapy, which destroys their white blood cells (the ones that fight infection and support your immune system) – consequently, these people are the most at risk for infection and sepsis.

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Hatzolah Melbourne

September 16th, 2010

Hatzolah Melbourne provides a high level of emergency pre-hospital care to the Jewish community in Melbourne. The privately owned Ambulance Service is fully funded through private donations and the volunteer commitment of many people, who have given up their time to become trained and capable of responding to medical emergencies 24 hours a day 365 days a year.

Many of the volunteers are Medical Practitioners, GPs, and have been trained by the Metropolitan Ambulance Service. Hatzolah volunteer first aiders/paramedics carry oxygen, automatic defibrillators, and first aid equipment.

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Private Paramedic

September 16th, 2010

Only public Ambulance Services in Australia are capable of being the primary response emergency paramedic response. However, some private Ambulance Services exist and require paramedics in a private organisation for the purpose of Ambulance transport of non critical patients.

Other private paramedic positions include being a private paramedic at ski resorts, special events (such as motor races, bikes, sports events) mines, oil rigs, cruise ship. 

Also, in Melbourne their is a privately owned and run Ambulance Services called Chevra Hatzolah, which provides emergency paramedical response and treatment for the Jewish Community. The Metropolitan Ambulance Service of Victoria provide primary emergency response (in conjunction with Chevra Hatzolah) to people of the Jewish Community in Melbourne. If you would like to know more about Chevra Hatzolah melbourne, please see the Hatzolah Melbourne page.

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Private Ambulance

September 16th, 2010

Private Ambulances are used in some areas around Ausralia and and globally.

In Australia no private Ambulance is capable of responding to a medical emergency as a primary response unit. However, private Ambulances and Ambulance Services do exist in the role of secondary transport. In Melbourne, there are multiple private Ambulance services which are capable of providing transport for injured or sick patients who have been assessed by paramedic in the Metropolitan Ambulance Service of Victoria as low priority and (although they require treatment in a hospital) they do not need any paramedic assessment or interventions enroute to hospital.

Othe private Ambulances in Australia include hospital to hospital transport services, which may be funded by the specifica hospital (both public and private).

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How to Assess ABCDE

September 16th, 2010

This page discusses assessment strategies for the basic ABCs:

Airway

Check consciousness

Assess ability to take a deep breath

Assess ability to speak in a full sentence – can the patient speak a full sentences, juse phrases, single words, or not at all

Assess if the airway is clear

Breathing

Look, listen and feel for the movement of air

Assess the adequacy of the breathing process – is their sufficient rate and volume of air being moved?

Assess work of breathing (patient effort versus efficacy)

Listen to the chest (through Auscultation) and identify any variances of normal breathing. Normal breathing should sound like soft air movements; absent breath sounds is very bad; wheezes suggests bronchospasm; crackles and rales indicates pulomonary oedema or infection.

Expose chest (while maintaining patient’s dignity) and assess for accessesory muscle involvement, such as sternocloidomastoid arching, pectoral muscles,external and internal intercostal muscles, which are all signs of increased respiratory distress

Circulation

Examine for life- threatening haemorrhage

Assess perfusion (level of consciousness, skin colour, pulse rate and blood preasure

Assess the pule mannually – is it regular or irregular, what is the rate (15 seconds x 4), skin colour, temperature, central and peripheral cap refil.

Disability (Neurology)

Measure level of consciousness (AVPU – Patient is Alert, responding to verbal stimuli, responds to pain, unconscious; GCS: Glascow Coma Score)

Check pupil size and functioning response (make sure you document pupil size)

Assess motor and sensory responses to all four limbs.

Assess ability to walk

Assess ability to smile

Exposure and Environment

Expose the patient (while maintaining their dignity) so that you can see any injuries, watch breathing, etc.

Look for a rash, wounds, contusions

Check temperature

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Assessing ABC

September 16th, 2010

This page discusses assessment strategies for the basic ABCs:

This is the most basic and also most important part of our job as paramedics. So long as you maintain a patient’s Airway, Breathing and Circulation until they get to hospital you have done your job as a paramedic well.

ABC

Airway

Check consciousness

Assess ability to take a deep breath

Assess ability to speak in a full sentence – can the patient speak a full sentences, juse phrases, single words, or not at all

Assess if the airway is clear

Breathing

Look, listen and feel for the movement of air

Assess the adequacy of the breathing process – is their sufficient rate and volume of air being moved?

Assess work of breathing (patient effort versus efficacy)

Listen to the chest (through Auscultation) and identify any variances of normal breathing. Normal breathing should sound like soft air movements; absent breath sounds is very bad; wheezes suggests bronchospasm; crackles and rales indicates pulomonary oedema or infection.

Circulation

Examine for life- threatening haemorrhage

Assess perfusion (level of consciousness, skin colour, pulse rate and blood preasure

Assess the pulse mannually – is it regular or irregular, what is the rate (15 seconds x 4), skin colour, temperature, central and peripheral cap refil.

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Advice For Paramedic Ride Alongs

September 15th, 2010

If you’re a paramedic student, a nurse or a medical officer and you have organised to come and do a paramedic ride along or ambulance ride along, these are some good words of wisdom or advice:

1. Show up early – no paramedic is going to want to show you stuff if you can’t be bothered turning up on time.

2. Dress presentable and ready to do the job (even if it is just an observational shift) – most Ambulance Services will advise you what to wear and what to bring

3. Make sure you have completed all the legal and medical documents that most Ambulance Services make you complete.

4. Remember, what happens on the truck stays on the truck! Basically, you are about to start walking into total strangers homes, when they are most vulnerable and provide (or observe paramdics providing) medical help in an emergency, so remember to respect your patients privacy, confidentiality and wishes. You will notice that when paramedics chat about their jobs and debrief (even when they’re making fun of certain patients) – that they never mention names, addresses or any identifiable measures.

5. Be interested in what is going on – if you’re not interested, what are you doing this for? Most paramedics are more than happy to impart what knowledge they have on anyone who keen and eager to learn… likewise however, most paramedics will gladly not show you anything if you don’t appear interested.

6. Enjoy yourself, this is an amazing experience.

7. If you’re a paramedic student -remember to keep your ears open and your mouth shut! You’ll learn alot more that way. This doesn’t mean to proclude you from discussing cases and things with the paramedic who’s looking after you, but just that you can learn alot from these people.

8. If you’re a medical student – try not to make us feel like we don’t know what we’re doing, and try to avoid telling us that your starting salary will be higher than our 8th year there after wage….

9. If you’re currently a nurse, I hope this provides an interesting insight into “why we didn’t get around to intubating, cannulating, inserting a naso gastric tube, and several other things for our patient before we arrive in hospitals”

10. If you’re currently a medical officer, I this provides an interesting insight into the unique challenges that paramedics face when the provide medical care in an out of hospital setting (which is nothing like a hospital. When we tube a patient, chances are they’re not fasted and they aren’t on a bed at chest hight).

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How Can I do A Paramedic Ride Along?

September 15th, 2010

Paramedic ride alongs are basically a chance for paramedic, medical and nursing students to ride along in an Ambulance and observe how paramedics treat and manage patients in their unique prehospital care environment, which is very different from providing the same medical care in a hospital.

Depending on what your current background is (are you a student, or do you work in the industry) as well as the location in which you would like to have an Ambulance Ride Along will determine whether or not you are able to participate in a ride along.

Because there are issues regarding patient confidentiality, observer safety and legitimacy of a “random” person being allowed into complete strangers homes during medical emergencies, some Ambulance Services will not allow you to participate in an Ambulance Ride Along.

If you would like to see what paramedics do, I would suggest contacting your local Ambulance Service and asking them what the process is. Most Ambulance Services will make you complete a criminal record check, and also identify a reason why you should be allowed to do a ride along. This will normally have to be something, such as being a current student in some health science degree or working in the industry. Most Ambulance Services wont just let you go on an Ambulance Ride Along just because you are curious what paramedics do, or you have seen a really cool TV show and would like to watch it for real.

Having said all this, some Ambulance Services (especially if they have a volunteer component) will gladly accept people with no medical or student background into their Service to participate in a ride along.

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Paramedic Ride Along

September 15th, 2010

Paramedic ride alongs are observational shifts that people in health or similar professions may choose to partake in so that they can get a better understanding about what paramedics do on the job. If you’re studying paramedics at university or medicine you will likely have an Ambulance Ride Along component where you can observed paramedics working during a short period.

The benefit of these ride along programs for paramedic students is that you can actually experience what we do as paramedics.

For Medical Students or Nursing Students an Ambulance ride along will provide a unique insight into what we do as paramedics, and the difficult challenges that we face providing emergency medical care in the pre-hospital environment.

If you get an opportunity to do an Ambulance Ride Along I recommend you take it as a great opportunity.

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Where does glycogenolysis Occur

September 15th, 2010

Glycogenolysis is the process that occurs in the body and converts glycogen polymers into glucose monomers.

Glycogenolysis physically occurs in the muscle and liver tissues, which is where glycogen is stored and released as a result of hormonal or adrenergic responses in order to increase the blood glucose level during times of stress such as the fight of flight sympathetic response.

In the normal healthy functioning individual, glycogen will automatically be released by the muscle and liver tissues as a response to low blood glucose levels. However, in insulin dependant diabetic patients, they often lose this ability to regulate blood glucose levels. Also, in patients who are alcoholics, or have become malnourished through poor diet, glycogen stores may be depleted and glycogenolysis may not be capable.

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Everything Paramedic

September 15th, 2010

 

Please review the following links to find out just about everything and anything you’ve ever wanted to know about paramedics, paramedic education, risk management, and new technologies in health:

 
  •  Umbilical Cord Donation
  •  Umbilical Cord Bank
  •  Stem Cell Basics
  •  How Strong To Be A Paramedic
  •  How fit do I need to be to become a paramedic
  •  Why do paramedics wear blue gloves?
  •  What Do Paramedics Wear?
  •  Why do Ambulance Paramedics Speed
  •  Stem Cell Technologies
  •  Stem Cell Treatment
  •  Cord Blood Medical Treatments
  •  How much does it cost to store cord blood?
  •  Umbilical Cord Blood Preservation
  •  Where Can I Donate Umbilical Cord Blood?
  •  Should I Save Umbilical Cord Blood For My Baby?
  •  Are there risks donating umbilical cord blood
  •  Placental Stem Cells
  •  Stem Cell Research Saves 13 Young Diabetics From Daily Insulin
  •  Stem Cell Research Experiments
  •  Stem Cell Research Pro and Cons
  •  What to do in a Car Accident
  •  Emergency Anecdote
  •  Paramedic Quotes
  •  Flight Paramedic Saudi Arabia
  •  Paramedic Jobs Middle East
  •  Paramedic Jobs Saudi Arabia
  •  Jobs in Health Dubai
  •  Paramedic Jobs Dubai
  •  Do I Have to Pay An Ambulance Bill?
  •  Health Care Jobs Dubai
  •  Accident At Work
  •  New York Construction Accident Lawyer
  •  Construction Accident Attorney
  •  How to Sue
  •  Paramedic Games
  •  Clot Dissolution
  •  Coagulation Control
  •  Clotting Cascade
  •  Coagulation
  •  Emergency Nursing Oil Rigs
  •  Lawyer Jokes
  •  Am I Entitled To Compensation?
  •  Can I Get Compensation For My Injury
  •  Do I need compensation?
  •  Ambulance Chaser
  •  How to Pick a No Win No Fee Lawyer
  •  How to Find a No Win No Fee Lawyer
  •  Compensation Lawyers
  •  No Win No Fee Lawyers
  •  No Win No Fee
  •  Mines Rescue
  •  Passing Paramedic Personality Tests
  •  Paramedic Personality Traits
  •  Titanic Disaster
  •  Family Assessment in Mental Health Emergencies
  •  Suicide Assessment
  •  Mental Status Assessment
  •  Therapeutic De-esculation
  •  Suicide Intervention
  •  Managing Aggression
  •  Temperament Profiles
  •  Limitations of Clinical Practice Guidelines
  •  Benefits of Clinical Practice Guidelines
  •  Clinical Practice Guidelines
  •  Strengths of Evidence-based Practice
  •  Critics View of EBP
  •  The Need for Evidence-based Practice
  •  Steps in Evidence-based Practice
  •  Principles of Evidence Based Practice
  •  Evidence-based Practice Defined
  •  Role of an Interim Commander
  •  Characteristics of a Bureaucracy
  •  Health Services Need Managers
  •  Economic Resources in Health
  •  Health Services Are Service Providers
  •  Strategic Change Management
  •  Overcoming Resistance to Change
  •  Paramedic Resistence to Change
  •  Resistence to Change in an Organization
  •  Nursing Change
  •  Change Management
  •  Change Management
  •  Power Bases
  •  Organisational Politics
  •  Power and Authority
  •  Conflict Resolution
  •  Effective Communication Skills
  •  Group Decision Making
  •  Ethical Decision Making
  •  Rational Decision Making
  •  Employee Perception
  •  Organisational Behaviour
  •  Paramedic Ethics
  •  Platelet Plug Formation
  •  Vascular Spasm
  •  Limitations of diagnostic measures by paramedics
  •  Haemostasis Mechanisms
  •  Haemostasis
  •  Worst Mine Accidents
  •  Mine Collapse
  •  Coal Mining Collapses
  •  Coal Mining Accidents
  •  Construction Accidents
  •  Why are paramedics so well trusted?
  •  Treating Cardiac Arrest
  •  History of Paramedics
  •  Paramedic Triage
  •  Triage Nurse
  •  Telephone Triage Nurse
  •  Triage Tags
  •  What to Ask a Triage Nurse
  •  Hospital Triage
  •  Most Trusted Profession
  •  Paramedic Intuition
  •  Intuition Evidence Based Practice
  •  Prehospital Triage
  •  Mine Injuries
  •  Common Injuries Mining
  •  Mining Australia
  •  Mining Employment
  •  Stem Cells
  •  Medical Careers
  •  Medical Chemistry
  •  Basic Medical Chemistry
  •  Stop Hand Tremors
  •  Hand Tremors
  •  paranormal activity true story
  •  You Know You Work for an A&E When
  •  Hospital Jokes
  •  Funny Medical Jokes
  •  Universal Laws
  •  Can Paramedics Intubate
  •  Paramedic Laughs
  •  Age Limit for Paramedics
  •  How old to become a paramedic in Australia
  •  How old to become a paramedic?
  •  A History of CPR
  •  Mechanical CPR
  •  Ambulance Hits Pedestrian
  •  Gulgong Hospital Closes
  •  Nose to Toes
  •  Emergency Response
  •  Scene Safety
  •  Scene Assessment
  •  Emergency Services
  •  How much does a paramedic make?
  •  How much does a mine medic make?
  •  Paramedic Exams
  •  Carbon Monoxide Poisoning Symptoms
  •  Carbon Monoxide Poisoning
  •  Organophosphate Poisoning
  •  Competitive Antagonists
  •  Antagonists
  •  Digoxin Toxicity
  •  Therapeutic Index
  •  Morphine Lyrics
  •  Morphine Sulfate
  •  Stroke Symptoms
  •  Emergency Stroke
  •  Eye Healing
  •  Eye Injuries
  •  Eye Injury Treatment
  •  3rd Degee Burns
  •  Burns treatment
  •  Burns effect
  •  Bad Doctor Jokes
  •  Short funny jokes
  •  Diabetic Emergencies
  •  Examples of osmosis
  •  Osmosis Cells
  •  Osmosis Diffusion
  •  Abdomen Pain
  •  Homeostasis

       *  Correlation Between ECG and the Heart

       * Types of Hypoxia

  •  Paramedic Science Laws
  •  Extended Care Paramedic
  •  EMT Jokes
  •  Code of Ethics for Patients
  •  Practical Jokes Gone Wrong
  •  Practical Jokes
  •  World Trade Centre and Port Arthur
  •  Ghost Stories
  •  Out of Body
  •  Near Death Experiences
  •  Near Death
  •  Afterlife
  •  Medical Songs (definitive list)
  •  Medical Music
  •  Ambulance Songs
  •  Medical Songs
  •  Evidence Based Practice in Paramedics
  •  Ambulance Billing
  •  Ambulance Analgesia
  •  Subarachnoid Haemorrhage
  •  Anaphylaxis
  •  Chainsaw Sharpening
  •  Chainsaw Accident
  •  How To Assess Perfusion
  •  Primary and Secondary Survey
  •  Paramedic Murphy’s Law
  •  Emergency Medical Services
  •  Paramedic Training
  •  EMT Jobs
  •  Paramedic Jobs
  •  Best medical TV shows of all time
  •  Funny Ambulance Jokes
  •  Funny Paramedic Jokes
  •  Things you don’t want to hear from a Paramedic…
  •  Things you don’t want to hear while having surgery…
  •  Paramedic Unions/Professional Associations
  •  When you know you’re a Paramedic
  •  Medical Jokes
  •  Emergency Nursing Jokes
  •  Paramedic Jokes…
  •  What is a Paramedic?
  •  Do I want to be a Paramedic?
  •  If I do a Paramedic Degree am I gauranteed a job?
  •  How do I become a Paramedic?
  •  How to Provide Basic First Aid – A Paramedic’s View
  •  What drugs can Paramedics give?
  •  I Hate Blood… and I’m a Paramedic
  •  What is it like to be a Paramedic?
  •  What is an EMT?
  •  What is the difference between PTOs and Paramedics
  •  What is the Difference Between Paramedic and ICP?
  •  What is the Difference Between Paramedic and EMT
  •  You Know You’re a Paramedic When (Definitive List)
  •  The Need for Paramedic ECG Interpretation Debate
  •  Stories From a Rookie Paramedic
  •  Paramedic… I See Dead People
  •  Paramedic… I See Stupid People
  •  Paramedic Medical “Attacks”
  •  Tricks of the Trade by Older Paramedics
  •  Most Annoying Questions to Ask a Paramedic
  •  Lies Told by Patients to Paramedics
  •  Lies Told by Paramedics to Patients
  •  Hypothetical Paramedic Case Studies
  •  Humorous Ambulance Paramedic Stories
  •  How to Work for Bureaucracy
  •  How to Safely Leave Your Patient at Home
  •  How to Drive an Ambulance as a Paramedic
  •  How to Cannulate in the Back of an Ambulance
  •  How to be a Good Paramedic
  •  How to Avoid Meeting the Coroner as a Paramedic
  •  How to Assess Pain as a Paramedic
  •  Funny EMT Stories
  •  How to Interpret an ECG as a Paramedic
  •  How to Auscultate Lung Sounds
  • Ambulance Paramedic Bureaucracy Stories

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Umbilical Cord Donation

September 15th, 2010

You can choose to donate your baby’s umbilical cord and placental blood to many organisations for the benefit of many people. Umbilical cord blood can be donated to medical research, which is concentrating on manipulating the amazing cellular blocks called stem cells (found in placental and umbilical cord blood) and are capable of dividing into any other cell imaginable. These stem cells may also be donated to public donation registries in most countries, in which they are stored and then donated for the use of patients who require treatment using the blood.

Why should I donate?

By donating to medical research, research into stem cells may provide the answer and solution to many medical illnesses and diseases.

Also, by donating to an individual or a public donor registry, you may be litterally giving someone (if not multiple people) the gift of life.

Please, don’t throw away your umbilical cord and placental blood, donate them today.

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Umbilical Cord Bank

September 15th, 2010

During a natural vaginal delivery birth, the umbilical cord and palcenta are usually delivered up to 30 minutes after the vaginal delivery of the newborn baby. In the majority of cases, this placenta and umbilical cord is inspected by the midwife or obstetrician to determine if any part has been torn are remains within the uterine wall or if there is anything unusual about this particular organ, which may provide evidence of potential disease or illness for the newborn. After this, the placenta and cord are both usually discarded.

Since the late 70s it was discovered that placental blood and umbilcal cord blood has the same haematopoeitic stem cells which are only found in bone marrow and are also capable of producing three different types of blood cells:

White blood cells

Red blood cells

Platelets

Throughout the past 30-40 years research has been conducted on umbilcal cord blood and stem cells control, and it has been discovered that these stem cells hold the key to solving many medical illnesses and diseases.

Because of this, many people are electing to either donate their baby’s umbilical cord blood and placental blood for research or for public donors. Others are storing their baby’s umblical cord blood in special private umbilical cord blood banks, with the view that it will provide a certain level of health insurance against certain cancers and medical diseases known to be cured with the stem cells found in umbilical cord blood.

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Stem Cell Basics

September 15th, 2010

Stem cells are basically the blank building blocks that the body will one day use to develop every part of the body as the body grows. Where a normal cell is only able to divide into more cells that are identical, stem cells are capable of dividing into another stem cell, or any other type of cell within the body.

In normal situations, stem cells are used to serve two purposes.

1. They are used in an unborn and young child to create new cells which will eventually make up the new organs within the body.

2. In the older child or adult, some stem cells are still found in certain parts of the body, and these stem cells are used to regrow or repair damaged tissues or organs.

Because of the 2nd normal use of stem cells, scientists hope to be able to develop a means of controlling this process and utilise it to regrow heart muscle and other tissues which are currently un-repairable once damaged.

This provides numerous health benefits for people in the future.

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How Strong To Be A Paramedic

September 15th, 2010

How strong do you need to be to become a paramedic?

Generally speaking, if you are a normal paramedic and work out of an Ambulance, you should primarily be thinking and using your mind, not your arms (and back). However, there will be times when you just can’t get a patient out of a tight position without using some sort of manual handling technique. It is for these times that it is important to maintain you core strength, so that you don’t injur your back.

Paramedics have a very high incidence of lower back injuries as a result of either poor lifting techniques, or more commonly, patients falling and pulling on paramedics as they fall. At the end of the day, if you don’t think you can lift a patient safely, you shuld be calling for more assistance such as more paramedics or fire officers.

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How fit do I need to be to become a paramedic

September 15th, 2010

Working as a paramedic requires that you use your mind to solve problems much more than using your physical strength. However, this said and told, paramedics still are required to be reasonably fit and active. This is because paramedics must still lift patients, assist to stand patients, use a stretcher, an occasionally do CPR for up to 30 minutes (our regular work out)…

Interestingly enough, although almost every Ambulance Service in Australia requires that you pass a fitness and medical test to join an Ambulance Service, I am not aware of an Ambulance Service that makes you have an annual fitness test.

Regardless of this, if you want to stay as an ambo/paramedic, you will want to stay fit and healthy so that you don’t injure your back.

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Why do paramedics wear blue gloves?

September 14th, 2010

Paramedics wear gloves to protect themselves from diseases, viruses, and bacteria  (as well as dirty bodily fluids, such as urine, fecal matter, vomit and many more). Paramedics also wear gloves so that the patient, who may be immunocompromised (their imune system has been lowered due to cancer treatment or disease) are not made sick or unwell because of the paramedic’s diseases or viruses. This is particularly important when a paramedic cannulates, gives injections, or treats open wounds in which there is a risk of transfering bacteria and viruses through the opening in the skin.

The reason paramedics wear blud gloves, instead of white gloves, is blue gloves are generally made out of Nitrile (which has a very very low allergenic property), where as white gloves are made out of latex, which many people are commonly allergic to. Because paramedics do not know if the person that they are attending are going to be allergic to latex or not, they treat everyone while wearing nitrile gloves.

This is the same for police officers who may wear blue nitrile gloves if they are helping people.

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What Do Paramedics Wear?

September 14th, 2010

Paramedics in each state of Australia wear a Uniform, but each state has its own very specific uniform.

Paramedics uniforms have to make the paramedic look professional, but also serve a purpose under the occupational health and safety act to be:

Clearly visible 

Fire retardent.

Protective (such as thick boots)

Identify you as a paramedic so that peope can clearly identify you as a paramedic at a scene

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Why do Ambulance Paramedics Speed

September 14th, 2010

Paramedics try to speed so that they can get to the site of an accident or medical emergency faster. However, with the exception of travelling on a long and straight highway at a much faster speed, paramedics who really race under lights and sirens generally don’t acheive much by doing so.

In tests done in Melbourne, it was found that most paramedics who really “raced” to the scene of an accident only arrived 60-90 seconds early (on average), but the paramedics often arrive stressed and not very well composed and collected.

The other obvious downside to speeding on the way to an emergency, is that you are placing yourself and everyone else on the road at a much greater risk of having an accident and the subsequent injuries.

By all means, don’t dawdle on the way to a job, but be composed and remember that if your heart starts to race (generally because of the sort of job that your going to – such as a paediatric cardiac arrest) this is a sign that you have to concentrate and make sure that you don’t let the adrenaline of the case cause you to take un-reasonable risks on the road, by driving like a maniac. No matter how sick or your your patient is.

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Stem Cell Technologies

September 14th, 2010

What are the current technologies available through the use of stem cells and technologies for stem cells research and development?

More to follow shortly…

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Stem Cell Treatment

September 14th, 2010

Stem cells are basically blank building blocks, which are capable of developing into just about any cell in the body. Unlike a normal cell, which can only reproduce itself, a stem cell is capable of reproducing muscle of the heart, lung, brain, and every other tissue and organ in the body. Stem cell research is leading to the development of many new medical treatments.

For many years bone marrow, and more recently, umbilical cord blood stem cells, have been used to treat cancer patients with conditions such as leukemia and lymphoma. This is because, during chemotherapy (which is where the chemically kill all fast growing cells, such as cancer) most normal growing cells are killed by the cytotoxic agents. This is why people undergoing chemotherapy often lose their hair. Because cytotoxic chemicals are unable to discriminate between the leukemia or neoplastic cells, and the hematopoietic stem cells within the bone marrow, a patient will require a bone marrow transplant to re-start the growing of red blood cells. This side effect of conventional chemotherapy strategies are now being overcome by stem cell transplants, which are able to regrow the bone marrow.

In the future, scientists and medical researchers alike, believe that stem cell treatment will be able to treat many medical disorders and certain diseases. These will hopefully include medical treatments for: brain damage,  heart disease, lung disease, a variety of cancers caused by disfunctioning cells, all types of diabetes, parkinson’s disease, multiple sclerosis, and a variety of other potentially devastating medical diseases and disorders.

What Are Stem Cells?

Stem cells are basically the simplest fundamental building blocks used in the human body to allow further development. Stem cells are basic cells, which hold the amazing potential to divide and develop into any other cell used in the human body. As a stem cell divides (like all living cells like to do) it has the capacity to divide into two stem cells indefinitely (provided the body remains alive) or divide into another type of cell, such as a skeletal cell, muscle cell, nerve cell or any other body tissue cell.

Stem cells act as an internal repair cells, providing the ability to replace destroyed or damaged cells naturally. More information about stem cells can be found on the US National Institute of Health here.

Stem Cell Therapy

What is involved in stem cell therapy? Stem cell therapy looks at medically introducing stem cells to damaged or broken cells, which have caused disease and or medical disorders.

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Cord Blood Medical Treatments

September 14th, 2010

Many people don’t realise just how much cord blood has improved current medical treatments for many diseases and disorders, as well as the benefits to future medical research.

Historically, cord blood stem cells have been proven effective in the treatment of many diseases, disorders and some cancers. Currently, cord blood stem cells have been used to treat nearly 100 serious diseases. In transplant medicine, a patient generally will undergo chemotherapy and then receive an infusion of cord blood stem cells to create a healthy blood and immune system. This is also a significant advantage to patients who are being treated for many cancers.

Cord blood stem cells are showing significant potential to treat conditions that have no cure today – like juvenile diabetes and brain injury. This new field, called regenerative medicine is researching using your baby’s stem cells to help repair or replace cells that have been damaged by disease or injury.

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How much does it cost to store cord blood?

September 14th, 2010

If you wish to store cord blood in a public umbilical cord blood bank, then it is free. However, this does not provide your baby with exclusive use of the cord blood if he or she ever needs it to fight of some disease or disorder.

Storing cord blood privately will cost between $40-50 per month in most states of the US and about $60 month in Australia. However, as this become more commonplace, umbilical cord blood storage will become cheaper.

Not sure how much benefit cord blood can provide? Check my Cord Blood Medical Treatments page.

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Umbilical Cord Blood Preservation

September 14th, 2010

How long can umbilical cord blood be preserved for?

Umbilical cord blood can (theoretically) be stored indefinitely if it is correctly stored in liquid nitrogen at negative 196Degree C. At this temperature, if left undisturbed, will alow most organic cells survive unchanged indefinitely. Although more research into umbilical cord blood preservation along with time will only be the true evidence of how long umbilical cord blood can be preserved for.

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Where Can I Donate Umbilical Cord Blood?

September 14th, 2010

Most public hospitals in Australia collect umbilical cord blood if requested.

This does not cost you, the mother or father anything.

It is recommended that you contact your local umbilical cord blood bank around your 34-5 week mark and make sure that your hospital accepts umbilical cord blood donations. If they don’t normally, there are still ways in which it can be organised without you travelling anywhere else or visiting another doctor or hospital.

What if I decide on the day that I really do want to donate my baby’s umbilical cord blood?

If the hospital that you are having your baby is a public hospital and normally collects umbilical cord blood then this shouldn’t be a problem. However, if you are having your baby in a private hospital and they don’t normally take umbilical cord blood, then this may not be possible.

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Should I Save Umbilical Cord Blood For My Baby?

September 14th, 2010

Deciding whether or not you should store your baby’s umbilical cord blood for public or private use is obviously a personal question.

The reality is, if you save it for your baby, it is very unlikely that you he or she will ever have a need for it. However, this doesn’t mean its not a nice form of insurance against leukaemia and other disorders which it can cure. But, if you donate it for public use, you may be saving many many lives as a result.

In Australia, we have multiple Umbilical Cord Blood Banks in NSW, QLD, Victoria, SA and WA.

You should be able to find an umbilical cord blood bank or information on donating umbilical cord blood on line. This website often has Umbilical Cord Donation advertisements which you may wish to review.

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Are there risks donating umbilical cord blood

September 14th, 2010

No, there are no risks involved in donating umbilical cord blood!

When you choose to donate umbilical cord blood for stem cell research this will have no affect whatsoever on the health or safety of yourself or your new baby. This is because stem cells removed from an umbilical cord blood are only removed after the baby is born and the placenta has been delivered. In a normal situation, if you were to choose not to donate the umbilical blood for stem cell research, you would just through the placenta away after birth. Now, you can use this to help advance medical technologies and improve the lives of many people in the future.

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Placental Stem Cells

September 14th, 2010

Stem cells found in the placenta and unbilical cord are now being used for stem cell research. 

Stem cells are fundamentally blank (or undisturbed) cells which are theoretically capable of growing into any cell, tissue or organ in the body. These cells offer tremendous hope for future health research, because they may one day hold the key to resolutions and solutions to many disorders, diseases and illness, such as cancer, parkinson’s disease, spinal cord injuries, diabets and many more.

How do they extract placental stem cells?

Stem cells are harvested from a placenta after the child has been born and the placenta delivered as per a normal delivery. The placenta is inspected for any disease or evidence of problems to the baby during the birth (as per normal) and then instead of throwing the placenta away, the placenta stem cells from the placenta are extracted and used for research or medical therapies.

There are many more stem cells found in placenta than in an unbilical cord.

How do they extract the stem cells from an unbilical cord?

As with the placenta, the physician or midwife waits until the placenta is naturally delivered and then extracts the blood from the unbilical cord.

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Stem Cell Research Successes

September 14th, 2010

In 2007 15 young persons with insulin dependent diabetes (type 1 insuline dependent juvenile diabetes) were admistered special stem cells in a research attempt to re-develop the islet of langerhans (the part of the pancreas that produces the insulin).

The study was a success and 13 of the 15 persons were able to cease their daily insulin injections, while 2 of the persons were unaffected.

Further research into this type of stem cell study to prove unequivocally the benefits or risks of such a procedure, but at this stage, stem cell research holds many good advances and news for people who suffer from diabetes.

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Stem Cell Research Experiments

September 14th, 2010

What sort of experiments are currently being done on the topic of stem cells?

Stem cells are called “stem” cells because they are very basic cells that are generally found in the faetus and young babies (as well as certain body tissues) and are able to grow into any cell or tissue in the organ. Where as most cells can only proliferate and create more cells like themselves.

1. Stem Cells are being tested to determine if they can be cultured (grown) in a petri dish so that only a small amount of stem cells can be used to make many stem cells.

2. Stem Cells are being used to re-grow or assist in the development of certain organs. For example, the redevelopment of the islet of langerhans have been attempted with some success so that diabetic patient no longer have to take insulin.

3. Stem Cells are being used in an attempt to re-grow aspects of a damaged heart muscle (which ordinarily can’t be replaced). If successful, this will mean that people who have suffered a heart attack (and in doing so damaged heart muscle) will be able to have lost heart muscle regrown/redeveloped.

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Stem Cell Research Pro and Cons

September 14th, 2010

Stem cell research is a relatively new science that potentially holds the medical treatments for many of the most debilitating and concerning diseases and disorders afflicting us today. Like all new sciences, there is great potential to do harm as well as provide benefits to future generation’s health and wellbeing. It is therefore, not surprising that the Pros and Cons of Stem Cell Research is still a very heated and debated issue amongst scientific researchers, moral activist groups, religious groups, and governments.

Stem cell are very basic building blocks (cells) that hold the unique capabilit of being able to divide into any cell type found in the human body. Unlike normal cells that can only proliferate their own cell type, such as skin tissue, hair tissue, etc, stem cells have the unique capablity of providing the basic stem for any other cell type. One of the greatest hopes of stem cell research is that scientist will one day be able to minipulate stem cells to divide and proliferate into specific cell types, such as nerve cells for patient who have had a spinal injury.

Pros of Stem Cell Research

The pros of stem cell research include the following areas of benefit to humanity:

1. Develop an entirely new science that can be used in medicine to treat current and future diseases.

2. Stem cell research hopes to improve degenerative diseases such as: Parkinson’s Disease, Alzeimer’s Disease, Multiple Sclerosis.

3. Stem cell research may provide the treatment for many cancers, by allowing doctors to remove the cancer affected organs and then using the patient’s own stem cells to literally, regrow their own organs, such as liver, lung, pancreas, etc.

4. Treat spinal cord injuries. If stem cell research allows scientists to develop a means of manipulating stem cells to form any type of cell, theoretically, stem cells can be used to regrow a patient’s own damaged spinal cord. This will allow people who have suffered a spinal cord injury to walk again.

5. Stem cell research will ultimately allow people to not only live longer, but, hopefully live much healthier lives, in which normal problems related to age will not cause a person to lose their quality of life. For example, people with arthritis, may be able to have this cured, and consequently they will be able to walk well into their 90s without assistance.

6. Stem cell resaerch can treat heart conditions, by regrowing a patient myocardial muscles (heart muscles) and allowing full repair of their heart and return to normal after a heart attack.

7. Total organ replacement will be possible. If a person loses an organ in an accident, or through disease, such as liver disease or kidney failure, they rarely are able to find an organ donor for everyone. However, through stem cell research, scientists will be able to regrow a person’s own organ in the event of organ tissue damage or disease. This will also lead to healthier and better options for people who do need organ transplants, because the organs will be derived from their own DNA. This will mean that any organ transplant will not cause their immune system to naturally combat the new organ and consequently, the debilitating immune suppresant medications normally required in organ transplants are not required.

8. Through stem cell research, live animal research (often inhumane) is required less and less.

Cons of Stem Cell Research

The following are cons of stem cell resarch:

1. Where can we ethically harvest stem cells in abundance? Although stem cells are found in adults and through umbilical cord blood and dental pulp in babies, these stem cells are relatively less ambundant than embryonic stem cells and are much older, which means their potential to proliferate is much less than “younger” embryonic stem cells. Harvesting embryonic stem cells opens up a multitude of ethical and moral delimas, including: who owns the rights to the stem cells, should people be selling stem cells, what if people start to intentionally get pregnant, only to abort their pregnancy so that they can sell their valuable stem cells?

2. Should we be playing GOD?

3. Where do we call enough enough? Are we supposed to live forever? Through stem cell therapies are we going to live to 100, 150 years or even older? If this happens, where do we live, how do we feed the massive population?

4. What if we start cloning humans in the future? What are the ethical implications of the human clone? What rights do human clones have?

5. Will we start creating only “beautiful” humans? Will everyone look tall, blonde, blue eyes, with perfect skin and an athletic frame?

Ultimately, stem cell research holds the potential keys to many disorders and may provide many technological improvement. Hopefully, so long as the stem cell researchers consider the ethical and moral ramifications of their actions, stem cell research should have some brilliant long term bennefits for society.

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What to do in a Car Accident

September 14th, 2010

What to do if you are in a car accident. If you are in a car accident, there a certain things that are good to do and certain things which you shouldn’t do depending on the type of car accident and the severity of your injuries. This provides a basic guide on what to do in a car accident.

What to do After a Car Accident

1. Secure the car – this means putting the park brake on. Even in a major car accident, a car may still have a tendency to roll and this may result in more injuries for the occupants (or for the rescuers and paramedics).

2. Turn the ignition key off – in most modern cars, all the electrics should shut down normally once you have had a car accident as a safety initiative after the car stops. However, in some cars (especially older cars) this is not necessarily the case. By turning the ignition off, there is less likelihood that a spark from the electronic egnition will cause a fire with any of the fuel that may have been spilled.

3. Have a gentle (but firm) feel over your whole body from head to toes and see that you haven’t been obviously injured anywhere. Often, after a car accident, a person will not actually notice some of their injuries until later.

4. Make sure that you can move your hands and wiggle your toes.

5. Make sure that no part of your body is trapped.

6. Have a look outside the car to see for any dangers (check for fallen power lines) – you would be surprised how many people survive a car accident only to get hit by an on-comming car or electrocuted by a fallen power line.

7. If you have neck pain or back pain – STAY IN YOUR CAR – paramedics will arrive soon and they will have special equipment to get you out of the car safely if you have injured your spine. Don’t worry about the car “exploding” or “catching alight” – it is extremely rare that these things happen, and when they do, it normally takes a while before a car will properly burn, so you will have time to get yourself out of the car.

8. If you don’t feel sore in the neck or back and you feel that it is safe to get out of your car, then by all means – get out of your car.

9. Make sure that everyone else is okay – this means everyone else in your car and any other cars or vehicles involved in the accident. Remember, you may not be the worst off… so check on everyone. I have literally been called by the driver of one vehicle with neck pain, only to find that in the other car (where no one has looked yet) there are two people badly injured.

10. If everyone is okay, exchange drivers licence and contact details with the driver of the other vehicle. Remember, in Australia, if you have been involved in a car accident which has caused more than $500 worth of damage to either vehicle, you are required by law to wait for police. You must wait for police if it is a major accident or if anyone has been injured. This is so that they can take details of the car accident and also test you for alcohol.

11. Exchange insurance details with the driver of the other vehicle and licence numbers/phone numbers/and address with other drivers.

12. Once all of this is done… you should go home and have a nice relaxing day or night. If you can, try not to spend the next few hours alone (just in case you pass out or have some other injury that arises afterwards).

13. Notify your insurance agency within 24 hours of the event, even if it wasn’t your fault, you should let your insurance company know what has happend in case there is anything else they want you to do.

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Emergency Anecdote

September 14th, 2010

This is a true story… from an Outback Australian town in which I was working as a paramedic.

I was called to a car that had rolled over (and down a ravine).

When we arrived, all we could see was the car half down the steep ravine and stopped with the front end of the car stuck on a rock and the body of the car almost at a 90 degree angle up the slope. We donned rescue harnesses and set up our ropes, so that we could make our way down to the car.

We called out to the occupants, but no one responded.

As I descended down the steep slope (attached to ropes) – I made certain that I didn’t become entangled or in any way attached to the car, which had the potential to fall at any moment. As I came around to the drivers side door, I found it had been opened and there were distinctive blood hand prints on the side of the door and body of the car as the driver had tried to climb up the hill.

I explored the rest of the car and found no occupants.

We organised police assistance and after securing the car, I made my way down to the bottom of the ravine to see if I could find our patient. No sign of him…

The search continued…

About two hours later (well after concluding that the patient had disappeared) – a car stopped on the side of the road and an older man climbed out…

“Is there a yellow car down there?” – the man asks…

“Yep…” I replied… “You haven’t seen the driver by chance?”

“Yeah, there’s a man down a the pub…” the man shakes his head and then continues to say “Says he hitch hiked his way to the pub after having some bad accident, where he nearly drove all the way off a cliff… says he was really lucky, and had to climb up the car to somehow get out… if you want to see him… he’s still drinkin pretty heavily at the pub”

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Paramedic Quotes

September 14th, 2010

These some paramedic quotes that I’ve heard over the years… some of them are funny, some of them are serious, and some of the paramedic quotes are quite inspirational.

Paramedic Quote 1

‘The only example of a bad paramedic case is a badly written case patient health care case sheet…’ – Australian Paramedic. This basically identifies the fact that few nurses read our case sheets, until something goes wrong and someone wants to point a finger. This is why it is so important to write accurate and descriptive case sheets so that it is clear to the reader why you have or have not treated them in such a way.

Paramedic Quote 2

‘Paramedics always seem to arrive too early… or too late in a cardiac arrest…’ – Australian Nurse. This basically identifies the fact that as a paramedic responding to a cardiac arrest, we often arrive too late to do anything about their sudden death, or too early, so that we are able to save their lives, but they are brain dead.

Paramedic Quote 3

‘This patient is suffering from FITHS Syndrome…’ – Australian Paramedic… I’ll let yo determine what the term “FITHS” refers to….

Paramedic Quote 4

‘Being a Paramedic involves 99% of the time sitting around, doing very little, and transfering routine patients to and from hospitals for routine procedures… and the other 1% treating someone in a medical emergency so extreme that you spend the whole time trying to keep your hands from shaking…’ – Australian Paramedic

Paramedic Quote 5

There are 172 known causes for a patient to lose consciousness… unless you have ruled out 171 of them, you are negligent to assume your patient has just had a vasovagal response

– Melbourne Clinical Training Officer

Paramedic Quote 6

‘If you have a difficult job to be done… give it to the lasiest man on the scene… he’ll always find the easiest way of doing it…’ – 2nd Most Lasy Paramedic

Paramedic Quote 7

‘That lasy paramedic is like a blister… he only ever comes out after all the hard work has been done…’

 

Paramedic Quote 8

“If something goes wrong… the Ambulance Service will always stand behind you… miles behind you…” – Any Paramedic who has been sued or taken to court over something that went wrong with a patient.

 Paramedic Quote 9

“Never argue with idiots, they just drag you down to their level and then beat you with experience…” – Annonymous Paramedic

Paramedic Quote 10

As a Paramedic you should always treat your patients as you would your Mother. This may include being tolerant with them when they are being difficult…

Paramedic Quote 11

They shall grow not old, as we that are left grow old; Age shall not weary them, nor the years condemn. At the going down of the sun and in the morning, We will remember them.

 – Laurence Binyon, 1914 and in Memory of those who paid the ultimate sacrifice for the way that we now live.

Paramedic Quote 12

A paramedic must straddle a fine line between having empathy and not taking it personal when they can’t save a life… 

– Any paramedic who has gone home and cried after a tough job…

Paramedic Quote 13

Sometimes the emergencies we attend appear as minor accidents unworthy of EMS attendance… but it is important to remember, what we see every day may be the scariest thing that has ever happened in the lives of some people… so be patient with the public, they may just believe you saved their life today…

– Any paramedic who has had to look after an hysterical patient…

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Flight Paramedic Saudi Arabia

September 14th, 2010

To be employed as a flight paramedic in Saudi Arabia, you should be a current paramedic, with extensive experience and preferably specialist qualifications in Intensive Care or Advanced Life Support.

If you gain a job as a Flight Paramedic in Saudi Arabia, you will get to experience being involved in a very advanced paramedical service, which includes state of the art diagnostic and clinical equipment.

If you are looking to become a flight paramedic in Saudi Arabia and you live overseas, these are some of the benefits you may receive:

1. Attractive Tax Free Salary

2. Good Annual Leave Allowances

3. Free medical insurance (for you and your family)

4. Annual round the world ticket (to visit your home or holiday).

5. Experience providing specialist assistance in pre-hospital care (paramedics)

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Paramedic Jobs Middle East

September 14th, 2010

The Middle East offers an extensive range of paramedic and medical jobs for overseas paramedics with experience and specialist skills, as well as a huge variety of experiences as a paramedic or EMT once over there.

These are some of the countries that are currently seeking paramedics:

1. Saudi Arabia

2. United Arab Emirates (Dubai)

3. Qatar

4. Kuwait

5. Bahrain

6.Iraq

7.Jordan

8. Egypt

All these areas provide excellent (Tax Free) salaries and living away from home packages, which often include: free medical, free around the world flight (once per year) and good working conditions.

If you’re interested in finding a paramedic job in the Middle East, please review one of the Job Advertisement on this site.

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Paramedic Jobs Saudi Arabia

September 14th, 2010

Saudi Arabia is often looking at employing highly experienced paramedics as paramedic specialists to join there various Ambulance Services and Emergency Response Teams for both on-road and fixed wing/helicopter medical retrievals.

What are the benefits of working in Saudi Arabia as a paramedic?

Saudi Arabia has some of the highest incidents of road accidents in the world, and employment as a paramedic in Saudi Arabia will involve a large amount of trauma and other significant injuries that will further inable paramedics to improve their skills.

In addition to competitive tax-free salaries, all paramedic positions include:

•Medical Care (including independents)
•Annual roundtrip airline tickets
•30-day annual leave
•Travel allowance
•Housing allowance

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Jobs in Health Dubai

September 14th, 2010

I’m a health care professional and I want to work in Dubai.

The health industry is a massive industry in Dubai and is often requiring more recruitment and employment of health proffesionals.

These are a lists of the health care jobs that Dubai is looking to employ from overseas:

1. Paramedics

2. Registered Nurses (especially if they have midwiffery, intensive care, or emergency experience and qualifications)

3. Medical Officers

4.Surgeons

5. Radiographers

6. Radiologists

7. Anaesthetists

8. Physiotherapists

And many more.

If you scroll through some of the google advertisements on this page, they are regularly advertising Job Opportunities in Health in Dubai.

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Paramedic Jobs Dubai

September 14th, 2010

Dubai is rapidly becoming the global business and vacation hub of the world. With the introduction of several of the world’s tallest buildings, largest shopping malls on earth,richest hotels, “Gold Vending Machines,” and an artificial world created out of sand islands, Dubai is becoming a renowned place to visit and do business in for people all around the world. This introduces a number of employment options for paramedics looking for a new experience in ambulance practice, with an advanced ambulance services.

Paramedic Jobs in Dubai are varied and provide a wide range of jobs in areas, such as advanced cardiology, trauma, paediatrics, and many other areas of health. Due to the giant influx of tourism and business, Dubai is very much in need of people for all forms of trade and professional backgrounds to work. The health industry particularly, is one of these industries in which the United Arab Imirates of Dubai is particularly after paramedics and health care professionals for recruitment. There are numerous employment opportunities and jobs available for Registered Nurses, Medical Officers, Paramedics, Radiologists and just about every other Health Professional in Dubai.

Paramedics are particularly sought after because of the massive increase in construction work which has resulted in an increase in work related accidents and injuries. This is another reason why it is easy for paramedics to get jobs in Dubai!

Paramedics who have training in Intensive Care and Advanced Life Support are especially wanted.

Benefits of being a Paramedic in Dubai?

Although many Ambulance Services (both Private and Public) in Dubai of different employment conditions for Paramedics from overseas, there are some of the main benefits that can be found for paramedic choosing to get a healthcare job in Dubai:

1. Tax free dollars

2. Good salary – usually $90 000 + US dollars per year depending on qualifications and experience

3. Free private health insurance for you and sometimes your family

4. Free round the world ticket to visit family (usually once per year of employment in Dubai).

5. The opportunity to work for a very technologically advanced forward moving Ambulance Service

6. High levels of exposure to traumatic emergencies due to the large amount of construction work

If you are a qualified paramedic or have 3 or more years experience as a paramedic, then you should have no trouble finding a job as a paramedic in
Dubai!

How hard is it to get a job as a paramedic or health care professional in Dubai?

If you are a qualified paramedic with at least three years experience or tertiary qalifications in health, you are well positioned to gain employment in Dubai. Obviously, the more experience you have and the higher your qualifications are he easier it is to get a job. For example, if you have tertiary or post graduate qualifications in health or paramedics, it will be easier for you to get a job that if you were only ever trained on road. Also, if you have specialty training, such as Intensive Care Paramedics or as a Flight Paramedic, you have a further improved likelihood to gain employment in Dubai or get a Dubai Job Offer!

Posted in Paramedic Jobs | 1 Comment »

Do I Have to Pay An Ambulance Bill?

September 14th, 2010

If you have contacted your local Ambulance Service in an emergency and requested paramedic assistance you may have to pay a bill for this service. Now, how much it costs and whether or not you have to pay for it depends on where you live and also on your specific circumstances. Each Ambulance Service in Australia has a different Ambulance Billing method, and again each Ambulance Service around the world has a different Ambulance Billing Service.

In most states of Australia, if you no on a current welfare program you will likely be liable for some for of Ambulance Bill if you use an Ambulance.

However, these are some of the reasons why people are exempt from an Ambulance Bill:

1. You are injured at work – then work cover must pay for the Ambulance costs.

2. You are currently unemployed and on a welfare program

3. You are disabled and have a disability pension or welfare card

4. You are a school child and your particular school has taken out a school children (while at school) Ambulance Cover policy

5. You are transported from one hospital to another (and the hospital pays for the cost)

6. You have been involved in a motor vehicle accident – and the green slip (compulsory medical and injury insurance) will cover your medical costs and Ambulance fees.

7. You have private health insurance that covers Ambulance transport costs (just check with your private health insurance company about this – some of them will only cover Ambulance costs if you are in a “life threatening emergency.”

8. Your state has a state Ambulance health plan (such as Queensland – which uses a small tax on electricity bills to pay for state Ambulance fees)

If you don’t have any of these things, chances are you may be up for an Ambulance bill. If you do have any of these factors, but you still received an Ambulance Bill – the back page of the Ambulance Bill should have a Patient Exemption section, which includes all of these categories to fill out – and then return it back to the Ambulance Service to fix, because you shouldn’t have to pay.

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Health Care Jobs Dubai

September 13th, 2010

If you are a registered health professional and want to work overseas, then Dubai probably has a job for you. Dubai is regularly employing overseas health care professionals with good working hours, lifestyle, and salaries. Many health jobs in Dubai also offer once a year free flights back to the person’s country of choice (often home to visit their family).

Dubai is situated on the Persian Gulf costal line of the Unite Arab Emerates and is a very busy global business district and area for vacationers around the world.

What health jobs are generally available in Dubai?

1. Registered Nurses – especially in areas such as Intensive Care and Emergency

2. Paramedics – especially those trained in Intensive Care

3. Physiotherapists

4. Medical Officers

5. Dentists

6.Orthodontists

7.Speach Therapists

8. Radiologist

And many more…

If you are interested in applying for a job in Dubai, check out one of our many health care jobs advertised on this site…

Many recruitment agency for jobs in Dubai will get you to upload your CV and they will do the rest!

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Accident At Work

September 13th, 2010

If you have an accident at work (especially as a paraemdic) – you must contact your immediate supervisor and report it (proabbly after you try to resolve the injury with basic first aid if required. If the injury is only minor, you should still document the incident (all Austrlian companies should have some policy in place to follow after having an accident at work.

Even if you don’t feel that sore now, it is important to document the incident, in case you develop more problems as a result of the injuries later, or your injuries worsen – is is much harder to go back to your boss a few weeks later and ask for assistance because you had an injury three weeks earlier that you didn’t report.

Another benefit of reporting is that the company that you work for can learn from these incidents and improve the system so that less employees become injured.

What if it looks like I’m going to be off work for some time?

If you have been significantly injured and the injury appears like it will keep you off work for some time, the company you work for will be responsible for providing you some form of compensation – this may be a return to work policy/ or work related injury payment. In Australia, workers compensation should cover any financial costs incurred as a result of this this accident. If you still believe that you have been far worse off as a result of the injury, and you believe the injury was the result of someone’s negligence or the company’s negligence, then you are entitled to financial compensation. A work injury lawyer or a compensation lawyer should be able to help you with this.

How much will it cost?

You may be able to find a compensation lawyer who works on a no win no fee basis. Otherwise, you will have to pay for a lawyer, and this may become pricy if you are not awarded a compensation. At either rate, make sure you know what you’re in for before you sign any contract.

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New York Construction Accident Lawyer

September 13th, 2010

Construction workers suffer the greatest amount of work related injuries and fatalities for any civillian land based work in the US. In New York alone, almost 9% of all Construction Workers will suffer a work related injury in a single calender year.

The reason for this level of inequity and increased danger for Construction Workers is because of the type of work required in construction.

Activities such as:

1.Heavy machinery

2.Mannual Handling

3. Hydraulic Lifting Devices

4. Working at heights

5. Working Above Dangerous Machines

6. Some Poor Safety Standards -due to time restraints.

7. Non-employee motor vehicles still within the area posing a significant threat to construction workers.

And many more…

However, there are very specific occupational health and safety standards and laws that all construction workers and construction companies are obliged to meet. At any point, if a construction worker, passerby or anyone else within the vicinity of the construction site are injured some occupational health and safety law has been broken. The construction company is obliged to provide a safe work environment, and the second you become injured, they have broken the law.

Because of the state specifc construction site safety laws, it is important to use a New York Construction Accident Lawyer to ensure that you get the financial compensation that you are entitled to. A good New York Construction Accident Lawyer will help you identify who is at fault and what sort of financial compensation should be sought. It is necessary to understand that this is not just for your own bennefit. By seeking financial compensation for an injury sustained in a Construction Site in New York, you are ensuring that Construction Safety Laws and Standards are followed and maintained because Construction Companies do not want to have to pay the compensation cost, that they will be obliged to pay under state and federal laws, if they fail to provide this safe working environment.

Where can I find a New York Construction Accident Lawyer?

In your local phone book you should be able to find a good New York Construction Accident Lawyer. Alternatively the internet has many good compensation lawyers to choose from. This webpage here has some New York Construction Accident Lawyers who advertise their firm at this page and may be able to provide you with more information.

Can I afford a New York Construction Accident Lawyer?

Even though New York Construction Accident Lawyers specialise in construction site legislation specific to New York, many of them offer a No Win No Pay system in which they get paid based on how much you are awarded in compensation costs. However, it is important to check with your specific lawyer on his or her fees and even if they do provide a No Win No Pay system, ask them about any out of pocket expenses or court fees that you should be aware of.

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Construction Accident Attorney

September 13th, 2010

According to the statistics Construction Work is the most dangerous land based work available in the civillain world.

These are some of the statistcs:

In both Australia and Europe a person is nearly 3 times more likely to die if they work in Construction than if they work in an office!

In the US alone almost 8% of all Construction workers sustain a non-fatal injury (of varying degrees and severity) each year alone!

According to the Occupational Health And Safety Manual in Europe the “Fall protection is needed in areas and activities that include, but are not limited to: ramps, runways, and other walkways; excavations; hoist areas; holes; formwork; leading edge work; unprotected sides and edges; overhand bricklaying and related work; roofing; precast erection; wall openings; residential construction; and other walking/working surfaces.”

Equipment on the job site must have light and reflectors if intended for night use. The glass in the cab of the equipment must be safety glass. The equipment must be used for their intended task at all times on the job site. Access and Egress is also an important part of excavation safety. Ramps used by equipment must be designed by a competent person, qualified in structural design. No person is allowed to cross underneath or stand underneath any loading or digging equipment. Employees are to remain at a safe distance from all equipment while it is operational.

These are some of the other major Hazards to construction workers:

1.Falls from height

2.Motor vehicle crashes

3.Excavation accidents

4.Electrocution

5.Machines

6. Being struck by falling objects.

7. High pressure oil injuries from hydraulic struts and hoses.

8. Noise

9. Asbestos

10. Solvents

11. Manual Handling Activies

In each country and state there are specific Occupational Health and Safety Laws which specifically target lessing the risk of injury to construction workers due to accidents. In most countries there are very stringent Occupational Health and Safety Laws and Regulations that govern how a construction worker may work. Under these laws, most people must ensure that they (themselves) have a safe working environment, that others are safe within their working environment and that the general public who may be walking bye or through the construction area are protected.

Obviously, if someone ends up injured in an accident at construction site, someone has failed, under the Occupational Health and Safety Act (this act may be different in other countries), and some form of mandatory safety measure has not been met. When this is the case, the person who has been injured has every right to contact a Construction Accident Attorney and seek financial compensation from those who were responsible. This will often be senior construction manager or work safety officer (who is generally indemnified by their construction company), who will ultimately have failed to provide a safe working environment and will be liable for the financial compensation.

How do you go about all this?

Any Law firm should be able to direct you to a compensation lawyer. However, due to the very specific nature of construction work and the safety laws that go with it, you may be better off talking to a Construction Accident Lawyer, who specialises in Construction Law and Construction Injury Compensation.

How much will it cost?

Some Construction Accident Attorneys will charge on a No Win No Fee basis, while others will have a set Fee based process. Be sure that before you sign anything or agree to anything, that you are fully aware of how much you will be liable for legal fees and court costs. Some No Win No Fee construction lawyers still charge you for court costs or other out of pocket expenses.

You may wish to review some of the advertisements for different lawyers on this webpage and see if any of them can help you out… good luck and be safe on a Construction Site.

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How to Sue

September 13th, 2010

If you have been injured as a result of another person or company’s incompetence or negligence, you may be entitled to some form of financial compensation.

How would I know anything about my rights?

Well, if you haven’t been to Law School for a number of years, chances are you’re about as clueless as the rest of us. So, your only option is to contact a compensation lawyer and discuss your injury and experience with him or her. What sort of lawyer do you need. Most law firms will have a lawyer who is capable of sueing for compensatory damages if he or she believes that, under the local law, it can be proven that you have been injured as a direct or indirect result of another person’s negligence or incompetence.

How much will this cost?

You can contact one of two different kind of compensation lawyers. Those who make you pay for their services (hourly fees) and those who are paid on a no win no pay basis. You can try some of the No Win No Fee ads on this webpage if you like. Just make sure that whichever lawyer you use, you make sure it is clear from the begining how you will be charged and if there is any “out of pocket” or additional fees that you may incur.

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Paramedic Games

September 13th, 2010

Okay, these are some games that can be played as a paramedic (I don’t necessarily advocate any of them as they are un-professional – but hey, sometimes you have to have fun at work – so just don’t get caught).

Paramedic Game 1.

See how much of the patient health care case sheet you can write before you arrive at a regular patient’s house. This only works if you have a regular patient who you visit on almost a daily basis. I’ve known of people who have been able to complete a case sheet for a regular patient before they even arrive at the house (and that’s including all the patient’s details such as DOB, Allergies, Meds, etc) – Potential downside – a patient health care record is a legal document and by not filling it out correctly you are breaking the law… just something to keep in mind.

Paramedic Game 2.

Pick a unique word or phrase for the day, such as “Good Morning” or “Wow, That’s Amazing” and see how many times you can say it to the patient without it becoming obvious you’re playing a game. I’ve heard of people taking this a little far and saying words such a “Cat” upwards of 40 times in front of the patient. The obvious trick is to see if you can uniquely blend it into the conversation nationallly. For example … “Hey was that a cat… no, not a cat, must have been a small dog…” – potential downside, you may get caught and look stupid (and a little unprofessional).

Paramedic Game 3.

See how many times you can get a patient to say a particular catch phrase or word. For example, in some areas with a high ethinic population, certain people are unable to say “Vomiting” and instead say “Womiting” – consequently, you may try and see how many times you can get the patient to say “Womiting” – Downside – you’re having a laugh on an Ethnic Minority (or Majority in some areas) bases, and this can lead to various complaints including racism and bigotry.

Paramedic Game 4

Guess what’s wrong with the patient before you get there based on the information on the MDT – For example, you are called to an 18 year old minor fall, and you may guess (correctly) that the patient has actually come off his motor bike while chasing a cow…

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Clot Dissolution

September 13th, 2010

Once coagulation has caused the formation of a clot the body will naturally commence a process called fibrinolysis, which causes the enzyme Plasmin to hydrolyse (break up) fibrin clots.

Basically, Plasmin is released from inactive Plasminogen (which circulates freely around the circulatory system in blood)

– Plasminogen causes the release of Plasmin

– Plasmin breaks down the fibrin molecule

-Fibrin – then becomes small enough that phagocytosis can start to remove the connective tissue through the blood stream.

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Coagulation Control

September 13th, 2010

The clotting process must eventually be slowed (and then stopped) otherwise the process would eventually cause all circulation to cease – which is not a good thing.

How does the body do this?

To prevent unwarranted and excessive clotting, blood contains several anticoagulant factors. At the site of an injury the body litterally sends as many coagulation factors into the wound site to cause clotting. Once these coagulation factors reach a critical level, the natural, anticoagulant factors become unable to stop a clot from forming. As the clotting factors travel outside of the wound area, there are many more anticoagulant factors than coagulant factors, and it is this dilution of coagulant factors, that stop blood clots from continuing forever until circulation ceases altogether.

These are some common anticoagulation factors:

1. Antithrombin (which is produced in the liver and stimulates the activation of thrombin).

2. Haparin (which is found both in the basophils and endothelial cells.

3. Prostacyclin – which acts to counteract the effects of thrombin by causing vasodilation.

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Clotting Cascade

September 13th, 2010

The clotting cascade is a complex set of negative feedback mechanisms used by the human body as a means of maintaining blood haemostasis.How does the clotting cascade work? The process of coagulation occurs as a sequential results of a complex cascade involving platelets and numerous clotting factors (enzymes /proteins); however, there are three main pathways in which this system is activated. These include: the Tissue Factor Pathway (previously known as the extrinsic pathway), the Contact Activation Pathway (previously known as the intrinsic pathway) and the Common Pathway.

Understanding the clotting cascade is often the bane of any paramedical or medical student because of the number of clotting factors and pathways. A thorough understanding of the clotting cascade is important because it is with this knowledge that complex bleeding disorders and patients who have had a significant traumatic injury that medical staff and paramedics are able to combat the coagulopathy.

Clotting Cascade Factors

These are the main factors within the Clotting Cascade:

Initially triggered by either intrinsic or extrinsic release of chemical mediators that have triggered the Common Pathway (Factor X) to be released, the following clotting cascade occurs:

– I Fibrinogen

-II Prothrombin

– III Tissue Factor

– IV Calcium Ions

– V Ace Globulin

-VI Prothrombinase

– VII Antihaemophilic Factor A

-VIII Plasma Thromboplastin Component

– IX Stuart Factor

– X Antihaemophilic Factor C

-XI Hageman’s Factor

-XII Fibrin Stabilising Factor

This system has been described as the ” Clotting Cascade” effect because it works like a cascade, in which each phaze in the process initiates the release of the next clotting factor or clotting retraction factor.  McCance & Huether (2002) acknowledge that ‘according to the cascade theory of coagulation each coagulation factors is converted into its active form by the preceeding factor until fibrin is produced’ (p.833).

The Tissue Factor Pathway (Extrinsic)

The Tissue Factor Pathway is the most prominent pathway involved in the clotting cascade and stimulates the release of the ‘Thrombin Burst’ in which thrombin is released. Thrombin circulates as a natural clotting factor in the normal healthy human circulatory system. When thrombin comes into contact with tissue factor (TF III) as a result of damage to collagen within the vasculature, the normally innate thrombin generates a ‘thrombin burst’ and commences the clotting cascade.

An example of the Tissue Factor Pathway/ Extrinsic pathway within the clotting cascade includes: when you cut yourself and this damages the collagen within the vasculature causing the contact of circulating thrombin with TFIII, which generates the commencement of the clotting cascade.

The Contact Activation Pathway (Intrinsic)

The Contact Activation Pathway (Intrinsic) is a much less common trigger for the clotting cascade and generally is not involved in haemostasis of normal, healthy individuals. The Contact Activation Pathway is activated during abnormal physiological parameters. Some of these pathophysiological conditions that may trigger the Contact Activation Pathway in the clotting cascade include: hyperlipidaemia, neutropenia/sepsis and any state of profound inflammation, which trigger the formation of a thrombus and thus activate the clotting cascade.

An example of the Contact Activation Pathway /Intrinsic pathway within the clotting cascade would be a patient who is suffering from Septic Shock and triggers the clotting cascade, which develops a clot and Disseminated Intravascular Coagulation (DIC) occurs.  Please view my Disseminated Intravascular Coagulation Page for more information on DIC.

The Common Pathway (Final Pathway)

The Common Pathway can be triggered by either the Extrinsic or Intrinsic Pathway of the clotting cascade and result in the use of Thrombi to develop a haemostatic plug and activate many of the other factors within the clotting cascade. Following activation by the contact factor or tissue factor pathways, the coagulation cascade is maintained in a prothrombotic state by the continued activation of FVIII and FIX to form the tenase complex (clot), until normal haemostatic responses trigger  the anticoagulant pathways. To learn more about the Anticoagulant Pathway, please review my Anticoagulant Pathway Page.

Virchow’s triad is clinically used to identify risks of thrombosis development in patients. Virchow’s Triad includes three broad categories of factors that are considered to contribute to thrombosis.

The Virchow’s triad consists of:

1. Alterations in normal blood flow

2. Injuries to the vascular endothelium

3. Alterations in the consistancy  of blood (hypercoagulability)

To learn more about Virchow’s Triad please review my Virchow’s Triad page

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Coagulation

September 13th, 2010

There are two pathways in which coagulation occurs.

These include: extrinsic pathways and intrinsic pathways.

Both the extrinsic pathway, which is where the damaged tissues from outside the wound cause a release of chemical mediators and the intrinsic pathway, which is where the blood (leaving the body through a wound) comes into contact with the collagen and stimulates the release of chemical mediators.

Through both of these coagulation pathways, the common pathway (factor X) is started, and this leads to the clotting cascade. If you’re interested in the full details of the coagulation pathways, please see the Clotting Cascade page.

Through this pathway, the common pathway (factor X) causes platelet phospholipids, factor X and factor V, and Caa Ions to join together and form Prothrombinase. This then converst teh soluble plasma protein Prothrombin into the enzyme thrombin. This then converst Fibrinogen into an insoluble protein called fibrin.

Are we confused yet? Yeah, so am I… but don’t worry, this is one of those things that’s interesting to learn about, but once you’re qualified you probably wont worry about too much… (unless you’re reading this because you’re a Medical Student – then you better concentrate).

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Emergency Nursing Oil Rigs

September 13th, 2010

Because oil rigs are often so remote and far removed from any normal means of health assessment and treatment, they all have either an emergency paramedic or emergency nurse and in some larger rigs an on-site doctor.

Who can gain employment as an Oil Rig paramedic/nurse?

Basically, you need to be both a registered nurse and a paramedic to be on an oil rig, depending on which country and where you want to work. Oil rigs like to employ Registered Nurses because they are trained and capable in providing longer term holistic care through the use of phone contact and phone orders by doctors, where as paramedics are used to working alone based on the clinical practice guidelines or protocols. Paramedics are also useful on an oil rig because of this fact, and because they often have more experience and great airway management skills as a result of providing pre-hospital care.

Although being either a paramedic or a nurse only will not preclude you from gaining employment on an oil rig, it is ideally better for you to be both a paramedic and a registered nurse. If you are only a registered nurse, you will need to have recent and strong experience as an RN in an emergency department.

If you can get a job as a nurse/paramedic on an off shore oil rig, you can definitely earn some good money ($120K plus), but the hours are long and you are away from family for some time.

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Lawyer Jokes

September 13th, 2010

These are some of the better lawyer jokes I’ve found in my time… I know they’re not exactly related to paramedics, but any paramedic who has been to coroner’s court or been sued by a patient will appreciate these lawyer jokes.

1. An honest lawyer, a tooth fairy, and a dishonest lawyer ate an expensive restaurant that cost about $500. When they all got up to leave, the billing money was gone. Who took the money? – Since there is no such thing as a tooth fairy, that only leaves one real person at the table…

2. Three brothers were at their father’s funeral. One was a drunk, the other was in big debt trouble and the third was a lawyer. Upon their father’s death, they were given a last living will contract by the lawyers that indicated their father’s last wishes to take donate all of his money to the three children, except $50,000 which he wished to be burried with, so that he would not be so poor in heaven. After the ceromony and as the three brothers went home and drank to their late father, the drunk owned up that  he had taken $5000 of the burried money! Everyone was aghast, but then the indebted child owned up that he had taken $10,000 to pay off the last of his visa bill. At this point the Lawyer son interrupted and said “You too are dispicable… I can’t believe you did this! Our poor father… I took $35,000 out of the coffin and replaced it with a cheque for the full $50,000!”

3. What’s the difference between a lawyer and a hooker? – One stops screwing you once you’re dead.

4. What do you have when you have 100 lawyers burried up to their necks in a lot of sand? – just not enough sand.

5. Why do drug research companies use lawyers instead of rats?

– Some people like rats

– The researchers find they don’t get attatched to lawyers

– Lawyers will do a lot of things that rats aren’t willing to do

–  Few people will get involved if animal rights groups start to complain about lawyers being treated inhumanely

– Its a cheap way of getting rid of all the lawyers

– Lawyers breed faster

-Lawyers are much harder to kill

6. Why do they burry lawyers 20 feet down, instead of the recommended 6 feet? – Because, deep, deep, down, lawyers really are good guys…

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Am I Entitled To Compensation?

September 13th, 2010

If you are asking yourself or a lawyer the question “am I entitled to compensation” after you have had an injury, there is a good chance that you are. A specialist lawyer who practices compensation law can review your specific legal circumstances and determine if you are entitled to some form of financial compensation as a result of another person or company’s negligence.

If you have been injured, hurt or financially set at a loss as a result of someone else’s incompetence, negligence or wilful harm, you should be entitled to financial compensation and a good compensation lawyer will advise you how to do this.

How do you go about this?

Unless you studied law for a number of years, chances are the best thing for you to do is contact a local compensation lawyer who can better determine if you are entitled to compensation for your injury and how to best go about it.

You can contact two types of compensation lawyers. Those who provide a law service on a no win no fee basis, and those who provide a law service on a fee basis. Both lawyers should clearly be able to communicate to you your options and the associated fees with any services that they are going to provide.

Remember, if the compensation that they tell you you’re entitled to doesn’t seem reasonable to you and appears more like winning the lotto, the chances are, it won’t look reasonable to the jury or judge and this may not be the lawyer for you. A good lawyer will tell you if you’re not entitled to compensation, or if you are entitled to compensation, but that it is unlikely that you will be granted it. In these cases, they may discuss other options with you. And sometimes, it’s just not worth your hassle to try to sue.

Am I Entitled To Financial Compensation?

Depending on the circumstances that have led to your misfortune and the determining that another person or organisation was at fault and the direct cause of your harm, you will be entitled to financial compensation. The financial compensation provided to you will depend on the level of damages caused, and how this has affected you.

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Can I Get Compensation For My Injury

September 13th, 2010

If you have just type “can I get compensation for my injury” – you probably have a reason to get compensation. Basically, depending on where you live (what country), you should be entitled to some form of financial compensation for any injury you sustain through the direct (and indirect) result of someone or some company’s negligence or incompetence.

Compensation is not designed to make people rich, but improve their situation, and try to alleviate some of the hindrances that have been set upon them as a result of someone else mistake. Most people don’t go out of their way to injure someone else or damage you during surgery – these are just mistakes, but when mistakes are made as a result of negligence or incompentance, then you are entitled to compensation for it so that you can return to your normal lifestyle.

All compensation lawyers and no win no fee lawyers understand that any injury that occurs now may a dramatic ramifications in the future, many weeks, months, years down the track – and compensation should consider these needs and future needs.

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Do I need compensation?

September 13th, 2010

If you are asking this question, it is likely that you may be entitled to and require some form of compensation for an injury sustained in an accident caused by another person or organisations negligence or gross incompetence.

Depending on the country that you live and where you were when this event occured, you should be entitled to some form of financial compensation for any injury that you sustain as a direct (and sometime indirect) result of another’s negligence.

These may include things such as:

1. Falling down a hole on a street that wasn’t clearly barricaded because the workmen had gone off to lunch.

2. Slipping on some oil in a shop front, while the owner knew that oil was spilling on the floor and chose to do nothing about it or provide any “reasonable” steps to ensure that someone knew about it and didn’t slip on it.

3. If someone causes a motor vehicle accident (crash) and you or your car are damaged as a result.

4. If someone hits you/is aggressive to you and injures you.

5.If someone who is paid to look after your medical well being fails in their duty to perform a task, such as an operation at a standard that their licence to practice such as task has determined. Basically, if a surgeon cuts the wrong thing and you end up sicker, more injured, more debilitated as a result – you should be entitled to some form of compensation.

The list here could go on forever. Basically, if you feel that you have been jeopardised as a result of someone else mistake (and sometimes it is just a mistake), then you should be compensated for it.

You may wish to discuss your individual situation with a compensation lawyer, such as a no win no pay lawyer or a fee paying (pay per hour or case) lawyer.

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Ambulance Chaser

September 13th, 2010

An ambulance chaser is often a derogatory term used for a Lawyer who is the first person who manages to speak to you after an accident. These can be fee based lawyers and no win no fee based lawyers, are they litterally make their living by finding compensation for people who have been injured through the direct or sometimes indirect negligence or incompetence of another person or organisation.

However, sometime a person should be looking at gaining some sort of compensation for an injury that they have sustained as a result of someone elses gross incompetence or negligence. Furthermore, sometimes an Ambulance Service, Health Service or Doctor is either too lazy or are trying to save money by not ordering the required tests and procedures. It is for these people, who Ambulance Chasers/Lawyers live for and actually provide the community a service by ensuring that it is finacially not worth these people’s while to take negligent “short cuts” with people’s medical interventions.

As a paramedic, I know a case where a patient was taken to hospital with a badly injured knee after dislocating it playing with her brother. When she arrived at the hospital (by Ambulance) she had been given a large amount of analgesia (pain relief), but it had not affected the severe agony that she was in. Her knee looked okay from the outside, but there was definitely something wrong (otherwise she wouldn’t be in agony). All her vital signs corresponded with someone in severe pain – her pulse was fast, her blood preasure was high. The doctor looked at her and decided she was okay and sent her home. I talked to the doctor (as the paramdic treating her) and asked why he didn’t order X-rays, because she was obviously in pain and something was causing that. To this, the doctor replied that it would cost his emergency department $400 to call out the on-call radiologist and that the patient was probably going to be okay.

She wasn’t okay, in the end, her patella was lodged into her poplateal nerve and over the course of the next 24 hours (before the patient could get to another hospital) she had lost the ability to use her right leg. Because of this doctor trying to save $400 a 16 year old girl now has a severe limp for the rest of her life.

If this patient sued the Doctor and Hospital, she would ensure that both the Doctor and the Hospital never tried to take such reckless short-cuts with a person’s health again.

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How to Pick a No Win No Fee Lawyer

September 13th, 2010

If you have been injured through the direct negligence of another person or company, you may be entitled to some form of financial compensation, to help you return to your normal lifestyle. This compensation isn’t necessarily designed to make you rich, but it will hopefully ensure that you are not finacially set at a loss because of someone elses incompetence or negligence.

If you can’t afford a lawyer, you may wish to look at a No Win No Fee Lawyer, who is willing to provide specialist knowledge on the topic of compensation law and do so on a No Win No Fee basis.

How do you pick a No Win No Fee Lawyer?

You can research individual No Win No Fee lawyers on-line (through ads just like these ones seen on this website), or find them in your local newspaper or phone book. Once you find some lawyers who are willing to work on a No Win No Fee basis, you should sit down and clearly go through a contract to ensure that there aren’t any hidden expenses. You don’t want to get dumped with a big bill at the end if you don’t win your case.

When you meet your lawyer, discuss with him or her, what your options are, and if these seem reasonable. If someone starts trying to tell you that they’re going to make you rich rich rich…. and the compensation appears much to good to be true and by no means a “reasonable” amount of compensation, these lawyers may be trying to scam you. A good lawyer will show you what is reasonably entitled to you and justify how or why the legal system will be willing to make sure you get it. If they can’t do this, on simple terms with you, they definitely can’t do this to convince a jury or even a judge to award you a large payment.

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How to Find a No Win No Fee Lawyer

September 13th, 2010

So, you have been injured as a direct result of someone or a company’s negligence and you want to be compensated. But you don’t have enough money to pay for a lawyer and all the potentially massive legal fees and court costs?

One option is to use a No Win No Fee lawyer, who only charges if you win the case, and only then does he or she take their comission (or fee) from the final pay out figure.

But how do you find a No Win No Fee lawyer?

You can check your local newspapers, the internet, or the No Win No Fee lawyer ads on this web page to review their firm and determine if they are the type of lawyers you are after.

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Compensation Lawyers

September 13th, 2010

Compensation lawyers are specialist lawyers who are trained to review your specific case and identify if and what sort of compensation would be reasonable to ensure that you have not been negatively affected (physically, financially, socially) by an event that was caused by another person or company’s direct negligence.

Some compensation lawyers work on a no win no fee basis, while other may charge a fee irrespective of your ability to win a legal case. A good compensation lawyer (either no win no fee or charge based lawyer) should be able to tell you early on, if you have a good case, and a reason to be compensated. Both types of compensation lawyers should be able to give you a clear, concise breakup of what your costs should be if you win or if you lose.

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No Win No Fee Lawyers

September 13th, 2010

“No Win No Fee” lawyer are lawyers who specialise in negligence claims and are willing to provide a service on the basis that if you do not win your law case, then the lawyer does not get paid either. Most areas around the world have attorneys who work on this basis. However, it is important that if you wish to use a “No Win No Fee” lawyer, that you must thoroughly read your contract with your lawyer before hand. Some of these lawyers have special clauses in their contracts that may make you legally responsible or liable for certain fees and services if you do not win your case. Also, many of the “No Win No Fee” lawyer services are legally entitled to charge you for their costs if you have witheld vital information prior to the lawyer accepting your case.

 Do I need to sue?

Most people feel that they don’t need to sue because it was an accident, and no one meant to injur you or damage you car, or because they are good people and just feel guilty about taking from someone else who has obviously just had a bad day.

This is fine, but you must remember that sometimes, and every circumstance is different, that sometimes a person is injured and they do not realise or understand the full impact that this injury will have on their lives until weeks, months or even years later. Many injuries require ongoing treatment for years. If you have a car accident and injur your back, this may be a problem that you will have to work with for the rest of your life.

Also, you have to think about how these things will affect your family. Compensation lawyers don’t look at making people rich quick and easily. Compensation lawyers look at making sure that you get what is fair and entitled to you as a compensation to assist you return to your normal life, and regain some of the things that you may have lost.

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No Win No Fee

September 13th, 2010

If you have been injured at work, on your way home, in a car, or just about anywhere, and the injury has been the result of someone elses direct irresponsibility and negligence, you may be entitled to some form of compensation. This does not necessarily mean that you have to sue them for rediculous amounts of money or that you should sue someone when you get injured just to make a “quick buck.”

However, what most people who have been injured don’t realise, is that getting injured may have more repercusions than just simply have a sore ankle or back. Getting injured may require surgery and medical costs. Many of these costs may be provided free of charge by the government health systems, but sometime the quality and the timing of the medical services can be better provided if you are a private paying customer. Furthermore, you may have the cost of perscription pills and other medical services as a result of your accident. Then you have to consider how long you may be off work for. I was injured and had 6months off work and consequently, had to pay for my mortgage with my savings, because once my sick leave entitlements ran out, I had to take leave without pay. 

These are some of the issues you may wish to discuss with a lawyer. However, one reason that most people don’t contact a lawyer is the fear that they will end up with a larger bill from their lawyer than they will get for compensation.

One solution to this problem is to consider a “No Win No Fee” lawyer who specialises in negligence claims and is willing to provide a service on the basis that if you do not win your law case, then the lawyer does not get paid either. Most areas around the world have attorneys who work on this basis. However, it is important that if you wish to use a “No Win No Fee” lawyer, that you must thoroughly read your contract with your lawyer before hand. Some of these lawyers have special clauses in their contracts that may make you legally responsible or liable for certain fees and services if you do not win your case. Also, many of the “No Win No Fee” lawyer services are legally entitled to charge you for their costs if you have witheld vital information prior to the lawyer accepting your case.

Please review some of the local No Win No Fee Lawyers who are advertised on this page if you think this may be what you need.

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Mines Rescue

September 13th, 2010

Paramedics generally aren’t involved in commercial mines rescue. Paramedics provide paramedical assistance once a patient is out of a mine. Most mines have actual miners, who are specially trained (on top of their normal mining duties) to be able to provide mines rescue assitance if required.

Do any paramedics descend into a collapsed mine to provide rescue?

Generally, paramedics do not enter a mine shaft. However, in certain remoter areas, paramedics may have undergone specialist training to equip them with the skills required to safely be involved in mines rescue. A lot of mines rescue also involves actual engineers planning, and developing new mine shafts to reach the trapped miners and this is not a rescue paramedics responsibility, because it is such a unique and specialist job.

At some remote mine sites there is a paramedic who has been specially trained in mining rescue and may work with engineeers and geologists in order to plan and provide mines rescue.

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Passing Paramedic Personality Tests

September 13th, 2010

Although there is little evidence that particular personalities do improve a persons likelihood of being a good paramedic and long-term continuation in the paramedic career path, many Ambulance Services still require a person to pass a paramedic personality test or psychometric evaluation.

These tests are often bizzare, and I have regularly watched people who I could immediately recognise as being competent paramedics be knocked back based on their personality, and likewise, watched many people who I wouldn’t let treat my cat, let alone an injured person, some how walk through the exams like a breeze.

What is in these exams?

Generally, these exams can’t be “faked” or “cheated” – meaning that they are designed in such a way that if you think you are giving them the answers that they want, they will most likely recognise this and fail you. The exams are different in each state, but basically consist of several (hundred) different questions, all worded in slightly different ways, so as to develop a pattern of your thought processes. It is because of this structure, that they are very hard to cheat. If you answer yes to several questions that show “high levels of empathy” in your personality, and then you start to answer no to questions taht also (but in a tricky sort of way) show “high levels of empathy” in your personality, the computer will realise this, and fail you.

So how do I pass a paramedic personality test?

The easiest way to pass a personality test for paramedics, is to literally circle the first thing that comes into your head for everything. Majority of the answers aren’t correct or have no “right” way of answering. The exams are designed to develop an idea of your overall thought processes and personality. They don’t care how you answer each individual question.  If you answer every question with the first thing that pops into your head, you will generally pass the paramedic  personality test.

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Paramedic Personality Traits

September 13th, 2010

Although little evidence has clearly demonstrated that paramedics must have a particular personality trait or be a particular personality type in order to be successful as a paramedic, it has often been hypothosized that paramedics are generally a certain “type” of personality.

It has been believed by so many that this golden “type” of personality that all paramedic must inherently have, that many Ambulance Service around the world select trainee paramedic candidates on the basis of a 4-6 hour personality test/psychometric evaluation. If you are about to apply for an Student Ambulance Paramedic position and you are about to undergo psychometric evaluations/personality tests, you may wish to review my Passing Paramedic Personality Tests page.

So what are the “ideal” paramedic traits?

1. Honesty

2.Integrity

3.Desire to help people

4. Confidence

5. Strength in oneself (whatever that means)

What are the actual paramedic traits that most paramedics who appear to last in the job have?

1. Risk taking personalities (most Ambos will either ride motor bikes, climb mountains, or do some other form of high risk taking activity on their days off)

2. Enjoy excitement and easily bored (I know, it seems to go against most of our work-load that is very mundane and routine, but most paramedics have a tendency to search fo excitement, and find that they get bored easily if they do too many similar things in a day).

3. A genuine desire (or at least willingness) to help others and do what is best for their patients  

4. Ability to fake confidence (you don’t have to be confident, so long as you can appear confident, that will do fine)

5. Discipline and ability to get up at all hours and do the job (irrespective of how much you want to roll over and go back to bed in Winter).

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Titanic Disaster

September 12th, 2010

Introduction

Aim/ Objectives

The disaster of the HMS Titanic Sinking will be examined. How the disaster occurred will then be reviewed; followed by why it occurred. Who and what it affected will then be looked at. Lastly, the long term emergency management planning implications as a result of the event will be addressed.

What was the event?

On the 10th of April 1912 the HMS Titanic left Southampton as the largest ship of her time filled with 2227 passengers and crew on board (although this exact figure are debated) heading towards New York where she was supposed to arrive on the 16th of April. Of these were many noted American industrialists, politicians, and artists. At 11:40pm on the 14th of April 1912 the HMS Titanic struck an iceberg at Latitude 41º 46′ N. Longitude 50º 14′. The iceberg scraped a series of holes along the starboard side of her hull for a distance of nearly 300 meters. Five to six of the sixteen watertight compartments were breached, and as one filled, it lowered the Titanic, allowing the water to quickly overflow into the following compartment. At 12:10 Captain Smith gave the order for the ship’s Marconi operators Jack Phillips and Harold Bride to send out a distress signal. At 12:20, the order was given to start preparing the life boats; and at 12:30 Smith gave the order to start loading them with women and children. Of the various ships contacted, the Cunard Liner, Capathia was the only one close enough to respond. Although at its greatest speed it would inevitably take at least 3 and a half hours to reach the Titanic. At 2:20 am on April the 15th 1912 the Titanic and the remaining passengers of around 1500 people still aboard sunk. The Titanic’s 20 lifeboats remained in the cold dark sea, at temperatures around freezing point. At 400am the Capathia arrived at the scene. At 8am the last of the survivors were picked up and the Capathia left for New York. Of the 2227 people aboard the Titanic, 1522 died, and 711 survived.    

How did it happen?

Although many theories of how and why the RMS Titanic sunk are still debated even today, some things can be seen as fact. In particular, the Titanic hit an iceberg on the 14th of April 1912 at approximately 11:40pm. At approximately 220am on the 15th of April 1912 the Titanic sunk leaving a large number of those on board to sink with her. After this, there are large variations in beliefs. At 11:40 the Titanic struck the iceberg cutting a slit of up to 300 feet below the water line towards the bow on the starboard side. Five to six of the water tight compartments were breached. As the watertight compartments only went up to E deck they filled and then overflowed to the next watertight compartment, until the flooding compartments gradually pulled the ship down by the bow. As the sinking bow lifted the stern a hundred feet in the air, Titanic’s own weight broke her back and ripped her in two. A lack of life boats and training in their use increased the enormity of the disaster.  

Why did it happen?

Through numerous resources it can be seen these were some of the contributing factors through the Titanic both sunk, and why so many on board died. The Titanic did receive various warnings throughout the day of large icebergs in the water, but partially due to either poor communication of the information, or poor judgement, Captain Smith did not order the ship to reduce its speed to something safer than 22 and a half knots. The night was crisp and without wind, making it very difficult to see the icebergs, as  ….  It has been found that ‘nine times as much ice floats unseen below the surface of the sea’ (Platt, R, 1997, p. 28). The lookout, Frederick Fleet, who spotted the iceberg in testifying before the hearing, stated that he, ‘could have spotted the ice earlier and in time to avoid it had the crow’s nest been supplied with binoculars.’ (how do I reference this?). The binoculars had been recalled earlier for the use of the officers on the bridge.

A contributor to the enormity of the loss of lives was a poor system of communicating between ships. The Californian, although visible to the Titanic in the distance could not respond to her CQD (basic call for help, like SOS) because she heard none of the Titanic’s ‘CQD messages because she had only one Marconi operator and he was asleep’ (Tim Coats,1999, p. 116).

There were two formal investigation completed into the loss of the Titanic, and American Inquiry and a British one. The American Inquiry was chaired by Republican Senator William Alden Smith. His findings were addressed to Congress on the 28th of May 1912. In which Smith criticized ‘the lack of “sufficient tests” on the  Titanic’s mechanical and lifesaving equipment, and the  “absolute unprepared ness” of crew in the face of emergency’ ( US Board of Inquiry…..). The British Board of Trade started that the ‘laxity of regulation and hasty inspection in the world is largedly indebted for this awful fatality.’ (find this reference) he then blamed ‘Captain Smith’s “overconfidence” and “indifference to danger” as a “direct and contributing cause of the disaster.”’

Who did it affect?

It affected all the passengers and crew of the Titanic, which approximated to around 2227 people. Many of whom were noted American industrialists, politicians, and artists. Of the better known people who died, the American millionaires J.J Astor, Benjamin Guggenheim, Mr and Mrs Isador Straus, Archibald Butt who was a good friend and advisor of the President at the time, along with the ship’s designer Thomas Andrews, all the Titanic’s musicians, and Captain Edward John Smith who after 40 years of success in the sea had planed to retire after this final voyage. Among the more notable survivors were Lightoller, the second officer, and J. Bruce Ismay, who greatly condemned by the general public for having not gone down with the ship. He had few friends for the remainder of his life, and of these, none ever mentioned the Titanic. His wife said, ‘the Titanic ruined both our lives emotionally.’ It affected thousands upon thousands of relatives who waited to discover if their loved ones survived. It affected thousands of people who were considering travel, but now feared for its safety.

What did it affect?

It affected many forms of legislation as to the building of sea vessels, and of their safety equipment. Many businesses flourished, while others died because of it. Some of these include the Lifeboat Building companies which were overrun with demand. Others were various Ocean Liner companies which became in less demand because fewer people felt safe to travel by sea; in particular The White Star’s reputation was damaged for many years and lost millions. The physical cost of the Titanic was estimated at….8888888, not to mention the cost of everything that went down with her, which amounted to 8888888. Another physical loss of the Titanic was that she was a Royal Mail Ship and more than and 10000**** letters were lost.

Long term emergency management planning implications as a result:

To enable future events to be Prevented, better Prepared for, Responded to and Recovered from.

‘Never in the history of mankind has there been one single event that has caused so thorough a revamping of. laws governing safety at sea.’

According to the Metallurgic Division of NIST in Metallurgy of the RMS Titanic, from tests on the hull’s steel, they found “the steel possessed a ductile-to-brittle transition temperature…making the material brittle at ice-water temperatures” (Foecke, Abstact).  Foecke, Tim Metallurgy of the RMS Titanic.

Gaithersburg, MD: U.S. Dept. of Commerce, Technology Administration, National Institute of Standards and Technology, Materials Science and Engineering Laboratory, 1998 Sections: Abstract, Conclusion.

To prevent such disasters, a stricter guideline was created as to the speeds allowed to be travelled in particular waters where icebergs are common; the structure of vessels were designed to withstand greater impact with icebergs. A 24 International Ice Patrol was created in 1913 to worn transatlantic shipping of icebergs in their vicinity.

To be better prepared for such disasters the complicated rules for the amount of lifeboats per tonnage of a vessel was changed to simply state, ‘every vessel must have enough lifeboats and lifejackets for everyone on board’ (have to find the reference). Information on the use of lifesaving equipment must be given prior to leaving dock.

“sufficient lifeboats to accommodate every passenger and every member of the crew” (Congr. Rec.-Senate,5/28/1912 , 7291)

To better respond to this disaster it was deemed that all vessels of 8888 passengers are to monitor 24 hour radios, so that those closest to the vessel could respond immediately. Senate inquiry found it “glaringly apparent [that] … [t]here must be an [wireless] operator on duty at all times, day and night” (Congr. Rec.-Senate,5/28/1912 , 7291).

To be improve recovery of such an event programs were put in place to have medical aid on all major ships 888888

Conclusion

It can therefore be seen that the disaster of the RMS Titanic Sinking was examined. What the even was will be looked at. How and why it occurred will then be observed. Followed by who and what it affected. And lastly, it will address all the long term emergency management planning implications as a result of the event.

As Walter Lord relates:

“But the engineers did not have the last word for very long…the perfect ship was no longer the vessel that best expressed the art of the shipbuilder. It was the ship that made the most money.”

Engineers today, who work in such safety-conscious designs as nuclear plants, use the military term “defense in depth”. Behind the first safety system lies another, and behind that, still another…each with its own backups. The Great Eastern had defense in depth against hull breach. By the era of the Titanic, liners had contented themselves with but a single “layer”, the all-too-short transverse bulkheads. Soon after the disaster, the sister ship Olympic, and many other liners with comparable designs, were being expensively retrofitted with an inner, second hull. Suddenly the “impossible costs” of such “extravagances” seemed affordable after all.

“Loss of Steamship ‘Titanic’,” Congressional Record-Senate.

28 May 1912.

“Loss of Steamship ‘Titanic’,” Congressional Record-Senate.

17 April 1912.

S O L A S (Consolidated edition, 2001)

Effective from 1 January 2001

Of all the international conventions dealing with maritime safety, the most important is the International Convention for the Safety of Life at Sea (SOLAS).

It is also one of the oldest, the first version having been adopted at a conference held in London in 1914. The incident which led to the convening of the 1914 Conference on Safety of Life at Sea was the sinking of the Titanic on her maiden voyage in April 1912, when more than 1,500 passengers and crew died.

http://www.jgarraio.pt/catalogo/IMO/safetydocs.htm

Never in the history of mankind has there been one single event that has caused so thorough a revamping of. laws governing safety at sea.’

The sinking of the Titanic is of special interest to the radio world because it was the primary cause of the standardization of radio procedure and other measures for safety at sea. From these measures might be mentioned the following:

1. Adoption of the Continental Morse code as a standard for all ship operators.

2. Adoption of the conventional “Q” signals.

3. Establishment of the Ice Patrol service in the North Atlantic.

4. The requirement for a continuous watch on all passenger vessels.

5. The requirement for auxiliary means of communication and a definite range for the main set.

6. The law regarding intercommunication regardless of the system employed. (It was a well known fact than in the early days a great deal of animosity existed between operators of competitive, companies.)

7. The standardization of SOS as the international distress signal.

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Family Assessment in Mental Health Emergencies

September 12th, 2010

According to Clare and Birchwood: ‘assessment of the family is essential for gaining an understanding of an individual’s social functioning, whether he or she is living with the family or not’ (Clare and Birchwood 1998, p. 51)

According to Clare and Birchwood the following are useful considerations when assessing a family context: ‘family or caregiver burden; family coping skills and styles, as well as beliefs and knowledge about mental illness; social and financial circumstances; values and expectations of the family’ (Clare and Birchwood 1998, p. 52).

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Suicide Assessment

September 12th, 2010

The NSW Centre for Mental Health in order to improve assessment, treatment and outcomes for mental health clients across NSW developed the Mental Health Outcomes and Assessment Tool (MH-OAT).

The initiative was designed to address three major goals:

1. Accurate assessment of all clients entering the mental health service with an aim of providing the most appropriate interventions.

2. Strengthening the assessment skills of all clinicians.

3. Standardisation of recording and reporting assessments and interventions to ensure continuity of care for clients moving within and across services’ (NSW Centre for Mental Health 2001).

According to Meadows and Singh, the following are indicators of likelihood of suicide:

1. Previous suicidal behavior or specific plans to attempt suicide in the past

2. Family history of a suicide

3. Sociomographic characteristics, including older age (>45y/o), male gender, divorced or separated status, and being unemployed

4. Specific psychiatric disorders, including depression;

5. Specific mental state findings, including stated suicidal ideation

6. Physical illness

7. Recent major loss or separation

8. Making wills or generally tidying up of personal affairs

9. The availability of lethal means’ (meadows and Singh 2001, p. 236).

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Mental Status Assessment

September 12th, 2010

The mental status assessment should be conducted ‘throughout the whole course of interaction with a patient’ (Meadows and Singh 2001, p. 230).  It does not, and in the pre-hospital care environment, should not be used as a written assessment, but a guideline for gaining an understanding of the patient’s mental status.

The following are very basic MSA topics:

Assess appearance and behavior. 

Assess speech.  Speech must be examined with both the form and content in consideration. What is the rate of a patient’s speech? What is the quantity of his or her speech? Does it flow? The tone is quite loud or soft. What is the content of his or speech? Is he or she gloomy and his pessimistic views appear to dominate his speech.

Assess mood and affect.

Assess thoughts?

Assess beliefs

Assess cognition

Assess insight.

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Therapeutic De-esculation

September 12th, 2010

According to Dernocoeur, ‘one way to assist in diffusing anger is to acknowledge a person’s right to it’ (Dernocoeur 1996, p. 43). Therefore, in this situation, you may say to Bernie ‘I understand why you’re angry… but can you give us an opportunity to try and help you?’

According to Sanders therapeutic communication is ‘a planned, deliberate, professional act that uses communication techniques to achieve a positive relationship and shared understanding of information for desired patient-care goals’ (Sanders 2001, p. 344).

Effective listening and feedback includes: ‘silence, reflection, facilitation, empathy, clarification, confrontation interpretation, explanation and summarization’ (Bledsoe 2000 p.470). Silence refers to giving Bernie the time to gather his thoughts and add to what he has said. Reflection means to check your understanding of what Bernie has had to say. Facilitation refers to encouraging Bernie to provide more information when it is required. Empathy requires allowing your body language to show that you understand, so that the patient feels accepted and more open to talking. Clarification means asking Bernie about anything you don’t truly understand. Confrontation refers to focusing the patient on one particular factor of the interview. Interpretation means that you state your interpretation of the information Bernie has supplied. Explanation means to share the importance of facts within the information related; and summarization means that the pre-hospital care worker re-phrases statements made by Bernie to ensure that he/she fully understands the message.                                                                    

Verbal de-escalation is where you offer the patient time to state his or her concerns; react in a non-judgemental way, explaining your desire to help sort out their current difficulties. Attempt to ascertain the cause of the violent behavior and try to calm the patient by responding calmly and evenly. Do not become aggressive or threatening in response.

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Suicide Intervention

September 12th, 2010

According to the Living Works Treatment Project, there are five helpful things to consider when managing suicidal individuals.

These are:

1.         Engage the suicidal person and explore his or her world from his or her perspective (using active listening techniques).

2.         Identify the person’s thoughts of suicide, identify the risk of suicide by asking directly: “Are you thinking about killing yourself?”

3.         Inquire about the reasons for his or her suicide

4.            Estimate the risk, – assess the seriousness of the threat, the risk factors, the protective factors, and the person’s potential for violence

5.         Form a contract with the individual to intervene, so as to reduce the risk of suicide (Living Works 1999, p. 58).

Successful intervention involves helping the suicidal person find hope and helping him/her move from a focus on the past and its losses and failures, through to the here and now, to look to the future, seeing options he or she does not see. At this stage one should try to work toward a plan or a contract with the subject that reduces the threat to life and encourages his desire to live. To instill hope, the paramedic needs to get the suicidal person to challenge two ideas. Firstly, that the pain will last forever, and secondly that the loss is everything. According to Seligman it is ‘these dimensions of permanence and persuasiveness that lead to hopelessness and helplessness’ (Seligman1991, p. 67).

Building a therapeutic relationship with a patient can be one of the most beneficial forms of intervention in this circumstance. The World Health Organization states that: ‘the clinician who is regarded as trustworthy, interested, helpful and understanding is more likely to engage the individual in ongoing and beneficial treatment’ (World Health Organization 2000, p 28). Avoid unusually prolonged eye contact and do not confront or corner the patient as this may cause him to become more aggressive and feel as though you are out to get him (NSW Health Department 2001, p. 9). Furthermore, try not to give patient ultimatums or ‘make or break’ situation, as these will only increase his agitation and possible violence.

Successful intervention involves helping the suicidal person find hope and helping him/her move from a focus on the past and its losses and failures, through to the here and now, to look to the future, seeing options he or she does not see. At this stage one should try to work toward a plan or a contract with the subject that reduces the threat to life and encourages his desire to live. To instill hope, the paramedic needs to get the suicidal person to challenge two ideas. Firstly, that the pain will last forever, and secondly that the loss is everything. According to Seligman it is ‘these dimensions of permanence and persuasiveness that lead to hopelessness and helplessness’ (Seligman1991, p. 67). 

Building a therapeutic relationship with a patient can be one of the most beneficial forms of intervention in this circumstance. The World Health Organization states that: ‘the clinician who is regarded as trustworthy, interested, helpful and understanding is more likely to engage the individual in ongoing and beneficial treatment’ (World Health Organization 2000, p 28). Avoid unusually prolonged eye contact and do not confront or corner the patient as this may cause him to become more aggressive and feel as though you are out to get him (NSW Health Department 2001, p. 9). Furthermore, try not to give patient ultimatums or ‘make or break’ situation, as these will only increase his agitation and possible violence. 

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Managing Aggression

September 12th, 2010

In managing our own safety, as he is yelling abuse at us and appears aggressive, we have four primary defenses.

According to NSW Health Department these means of controlling aggression are:

1.         Verbal de-escalation/communication

2.            Medication/sedation

3.            Physical restraint

4.         Calling for police assistance

(Centre for Mental Health 2002, p. 43)

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Temperament Profiles

September 12th, 2010

The aim of this paper is to introduce the seven temperament components used in a temperament profile and describe the basic needs that are associated with people with strengths and weaknesses in each temperament component.

The objectives of this paper include: describing the seven temperament components used in a temperament profile by giving references to incidents involving people with obvious strong or weak component needs, based on observations from my own experiences, each component of a temperament profile will be explained in greater depth.

 Objectivity

 This component develops rational, coherent behaviour and control over a person’s emotional state. For instance a person with a strong objectivity component may be a very logical and straightforward person in an emergency; however, at home may not show emotions within his or her relationships.

Strong need example: Michael has a strong objectivity need. This can be seen by the fact that for his entire life he has done exactly what he believes is best from a conservative, objective viewpoint. He is very academic, diligent and committed to his success. At high school he chose all the subjects that were considered most appropriate, therefore he would be able to the best marks possible and as such may have the greatest likelihood of getting a good job. When he finished school, he really wanted to become a pilot, but decided that studying Accountancy at Sydney University may supply him with a more reliable career.

Weak need example:  Amelia has a weak objectivity need. This can be seen by the fact that she jumps at new ideas without thinking about their consequences. When her job gets too tough or stressful she finds another job. She quite happily goes in and out of relationships, often believing that this will be the one she’ll marry.  

Self-Centredness

This component deals with a person’s desire to get ahead in life and improve themselves; be it financial, social stature, prestige or in any other field. 

Strong need example: Michelle has a strong Self-Centredness need. This can be seen by the fact that everything she does can be seen to have been done to improve her evident social stature and success. She chose to study Law at Sydney University because it was the most prestigious degree she could think of. She had two men who she liked a lot while going through University and when asked why she decided to marry the one she did, she said, ‘He has a family name has a far better financial reputation in society… and he owns a house in the Eastern Suburbs.’

Weak need example: Adam has a weak Self-Centeredness need. This can be seen because, although he has plenty of money he still wears cheap clothes because he finds them comfortable. Money is not particularly important to him and neither is social prestige, so long as he’s happy.

Gregarious Energetic

This component deals with a person’s level of social interaction. Those who have a high level of gregarious/ energetic need require the company of other people, they like to be the social person at a party and if they find it difficult to be alone. They are easy to communicate with because they enjoy the company of other people, although not necessarily one on one conversations. In managing these sort of people, you are better off utilising them in a group or in some form of activity that does not require them to be alone for long periods.

Strong need example: Rowena has a very strong Gregarious/ Energetic need. She likes parties, social events, and any excuse to have fun with a lot of people. She finds it hard to sit down and do nothing – her idea of a good vacation includes lots of people, lots of drinking and lots of activities, without a minute to spare in-between.

Weak need example: Amisha has a very weak Gregarious/ Energetic need. She is happy to be alone. She likes the peacefulness and tranquillity of sitting by herself. Her idea of a great holiday is one where you get to sleep in until midday and enjoy things in your own time.

Cautious/Self Critical

This component deals with how much a person worries about the future and about himself or herself. In particular, a person with a strong Cautious/Self Critical need will always be nervous or concerned about what is going to happen. On the other side of the spectrum, in those with a weak Cautious/Self Critical need they rarely considered the possible outcomes of their actions and may appear as ‘dangerous’ or ‘gutsy.’ In communicating with these people you must try to reassure them and not give them the opportunity to foresee the worst in what you are about to say. In managing these people in an emergency, you should focus on reassurance and building on their confidence.

Strong need example: Daniel has a strong Cautious/Self Critical need. This can be seen because all his choices in life have been governed by his fear of choosing the wrong option. He wanted to change schools when he was younger, but worried that he would never be able to meet new people at the new school. He was offered a job, doing something he enjoyed, but turned it down, because he felt nervous about quitting his current job, and didn’t know if he was good enough to do the new job, even though he would enjoy it.

Thoughtful/ Imaginative

This deals with how much a person considers things in general. It has to do with a person’s insightfulness. People with strong Thoughtful/ imaginative needs, when combined with genuine competence may be useful in providing good insight into various issues. Often considered as idealistic. These people genuinely are interested in the things that are happening around them, and often give thought to what has just happened or is currently happening. When communicating with such people, it may be difficult as they may wish to consider things by themselves, but other times are quite open to discussing their thoughts with anyone willing to take interest in them. When managing such people, you should make it obvious that you are genuinely interested in what they have to say.

Strong need example: Imogen has a strong Thoughtful/Imaginative need. She likes to ponder things on her own. When something happens to her, she would rather recollect the situation in her own mind, on her own, than talk to a lot of people about it. Many people consider her to be a ‘loner,’ but those who know her well find that they can comfortably share any experience with her.  

Power Exerting

This deals with a person’s need to be in control. A person with a strong needs likes to have power, likes to be in command of a situation, and refuses to let go of his or her authority. These people do very well when they are in charge. Those with weak needs are born ‘followers,’ as opposed to ‘leaders.’ When communicating with people who have a strong need in this component, try to avoid direct confrontation. Try to avoid getting into an ‘I’m right you’re wrong’ situation, because they will fight you until the end on the subject. When managing these type of people, you should endeavour to place them in positions in which they have control. Assuming they are competent, as leaders they will be great assets, but, if placed in a ‘follower’s’ role they may become resentful and a liability.

Strong need example: Fiona has strong Power Exerting need. This can be seen by the fact that she is in complete control of everything and everyone around her. She is the head of her own successful business, and no one will dare disagree with her at work. Her family know that if you get her started on an argument you may as well just give in and tell her she’s right at the beginning. That, if you do start an argument, she will enjoy proving that you were ‘wrong’ and she was ‘right.’

Perfectionism

This component involves a person’s desire to get something done right. Those with a strong need in this component will spend hours working on the minute detail of a project to ensure that it is perfect. Where as those who have a weak need in this component will gladly say that ‘it’s good enough.’ When communicating with a person with a strong need, try to find a time when they are not involved in their project. When managing these people, try to give them work that requires attention to detail without so much requirement of specific time restraints. Try to avoid giving them tasks that are time orientated and do not require any real attention to detail.

Strong need example: Mitchell has a very strong Perfectionism need. This can be seen by the fact that he is fanatical about getting things right in everything he does. He is a graphic designer, and when completing a new project all his friends know not to interrupt him because he is entwined with any project until he is done. When he was at school, he would often miss a submission of an assignment by the due date because he was never quite ‘happy’ with his work.

Weak need example: Ben’s has a weak Perfectionism need. This can be seen by the fact that he likes to get things done quickly. He is a hard worker, but believes if its close enough, its good enough. If put to work that does not require specific detail, however, he can be very industrious.

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Limitations of Clinical Practice Guidelines

September 12th, 2010

The most important potential limitation of guidelines is that the recommendations made may not only be wrong but may lead to potentially negative health outcomes. Unless guidelines are frequently reviewed and updated, through the use of current, valid research, and EBP principles applied, guidelines may be promoting the use of treatments that are wrong and possibly harmful. According to Hoolf et al ‘recommendations that do not take due account of the evidence can result in sub-optimal, ineffective or harmful practice’ (1999, p.3).

Guidelines that are inflexible may cause harm by leaving insufficient ability for clinicians to adapt guidelines to the medical need of their patients, based on the evidence acquired from the clinical examination, medical history, and events leading up to the illness of injury (Shapiro et al1993, p. 219.

Even if the clinical guideline is excellent for a specific patient, incorrect diagnosis on the clinicians part, or ambiguity either the presenting patient or guideline, may lead to the use of the wrong guideline, and subsequent intervention; ultimately leading to a potentially negative health outcome.

Some clinical guidelines are created without sufficient scientific evidence and research. There are many clinical conditions in which there just hasn’t been enough good medical evidence to support the most appropriate and beneficial treatment. Therefore, what to recommend is often lacking, misleading, or misinterpreted. Only a small subset of what is done in medicine has been tested in appropriate, well-designed studies. Where studies do exist, the findings may be misleading because of design flaws that contribute to bias or poor generalisability. Guideline development groups often lack the time, resources, and skills to gather and scrutinise every last piece of evidence. Even when the data are certain, recommendations for or against interventions will involve subjective value judgments when the benefits are weighed against the harms. The value judgment made by a guideline development group may be the wrong choice for individual patients (Hoolf et al 1999, p.2).

For example the use of lignocaine versus amiodarone in VF arrest. Based on the ethical implications of developing good evidence, such as a randomly controlled double blind study, as to the benefit of using lignocaine or amiodarone in a patient with ventricular fibrillation (VF) in cardiac arrest, very little research has been conducted. As a result, many clinical guidelines on the subject continue to produce guidelines based on what has always been done, as opposed what has the best evidence or potential health benefits. According to Kudenchuck, Cobb and Copass who conducted a comparative study, within the UK, of intravenous amiodarone and intravenous lignocaine in ongoing shock-resistant VF in a small, randomized preliminary study (n=20 patients), which showed statistically significant improvement in resuscitation rates with amiodarone versus lignocaine (Kudenchuck et al1999, p. 871-2). However, further study, with larger cohorts were considered ethically inappropriate. Because such little study has been done conducted to suggest that amiodarone has some clinical benefits and better patient health outcomes than lignocaine, many clinical practice guidelines still recommend the use of lignocaine in VF. For example, NSW Ambulance Service still utilise the clinical intervention of lignocaine in VF cardiac arrest as opposed to amiodarone, based on the concept that it what we have always used (Adelstein and O’Connell 2001, protocol 15).

Furthermore, recommendations within clinical practice guidelines are often influenced by the opinions, clinical experience and composition of the guideline development group. Tests and treatments that experts believe are good for patients may in practice be inferior to other options, ineffective, or even harmful. The beliefs, to which experts subscribe, often in the face of conflicting data, can be based on misconceptions and personal recollections that misrepresent population norms (Woolf 1997, p. 205-8).  This, in turn, may cause outdated practices and recommendations to perpetuate outmoded practices and technologies.

When developing clinical practice guidelines the patients’ needs may not be the only priority in making recommendations. Practices that are suboptimal from the patient’s perspective may be recommended to help control costs, serve societal needs, or protect special interests (those of doctors, risk managers, or politicians, for example).

The promotion of flawed guidelines by practices, payers, or healthcare systems can encourage, if not institutionalise, the delivery of ineffective, harmful, or wasteful interventions; while the same parties that stand to benefit from guidelines, such as the patients, healthcare professionals and the healthcare system may all be harmed (Field and Lohr 1990, p.4).

Flawed clinical guidelines harm practitioners by providing inaccurate scientific information and clinical advice, thereby compromising the quality of care. They may encourage ineffective, harmful, or wasteful interventions. Even when guidelines are correct, clinicians often find them inconvenient and time consuming to use. According to Feder ‘conflicting guidelines from different professional bodies can also confuse and frustrate practitioners’ (1994, p. 2-3).

Clinical practice guidelines can also hurt clinicians professionally. Auditors and managers may unfairly judge the quality of care based on criteria from invalid guidelines. The well-intentioned effort to make guidelines explicit and practical encourages the injudicious use of certain words such as ‘should’ instead of ‘may,’ and arbitrary numbers such as months of treatment and time intervals between tests, and simplistic algorithms when supporting evidence may be lacking. Algorithms that reduce patient care into a sequence of binary (yes/no) decisions often do injustice to the complexity of medicine and the parallel and iterative thought processes inherent in clinical judgment (Hurwitz and Eccles 1992, 1-2). Words, numbers, and simplistic algorithms can be used by those who judge clinicians to repudiate unfairly those who, for legitimate reasons, follow different practice policies. Guidelines are also potentially harmful to doctors as citable evidence for malpractice litigation and because of their economic implications (Hurwitz and Eccles 1992, 1-2).

Healthcare systems and payers may be harmed by guidelines if following them escalates utilisation, compromises operating efficiency, or wastes limited resources. Some clinical guidelines, especially those developed by medical and other professional groups unconcerned about financing, may advocate costly interventions that are unaffordable or that cut into resources needed for more effective services within the organisation (Delamothe and Smith 1998, p.1111-12).

Clinicians may seek secular (and even self serving) benefits from guidelines. In some healthcare systems, guidelines prompt government or private payers to provide coverage or to reimburse doctors for services. According to Feder, ‘specialties engaged in ‘turf wars’ to gain ownership over specific procedures or treatments may publish a guideline to affirm their role’ (1994, p. 2-3). Clinicians may turn to guidelines for medicolegal protection or to reinforce their position in dealing with administrators who disagree with their practice policies.

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Benefits of Clinical Practice Guidelines

September 12th, 2010

The most paramount potential benefit of the implementation and use of clinical practice guidelines is the improvement of health outcomes.  Guidelines that promote interventions of proven clinical benefit and discourage ineffective ones have the ‘potential to reduce morbidity and mortality while improving the quality of life’ (Woolf, Grol, Hutchinson, Eccles, and Grimshaw 1999, p.527). Although it has been shown in rigorous evaluations that clinical practice guidelines can improve the quality of care, whether they achieve this in daily practice is less clear (Field and Lohr 1992, p. 7), This is partly because patients, doctors, payers, and managers define quality differently and because current evidence about the effectiveness of guidelines is incomplete.

In circumstances such as pre-hospital care and emergency medicine the use of guidelines may benefit potential health outcomes, based on their ability to simplify clinical decisions in situations often wrought with urgency and confusion. For example, NSW Ambulance Service has utilised the benefits of clinical practice guidelines based on the concept that ‘the vast majority have omitted background materials, thereby highlighting the steps required to deliver the appropriate pre-hospital care (Adelstein and O’Connell 2001, p.1).

For example, if a clinician wanted to rapidly treat bradycardia as a Paramedic in NSW Ambulance Service he or she may attempt to process the first step in the EBP, by converting the information needs into answerable questions. In this case, how do you treat a patient with bradycardia who is poorly perfused? Through the research and evidence accumulated by those on the clinical practice guidelines committee the second step in the process, tracking down the best evidence with which to answer the questions may be achieved; in particular the bradycardia guideline written, based on current research and clinical practice evidence. The third step in the process, critically appraise the evidence for usefulness, would be rapidly achieved by answering the question, will these clinical guidelines successfully treat this patient? The Fourth step in the process, apply the results to the clinical practice, would then be put into place by the administration of atropine, followed by adrenaline the patient’s heart rate (HR) did not increase or perfusion did not improve with atropine (Adelstein and O’Connell 2001, Protocol 10). Lastly, the fifth step in EBP, evaluate the performance, would be applied by clinically examining the patient afterwards and determining whether the patient responded to the treatment adequately. In this case: did the patient’s HR increase and perfusion improve? In this circumstance the Paramedic may be capable of delivering EBP without reducing physical time of urgent treatment, so long as those involved in writing the guidelines have done so through the use of EBP.

Guidelines can improve the consistency of care. Studies around the world show that the ‘frequency with which procedures are performed varies dramatically among doctors, specialties, and geographical regions’ (Chassin, Brook, Park, Keesey , Fink, Kosecoff 1986, p. 314). It has been seen that many patients with identical clinical problems receive different and conflicting care depending on their pre-hospital clinician, ambulance service, hospital, or physical location. Guidelines may offer a solution, by making it more likely that patients will be cared for in the same manner regardless of where or by whom they are treated. In NSW Ambulance Service all clinicians practice the same clinical procedures based on the evidence applied in the clinical practice guidelines. For example the treatment for vomiting and nausea in NSW Ambulance Service includes the administration of metoclopramide and then treating associated symptoms if present, such as dehydration or hypovolemia (Adelstein and O’Connell 2001, Protocol 62). This will ensure consistency of treatment, providing equal quality of health care and EBP throughout NSW; however, the obvious downside is if this treatment is incorrect, in which case it will only ensure the equally incorrect health care throughout NSW.

In this case, there is some evidence to suggest that although metroclopramide is successful in treating nausea, there is no evidence that this the case when the nausea is related to motion sickness. According to Golembiewski, Chernin and Chopra ‘there is no evidence to suggest that metoclopramide actually works in patients with motion related nausea’ (2005, p.5).

Clinical guidelines can improve the quality of clinical decisions. By offering explicit recommendations for clinicians who are uncertain about how to proceed. Clinical practice guidelines are able to provide the rapid means of providing conscientious, explicit and judicious use of current best evidence without the time normally required to gather such evidence. Guidelines may overturn the beliefs of doctors accustomed to outdated practices, improve the consistency of care, and provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment policies. Guidelines based on a critical appraisal of scientific evidence (evidence based guidelines) clarify which interventions are of proved benefit and document the quality of the supporting data. They alert clinicians to interventions unsupported by good science, reinforce the importance and methods of critical appraisal, and call attention to ineffective, dangerous, and wasteful practices.

Clinical guidelines can support quality improvement activities. The first step in designing quality assessment tools, such as standing orders, reminder systems, critical care pathways, algorithms and audits, is to reach an agreement on how patients should be treated, often by developing a guideline (Agency for Health Care Policy and Research 1995, p. 95). Guidelines are a common point of reference for prospective and retrospective audits of clinicians’ or hospitals’ practices: the tests, treatments, and treatment goals recommended in guidelines provide ready process measures (review criteria) for rating compliance with best care practices (Agency for Health Care Policy and Research 1995, p. 95)

Medical researchers benefit from the spotlight that evidence-based guidelines shine on gaps in the evidence. The methods of guideline development that emphasise systematic reviews focus attention on key research questions that must be answered to establish the effectiveness of an intervention (Chassin et al 1986, p. 314) and highlight gaps in the known literature. Critical appraisal of the evidence identifies design flaws in existing studies. Recognising the presence and absence of evidence can redirect the work of investigators and encourage funding agencies to support studies that fulfil this effectiveness based agenda (Hoolf et al 1999, p.4).

Healthcare systems that provide services, and government bodies and private insurers that pay for them, have found that ‘clinical guidelines may be effective in improving efficiency (often by standardising care) and optimising value for money’ (Shapiro, Lasker, Bindman and Lee 1993, p. 219). Implementation of certain guidelines reduces outlays for hospitalisation, prescription drugs, surgery, and other procedures. Publicising adherence to guidelines may also improve public image, sending messages of commitment to excellence and quality. Such messages can promote good will, political support, and (in some healthcare systems) revenue. Many believe that the economic motive behind clinical guidelines is the principal reason for their popularity (Grimshaw and Hutchinson 1995, p.2).

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Clinical Practice Guidelines

September 12th, 2010

The Institute of Medicine Washington defined clinical guidelines as a ‘systematically developed set of statements to assist the practitioner and patient’s decisions about appropriate health care for specific clinical circumstances’ (Field and Lohr 1990, p.4). They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice. According to the NSW Ambulance Service ‘protocols have been designed to streamline patient care’ (Adelstein and O’Connell 2001, p.1).

According to Choudhdry, Stelfox and Detsky the ‘ascendency of evidence-based medicine over the last decade has fostered an unprecedented growth in clinical practice guidelines’ (2002, p.612). Departments of health and associated agencies, specialty societies and other medical organisations have all embraced the development of guidelines in the belief that adherence to their recommendations translates into benefits for patients (improved outcomes), practitioners (improved quality of care), and providers (improved cost-effectiveness)(Chassin et al 1986, p. 314).

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Strengths of Evidence-based Practice

September 12th, 2010

Some of the many strengths of EBP include: finding better procedures, stopping negative procedures, learning from other people’s mistakes, providing a basis for clinical judgment, legal protection, best utilization of resources and ultimately best clinical practice (Straus et al 2000, p. 837-40; Trinder 2000, p. 2; ).

By utilising the evidence to provide the best practice possible, a clinician or practitioner is capable of reducing if not removing the possible harms of treatment. According to Trinder ‘EBP remains firmly committed to the modernist promise that risk can be assessed and controlled by expert knowledge and that potential harm of interventions can be minimised and the potential benefits maximised’ (2000, p. 7-8).

EBP is an approach that ‘promotes the collection, interpretation, and integration of client-reported, clinician-observed, and research-derived evidence’ (McKibbon, Wilczynski, Hayward, Walker-Dilks, & Haynes 1995, p. 4). It does not command your clinical decisions, but may be utilised to ensure that through the ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of your client you have developed the most effective and efficient treatment decision for your patient (1997, p. 2). 

EBP may help identify procedures that are not cost-effective and may be dropped. This is not to say that it will drop procedures and change the management plan of a patient based on economic restraints, but that it will look for more effective methods of providing treatment (Straus et al 2000, p.839). Likewise, EBP may help identify new procedures and justify their cost. According to Trinder ‘supporters and advocates of EBP claim that the approach results in the best practice and the best use of resources’ (2000, p. 2).

EBP may become the common language through which different healthcare disciplines communicate, such as the medical, physiotherapy, nursing and paramedical disciplines (Sackett et al, 1997, p.17). Furtheremore EBP principles do not change from undergraduate to post-graduate education and hence are a greater advantage to the life-long process of study associated with any professional clinician or practitioner (Echt et al 1991, p. 781-2).

Weaknesses of evidence based practice

The weaknesses of EBP include: the limitations to samples in research, the required need to still make clinical judgments (EBP is only a guideline), the fact that information develops rapidly and beyond one person therefore protocols are useful, the fact that it requires new skills from clinicians, may in fact raise and not necessarily lower the cost of health care, it cannot replace experience, and the paucity of proof that EBP actually works (Straus and McAlister 2000, p. 838; Trinder 2000, p. 2).

EBP requires new skills of the clinician, including efficient literature-searching, and the application of formal rules of evidence in evaluating the clinical literature, such as the five steps in the process of EBP as described by Sacket et al (1997, p. 3).

EBP is also not an ivory tower or armchair medicine but a way of staying on top of a busy professional life. It is not an alternative to experience.

EBP is not cook-book medicine imposed from above and slavishly followed but an active process which integrates the doctor’s own expertise, the external evidence and the patients’ preferences. Clinical guidelines are similarly subject to this flexible approach. External clinical evidence can inform but never replace individual clinical expertise and it is this expertise that decides even whether the external evidence is relevant to the patient at all (Howizts 1996, p. 320).

EBP is not necessarily a cost-cutting exercise but a method of looking for the most effective ways to improve the quality and quantity of patients’ lives. This may in fact raise, not lower, the cost of care (Straus et al 2000, p.839).

Because EBP requires an upwards approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision (Coats 2004, p.4-5). Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient’s clinical state, predicament, and preferences, and thus whether it should be applied.

EBP involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a ‘diagnostic test, a clinician needs to find proper cross-sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial’ (Oxman, Sackett, and Guyatt 1993, p. 2). For a question about prognosis, a clinician needs a proper follow-up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence required will come from the basic sciences such as genetics, immunology and basic pathophysiology. It is when asking questions about therapy that one should try to ‘avoid the non-experimental approaches, since these routinely lead to false-positive conclusions about efficacy’ (Coats 2004, p.2-3).

Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the ‘gold standard’ for judging whether a treatment does more good than harm. However, according to Straus et al, even though ‘randomised clinical trials are considered to be the ‘gold standard’ for establishing the effects of an intervention, they are not necessarily the best sources for answering questions about diagnosis, prognosis or harm’ (1997, p.839). Furthermore, some questions about therapy that would ordinarily require randomised trials, may not require randomised when trials of successful interventions would prove otherwise fatal or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient’s predicament, a clinician should follow the trial to the next best external evidence and work from there.

Despite its ancient origins, evidence-based medicine remains a relatively young discipline whose positive impacts are just beginning to be validated and it will continue to evolve (Oxman et al 1993, p. 2). This evolution will be enhanced as various undergraduate, post-graduate, and continuing medical education programmes adopt and adapt it to their learners’ needs. These programmes, and their evaluation, will provide further information and understanding about what EBP is, and what it is not. As yet, however, there is ‘no good evidence to suggest that EBP actually works (Trinder 2000, p.4).

Critical appraisal of clinical practice involves additional time and effort, and may be perceived as wasteful; however, this time and effort may be reduced by clinicians developing effective searching skills and simple guidelines for assessing the validity of research papers. In addition, one can emphasize that critical appraisal, as a strategy for solving clinical problems is most appropriate when the problems are common in one’s own practice (Oxman et al 1993, p. 3).

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Critics View of EBP

September 12th, 2010

Critics have argued against EBP on the basis of many common misperceptions of EBP as well as many correct failings associated with EBP. These primarily include: the argument that many doctors were already doing these things; that good evidence is often deficient in many areas; that lack of evidence and lack of benefit are not the same; that the more data are pooled and aggregated the greater the difficulty in comparing the patients in the studies with the patients presenting; that EBP is a covert method or rationing resources, is overly simplistic and often restrains professionals; that many clinicians lack the time and resources to practice EBP and require new skills to utilize EBP (Guyatt, Cairns, Churchill 1992, p.268; Trinder 2000, p.2; and Straus 2000, p. 837-9).  Furthermore, those who agree that ‘EBP makes good sense in theory, have quite appropriately demanded evidence for whether it improves patient outcomes’ (Miles, Bentley, Polychronis and Grey 1997, p. 83-5). Although, the ethical and moral implications of such a randomized controlled trial, relating to withholding evidence in the clinical treatment of patients may never be appropriately justifiable.

In developing the EBP some have argued that the new paradigm is sometimes misinterpreted. For example, many have argued that EBP recognition of the limitations of intuition, experience, and understanding of pathophysiology in permitting strong inferences are a rejection of these routes to knowledge altogether.

A common critic misperception or argument against EBP is that it ignores the clinical experience and clinical intuition of the practitioner or clinician.  In many ways it is important to expose learners to exceptional clinicians who have a gift for intuitive diagnosis, a talent for precise observation, and excellent judgement in making difficult management decisions. Untested signs and symptoms should not be rejected out of hand. They may prove extremely useful, and ultimately be proved valid through rigorous testing. The more experienced clinicians can dissect the process they use in diagnosis, and clearly present it to learners, the greater the benefit. Similarly, the gain for students will be greatest when clues to optimal diagnosis and treatment are culled from the barrage of clinical information in a systematic and reproducible fashion (Craig, Irwig and Stockler 2001, p. 1-3).

Institutional experience can also provide important insights. Diagnostic tests may differ in their accuracy depending on the skill of the practitioner. A local expert in, for instance, diagnostic ultrasound, may produce far better results that the average from the published literature. The effectiveness and complications associated with therapeutic interventions, particularly surgical procedures, may also differ across institutions. When optimal care is taken to both record observations reproducibly and avoid bias, clinical and institutional experience evolves into the systematic search for knowledge that forms the core of evidence-based medicine (Straus and McAlister 2000, p.839).

Another argument is that the understanding of basic investigation and pathophysiology plays no part in evidence-based medicine. The dearth of adequate evidence demands that clinical problem-solving must rely on an understanding of underlying pathophysiology. Moreover, a good understanding of pathophysiology is necessary for interpreting clinical observations and for appropriate interpretation of evidence. However, numerous studies have ‘demonstrated the potential fallibility of extrapolating directly from the bench to the bedside without the intervening step of proving the assumptions to be valine in human subjects’ (Echt, Leibson, Mitchell, Peters, Obias 1991, p. 781).

Some critics have argued that EBP ignores standard aspects of clinical training such as the physical examination. A careful history and physical examination provides much, and often the best, evidence for diagnosis and directs treatment decisions. The clinical teacher of EBP must give considerable attention to teaching the methods of history and clinical examination, with particular attention to which items have demonstrated validity and to strategies to enhance observer agreement (Echt et al 1991, p. 781-2).

Large randomized controlled trials are extraordinarly useful for examining discrete interventions for carefully defined medical conditions. The more complex the patient population, the conditions, and the intervention, the more difficult it is to separate the treatment effect from random variation. Because of this, a number of studies obtain insignificant results, either because there is insufficient power to show a difference, or because the groups are not well-enough ‘controlled’ (Straus et al 2000, p.839).

Furthermore, the critic may argue that EBP has been most practised when the intervention tested is a drug. Applying the methods to other forms of treatment may be harder, particularly those requiring the active participation of the patient because bliding is is more difficult (Stephenson and Imrie 1998, p.1). The types of trials considered ‘gold standard’ (i.e. randomized double-blind placebo-controlled trials) are very expensive and thus funding sources play a role in what gets investigated. For example, the government funds a large number of preventive medicine studies that endeavor to improve public health as a whole, while pharmaceutical companies fund studies intended to demonstrate the efficacy and safety of a particular drugs, so long as the outcomes are in their favour (Coats 2004, p.2-3). Furtheremore, ‘determining feasibility and relevance to the real world is often difficult’ (Stephenson and Imrie 1998, p.2).

One of the fears of EBP is that purchasers and managers will control it in order to cut the costs of health care. This would not only be a misuse of EBP but suggests a fundamental misunderstanding of its financial consequences. Doctors practising EBP will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care (Straus et al 2000, p.839).

Many of the studies that are published in medical journals may not be representative of all the studies that are completed on a given topic (published and unpublished) or may be misleading due to conflicts of interest (i.e. publication bias); therefore the array of evidence available on particular therapies may not be well-represented in the literature.

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The Need for Evidence-based Practice

September 12th, 2010

Proponents of EBP argue the need for EBP with four main points. These are: ‘the research-practice gap, poor quality of most research, information overload and practice which is not evidence-based’ (Trinder 2000, p.3-4).

During the last century there has been an exponential growth of research and knowledge (Humphreys, McCutcheon 1994, p.18). The growth of health care information has been particularly rapid in diagnostic and therapeutic technologies, with the sheer volume of medical papers published doubling every 10 to 15 years (Hook 1999, p.3) and electronic access to full text articles and journals available since 1998 (Delamothe and Smith 1998, p.1109-10). Although, with all this research it was still argued that many medically based practitioners have a research-practice gap, which basically means that there is a limited extent to which they utilize and draw upon research finding to determine or guide their actions. Ultimately, they rely on indicators such as ‘prior knowledge, prejudice, outcomes of previous cases, fads or fashions, and advice from senior colleagues’ (Trinder 2000, p.4). With this expansion of information, our knowledge should be greater and our practice should be more effective. Unfortunately this is too often not the case (Walker, Grimshaw , Johnston, Pitts, Steen , Eccles 2003, p.19). This recognised gap between best evidence and practice is one of the driving forces behind the development of EBP.

Furthermore, it can be seen that many of those who do utilise research findings note that most research is methodically weak and of a generally poor quality. For example, the studies have not utilised the ‘gold standard of research, such as a well conducted randomized controlled trial (RCT)’(Trinder 2000, p. 4).

Those who do find research papers often discover information overload, which relates to the sheer amount of research papers available. According to Hook the volume of medical papers published doubles every 10 to 15 years (1999, p.3). Therefore the task of distinguishing between rigorous and useful research and poor or unreliable research has become a much more difficult task for clinicians and practitioners (Trinder 2000, p. 4).

Lastly, it can be seen that many practitioners are utilising techniques that are not based on evidence. The consequences of these previous factors result in the continual utilisation of medical interventions that have ‘been shown to be ineffective, harmful, slow or limited adoption of interventions which have been proven to be effective or more effective, and there continue to be variances in practice’ (Trinder 2000, p.4).

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Steps in Evidence-based Practice

September 12th, 2010

 

 According to Cook, Jaeschke, Guyatt, the ‘five steps of EBP were first described in 1992 and most steps have now been subjected to trials of teaching effectiveness’ (1992 p. 275-82) The process of EBP includes the following steps:

1.            converting information needs into answerable questions;

2.         tracking down, with maximum efficiency, the best evidence with which to answer them (whether from clinical examination, diagnostic laboratory, research evidence or other sources);

3.            critically appraise that evidence for its validity and usefulness;

4.         apply the results of this appraisal in our clinical practice; and

5.            evaluate our performance

(Sacket et al 1997, p. 3).

This five-step model forms the basis for both clinical practice and teaching EBP, and as Rosenberg and Donald have observed ‘an immediate attraction of evidence-based medicine is that it integrates medical education with clinical practice’ (1995, p. 1122- 3). Good practice including effective clinical decision-making, step 4 of the EBP process, requires the explicit research evidence and non-research knowledge (tacit knowledge or accumulated wisdom). Clinical decision-making is the ‘end point of a process that includes clinical reasoning, problem solving, and awareness of patient and health care context’ (Maudsley 2000, p. 63).

Since 1990, when EBP was introduced, it has broadened to reflect the benefits of entire health care teams and organisations adopting a shared evidence-based approach. This emphasises the fact that evidence-based practitioners may share more attitudes in common with other evidence-based practitioners than with non evidence-based colleagues from their own profession who do not embrace an evidence-based paradigm (American Medical Association 1992, p.4).

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Principles of Evidence Based Practice

September 12th, 2010

According to Sackett et al, the principles of EBP are based on a ‘process of lifelong, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues’ (1997, p. 3). By basing one’s clinical practice on the conscientious and judicious use of best evidence, one may enhance his or her clinical capabilities and ultimately the health outcomes of their patients.

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Evidence-based Practice Defined

September 12th, 2010

According to Sackett, Richardson, Rosenberg & Haynes EBP is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of your client’ (1997, p. 2).  EBP integrates individual clinical expertise with the best available external clinical evidence from systematic research; the evidence, by itself, cannot make a decision for you, but it can help support the patient care process. The initial definition of EBP was within the context of medicine, where it is was well recognised that ‘many treatments do not work as hoped’ (Doust and Del 2004, p. 474-5).  EBP is a total process beginning with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence then must be applied by a clinician with expertise in considering the patient’s unique values and needs. The final aspect of the process is evaluation of the effectiveness of care and the continual improvement of the process (Sacket et al, 1997, p.3).

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Role of an Interim Commander

September 12th, 2010

The main information required from the interim Commander could be primarily obtained by considering the acronym ‘METHANE’ (Hodgetts 2002, p.27). Through this acronym one may communicate to gather such information as: the fact the interim Commander has already ‘declared’ a major incident or placed it on ‘standby.’ The exact location of the incident should be obtained, such as a grid reference or the crossroad names. The type of incident, such as a ‘bus crash’ should be determined. The hazards that are involved and present in the incident, such as broken glass, possible fuel leakage, traffic hazards, possible electrical 240 volt inverters still active on the bus, biohazards, such as blood and sewage, and debris should be communicated, and whether or not they are easily removed or have to be worked around should be noted. Potential hazards such as fuel on the road may potentially become a serious hazard. The access and egress to the casualties involved in the incident should be communicated. Likewise, the number of casualties should be stated, including an idea of how injured the majority are, because a bus full of priority three casualties (walking) will require different resources to a bus full of priority one casualties (immediate medical attention). Lastly, the emergency services required and those that are already en-route should be determined.

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Characteristics of a Bureaucracy

September 12th, 2010

The following paper has been written to determine how and why the metaphor of an organisation as a machine can be applied to the organisation structure known as a bureaucracy. In order to do this, a definition and explanation of an organisation will be given, followed by an explanation of the metaphor of an organisation as a machine. A description of the organisational structure defined as a bureaucracy will then be examined through a study of an established bureaucracy. Lastly, an application of the metaphor of an organisation as a machine will be applied to the organisational structure known as a bureaucracy.

According to Robbins and Barnwell an organisation is, ‘a consciously coordinated social entity, with a relatively identifiable boundary, that functions on a relatively continuous basis in order to achieve a common goal or set of goals’ (2002, p. 6). In the broad spectrum of the term organisation, one may see that they ‘exist to achieve goals and objectives’ (Forrest and Johnstone 2004, p. 10). Thus it can be said that an organisation has a specific goal, and the members of that organisation coordinate their efforts to achieve the goal or goals of that organisation. Clinton and Scheiwe state that the goal of an organisation should be the ‘starting point of any organisation as seen in its mission statement’ (1998, p.174). As an example, NSW Justice Health has as its mission statement: ‘to achieve measurable and sustained health care outcomes leading to international best practice for those within the NSW Criminal Justice System’ (NSW Justice Health 2005). To do this, as an organisation, Justice Health has employed Doctors, Nurses, Corrective Service Officers, Dieticians, Physiotherapists, Occupational therapists and Pharmacists to work, in a coordinated fashion, to produce the organisation’s goal: ‘better health for its clients.’   

Pinnnock states: ‘traditional management theory has relied on the metaphor of the organisation as a machine’ (2004, p.1). According to the Oxford English Dictionary the term metaphor means, ‘a name or descriptive word that is transferred to an object or action different from, but analogous to, that to which it is literally applicable’ (1993, p.1758). For example, one may write, ‘he had a heart of stone’ giving the view of a man with a hard, cold, stone-like character. According to the Oxford English Dictionary a Machine is, ‘an apparatus applying mechanical power, having several parts each with a definite function’ (1993, p. 488). Similarly an organisation is compiled of several parts, each fulfilling a specific function in order achieve the set coordinated goals or ‘the mechanical power.’ This concept will be further examined by a study of Mintzberg’s five elements of an organisation.

Henry Mintzberg’s five elements of an organisation include: ‘the operating core, strategic apex, middle line, technostructure, and support staff’ (Mintzberg1983, p. 262).  The operating core, which includes the ‘employees who perform the basic work related to the production of products and services’ (Robbins and Barnwell 2002, p. 111) could be considered as the cogs and wheels in a machine that allow it to physically function. In Justice Health this would include the nurses, officers, dieticians and other various staff as they have direct interaction with the clients.

The strategic apex includes the, ‘top level managers, who are charged with the overall responsibility of the organisation’ (Robbins and Barnwell 2002, p. 111) These managers could be viewed as the computer chips or decision making part of the machine. In Justice health, this would entail the Chief Executive Officer, Nurse Managers, and Directors.

The middle line managers include, ‘managers who connect the operating core with the strategic apex’ (Robbins and Barnwell 2002, p. 111). In Justice health this would include Clinical Nurse Unit Managers who make decisions regarding their designated ward but are still accountable to the top-level mangers. These may be considered as the computer chips in the ABS brakes, as they control specific aspects of the machine.

The technostructure, which are the, ‘analysts who have the responsibility for effecting certain forms of standardisation in the organisation’ (Robbins and Barnwell 2002, p. 111) could be seen as the control settings on a machine.

The support staff, which includes, ‘the people who fill the staff units that provide indirect support services for the organisation’ (Robbins and Barnwell 2002, p. 111) could be seen as the oil that make the machine run smoothly. In Justice Health this could be Human Resources, Administration, warehousing and stores.

This concept of the metaphor of an organisation as a machine is further exemplified by considering the words one often uses to describe our organisations. For example our vocabulary is compiled of words that delineate an organisation as a machine-like military unit, such as: ‘headquarters, division, strategy, officer, policy unit, fostering campaign, tactics, or front-line staff’ (Pinnock 2004, p.1). They help create an image of a place where activities are directed and regulated through central command systems. These words convey comforting ideas of order, clarity, control, conformity and perfect communication. They imply that the people at the top can specify and foretell desired actions and all organisational staff have to do is follow orders. It is for these reasons that many people have come to develop the metaphor of an organisation as a machine. In this concept, we get the image of all the people in the organisation as cogs, wheels and mechanical parts of a machine.  If everyone does their part then the organisation, run by humans will function as a machine does, smoothly, in coordination, without flaw.  

However, on the other hand, a machine could be considered to be uncaring and non-emotional. It has its purpose to fulfil and rolls over anything in its path to achieve its own personal objective without seeing ‘the big picture’ or in fact, the human side of an organisation and goal achievement. Such could be considered the case with the organisational structure known as a bureaucracy.

According to Robbins and Barnwell a bureaucracy can be defined as, ‘an organisational form characterized by a division of labour, a well-defined authority hierarchy, high formalization, impersonality, employment decisions based on merit, career tracks for employees and distinct separation of members organisational and personal lives’ (2002, p. 487).

Max Weber, a German sociologist, developed in the early part of the 20th century what is known today as the organisational structure called a bureaucracy. Weber described his ideal type of organisation that he called a bureaucracy as ‘a system characterized by a divisions of labour, a clearly defined hierarchy, formal selection, formal rules and regulations, impersonality and career orientation’ (Robbins, Bergman, Stagg and Coulter 2000, p.48).  

Through a study of these seven principles, one can see that the health organisation Wentworth Area Health Service is an example of the organisational structure known as a bureaucracy.

Wentworth Area Health Service has a strict division of labour in which, ‘jobs are broken down into simple, routine and well-defined tasks’ (Robbins and Barnwell 2002, p.308). For example, a Ward Clerk organises the medical records of clients and as such is not allowed to assist in lifting clients as that is considered to be a Wardsperson’s job. Similarly, a Wardsperson would not be expected to organise medical records as a Ward Clerk would.

Wentworth Area Health Service has a well-defined authority hierarchy, through which, ‘a multi-level formal structure, with a hierarchy of positions, ensures that each lower position is under the supervision and control of a higher one’ (Robbins and Barnwell 2002, p.308). For example, the CEO may partake in the original decision on how many beds to have in each ward of a hospital, then the senior Doctors and Nurse Unit Manager of a ward may make a decision, based on the amount of nurses, beds and equipment available whether or not to accept a new patient from another hospital. Once that patient arrives, the treating Doctor may order the Nurse to administer specific drugs, but the Nurse cannot order the Doctor to administer specific drugs.

There is a high level of formalisation, such as, ‘a dependence on formal rules, and procedures to ensure uniformity and to regulate the behaviour of job holders’ (Robbins and Barnwell 2002, p.308). For example, each medical procedure has a formal written protocol describing the exact steps for how that procedure should be conducted and by what person, such as a Doctor, Nurse, Wardsperson or Ward Clerk.

A high degree of impersonality occurs, such as ‘sanctions applied uniformly and impersonally to avoid involvement with individual personalities and personal preferences of members’ (Robbins and Barnwell 2002, p.308). For example, decisions on who to treat first are based on a prioritising triage system, that objectively considers who needs to be seen most urgently, and not based on personal decisions about liking/disliking a client.

Employment decisions are based on merit such as, ‘promotion decisions based on technical qualifications, competence and performance of the candidates’ (Robbins and Barnwell 2002, p.308). For example, equal employment opportunity is seen to be enforced and discrimination or preferential treatment of specific members or minorities is not allowed.

There are career tracks for employees and ‘members are expected to pursue a career in the organation’ (Robbins and Barnwell 2002, p.308).  For example, a Registered Nurse may become better qualified and specialise in a specific field such as Intensive Care Nursing, then become a Clinical Nurse Specialist, an Educator, a Clinical Nurse Unit Manager, Nurse Unit Manager, Nurse Manager (for the hospital) or eventually a Director or even the CEO.

There is a distinct ‘separation of members’ organisational and personal lives such as ‘completely separate personal affairs and kinship ties from work-related activities’ (Robbins and Barnwell 2002, p.308). For example, an employee is not supposed to engage in a romantic relationship with another co-worker, unless their roles in the organisation are completely separate.

Although many characteristics of Weber’s bureaucracy are still evident in large organisations, his model is not as popular as it was a decade ago. According to Robbins et al many managers today feel that a bureaucracy’s emphasis on a strict division of labour, adherence to formal rules and regulations, and impersonal application of rules and control, ‘takes away the individual employee’s creativity and flexibility to respond to the dynamic and complex changes taking place in the global market, making them more like machines, and less like self-thinking humans’ (2000, p. 49). Morgan further emphasizes this concept by stating that a ‘bureaucracy can have dehumanizing effect upon employees, making them more like machines, especially those at the lower levels of the organsational hierarchy’ (1986, p.35).

A bureaucracy relies on, ‘standardised work processes for coordination and control’ (Robbins and Barnwell 2002, p. 114). A ‘machine bureaucracy has highly routine operating tasks, formalized rules and regulations, tasks that are grouped into functional departments, centralized authority and a decision making system that follows the chain of command’ (Robbins and Barnwell 2002, p. 114).

The bureaucracy form is very standardized; rules regulations and protocols are officially formalized. Morgan describes a bureaucratic organisation as, ‘an organisation that is designed and operated as if they were machines’ (1986, p. 22). As a consequence, ‘we tend to expect them to operate as machines: in routinized, efficient, reliable and predictable ways’ (Morgan 1986, p. 220).

A bureaucracy can cause conflicts within the organisation due to the separate units and individuals placing their own unit’s objectives before all others, including the organisation as a whole. Problems arise when change is needed within the organisation, as employees within a bureaucratic organisation are ‘influenced by the rules and regulations and therefore adapting to change becomes difficult’ (Duffield and Stein-Parbury 1992, p. 35). 

According to Coser, Weber wrote in 1946 that, ‘the decisive reason for the advance of the bureaucratic organisation has always been its purely technical superiority over any former organisation. The fully developed bureaucratic mechanism compares with other organisations exactly as does the machine with non-mechanical modes of production’ (as sited by Coser 1977, p. 231).

Weber argued for bureaucracy’s, ‘indispensability for the attainment of the goals of any organisation in an industrial or capitalist society’ (Coser 1977, p. 231). In Weber’s idealized bureaucracy, no personal relations or feelings interfered with the job, making his bureaucratic officials rather robotic and thus mechanistic.

It can be seen that the bureaucracy as a machine has negative features in real practice. The most influential arguments against a bureaucracy were developed by Robert Merton. Merton wrote in 1940 that there was a tendency for ‘the rules to become more important than the ends they were designed to serve, resulting in goal displacement and loss of organisational effectiveness’ (Merton 1957, p.196). He argued that the demands on officials to conform to bureaucratic regulations led to ritualism, rigidity, and difficulties in dealing with the general public. Almost from its beginning the common complaints about bureaucracy have been concerning its impersonal nature and its inefficiency, which seem to be the same complaints we have today.

An example of an organisation known as a bureaucracy may act like a machine and become difficult to work with is the health organisation Wentworth Area Health Service (WAHS). In WAHS there is a protocol regarding the removal of oxygen cylinders from a resuscitation trolley, which states, ‘The oxygen cylinder is never to be removed from resuscitation trolley’ (WAHS Resuscitation Trolley Protocol, p. 7). In an emergency a patient went into a respiratory arrest and required oxygen. The resuscitation trolley was then taken to the patient and the Doctor attempted to intubate the patient. After three attempts the Doctor decided to manually bag the patient with a lurdel bag and transfer the patient to the Intensive Care Unit where she would try to intubate again. The senior nurse on the ward, who was an officious bureaucratic machine in the organisation known as WAHS, followed the Resuscitation Trolley Protocol to the exact word, as a machine does, and said that the Doctor would have to have an oxygen cylinder sent up to the ward from somewhere else because the oxygen cylinder on the Resuscitation Trolley is not to be removed. The Doctor argued that this was the specific purpose with which the oxygen bottle is required, but the Nurse argued that the Protocol is specific and therefore she must go find her own oxygen bottle from somewhere else.  

The following paper has therefore been written to determine how and why the metaphor of an organisation as a machine can be applied to the organisation structure known as a bureaucracy. In order to do this, a definition and explanation of an organisation has been given, followed by an explanation of the metaphor of an organisation as a machine. Specifically, the concept of Henry Mintzberg’s five elements in an organisation was applied to the health organisation Justice Health.  A description of the organisational structure defined as a bureaucracy was then examined through a study of the established health organisational bureaucracy known as Wentworth Area Health Service. Lastly, an application of the metaphor of an organisation as a machine was applied to the organisation structure known as a bureaucracy and an example of WAHS was examined to see how true this concept really was.

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Health Services Need Managers

September 12th, 2010

Managers of health services today have a difficult position, but a very necessary one. They must make their service run smoothly and, in particular, contain costs when most spending decisions are frequently outside their control. Primary care is ‘mainly demand-led and referral is, to managers and many professionals as well, an impenetrable black art’ (Bureau of Labour, 2004, p. 1).

Healthcare as an organisation is a business and, like every other business, it needs good management to keep it running efficiently and effectively. The structure and financing of healthcare is changing rapidly. Future medical and health services managers must be ‘prepared to deal with evolving integrated healthcare delivery systems, technological innovations, an increasingly complex regulatory environment, restructuring of work, and an increased focus on preventive care’ (Australian Healthcare Association 2004). They will be called upon to improve efficiency in healthcare facilities and the quality of the healthcare provided. Increasingly, medical and health services managers will work in organisations in which they must optimize efficiency of a variety of interrelated services.

According to Robbins and Barnwell, ‘an organisation is a consciously coordinated social entity, with a relatively identifiable boundary, that functions on a relatively continuous basis to achieve a common goal or set of goals’ (2002, p. 6). Based on this, one can see that health services organisations have the primary goals (objectives) to provide health care in the most efficient yet cost effective manner. 

Management seeks efficiency and effectiveness. Efficiency refers to the relationship between the inputs and the outputs. Basically resources usage should equal a certain amount of goals attained. The greater the amount of goals attained with the least amount of resources used equals the greater the efficiency. According to Robbins, Stagg and Coulter ‘a manager is someone who integrates and coordinates the work of others’ (2000, p. 7). Therefore it is important for managers to spend their time ‘managing’ things as opposed to doing things themselves. By delegating work their function management can increase organisational achievements. Poor management spends its time ‘doing rather than managing, and this limits their day-to-day achievements’ (College of Nursing 2002, p. 10).

Organisational structure defines how tasks are to be allocated, areas of responsibility and authority, who reports to whom, and the formal coordinating mechanisms and interaction patterns that will be followed. For an organisation to work efficiently there must be a management structure to implement ‘good planning, organizing, leading and controlling to ensure paramount achievement of the organisation’s stated purpose’ (Clinton and Scheiwe 1998, p. 151).

Through planning, management determines the ‘specific goals of the organisation, establishing an overall strategy for achieving these goals, and developing a comprehensive hierarchy of plans to integrate and coordinate activities’ (Robbins, Bergman and Stagg 1997, p. 8). For example, in the NSW health system the government determined a shortage of health staff due to growing demands of an ageing population (NSW Health 2005). Through the hierarchy of the NSW health system, the senior management defined specific goals such as: ‘to increase nurses.’ Management then developed a strategy to achieve that goal and sub-plans to coordinate the activities. In this case, management have decided to ‘double the size of the state’s intake of trainee enrolled nurses, re-launch the re-connect nursing program and support nursing scholarships’ (NSW Health 2005).

Organising is the process management undertakes to ‘design an organisation’s structure and includes the determination of what tasks are to be done and who is to do them, how tasks are to be grouped and where decisions are to be made’ (Robbins, Bergman and Stagg 1997, p. 8). In this case decisions would be made about where the funding would come for each program, who was responsible for the management of each program, and the structure and framework of the programs.

Leading is the function in which management undertakes to coordinate its human resources. When managers ‘motivate subordinates, direct the activities of others, select the most effective communication channel, or resolve conflicts among members, they are engaging in leading’ (Robbins, Bergman and Stagg 1997, p. 8). In this case the state government would direct the CEOs of individual hospitals, the CEOs would lead the individual managers of each department and the managers of each department would coordinate the people (the operating core).

Controlling deals with ‘monitoring activities to ensure that they are accomplished as planned’ (Robbins, Bergman and Stagg 1997, p. 8). This would include audits of the intake of the nurses, nurses on duty, how many nurses are short for individual hospitals/departments per shift.

***

The role of management has varied throughout time and different definitions are numerous. According to Anderson, management is described as: ‘the process of organisational goal setting and decision making about the efficient and effective use of organizational resources in order to ensure high organisational performance’ (cited by Clinton and Scheiwe 1998, p. 144). Mary Parker Follet, an early management theorist and writer, believed that management is ‘the art of getting things done through people. Follet was the first advocate for the concept of participative/collective decision making, suggesting that managers should have authority with, rather than over, employees’ (Marquis and Huston 1996, p. 10).

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Economic Resources in Health

September 12th, 2010

 

What relevance does the concept of economic resources have to health service organizations?

The term economic resources refers to those ‘resources which make it possible for an organisation to provide their goods and/or services’ (Forrest and Johnstone 2004, p. 12). Specifically, when related to the health service organisations these resources can be broken further down and categorized by: ‘natural resources, capital resources, and human resources’ (Forrest and Johnstone 2004, p. 12).

Within the health service organisation the natural resources include: the physical space and environment that the service provided occurs. The capital resources include: the equipment, such as ventilators, beds, lifting devices, drugs and financial support. The human resources includes: the people with the knowledge to deliver the health services needed, such as the nurses, doctors, paramedics, dentists, radiographers, pharmacists and wardspersons.

Most service provider based organisations use human and capital resources to provide their services, and for some health service organizations, ‘total human cost represents up to 80% of total cost of operation’ (Forrest and Johnstone 2004, p. 12).

Shortell and Kaluzny state that: ‘while health care organisations are not greatly different from other organisations, they are subject to enormous economic and social pressures’ (1997, p.12). Health delivery today is having difficulty coordinating its services within ever tightening constraints of the health care budget.  Recently there has been an amalgamation in the Western Sydney Health Service, that resulted in less middle managers. Now each middle manager overseas larger regional areas than they had previously. This was an economic rationalisation that will directly influence service delivery in the coming years.

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Health Services Are Service Providers

September 12th, 2010

According to Robbins, Berman, Stagg, and Coulter ‘an organisation is a deliberate arrangement of people to accomplish some specific purpose’ (2000, p.5). In the broad spectrum of the term organisation, one may see that they ‘exist to achieve goals and objectives’ (Forrest and Johnstone 2004, p. 10). This can further be divided into the concept of producing either goods/ or services to meet the needs of the organisations existing and / or potential customers or clients. This refers to ‘providing a service rather than manufacturing or producing tangible goods such as a car or refrigerator’ (Forrest and Johnstone 2004, p. 10).

It has often been said that the ‘starting point of any organization must be its mission statement’ (Clinton and Scheiwe, 1998, p.174).  Health services organisations are primarily service providers and not producers of goods. An example of this can be seen by viewing the missions statement of the Southern Area Health Service, which states it is: ‘committed to promoting, protecting and maintaining the health of the community it serves’ (SAHS Mission Statement 2002). It further emphasizes this concept by stating its purpose: ‘in all aspects of our work we strive to achieve better health, good health care by: 

·  making available a range of quality health care services

·  advocating a ‘wellness’ approach

·  encouraging individuals to participate in their own health care

·   supporting and facilitating staff and community involvement in planning for the future’ (SAHS Mission Statement 2002).

According to Robbins, Berman, Stagg, and Coulter, (2000, p. 362-363) organisational structure follows organisational strategy. For an organisation to operate, it has various functions it has to fulfil, and decisions and actions taken in one organisational area will affect other areas. This is known as interdependency characteristics of systems according to Robbins et al (2000).

According to Mintzberg there are five basic parts to any organisation. These include:

1.         The operating core

2.         The strategic apex

3.         The middle line

4.         The technostructure

5.         The support structure

(Mintzberg 1983, p. 262).

The concept that health service organisations are primarily service providers can be further delineated by viewing the framework or support structure of a health organisation.  NSW Justice Health can be used as an example. Its mission statement is  ‘Achieving measurable and sustained health care outcomes leading to international best practice for those within the NSW Criminal Justice System’ (NSW Justice Health 2005).

Justice Health organisational structure has a divisional structure (Robbins and Barnwell 2002, p.116). The CEO is overall responsible for the Organisation and thus he is at the top of the organizing board. He is responsible to the minister for health, the director general and the board. According to Mintzberg this CEO and his divisional officers would constitute ‘strategic apex,’ which plans and manages overall functions (Bolman and Deal, 1997, p.62). The CEO has six different sections (Directors and Divisions) beneath him/ her: The Director of Population Health & Centre for Health Research; the Director Forensic Mental Health; Director of Finance, Director of Corporate services; Director of Juvinile Health, and Clinical and Nursing Services.

The Corporate Services Director acts as a back up to service the organization itself – and again, is not directly responsible for service delivery to inmates (clients). According to Mintzberg (Bolman and Deal, 1997, p.62) this Division would constitute the ‘supporting staff’ as well as the, ‘techno-structure,’ which ensures technical standardization. The Corporate Services section delivers and arranges service for the organization itself. Thus a manager of employee services, information technology, business manager, learning and development coordinator and manager of commercial services are in this section.

The Director in Clinical and Nursing Services is the support arm that is most relevant to the Nursing Staff of Justice Health. According to Mintzberg (Bolman and Deal, 1997, p.62) this division would constitute ‘the operating core.’ This is where the main service delivery area is, and the area where the mission of the organization is directly fulfilled. Justice Health offers services to clients (inmates) through five main clinical streams: drug and alcohol, mental health, population health, primary health and clinical services. Clinical services relates to dental services, radiographers, pharmacists, clinical service development and quality improvement. Thus at this point the organization has a matrix or hybrid design (Montgomery, 2002) as it incorporates features of both functional and product line/ divisional design.

According the Montgomery the matrix design ‘includes both a vertical and a horizontal chain of command’ (2002, p. 271). Thus, the Nurse Unit Manager has her own direct senior, in her own vertical line of command; however, concerning ‘infection control,’ ‘public health,’ ‘mental health’ or ‘drug and alcohol’ issues the directors of these areas are also her ‘direct’ senior  (from the side). This design is helpful as the expert on each subject is near to hand, yet the day to day individual service delivery to clients is the responsibility of the Nurse Manager and his or her staff.

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Strategic Change Management

September 12th, 2010

 

A suggested change protocol

As with every faculty of study, there are numerous school’s of thought as to the methodology of change management. In order to determine a successful change protocol one must consider some of these school’s of thought.

Although there can be many goals of a planned change; fundamentally, the goals are: to improve the ability of the organisation by adapting to changes in its environment, and to seek a change in employee behaviour; with the ultimate goal of these changes to improve organisational effectiveness and efficiency (Kotter 1995, p.2-3).

According to Shani and Pasmore, the processes of change management include: ‘diagnosis, analysis, feedback, action and evaluation’ (1985, p. 438). Through the process of diagnosis, an organisation’s change agent, may gather information about the individual and groups perception of the possible change. Through analysis he or she may determine the main problems the individuals and groups within the organisation may focus in on. After this, the feedback stage requires the involvement of the individuals and groups (the employees) to develop a solution. The fourth stage, the action part, requires the change to be set in motion. The final step is evaluation, which determines the actual change’s effectiveness, and ultimately, has it made the organisation more effective and efficient?

At all times, the organisation should involve and gain the support of the people within the system. Management should understand where the organisation is at the moment; where it is desired to be, when, why, and what the measures will be for having got it there. According to Kotter, plans should be in place to ‘develop appropriate, achievable, and measurable stages of the change, while involving, enabling and facilitating the involvement of people, as early and openly as is possible’ (Kotter 1995, p.2-3).

Change must be realistic, achievable and measurable (Kotter 1995, p.6). These aspects are especially relevant to managing individual and group change. Before starting organisational change, an organisation must determine what it wants to achieve with this change; why, and how will it know that the change has been achieved. It then must address who is affected by this change, and how they will react to it. Lastly, how much of this change the organisation is capable of achieving independently, and what aspects of the change does it need specialist or outside help to achieve.

Lewin argued that ‘successful change in organisations should follow three steps: unfreezing from the status quo, movement to a new state, and then refreezing of the new status quo’ (as cited by Robbins et al 2004, p. 575). For example, when applying Lewin’s three step model to the recent change within Nepean Hospital, one may see that the status quo, or equilibrium is the perception that the only way to move a patient from a bed to a chair is to ‘physically lift’ and the cultural belief that ‘nurses are supposed to lift.’ To move from this ‘equilibrium, and overcome the pressures of individual resistance and group conformity requires unfreezing’ (Lewin, as cited by Robbins et al 2004, p. 575).

In order to unfreeze these concepts, the organisation may increase the driving forces that direct organisational behaviour away from the status quo. In this case the driving forces of the change includes the introduction of new technologies making it physically easier to utilize the technology of a Hover Mat, the nature of the workforce including the increased professionalism, the change in social trends increasing the amount of obese people in society today, and the economical and political benefits of decreasing the workers compensation claims associated with back injuries caused by poor manual handling methods. Through education, the organisation may change the perception of individuals and groups to understand the greater need for these changes.

Alternatively, the restraining forces, which decrease the movement from the existing equilibrium, may be decreased. In this circumstance, individual’s who oppose the change on cultural views, may be educated and in doing so, change their perception of the change. According to Kotter, ‘it is often individual’s who oppose change, where groups are merely conforming to individual’s views’ (1995, p.6). By changing the perception of individuals, groups that oppose the change, may dissipate, allowing for the unfreezing process to occur.

Furthermore, an organisation may apply both the previous concepts to promote the unfreezing process, and in doing so, the movement process, from the ‘old’ way of transferring a patient from a bed to a chair to the ‘new’ way is capable.

Lastly, as the movement ceases, equilibrium develops, and the refreezing process begins, and the new organisational cultural norms start to develop.

By considering these concepts, Nepean Hospital may be able to develop a change protocol to be used whenever the organisation intends to implement a change; regardless of whether or not it is going to affect the individual employee, group or organisational structure. By utilizing a change protocol, the organisation, may be able to implement change more successfully, by decreasing the resistance to the change by the individuals and groups and increasing effectiveness and efficiency of the organization. This a suggested change protocol:

1.            Determine the need for change

2.         Involve all employees in the process

3.            Determine possible problems associated with the change by communicating with the individuals and groups (employees of the organization)

4.            Determine possible solutions for overcoming the resistance to the change, whether it be by altering the change itself, or the perception of those who ultimately going to be affected by the change

5.            Implement the change

6.            Evaluate the change, to determine whether or not it has been successful; for example, has the organization become more or less effective as a result?

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Overcoming Resistance to Change

September 12th, 2010

This resistance is being overcome through education, communication, participation, facilitation and support.

Education has been promoted through the use of in-services on the product, its benefits and how to use it. Each unit within the organisation of Nepean Hospital utilized a Hover Mat liaison officer, who assisted with the ongoing education, and promoton of the product/ procedure. Education was further utilized by engaging each employee, who would actively utilize the product, by allowing him or her to experience the patient comfort benefit when being transferred from a bed to a chair by physically having a go of being the ‘pretend’ patient.

Communication was established between the employees and the organisation allowing both parties to discuss their concerns and their views of the new product and the procedures that were being implemented with its use. Some methods of communication included the use of employees filling out specific product questionnaires, and the use of Hover Mat liaison officer who actually participated in the use of Hover Mats within the unit allowing all concerns and viewpoints to be communicated at an informal, as well as formal level. 

According to Robbins et al, ‘it is hard for an individual to resist a change decision in which they participated’ (2004, p. 579). In this circumstance, many employees within Nepean Hospital were given the opportunity to participate within the decision making process by trialing the product before it was implemented, writing suggestions for what they would like the organisation to implement, and a problems that they could see with the change. 

Facilitation and support were offered to all employees, with specific attention to those who were resisting or opposing the change based on difficulty, or a lack of desire to learn new skills. Methods such as ensuring help was offered to use the new product when required, the use of a paid compulsory in-service, and continual positive reinforcement of the product were developed. 

Strategies that could be implemented to make the change go more smoothly

One of the main factors that could have made the change go more smoothly was if

employee participation was better utilized. Robbins et al notes that it is ‘difficult of individuals to resist a change decision in which they participated’ (2004, p.573). Management at SWAHS involved in the decision making process that ultimately decided in the use and implementation of the Hover Mat utilized this concept, by suggesting several means of overcoming the problem and allowing the employees to communicate which ones they would prefer.  Other methods of involving individual employees in the change decision, included the use of employees on the Hover Mat Implementation Committee; the downside to involving individuals of all levels within the organisation to participate within the decision making process is that they may not have the expertise required to objectively choose the best product and ultimately, this process will be more time consuming.

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Paramedic Resistence to Change

September 12th, 2010

Employees from all forms of organizations are reluctant to change. This is particularly the case with many paramedics, who have been trained an original way, and do not wish to change their views or their concepts on the topic of paramedic training.

Everytime there is a major change to Ambulance Practice, there are many “old school” paramedics who thoroughly resist the change.

This is particularly difficult in the profession of paramedics, because, like other forms of medicine, paramedicine is a very dynamic profession, which is currently improving and advancing in medical technologies.

Furthermore, with the adjunct of many new computer systems, such as Electronic Medical Records (EMR), Mobile Data Terminals (MDT) and modern diagnostic equipment paramedics require to maintain a dilegent openess towards change.

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Resistence to Change in an Organization

September 12th, 2010

According to Robbins et al ‘one of the most well-documented facts is that organisations and their members resist change’ (2004, p. 570). This was no exception within Nepean Hospital.

The individuals resisted the change by not wanting to put the Hover Mats underneath the patients because they found it a hassle, they forgot, or they thought it could be bad for the patients.  Furthermore, they resisted the concept that every patient being physically transferred from a bed to a chair must have a Hover Mat based on their habit of lifting, which had been developed over years of physically lifting patients, when required. The fear of the unknown was another factor of individual resistance. According to Robbins et al, ‘change substitutes ambiguity and uncertainty for the known’ (2004, p.572). In this case, people who had used the equipment before were not only unsure as to how to use it, but feared the concept of using it.

The groups of people resisted the change based on the erroneous cultural belief that ‘if you can’t lift you shouldn’t be a nurse.’ There was the cultural view from the older nurses that the young nurses are weak, and that the use of devices such as hover mats are further proving how weak the next generation of nursing is becoming. This, in turn, caused conflict, and degradation of the organisational team to individual groups. Based on this cultural belief, groups resisted the change, based more on group inertia than individual beliefs. This inertia was further developed by many union norms viewing the product as the organisation’s method of ‘passing the buck’ or putting the onus of a back injury on the individual employee.

The organisation, although promoting the new device, refused to pay for enough Hover Mats to be used by every patient, while putting the blame back on the individuals to ‘use the hover mats where needed or be liable for the injury you sustain.’

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Nursing Change

September 12th, 2010

The type of change was both a technological and a cultural one. Technologically, a means of physically moving a patient from a bed a to a chair had been developed and was now to be utilized, for easier and safer modes of conducting a procedure. This technology consisted of the ability to produce a small hover-craft effectively making it safer to transfer a patient from a bed to a chair and back again. Culturally, the change applied to the concept that as an organisation, for years it had been considered the organisational norm to be tough and physically capable of lifting and moving patients. The words ‘if you can’t lift them, you shouldn’t be nursing.’ were all too common. Where as now, the concept that is trying to be applied is ‘if you can’t lift them get mechanical assistance.’  

The driving force of the change

The driving forces of the change includes the introduction of new technologies making it physically easier to utilize the technology of a Hover Mat, the nature of the workforce including the increased professionalism, the change in social trends increasing the amount of obese people in society today, and the economical and political benefits of decreasing the workers compensation claims associated with back injuries caused by poor manual handling methods. The new technology was the invention of the ‘Hover Mat,’ which allowed the safer transfer of a patient from a bed to a chair and back again. 

The change in the nature of the workforce included over the years the introduction of degree trained nurses and with it increased professionalism, which pushed the unions to further decrease the amount of back injuries associated with nursing, as nurses were no longer looked upon as labourers.

The change in social trends involved societies developing increasingly sedentary lifestyles, while maintaining high food intakes, leading to increased obesity within society. This causes patients to be heavier and forces the drive for physical change in manual handling methods. Economical restraints have found that it is more viable to ensure a safer working environment than to spend vast amounts of money on workers compensation claims due to back injuries (Sydney Western Area Health Service 2005, p. 4).

Lastly, it was political necessary to show the general public that the health organisations were committed to decreasing the high level of back injuries due to poor manual handling devices and methods, as a failure to do so, would cause more and more persons, as well as those already within the industry to opt towards other career paths.

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Change Management

September 12th, 2010

 

Change related to the individual, group and organisation

This change affects the individual, group and the organisation in many aspects. However, it most greatly affects the individual and the group. This change affects the individual based on their day to day work protocols and procedures; in doing so, it causes them to forget the old way of completing a task, and develop the new skills involved in performing the new way. It also affects the individual based on their cultural expectations, such as the concept that one must be physically strong in order to be a nurse.

It affects the group based on their work protocols and procedures when transferring a patient, as well as affecting their cultural beliefs regarding what defines a nurse. It affects the decision making process of people within the group, based on what they previously believed to be an okay physical requirement. It affects the group in the way they work together, because there will be some who repudiate the cultural change, and this may affect the group, because others may wish to conform. For example, some individuals within the groups, may wish to boycott the new technology and views associated with it, and because of the minority’s desire to conform to the group, groups of nurse will not utilize the new technology.

Lastly, it affects the organistion in the way it structures protocols. For example, number of staffing required during a transfer may be reduced. Furthermore, due to conflicting views off the change, the introduction of conflict within the organization may develop; and, depending on the outcome of this conflict, it may be either good or bad for the organisation (Capozzoli 1995, p. 2).

Analysis of organisational change in terms of work culture and ethical considerations

According to Robbins et al, work culture may be defined as ‘a system of shared meaning held by members that distinguishes the organization from other organisations’ (2004, p.439). In Nepean Hospital, there are many work cultures that distinguishes the organisation from that of other organisations; however, with reference to this specific change, the most prominent shared meaning is ‘that to be a nurse, you must be physically tough.’ This organsiational change has affected the organisational culture by shifting the old meaning of a nurse as ‘becoming tougher if he or she can’t lift,’ to the new concept of ‘nurses require technologies, not strength.’

According to Preston ethics may defined as ‘doing what is right, fair, just or good; what we should do, not just what is the case or what is the most acceptable or expedient’ (2001 p.18). Although ethics, by their sheer nature, are arguable, and open to the specific perception of the individuals viewing them, many can argue that this change has been ethically right and beneficial. In this case, the change to Nepean Hospital may be considered ethically right, based on the concepts of utilitarianism, which is the ‘goal of providing the greatest good for the greatest number’ (Robbins et al 2004, p.151). This is because it improves the working conditions of all the employees involved or directly affected by the change, as well as making it safer for those patients who require the use of the changed technology as a patient.

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Change Management

September 12th, 2010

The following paper will identify and describe a recent change to work practice in the organisation Nepean Hospital. It will then relate that change primarily to the individual and group, and briefly, the organisation. An analysis of the change in terms of the concept of organisational change will be discussed, focusing primarily on: the type of change, the force driving the change, the resistance to the change, how this was overcome, and, what strategies could be implemented to enable the change to go smoothly next time. Lastly, a change protocol will be suggested for future changes within Nepean Hospital.

Change identified and described

Nepean hospital is a professional bureaucracy, because it relies on the coordination and standardization of skills and its associated design parameter, training and indoctrination. It hires duly trained and indoctrinated specialists and professionals, for the operating core, and then gives them considerable control over their work. For example, the Doctors and Nurses have a reasonable level of autonomy and, while working somewhat independently of their colleagues, work closely with the clients he or she serves (Robbins and Barnwell 2002, p. 487-8).

As part of a day-to-day activity in Nepean Hospital unconscious or immobile patients of all sizes and weights are transferred from their beds to chairs so as they can be sat up for better lung expansion. Until recently, this process has been accomplished primarily by two methods. These methods were: the ‘Top and Tail’ carry, which involved physically carrying the patient from the bed to the chair with two nurses, and the ‘Pat Slide,’ which involves physically sliding them across with a draw sheet. Both of these methods involved considerable strength and carried with them the risk of back injuries.

According to Sanders ‘decision making occurs as a reaction to a problem’ (1999, p. 44); this is where there is a discrepancy between some current state of affairs and some desired state, requiring the consideration of an alternative course of action (change). It can therefore be seen that ‘the awareness that a problem exists and that a decision needs to be made is a perceptual issue’ (Robbins et al 2004, p. 139). At this stage in the development of the organisation, Nepean Hospital, it was determined that there is a problem with the current methodology of moving a patient from a bed to a chair.

As a reaction to this problem, and the fact that considerable workers compensation claims were being made, the invention of the ‘Hover Mat’ occurred, which involves an inflatable sheet that may act as a hover craft ensuring much easier and safer transfers of patients. And in 2001 it was implemented as the only method of transferring immobile patients (who don’t have a spinal injury) from a bed to chair. The change in itself removed the old concept that you must be stronger and tougher if you want to successfully transfer a patient, to the new concept that you must make it safe to do so, regardless of your strength by using a ‘Hover Mat.’

The type of change in this circumstance was both a technological and cultural change. This is because it required the removal of the old knowledge on how to physically transfer a person from a bed to a chair and the indoctrination or education of the new technological way to move a person from a bed to a chair. It also required the cultural change, from the old view that ‘if you’re not tough, you shouldn’t be nursing’ and ‘it’s the nurses job to lift’ to the new view that you must ‘take care of your back, ’and  ‘if you can’t easily and safely lift it, use technology that can.’

Change related to the individual, group and organisation

This change affects the individual, group and the organisation in many aspects. However, it most greatly affects the individual and the group. This change affects the individual based on their day to day work protocols and procedures; in doing so, it causes them to forget the old way of completing a task, and develop the new skills involved in performing the new way. It also affects the individual based on their cultural expectations, such as the concept that one must be physically strong in order to be a nurse.

It affects the group based on their work protocols and procedures when transferring a patient, as well as affecting their cultural beliefs regarding what defines a nurse. It affects the decision making process of people within the group, based on what they previously believed to be an okay physical requirement. It affects the group in the way they work together, because there will be some who repudiate the cultural change, and this may affect the group, because others may wish to conform. For example, some individuals within the groups, may wish to boycott the new technology and views associated with it, and because of the minority’s desire to conform to the group, groups of nurse will not utilize the new technology.

Lastly, it affects the organistion in the way it structures protocols. For example, number of staffing required during a transfer may be reduced. Furthermore, due to conflicting views off the change, the introduction of conflict within the organization may develop; and, depending on the outcome of this conflict, it may be either good or bad for the organisation (Capozzoli 1995, p. 2).

Analysis of organisational change in terms of work culture and ethical considerations

According to Robbins et al, work culture may be defined as ‘a system of shared meaning held by members that distinguishes the organization from other organisations’ (2004, p.439). In Nepean Hospital, there are many work cultures that distinguishes the organisation from that of other organisations; however, with reference to this specific change, the most prominent shared meaning is ‘that to be a nurse, you must be physically tough.’ This organsiational change has affected the organisational culture by shifting the old meaning of a nurse as ‘becoming tougher if he or she can’t lift,’ to the new concept of ‘nurses require technologies, not strength.’

According to Preston ethics may defined as ‘doing what is right, fair, just or good; what we should do, not just what is the case or what is the most acceptable or expedient’ (2001 p.18). Although ethics, by their sheer nature, are arguable, and open to the specific perception of the individuals viewing them, many can argue that this change has been ethically right and beneficial. In this case, the change to Nepean Hospital may be considered ethically right, based on the concepts of utilitarianism, which is the ‘goal of providing the greatest good for the greatest number’ (Robbins et al 2004, p.151). This is because it improves the working conditions of all the employees involved or directly affected by the change, as well as making it safer for those patients who require the use of the changed technology as a patient.

The type of change

The type of change was both a technological and a cultural one. Technologically, a means of physically moving a patient from a bed a to a chair had been developed and was now to be utilized, for easier and safer modes of conducting a procedure. This technology consisted of the ability to produce a small hover-craft effectively making it safer to transfer a patient from a bed to a chair and back again. Culturally, the change applied to the concept that as an organisation, for years it had been considered the organisational norm to be tough and physically capable of lifting and moving patients. The words ‘if you can’t lift them, you shouldn’t be nursing.’ were all too common. Where as now, the concept that is trying to be applied is ‘if you can’t lift them get mechanical assistance.’

The driving force of the change

The driving forces of the change includes the introduction of new technologies making it physically easier to utilize the technology of a Hover Mat, the nature of the workforce including the increased professionalism, the change in social trends increasing the amount of obese people in society today, and the economical and political benefits of decreasing the workers compensation claims associated with back injuries caused by poor manual handling methods. The new technology was the invention of the ‘Hover Mat,’ which allowed the safer transfer of a patient from a bed to a chair and back again.

The change in the nature of the workforce included over the years the introduction of degree trained nurses and with it increased professionalism, which pushed the unions to further decrease the amount of back injuries associated with nursing, as nurses were no longer looked upon as labourers.

The change in social trends involved societies developing increasingly sedentary lifestyles, while maintaining high food intakes, leading to increased obesity within society. This causes patients to be heavier and forces the drive for physical change in manual handling methods. Economical restraints have found that it is more viable to ensure a safer working environment than to spend vast amounts of money on workers compensation claims due to back injuries (Sydney Western Area Health Service 2005, p. 4).

Lastly, it was political necessary to show the general public that the health organisations were committed to decreasing the high level of back injuries due to poor manual handling devices and methods, as a failure to do so, would cause more and more persons, as well as those already within the industry to opt towards other career paths.

Describe the resistance to the change

According to Robbins et al ‘one of the most well-documented facts is that organisations and their members resist change’ (2004, p. 570). This was no exception within Nepean Hospital.

The individuals resisted the change by not wanting to put the Hover Mats underneath the patients because they found it a hassle, they forgot, or they thought it could be bad for the patients.  Furthermore, they resisted the concept that every patient being physically transferred from a bed to a chair must have a Hover Mat based on their habit of lifting, which had been developed over years of physically lifting patients, when required. The fear of the unknown was another factor of individual resistance. According to Robbins et al, ‘change substitutes ambiguity and uncertainty for the known’ (2004, p.572). In this case, people who had used the equipment before were not only unsure as to how to use it, but feared the concept of using it.

The groups of people resisted the change based on the erroneous cultural belief that ‘if you can’t lift you shouldn’t be a nurse.’ There was the cultural view from the older nurses that the young nurses are weak, and that the use of devices such as hover mats are further proving how weak the next generation of nursing is becoming. This, in turn, caused conflict, and degradation of the organisational team to individual groups. Based on this cultural belief, groups resisted the change, based more on group inertia than individual beliefs. This inertia was further developed by many union norms viewing the product as the organisation’s method of ‘passing the buck’ or putting the onus of a back injury on the individual employee.

The organisation, although promoting the new device, refused to pay for enough Hover Mats to be used by every patient, while putting the blame back on the individuals to ‘use the hover mats where needed or be liable for the injury you sustain.’

How this resistance was overcome

This resistance is being overcome through education, communication, participation, facilitation and support.

Education has been promoted through the use of in-services on the product, its benefits and how to use it. Each unit within the organisation of Nepean Hospital utilized a Hover Mat liaison officer, who assisted with the ongoing education, and promoton of the product/ procedure. Education was further utilized by engaging each employee, who would actively utilize the product, by allowing him or her to experience the patient comfort benefit when being transferred from a bed to a chair by physically having a go of being the ‘pretend’ patient.

Communication was established between the employees and the organisation allowing both parties to discuss their concerns and their views of the new product and the procedures that were being implemented with its use. Some methods of communication included the use of employees filling out specific product questionnaires, and the use of Hover Mat liaison officer who actually participated in the use of Hover Mats within the unit allowing all concerns and viewpoints to be communicated at an informal, as well as formal level.

According to Robbins et al, ‘it is hard for an individual to resist a change decision in which they participated’ (2004, p. 579). In this circumstance, many employees within Nepean Hospital were given the opportunity to participate within the decision making process by trialing the product before it was implemented, writing suggestions for what they would like the organisation to implement, and a problems that they could see with the change.

Facilitation and support were offered to all employees, with specific attention to those who were resisting or opposing the change based on difficulty, or a lack of desire to learn new skills. Methods such as ensuring help was offered to use the new product when required, the use of a paid compulsory in-service, and continual positive reinforcement of the product were developed.

Strategies that could be implemented to make the change go more smoothly

One of the main factors that could have made the change go more smoothly was if

employee participation was better utilized. Robbins et al notes that it is ‘difficult of individuals to resist a change decision in which they participated’ (2004, p.573). Management at SWAHS involved in the decision making process that ultimately decided in the use and implementation of the Hover Mat utilized this concept, by suggesting several means of overcoming the problem and allowing the employees to communicate which ones they would prefer.  Other methods of involving individual employees in the change decision, included the use of employees on the Hover Mat Implementation Committee; the downside to involving individuals of all levels within the organisation to participate within the decision making process is that they may not have the expertise required to objectively choose the best product and ultimately, this process will be more time consuming.

A suggested change protocol

As with every faculty of study, there are numerous school’s of thought as to the methodology of change management. In order to determine a successful change protocol one must consider some of these school’s of thought.

Although there can be many goals of a planned change; fundamentally, the goals are: to improve the ability of the organisation by adapting to changes in its environment, and to seek a change in employee behaviour; with the ultimate goal of these changes to improve organisational effectiveness and efficiency (Kotter 1995, p.2-3).

According to Shani and Pasmore, the processes of change management include: ‘diagnosis, analysis, feedback, action and evaluation’ (1985, p. 438). Through the process of diagnosis, an organisation’s change agent, may gather information about the individual and groups perception of the possible change. Through analysis he or she may determine the main problems the individuals and groups within the organisation may focus in on. After this, the feedback stage requires the involvement of the individuals and groups (the employees) to develop a solution. The fourth stage, the action part, requires the change to be set in motion. The final step is evaluation, which determines the actual change’s effectiveness, and ultimately, has it made the organisation more effective and efficient?

At all times, the organisation should involve and gain the support of the people within the system. Management should understand where the organisation is at the moment; where it is desired to be, when, why, and what the measures will be for having got it there. According to Kotter, plans should be in place to ‘develop appropriate, achievable, and measurable stages of the change, while involving, enabling and facilitating the involvement of people, as early and openly as is possible’ (Kotter 1995, p.2-3).

Change must be realistic, achievable and measurable (Kotter 1995, p.6). These aspects are especially relevant to managing individual and group change. Before starting organisational change, an organisation must determine what it wants to achieve with this change; why, and how will it know that the change has been achieved. It then must address who is affected by this change, and how they will react to it. Lastly, how much of this change the organisation is capable of achieving independently, and what aspects of the change does it need specialist or outside help to achieve.

Lewin argued that ‘successful change in organisations should follow three steps: unfreezing from the status quo, movement to a new state, and then refreezing of the new status quo’ (as cited by Robbins et al 2004, p. 575). For example, when applying Lewin’s three step model to the recent change within Nepean Hospital, one may see that the status quo, or equilibrium is the perception that the only way to move a patient from a bed to a chair is to ‘physically lift’ and the cultural belief that ‘nurses are supposed to lift.’ To move from this ‘equilibrium, and overcome the pressures of individual resistance and group conformity requires unfreezing’ (Lewin, as cited by Robbins et al 2004, p. 575).

In order to unfreeze these concepts, the organisation may increase the driving forces that direct organisational behaviour away from the status quo. In this case the driving forces of the change includes the introduction of new technologies making it physically easier to utilize the technology of a Hover Mat, the nature of the workforce including the increased professionalism, the change in social trends increasing the amount of obese people in society today, and the economical and political benefits of decreasing the workers compensation claims associated with back injuries caused by poor manual handling methods. Through education, the organisation may change the perception of individuals and groups to understand the greater need for these changes.

Alternatively, the restraining forces, which decrease the movement from the existing equilibrium, may be decreased. In this circumstance, individual’s who oppose the change on cultural views, may be educated and in doing so, change their perception of the change. According to Kotter, ‘it is often individual’s who oppose change, where groups are merely conforming to individual’s views’ (1995, p.6). By changing the perception of individuals, groups that oppose the change, may dissipate, allowing for the unfreezing process to occur.

Furthermore, an organisation may apply both the previous concepts to promote the unfreezing process, and in doing so, the movement process, from the ‘old’ way of transferring a patient from a bed to a chair to the ‘new’ way is capable.

Lastly, as the movement ceases, equilibrium develops, and the refreezing process begins, and the new organisational cultural norms start to develop.

By considering these concepts, Nepean Hospital may be able to develop a change protocol to be used whenever the organisation intends to implement a change; regardless of whether or not it is going to affect the individual employee, group or organisational structure. By utilizing a change protocol, the organisation, may be able to implement change more successfully, by decreasing the resistance to the change by the individuals and groups and increasing effectiveness and efficiency of the organization. This a suggested change protocol for Nepean Hospital,

1.            Determine the need for change

2.         Involve all employees in the process

3.            Determine possible problems associated with the change by communicating with the individuals and groups (employees of the organization)

4.            Determine possible solutions for overcoming the resistance to the change, whether it be by altering the change itself, or the perception of those who ultimately going to be affected by the change

5.            Implement the change

6.            Evaluate the change, to determine whether or not it has been successful; for example, has the organization become more or less effective as a result?

Conclusion

The following paper has identified and described a recent change to work practice in the organisation Nepean Hospital. In this case, the change has been both technological and cultural through the introduction of a technology and technique (the Hover Mat). It then related that change to the individuals, groups and the organization structure.  An analysis of the change in terms of the concept of organisational change was then discussed, focusing primarily on the concepts of: type of change, force driving the change, resistance to change, how this was overcome, and, what strategies could be implemented to enable the change to go smoothly next time. Lastly, a change protocol was suggested for future changes in within Nepean Hospital.

References

Capozzali, K. 1995, Resolving Conflict Within Teams, Journal for Quality and Participation, Dec Ed

Forrest, L. and Johnstone, L. 2004, Health Services Organisations DE Modules, Charles Sturt University Printing, Bathurst

Kotter, J. 1995, Leading Change, Harvard Business School Press, USA

Preston, N. 2001, Understanding Ethics, 2nd ed, The Federation Press, Annandale, Australia

Robbins, S. Millett, B. Waters-Marsh, T 2004, Organisational Behvaviour, Pearson’s Education Australia, NSW, Australia

Robbins, P. and Barnwell, N. 2002, Orgnaisation theory: concepts and cases, 4th Ed, Prentice Hall, Sydney

Robbins, P. Bergman, R. Stagg, I. and Coulter, M. 2000, Management, Prentice Hall, Sydney

Sanders, R. 1999, The Executive Decision-making Process: Identifying Problems and Assessing Outcomes, CT Quorum, Westport

Shani, A. and Pasmore W. 1985, Contemporary organizational Development: Current Thinking and Applications, Trinity College Printing, Barcelona

Sydney Western Area Health Service 2005, Mission Statement,

http://www.pnc.com.au/~wamhs/whatiswahms.htm, last updated 3/2/2005, viewed on the 12/9/05

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Power Bases

September 12th, 2010

 

There are seven bases for power, with four being formal and three being personal (Robbins et al 2004, p.394-6). These include: coercive, reward, legitimate, information, expert, referent, and charismatic power.

Coercive power is primarily dependant on fear. In this respect an employee is influenced by another person based on their fear of what might occur if they do not comply. An example in ICU may be a manager who asks you to do him or her a favor, and there is a fear that a refusal may mean that you will not get the promotion you have been expecting.

Reward power may be seen as the opposite to coercive power, in the sense that it deals with achieving one’s goals by being compliant. In ICU an example of this may be when it is not busy, a NUM may tell a nurse ‘if you check and re-stock the resuscitation trolleys you may go early.’ 

Legitimate power is similar to one’s authority, because it represents the formal authority a person has over another person based on their position within the organisation’s hierarchy. An example of this may be a clinical NUM asking, or assigning a nurse to look after a certain patient or patients.

Information power is the result of power obtained through a control of information that others need or are dependent on. For example, the store-person in ICU has a certain level of power based on the fact he is the only person who knows where to order all of the organisations supplies, therefore making the organisation dependant on him.

Expert power refers to the influence a person may have if they have a special skill or knowledge that is rare and required. For example, a computer programmer who has been employed to set up a specific computer system in ICU to monitor each patient’s vital signs, who may be one of a hand full of people with the expertise to do such a task will have enormous expert power, based on the organisation’s dependence on his or her skill.

Referent power has to do with genuinely liking someone, and wanting that person to like you back. For example, an exceptional doctor or physiotherapist who you want to be like will have a certain level of referent power based on your desire for them to like you. Inadvertently, you will want to do what they want you  to do.

Charismatic power is virtually referent power based on an individual’s personality and interpersonal style being that which others respect and admire. An example of this may be the manager whose charisma, and general personality, allows everyone to want to work for him or her and be genuinely happy to do what he or she wants them to do.

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Organisational Politics

September 12th, 2010

Factors that contribute to political behavior in organisations may be both individual and organisational in nature. Individual factors include: an inability to progress through the hierarchy via normal methods of advancement, personal investment into the organization and higher likelihood of success through illegitimate influences (Langdon and Marshal 1998, p. 122; Robbins et al 2004, p.405-7). According to Langdon and Marshal, it has often been said that ‘employees resort to political behaviour when they feel that their career will not move ahead through competence, hard work or sheer luck’ (1998, p.121). In this respect, individuals attempt to influence other people in order to gain power and motivate their own advancement. Some people may have investments in the organisation or another organisation that directly relates to their employment, therefore rely on politics to influence and exert their power to directly gain from the organisations advancement. Lastly, people may find it physically easier to manipulate their influence over the organisation in order to advance more rapidly than a legitimate method.

Organisational factors include: when the organisation’s resources are limited, when the pattern or resources have changed or are changing, and when there is an opportunity for promotions (Robbins et al 2004, p.407). When an organisation’s resources are limited someone is going to go short, and everyone believes that they shouldn’t have to. Common resources include: departmental budgets, salaries, space allocations, responsibilities, human resources, and equipment. When there is a shortage many believe that ‘the facts that are used to allocate resources are open to interpretation and manipulation’ (Robbins et al 2004, p.403). An example of this in Nepean Hospital may be where there are only 15 ‘syringe drivers’ in the hospital, but 20 nurses require them for their patients and therefore some nurses may resort to political behaviour to ensure that they do not miss out. When the pattern of resources change or are changing, individuals may see this as an opportunity to increase their department’s resources. Lastly, when there is an opportunity for promotion, many individuals will utilize political behaviour to ensure that they have a greater likelihood of achieving that advancement.

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Power and Authority

September 12th, 2010

Power may be seen as ‘the capacity that A has to influence the behavior of B, so that B acts in accordance to A’s wishes’ (Bass and Stogdill, as cited by Robbins et al 2004, p.394). In Nepean Hospital this power may be given to the Clinical Nurse Unit Manager (NUM) and allows the NUM to influence the behavior of the nurses, wardspersons, and in many respects the doctors who work for the organisation. One of the most fundamental factors of power is that of dependency. In the example of person A and B, this refers to B’s relationship to A when A possesses something that B requires (Bass and Stogdill 20004, p. 394). In this case, persons (employees) may be dependant on the income, which is exchanged for hours at work, or promotion, as being more or less likely, based on their ability to follow the NUM’s decisions.

Authority is primarily associated with legitimate power, such as a manager using his or her power to direct employees. Therefore authority still refers to a person having influence over others, but that this influence is legitimate; where as power in itself may be used by anyone who is capable of influencing others.

Influence is neither power or authority, but a method of developing such power or authority. Through influence, power is achieved. For example, a person who does not have the authority to influence power over another employee may find they are capable of influencing another person by offering something that the other person is dependent on.

Politics may be described as power in action, or a means of achieving one’s goal through influence and power. Through political behavior people are able to ‘influence or attempt to influence the distribution of advantages and disadvantages within the organisation’ (Farrell and Petersen 1982, p.405). This is often done without authority.

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Conflict Resolution

September 12th, 2010

According to the Oxford English Dictionary conflict may be defined as ‘the clashing or variance of opposed principles or beliefs’ (2002, p. 484). Conflict, in itself, may be both good and bad; however the physical outcome of that conflict determines whether or not such a conflict is constructive or destructive.

Advantages of conflict can include:

  1. People change and grow personally from the conflict
  2. The conflict results in a solution to a problem
  3. It increases the involvement of everyone affected by the conflict
  4. It builds cohesiveness among the members of a team

(Capozzoli 1995, p. 2).

For example, as most conflicts are the result of clashing opinions or principles one of the possible advantages of conflict, if properly resolved, may involve the personal growth and development by changing an individual or group’s perception of something. Furthermore, this resolution may actually result in the development of a solution to a problem. Although not always the case, conflict may at times, increase the involvement of everyone within a group or organization. Lastly, through its resolution, a group or organsation may develop a more cohesive relationship.

Disadvantages of conflict may include:

  1. No decision is reached and the problem still exist
  2. It diverts energy from more value adding activities or issues
  3. It destroys the morale of teams or individual teams members
  4. It polarizes or divides teams or groups of people.

(Capozzoli 1995, p. 2).

When no decision is reached and the problem remains group separation may result, while no solution to the problem actually develops. Also, when the conflict begins to divert energy from the more valuable activities, conflict become disadvantageous and ultimately, detrimental to the effective and efficient goal outcomes of the organisation. When conflict starts to destroy the morale of teams or individual team members, it degrades the positive perception of those within the organisation, and furthermore decreases the goal outcomes of the organization. Lastly, disadvantageous conflict may polarize or divide teams within the organsation, resulting in a reduced overall team, and the production of more groups of people (as opposed to teams).

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Effective Communication Skills

September 12th, 2010

Upward communication relates to the movement of information from people of a lower level on the organisation’s hierarchy, such as the lower level employees: clinical nurses, wardspersons, and wardclerks to those at the higher end of the hierarchy, such as the managers, directors, and chief executive officers (CEOs). Upwards communication refers to such things as suggestions, made to the lower level managers; or complaints, which are then sent upwards toward management. In contrast, downward communication deals with the movement of information from those at the higher end of the hierarchy to those at the lower end such as standing orders, when to have your meal breaks and basic organisational decisions made.

Upwards communication could be analogized with sending a computer the information with which it makes a decision, where the lower level employees are sending the managers information about the good things and the bad things about the organisation at a day to day level, and the managers are receiving it as a means of making decisions, which they will then process and pass back downwards as orders.

To understand the various forms of communication barriers, one must first understand the elements of communication and consider that a barrier exists when one or more of these elements are interrupted. According to Brown and Forrest, the main elements of communication are: ‘the communicator, encoding, the message, the medium, decoding, the receiver and the feedback’ (2005, p.83). Specific forms of communication barriers include, but are not limited to: filtering, selective perception, frame of reference, selective listening, value judgments, source credibility, semantic problems, filtering, language, status differences, proxemic behaviour, time pressures, stress, and communication overload. 

Filtering is when a message sender (the communicator) purposefully manipulates information so that it is received more favorably by the message recipient (the receiver). A basic example of this at Nepean Hospital would be where an intern or young doctor fails to successfully put a central venous line in, but says to his or her superior doctor, ‘I’ve gotten five of those in today,’ but neglected to mention that he had attempted it on twenty patients.

Selective perception is when a person receives information selectively based on ‘their needs, motivations, experience, background, and other characteristics’ (Robbins et al 2004, p. 320). For example, one may selectively perceive that he or she is being attacked because the manager is speaking very loudly, and based on previous experiences he or she perceives this to mean that they are angry, when it may not be so.

Communication overload is where more information is communicated than can be physically processed by the individuals receiving that information, such as a manager being told about several problems that must be rectified immediately during a five minute period.

Language barriers deal with the concept that words may ‘mean different things to different people’ (Robbins et al 2004, p. 320), allowing them to misunderstand simple communications. A basic example may be that a manager hears the statement that ‘I didn’t come to work yesterday because I was hit by a bat while teaching my son to play’ and the receiver receives the image of the person being hit by a flying bat and decides he must be lying, because bats attack people.

Emotions determine how a person receives a message. For example, a person who is feeling happy will often receive a message of criticism better than a person who is already feeling angry and upset.

Examples of common communication barriers evident at Nepean ICU include: high levels of stress, communication overload, noise barriers, time constraints and selective listening. For example, the stress that if you do not receive the communication properly (such as a type of drug and its dose) you may kill a person increases the difficulty in understanding a communication. Often, because of the nature of intensive care patients may often have many things required simultaneously, such as taking down the patient’s vital sign observations, administering Nor Adrenaline, taking a blood sugar level, raising their temperature with a Bair Hugger, and ensuring the patient’s relatives know what’s going on, which all leads to information overload. Noise is another major communication barrier because there are numerous alarms, people speaking, and other sounds within the environment therefore causing a barrier at the medium. Time constraints on communication may cause a barrier. For example, when you are giving a hand over to another nurse or doctor about a patient’s medical history, you know that you have only a limited amount of time to spend doing so, and in that time you must communicate all the necessary information. Selective listening may be a barrier, especially when there has been a recent change to protocols or doctors. For example, when a person has been used to administering most drugs with normal saline, and all of a sudden the doctor requests it to be administered with Hartmans fluid one may inadvertently ‘hear’ normal saline.

The most common and important strategies implemented for overcoming these communication barriers are the use of communication feedback techniques, such as double and triple checking drug type and doses. For example, if the doctor (the communicator) asks for ‘2.5mg of morphine IV’ you should routinely then check via a communication feedback system and ask ‘2.5mg of morphine IV?’ Alternatively, if it is a written communication, you may then check for yourself that it states ‘2.5 mg of morphine IV’ and then give that piece of written communication to another colleague and ask them to tell you what it says.

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Group Decision Making

September 12th, 2010

As with many choices or schools of thought, there is no right or wrong answer all the time. In some circumstances groups make better decisions than individuals; however, it can also be seen that in some circumstances individuals make better decisions than groups. As a group, there is an increased capability to develop alternatives to a problem, but due to the larger number of people involved in the rational decision making-process, evaluating and selecting the best alternative may take a larger amount of time. This increase in time may be due to internal conflicts and pressures of attempting to conform.

It can be seen that groups make better decisions based on the following concepts: the ability to utilize a greater amount of knowledge due to an aggregation of the resources of several individuals; the ability to develop a larger diversity of views; greater acceptance of a solution; and an increased legitimacy, due to a decision-making process that is consistent with democratic ideals (Robbins et al 2004, p. 261).

Likewise, it can be seen that groups make poor decisions based on the following concepts: an increased time consumption when dealing with a group decision making process, as opposed to one decision maker; the pressure to conform amongst individuals within the group cause a withholding of actual decisions; the domination by the few may block the good ideas of the many; lastly, ambiguous responsibility means that no one person is responsible for the end product (Robbins et al 2004, p. 261-2).

Group structure determines the behavior of members and makes it possible to explain and predict a large portion of individual behavior within the group. Some of the variables of a group structure include: ‘formal leadership, roles, norms, status, group size and composition of the group’ (Robbins et al 2004, p. 248).

Groupthink determines how a group deals with group norms, such as situations in which the high pressure for conformity deters the group from critically evaluating unusual, minority or unpopular views (Robbins et al 2004, p. 248-9). An example of this in a health organization may be a group of doctors trying to determine how to medically treat a patient who is both an alcoholic and a drug addict. Based on group perception, of these clients ‘bringing it all upon themselves.’ Thus, individuals within the group, in their need to conform to the group’s perception may not act appropriately or ethically, where as an individual may respond differently.

Group decision-making techniques include: interacting groups, brainstorming, and nominal group techniques (Robbins et al 2004, p.265). In interacting groups many participants censor their ideas; however, through brainstorming individuals are encouraged to develop all alternatives, reducing conformity and providing the most number of alternatives. Unfortunately, this may result in an overload of possible decisions. Lastly, the use of nominal group techniques relates to the concept of group decision-making in which individual members put forward their ideas and their alternatives in an objective manner, without the restriction of discussion and interpersonal communication.

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Ethical Decision Making

September 12th, 2010

What is ethical? According to the Oxford English Dictionary the term ethical may be defined as: ‘of or pertaining to morality or the science of ethics; pertaining to morals’ (2002, p. 864). However, based on this definition, an ethical person may be different based on the country, culture, and ultimately, that person’s perspective and the perspective of those people living in that person’s environment. What one person may view as ethical in Asia may not be perceived as ethical in Australia and vice versa.

Fundamentally, unethical decisions are a function of the individual decision maker, who has low ethical principles; however, what is considered ethical or unethical may change based on a person’s work environment, such as the country he or she lives or works within, the culture of that environment and what is considered to be the organisational norm.

Cavanagh, Moberg and Valasquez suggest ‘an individual can use three different criteria in making ethical choices’ (1981, p. 265). These include: utilitarianism, which is the goal to provide the greatest good for the greatest number of people (Robbins et al 2004, p. 151); rights, which calls upon individuals to make decisions consistent with fundamental liberties, such as the right to privacy, free speech and due process; and justice, which requires individuals to impose and enforce rules fairly and impartially so that there can equitable distribution of benefits and costs.

 According to Kohlberg the ‘evidence indicates that people with high ethical principles will follow them in spite of what others do or the dictates of organisational norms’ (cited by Robbins et al 2004, p. 152). However, it is just as evident that if a ‘person’s ethical development is not of the highest level, he or she is more likely to be influenced by strong cultures’ (Robbins et al 2004, p. 152-3).

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Rational Decision Making

September 12th, 2010

Individuals in an organisation make decisions, based on two or more alternative choices. According to Sanders ‘decision making occurs as a reaction to a problem’ (1999, p. 44); this is where there is a discrepancy between some current state of affairs and some desired state, requiring the consideration of an alternative course of action. It can therefore be seen that ‘the awareness that a problem exists and that a decision needs to be made is a perceptual issue’ (Robbins et al 2004, p. 139). This is because the need to choose, and the decision between the two that is eventually derived, is based on the decision maker’s perception of what is the best decision. In order to do this successfully, every decision must require the interpretation and evaluation of information (Robbins et al, 2004, p. 139). Furthermore, successful decision-making requires the three components of creativity. These include, ‘expertise, creativity skills and task motivation’ (Amabile 1997, p. 43)

The optimum decision maker is rational. According to Simon a rational decision maker is one who ‘makes consistent, value-maximising choices within specified constraints’ (1986, p. 209).  The most prominent key to developing the most rational decision, is to have a thorough understanding of the processes required to develop such a decision and this key can be developed by understanding the six steps in the rational decision-making model (Harrison 1999, p. 76).

These include:

  1. define the problem
  2. identify the decision criteria
  3. allocate weights to the criteria
  4. develop the alternatives
  5. evaluate the alternatives
  6. select the best alternative

(Harrison 1999, p. 76)

One unit of Nepean Hospital is its Intensive Care Unit (ICU). Part of the daily routine within ICU requires frequent manual handling of the unconscious or unable to move patients as a prophylaxis to pressure area sores. Due to the growing rate of obesity in society, many clients weigh in excess of 150kgs, making it both physically difficult and dangerous to roll the patients and slide them up the bed.  Based on the rational decision-making model, the first step has been determined: it is unsafe to manually move the patients of this weight.

Now the second step is to determine a decision criteria, in this case: to develop a means of safely moving an unconscious client who weighs in excess of 150kgs, to do so in a cost effective manner, keep the human resources required to a minimum, and be capable of doing it in a time effective manner.

The third step in this process is to allocate weights to the criteria. In this case, the most important criteria is to be able to move the unconscious client who weighs in excess of 150kgs safely, followed by doing so in a cost effective manner, with the least amount of time involvement, lastly followed by doing so with the least amount of human resources.

The fourth stage is to develop the alternatives. These can include: utilize an air mattress that reduces the frequency in which you must move the patient, utilize a bed that has good tilting options, allowing for the use of gravity assisted movement, the utilization of hover mattresses that decrease the physical effort of moving a patient, the use of a Jordan Frame to mechanically lift the patient and the use of 4 to 6 employees where 2 would be sufficient for a lighter patient.

The fifth stage is now to ‘evaluate and analyze the alternatives by rating each alternative on each criterion’ (Robbins et al 2004, p. 140). In this case, the first option of an air mattress would be useful by decreasing the frequency in which employees must move the patient; however, it does not make it easier of safer when they do have to; furthermore, the cost of hiring such a bed may be very dear on economic restraints, but it will be more efficient on human resources. The second option would be beneficial in reducing the danger in moving such a patient, however, many patients in ICU are not able to be tilted downwards due to head injuries and poor lung function, making such an option poor for the patient’s safety; however based on both financial and human constraints this would be an excellent option in many cases. The third option allows the mattress to inflate with air acting as a hovercraft and making it physically much easier to move the patient. This makes it safer. Economically, it requires some original outlay, but can be used on literally thousands of patients so long as it is properly cleaned, as well as allowing less employees to be required when moving the patient, and doing so in a time effective manner. Lastly, the use of a Jordan Frame, does provide a very safe manner of moving a patient, with reasonable small financial cost, minimal human resource expenditure, but excessive time involvement.

The last stage in the process of determining a rational decision is to select the best alternative. In this, case the third option, being that of the hover mattress achieves the highest score when evaluating each alternative against the weighted criteria.

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Employee Perception

September 12th, 2010

According to Robbins, perception can be defined as ‘a process by which individuals organise and interpret their sensory impressions in order to give meaning to their environment’ (2004, p. 132). Perception is not necessarily based on reality, but is merely a perspective from a particular individual’s view of a situation. In dealing with the concept of organisational behaviour, perception becomes important because ‘people’s behaviour is based on their perception of what reality is, not on reality itself; the world as it is perceived is the world that is behaviourally important’ (Robbins et al 2004, p.132).

Factors influencing a person’s perception can be broken down into three main categories. These include: the situation, the perceiver and the target. For example, the factors in the situation may include: time, work setting, or social setting. Where as the factors in the perceiver may include: attitudes, motives, interests, experiences and expectations. Lastly, the factors in the target may include: novelty, motion, sounds, size background, proximity, and similarity (Robbins et al 2004, p. 132). 

Perception affects our working relationships in many ways relating to the factors of organisational behaviour, such as: individual, group or structure. For example, based on the situation, perceiver and target we may have the perception that the people we are working with are no good at their job, and therefore we may tend to avoid working with them, in fear of being held responsible for their mistakes, and in doing so, affecting our working relationship with our team members, and ultimately, the effectiveness and efficiency of the organisation. Alternatively, it may affect the group within the organisation by the way they medically treat people who have come from a specific lower socio-economical suburb, based on their overall prejudice against people who live in the lower socio-economical suburb. Alternatively, it can affect the structural perception of the organisation Nepean Hospital and in doing so, lead to possibly negative health outcomes. For example, based on the structural and group perception that all drug addicts are after opioids (such as morphine or fentanyl) when they come to hospital a doctor or nurse may overlook a fundamental presenting symptom of the patient, by assuming that they are after opioids and not perform further diagnostic techniques. This may result in the negative health outcomes of the patient (organisational ineffectiveness).

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Organisational Behaviour

September 12th, 2010

In order to understand organisational behaviour, one must develop an understanding of the term organisation. According to Robbins and Barnwell an organisation is ‘a consciously coordinated social entity, with a relatively identifiable boundary, that functions on a relatively continuous basis in order to achieve a common goal or set of goals’ (2002, p. 6). In the broad spectrum of the term organisation, one may see that they ‘exist to achieve goals and objectives’ (Forrest and Johnstone 2004, p. 10). For example the health organisation Nepean Hospital can be seen as an organisation, because all its members (employees) work in a consciously coordinated social entity, in order to perform the continuous function to achieve the common goal, of providing health for the general public.

 Organisational behaviour is the study of what the people who make up an organisation think, feel and do in and around organisations. It explores individual emotions and behaviour, team dynamics and the systems and structures of organisations. Organisational behaviour seeks to provide an understanding of the factors necessary for managers to create an organisation that is more ‘effective’ than its competitors. Through a study of organisational behaviour managers may attempt to develop organisational citizenship within its employees.  According to Robbins, Millett and Waters-Marsh organisational behaviour is ‘a field of study that investigates the impact that individuals, groups and structure have on behaviour within organisations for the purpose of applying such knowledge towards improving an organisation’s effectiveness’ (2004, p. p.).

This concept attempts to understand three specific determinants of organisational behaviour: individuals, groups and structure (Robbins et al 2004, p.9). In the organisation Nepean Hospital the mission statement is ‘to improve health outcomes of the general public’ (Sydney Western Area Health Service Mission Statement 2005) and all three of these determinants of organisational behaviour may be seen. The individual employees may include the nurses, doctors, wardspersons, ward clerks, cleaners, managers, and staff specialists. The groups may include the medical teams, neurosurgical, renal, medical emergency teams, groups of nurses, nurses and wardspersons.

The structure, in this case is a matrix design. According to Montgomery the matrix design ‘includes both a vertical and a horizontal chain of command’ (2002, p. 271). Thus, the Nurse Unit Manager has her own direct senior, in her own vertical line of command; however, concerning ‘infection control,’ ‘public health,’ ‘mental health’ or ‘drug and alcohol’ issues the directors of these areas are also her ‘direct’ senior (from the side). This design is helpful as the expert on each subject is near to hand, yet the day to day individual service delivery to clients is the responsibility of the Nurse Manager and his or her staff. 

By developing an understanding of organisational behaviour, managers of organisations are better equipped and capable of managing people so that they physically want to do all that they can to further increase the efficiency and effectiveness of the organisation.

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Paramedic Ethics

September 12th, 2010

Because paramedics hold a position of so much power of the people who they treat, because their patients are often injured, sick and vulnerable paramedics must have sound ethics and moral values. Most Ambulance Services have a Code of Conduct or a set of Paramedic Ethics that must be maintained.

Ethics is basically a branch of philosophy that explores the values of good and evil, right and wrong in all decisions that a person makes. Morals, however, explore the social, religious and personal standards of what is right.

These are the main ethics and morals that I believe paramedics should uphold:

1.  When in doubt about the right choice, a paramedic should ultimately ask themselvess the question – “What is best for my patient?” So long as I can honestly say to myself that I have done what I believe is best for my patient, than I have done my job as a paramedic.

2. Be honest – don’t lie to your patients (even when its much more simple to do so). Patients have a right to know what is going on, if you think they are having a heart attack, and they really want to know, tell them what you honestly think – most patients know when they are dying or very sick, don’t try to hide it from them. Your patients will appreciate it and will trust you more if you are honest with them.

3. Treat every patient just as well and don’t descriminate against them because of their race, ethnicity, religion, disability,etc.

4. Don’t steal (that’s pretty obvious), but it is particularly important as a paramedic, because you walk into complete strangers’ houses while they are in vulnerable positions, and the chance to steal is available to you, which is why you need to be above reproach.

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Platelet Plug Formation

September 12th, 2010

A platelet plug is formed through the following processes in order to literally plug a hole in the wall of the vascular lumen:

1. Platelet Adhession – during this process the platelets bind to collagen that has become exposed due to the damage in the vascular wall during the initial injury.

2. Platelet Release Reaction (Degranulation) – This is where blood has come into contact with collagen and caused the release of  platelet release chemicals

3. Aggregation – Fibrinogen, released when the blood cells come into contact with the exposed collagen, then binds platelets together at specific receptor sites. This then creates a plately plug.

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Vascular Spasm

September 12th, 2010

This is where there is an immediate, but temporary closure of blood vasculature as a result of:


1. Contraction of the smooth muscles within the vacular lumen and in smaller blood vessel walls complete closure of the vessel lumen through contraction.


2. The Nervous System is activated to release systemic reflexes


3. Chemical are released which stimulate vascular spasm

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Limitations of diagnostic measures by paramedics

September 12th, 2010

Paramedics, because of the nature of the work that they provide, must become very good diagnostitians and very capable of using hand and eye based diagnostic measures. Paramedic’s aren’t Doctors and do not diagnose people. However, they must determine theories of probable injuries or illness including differential diagnosis, from which they can base their treatment plans.

Paramedics are limited by their skills, experience, knowledge and the equipment available to them. Because paramedics do not have the same level of diagnostic equipment as used in hospitals, such as ultrasound, x-rays, blood pathology and many other medical diagnostic tools, they must rely on good on the following:

1. Good history taking

2. Good assessment skills including thorough baseline observations, such as level of consciousness, skin colour, pulse and blood preasure, and excellent skills in palpating and analysing pain through PQRST pain assessments.

3. A thorough assessment of patients medications and previous medical history.

4. Good examination of the patients recent events which lead up to the event to determine if anything is related. For example, if a patient has right shoulder tip pain and have been eating food rich in oils earlier today, it is a good indication of cholicystitis or some form of gallbladder pain.

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Haemostasis Mechanisms

September 12th, 2010

There are four main mechanisms which control haemostasis. These are: Vascular Spasm, Platelet Plug Formation, Coagulation and Clot Retraction.

Vascular Spasm – this occurs in response to the immediate injury and stimulates the closure of the blood vessel wall by a sudden contraction of the smooth muscles within the vascular lumen; nervous system reflexes, chemicals mediators are then used to cause further vascular spasm while other mediators move into the area, such as platelets and thromboxan. This response occurs rapidly, but ceases after the inflammatory response.

Platelet Plug Formation – Platelets are developed during blood development and circulate around normal blood within the vasculature. Once an injury has caused the smooth surface of the vascular wall to open, platelets are no longer able to easily and smoothly slide around in the blood and immediately start to bind and accumulate into an aggregation of platelets that will eventually form a plug in order to fill the hole.

Coagulation (The Formation of a Clot) – although vascular spasm and platelet plugs may close most small wounds, a large would will require full coagulation, which is the formation of a proper clot. Coagulation factors are usually found within the plasma in normal blood, but are inactive until the vascular wall is damaged and the coagulation factors are activated.

Clot Retration and Dissolution – once the clot has been formed and has stopped the leakage of blood and the wound starts to heal, the clot starts to retract as a result of a hardening of the clot, as a result of contactiel proteins called actin and myosin, which pull the clot together. As the clot condenses, the serum, which is made up of fibrinogen and some clotting factors are literally squeezed out of the clot, which pulls the damaged vessels together. Disolution occurs as the clot dissolves and within a few days fibrinolysis (break up of fibrin) as a secondary result of plasmin release occurs.

 

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Haemostasis

September 12th, 2010

Haemostasis is the body’s way of ensuring that it doesn’t accidentally spill out too much blood when skin and vasculature is injured. Through a process of haemostasis, the body maintains an equilibrium between blood clotting too much and not clotting fast enough. The body uses control mechanisms to limit clotting and dissolve clots that are no longer needed. An abnormality in a ny part of this system that controls bleeding can lead to excessive bleeding or excessive clotting. Both of which are bad. If the body is clotting too much, the person will develop clots where they do not want to develop clots, such as a Deep Vein Thrombosis, which may travel through the vasculature system into the lungs, where if large enough, it may become lodged in the pulmonary artery causing a fatal pulmonary emoblism. Furthermore, if the body doesn’t clot enough, even the most minor injury may result in a patient bleeding to death.

Haemostasis is maintained through 4 main mechanism pathways, and these include:

1. Vascular spasm

2. Platelet plug formation

3. Coagulation

4.Clot retraction and dissolution

If you would like to learn more about the 4 main mechanisms involved in  haemostasis, please review my Haemostasis Mechanisms page.

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Worst Mine Accidents

September 12th, 2010

Throughout history mining has been considered one of the most dangerous professions as a result of hazardous gasses, mine collapses, and the use of heavy machinery. With the introduction of Occupational Health and Safety laws mines and the better development of knowledge in the area of mining geology and mining equipment, the accident rates have decreased. However, it should be noted that mining is still considered one of the most dangerous occupations in society today.

I used to work as a paramedic in the Ulan region of NSW and was always fascinated by the way that the mines, to this day, would keep a score board of how many days it had been since the last work related accident. In four years working within the area, I doubt I ever saw the score board up above 15 days. Admittedly, many of these were minor injuries and accidents and it is very unusual to find a mine collapse or a major incident in an Australian mine. But it does still happen and lets face it, how many other occupations keep a score board for the amount of days since the last injury at work?

Worst Mine Accidents Throughout History

These are some of the worst mine accidents throughout history.

In Australia, the worst mine accident in history was in the Mount Kembla Mine Disaster in 1902 where 96 men and boys were killed when a gas/coal dust caused a major explosion.

In Canada, the worst mine disaster was when a set of mine disasters collectively called the Springhil Mining Disasters. One involving a gass fire, another a runaway rail cart which caused an explosion, and the last an undergound earthquake.

In Chile, it is argued to be the El Teniente, in which almost 400 people died from smoke inhalation.

In China, in 1942 Benxihue Colliery has a coal dust explosion, which killed more than 1500 people who were working there that day.

In the UK, the South Wales Coalfield had many mine accidents during 1850-1930, which accumulated more than 3000 deaths over the years

In the USA, Monongah Mining Disaster, in 1907, a coal mine had a coal dust explosion,which resulted in more than 300 persons death.

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Mine Collapse

September 12th, 2010

Mine collapses are become rarer and rarer; however, this is not to say that they do not occur at all anymore. Around the world, more than 50 000 people are injured or killed in mine collapse or mining injuries. The risk of mine collapse is higher in coal and hard rock mines.

The majority of deaths occured in mine collapses are in developing worlds, in which the mining occupational health and safety legislations are not as stringent, or not even in place.

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Coal Mining Collapses

September 12th, 2010

Due to the strict occupational health and safety legislation in Australia, coal mining collapses are an extremenly rare occurance. However, they can still happen. Thousands of miners around the world still die in mine collapses, where the risk management strategies and legislations are not as stringent as in Australia.

The last major mine collapse in Australia was in 1902 in Mount Kembla.

Mining accidents can have a variety of causes These include leaks involving poisonous gases such as hydrogen sulphide or explosive natural gases, which will eventually build up to lethal level and explode, causing a mine collapse.

Firedamp or methane build up may cause explosions.

Collapsing of mine stopes, mining-induced seismicity, flooding, or general mechanical errors from improperly used or malfunctioning mining equipment (such as safety lamps or electrical equipment).

Explosions underground cause vibrations which may weaken mine stopes or cause seismic complications, that can trigger methane and coal dust explosions. 

Mining accidents can have a variety of causes These include leaks involving poisonous gases such as hydrogen sulphide or explosive natural gases, which will eventually build up to lethal level and explode, causing a mine collapse.

 

Firedamp or methane build up may cause explosions.

 

Collapsing of mine stopes, mining-induced seismicity, flooding, or general mechanical errors from improperly used or malfunctioning mining equipment (such as safety lamps or electrical equipment).

 

Explosions underground cause vibrations which may weaken mine stopes or cause seismic complications, that can trigger methane and coal dust explosions.

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Coal Mining Accidents

September 11th, 2010

Although Occupational Health and Safety laws have progressed the safety of mine empoyees drematically over the past ten years in Australia, the risk working in a mine environment is still much higher than in other industries. Furthermore, the risks involved in underground mining is higher than above ground (open cut) mines.

What are some common mine accidents?

Soft tissue injuries, scrapes, bruises, and general enjuries that you would expect to get working in any trade industry that involves using your hands to do manual work and equipment.

High pressure hydrolic oil injuries. These are quite significant injuries that involves high pressure oil being forced in through the selectively permeable membranes and into the body lymphatic system and underneath the skin. Because the body does’t like the oil (it sees it as an irritant) the body develops an imune response (inflamation) and continues to swell. If left untreated, this will lead to tissue damage and eventually loss of limbs or affected area. Treatment involves surgical interventions, opening and debridement (cleaning with sterile water or saline).

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Construction Accidents

September 11th, 2010

Labourers in Construction  have traditionally been paid more than labourers in most every other profession due to the high risk of construction accidents. In Australia the adancements in risk management and occupational health and safety have reduced the risk to construction workers, but the statistics in Australia still show significant increased likelihood of consctruction based injuries than any other industry.

What can help reduce construction injuries? Implementation of good occupational health and safety policies and protocols. This include induction training and awareness of the dangers involved and how to mitigate these risks.

Also, a strong culture amongst construction workers to wear the correct personal protective equipment, including strong gloves, boots, helmet, and eyeprotection at a minimum.

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Why are paramedics so well trusted?

September 11th, 2010

Paramedics have to be held accountable to a higher standard than most people, because their job (as a paramedic) involves them entering complete stranger’s houses, providing help, while people are most vulnerable, often to children, women, people with disabilities and people of ethnic minorities.

Paramedics often carry strong analgesic drugs (for pain relief), which are easily abused if the paramedic is not thoroughly responsible and trustworthy.

In Australia, all paramedics must have a criminal record check and ability to work with children check prior to employment as a paramedic. Often, many criminal offences, whether occuring before or after joining an Ambulance Service, will preclude them from entering ther profession or continuing as a paramedic.

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Treating Cardiac Arrest

September 11th, 2010

In most parts of the world, people who suffer a sudden cardiac arrest outside of the hospital setting have a less than 1% chance of surviving and being capable of one day walking out of the hospital and returning to their previous lives. So, why is so much time spent training, researching and focussing on treating cardiac arrests?

First of all, this is the exciting stuff, and the stuff that ends up on television… so, unfortunately, even if you know that you’re probably not doing anyone any favours, you’re still going to spend alot of your career as a paramedic practicing CPR and Cardiac Arrest drills.

Secondly, there is still that 1% chance that you will have quite literally saved a person’s life! It does happen from time to time…

Thirdly, and this was an interesting different concept… the rate of survival as far as the patient making it to hospital and then dying later is much higher than 1% (some statistics say as high as 26%), and these patients, sometime have previously agreed to be an organ donor. I treated an 18 year old with a bad traumatic brain injury (okay, most of his brain was missing) and we knew that even if we could treat his cardiac arrest, he was never going to be conscious again. However, the mother was there, and she insisted and so we continued. He got a cardiac output back, and we got him to hospital. I recieved a phone call from a doctor who was part of the organ donation team thanking me… as a result of prolonging this persons life, he was able to contribute his organs to 7 other persons who could survive. This is now the number one reason that I make sure that I’m good at treating cardiac arrests.

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History of Paramedics

September 11th, 2010

The concept of paramedics has been around since the early days of Roman conquest, in which the older and less physically capable warriors were used intermittently to remove wounded soldiers. The concept of stretcher barers in Ambulance Paramedic’s more basic form has been documented as early as the 16th century in England.

However, the term Paramedic didn’t develop until the Vietnam war, in which Doctors had no desire to go out and provide intensive medical care to patients badly wounded in the battlefield. Consequently, medics (or para-medics -meaning part of a Doctor) were instructed in advanced medical skills such as intubation and cannulation and sent out into the field to do work that was ordinarily reserved for Doctors. Some studies in the US found that the inteventions of paramedics in Vietnam were making the survival rates of major trauma in Vietnam better than those on American Highways.  After the Vietnam war, the concept of “Paramedics” in civillian Ambulance Services were introduced, as since then, the role of paramedics have been taking greater and greater responsibilities as their training and skills continue to enhance.

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Paramedic Triage

September 11th, 2010

Triage is the process of “seiving” out the most sick and injured patients from the least sick and injured patients. It was created during war time, when doctors had too many patients for them to physically treat within the required timeframes to save the lives of patients with massive trauma from bullets and explosions. Consequently, the doctors told the nurses to only let the patients with the most life-threatening injuries (who could survive) in. This process was then termed “triage,” which literally means in French “To Seive.”

Paramedics use a smiliar triage system when they arrive on a scene and there are more patients than they have paramedics or resources to manage. Most Ambulance Services use a different system of triaging critically ill patients, but the concept remains the same – “Provide the greatest good for the greatest number of patients”  and it is well acknowledged that you can’t treat everyone as you would normally if you only had one patient.

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Triage Nurse

September 11th, 2010

The term triage in French litterally means “To sieve” and in hospitals these days, this job is given to a senior nurse who has been specially trained in the process of sieving or filtering sick or injured patients in order to identify a priority list of patients to be treated.

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Telephone Triage Nurse

September 11th, 2010

Telephone triage nurses take phone calls around Australia and triage them based on predesigned, set algorithms, which are designed to determine the severity of the caller’s complaint. They are able to direct the caller to the appropriate emergency facility or non-emergency facility, including local GPs, radiology departments, community nursing, and many other allied health care workers.

Another role of the telephone triage nurse is to help monitor the condition of a patient who has recently returned home after surgery or some form of medical treatment. For example, if a patient has returned home after having orthopaedic (bone) surgery and elderly placing him or her at a high risk of secondary health complications, the triage telephone nurse may contact that patient and ensure that he or she are not deteriorating. Furthermore, if the patient’s condition is worsening, the triage nurse may organise the appropriate interventions, even if this means the patient needs to go back to hospital by Ambulance.

Because telephone triage nurses can’t physically see their patients, they need to have excellent verbal communication skills to ensure that they can correctly determine the severity of their illness or injury.

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Triage Tags

September 11th, 2010

Triage tags are used in all states of Australia during multiple victim situations, in which there are more victims than there are paramedics or resources to treat them.

The key concept here, is to provide the most amount of good to the greatest number of people. The triage tagging system acknowledges that it will not necessarily provide the best treatment for each victim, but ultimately, it will provide the most amount of help to the greatest amount of people.

Most states use a slightly different tag system and within each state, the Ambulance Service and the Hospitals should have a coinciding system (otherwise patients will be miss-categorized once they arrive at the various hospitals).

What are the tags?

Green – walking

White – unable to be helped

Red – critical, but potentially viable, requires most treatment

Orange – not too critical, but may deteriorate.

Remember, excluding white, all the other victims within all the other tag colours may change. This is a dynamic system, and it is possible for a patient who is walking to then continue to lose blood and become a red label. So make sure your green tag victims stay together so that they can let you know (as the paramedic) if someone is deteriorating. Likewise, a patient who starts out as red, may end up walking away. Keep assessing and reassessing.

Please make sure that you check your own state or country to determine what triage tag system you use.

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What to Ask a Triage Nurse

September 11th, 2010

Some questions that you may want to ask your triage nurse…

Can I eat or drink anything?

Sometimes you should not eat or drink anything while you are waiting to see a doctor because you may need to have a test or an operation which requires your stomach to be empty.

Can I get some pain relief?

Tell the triage nurse if you are in pain while waiting or if you feel your condition is getting worse. Be aware that some types of analgesia (pain relief) cannot be administered to patients unless they are actually in the hospital. This is because they have potentially dangerous side effects and you need to be monitored, not because the triage nurse wants to see you in pain.

 Medications

Let the triage nurse know what medications you are on and when you need to take them.

 Can I contact anyone?

Ask the triage nurse if you should contact family, relatives or friends to let them know you are in Emergency.

Interpreters

The staff can arrange an interpreter for you, if necessary.

Can I smoke?

All NSW Public Hospitals are smoke-free environments – if you really need to smoke, please walk to the end of the hospital grounds.

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Hospital Triage

September 11th, 2010

The term triage was originally developed during war, in which there were too many patients for the doctors and nurses to treat during a reasonable amount of time. Consequently, the doctors started to tell the nures to pick out the most injured patients and let him see those patients first.

The word triage, litterally means in French “To sieve” and refers to a sieving process or filtering process that removes the most sick or injured patients to be seen first.

This process has now carried over to general hospital triaging and it is still the responsibility of the nurses (generally, one, very well trained senior nurse called the triage nurse) to sieve out the sickest patients in the waiting room to be seen by the Doctor or Nurses first.

It is because of this triage system that sometimes you may attend a hospital emergency waiting room and be told that you have about a half an hour wait only to find out that in half an hour you now have an hour wait – be happy about this, this means that there are some much “sicker” patients than you, who are ahead of you in the line. It also means that, if you or a family member/loved one does get seriously injured (such as in a car accident) you will be able to be seen as early as possible by the doctors or nurses.

How does it work?

Most countries have their own triage systems, but in Australia, we hae a five category triage system.

The Five Triage Categories

Triage category Description

1 People who need to have treatment immediately or within two minutes are categorised as having an immediately life-threatening condition. People in this group are critically ill and require immediate attention. Most would have arrived in Emergency Department by Ambulance. They would probably be suffering from a critical injury or cardiac arrest.

2 People who need to have treatment within 10 minutes are categorised as having an imminently life-threatening condition. People in this group suffer from a critical illness or are in very severe pain. People with serious chest pains, difficulty in breathing and severe fractures are included in this group.

3 People who need to have treatment within 30 minutes are categorised as having a potentially life-threatening condition. People in this group suffer from severe illness, bleed heavily from cuts, have major fractures, or be dehydrated.

4 People who need to have treatment within one hour are categorised as having a potentially serious condition. People in this group have less severe symptoms or injuries, such as a foreign body in the eye, sprained ankle, migraine or earache.

5 People who need to have treatment within two hours are categorised as having a less urgent condition. People in this group have minor illnesses or symptoms that may have been present for more than a week, such as rashes or minor aches and pains.

(Per NSW Health Website)

What should I Ask and what should I Tell The Triage Nurse?

You shouldn’t have to think about what to ask or tell the triage nurse except why you have come to an emergency department today. The triage nurse will be a very senior, competent and well trained nurse, who will have experience taking a history from a patient to determine how sick/injured they are. If a triage nurse gives you a low triage score and asks you to wait in the waiting room, this does not mean that he or she is doing it to punish you, simply that there are currently too many patients to be seen immediately in the waiting room. They will eventually get around to you.

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Most Trusted Profession

September 11th, 2010

Every year the Readers Digest takes a poll that reports people’s view of various professions and rates who they most trust through to who they trust the least. Ambulance paramedics have ranked number one for the last seven years in a row, which as a paramedic, I’m proud to say, means that the people in Australia find Ambulance Paramedics very trustworthy. This is ahead of Doctors, The Firebrigade, Nurses and Pilots, who are all considered very trustworthy professions. Paramedics and Firebrigade Officers have regularly competed for the title of Most Trusted Profession and 2010 Paramedics were found to be just slightly above Firebrigade Officers. So, for those of you in the US who have joined EMT/Firebrigades, you would most certainly be at the top of the most trusted profession!

It must be acknowledged that this poll is for Readers Digest Australia and only indicates the views of the most trusted profession from people in Australia (because there are other polls out there, who don’t indicate paramedics as the number one most trusted profession).

This just show what a great job paramedics can do for the community, and how well we are still appreciated and respected by the community, and the importance of maintaining a level of competence and commitment to the community that allows us to deserve to remain Australia’s Most Trusted Profession.

Paramedics must maintain a high level of trustworthiness and should be held accountable to a higher level of honesty and trustworthiness, because we treat people when they are at their weakest and most vulnerable, we walk into their homes during time of need.

Hopefully we will maintain this level of honesty that has bestowed the accolade of “most trusted professionals.”

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Paramedic Intuition

September 11th, 2010

Paramedics develop an intuition or sixth sense for how a patient is going or a scene is progressing based on their responses of previous experiences, gathered over many years working on the road…

These are some of the clinical words of wisdom and clinical tricks of the trade that often trigger a paramedic’s intuition about a patient deteriorating (even if they don’t realise it), which I have noticed over the years.

1. The patient says “I feel like I’m going to die” – this sounds obvious, but often, junior paramedics don’t realise that when a patient says this, they often mean it and they have their own intuition that they are about to die, so take them very seriously and get them to hospital quick.

2. The patient says “This feels like last time, just before I collapsed” – again, obvious, but important to pick up.

3. When a patient develops repetitive questioning after a head injury. This is a sign that they have had a significant head injury and may deteriorate very quickly.

4. When the injuries don’t match up with the complaint that the patient has made – you must look at who is lying to you, or why the patient doesn’t realise what has happened. This may be a serious trigger or alarm bell for those of you who are treating children or womem who may be being abused.

5. When the patient or friend appears overly keen to get you to follow them – try to slow them down, nothing’s worth rushing too much, and you don’t want to end up being drawn into something dangerous.

6. When a bystander meets you at the scene and tries to get you to go first into an unlit house – some people still try to harm paramedics so that they can get drugs.

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Intuition Evidence Based Practice

September 11th, 2010

Is there evidence based practice that supports paramedic intuition?

Paramedics often employ intuition, developed over years of experience in the job, to identify when a job is going to go bad. This includes when a patient is going to suddenly deteriorate or when a patient or friend (or scene for that matter) is about to become violent or dangerous to the paramedics.

Evidence based practice acknowledges that although some skills, thought process or methods have intrinsic values, ultimately, the benefit of any theory must be capable of providing some form of evidence that vallidates such a basis of practice.

So how does paramedic intuition meet this criteria?

Although limited research has been conducted into the validity of paramedic intuition, any paramedic who has worked with a good, competent, and often very experienced paramedic, will immediately recognise the benefit of this paramedic intuition. Based on anecdotal evidence, you will see that many times (but not always) a good paramedic will identify a nagging intuition that a patient is going to deteriorate, while there a no obvious clinical indications for this. 

One theory for this is that paramedics develop a form of intuition, based on a subconscious categorization of every patient/ case they have been involved in. As the years of experience gather, paramedics subconsciously connect all these experiences, so that while a patient’s vital signs may appear normal, they get a “gut” feeling that things are going to change and react accordingly, by doing things such as cannulating early and drawing up drugs proactively. 

What are some triggers for paramedic intuition? Check my paramedic intuition page…

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Prehospital Triage

September 11th, 2010

In prehospital care (paramedics), when we arrive on a scene and have more victims than we have paramedics or resources to treat the patients we follow a trauma triage tagging system. Unfortunately, most states have a different variance on the trauma triage tagging system.

The concept of prehospital triage, like hospital triage is that you recognise that you cannot help everyone, so your aims and objectives must target providing the most amount of good for the greatest amount of people. This means that your treatment plans may vary considerably from when you have only one patient to contend with.

In NSW, paramedics will immediately notify their communications centre that there is a multiple victim situation and take a walk around, head count of the victims at the scene. At this stage, the only treatment that will occur is removing patients from immediate danger (if it can be done safely) and basic airway manouvers, such as rolling patients on their side and head tilt.

The triage labels in NSW include the following:

Green – this is for walking patients. If they can walk, they’re probably not your main concern right now ( but this does not mean that they can’t deteriorate later, so keep all your green patients together where you can still check up on them).

White – This is for victims who are not able to maintain their own airway (after simple aireway manoeuvres, such as head tilt, rolling the patient) and basically states that the patient is dead and not to be worked on.

Red – Very sick. These are life-threatening patients who require your help as early as possible. Identified by victims with a respiratory rate of less than 10 or greater than 30 or with a capillary refil of greater than 2 seconds.

Orange – Potentaillly lifethreatening. These patients can deteriorate. They are identified as having a respiratory rate within the 10-30 rate range and a capillary refil of less than 2 seconds, but are currently unable to walk.

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Mine Injuries

September 10th, 2010

These are some common mine injuries that occur in Australia.

Hydrolic Oil Pressure Injury – in which a hydrolic strut ruptures or bursts and causes high pressure hydrolic oil to be injected into the skin. Due to the severe pressure oil can force its way through the selectively permeable membranes and under the skin. This oil is recognised by the body as an irritant and will cause an inflamatory response, which leads to swelling and eventually, will result in a non-traumatic crush injury of the limb that has been affected. Treatment includes surgery within 4 hours of the injury.

Traumatic Crush Injuries – heavy machinery that is necessary for the operation of a mine make the possibility of traumatic crush injuries higher than in any other field, even if occupational health and safety regulations and legislation have improved this situation.

Burns – as the result of steam and multiple engines.

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Common Injuries Mining

September 10th, 2010

Mining for any oar either in open cut mines or underground mines does have some intrinsic risks associated with the industry. Even though advances in risk management, occupational health and safety as well as protective equipment have decreased the likelihood and severity of injuries, the mining industry by it’s very nature has more inherent risks.

So what are some of the injuries that mine paramedics or mine medics have to deal with?

Crush injuries – as a result of falling rocks (in severe situaitons -very uncommon in Australian mines these days). Crush injuries as a result of equipment falls are more common.

Hydrolic oil injuries – as a result of struts rupturing and spurting high pressured oil. This is a very serious injury and should be taken as such.

Back injuries – although miners rarely life rocks by hand anymore, miners still move heavy machinery on a regular basis and have a higher rate of back injuries than people employed in other industries.

Cuts, Scrapes, and Bruises – like with any other trade industry, these injuries are common.

Normal medical problems – still occur like in every other industry, but may be exacerbated by the working conditions.

Breathing problems -asthma and breathing problems can occur as a result of high levels of dust, pollutants and other antigens in the air.

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Mining Australia

September 10th, 2010

What does Australia mine? Australia mines just about every type of metal found. We mine coal, iron, diamond, gold, shale, uranium, and just about anything and everything else that you could imagine brining out of the ground.

This leads to the production of many mining jobs and employment in industries which aid or assist mines. Historically, mining booms in Australia have encouraged immigration booms.

How much training do you need to get employed in mining?

Mines employ people from all walks of life and all levels of education. Mines in Australia employ people with just about every trade background, and degrees in engineering, risk management, safety, nursing, and management.

Mine Jobs

Engineer, transport officer, miner, geologist.

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Mining Employment

September 10th, 2010

Australia’s largest resources are the minerals which it obtains through mining and exports overseas and around the world. Any industry which produces so much money must have numerous employment opportunities and mining is not different.

Mines employ people from all trade backgrounds, including: plumbers, electricians, mechanics (especially desiel mechanicas); engineers, miners safety officers/OH&S officers and mines rescue/medics/or paramedics. Many mines employ people on traineeships or trade apprentices.

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Stem Cells

September 10th, 2010

On September 10, 2010 the US court lifts the ban on stem cell funding! During his term, George Bush, banned federal funding for research on embryonic stem cells, because religious conservatives believe that life begins at conception and that the research often involves the disposal of embryos. In 2009, Obama pledged to reverse the ban on federal funding for research into embryonic stem cells, which was applauded by the scientific community, who believe that the field may have a huge potential in treating serious diseases like some forms of diabetes, cancer, Parkinson’s disease and many more. And now, on the 10th of 2010 the ban was lifted, allowing researches to obtain federal funding for research into embryonic stem cells.

Researchers believe stem cells will provide two significant avenues for medical advancements. These include, primarily, the ability to conduct research that cannot be performed inside the body (due to the risk of death of that person) and secondary, scientists believe that they can also coax the foundational cells into cardiac, pancreatic, brain cells, nerve cells and many more in order to replace damaged or infected cells. This may, ultimately, allow the tissues and organs to rebuild themselves

What types of stem cells are being examined for their potential medical research?

Embryonic stem cells, which are extracted from human embryos. The human embryos are developed in vitro (a laboratory dish), where they are not derived from eggs fertilised  in a woman’s body.  

Adult stem cells, which are taken from the body or from elements discarded after birth, such as the umbilical cord. Adult stem cells are undifferentiated (which basically means that they have the potential to grow into another type of cell, but haven’t yet). These cells are being found in more and more parts of adult human body, and lead scientists to believe in massive benefits to future transplant development.

Induced pluripotent stem cells – adult stem cells that have been genetically modified to resemble embryonic stem cells. In theory, these cells could be used just as an embryonic stem cell to develop into any other cell in the body, but in clinical practice, researchers still have doubt about their differences to embryonic stem cells and acknowledge that much more needs to be known on the topic.

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Medical Careers

September 10th, 2010

So, you’ve decided that you want to make a career out of something medical, but your not sure what? The good things is, most medical jobs, from medical scientists, researcher, nurse, doctor, paramedic, physiotherapist and many others all start the tertiary training in very similar ways. They all cover anatomy and physiology, chemistry, basic physics and some maths (not too much maths though, thank goodness). This works out well for those of you who don’t really know what you want to be when you grow up, because it makes it much easier to change early on in your tertiary training/education.

So what are some medical careers to think about…

Medicine… okay, you want to be a Doctor? That’s great… how many years of study are you willing to do? If the answer is anything less than “every year for the rest of my working life” than, don’t become a Doctor. Medicine is a great profession, but it is something that you have to love and enjoy studying to be good at… you can become many things in life and not have to worry too much about studying after your in, but medicine is not one of those things. In medicine you have to study for many years to get into medical school, then many years to complete medical school, then many years to complete internships, registrar training and specialist training, then you have to study very hard to keep up to date with recent advancements and maintain your registered certificate to practice. If you enjoy studying, and you like helping people, medicine is a great job. In Australia, most Medical Degrees require you to spend 6 years full time to achieve a Bachelor of Medicine. However, these days, alot of a Universities allow students to study medicine through a post-graduate course. This means that they have a 3 year undergraduate degree (in anything they choose) and then apply to complete a 4 year post-graduate degree in Medicine.

Nursing… Okay, nursing is another great job. Nursing is another career that involves alot of study these days, but a little less than medicine. The job is much more people orientated and involves alot of interaction with patients. This has its pros and cons, too however. Most nurses I know don’t necessarily like people anymore… but there are some people who love the job and wouldn’t change it for the world. The world needs nurses (especially good nurses) so if you’re interested in a career in nursing that is great. Most countries require people to study full time for about 3-4 years to comlete a Bachelor of Nursing or Bachelor of Health Science Degree. You then need to undergo a 1 year internship/graduate program as a nurse.

Paramedics – Okay, so I’m a paramedic, so obviously I’m a little biased here. Paramedics are one of the few medical careers or jobs that can be trained “on the job” although, these days it is usually through a 3 year full time tertiary study followed by a 1 year traineeship/internship. Paramedics gain a lot of medical knowledge over their career, and become very good at managing the ABCDEs of emergency medicine.

Physiotherapy – is usually 4 years full time at university followed by a 1 year full time graduate program. Physiotherapy is a very good job that can open doors to working just about anywhere in the world. You can work for yourself in private practice or public, or contract to cruise ships. The opportunities are endless. One word of warning, however, a large aspect of the job of Physiotherapist is respiratory therapy/chest therapy (this involves improvement patients lungs, but often results in excess sputum… if you can’t handle sputum… this may not be the job for you).

Medical Research or Lab Technician. Okay, so you are serious when you say you enjoy studying… you can become a medical researcher or lab technician with endless opportunities to research by doing a 3 year full time medical science degree. Then, if you get bored of the lab (some people love it), you are well set up to study any other medical field.

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Medical Chemistry

September 10th, 2010

We have already learned that basic chemistry involves the study of matter, mass and weight, and that matter is made up of elements, and elements are made up of atoms, which are indivisible, until you look deeper and find that they too are made up of neutrons, protons and electrons!

Now what?

Lets look at atomic numbers and mass numbers. The atomic number of an element is “equal to the number of protons in each atom, and because the number of electrons and protons is equal, the atomic number is also the number of electrons in an atom” (Seeley, Stevens & Tate 2006, p. 27). The mass number of an element, however, is the number of protons plus the number of neutrons in an atom. For example, the mass number fo oxygen is 16 because it has 8 protons and 8 neutrons.

What happens when things aren’t working the way they were meant to…

More to come on isotopes, hydrogen bonds, covalent bonding, solubility and dissociation soon!

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Basic Medical Chemistry

September 10th, 2010

Chemistry has to do with matter, mass and weight. All things, living and nonliving are composed of matter, which is a “thing” that occupies some form of space and has some amount of mass. Mass, is the amount of matter in an object, and weight identifies the gravitational pull that acts upon that given object… are we confused yet?

Elements and their atoms

Lets start at the beginning of chemistry… lets take an element (the most basic type of matter with individually unique chemical properties). An element is made up of atoms which are of the same atoms. An atom is an indivisible particle of an element.

But wait, an atom gets smaller…

An atom is made up of three small “subatomic” particles. These include: an electron, which has a negative charge, a proton which has a positive charge and neutron, which has no electrical charge at all. Both protons and neutrons join together to form the nucleus (in shell of an atom). Electrons then move around the nucleus.

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Stop Hand Tremors

September 10th, 2010

These are some techniques that I have used to try to stop hand tremors. Some of them have helped me, but fundamentally, I have just had to work out how to do my job with hands that shake.

Exercise – exercising releases chemical mediators called endorphins (not too dissimilar in chemical nature to morphine), which causes the body to naturally rellax and provide natural analgesia for pain. This is why some people can become literally addicted to exercise, because they enjoy the high that they get after exercising. Likewise, some people who are used to regular strenuous exercise, may find that they devellop depression or mood swings as a result of being unable to exercise.

Manage your sleep deprivation. I’m a shift worker, and I understand just how hard it is to get enough sleep. Unfortunately, sleep is like a piggy-bank, if you withdraw too much awake time without replenishing it, you run out, so make sure that if your a becoming sleep deprived, you take steps to have extra sleep later to make up for it. If your sleep piggy-bank is short, it needs re-filling!

Rellax more – this sounds obvious, and easier said than done, but even taking the time to watch a movie, catch up with friends, have a hot bath, or a glass of wine (try to avoid the whole bottle though) all make a big difference in the levels of serotinin (mood stabiliser/natural rellaxant in the body), which reduce the symptoms of hand tremors.

Take up some form or rellaxing activity, such as Tai Chi, Yoga, or Pilates.

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Hand Tremors

September 10th, 2010

Every paramedic at some point in their career will find themselves having to cannulate in a difficult (and nerve racking) situation, and they will pull out all their cannulation gear, only to find that their hands are shaking (hand tremors).

What causes this, and how can I still cannulate if this happens?

Unless you have some particular medical condition, such as Parkinson’s Disease hand tremors are fundamentally caused as a result of the brain suggesting (on no uncertain terms) to the adrenal glands to release more adrenaline as a result of some sympathetic stimulation (fight or flight response), and it is this circulating adrenaline that makes your hands shake or tremor. Now, everyone’s sympathetic nervous system responds differently to a situation. For some, even if they are nervous or agitated, they do not release much adrenaline, in others, they may be only mildy anxious, and their hands start trembling uncontrolably.

When I started as a paramedic (over 10 years ago now), I found my hands developed a small tremor just before I cannulated a patient, and progressively develloped into a severe, uncontrollable tremor by the time I had finished cannulating. Over the years, I had assumed that my hands would cease to tremble once I had become experienced and confident in cannulation and in my duties as a paramedic. This was not the case, and here I am, more than 10 years later, with terribly shaky/trembling hands everytime I go to cannulate (even when I really don’t feel nervous).

So what do you do?

I’ve successfully cannulated somewhere around the 8000 times mark, but still my hands shake… most new people who I work with assume I’m nervous or not good at my job. But I very rarely miss a cannulae, and everyone who has worked with me, will ask my help to cannulate if they are having trouble with a patient who has difficult veins.  So this is what I do. I’ve already been to the Doctors and rule out any organic cause for hand tremors (such as Parkinson’s Disease or Hyperthyroidsim).

When I go to cannulate, I get everything ready…  I pick my vein, clean it, and get it ready for venepuncture. Then I make myself comfortable. If I’m in the Ambulance, I sit down and make sure the arm is resting on the patient’s lap or my knee so that I have something to brace myself on. I normally calmly talk to the patient about, just about anything that he or she wants to talk about (their work, the weather, I don’t really care what, just so long as I’ve got them thinking about other things, and it gives them the idea that you know what your doing so well, that you can concentrate solely on them and still cannulate). If I’m at a patients house, I will take a chair that is nearby (if one exists) and use it to make myself comfortable (alternatively, I will crouch down or even sit down if it is safe to do so). Then, when I’m all ready… I firmly anchor the vein down with my left hand  (I’m right handed so I cannulate with my right hand). And I visualise exactly where the cannulae needs to go and then I insert the cannulae. The whole process of venepuncture (puncturing the vein as you insert the cannulae) generally only takes me about 5 seconds (but may be longer if it is a difficulate vein to cannulate. I find, if you’re going to successfully get a cannulae in, it will either take about 5 seconds or it wont happen at all. My hands are far too shaky to actually stay and fiddle with the fine motory skills required to cannulate. But so long as I anchor the vein well with my left hand, and rest my right on my knee or something, it generally works.

If you want to see normal methods for stopping hand tremors, you may want to check my other article Stop Hand Tremors.

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paranormal activity true story

September 9th, 2010

This is a true story from a Doctor who I was working with that shows a very paranormal activity involving one of his patients.

The Doctor was a Senior Professor of Emergency Medicine working in an Emergency Department in Australia. While checking in his emails early in the morning he read an email that he had received late in the night before. It said the following: “Dear Doctor (Name Removed for confidentiality reasons), I need to see you desperately. Please, can you meet me in your office tomorrow at 1oam?” – and then the patients name (lets say *Michael Invintas).

The Doctor looked at his watch and saw that it was already 1030am… he asked the one of the ward clarks at the front desk if there were any messages for him? No…

A short while later, he was called into the main emergency department to assist in the management of a cardiac arrest of a 21 year old man… he assisted, and eventually, after half an hour without any improvements, he declared the patient deceased…

The Doctor asked about the patient’s history, but was told that the patient had come in by Ambulance and the only history they had on him was his name “Michael Invintas.”

He instantly realised that this was the person who had emailed him the night before… he replied to the email, in the hope that it was just a coincidence about the name, but never received a reply. The coroners report never identified a cause of death.

* Denotes a fictional name replacing the real name of the patient to maintain confidentiality.

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You Know You Work for an A&E When

September 9th, 2010

Some time ago we posted a list of the most common ways that you can recognise the fact that you work as a paramedic. As emergency nurses started to read the list, they decided to come up with their own version. So, this is: “You know you work for an A&E When…” – I hope you enjoy if you’re an ED nurse.

You Know You Work for an A&E When:

1. You find yourself regularly asking people “Now, what part of this complaint fits into the Accident part or the Emergency part of A and E? Because, sorry, I really do need it to fit into one of those categories to let you see a Doctor…”

2. You see any person with a welfare card as your “employer”

3.You and all your friends work for an emergency service or a hospital

4.You marry an Ambo, Nurse or Doctor (sometimes if you want to step outside of this routine you may marry a Cop)

5.It drives you absolutely nuts when someone asks you if you ever think about going to university so that you can make medical decisions on your own.

6.You know that when a kid has been injured the person who will take up most of your time managing at the scene will be the parent, regardless of how sick or injured the child is

7.When a patient arrive at your ED and your first impression is, Umm why have you come here?

8.You thrive on serious trauma (and no, a paper cut doesn’t count a serious trauma people!)

9.You know that Full Moon = Insanity.

10.When you’re always checking out peoples’ veins for IV access.

11.Unconscious = cooperative.

12.You’re up at 2:00 am on Facebook, all in a day’s work.

13.Random phones and buzzers send your heart into VF

14.You get back pain just looking at really fat people!

15.Your dinner conversations often migrate toward that really messy trauma or explosive diarrhea call and you won’t lose your appetite.

16.If you’ve ever conducted a practical joke using oxygen tubing.

17.If you have use lignocaine gel on people’s phones, car handles or any door handle

18.If you find skipping with an oxygen tubing a good form of exercise

19.When your home first-aid kit consists of OP airways, maternity kits and bag and masks!

20.When your quick remedies kit for a hangover includes: 1L of Hartmann’s and a Maxalon

21.When you’ve wanted to hold a seminar on ’Suicide – How to Get It Right The FIRST Time.”

22.When you have come to the conclusion that you are sicker than 3/4 of the people in the emergency department

23.When you wash your hands before using the bathroom.

24.When you are watching TV and get annoyed and point out all the inconsistencies of the TV medics.

25.All your “funniest” stories are considered vulgar and disgusting

26.You tell the best story ever, and you’re the only one who can see the humor in it

27.“LOL” doesn’t mean “laughing out loud” but rather it means “little old lady.”

28.You have at least one “things up people’s butts” story.

29.You often finish a story with “and then he died”

30.When you think you did a great job… even though the patient still ended up dead

31.You’re covered in some bodily fluid or another more often than not and it doesn’t bother you.

32.You’re tempted to use “oxygen therapy” on all annoying people, not just patients: an O2 tank over the head fixes everything (especially in combative patients).

33.You want to throw something at the TV when they shock assystole on some TV show.

34.When a patient arrive in your ED and a relative says that you will need a chair because the patient can’t walk – umm… I will make that decision!

35.When you come home in a clean uniform after a shift and your spouse automatically becomes suspicious of your whereabouts.

36.You remember every patient by their injury or disease and not their name.

37.You describe a hospital gown as a “nice backless number”

38.You know every party illicit drug ever invented and what the “popular” ones are this week

39.You believe that most occupants of an MVA don’t have a spinal injury

40.Believe all patients lie

41.Although, unable to speak any other language, are adeptly fluent in all hand languages to signify that if the patient can walk into the Emergency Department, they can walk to the see the Doctor!

42.You know that its easier and more accurate to check a patient’s medications than to ask them what previous medical illnesses they have.

43.Have been caught out at some stage by suggesting that you will decide if a patient can walk or not, only to find that they have a broken leg.

44.You class CPR as one of your weekly exercise workouts

45You’ve described a patient who has suddenly died as having made “a good innings”

46You’ve made jokes, which you have honestly thought were funny, about a funny way in which a patient has died

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Hospital Jokes

September 9th, 2010

Here are some stupid hospital jokes for those of you who work in a hospital and want some hospital humor or are paramedics and stuck in the corridors of an emergency department.

Hospital jokes one:

Patient: “Hey Doc, I can’t seem to get to sleep…”

Doctor: “Hmm… why don’t you try laying right on the edge… and maybe you’ll fall soon enough…”

Hospital jokes two:

In regard to any necessary medical equipment… “Yeah, I’m sure management will remember to buy that!”\

Hospital jokes three:

A doctor examining a woman who had been rushed to the Emergency Room, took the husband aside, and said, ‘I don’t like the looks of your wife at all.’ ‘Me neither doc,’ said the husband. ‘But she’s a great cook and really good with the kids.’

Hospital jokes four:

Patient: “Doc… I’m addicted to scrabble!”

Doctor: “My word…”

Hospital Jokes Five:

(this one may offend some people)

An obstetrician delivers a baby… trips, loses grip of the baby and it flies across the room, and out the window… the mother screams… and the obstetrician laughs and says: “don’t worry… it was just a joke… your baby was stillborn…”

Hospital Jokes Six:

“Doc… I can’t help but dream about fishing… I lie awake at night and focus on my fishing in the river…”

Doctor: “Oh, I’m free next weekend – you should drop me a line…”

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Funny Medical Jokes

September 9th, 2010

These are some more funny medical jokes for you all…

A doctor examining a woman who had been rushed to the Emergency Room, took the husband aside, and said, ‘I don’t like the looks of your wife at all.’ ‘Me neither doc,’ said the husband. ‘But she’s a great cook and really good with the kids.’

An old man goes to the Wizard to ask him if he can remove a curse he has been living with for the last 40 years. The Wizard says, ‘Maybe, but you will have to tell me the exact words that were used to put the curse on you.’ The old man says without hesitation, ‘I now pronounce you man and wife.’

While shopping for vacation clothes, my husband and I passed a display of bathing suits. It had been at least ten years and twenty pounds since I had even considered buying a bathing suit, so I sought my husband’s advice. ‘What do you think?’ I asked.. ‘Should I get a bikini or an all-in-one?’ ‘Better get a bikini,’ he replied ‘You’d never get it all in one.’

The graveside service just barely finished, when there was a massive clap of thunder, followed by a tremendous bolt of lightning, accompanied by even more thunder rumbling in the distance. The little old man looked at the preacher and calmly said, ‘Well…..she’s arrived there now.’

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Universal Laws

September 9th, 2010

Working as a paramedic has taught me that there is a certain order to the universe. In fact it is almost nice to know that there is a reason to everything, a purpose… these are some of the universal laws show unequivocally, the outcome of any situation. Hope you enjoy these…

1. Law of Mechanical Repair – After your hands, arms and just about everywhere else becomes coated with oil, your nose will begin to itch.

2. Law of Accidental Numbers – If you dial a wrong number, you never get a busy signal and someone always answers.

 3. Law of Gravity – Anything important, any tool, any item such as a  nut, bolt, screw, or fuse, when dropped, will roll to the least accessible corner.

4. Law of Toast – A secondary law of gravity, which acknowledge the fact that given the 50/50 likelihood that a new toasted sandwhich, when dropped will land on either side up, for some reason, 100% of the time it will land with the peanut butter and honey side facing downwards 

5. Law of Probability -The probability of being watched is directly proportional to the stupidity of your act

6. Law of the Alibi – If you tell the boss you were late for work because your Grandmother died, the very next morning your Grandmother will die.

 7. Variation Law – If you change lines (or traffic lanes), the one you were in will always move faster than the one you are in now (works every time).

8. Law of the Bath – When the body is fully immersed in water, the telephone rings.

9. Law of Close Encounters -The probability of meeting someone you know increases dramatically when you are with someone you don’t want to be seen with.

10. Law of the Result – When you try to prove to someone that a machine won’t work, it will.

11. Law of reach – The severity of the itch is inversely proportional to the reach.

12. Law of the Theater – At any event, the people whose seats are furthest from the aisle, always arrive last.  They are the ones who will leave their seats several times to go for food, beer, or the toilet and who leave early before the end of the performance or the game is over. The folks in the aisle seats come early, never move once, have long gangly legs or big bellies, and stay to the bitter end of the performance. 

 13. The Coffee Law – As soon as you sit down to a cup of hot coffee, something will always arise that requires your immediate action and will ask you to do something which will last until the coffee is cold.

 14. Murphy’s Law of Lockers – If there are only two people in a locker room, they will have adjacent lockers.

15. Law of Logical Argument – Anything is possible if you don’t know what you are talking about.

 16.Law of Physical Appearance – If the clothes fit, they’re ugly.

 17. Law of Public Speaking – A closed mouth gathers no feet.

18. Law of Commercial Marketing  – As soon as you find a product that you really like, they will stop making it.

19. Doctors’ Law – If you don’t feel well, make an appointment to go to the doctor, by the time you get there you’ll feel better. But don’t make an appointment, and you’ll stay sick.

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Can Paramedics Intubate

September 8th, 2010

Intubation is an advanced life support skill which involves inserting a tube into the trachea and through the vocal cords in order to obtain a very safe, secure airway in which to ventilate an unconscious person.

Not all paramedics in Australia can intubate. In general, this skill is reserved for Intensive Care Paramedics who have undergone extensive training and experience in opperating theatres.

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Paramedic Laughs

September 8th, 2010

Being a paramedic can, at times, be very stressful. Consequently, most paramedics have a good sense of humour and have fun at work (when they can get away with it). Not many paramedics last in the job if they don’t have a good sense of humour. So, here are some more jokes, and laughs for paramedics…

These are some music songs that we matched with work as a paramedic just for laughs:

Venus – Bananarama: When arterial blood gas sample is venous

Harder to Breathe – Maroon 5: Short of breath patients

Breathe – The Prodigy: Specific to patients on Bipap (Breath the pressure)

Pressure Down – John Farnham: Hypertensive patients or letting air out of the pressure bags

Check On It – Beyonce: Nurses needing a drug checked

DOA – Foo Fighters: The white meat truck

Confide in Me – Kylie Minogue: Psych registrar song

Push It – Salt ‘n’ Pepa: Wardsperson/porters song/pushing IV drugs

No Scrubs – TLC: Soiled uniform and need to change into scrubs

Dizzy – Spin Doctors: Dizziness

Hot In Here – Nelly: Trauma gown songs/failure of air conditioning

Hot Stuff – : Skanky psych/D&A patients

I Want That Man – Deborah Harry: Skanky psych/D&A patients

And these are a few things that you probably don’t wont to hear your surgion say… (this is just for laughs):

1. “I wonder where this… thingie goes…”

2. “Did anyone see where my watch went?”

3.” Hey, Cleaner… you’ve seen this before… can you to finish this…  I have an important date…”

4. “We’re going to the mop for all this blood that I’ve spilt…”

5. “Which leg was I supposed to amputate?”

6. “Didn’t I have 5 forcepts before I closed him up?”

7. “I wonder if… there’s some way I can put this… part… back where it came from?”

8. “Oh this… nah…. she’ll probably be alright without  these extra parts”

9. “Hmmm… maybe I better put these parts somewhere… you know… in case we find out we need them or something…”

10. “Hang on a second… if this his spleen… then what did I just take out?”

11.  “You know… there’s a heck of a lot of money in kidneys… and, the guy already has two of them…”

12. “Sterile… smerile… the floors clean… I mean… the Cleaners mopped it, right?”

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Age Limit for Paramedics

September 8th, 2010

In Australia, there is no mandatory retirement age in which paramedics must retire. So long as a paramedic is fit and able to do their job, they can work as long as they wish (although, I think I’ll be off on a long holiday when I reach that age)…

I have worked with paramedics as old as 72 – one of whom, is still very keen and very much up to date with current technological improvements, and clinical skills.

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How old to become a paramedic in Australia

September 8th, 2010

Age is not necessarily a restraint for younger persons attempting to gain employment as a paramedic in Australia. However, in virtually all our Ambulance Services, paramedics must obtain a full (un-provisional) drivers licence prior to gaining employment. Because the age limit for gaining a full drivers licence is either 18 or 21 in most states of Australia, this means that most people must, at the very minimum be at least 18 or 21 to gain employment as a paramedic in Australia.

Can I join earlier, and just treat the patients and not drive? No, in Australia paramedics are both treating officers and drivers.

Realistically speaking, most people who join an Ambulance Service in Australia are about 25 years or older (this does not mean that it is impossible for you to become a paramedic if you are younger). This is because, employment as a paramedic is very competitive, and consequently, most people who are successful either have prior experience (either in a similar field such as nursing, or another field) or have tertiary qualifications. However, I have met people who did brilliantly at the exams and interviewed well enough to get in as young as 21.

If you’re interested in becoming a paramedic – I thoroughly recommend it, its the best job in the world.

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How old to become a paramedic?

September 8th, 2010

Technically, most Ambulance Services do not set any particular age limit for applicants to become paramedics.

However, most Ambulance Services do require that their paramedics have a full un-provisional drivers licence before they can be employed. So, depending on the state, most employees must, at a minimum be 18 or 21 years old depending on their state age for obtaining a full drivers licence.

However, it should be noted that employment as a Paramedic is often very competitive and it is unlikely (but not impossible) for people to become paramedics without having other work experiences or tertiary qualifications.

If you’re keen to become a paramedic I wish you luck, its the best job in the world.

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A History of CPR

September 7th, 2010

Although Cardiopulmonary Resuscitation (CPR) may not necessarily revive (or resurrect) a person who has suffered a cardiac arrest, it is the only known method curently of keeping someone who has suffered a cardiac arrest alive long enough for other medical interventions to have some affect. It should still be acknowledge that even with good, effective CPR, the likelihood of longterm survival is minimal – but without any CPR, it is absolutely zero. So, where did CPR come from and how did we start performing CPR?

Early attempts at resuscitation following cardiac arrest were documented as early as the late 1760. In Amersterdam, a society of intelligent persons gathered to form the “Society for the Recovery of Drowned Persons” in an attempt to resolve the many deaths that occured as a result of drowings in the many canals. The Society develloped a list of recommendations, which were believed to be attributed to the saving of many a drowned persons life. These recommendations included:

Warming the Victim

Removing the water from their body by lowering their head below their feet

Sustaining manual pressure to the abdomen

Respirations of the victim (through techniques not too dissimilar to present day “mouth to mouth”

Blood letting

And finally tickling of the throat to coax them back into existence

Although many of these techniques seem ridiculous to the modern day physician (or paramedic), the ideas developed by these people caused a paradigm shift in their views of the dead (or at least the recently dead), in which they started to consider the possibility that some form of intervention could bring the dead, or at least the recently dead, back to life.

These techniques, and many variances of these techniques continued until the late 1950s and the early 1960s. In the early 1880-90s physicians recognised the need to maintain circulation of the blood, but were helpless to devise a method in which they could do so.

In the early 1960 two Doctors identified while working on a trial involving Dogs that a certain amount of pressure could be applied to make the blood circulate and create a femoral pulse. Multiple variances on the attempts allowed them develop ideal locations for chest compressions. From this they determined the possibility of combing chest compressions with mouth to mouth to achieve resuscitation!

Since then, the International Liason Committee on Resuscitation was formed in 1992 and since then have changed the ratios of chest compressions and respirations to achieve the greatest likelihood of success. However, fundamentally, CPR, has not changed since its inception in the early 1960s.

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Mechanical CPR

September 7th, 2010

 

The longterm survival percentage of patients following cardiac arrest is still very small (in some areas less than 1% of patients suffering a cardiac arrest outside of the hospital survive and are able to eventually walk of hospital and return to their normal lives as lived prior to the cardiac arrest). However, for that 1% much time, training and new technologies for paramedics, nurses and doctors concentrates on improving this percentage and the long-term health benefits of these patients and a mechanical CPR device is one of those new technologies.

Although few interventions in cardiac arrest have been proven through evidence based practice to be of bennefit to the patient, it has been unequivically acknolwedge that without good, effective, CPR the patient has no chance of survival and gaining long-term recovery. According to Murad and Hayward (2008), who conducted a review of clinical trials of the new mechanical CPR device ‘there is no evidence supporting the routine use of mechanical CPR devices in patients suffering out of hospital cardiac arrests.’

So what is this mechanical CPR device and how does it work? There are currently two main mechanical CPR device systems that are currently approved for use in the USA. These include the Thumper 1007 and the Autopulse Resuscitation System 100.

The “Thumper” mechanical CPR device has actually been available to markets since the 1960 and the current version in 2007 the Thumper 1007, includes fully automated compression and ventilator system, which has been seen to show significant improvements in clinical trials involving animals. 

In 2003 the medical technologies company, Revivant joined with forces with Zoll to develop and market a new mechanical CPR device called the Autopulse Resusciation System 100. In this system, the mechanical CPR device actually pumps the cardiac muscle at a greater than normal rate/depth to produce a greater cardiac output than is capable in human/paramedic based CPR. It hopes to improve longterm outcomes of patients who would otherwise not have a chance.  

As of yet, no Ambulance Service in Austrlia currently has or is trialling a mechanical CPR device.

References:

Murad, A. & Hayward, E. (2008): Is mechanical CPR better than manual CPR? Southmead Hospital, North Bristol. Best Evidence Topics.

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Ambulance Hits Pedestrian

September 6th, 2010

On Friday the 3rd of September an Ambulance collided with a pedestrian in Sydney while responding to an emergency under lights and sirens. The paramedics in the Ambulance attempted to resuscitate the pedestrian to no avail. Although the circumstances of this situation are unknown, it highlights the concept in Ambulance, that it is better to arrive at an emergency scene alive and a little later, than not at all. While responding to medical emergencies are a routine part of an Ambulance Paramedic’s daily routine, it can never be emphasized too much the importance of perspective in their attempt to arrive with mimimum delay.

This article makes no suggestion whatsover that the paramedics were at fault here, but that the story emphasizes the potential risks that paramedics must mitigate every time they respond to an emergency under lights and sirens, as well as the enormous responsbility that this places on them, for their own lives and others.

The ramifications of this disaster on the paramedics although unknown, may continue for years to come. We wish them luck in whatever methods they need to use, to continue after this experience.

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Gulgong Hospital Closes

September 6th, 2010

The Gulgong Hospital was built in 1901 and has serviced the Gulgong and surrounding community for over one century. On Sunday the 28th of August at 8pm the doors of Gulgong hospital closed indefinitely as a result of a Work Cover Report from early this year that found the hospital to be lacking in many safety necessities. The community of Gulgong are currently still undergoing negotiations with the Greater Western Area Health Service (GWAHS) in an attempt to meet a resolution, which will allow 24 hour emergency health care to be available to the community. 

While an agreement is being determined for the provision of emergency healthcare in the future, GWAHS has come to the agreement to keep the emergency department at Gulgong Hospital open for 12 hours a day (8am to 8pm Monday to Friday) and for 8 hours a day on the weekends (but these times are currently being reviewed.

The Ambulance Service of NSW has advised that it will continue to provide 24 hour prehospital emergency health care and transport of sick and injured persons within the community of Gulgong. However, it should be noted that the paramedics at Gulgong station will now be providing this level of care during transport times of a minimum of 30 minutes to the nearest hospital or Emergency Doctor!  Another consideration that needs to be addressed by GWAHS is the fact that, so long as the paramedics are transporting to another hospital facility, Gulgong will have to wait, at a minimum 30 minutes for the next Ambulance to be able to attend a medical emergency, while it travels from the next nearest Ambulance station.

According to local residents who have recently attended the Gulgong Hospital as a result of injuries or illnesses, there have been many patients in just the last few weeks, leading up to the closure of Gulgong Hospital, who have suffered life-threatening injuries, or cardiac arrests, who literally owe their lives to the fact that Gulgong Hospital was open at the time and was able to provide life saving care and treatment by specially trained Doctors and Nurses.  

This article further emphasizes the current trend in emergency health and community health, which represents the changes in the role of the modern paramedic, in which he or she is treating patients for longer and longer, and more holistically than ever before. We wish the town of Gulgong good luck in the future for gaining support and a 24 hour hospital in the future.

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Nose to Toes

September 5th, 2010

This is how you perform a nose to toes secondary assessment as a paramedic, nurse or doctor. It should be noted that before a nose to toes secondary assessment is performed a primary assessment including ABCD should be first performed.

To complete a thorough nose to toes assessment you should assess the following from the head down (generally because the head is just about the most vital part of the body and tells you most things).

Head: look at the person’s head to see if there are any abnormalities, colour differences, contusions, swelling. Gently run your hands (with gloves on) over the hair from the front through to the occiput (back of the head). Then examine the eyes, nose, mouth and ears for signs of bleeding or CSF leakage (cerebral spinal fluid). Ask the patient to gently clench his or her teeth and run their tongue around their mouth to see if there is any bleeding. Assess the eyes. Have a look with a pen torch and assess the eyes to see if they are equal, reactive to light, and document the size of the pupils (this may indicate many things, such as adrenaline, opioid drugs, etc in the system).

Neck: Feel the neck and assess for pain, discomfort, or any defformity.

Chest: while gently feeling the rib cage with both hands ask the patient to take a deep breath. Watch for any signs of discomfort, such as grimacing, or difficulty taking a deep breath. Make sure to note where it hurts, if it hurts. Expose the chest so that you can clearly see if the chest is expanding symmetrically or asymetrically (as in the case of a flailed segment of the rib cage). Be careful if you are a man assessing a woman here (okay, even if you are a woman assessing a woman, you better be careful about this – and alway try to keep them modest). Assess for respiratory rate and the effort of that rate. Look to see how deep the patient is breathing – is it shallow or deep? Now use some equipment. That stethescope that makes you look like a doctor. Use it to assess the breath sounds. A normal breath should be heard by using a reasonable stethescope, and should sound like air softly moving in and out. Assess any abnormal sounds, such as wheezes, crackles, absent breath sounds or stridor. Now assess whether these sounds change if the patient takes a deep cough? Or, if the sounds are heard on the inspiratory phase or the expiratory phase? How well can the person speak? Can they speak a full sentence, only short phrases, single words, or nothing at all? How anxious do they appear? How distressed do they appear?

Abdomen: Expose the abdomen and gently palpate each of the four primary quadrands of the abdomen. Assess for guarding, regidity, tenderness. As with all other pain assessments, assess for OPQRST (see pain assessment). Assess for fullness. If it appears distended, ask if this is normal.

Pelvis: Gently feel the pelvis and ask if there is any pain. In Australia, we no longer “spring” the pelvis to assess if it has been fractured. This is because there is the risk that you will make the pelvis much worse if they do happen to have an open book pelvis fracture.

Motor/sensory: Assess the motor sensory results of all four limbs. Ask the patient to squeeze your hands. Feel for equal or unequal strength. Squeeze each hand individually afterwards, and ask them to tell you which hand you have just squeezed. Ask them to push down and pull up with both feet. Again, assess for an equalness or unequalness to the strengtha and ability. Expose the feet and assess their sensory response by apply gentle stimulus to each individual foot.

Back: If still unsure if the patient has had a spinal injury, log roll the patient onto their side, and expose the back. Gently palpate the spine, from the upper cervical region down to the lower lumber region. Assess for the continuity of the bones in the spine. Look for obvious deformity or contusions. This is an important part of a noes to toes assessment of a patient. I have made the mistake of taking a patient into an ED without assessing their back (because I was too concerned with the injuries to the patient’s legs. However, when they rolled the patient in the ED they found a large branch penetrating through his back. It wouldn’t have changed my treatment of him, but it would have made me look like a more competent paramedic when I gave my handover to the resuscitation team in the ED.

Final Assessments: if you are satisfied that the person does not have a spinal injury and they are capable of standing up, assess their abilty to walk. Watch to see if they favour one side or the other. If they appear to have trouble, ask if this is normal or new?

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Emergency Response

September 3rd, 2010

What is it like to respond to an emergency?

Members of emergency services, such as Police, Fire and Ambulance are the few people who are lucky enough to respond to emergencies every day. These emergency can be medical, fire related, disaster related, or security based. When you get the “call” to attend an emergency, your sympathetic nervous system (the part of your nervous system that makes your senses heightened)  cause all your senses to become heightened.

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Scene Safety

September 3rd, 2010

Paramedic Scene Safety – “The number one priority for me when I start a shift… is to be able to finish my job for the day and go home to my family… that’s why my first thought is to scene safety… and ONLY then… all other issues… ” Australian Paramedic (And just about every other Paramedic in the world).

Scene safety for paramedics requires the paramedics to think 2-3 steps ahead of themselves at all time and consider all the possible “what if” scenarios and their possibly solutions. For example, when I arrive at a scene, I park the Ambulance in such a way that I know that if things go bad at the scene, I can drive out forwards and easily if I have to make a quick “get away.” When I walk into a house, I’m constantly assessing where I could move, or what I could do if the patient became violent, or if someone else came into the house. I try to always stick together with my paramedic partner – often it takes more than one pair of eyes to pick up a problem.

For example, one day I was called to a 40 year old who had had a query cardiac arrest. With the hightened nerves, I rapidly approached the patients bedroom and was just about to commence CPR, when my partner stopped me. He had noticed a power cord running for the wall power plug to the patient. We switched the power off and then removed the wire – the patient had intentionally killed himself with high power electricity and I was just about to follow him to his death by touching him. Early lesson for me on scene safety and its importance.

All scenes can turn bad

More often than not, we are allowed to do our job primarily unhindered, and I don’t go around to every job paranoid that I’m going to be attacked. But, as you build up experience, and skills in the area of risk managment, you develop an ability to have a sub-conscious thought process in the back of your mind that constantly assesses and reasesses the scene for safety problems, so that you don’t end up caught out unaware. This way, when only subtle changes are made, something triggers in your mind, to make you realise when the scene is going down hill.

For example, I once was treating an 88 year old lady with chest pain – we attached the ECG and she had increased ST elevation (not a good sign on the monitor). Anyway, her 21 year old grandson was there, and my partner (who recognised the need to get going to hospital) went outside to get the stretcher. By the time he had returned, the patient’s grandson had attacked me with a knife because he wanted drugs.

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Scene Assessment

September 3rd, 2010

How do paramedics assess a scene? Paramedic work in unique and dynamic environments. Emergencies, by their very nature are often dangerous and do not make very safe working environments or scenes for paramedic.

Paramedics start assessing a scene well before they get to the actual scene. For example, they are gaining information from the emergency call taker who will have asked a pre-developed set of questions designed at identifying as much information about the scene before the paramedics arrive. This is also where the scene safety commences, because the emergency call taker will be telling the patient or the person who has called for an Ambulance information that will make it safer for the paramedics to do their jobs. Information, such as – telling them to turn their lights on at night, turning of power if power lines are down, asking them if someone is being agressive or violent on the scene.

Windscreen Assessment

When a paramedic arrives on a scene the first thing that he or she does is assess the scene briefly from the windscreen (while he/she is still in the Ambulance).

The paramedic is looking for risks and important informations, such as:

Where the dangers are on the scene?

Where the best place to park would be, while keeping in mind the need for access and egress?

What other resources do I know now that I will need?

Out of the Ambulance Scene Assessment

Scene assessment continues once out of the Ambulance. Paramedics are constantly assessing their surroundings. What is in front of them and what is behind them?

Remember to look around, look left, look right and don’t forget to look up and down! Many paramedics and EMS personnel have been badly injured on a scene because they failed to look up and see the power lines that had fallen down during a motor vehicle crash.

Lessons Learned in Scene Assessment:

These are the most valuable lessons that I have learned in more than 12 years as a paramedic about scene assessment:

1. Get as much information about the scene that you’re attending before you even get there. If there has been reports of a motor vehicle into a power pole, ask if anyone can confirm that there are fallen power lines or not. If you have been called to a gun shot wound, ask about the perpetrator – is he or she still on the scene? What about the Police, have they arrived yet?

2. As you arrive at the scene, approach slowly and have a good look (this means both paramedics, not just the driver). Look out, around and don’t forget about looking up for power lines or things that may fall.

3. If you’re not confident that the scene is safe, get out of there and get help. Let the casualties know not to move and that you’re going to get help.

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Emergency Services

September 3rd, 2010

Emergency services in Australia is a term that defines any service that provides support and aid during an emergency and can be broken into two main categories – volunteer emergency services and full time emergency services. Both of which provide a valuable and important service to the community.

Volunteer Emergency Services in Australia

St John’s Volunteer Ambulance Service

State Emergency Services (SES)

Volunteer Rescue Services

Rural Fire Brigade (Voluntary)

Full time Emergency Services in Australia

Ambulance Services (for each state)

Police Services (for each state)

Fire Brigade (for each state)

State Emergency Services (Full time commanders)

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How much does a paramedic make?

September 3rd, 2010

Paramedics in Australia make different money depending on which state they work in. Unless they work in a state that has a composite wage (everything rolled into one salary, such as overtime, night shift and weekend penalties), most paramedic earn a lot more than their base salary.

On average, most paramedics around the state have a base salary of $45-55 000. However, this does not mean that most paramedic only earn this much. In most states, the average paramedic would earn close to double this. In some areas, where paramedics are required to work “on call” or regularly work at other areas and ear “living away from home allowances” they are capable of earning $120,000 + per year.

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How much does a mine medic make?

September 3rd, 2010

Mine medics or mine paramedics in Australia earn between $80,000-120 000 per year as a salary, but can be much higher depeding on additional allowances, such as overtime, rescue/danger, living away from home allowances and additional roles, such as fire response, rescue response, and security.

Most mine medics in Australia are employed as primary first aiders (with higher skills and medical abilities/ knowledge), but they also serve a secondary role. In some mines, this means being the Store Person as well as the medic. At the other end of the spectrum, some mines employe Occupational Health and Safety Officers (OH&S) who are also trained paramedics or medics. Some of these people can earn much higher wages into the $140-50, 000 bracket.

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Paramedic Exams

September 3rd, 2010

These are some ol examp practice and preparation stuff for a first year university student of paramedics, clinical practice or nursing.

An allergic reaction occurs when an antibody binds with an antigen causing a hypersensitive reaction to antibodies bound to mast cells, neutrophils or basophils.

Antigens can enter the body through:

  1. ingestion
  2. inhalation
  3. injection
  4. absorption

 

S&S of the release of histamines: decreased BP, increased GIT secretions, rhinorrhea, lacrimation, angioedema, urticaria, flushing, hyperaemia, pruritis

S&S of the release of leukotrienes: wheezes, coronary vaso-constriction (v.c.), hypotension

S&S of eosinophil chemotactic factor: increased temp, chills, bronchospasm, and pulmonary v.c.

PHC drugs used in the treatment of anaphylaxis include: Adrenaline 0.5 mls of 1:1000 IM, Salbutomol (if bronchospasm is present) at 5mgs:2.5mls via nebuliser or IPPV, hartmann’s 20mls/kg as a rapid bolus is signs of relative hypovolaemia manifests

Opsinisation – is a substance that makes bacteria more susceptible to phagocytosis

The four main functions of antibodies are to:

  1. neutralize bacterial toxins
  2. neutraise viruses
  3. opsonise bacteria, and
  4. activate elements of the inflammatory response

 

Antibodies are proteins

Innate immunity vs acquired immunity

Innate refers to the immune defenses that lack immunological memory

Acquired immunity occurs after birth and is a result of the immune response

Humoral immunity: uses the B-cells (human bursal equivalent)

Cell-mediated immunity: uses the T-cells (thymus cells)

Hydrophilic – loves water

Hydrolytic – kills/ lysis in water

Hydrophobic – hates/ fears water

Primary response – immediate

Secondary response – occurs once the antibodies have been developed and is much more effective

Antigens trigger a response

Antibodies are proteins produced in response to antigenic invasion

Drugs of dependence (DDs) – S8 eg morphine, must be double locked, registered and accountable for the balance, lost/stolen ampoules must be reported to the police

Macro drip rate: DR 20/60

Micro drip rate: DR 60/60

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Carbon Monoxide Poisoning Symptoms

September 2nd, 2010

What are the sypmtoms of carbon monoxide poisoning?

Carbon Monoxide has approximately a 200 time greater affinity (desire to bind with) with haemoglobin (red oxygen carrying blood cells) than oxygen. Consequently, carbon monoxide will take the place of most haemoglobin and stop oxygen from being able to bind to it and travel to the various tissues and vital organs of the body. The key symptoms show that the body is litterally starved of oxygen, and are not that much different than if the patient really was unable to breath.

The Key Symptoms of Carbon Monoxide Poisoning

Shortness of breath

Dizziness

General feeling of malaise or feeling unwell

Lethargy

Headache

Weakness

Tricky signs of carbon monoxide poisoning

Unlike normal stages of hypoxia (lack of oxygen to the body) in which a patient looks pale, these patient often appear red or even flushed.

Furthermore, because SaO2 monitors (oxygen saturations) monitor the amount of molecules that are binding with the haemoglobin (and are not able to differentiate between oxygen or carbon monoxide molecules) these patients will almost always read as saturating at 100%.

Late Symptoms of Carbon Monoxide Poisoning

Severe dizziness

Unstable gait

Black outs

Unconsciousness

Death

What to do if suspect Carbon Monoxide Poisoning?

Remove yourself and the patient from the source of the carbon monoxide poisoning. Even just walking outside where there is open air should stop the situation from getting any worse.

Call an Ambulance

Paramedics will provide 100% oxygen which will slowly compete with the carbon monoxide for positions on haemoglobin. Because carbon monoxide has a greater affinity than oxygen for haemoglobin, the only way that oxygen can compete is to saturate the lungs with 100% oxygen until the number of oxygen molecule is much greater than the number of Carbon Monoxide molecules.

 

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Carbon Monoxide Poisoning

September 2nd, 2010

Carbon Monoxide Poisoning – Intentional carbon monoxide poisonings used to be a common case for paramedics. Fortunately, since the early 1990s changes in motor vehicle efficiency made it more difficult for people to use this as a means of suicide. However, this does not preclude people from trying, or from people using older vehicles to poison themselves with carbon monoxide.

In most cases a diagnosis of carbon monoxide poisoning clear to the paramedic upon arrival at a scene due to the contraption set up in a vehicle with the exhaust fumes filling the car (that remains running). However, in some cases, the diagnosis of carbon monoxide poisoning is much less clear. For example, where a person has been working in close proximity to heavy machinery in a closed space, or where an internal exhaust pipe has been damaged causing carbon monoxide to leak into a vehicle. In these cases, the diagnosis of carbon monoxide poisoning is much less clear. ‘

Carbon monoxide in itself is a clolourless, odorless gas (although the exhaust/combustion residue will normally be identified).

Carbon Monoxide Signs and Symptoms

Signs of poisoning include: cherry red skin and mucous membranes as a result of bright red COHb (Thorn, Adams, Isselbacher and Petersdorf 1977, p. 693); confusion, dizziness, headache, visual disturbances, nausea, vomiting, early onset of fatigue with little physical exhaustion, coma, hyper-reflexia, convulsions, and arrhythmias. Acute exposure: depends on level of COHb. Generally no symptoms are experienced when COHb levels < 10% while levels > 60% associated with coma and cardiorespiratory arrest (Sanders 2001, p.610). Late symptoms include neuropsychiatric complications, which may develop weeks after exposure. These include memory loss, impaired intellect, and signs of cerebellar and mid-brain damage.

Oxygen SPO2 may falsely read as high as 99-100% because it is measuring the CO molecules combined with the Haem molecules and not Oxygen combined with the Haem molecules.

Carbon monoxide inhalation causes many noticeable physiological changes in a patient although it does not physically harm lung tissue, it causes a reversible displacement of oxygen on the haemoglobin molecule, forming carboxyhemoglobin (COHb). As a result, there are low circulating volumes of oxygen despite normal partial pressures and in addition it requires tissues to become very hypoxic before oxygen is released from haemoglobin to oxygenate cells.

Carbon monoxide poisoning causes anaemic hypoxia, which is where the blood oxygen partial pressure is normal, but there is a lack of normal haemoglobin (Hb) or altered haemoglobin used for oxygen carriage. In CO poisoning, CO molecules occupy the oxygen sites on the Hb, therefore making it difficult for oxygen to take its place on the Hb molecule. There are four oxygen carrying ‘carriages’ on one Hb molecule and all four of these can become occupied by O2, CO or CO2. CO has an affinity for Hb 200-250 times that of oxygen, this means that even low concentrations of inspired CO can result in tissue hypoxia, inadequate cellular oxygenation, inadequate cellular and organ function and eventually death

According to the Hong Kong College of Anaesthesiologists the ‘elimination ½ life of CO reduces from 250 minutes when breathing air to 59 mins breathing 100% O2 and 22 min when breathing 100% O2 at 2.2 atmospheres’ (Hong Kong College of Anaesthesiologists 2004).

Carbon Monoxide Treatment

Remove the patient away from the site of CO exposure as soon as safely possible. As with all burn injuries, the safety of the paramedics (and other rescuers) must be the first consideration in managing the victims of gaseous injury. Administration of 100% O2 is very important as this increases the partial pressure of inspired O2, which increases the chance of O2 binding to the Hb molecules and removing the CO.

The greater the amount of O2 in inspired air, the greater the partial pressure of oxygen (PaO2) in the alveoli and the higher the PaO2 in alveoli the greater the promotion of diffusion across the alveolus into the capillaries.The route of 100% O2 administration depends on the patient’s level of respiration. At a minimum, a patient suspected of suffering a CO inhalation poisoning should be on a non-rebreathing O2 mask at 14l/min and if respirations are inadequate the patient should be assisted as much as required with intermittent positive pressure ventilation (IPPV) via a resuscitation bag (Sanders 2002, pp 612).

If unconscious or unable to maintain his/her own airway, patient should be intubated and ventilated manually.  In severe poisoning assume cerebral oedema and treat accordingly. Although the use of hyperbaric oxygen is still debatable, the Hong Kong College of Anaesthesiologists believe that two categories of patients should be treated with hyperbaric oxygen. The ‘conscious patient with COHb level > 20% and a depressed level of consciousness who is able to maintain their own airway’ and ‘after the recovery of a patient’s consciousness after an initial COHb level of > 40%’ (Hong Kong College of Anaesthesiologists 2004).

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Organophosphate Poisoning

September 2nd, 2010

Organophosphates poisonings are becoming less common for paramedics, but hold a very high level of mortality and are dangerous for all persons involved. Because of this, paramedics must thoroughly understand the pathophysiology and signs and symptoms of organophosphate poisoning.

Organophosphates are found in pesticides, herbicides and nerve gas. Due to their particularly sinister properties, many countries have banned the use of organophosphates in agriculture, however, this does not mean that there aren’t older organophosphates around in peoples sheds, homes, or garages. Furthermore, with the increasing fear of terrorist attacks, organophosphate based nerve gases, although unlikely, are always a possibility.

So, how do organophosphates work?

Organophosphates irreversibly bind to cholinesterase, causing the phosphorylation and deactivation of acetycholinesterase (AchE). The clinical effects are secondary to acetlycholine (ACh) excess at cholinergic junctions (muscarinic effects), in the CNS, at skeletal nerve-muscle junctions, and at autonomic ganglia (nicotinic effects).

Pathophysiology of Organophosphate Poisoning

ACh is a simple molecule synthesized from choline and acetyl-CoA through the action of choline acetyl-transferase. Neurons that synthesize and release ACh are termed cholinergic neurons. When an action potential reaches the terminal button of a presynaptic neuron a voltage-gated calcium channel is opened. The influx of calcium ions, Ca2+, stimulates the exocytosis of presynaptic vesicles containing ACh, which is thereby released into the synaptic cleft. Once released, ACh must be removed rapidly in order to allow repolarization to take place; this step, hydrolysis, is carried out by the enzyme, AchE. The AchE found at nerve endings is anchored to the plasma membrane through a glycolipid.

ACh receptors are ligand-gated cation channels composed of four different polypeptide. Two main classes of ACh receptors have been identified on the basis of their responsiveness. These are the muscarinic and nicotinic receptors. Both receptor classes are abundant in the human brain. Nicotinic receptors are further divided into those found at neuromuscular junctions and those found at neuronal synapses. The activation of ACh receptors by the binding of ACh leads to an influx of Na+ into the cell and an efflux of K+, resulting in a depolarisation of the postsynaptic neuron and the initiation of a new action potential. When AchE is inhibited ACh accumulates at the synapses, and cholinergic ‘overdrive’ occurs with resulting signs and symptoms characteritistics of the stimulation of the parasympathetic nervous system.

All signs and symptoms of acute organophosphate poisoning are cholinergic in nature and effect muscarinic, nicotinic and CNS receptors. These effects develop within minutes to hours, depending on the type of exposure. The quickest symptoms occur with inhalation, followed by GIT absorption and dermal exposure, with respiratory symptoms being the most critical. The primary cause of death in acute poisoning is usually respiratory failure with a contributing cardiovascular component.

As paramedics, we are most likely to see the results of parasympathetic overdrive, which leads to the SLUDGE effect. SLUDGE stands for: salivation, lacrimation, urination, defication, GIT disturbances, and emesis.

Patient assessments

The primary signs of organophosphate poisoning include: ‘salivation, bronchorrhea, bronchospasm, sweating, colicky abdominal pain, diarrhoea, miosis, fasciculation progressing to muscle paralysis, and bradycardia leading to asystole.

Signs of specific muscarinic stimulation include those which are indicative of parasympathetic stimulation such as: miosis, blurred vision, increased secretions, decreased heart rate, bronchoconstriction, nausea, vomiting, abdominal cramps, incontinence, polyuria.

Signs of specific nicotinic stimulation is often followed by nicotinic depression in organophosphate poisoning and include those which are often associated with sympathomimetic stimulation, such as: weakness, cramps, fasciculation, increased HR and BP then decreased BP and HR, variable symptoms from anxiety & restlessness to confusion, obtundation, coma and fits.

The patient can have wheezing, chest tightness, and productive cough. The bronchorrhea can be significant with frothy and/or bloody sputum and severe pulmonary oedema. Toxic myocardiopathy has been noted in some severe OP poisonings. Bradycardia is the usual cardiac sign, but there can be tachycardia and hypertension from nicotinic, sympathetic stimulation. Dizziness, headache and the SLUDGE syndrome of salivation, lacrimation, urination, defecation, GI upset and emesis are some of the common early symptoms reported. Sweating and rhinorrhea also frequently are present. Weakness, fasciculations, incoordination, and GI distress all are markers of a worsening poisoned condition. Pulmonary oedema may be a late manifestation of OP poisoning. Blurry or darkened vision can be present with miosis. Confusion, anxiety, restlessness and toxic psychosis can occur and there have been reports of memory loss and depression.

The benefits and limitations of atropine as a treatment strategy in organophosphate poisoning.

Atropine is a cholinergic blocking drug that functions as a competitive muscarinic antagonist. It works by occupying muscarinic receptor sites, preventing or reducing the mucarinic response to acetylcholine. Atropine can be given to antagonize the muscarinic effects of organophosphate poisoning, and in doing so the cholinergic effects, such as bradycardia, salivation, lacrimation, urination, defecation, GI upset and emesis. Specifically, atropine blocks the action of the vagus nerve and therefore increases the sino-atrial rate. Atropine does not affect nicotinic autonomic ganglia.

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Competitive Antagonists

September 2nd, 2010

What is a competitive antagonist?

A competitive antagonist is a drug or chemical which binds to a specific receptor site and once there, blocks another drug or chemical from binding to that site. While the competitive antagonist binds to a particular drug receptor site, another drug must compete to gain access to that receptor. Normally, if both drugs have the same affinity (conectivity and likeness) for the receptor, then the only way they can compete with each other is by having more drugs.

For example,

Naloxone is a competitive antagonist that competes for the opioid receptor sites within the body. This has the medical significance, that any patient who has had either an opioid overdose (as a result of excessive opioid analgesia) or heroin overdose – a doctor, nurse or paramedic may administer naloxone and it will compete as an antagonist with the opioids already in the body for a spot on the opioid receptors, but it will not cause any affect on the opioid receptors

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What is an Antagonist Drug?

September 2nd, 2010

The term antagonist can refer to both pharmaceuticals (drugs) and also to literary concepts.

What is a drug antagonist?

A drug antagonist is any drug that binds with a specific chemical receptor within the body, and in doing so, precludes another drug from binding to such a receptor and therefore stops the original drug from having an affect on the body.
 

Examples of antagonists


Competitive Antagonists: Distinguishing between the antagonists naloxone and flumazenil.

Naloxone is an opiate antagonist, which ‘binds to opiate receptor sites and competes with opiate agonists for their spaces on opiate receptor sites’ (MIMS Annual 2003 p. 4-433). Flumazenil, like naloxone is an antagonist drug, but unlike naloxone, which acts on opiate receptor sites, it acts on benzodiazapine (BZ) receptor sites. Flumazenil binds to the ‘BZ receptor sites and blocks the agonists through competitive inhibition’(Bryant and Knights 2003, p271). By binding to gamma-aminobutyric acid (GABA) gated chloride channels flumazenil blocks the Cl flow, where BZs open the Cl flow.

A proportion of all drug molecules entering into the blood stream bind to proteins to form drug-protein complexes. ‘Acidic drugs bind mainly to albumin, while basic drugs bind to acid glyco-proteins contained in the blood’ (Bryant and Knight 2003, p.108). Because of the size of the molecules formed by plasma protein drug complexes, drugs which are bound to proteins cannot pass through the plasma membrane of the vascular system, and are therefore are unable to cause their desired effect on their target cells or organ. Galbraith states that ‘because protein-drug-complexes are large they cannot diffuse into the target cells or tissues and act on the body’ (Galbraith 1998, p. 79). ‘The stronger the protein binding, the less of the free drug that will be present in the plasma and the longer the drug will remain within the vascular system increasing the drugs ½ life’ (Galbraith 1998, pp.1081).

If a drug, such as the BZ midazalam has a 95% plasma protein bound concentration, only 5% of it is actually having an effect on the desired cell or organ. Because drugs bind with proteins and then release and bind with new proteins, the entire concentration of a drug will eventually pass through the plasma membrane and into the interstitial space. Therefore, the concept of plasma protein binding becomes of clinical importance, as paramedics by considering a drugs half-life. If it has a large percentile protein bound, it will take longer for the drug to release from the proteins and take effect on the desired cells or organs. When giving an antagonist, such as the BZ antagonist flumazenil, which is only ‘50% bound to protein’(MIMS Annual 1997, p. 20-1123) as opposed to midazalam which is ‘95% bound to protein’ (MIMS Annual 2003 p. 4-433) the drug ½ life will be much longer for the midazalam as opposed to flumazenil. It is for this reason that repeated doses of the antagonist may have to be given, as the antagonist may be completely out of the system while large percentages of the agonist remain within the intravenous space as protein-drug complexes. According to the Australian Medicines Handbook the ‘1/2 life of flumazenil is about one hour which is much shorter than that of all BZ; therefore repeated doses of flumazenil are required to maintain effect’ (Australian Medicines Handbook 2003).

Because albumin and other plasma proteins provide a number of binding sites, two drugs can compete with one another for the same site and displace each other (Bryant & Knights, 2003, p 109). For competitiveness antagonist have: Drug + antagonist + receptor = D and R + A and R. For a fixed total amount of receptors, the two ligands D and A compete for binding at the receptor. These two ligands compete for the same site on the receptor. Increasing the concentration of D or A displaces the equilibrium towards the formation of the corresponding receptor complex (Galbraith 1998, pp. 1081-3). Therefore, in an overdose situation, such as Heroin, large doses of the antagonist Naloxone may need to be administered to displace the equilibrium in competition of the opiate receptor sites.

A noncompetitive antagonist cannot be displaced by increasing the concentration of agonist. This is often due to different binding sites on the receptor for the agonist and antagonist. Irreversible antagonists form covalent bonds with the receptor and therefore cannot be displaced by other ligands, neither naloxone or flumazenil do this, and therefore their effects can diminish, as their agonist steal their spaces on the receptor molecules. Consequently if an opiate or BZ antagonist has a longer 1/2 than the antagonist, or has a larger plasma drug concentration, it may still occupy the receptor sites and therefore the need for repeated doses of the antagonists may be required to maintain the desired affect.

What is an antagonist in litterary terms?

In literary terms the antagonists is the person who is opposed to, or competes againsts a specific oppenent.

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Digoxin Toxicity

September 2nd, 2010

What factors predispose patients to digoxin toxicity?

If a patient is on a loop diuretic, such as frusemide (lasix) which decreases the level of K+ ions throughout the body rapidly, this can lead to digoxin toxicity. Digoxin acts by inhibiting the Na+ K+ pump causing an increase in NA+ in the intercellular fluid, which results in a reduced Na+ Ca++ exchange by anti-port mechanism, causing an increase in Ca++ ion accumulation in the myocardial sarcoplasmic reticulum (Totora and Grabawski 1996, p. 63). This increase in Ca++ ions will increase the force of myocardial contraction. This is because ‘Ca+ is necessary for normal muscle contration and thus elevated Ca+ levels increase force of contraction’ (Galbraith 1997, p. 378). Therefore a decrease in myocardial K would cause a further decrease in Na+K+ pump activity therefore decrease AV node activity causing an increase in ectopic pacemaker activity and would also cause an increase in vagal stimulation, causing bradycardia.

Furthermore, if a patient is on Slow K this can cause a patient to develop a K+ electrolyte imbalance. If he has not been taking enough K+ he could become hypokalaemic which would ‘increase the effects of diogoxin, causing toxicity and braydcardia’or alternatively, he could have been incorrectly dosed and given too much K+ causing hyperkalaemia which in turn could make the ‘effects of digoxin to be decreased and he could become tachycardic’ (Galbraith 1997, p. 379) although his assessment findings are not indicative of hyperkalaemia.

Because digoxin has a very low therapeutic range of 1-2mcg/l plasma concentration (Oh 1997, p. 968) any incorrect dosing or unconsidered metabolic or physical variances in this gentleman could cause him to become overdosed with digoxin.

Advanced age predisposes a person to Digoxin toxicity. This is because any ‘increase in age, especially greater than 45 years of age, declines the functional capacity of most major organ including kidneys, liver and cardiac function’ (Sander, 2001, p262). A decrease in Glomerulus’s Filtration Rate (GFR) in elderly patients makes it hard to determine the exact dose, as their rate of excretion may be hard to establish.

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Therapeutic Index

September 2nd, 2010

 

Explaining toxicity in relation to therapeutic range

The therapeutic range demonstrates the ‘relationship between the plasma drug concentration and the therapeutic response or toxicity over a certain time period’(Bryant and Knights, 2003, p 119). It measures on the lower end of the drug concentration scale, the minimal effective drug plasma concentration, in which anything below is deemed un-effective. On the higher end of the scale, the maximum non-toxic drug plasma concentration, with anything above being a toxic dose. The area in between these two is called the therapeutic range (Galbraith 1997, pp.87-9). 

Many factors must be considered in benefit-to-risk analysis for a specific patient. Each patient reacts differently to drugs and chemicals. Patient-related factors include age, sex, pregnancy status, occupation, social circumstances, and genetic traits. Any ‘factor alone or in combination may influence the course and severity of the disease or the response to a drug’ (Bryant and Knights 2003, p. 119).

Toxicity is defined by Mosby’s Medical dictionary as: ‘the undesired condition as a result of too much exposure to a substance or drug, which do not cause adverse effects in smaller amounts’ (Anderson 1998, p. 1632). Fundamentally, any dose that is above the minimum non-toxic level may cause toxicity.

Digoxin has a very low therapeutic index of 1-2 mcg/l with a toxic dose being between 2-9mcg/l and an ineffective dose of <1 (Oh 1997, p. 968) and therefore it is an easy drug to overdose or underdose. Levels above the maximum non –toxic range may cause toxicity.

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Morphine Lyrics

September 2nd, 2010

What songs have morphine in them?

More than 500 songs use the term morphine as a metaphor or to relate to their experiences in pain and suffering.

Who was the most popular artist who used the words morhine?

Michael Jackson

Pink also used the word morphine in “Just like a Pill”

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Morphine Sulfate

September 2nd, 2010

GTN and Morphine: A contrast of the pharmacokinetics and pharmacodynamics  

Glyceryl Trinitrate (GTN)

Pharmacokinetics

Glyceryl Trinitrate (GTN) can be administered and absorbed ‘intravenously; as a paste; transdermally; as an intradermal implant; through a lingual aerosol and as a sublingual tablet’ (Galbraith 1997, p. 380). A sublingual tablet is the most common route of administration in the NSW Ambulance Service pre-hospital management of ischaemic chest pain, and the site of absorption is the ‘buccal mucosa’ (MIMS Annual 1997, p2-152). Although GTN is rapidly absorbed in the gastrointestinal tract (GIT) the extensive first-pass metabolism in the liver causes the bioavailibity of oral administration to render the drug ineffective. Bryant and Knights state that ‘drugs absorbed through the GIT enter the hepatic portal vein and are taken directly into the liver; therefore, any drug which is metabolized predominantly by the liver may be largely metabolized before it reaches its target site of action’ (Bryant and Knights 2003, p 418). After absorption at the buccal muscosa, the drug is distributed throughout the body via the vascular system; as the circulatory system is the target site, the effects can be seen rapidly. ‘Peak plasma concentration levels are achieved within 4 minutes of sublingual administration’ (MIMS Annual 1997, p. 2-152).  Metabolism is predominantly via the liver with excretion being via the kidneys. ‘GTN is predominantly metabolized in the liver by glutthione organic nitrate reuctase. This is completed on the first pass through the portal circulation, resulting in rapid termination of action’ (Oh 1998, p. 155). 

Pharmacodynamics

Oh states that ‘once nitrate is absorbed and within the circulatory system it is taken up by the vascular smooth muscle where it becomes the active form of nitric oxide’ (Oh 1998, p. 155). Nitric oxide then ‘activates guanylate cyclase, which then catalyses cyclic GTP to cyclic GMP’ (Galbraith 2003, p.378). Cyclic GMP decreases intracellular calcium ion levels and it is this reduction in intracellular calcium ion levels that cause a decrease in vascular smooth muscle strength, causing vasodilatation (Bryant and Knights 2003, p420).

By dilating the veins, GTN decreases the amount of blood returned to the heart (preload), which reduces left ventricular end-diastolic volume. This decrease in blood return helps reduce the myocardial oxygen demand. Galbraith states that ‘by decreasing cardiac preload you decrease the cardiac workload and the myocardial oxygen demand is thus lowered’ (Galbraith 1998, p. 380). Dilating arteries reduces systemic vascular resistance, systolic arterial pressure and mean arterial pressure (afterload), which then lowers myocardial oxygen demand. Dilation of coronary arteries redistributes blood flow along the collateral channels and from the epicardial to the endocardial regions and therefore increases oxygen to the ischaemic aspects of the myocardium (Mayer 2001, p 116).

Morphine 

Pharmacokinetics

Administration and absorption can be done through ‘subcutaneous injection, intramuscularly injection and intravenous injection’ (MIMS Annual 2003 p. 4-433). Like GTN, absorption through the GIT is rapid, but as a result of the first-pass metabolism in the liver, oral administration is often ineffective. Morphine is not particularly highly protein bound, at ‘35% being bound to plasma protein’ (Bryant and Knights 2003, p247) and is relatively hydrophilic so it crosses slowly into the CNS. Plasma half-life is achieved between 2-3 hours after administration (MIMS Annual 2003 p. 4 –433). Similar to GTN it is metabolized by the liver and excreted via the kidneys, and small amounts are excreted as bile and feaces (MIMS Annual 2003 p. 4 –433). 

Pharmacodynamics

Similar to other opiates, morphine acts as an agonist with stereospecific and saturable binding sites/receptors in the brain, spinal cord and other tissues.

Morphine exerts its primary affect on the central nervous system (CNS) and organs containing smooth muscle. Effects include: ‘analgesia, drowsiness, alteration in mood (euphoria), reduction in body temperature, depression of the respiratory drive, cough suppression and miosis’ (Hollinger 1997, p. 384). There are high concentrations of receptors for the body’s natural opioids such as the endorphins and enkephalins in many areas of the CNS, particularly in the ‘grey matter of the midbrain, the limbic system and at the interneruons in the dorsal horn areas’ (Bryant and Knights 2003, p. 235). These areas are known to be involved in pain transmission or perception. The enkephalins (pentapeptides), endophins (larger polypeptides) and dynorphins are believed to be the body’s natural pain-relieving chemicals and act by enhancing the inhibitory effects at opiate receptors (Bryant and Knights, 2003 pp235-6).

The body’s endogenous opiate receptors sites are known as ‘delta, epsilon, kappa, mu receptors’ (Galbraith 1998, p.336) These are inhibitory neurotransmitters which suppress pain messages to the CNS from the periphery. Morphine acts by binding to these opiate receptor sites and blocking the transmission of the substance P (pain). At the spinal level morphine stimulates opiate receptors and thus inhibits the release of substance P from dorsal horn neurons (Bryant and Knights 2003, p.245). At supraspinal levels, ‘opiates act to close the gate in the dorsal horn, thus inhibiting afferent transmission of the substance P’ (Bryant and Knights 2003, p 245). It is also capable of altering perception and emotional responses to pain because opiate receptors are widely distributed in the CNS, especially in the limbic system, thalamus, hypothalamus and midbrain (MIMS Annual 2003 p. 4 –433) When pain perception is inhibited the analgesic effect of morphine is enhanced.

Opiate receptors are G-protein-coupled receptors, ‘activation of which inhibits adenylate cyclase and reduces cylclic adenosisne monophosphate (cAMP) levels’(Galbraith 1997, p.335). Neuronal excitability and transmitter release are both decreased as a result of reduced cAMP, leading to inhibitory effects at the cellular level.

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Stroke Symptoms

September 2nd, 2010

What are the symptoms of a stroke?

The main symptoms of a stroke include changes to a persons’ :

Face

Assymetrical appearance – check if they can smile and will show any weakness on the facial muscles or facial droop.

Arms and Legs

Weaknesses in their arms or legs – this can be one sided (hemiplegia) or bilateral weaknesses.

Speech

Difficulty speaking, strange speech, inabilty to speak. Disorientation. Confusion.

Time

How long have these symptoms lasted for? If they only last a couple minutes the person may have just had a transient cerebral event (TIA), but if they remain unresolved, then it is likely the person has had a Cerebral Vascular Accident (CVA). It should be noted though that these terms are no longer in use in Australia very much anymore and have been replaced with the simple term Stroke, which encompasses all cerebral events.

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Emergency Stroke

September 2nd, 2010

About a stroke

A stroke is some form of damage to the brain as a result of haemorrhage or ischeamia. As a result of this, the patient may decrease their consciousness or their speech. Some signs and symptoms of a stroke include: dizziness, weakness (on either side or both sides of the body), difficulty in speaking, facial droop, or paralysis.

Haemorrhagic versus Ischeamic

A haemorrhagic stroke is where the blood vessel has been broken and blood has pooled in the brain. An ischeamic stroke is where a clot has formed in the cerebral vasculature, and stopped blood reaching the cerebral tissues, resulting in distal tissues ischaemia.

Stroke assessment

There are multiple techniques and methods for assessing a patient who appears to have had a stroke.

One method that is common these days is the FAST method in which we check:

Face – for symmetry, can they smile?

Arms and limbs – do they have equal movement and sensation to both arms and legs?

Speech – are they speaking normally?

Time – when did this happen? Has it changed at all?

What else could it be?

Consider hypoglycaemia

Consider other drug involvement

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Eye Healing

September 2nd, 2010

How well do eyes heal?

The eye is a very resiliant and capable part of the body, which heals itself from most minor, moderate injuries and even major injuries.

How does it heal?

If the highly sensitive cornea is damaged, new/healthy cells slide immediately slide over and patch the injury before infection occurs and vision is affected. If the injury penetrates the cornea more deeply; however, the healing process will take longer. This can result in greater pain, blurred vision, tearing, redness, and extreme sensitivity to light. These problems may require specialist medical interventions. Very deep injuries may result in corneal scarring, which causes a haze to develop on the cornea that can greatly impair vision. The main solution for this is corneal transplantation.

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Eye Injuries

September 2nd, 2010

What are common eye injuries?

In my experience, eye injuries come from a broad range of accidents. These are a list of the common eye injuries we deal with as paramedics.

Oleoresin Spray

Patients who have gotten Oleoresin Spray (Pepper Spray) in their eyes would be the most common eye injury that we treat in todays society. These are just as frequently the Police Officers using it as the Offenders (or crooks) who are being sprayed. This is because wind and various other factors may cause the spray to land everywhere. Also, different people have different reactions to it. Some people may be particularly allergic to some of the additives in Oleoresin Spray, and as a result their eyes become worse than others.

Hayfever

The various pollens and dustmites that cause most people to develop heyfever will affect the eye differently in different people. Most people barely notice it. However, some people develop severe irritation and swelling around the eyes as a result of heyfever.

Penetrating Injuries

Penetrating eye injuries come from a myriad of accidents, all of which, generally result in the patient stating to me “wow, I wish I had of been wearing my safety goggles” – which they normally end up having on them, but not actually wearing at the time. Common penetrating injuries that I’ve seen include: metal fragmants while people are hamering or chiseling, bits of broken wood and glass fragmants. Most penetrating eye injuries are very rare. This is because the corneal reflex, which causes the eyelids to immediate close and block anything that is falling into the eye, works very fast.

Violence

Blunt trauma to the head (such as with a closed fist during a fight) can sometime damage the eyes. Also, in some violent situations, I have seen people use screw drivers as knives, which have, on occasion penetrated the eye ( but these are uncommon eye injuries.

Light or Sparks

Anyone who has been a welder for many years will tell you of the story of someone who thought they could get the quick welding job done without a visor (special sunglasses/head protection). The patient may be alright while welding, but afterwards, the eye iris becomes damaged.

Smoke

Smoke is an irritant, and like all irritants it will cause the eyes to become red and sore.

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Eye Injury Treatment

September 2nd, 2010

Eye injuries aren’t very nice… okay, they are one of my pet-hates at work, treating eye injuries. I’m sure they’re not much fun for the patient with the eye injury either. However, it is good to know that the cornea, which is basically the safety cover over the lens, is the most resilient and has the most self rejuvenating and healing properties of cells in virtually the entire body. This means that, in most cases, where a person has been splashed with acid, or experienced some eye trauma and are no longer able to see, will eventually re-gain their sight. In many cases of hydrochloric acid burns (quite common in some industries, such as pool cleaning) patients are able to treat their eye injuries and gain full sight within 24 hours.

Types of Eye Injuries

Trauma

In eye trauma, we control haemorrhage around the yee or eyelids with direct pressure, but make sure that we do not place any pressure on the eyebal itself.

Chemical Burns

If caustic powder is present, you must remove this prior to irrigating the area. Then irrigate the area with as much water as possible (preferably saline if possible). We do this for about 20 minutes, but the longer you can stand it the better generally. Continue irrigating if in doubt. Make sure you retract the lids to ensure thorough flushing throughout. Contact lenses should be removed if they are still insitu.

Oleoresin Capsicum

Oleoresin Capsicum spray is one of the more common defensive techniques that Law Enforcement utilize to protect themselves from violent persons and as a non-lethal means of breaking up a altercation. Paramedics treat patients who have been exposed to oleoresin capsicum spray by providing a acid buffer such as baby shampoo. It is important to allow the patient to wash their own eyes so that you do not become contaminated with oleoresin capsicum spray.

Eye Injury Paramedic Treatment 

Protect the eye

Try not to let the patient rub their eyes – this only makes it more inflamed and ultimately hurts them more. You may apply an eyepad lightly taped in position. There is no benefit from covering the good eye and this will often just make the patient more agitated and may lead to motion sickness and vomiting which is very bad in eye injuries because it results in an increase in intra-occular pressure (pressure on the eyeball), which is bad.

Provide an antiemetic

Because we do not want these patients to vomit, it is important to administer an antiemetic. Often, while having one eye covered patients may become disorientated and develop motion sickness. Therefore, antiemetics should be aimed at treating motion sickness, such as promethazine or ondansetron

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3rd Degee Burns

September 2nd, 2010

The terms 1st, 2nd and 3rd degree burns are no longer used in Australia. However, I believe they are still used in some parts of the world. Also, due to the wonders of modern TV shows that still use the terms 1st, 2nd and 3rd degree burns, it is important to know how these relate to our current standard for classifying burns, because many patients will still use these terms.

1st degree burn

A 1st degree burn basically is a very minor burn that only affects the outer area of the skin (epidermis). There is some redness around the area, but no full blistering.

2nd degree burn

This burn is very similar to a 1st degree burn in the sense that the skin area is very red, but it is worse than a 1st degree burn because of the fact that it also has some blistering.

3rd degree burn

This is the very bad burn. In this burn, everything has been damaged, all the way down to the bone. There should be black charring throughout the whole burns area. The patient is unlikely to feel the pain at the site, because all the nerve cells will have been destroyed (however, they can still feel pain on the outer areas where there are some damaged and some intact nerve cells).

How do all these types of burns relate to what we have in Australia?

In Australia we have three main classifications of burns. These include: superficial, partial and full thickness.

Superficial

Superficial burns are similar to the old 1st degree burn, in which the epidermis is damaged, there is redness, and there are no blisters

Partial thickness burns

Partial thickness burns are similar to 2nd degree burns. They still have damage to the epidermis, some of the dermis, redness, but they also have the inclusion of blistering

Full thickness burns

Full thickness burns are the most severe classification of burns, and is similar to 3rd degree burns. In these burns the patient will have damaged tissue from the epidermis all the way down to the bone and all tissues inbetween. These patients are at great risk of infection.

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Burns Treatment

September 2nd, 2010

Burns are a type of injury to the skin tissues, nerves, muscles and bones as a result of direct transfer of heat by: electricity, radiation, chemicals, light, fire, and friction. The resulting damage to the tissue can be superficial, partial thickness and full thickness.

The best thing that people can do at the onset of a burn is to immediately cool the area with cool running water from a shower, hose, tap or any other method for at least 20 minutes. This doesn’t preclude you from calling an Ambulance while you do this. If you don’t have clean running water, but there is some water available, soak towels or clean linnen into the water and then use this to gently lay on the burns wound.

Assess burns injury

We look for signs of airway involvement (these are all bad signs):

Hoarse voice

Inspiratory stridor

Singed facial and nasal hairs

See-saw breathing

Carbonaceous material around mouth, nose, or in the sputum.

How do we classify burns in Australia?

Burns are divided into three categories. These are,

Superficial (like a bad sunburn)

Partial thickness  (mild blistering)

Full thickness (black charring of the skin) 

We then assess the burns area to determine a percentage of the skin affected. Their are multiple different techniques or algorithms for working this out. In Australia, I believe most Ambulance Services work on the Rule of Nines.

Assessing Body Surface Area

Rule of Nines

In this system, we divide the rule up into Adult patients and Paediatric patients (ultimately, its is only a guide of how much the body has been burned for fluid resusciation purposes).

For an Adult

We attribute:

9% for head

18% front torso

18% back torso

9% each arm

18% each leg

1% for the groin

For Paediatrics

18% for head

18% front torso

18% back torso

14% each leg

9% each arm

Palm and fingers of patient

You can also use the size of the patient’s palm and fingers relates to 1% of their total body. You can therefore use this to give a rough estimate of the total surface area of burns.

Burns area care

Remove all jewellery, tigh, burt or wet clothing, and if the burn is in a limb, elevate the limb to reduce swelling.

Fluid replacement formula

Each Ambulance Service has its own formula for calculating fluid replacement post burns.

This is one formula:

Percentage of Burns Surface Area (BSA) x Weight – over 4 hours.

For example, if we have an adult patient who as 15% burns and weighs 70kg, we would calculate,

BSA15 x 70kg =1050 mls of fluid. We then administer this over 4 hours – about 262mls per hour

Assess temperature

These patients are very susceptible to hypothermia due to excessive cooling. You should regularly check the patients emperature and keep them warm.

Burns Pathophysiology –When large parts of the body is burnt this will effect most other sytems of the body. This is why treatment of severe burns, as a paramedic, nurse or doctor requires continuous monitoring of other body systems, and treatment holistically, including replacement of electrolytes, plasma, and fluids.

These are the main body systems which are affected by severe burns.

Skeletal System

Red bone marrow replaces red blood cells which is destroyed by the burnt skin. If the burns area is too large for the bone marrow to compensate for the loss in red blood cells, the patient will require blood transfusions to survive.

Cardiovascular System

Burning of the skin will lead to an increase in capillary permeability, which causes an increase in blood vasculature – this then results in a decrease of blood pressure as well as live blood volume. This further decreases the blood flow and oxygenation to tissues, which then also results in oedema, shock and eventually death.

Muscular System

Anytime the body becomes hypermetabolic (which is does in the case of a burn), one first areas to be targeted is muscle mass.

Nervous System

Pain is primarily only felt in the partial-thickness burns, where as in full thick-ness burns the nerve cells are destroyed and the patient will feel nothing. As a result of the abnormal levels of circulating potasium ions (K+) such as high K+ due to cellular destruction and the efflux (outward flow) of potasium ions causing hyperkalaemia (high potasium) or hypokalaemia (low potasium) as a result of rapid K+ loss as a result of fluid in the burn, the nervous system transmission of messages, may work faster or slower than normal or not at all.

Respiratory System

Airway obstruction caused by gross oedema of the throat. Also, these patients may have an increased respiratory rate as a result of pulmonary oedema (secondary to smoke inhalation) or increased respiratory rate as an attempt to compensate the increased metabolic rate.

Endocrine System

Increased secretions of adrenaline and nor-adrenaline in response to the injury may lead to increased body temperature and increased cell metabolism.

Lymphatic System

Inflammation increases as a result of damaged tissue, which results in greater strain on the lymphatic system and pitting oedema.

Immune System

Decreased response as a result of excessive strain on the lymphatic system and due to increased infection as a result of burns area removing the first line of infection defence.

Digestive

Due to the potential hypovolaemic state in which a body with severe burns is likely to be in, their is a decrease in blood availability in the intestinal lining and liver. The intestinal lining automatically increases nutrients required to support metabolsim and repair of damaged cells.

Urinary

The kidneys compensate for the increased fluid loss as a result of the burn area by decreasing urine output. The potential detriment of this change is the potential for kidney damage as a result of poor perfusion.

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Burns Pathophysiology

September 2nd, 2010

Burns Pathophysiology  –When large parts of the body is burnt this will effect most other sytems of the body. This is why treatment of severe burns, as a paramedic, nurse or doctor requires continuous monitoring of other body systems, and treatment holistically, including replacement of electrolytes, plasma, and fluids.

These are the main body systems which are affected by severe burns.

Skeletal System

Red bone marrow replaces red blood cells which is destroyed by the burnt skin. If the burns area is too large for the bone marrow to compensate for the loss in red blood cells, the patient will require blood transfusions to survive.

Cardiovascular System

Burning of the skin will lead to an increase in capillary permeability, which causes an increase in blood vasculature – this then results in a decrease of blood pressure as well as live blood volume. This further decreases the blood flow and oxygenation to tissues, which then also results in oedema, shock and eventually death.

Muscular System

Anytime the body becomes hypermetabolic (which is does in the case of a burn), one first areas to be targeted is muscle mass.

Nervous System

Pain is primarily only felt in the partial-thickness burns, where as in full thick-ness burns the nerve cells are destroyed and the patient will feel nothing. As a result of the abnormal levels of circulating potasium ions (K+) such as high K+ due to cellular destruction and the efflux (outward flow) of potasium ions causing hyperkalaemia (high potasium) or hypokalaemia (low potasium) as a result of rapid K+ loss as a result of fluid in the burn, the nervous system transmission of messages, may work faster or slower than normal or not at all.  

Respiratory System

Airway obstruction caused by gross oedema of the throat. Also, these patients may have an increased respiratory rate as a result of pulmonary oedema (secondary to smoke inhalation) or increased respiratory rate as an attempt to compensate the increased metabolic rate.

Endocrine System

Increased secretions of adrenaline and nor-adrenaline in response to the injury may lead to increased body temperature and increased cell metabolism.

Lymphatic System

Inflammation increases as a result of damaged tissue, which results in greater strain on the lymphatic system and pitting oedema.

Immune System

Decreased response as a result of excessive strain on the lymphatic system and due to increased infection as a result of burns area removing the first line of infection defence.

Digestive

Due to the potential hypovolaemic state in which a body with severe burns is likely to be in, their is a decrease in blood availability in the intestinal lining and liver. The intestinal lining automatically increases nutrients required to support metabolsim and repair of damaged cells.

Urinary

The kidneys compensate for the increased fluid loss as a result of the burn area by decreasing urine output. The potential detriment of this change is the potential for kidney damage as a result of poor perfusion.

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Bad Doctor Jokes

September 2nd, 2010

John can’t get that nagging voice out of his head…

“John… every doctor’s done this with his patient at some stage…”

“John… I know you’re not supposed to do this with your patient…”

“But John… every Doctor does at some time… its not your fault who you fallf or… you can’t help that, can you?”

John… just couldn’t get out of his head the other nagging voice…

“John….”

“John…”

“John…”

“John… you’re a vet John…”

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Short funny jokes

September 2nd, 2010

These are some short funny jokes about paramedics, EMTs, and what we do (thrown in with a few other stupid jokes)

Short funny joke 1

While the patient is about to be placed under anaesthetic the Doctor asks the patient “why do you look so nervous?”

“Well, this is my first operation… you see… and I just don’t know how I will go…”

The doctor smiles and says “This is my first operation too… but I’m not nervous… I think I’m going to do really well!”

Short funny joke 2

Receptionist asks the patient “Would you like an appoitment for next week?” Patient – “No, I’m sick now…”

Short funny joke 3

“Of course I need it done today… if I wanted it done tomorrow, I would have asked for it tomorrow!”

Short funny joke 4

What did the blind carpenter do at the start of his day? – He picked up his hammer and SAW!”

Short funny joke 5

“Doctor, if I do manage give up smoking, drugs, and gratuituous sex with lots of random women… will this make me live long?” Doctor looks at the patient “Hmm, no, but it will definitely make it feel longer…”

Short funny joke 6

“I’ve heard that alcohol deceases your blood presure… and cafeine increases it… therefore… I must have a perfectly average blood pressure!

Short funny joke 7.

more to come…

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Diabetic Emergencies

September 1st, 2010

Diabetic Emergencies – paramedics regularly attend a variety of diabetic emergencies. Many diabetic emergencies can be avoided through good diabetic education. This is why it is so important for paramedics to have a thorough understanding of the disease process of diabetes, so that you can provide good basic diabetic advice.

What organs are involved in diabetes?

Pancreas – Is both an exocrine and endocrine gland. The exocrine portion functions in digestion. Its endocrine functions are relevant to the pathophysiology of diabetes.

It is a flattened organ of 12.5-15cm length, consisting of a head, body and tail. It is located posteriorly to the stomach and is attached to the small intestine and the spleen.

The majority of the pancreas (99%), is made up of clusters called acini which are the exocrine portion. It has 700 000 – 1000 000 small endocrine glands, the pancreatic islets (islets of Langerhans) which are scattered throughout the organ and consist of:

Alpha cells (20%) that secrete glucagon

Beta cells (70%) that secrete insulin  

Delta cells (5%) that secrete somatostatin

F cells that secrete pancreatic polypeptide

Liver

In the average adult the liver weighs between 1200-1600gms.

It is located in the right upper quadrant below the diaphragm and consists of two lobes.

It has numerous functions. The functions related to diabetic crises are described  below.

The liver stores excess glucose in the form of the polymer glycogen. When stimulated by certain hormones the liver performs glycogenesis and gluconeogenesis.

 

Some terms about diabetes

 

Glycogenolysis– the breakdown of glycogen into glucose.

Gluconeogenesis – the creation of glucose from lactate, amino acids (not including leucine and lysine) and glycerol.

Diabetes – “comes from the Greek word meaning to siphon”

Mellitus – “comes from a the Latin word that means sweet like honey” (Lundstrom & Rossini, 1998)

It was first described by Ebers Papyrus in 1500 BC.

In 10 AD Celsus developed a clinical description and in 20 AD Aretaeus gave it the name diabetes.

In 1869 Langerhans describes the clusters of cells in the pancreas.

In 1921 Banting and Best discovered that insulin injections lowers blood sugar levels in animals.

There are two types of diabetes mellitus.

Type 1 Diabetes Mellitus (DM1) is one of the most common childhood diseases and accounts for 10% of DM.

Other names include, insulin dependent diabetes mellitus (IDDM), juvenile onset diabetes, brittle diabetes and ketosis-prone diabetes.

Its peak onset is between ages 11 and 13, with onset usually earlier for girls than boys. It rarely occurs before the age of 1yr or after 30yrs.

The person is usually of normal weight or underweight.

DM1 results from the complete lack of insulin due to a loss of Beta Cells.

Though it is both alpha and beta cells that are abnormal. Hyperglycaemia is not caused simply by insulin, rather and imbalance between insulin and glucose in the portal vein.

The destructions of the islets of Langerhans is related to:

Genetic susceptibility,   

Autoimmunity

Environmental factors

Chemicals eg the drug streptozocin, an antibiotic and antineoplastic.

Illness eg mumps and rubella.

DM1 is controlled by regular daily insulin injections and regular self monitoring of BSL.

Types of insulin used in diabetes mellitus type 1

Insulin for treating diabetes with exogenous forms of insulin began in the 1920’s. The majority of these were made from either pork or beef pancreas.

As technology has progressed, genetic engineering has allowed for the manufacture of insulin closer to that of human insulin.

Both animal insulin and “human” insulin are classified by their onset of action.

Rapid-acting – have a fast onset and short duration.

Short acting – have a longer onset time but about the same duration as rapid-acting.

Intermediate-acting – have a longer onset time, but a much longer duration.

Long-acting – Again have a longer onset time, and an even longer duration

Premixed insulins – have a moderately rapid onset time and a long intermediate time of duration.  

Type two diabetes DM2, results due to a relative lack of insulin. 90% of people with diabetes have this type.

Other names include, non-insulin dependant diabetes mellitus (NIDDM), maturity-onset diabetes, adult-onset diabetes, ketosis-resistant diabetes, stable diabetes. 

It usually has an onset in people over the age of 40 and who are over weight, but this trend appears to be changing to affect younger people also in their early twenties, as diet and seddentary lifestyles are changing.

It is more prevalent in some racial groups including, Pacific Islanders, Japanese, Puerto Ricans, Hispanics, and African Americans all have a higher likelihood of developing Diabetes Mellitus Type 2

DM2 results from a genetic predisposition and environmental and other risk factors, such as long term obesity.

DM2 is controlled by diet and sometimes oral medication is also needed. These medications fall under five categories.

Sulfonylureas – stimulate the secretion of insulin from the pancreas.

Meglitinides – act like sulfonylureas only they are faster acting.

Biguanide – reduces hepatic glucose production.

Alpha-glucosidase inhibitors – delay carbohydrate absorption from the small intestine.

Thiazolidinediones – increase insulin receptor sensitivity to insulin.

Differentiating Type DM type 1 and type 2

DM1

Onset is acute with symptoms of:

Polyuria, polydipsia (excessive thirst), and polyphagia,

There may be a sweet odour in the breath,

Occasionally diabetic coma is the initial symptom.

DM2

Onset is insidious with nondescript symptoms including:

Pruritus

Recurrent infections

Visual changes

Paresthesia

Some of the classic symptoms of DM1 may be present.

Gestational diabetes

Gestational diabetes arises when there is glucose intolerance that occurs during pregnancy.

Risk factors include:

Glycosuria

Familial history of diabetes

Obesity

Increased age of mother

Mother who has had five or more children

Previous complicated pregnancy.

Once the baby is born, the abnormal blood glucose levels usually return to normal.

Diabetes Insipidus

Although it is not related to the emergencies that will be discussed, it is another form of diabetes worth mentioning.

Diabetes insipidus differs from DM as it does not involve insulin and glucose. Instead there is either unresponsiveness of the kidneys to ADH or a lack of ADH secretions from the pituitary.

It is typified by copious urination and excessive polydipsia.

Its cause can be:

Familial

Idiopathic (basically means we have no idea why this happens)

Neurogenic

Nephrogenic

Psychogenic

Blood glucose level, or blood sugar level (BSL) reflects the balance of glucose absorbed by the intestines, the amount released by the liver into the bloodstream and the amount going from the blood- stream into the tissues.

When blood glucose becomes to high, the kidneys try to correct the hyperosmolarity by excreting the excess. However water will follow by way of osmosis, hence the polyuria. Polyuria causes the brain to send a thirst message, hence the polydipsia. This continued will lead to dehydration and hence dry skin, pruritus and blurred vision.

What drugs are involved?

Insulin

Is a catabolic water soluble hormone.

Insulin is the only hormone which directly promotes cell uptake of glucose.

All cells need glucose for energy provision, however, glucose does not easily enter the cell. Insulin links with the plasma membrane receptor tyrosine kinase instigating autophosphorylation of tyrosine kinase which activates glucose transporters.

Insulin also promotes the synthesis of proteins, carbohydrates, lipids and nucleic acids.

The extracellular transport of ions such as K+, PO4 and Mg+ is also promoted by insulin.

When there is no insulin to assist glucose movement into the cells they starve, hence the symptom of polyphagia.

Glucagon

Glucagon is an anabolic hormone, produced by the alpha cells of the pancreas and in the cells that line the GIT. It stimulates both glycogenolysis and gluconeogenesis and raises blood sugar levels within a few minutes. Its release is stimulated by high glucose levels and sympathetic stimulation.

Adrenaline

Adrenaline (ADR) has fast acting effects promoting glycogenolysis and gluconeogenesis. It also has more delayed effects of suppressing insulin release and decreasing cell reception of insulin.  

Cortisol

Is secreted by the adrenal glands.

Acts more slowly and stimulates gluconeogenesis and decreases cell response to insulin.

Growth Hormone (Somatotropin)

Is secreted from the pituitary gland and acts in the same way as cortisol.

Glucagon, Adrenaline, Cortisol and Growth Hormone are all Counterregulatory Hormones

Somatostatin

Inhibits the secretion of insulin and glucagon.

Slows absorption of nutrients from the GIT.

Pancreatic Polypeptide

Inhibits somatostatin secretion, gallbladder contraction and secretion of pancreatic digestive enzymes. 

If a person with diabetes takes to much insulin, exercises or drinks alcohol without taking precautions, there can be a decrease in blood glucose levels.

It is believed that the hypothalamus is responsible for detecting a critical decrease in systemic glucose levels (about 70mg/dL). The counterregulatory hormones are released.

Adrenaline then causes the classic symptoms of hypoglycaemia, ie. nervousness, tachycardia, shakes etc.

As the brain requires a high amount of glucose, if the levels are not increased to a sufficient level, then more severe symptoms such as seizure and coma can occur.                                                            

Signs and symptoms of hypoglycaemia

The body

Increases heart rate

Diaphoresis

Tremors

Anxiety

Hunger

Nausea

Mostly attributed to the release of adrenaline.

The Central Nervous System (CNS)

Faintness

Confusion

Headache

Coma

Seizures

Delayed reflexes

Slurred speech

These symptoms are directly related to the brain being starved of glucose.

Hypoglycaemic unawareness is when a person with diabetes does not get obvious warning signs when they  have a low blood glucose level.

Some people with diabetes develop hypoglycaemic unawareness because they have repeated episodes of hypoglycaemia and their body becomes accustomed to the decreasing levels of glucose. The level of glucose has to become severely low for the release of adrenaline to occur, hence, a lack of symptoms. At the same time however, the brain still suffers at the same decrease in glucose level. So the decrease in glucose level to cause symptoms is lower than that which will cause a decrease in level of consciousness.

Some more terms to know

Hyperglycaemia – “a greater than normal amount of glucose in the blood” (Anderson 2002, p 844)

Ketoacidosis – “acidosis accompanied by an increase of ketones in the body, resulting from extensive breakdown of fats because of faulty carbohydrate metabolism” (Anderson 2002, p 8954)

Pathophysiology of hyperglycaemia and keto-accidosis

As insulin promotes glucose uptake from the blood stream into the tissues, a lack of insulin or its inability to perform its function, will cause a hyperosmolarity of glucose in the blood. As the cells are being starved of glucose there is an increase in consuming of food and therefore the entry of more sugars, causing a vicious cycle.

Due to the lack of intracellular glucose the cells use fats and proteins for energy. Fats undergoing this process create ketones which the body tries to excrete via urination and in the breath (hence Kussmauls respirations); proteins create ammonia and shows as an increase in ammonia in the urine.

Hypoglycaemia versus Hyperglycaemia

Hypoglycaemia

Rapid onset

Cool, moist skin

Full bounding pulse

Normal BP

Normal resps

May appear intoxicated, irrational.

Hyperglycaemia

Slow onset

Dry, warm skin

Rapid and weak pulse

Normal to low BP

Kussmauls respirations, sweet odour to breath.

Appear very sick.

Hyperosmolar Hyperglycaemic Nonketotic Coma (HHNC) 

HHNC can occur in individuals when hyperglycaemia occurs with the presence of some residual insulin.

The insulin is in sufficient concentrations to prevent ketogenesis but in insufficient concentrations to enable glucose use in the peripheral tissues, or decrease gluconeogenesis.

Precipitating Factors

Increased age.

Underlying cardiac or renal disease.

Decrease in either insulin secretion or action.

Increase insulin requirement eg physical or mental stress.

Use of medications such as diuretics, beta blockers, dilantin and sympathomimetics. 

Supplemental nutrition, either parenteral or enteral.

Signs and Symptoms

Weakness

Thirst

Polyuria

Weight loss

Extreme dehydration

Flushed dry skin

Dry mucous membranes

Loss of consciousness

Tachycardia

Hypotension

Tachypnoea

HHNC presentation differs from hyperglycaemia/ketoacidosis as:

There is intense thirst due to the bodies attempt to dilute the hyperosmolarity of blood glucose.

Vomiting is uncommon

Breathing is shallow and tachypnoeic. Not deep and tachyopnoeic.

There is no sweet odour of the breath.

Seizures and coma can occur, which is rare in hyperglycaemia/ketoacidosis  

Diabetic emergencies present with a myriad of signs and symptoms which mimic other common problems. The Ambulance Officer needs to be weary of this.

Diabetic ketoacidosis rarely causes coma, keep in mind other possible causes.

Hypoglycaemia can happen rapidly whatever the person is doing, even driving cars. As a result accidents can happen.

So….

Look for med alerts, but don’t discard the possibility someone has diabetes just

because they do not have a med alert.

Take a thorough history and assessment.

Compliance to medication, use of other drugs, illness eg. infection, last meal and events leading up to onset eg. exercise/stressful situation are all specifically important questions when attending a patient with diabetes.

It is essential to take a blood glucose level test.

BEWARE of the silent infarct. Diabetes has effects on the nervous system and cardiovascular system resulting in neuropathies and an increased risk of cardiac complications. These two factors combined can lead to a silent infarct ie, an asymptomatic AMI.

Summary of Diabetic Emergencies

There are a few different types of diabetes.

DM2 is the more common of the two, mostly effects the older population and can be controlled by diet, exercise and oral medications.

DM1 is less common and usually has an onset in childhood or adolescence. Management requires regular insulin injections.

Gestational diabetes occurs during pregnancy, but usually dissipates after parturition.

Diabetes insipidus differs from the others as it is related to the bodies response to ADH

The liver and the pancreas are the two main organs involved.

The major clinical factor of diabetes mellitus is the difficulty in maintaining glucose level homeostasis.

The hormones insulin, glucagon, ADR, cortisol, somatotropin, somatostatin and pancreatic polypeptide are all involved either directly or indirectly.

Insulin non-existence or insufficiency being causes, Glucagon, ADR, Cortisol and Somatotropin being the counterregulatory hormones which, act when glucose levels drop, causing the early symptoms.

Hypoglycaemia occurs with low blood glucose levels. After many episodes a person with diabetes may develop hypoglycaemic unawareness.

Hyperglycaemia occurs with high blood glucose levels. It can occur with or without ketoacidosis.

The treatment of hypoglycaemia and hyperglycaemia is outlined in protocol 40.

Hypoglycaemia treatment depends on the Patient’s LOC. If they are conscious they should be given food or drink with sugar in it followed by a carbohydrate. If they have a decreased LOC then either glucacon or dextrose should be administered.

Hyperglycaemia administer Hartmanns if the BSL is 17mmol or more. Be wary of other associated conditions.

Most importantly, take a thorough history and assessment at all times to make sure you identify the presenting problem correctly.

Diabetic emergencies can appear like other common problems.

Patients with diabetes can have neuropathies and other underlying problems that can complicate the presenting problem.

Alcoholic diabetic patients may have a Vitamin B1 deficiency that will need supplementation when given dextrose.

The management of diabetes is personalised and can be effected by subtle changes in health diet and activity, therefore can be common pre-hospital patients. Knowing adequate information on the complexities of diabetes will assist in better pre-hospital care and patient outcomes.

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Examples of Osmosis

September 1st, 2010

Osmosis can be defined as the diffusion of a solvent (water) across a selectively permeable membrane from an area of less concentration of solutes (such as salt) into an area with a higher concentration of solutes. This is an important scientific concept that has many practical applications in medicine, paramedics, nursing and many areas of general science and physics.

Practical Examples of Osmosis in Medicine

Basically, this concept becomes important when we start to administer hypertonic or hypotonic solutions. We understand that if we were to admister 100% sterile water intraveneously to patients who are dehydrated, the cells within the vasculature (blood vessels) would draw up all that fluid due to the osmotic gradient shift (this basically means that the fluid will want to shift into the cells) and this will cause the local cells to swell and lyse (rupture). This means that the red blood cells themselves will no longer be capable of carrying oxygen and serving their purpose.

Likewise, if you were to administer 50% glucose intravenously, the hypertonic solution (lots of solutes) will cause a lot of fluid to shift towards it. Now, so long as the canula is in a large vein, it will be able to draw fluid from a large area. However, if the canula is inserted in a small vein or accidentally inserted into the intersitial space and not a vein, it will not be able to draw fluid from all over, and consequently draw all the fluid from the surrounding cells. This will cause the cells to shrink (crenate) and again, become unable to sustain life. In these circumstance, patients may develop cellulitis or damaged veins.

Examples of Osmosis in Cells?

This becomes important when looking at the structure of cells in biology.

If a cell has a high concentration of a solute (salt) it will draw fluid into its cell. If allowed to continue to do this, it will eventually swell up and rupture (this is called cell lysis).

If a cell has a low concentration of a solute it will lose fluid as the fluid within its cell is allowed to be drawn out of the cell through osmosis and into the intersitial space. This will cause the cell to shrink (this is called cell crenation).

 

Examples of Osmosis Applied

The following are examples of osmosis for those of you who need to see an example to clearly understand science (like me)…

Example of osmosis 1.

If you put rice into a bowl of water, the water will move into the rice causing them to swell, while causing the water level to drop.

Osmosis example 2.

If a cell is placed in a container which is full of a hypotonic solution (not many solutes) than the fluid in that container will naturally want to be drawn into the cell and this will cause the cell to swell up and rupture (lyse).

Example of osmosis 3.

If a cell is placed in a container which is full of a hypertonic solution, than the cell will lose fluid as it is diffused outof the cell into the area of greater solute concentration. This will cause the cell to shrink (crenate).

Example of osmosis 4.

In medicine, if a patient drawns in salt water, the hypertonic water in the lungs will cause more fluid to be drawn out of the pulmonary arteries into the alvioli and lungs. This will more often result in pulmonary oedema than a patient who has drawned in fresh water.

Example of osmosis 5.

If you admister normal saline to a patient intraveneously (which has the same osmolarity as blood / the same amount of solutes as blood) it will mean that the fluid remains unchanged, because their is no osmotic gradient (basically all the fluid stays the same). Now, if you were to give mannitol (which is a very hypertonic solution) the fluid within the blood will be drawn out of the cells and into the mannitol solution.

Example of osmosis 6

When the stem of a plant is cut and placed in water (for example a vase), the water will move up through the stem by a process of osmosis, in which the water is flowing to the higher concentration of solvents (found in the plant).

By understanding these examples of osmosis you will be able to better apply the concept of osmosis to practical uses in medicine, paramedicine, nursing, and many fields of general science.

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Osmosis Diffusion

September 1st, 2010

Osmosis – the diffusion of solvent (water) across a selectively permeable membrane from an area of less concentration of solutes (such as salt) into an area with a higher concentration of solutes.

For example,

If a patient has a drowns in salt water, the salt water in the lungs (which is of a higher solute concentration than blood) will draw fluid from the blood within the alveoli/pulmonary arteries, into the lungs.

Osmotic pressure – the force required to prevent the movement of water by osmosis across a selectively permeable membrane.

Hydrostatic pressure – basically this refers to the pressure that the fluid itself exerts. This means the higher the fluid, the greater the hydrostatic pressure due to the weight of the fluid exerting itself.

Isotonic solution: a solution with the same amount of solutes as the solution outside the selectively permeable membrane. As a result, the fluid does not shift anywhere, but remains constant.

Hypotonic solution: a solution with less solutes than the outside. This causes the fluid to leave the area and shift into an area with a greater concentration of solutes.

For example,

As a paramedic, if you were to inject sterile water into a patients vein, the fluid would shift into all the cells within the vasculature because they have a higher level of solutes.

Hypertonic solution: a solution with a higher amount of solutes than the outside area. This results in a shift of fluid from the outside into the area with greater solutes.

For example,

In paramedics, this would be like administering 50% Glucose to a patient – because of the high concentration of solutes in the 50% Glucose, fluid from the vasculature will automatically be drawn to that area.

For more examples of osmosis, please visit my examples of osmosis page.

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Homeostasis

September 1st, 2010

Homeostasis is the balance, continuation and overall equilibrium of a system based on a balance of a specific set of values considered normal in maintaining the specific system. This can refer to an environment, planet, or body. All living things must maintain a level of homeostasis to survive. The term homeostasis is often considered in science and in medicine as a means of maintaining the equilibrium of the body. In medicine, a review of a person’s homeostasis is paramount in determining the cause of an illness or the treatment of a disease. Physiological homeostasis can be defined as the maintenance of a variable around an ideal normal value with a living system. This value fluctuates around a set point to establish a normal rage of values and maintain equilibrium.

How does homeostasis work in the human body?

Homeostatic regulating factors include the following three elements: the receptor, the control center and effector. The receptor receives information that the
homeostasis (balance of normal values in the body) has been disrupted, where the control center reviews this information and sends a message to the effector
in order to instigate some form of change in the body. For example, in regulating blood pressure, there are baro-receptors in the large vessels of the body, which detect a raise in blood pressure, which is then received as a message in the control center (brain), which then messages various effectors in the body, such as the heart to stop beating so forcefully and therefore reduce the blood pressure.

Here is a link to a video that demonstrates homeostasis:

httpv://www.youtube.com/watch?v=DFyt7FJn-UM&feature=related

Mechanisms of Homeostasis in the Body

There are two main mechanisms that maintain homeostasis in the body and these are: positive and negative feedback mechanisms.

Negative Feedback Mechanism

A negative feedback system is the most common type of regulation used by the body. In this system, the body acts to remove or hinder and deviation from the set ‘ideal’ state. The body does this with three main components. A receptor that acknowledges that something has deviated from the ‘ideal,’ a control center, which establishes the set point in which a variable is maintained, and an effector, which is capable of changing the variable.

An example of a Negative Feedback Mechanism in the human body would be:

A patient loses blood and consequently the blood pressure is decreased. As the body’s normal blood pressure deviates lower than the ‘ideal’ the body’s receptors (primarily located in large blood vessels around the heart and neck) pick up this deviation. The receptors then tell the control center, which identifies the deviation, and tells the effector (in this case, primarily the heart – to start contracting stronger and faster, and the kidneys to start retaining salt and therefore fluid). This will then increase blood pressure.

Another example of a Negative Feedback System in the human body includes the Renin Angiotensin
Aldosterone Pathway (RAA).

Positive Feedback Mechanism

Positive responses are not common in healthy people. Positive mechanisms basically mean that when a deviation from a normal value occurs, the response of the system is to make hat deviation even greater. Therefore, a cycle is created, that leads away from homeostasis.

An example of a positive feedback mechanism would include the following:

During child birth the mother’s body produces the hormone oxytocin to increase the pressure and regularity of uterine contractions. The more the baby puts more pressure on the vaginal wall (as a result of the contractions), the body releases more oxytocin, and the contractions get stronger again. This cycle continues until the baby is born. However, if the baby cannot be born (such as the case in cephalic pelvis disproportionation –too large a head for the pelvis) the cycle will continue until both mother and baby eventually die.
Homeostasis in the Blood

Homeostasis in blood is called haemostasis. Haemostasis, like homeostasis refers to maintaining systems within the body within normal, pre-determined ranges, and in the case of haemostasis, it specifically refers to maintaining a stable flow and level of blood within the circulatory system. Mechanisms of haemostasis include: platelets, blood proteins, and vasculature. Haemostasis is a sign of a negative feedback mechanism, where the body recognises that it is bleeding, and consequently causes the vasculature to constrict, develop platelet plugs and cause the blood to clot in order to cease haemorrhaging.

Homeostasis in the Lungs

CO2 increases in the blood are detected by carotid chemoreceptors and cause the lungs to breathe deeper and faster. Lack of CO2 causes the lungs to breathe slower. This is a negative feedback mechanism, in which the body makes physiological changes to improve the CO2 and O2 ratios in the blood. The body also identifies the pH of blood and works around a physiological normal value of 7.35 to 7.45. If a person becomes acidotic (<7.35) he or she will increase respiratory effort to remove the acidic CO2; if a person becomes laccolitic (>7.45) then the respiratory effort is slowed to allow more CO2 into the circulatory system.

Homeostasis for Blood Pressure

Blood pressure homeostasis is managed by the negative feedback in the RAA Pathway when the blood pressure is identified in the baro-receptors in the carotid arteries and determined as too low. When the blood pressure is too high, the reflex bradycardia response is initiated and causes the heart to beat slower and therefore reduce the blood pressure, while conserving the energy in the heart.

Homeostasis for the Kidneys

Homeostasis for the kidneys is also managed by the negative feedback mechanisms involved in the RAA Pathway.

Homeostasis of the Blood Glucose Levels

If a patient’s blood glucose levels are below a normal value (such as <4 mmols) then the liver converts glycogen stores (found in the liver) into glucose through a negative feedback process called glycogenolysis. If a patient has abnormally high blood glucose levels (such as >18 mmols) then the patient’s pancreas will produce more insulin to remove the blood glucose.

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Correlation Between ECG and the Heart

August 31st, 2010

Correlation between an ECG and the Heart

 P wave = SA Node

Under normal conditions, electrical activity is spontaneously generated by the SA node, which, under normal conditions is the physiological pacemaker. The electrical impulse is the continued through the right atrium and through Bachmann’s bundle to the left atrium. This stimulating causes the muscle of both the atria to contract (myocardium). The conduction of the electrical impulse throughout both the left and the right atria can be seen as the ‘P wave’ in an ECG. As the electrical activity is spreading throughout the atria, it travels via specialized pathways, known as internodal tracts. These lead from the SA node to the AV node.

PR interval = AV node and Bundles Branches:

The AV node then delays the conduction of this electrical activity through to the ventricles. This delay is important, because if the conduction continued at a continuous rate, the atria and ventricles would contract at the same time. This would leave make the pump (heart) work ineffectively. This delay can be seen on the PR segment on the ECG, before the AV node propagates the electrical activity down the bundle of his and ventricles.

The distal portion of the AV node is known as the bundle of His. The bundle of His splits into two branches in the interventricular septum, the left bundle branch and the right bundle branch. The left bundle branch activates the left ventricle, while the right bundle branch activates the right ventricle. The left bundle branch is short, splitting into the left anterior fascicle and the left posterior fascicle. The left posterior fascicle is relatively short and broad, with dual blood supply, making it particularly resistant to ischemic damage. The left posterior fascicle transmits impulses to the papillary muscles, leading to mitral valve closure. As the left posterior fascicle is shorter and broader than the right, impulses reach the papillary muscles just prior to depolarization, and therefore contraction, of the left ventricle myocardium. This allows pre-tensioning of the chordae tendinae, increasing the resistance to flow through the mitral valve during left ventricular contraction.

QRS complex = Purkinje fibers and ventricular contraction

The two bundle branches taper out to produce numerous purkinje fibers, which stimulate individual groups of myocardial cells to contract.

The spread of electrical activity (depolarization) through the ventricular myocardium produces the QRS complex on the ECG.

T wave = Ventricular repolarization

The final event of the cycle is the repolarization of the ventricles. The PQRS portion of an ECG is influenced by the sympathetic nervous system; where as the T wave is influenced by the parasympathetic nervous system guided by the vagus nerve.

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Types of Hypoxia

August 31st, 2010

Four Types of Hypoxia – hypoxia is defined by a lack of oxygen exchange at cellular level and can be caused by four different types of hypoxia. These include: hypoxic hypoxia, ischaemic hypoxia, anaemic hypoxia and histotoxic hypoxia.

Hypoxic Hypoxia

Lack of oxygen getting from the lungs to the heart. This can be as a result of a defective mechanism of oxygenation in the lungs, low amount of oxygen in the air, abnormal pulmonary function.

Ischemic Hypoxia

Often called stagnant hypoxia, this form of hypoxia is the result of an inability or failure of the heart to transport oxygenated blood around the body.

Anaemic Hypoxia

This occurs in the vasculature and is defined by the lack of oxygen carrying blood cells, such as in the case of severe bleeding or anaemia, in which the lungs still get oxygen to the heart and the heart still pumps, but there is an insufficiency of oxygen carrying blood to be pumped around the body.

Histotoxic Hypoxia

This is where the oxygen makes it all the way to the blood cells in the desired area, but the actual cells themselves aren’t able to take the oxygen. This also commonly known as oxygen affinity hypoxia, and is fund in Carbon Monoxide poisoning and Cyanide Poisoning, in which the haemoglobin develop a severe affinity with oxygen and does not release the oxygen to the cells.

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Paramedic Science Laws

August 31st, 2010

Paramedical Science Laws

Boyles Law

For a fixed amount of an ideal gas kept at a fixed temperature, P [pressure] and V [volume] are inversely proportional (while one increases, the other decreases).

For a practical paramedical example:

This means that if a SCUBA diver holds his/her breath at a depth of 10 metres of water (which doubles the pressure exerted on the air in the lungs) the volume of the air in his lungs will be half that at which it would be at the surface. This becomes important, because if the diver was have taken a deep breath and filled his lungs with air at a depth of 10metres, and then held his breath as he returned to the surface – the volume of air would have doubled as the pressure halved, and because he lungs cannot hold this much air, something would have burst.

Henry’s Law

At a constant temperature, the amount of a given gas dissolved in a given type and volume of liquid is directly proportional to the partial pressureof that gas in equilibrium with that liquid.

For a practical paramedical example:

This basically means that if a patient is receiving normal air, which has 21% oxygen into his lungs the partial patial pressure of oxygen which is being diffused across the alvioli is only 21% of the overall partial pressure. Now, however, if you change this equation to 100% oxygen, the full partial pressure of oxygen can be exerted to difuse across the alvioli. This is why we treat patients with shortness of breath with high concentration oxygen.

Dalton’s Law

The total pressure exerted by a mixture of gas is equal to the sum of the parital pressures of each individual component in a gas mixture.

For a practical paramedic example:

The concentration of dissolved gas depends on the partial pressure of the gas. The partial pressure controls the number of gas molecule collisions with the surface of the solution. If the partial pressure is doubled the number of collisions with the surface will double. The increased number of collisions produce more dissolved gas. Therefore, if the patient receives a higher level concentration of oxgyen, therefore increasing the partial pressure of oxygen concentration, there will be a geater amount of oxygen that can diffuse across the alvioli membranes.

Bernoulli’s Principle:

Bernoulli’s principle states that the flow rate of a non-compresible fluid increases where the pessure (resistance) decreases and vice versa.  Bernoulli’s principle basically works on the principle that if a fluid is unable to be compressed and the diameter of a pipe is decreased, the fluid rate will have to decrease in order to all fit through the narrowed pipe.

An example of Bernoulli’s principle in medicine or paramedicine follows:

When a patient has a myocardial infarction due to a blockage in one or more of their coronary arteries, the diameter of the pipe (the coronary artery) decreases, and therefore the pressure increases and the rate of flow decreases. This is why the heart ends up with less blood flow and a decrease in coronary perfusion.

Partial Pressure

The pressure that one component of a mixture of gas would exert if it were alone

Kinetic Energy

KE = ½  MV2

This means that Kenetic Energy (K/E) equals one half times the mass time the velocity squared.

In a practical paramedic sense: this means that a patient who weighs 80kgs (Mass in Kg) is travelling at 3 metres per second on a bycycle (Velocity is metres per second) hits a brick wall – this patient will have to disperse a total of 80kg x 3 squared x ½ = 360 joules of kinetic energy.

This can become important as a paramedic when you consider that man on a bycycle with an overal KE of 360joules collides head on with a car which has an overall KE of 12000 joules which must also be dispersed to make the car stop – you can understand how injured the patient on ht bycycle will be. Admitedly, you could also just look at your patient to realise that he’s been hit by a much bigger object.

Starling’s Law

The greater the blood volume (BV) entering the heart during diastole, the greater the BV ejected during the systolic contraction of the heart.

Cushing’s Triad

Identifies significant indication of raised ICP, often a late sign. Includes: Respiratory changes/ Irregularities, Widened Pulse Pressure, and Bradycardia.

Kehr’s Sign

Kehr’s sign is the presense of shoulder tip pain associated with abdominal pain and often relates to refered pain from organ injury or damage within the abdomen.

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Extended Care Paramedic

August 31st, 2010

What is an extended care paramedic?

An extended care paramedic is a relatively new concept in Ambulance and is similar to Paramedic Practitioners in other countries. Basically, the extended care paramedic program was designed to relieve the overburdened emergency departments from their low priority and low acuity patients who could, conceivably be treated safely at home, or in other means, such as extended care paramedics with specialised training is certain areas of hospital care, GPs, Physiotherapists, Community Health and other members of the multidisciplinary health teams. ECPs provide alternate care pathways for patients and assist in reducing unnecessary transport to hospital. Attendance by an ECP reduces the disruption to patients and their carers that is associated with a trip to hospital. If after assessment, the patient still needs to go to hospital, the ECP will arrange this. Patients receive more tailored care and if needed, will be managed in collaboration with other health professionals that are appropriate to their needs.

What states currently use ECPs?

Currently, the Ambulance Service of NSW and the Ambulance Service of South Austalia have implemented Extended Care Paramedic programs. Although, I believe some other Ambulance Services in Australia are currently considering implementing or currently implementing their own extended care paramedic programs.

How is an ECP dispatched?

ECPs generally only attend patients who have made a call to triple zero (000). An ECP may be also be dispatched because requirements through phone consultation or emergency paramedic crew referral.

What equipment and procedures to ECP paramedics perform?

Normal ambulance kits, 12 lead ECG, Point of care testing using i-STAT machine.

ECPs may take blood and test: electrolytes, troponin I, INR, and multiple other blood specimens. Which may be then taken to specified pathology testing companies for processing with a copy of the results sent to the patient’s GP

ECPs may treat multiple injuries and ailments through the skill and use of: Suturing equipment, wound glue and extensive range of wound dressings, plaster of paris for backslabs, ENT assessment – otoscope. Ring cutters for ring removal. ECPs may assess and change Urinary catheters and PEG’s

What extra medications do they have?

Antibiotics, Bronchodilators, puffers, spacers and peak flow meters, analgesics –  including panadeine forte, panaedine, ibrufen, paracetamol, endone, NSAID, Steroids, Antiemetics, Antispasmodic, Antidiarrhoea, Antihistamine, ADT (tetanus vaccine), Gastrolyte and ural.

What cases do ECPs usually spend their day doing?

Wound care including suturing and skin tears, pain management, chronic pain (musculoskeletal) and palliative care patients with break through pain, gastroenteritis – diarrhoea and vomiting, catheter/urinary tract infection/urinary retention,  replacement of urinary catheters – female, male and supra pubic with acute problems (acute and non-acute), rehydration/heat/dehydration, cellulitis, chest infections,  PEG replacements, and epistaxis.

What other health care professionals do ECPs liaise with?

General and other medical practitioners, Community Health, Palliative care services, Carers Respite Centre, Physiotherapists.

This shows the dynamic nature of paramedics and pre-hospital care as a vocation, and is a good exmaple of how these Ambulance Services are improving and furthering their paramedic spectrums through advancements of knowledge and skill bases and responsibilities.

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EMT Jokes

August 29th, 2010

These are the jokes for EMTs and Paramedics… just for laughs…

EMT Joke 1

What’s the difference between a man with no arms and a paramedic? – the man with no arms has an excuse for not lifting anything.

EMT Joke 2

Why do you call a paramedic a “frog?” – Everyone they touch crokes…

EMT Joke 3

How many paramedics does it take to change a lightglobe? – One, he just holds the globe up, and waits for the world to revolve around him.

EMT Joke 4

What’s the difference between God and a Paramedic? – God doesn’t go around with the delusion that he’s a Paramedic.

EMT Joke 5.

Turning your lights and sirens on will “actually” convince people to move out of your way… – has never happened.

EMT Joke 6.

“Its only a little needle”

EMT Joke 7.

“I have to insert this little needle in your arm… I promise this wont hurt me a bit…”

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Code of Ethics for Patients

August 29th, 2010

Over the years many codes of parmedic ethics, codes of paramedic values, codes for just about everything related to paramedic work has been created and implemented into various Ambulance Services around the world… this is a dedication to the development of a “code of ethics for patients.”

1. Thou shall tell the truth to thee paramedic and not change thou story when thou talks to the triage nurse– paramedics hate it when the just finish telling the triage nurse that the patient is not allergic to anything, only to have the nurse then be told by the patient that, yes, indeed they are deadly allergic to penicillin, morphine, etc.

2. Thou shall at least “try” to suffer from the disease in which you have called a paramedic to treat – calling for an Ambulance for “chest pain,” when you’ve sprained your ankle is not funny…

3. Thou shall not re-tell any experiences relating to a paramedic’s mild short-commings in their ability to treat a patient – the bond between paramedic and patient is sacred and it would be sacrilege (not to mention embarrassing for the paramedic) to tell of how it took the paramedic 8 times to get a simple cannula.

4. Thou shall only do something “really” stupid once –  paramedics hate to continuously respond to the same patient day in day out for the same stupid accident that was obviously foreseable!

5. Thou shall name thee baby that has been delivered by thee paramedic by said paramedic’s name – its probably the least you can do after all the disgusting work he/she had to go through to deliver it (not to mention the after clean up in the Ambulance!)

6. Thou shall not expect thou beloved paramedic to share in thee discomfort – okay, so your legs badly broken, it wasn’t the paramedic’s fault – why should he/she share in your discomfort?

7. Thou shall only call am Ambulance for useless reasons after hours – paramedics hate having their time wasted on non-serious emergencies – that is, except when they are on call and making a heap of money for the call out.

8.Thou shall not die whilst in the care of a paramedic before arriving at a hospital – this only causes needless inconvenience to the paramedic in relation to coroners investigations, not to mention the embarrassment when it turns out to be his/or her fault!

9. Thou shall not complain about experimental treatments – this may not actually benefit your health outcomes (okay, it may be detrimental), but it will lead to future research, studies, or at least end a social bet or argument about what would happen if you did such a thing to a patient, once and for all!

10. Do not complain if the treatment provided by a paramedic fails to bring relief – its not his/her fault that the drugs don’t work, or that you are so sick that you were probably going to die anyway… complaining about it, just causes needless trouble for the paramedic.

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Practical Jokes Gone Wrong

August 29th, 2010

Being written now

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Practical Jokes

August 29th, 2010

Paramedics have alot of time on their hands while at work… okay, sometimes too much time on their hands…. and like all people with too much time on their hands they find useless, silly, and often quite dangerous ways of wasting such time… this page is dedicated to the wonderful practical jokes that I have been witness to, partaken in or heard about in my time as a paramedic.

Practical Joke 1.

In stations where there are bunk beds – attach a bag of fluids to a giving set to the underside of the top bunk (hartmans or any other clear liquid shall do just fine). Everytime the person on the top rolls over, pressure should reach the fluid bag and cause a little bit of fluid to dribble off the bed onto the person below. As the person below wakes up to explore where they are getting wet – the person on top may wish to get up, and get up and quickly run to the bathroom…

Practical Joke 2.

Using lignocaine gel onto the door handle of the ambulance so that the other paramedic slips while opening the door – alternatives to this are using lignocaine gel onto the handle of the phone and then calling the phone.. this is very messy, and not all that funny after the first time.

Practical Joke 3

Moving cars – this is always fun. I worked in a bad area a few years ago, and it was normal custom to move your cars from the outside car park to the inside of the Ambulance Bay at night – one night a friend of mine got stuck out on a case before she had time to take her car in. While she was out, we found her keys and moved her car up the street. The possible down side to this… is the potential for the car to actually then get stolen, leading to a world of embarrassment and justifications…

Practical Joke 4

An alternative to moving cars, includes using bricks to support the weight of the car and then removing the tyres from the car – downside to this – its a lot of work!

Practical Joke 5

Get someone to hide in a body bag, while another paramedic explains to the first paramedic that they’ve just attended the worst “burns” patient who has now died and you are taking up to the hospital. Then suggest that they “have to” see the interesting way the patient ended up burnt. While the first paramedic opens up the body bag, the other paramedic (laying still in the body bag) can sit up and say “I’m not dead yet…” – possible down side: paramedic being tricked may assume the person in the body bag is a demon and kill him…

Practical Joke 6

During the middle of the night, while you’re already out on an emergency, or after an emergency, call the Station Phone and say that you have a cardiac arrest… by the time they jump up and call on the radio that they are responding – the despatcher will ask them what they are talking about? – If you’re really mean, you can then call back five minutes later when you think they have gone back to sleep, and say “Sorry, we had a mistake before, the cardiac arrest is at … such and such location…” – downside – the paramedics on the job wont actually answer the phone or listen the next time the get called to a cardiac arrest.

Practical Joke 7

If someone is a bit of a practical joker, but is always careful to look after everything they have by locking it in their locker… one day, while he or she is out on a job, come in (maybe even on a day off work) and cut the padlock with a pair of bolt cutters, and then brick up the inside of the locker… this becomes even more funny, afterwards, when he or she decides the jokes over, and just wants their keys for their car – so they can drive home. Downside to this is that he or she may actually kill you after you own up to it…

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World Trade Centre and Port Arthur

August 27th, 2010

 

World Trade Centre and Port Arthur Incidents – A Comparison and Lessons Learned in Emergency Management

The World Trade Centre and Port Arthur massacre were both unparallel man-made disasters associated with terrorist acts. Commonalities in both Major Incidents were the unprecedented degree of violence directed at their victims and thorough inability of the local resources of either incident to manage the major medical incident (Byrnes 2002, p. 196-211; and Tasmanian Disaster Committee 1997, p.1-13).

The World Trade Centre had an enormous loss of life (a total of 2, 823 people), which included the responders to the tragedy, with the death of ‘72 law enforcement officers, and 344 firefighters’ (Byrnes 2002, p. 211). The planning stage of the incident became almost unparallel to any other man-made incident . One of the largest contributing factors in access to the scene and its victims were because of the collapse of two man-made structures and the subsequent secondary explosions of fuel and hazardous fumes, toxic gasses, and debris (Byrnes 2002, p.198-9). Although rendering an enormous amount of damage, the attack occurred within a relatively short period of time. However, due to the location of the incident there was a large contingent of emergency services readily available, including the Port Authority Police Department and the New York Police Department (Byrnes 2002, p. 82-3). Due to communication and physical barriers, such as the collapse of the twin towers, organisational isolation occurred and many teams of services were separated.

By contrast, the Port Arthur Massacre was perpetrated by a single gunman. The scale was relatively smaller and the isolation was caused by rural distances, while the difficulties encountered in responding related to the remote environment, such as a lack of medical resources, personnel and enormous transport distances to definitive treatment (Tasmanian State Disaster Committee 1997, p.2-3). The attack was more localized towards the local community and the hazards were more primary due to threatened gunfire with relatively less building and environmental damage. The planning stage was of a much smaller duration and the execution was more random. The police presence was initially non-existent (Tasmanian State Disaster Committee 1997, p.2-3).

Comparisons of the two incidents appear limited to the tragic and horrific nature of both events because of the diverse nature of the two incidents. Both involved the needless loss of human life and subsequent confusion that affected the ability of the coordinated responses to the major incident. The scale of the two incidents differ in the numbers of killed and injured; however, when comparing statistically, the smaller Port Arthur incident may even have a higher percentage of victims on a pro-rata community basis. There were thirty five killed in Port Arthur massacre compared to close to 3000 in the World Trade Centre (Byrnes 2002, p. 196-211; and Tasmanian Disaster Committee 1997, p.1-13).

The World Trade Centre incident involved a long term coordinated attack over many years whilst the Port Arthur massacre appears to be a more random response; although, even this was preplanned to some extent, as evident by the fact that the perpetrator carried a bag with numerous weapons and ammunition into the Café at Port Arthur, showing that he planned to kill more people than one weapon with one cartridge was capable of (Tasmanian Disaster Committee 1997, p.5).  The terrain and access to casualties vary considerably. The access to the World Trade Centre victims was restricted because of the building collapse and fire whilst the Port Arthur victims had access restricted because of the threatened gunfire and rural location.

Due to the isolation of Port Arthur there were less available resources than the World Trade Centre had available, which was in the middle of the New York city, with all the resources available. According to Cato the ‘initial response to Port Arthur involved two local doctors and three ambulances’ (2002, p.70).

At the World Trade Centre there were approximately 400 rescue workers killed during the rescue attempt due to the hazards at the scene, as opposed to no rescue workers injured in the Port Arthur incident, because the only major hazard (the perpetrator) did not come back and kill the rescuers. However, much of this, was due to sheer luck on the rescuers part and the difference in circumstances, as the rescuers for both incidents continued their work without ensuring that the hazards were removed or reduced.

At the World Trade Centre there were tremendous transportation difficulties related to access and egress due to the substantial vehicle damage caused by the destruction of the World Trade Centre. According to Byrnes the ‘airports were closed thirty six minutes after the event and all bridges and tunnels were closed at a similar time interval following the airport closure’ (2002, p. 198-200).  In contrast, there were no airport closures in the Port Arthur massacre; however, there were difficulties with access and egress based on the isolation of the incident. According to the Tasmanian State Disaster Committee, ‘the closest ambulance was fifteen minutes away in a small country town’ (1997, p.5).

There are obvious differences in the number of perpetrators of the two incidents with a single planner for the Port Arthur incident compared with many planners and terrorists involved in the World Trade Centre. According to Cato the ‘initial fatalities were those on the aircraft and the impact are where almost one hundred percent of those involved died’ (2002, p. 64). In contrast, the perpetrator killed those he could locate in various locations of Port Arthur. According to Cato ‘the killing spree was the worst ever in the world at that time’ (2002, p.70); similarly, the same can be said about World Trade Centre incident (Byrnes 2002, p.211).

The World Trade Centre incident was and still is regarded as an attack on the United States of America as a nation, whilst the Port Arthur massacre was the result of unclear motifs. It is unclear to what extent Bryant’s schizophrenic illness contributed to a delusional attack on his victims however it is clear the World Trade Centre attackers had clear and precise intentions.

There were much more police authorities at the World Trade Centre incident including the Port Police Authority and Police Department. The bi-state nature of policing may have affected the coordinated response. The police response at Port Arthur in comparison was achieved by an establishment of a Police Operations centre directing a forward command and a special response group. At the World Trade Centre incident there were by comparison numerous Federal law enforcement agencies and although the senior agency was the Port Authority Police Department there were problems with jurisdiction and coordination (Byrnes 2002, p.197). This broadening of jurisdiction lead to communication and response difficulties, because each agency communicated on different frequencies and systems.

There were considerably more agencies involved at the World Trade Centre; by comparison, the agencies involved at Port Arthur are considerably less and therefore the communication difficulties, duplication of orders and confusion at Port Arthur were similarly less also.

Both incidents have had far reaching ramifications. For example, according to Dutton, ‘gun laws in Australia were changed on a national level virtually overnight’ (1998, p. 225) and at the World Trade Centre the ‘President and Congress are seeking to increase the nations’ preparedness through a massive reorganization of homeland security agencies (Byrnes 2002, p. 90).

The World Trade Centre involved substantial material and property damage with the collapse of the twin towers. In contrast no such material destruction occurred at Port Arthur. The comparison of the two incidents is subjective as no two people’s perception will be the same of each incident. Comparisons need to be made for a constructive purpose such as analyzing the respective responses. This information may assist in developing a framework to develop policies and resources should a further incident occur.

In conclusion, comparisons can best be determined by analyzing the incident into varying components. Access was restricted in the World Trade Centre because o building collapse whilst access to victims in the Port Arthur incident was restricted because of potential gunfire. Isolation at Port Arthur was due to geographical distances whilst isolation a the World Trade Centre was due to physical barriers such as building collapse causing fire and noxious gases and communications difficulties.

Question 2

Evaluate the medical management response to the World Trade Centre and the Port Arthur incidents (approx 1000 words).

Medical management response was chaotic at the World Trade Centre; largely due to difficulties with communications and brought to notice their total unprepared ability to cope with a disaster of this magnitude. There was medical assistance available but the execution of service delivery was ineffective due to poor coordination and also compromised because of physical barriers (Fire Department of New York 2004, p.3).

Medical management response at Port Arthur was compromised due to rural isolation and the lack of police presence during the first few hours of the incident response. This Major Incident also highlighted the lack of resources such as paramedic equipment and the difficulties encountered in transporting these resources to the scenes.

Unintentionally the first rule of first aid was neglected at the World Trade Centre. According to Hogetts and Mackway-Jones, ‘the first, most important consideration for pre-hospital care workers is whether or not it is physically safe for you to proceed’ (2002, p.45). Communication difficulties are enormous due to ‘channel congestion with many emergency responders operating on the wrong channel’ (Fire Department of New York 2004, p.8). We are further advised that the emergency dispatchers were overwhelmed with the situation. It is further seen that information flow to the incident commanders was limited due to this poor communication. Impinging on emergency response was the reconvening of a command structure after the second collapse of the World Trade Centre, despite command being restored, the communication problems continued. There were enormous problems with the dispatching of ambulances as some officers had responded without sanction (Byrnes 2002, p.199-200). Furthermore, the dispatching system broke down due to the enormity of the disaster with the coordinators loosing control of the tracking of their vehicles. Patient paperwork was discarded in an attempt to minimize transport and turn around times therefore reducing the ability of the system to track patient’s status and whereabouts.

Perhaps the greatest difficulty in medical management arose because of the inability of the responders to access the majority of the victims. Not only did the responders to the World Trade Centre have to contend with the twin towers collapse, but two neighboring buildings and a hotel also collapsed. What followed was an overwhelming inability to control the situation. Many ambulances, fire trucks and police vehicles were destroyed by the falling debris (Fire Department New York 2004, p.6).

The Port Arthur incident appears to be managed well considering the limited resources as listed in (Tasmanian State Disaster Committee 1997, p.14). However, it was clear that they were hampered by limited information being dispatched about the scene. There is a similar response to the World Trade Centre in that some responders failed to adhere to prior training and attended the scene without due safety considerations. The difference being that the responders at Port Arthur were luckier than their counterparts at the World Trade Centre, with no responder loss of life. Communication problems existed at Port Arthur as seen by the recommendation to improve mobile communications equipment at remote locations in the future. The responders to Port Arthur massacre were initially fragmented due to the geographical isolation of Port Arthur. There were also problems in Tasmania with inadequate oxygen supplies (Morgan 2004, p 35).

Both incidents overwhelmed the available medical resources thereby reducing the effectiveness of the medical management. The medical management was largely affected at the World Trade Centre by communication difficulties affecting information flow, whilst Port Arthur suffered because of geographical isolation and insufficient localized resources, which had not been geared to cover such an unforeseen contingency. There was also deficient information originating from the critical incident, which create difficulties in formulating an adequate response. Even if there had been foresight of an impending disaster it would have been difficult to justify the expense on economic grounds to prepare for such an emergency (Tasmanian State Disaster Committee 1997, p. 37).

At the World Trade Centre the command system failed as they were inadequately prepared for such a disaster. The communication system became inadequate for the scale of the disaster. In contrast, the Port Arthur massacre communication system was hindered because of poor mobile communications within the area (Tasmanian State Disaster Committee 1997, p. 15).

Hazards including fire, collapsed buildings and noxious gases hindered the rescue attempts and prevented effective medical management at the World Trade Centre. This was exacerbated by the confusion levels, which contributed to the emergency tracking of their resources becoming severely jeopardized.

Medically the Port Arthur incident had been fortunate in that there had been recent code brown training and there had been a recent Critical Incident course held at Hobart from which volunteers were dispatched to the scene. There was also a fortunate occurrence in that there was additional helicopter support which may not have been available had the critical incident happened the next day (Morgan 1997, p.32). There was also a recent External Disaster Course, which had been held at the Royal Hobart Hospital. Medical management was exceptionally difficult because at Port Arthur there were no police present in the first couple of hours.

Both incidents reflect the need for adequate medical pre-planning prior to the incidents even with adequate pre-planning it is the adequate execution of these plans that often require scrutiny.

As Port Arthur is ninety minutes by road from Hobart Hospital there was a need for helicopter transport. As an inquiry concluded these facilities were insufficiently equipped with adequate resuscitation equipment.

Communication difficulties at both incidents related to channels being overloaded with information that could not be adequately processed. 

Port Arthur was lucky in that the distance and geographical terrain provided time for the local hospitals to prepare for the incoming victims, but also increase transport times for critically ill patients.

In conclusion, both incidents lacked adequate medical pre-planning and communication resources. There were different medical management issues at both incidents. The World Trade Centre incident was affected by poor communication and the inability of the responders to access the victims. The Port Arthur incident was affected by communication inadequacies and geographical isolation and limited resources.

Question 3

Evaluate the psychological impact on emergency medical service responders to incidents such as the World Trade Centre and the Port Arthur.

The psychological impact of medical responders to Major Incidents has far reaching ramifications. Three distinct event stressors are elicited by Smith and these include: ‘personal loss or injury; mission failure and; traumatic stimuli’ (Smith 2005, p. 5). It is apparent that post traumatic stress from a major incident may be intensified because of the incident adding to an already high stress level accumulated from working in an already stressful industry (cumulative stress) (Smith 2005, p.7). Emergency personnel, such as Police, Fire and Ambulance Services Personnel may all develop this form of cumulative stress, making them more vulnerable after a Major Incident. It is apparent that being involved in a Major Incident is not a necessary prerequisite for the establishment of Post Traumatic Stress. Hodgets et al state that ‘psychological problems are common; they occur in the injured survivors, and the rescuers of Major events’ (2002, p. 199). The ability of the individual to cope with traumatic stress depends on personal coping abilities and the amount of pre-accumulated stress that has occurred for that individual. According to Homer, the effects of Critical Incident Stress may be broken down into the following categories:

1.         physical

2.         thinking

3.            emotions

4.            behaviour

5.            perception

6.         re-experiencing

7.            spiritually

(2005, p. 5)

Acccording to Homer, further factors that influence the severity of an incident are:

1.         taking it personally

2.            mistakes in judgment

3.         making the situation worse

4.            equipment failure

5.            command failure

6.         line of death or injury

7.         role confusion

8.         role conflict

9.         aspects of victims

10.       types of injuries

11.       aspects o the incidents

12.       aspects of the helper; and

13.            triggering incidents

(2005, p. 8-9).

It is obvious from these factors that many were apparent at both the Port Arthur massacre and at the World Trade Centre incidents. As an example there was command failure at the World Trade Centre and equipment failure at the Port Arthur massacre. Especially during the early stages of both major incidents there was little or no available stress management available. They were unable to moderate their stress in the early stages. This stress was further enhanced by their general rescuer mentality, whereby officers were compelled to continue until completion of their duty, regardless of fatigue. There was also anger when some officers were instructed to attend to other matters whilst the disaster was in progress.

Post Traumatic Stress can affect individuals differently but the effects of Critical Incidents previously listed give an indication of possible outcomes.

In evaluating the psychological effects on the responders it is apparent that the size of the incident does not necessarily correlate with the extent of the Post Traumatic Stress; as even a minor incident or stimulus may be enough to render a victim subject to this disorder. It is up to the medical management to be able to evaluate the effects o the responders and provide appropriate action. This was clearly not done effectively at the World Trade Centre and was also lacking at Port Arthur. At the World Trade Centre incident responders were left too long at the scene and had to attempt to cope with the death of their colleagues and the insecurity of not having sufficient knowledge of what was occurring. Comparatively, the responders to the Port Arthur Massacre did not have colleagues who died in the incident; however, many of the first responders were locals and would have known people there, and had to work with uncertainty that the perpetrator’s location was unknown.

The role of the medical manager in the provision of care for the responders was lacking at both disasters. The role of critical debriefing sessions are still debated. Many believe that a critical debriefing session is essential after a Critical Incident, just after the event. However, according to Gist and Woodall, as cited by Smith, ‘immediate group and peer debriefing sessions may cause a secondary psychological trauma’ (2005, p. 5). Furtheremore, it should be noted that it is just as critical to recognize stress during the incident and for medical management to take appropriate action, as afterwards (Homer 2005, p.9).

Every responder would have experienced varying stressors at the incident however every responder would have reacted differently to the situation. Only time would have been able to depict how much a responder was affected. Therefore, debriefing sessions and counseling should be available to all responders, even years after an incident.

According to Byrnes, ‘probably the biggest post-incident issue for rescuers within the World Trade Centre incident was having to come to terms with the gruesome reality that the overwhelming majority of victims were atomized in the collapse’ (2002, p.200). This was intensified by long shifts and the inability to locate workmates. This concept was further considered by noting that ‘horrendous effects of frustration and stress become apparent when working for extended periods at a Major Incident’ (Byrnes 2002, p. 200). Responders to both Major Incidents became only too aware of their own mortality and vulnerability, while medical management failed to mitigate this stress as they were poorly prepared for such Major Incidents. As with many other incidents, they were considered too unlikely to prepare for such an event.

References:

Byrnes J. 2002, The World Trade Centre Attacks, Australian Police Journal, September. Vol. 56. No. 3

Cato D 2002, The Health Aspects of Dealiwng with Disasters in Australia, South Western Area Health Service, NSW, Australia

Dutton, G. 1998, The Port Arthur Shooting Incident, Australian Police Journal, December, Australia

Fire Department of New York 2004, Final Report of the World Trade Center Tragedy on September 11, 2001

Heide E. 1989, Disasters are Different: Principles of Preparation and Coordination. CV Mosby Company, Toronto USA

Hodgetts T, Mackway, Jones K 2002, Major Incident Medical Management and Support, 2nd Ed, Advanced Life Support Group. BMJ Books, Tavistock Square, London, England

Hodgetts T, Juul O, Abraham K, Webb, Homer T. 2004, Reading Materials Charles Sturt University (Modules 1-4) Faculty of Health Studies, Learning Materials Centre, Bathurst, NSW, Australia

Smith, H. 2005, Mental Health Effects and Response to Disasters, Lecture Notes, Bathurst Australia

Tasmanian State Disaster Committee 1997, Port Arthur Seminar Papers, Emergency Management Australia, Victoria, Australia

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Out of Body

August 26th, 2010

Whether you’re religious or not anyone who has seen a dead person can tell you that there’s something missing, something that’s just not there – and I’m not talking about good colour, rise and fall of the chest, a heartbeat and a good strong pulse. I mean, even if you watch a patient who is in intensive care and is being ventilated, you can tell that there’s something different with them when they die (even if the ventilator keeps mechanically breathing for them)…

I’m not particularly religious, and I honestly don’t have answers for the experiences that I have witnessed or heard about from some of my patients who have been near death, but I think a lot of paramedics can tell you that they have seen or at least heard of some of these out of body experiences in their time as paramedics.

These are some of the out of body stories that I heard during my time as a paramedc. All names are fictional to ensure privacy and confidentiality, but the experiences are true.

We were called to  a 49 male who had developed chest pain and dialled  dialled “OOO” for an Ambulance. My partner and I were the first Ambulance on scene to treat a patient with chest pain. By the time we had arrived the man had collapsed and had stopped breathing. We assessed him and found that he was in cardiac arrest. We applied a monitor and found that he was in assytole (the line which means that there is absolutely no electrical activity – and is ussually a sign that the person has been in cardiac arrest for a while, and has little hope of survival). We called for back up and commenced CPR and the rest of the cardiac arrest drill, including intubating the patient and administering IV adrenaline. Our back arrived shortly and we continued the resuscitation efforts. 

We ended up working on the patient for 20 minutes without any change. One of the senior paramedics said “Okay, what do you guys reckon? Shall we call it?” I was working with a new probationer (Rookie Paramedic) and said, “No, he can use some more experience with CPR, lets run this until we finish the assystole protocol all the way through” (at that stage, included 30 minutes of CPR). The senior paramedic laughed and said, “Hey, if you want him to get more experience in CPR, there’s a maniquien back at the station, he’s got just as much chance resuscitating it than this guy…”

Almost as though the out of body person had heard that and decided, hey, no I don’t want to die just yet… we had a miraculous spontaneous return of circulation (this virtually never happens – and patients still rarely live long term after this much down time). We expedite him to hospital. Two days later we found out that they had stented his heart and that he had been extubated and was neurologically intact in cardiac ICU. No way, we think – good for him!

That was the last we really thought about it… and probably would have been the last we ever thought about him… if it wasn’t for the knock at our station door one early morning…

“Hi… Frank…” The man looks at me “My name’s John… I believe we met a couple months ago…”

I look at him… and try and work out when I treated him and what for – usually, its previous patients who are telling me that they met me a few months ago and often assume that because they had a life-threatening injury they would stand out in my memory… they don’t always… but I did remember something about this guy… I just couldn’t place it?

The man sees my confusion.

“Last time we met my heart wasn’t working… in fact, they tell me it had stopped completely…”

Now I know who he is…

I invite him in and we get chatting…. and find out about how he’s doing. Finally he turns around and says.. “I want to thank you for giving me an extra 10 minutes of CPR… even if it was only so that your rookie could practice CPR…”

“Sorry, I say…” instantly aware of how close this man was to dying because we were going to quit early…

“I was there… you see… I saw the whole thing… and I remember Jack saying that he wanted to ‘call it’ and you saying that your probationer needed extra work on his CPR anyway, so you may as well keep going…”

I’m shocked and fascinated at the same time…

“Really… what else do you remember…”

“Well, I remember that the other paramedic suggested that there would be just as much likelihood of resuscitating the manequien back at the station as resuscitating me…. and it was about then that I realised that this was serious and that if I wanted to live… I was going to have to get back in that body… and the next thing I know… I’m in hospital a few days later…”

I called the other paramedics who I had done the job with… those who weren’t working today… and they all came around to hear this story…

The lessons of this story is this – always do your best as though someone is watching (because sometimes someone is watching), never say things about dead people that you wouldn’t say to them if they could actually hear…

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Near Death Experiences

August 26th, 2010

You don’t have to be a paramedic for very long before you get see many near death experiences…

Near death death experiences appear to be different for everyone and fortunately, although we as paramedics see these near death experiences regularly, we are only witnesses to it. These few stories are the accounts of patients who I have talked to after near death experiences such as a return of spontaneous circulation after cardiac arrest.

Everyone seems to experience these things differently – sometimes it depends how long they were down for (dead), what was happining around them at the time (such as noise, lights, etc) and sometimes their religious backgrounds play a part in what they see of think they see. This is not to say that I have resuscitated many people over my time who were not religious and still heard or saw things… the truth is, until we all travel to that “next stage of life/death” – this is just about as close a report as we’re going to get…

Patient John – had a history of ectopic beats leading into VF and was awaiting ablation surgery to remove his excess pacemakers. Over the course of 3 months – we cardioverted him (shocked him) during a VF cardiac arrest 5 times, each time with a good outcome and a return of circulation. One day, I asked him what he saw/felt. He said he normally saw bright lights… but that the last time he saw nothing/heard nothing…. and felt nothing…

Patient Jenny – had called us with chest pain, and then during treatment for the pain in her chest, I asked her a question and I noticed that as I did, her eyes dilated fully, she went rigid and stopped breathing (she had gone into an assystolic arrest). Over the course of 2 minutes of CPR, she had a spontaneous return of circulation… she became fully conscious within 10 minutes (about the time we were arriving at hospital). When asked what she saw/felt – she said it was as though someone had just stopped time in her life and now restarted it (and she has no idea what happened in between that time)…

Patient Sam – Had a VF cardiac arrest in front of an Ambulance Station. He was shocked twice and regained circulation. He was unconscious for 24 hours, but when we got a chance to talk to him, he said that remembered thinking everytime he heard the defibrillator charge up that it was going to hurt… and said that, although the pain never came, he was intensely aware of everytime we shocked him…

Patient Michael – Had a sick sinnus syndrome (basically his normal heart pacemaker wasn’t working and consequently his heart was throwing off all sorts of bad rhythyms). Otherwise, however, he was perfectly well. Consequently, every time we’d start CPR on him he would yell, kick and scream until we stopped – and then he would lie there unconscious wihtout a pulse until we started CPR again… eventually an external pacemaker was used and the patient became conscious and told us that he kept on having the worse nightmare…

More stories to come…

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Near Death

August 26th, 2010

Currently being built

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Afterlife

August 26th, 2010

This page is currently being created. But will discuss real experiences told by patients who have been very close to the afterlife. Patients how have had a return of spontaneous circulation after cardiac arrest.

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Medical Songs (definitive list)

August 25th, 2010

Okay, here’s the definitive list of medical songs (songs that we’ve changed so that they apply to medicine)… enjoy

Medical Song 1

Shackles – Mary Mary: When psych patients are shackled to the bed

Medical Song 2

Venus – Bananarama: When arterial blood gas sample is venous

Medical Song 3

Harder to Breathe – Maroon 5: Short of breath patients

Medical Song 4

Breathe – The Prodigy: Specific to patients on Bipap (Breath the pressure)

Medical Song 5

Pressure Down – John Farnham: Hypertensive patients or letting air out of the pressure bags

Medical Song 6

Check On It – Beyonce: Nurses needing a drug checked

Medical Song 7

DOA – Foo Fighters: The white meat truck

Medical Song 8

Confide in Me – Kylie Minogue: Psych registrar song

Medical Song 9

Push It – Salt ‘n’ Pepa: Wardsperson/porters song/pushing IV drugs

Medical Song10

No Scrubs – TLC: Soiled uniform and need to change into scrubs

Medical Song 11

Dizzy – Spin Doctors: Dizziness

Medical Song 12

Hot In Here – Nelly: Trauma gown songs/failure of air conditioning

Medical song 13

Hot Stuff – : Skanky psych/D&A patients

Medical song 14

I Want That Man – Deborah Harry: Skanky psych/D&A patients

Medical song 15

Can You Feel It – Jackson 5: Testing neurovascular status

Medical song 16

Stayin’ Alive – The Bee Gees: Arrest song

Medical Song 17

Night Fever – The Bee Gees: Nocturnal Diaphoresis

Medical Song 18

Purple Pills – Eminem: Epilim song

Medical Song 19

All By Myself – Jamie O’Neal: When you sign on and there is no one to work with

Medical Song 20

Help – The Beatles: Depressed patients

Medical Song 21

Gloria – Laura Brannigan: Old grannies who are named Gloria

Medical Song 22

Come on Eileen – : Old grannies who are named Eileen

Medical Song 23

Fallin’ – Alicia Keys: #NOF’s/falls patients

Medical Song 24

Pump Up The Jam – Technotronic: Pumping the bed up/CPR song

Medical Song 25

If I Could –1927: For patients born in 1927

Medical Song 26

I Feel The Earth Move – Martika: Fat truck/obese patients/bariatric patients

Medical song 27

Slipknot:….. People = Shit

Medical Song 28

Hungry Like The Wolf – Duran Duran: Patients complaining of not getting food

Medical Song 29

Blister in the Sun – Violent Femmes: 1st degree burns

Medical Song 30

Wake Me Up Before you go go – Wham: Unconscious patients/sedated patients

Medical Song 31

Broken Bones – Love Inc.: Fractures

Medical Song 32

Hold The Line – Toto: Propofol priming/CDA fluids/Ward clerks

Medical Song 33

All Fired Up – Pat Benatar: Triage nurse song

Medical Song 34

(I can’t get no) Satisfaction – Rolling Stones: Category 4/5 patients in waiting room/impotence

Medical Song 35

Heaven Help my heart – Tina Arena: AMI

Medical Song 36

What’s The Story Morning Glory? – Oasis: Handover song/priapism

Medical Song 37

Dressed for success – Roxette: Discharged patients

Medical Song 38

What About Me – Moving Pictures: Category 4/5 patients in waiting room

Medical Song 39

It’s All Been Done – Barenaked Ladies: When a nurse has done your work for you (doctors)

Medical Song 40

Rollin’ Like a River – Credence Clearwater Revival: Rolling off NART stretcher onto bed/urinary incontinence

Medical Song 41

Should I Stay or should I go – The Clash: Patients in waiting room

Medical Song 42

Disease – Matchbox 20: Infectious patients

Medical Song 43

Catch my disease – Ben Lee: Patients who cough in your face/isolation room

Medical Song 44

Patience – Guns n Roses: Whingeing relatives/patients

Medical Song 45

Reach Out – The Four Tops: Transferring patient’s via patslide

Medical Song 46

Achy Breaky Heart – Billy Ray Cyrus: Chest pain

Medical Song 47

Cheap Wine – Cold Chisel: Intoxicated patients

Medical Song 48

Yellow – Coldplay: Jaundiced patients

Medical Song 49

Knocking on heaven’s door – Guns n Roses: Bed 30/Code 4 song

Medical Song 50

Rescue Me – Aretha Franklin: Rescue truck

Medical Song 51

Stupid Girl – Garbage: Psych/OD patients

Medical Song 52

Pump It Harder – Black Eyed Peas: Cardiac arrest

Medical Song 53

The Nartbush – Tina Turner: NART

Medical Song 54

Looking out my backdoor – Credence Clearwater Revivial: PR check/polyps

Medical Song 55

Cuts like a knife – Bryan Adams: Chest tube/self harm

Medical Song 56

I Just Died In Your Arms Tonight – Cutting Crew: Self explanatory

Medical Song 57

Electric Blue – Icehouse: Song for VF arrests

Medical Song 58

Burn For You – John Farnham: Burns patients

Medical Song 59

Should Have Known Better – Richard Marx: Patients who have accidents/Drink drivers/unplanned pregnancies

Medical Song 60

The Key – Urban Cookie Collective: Buzzing for blue keys

Medical Song 61

Ring of Fire – Johnny Cash: Haemmorhoids/7/7 history of diarrhoea

Medical Song 62

Suspicious Minds – Elvis: Paranoid schizophrenics

Medical song 63

Survivor – Destiny’s Child: Patients surviving arrests

Medical Song 64

They don’t care about us – Michael Jackson: Patients in waiting room

Medical Song 65

We’re Not Gonna Take It – Twisted Sister: Patient refusing meds

Medical Song 66

You’re The Voice (try and understand it) – John Farnham: Expressive dysphasia

Medical Song 67

Bring Me To Life – Evanesence: Arrested patients/heroin OD

Medical Song 68

I Want Candy – Aaron Carter: Hypoglycaemic patients

Medical Song 69

Bad Medicine – Bon Jovi: DD drugs

Medical Song 70

Hit Me With Your Best Shot – Pat Benatar: Gun shot wound/IM injection

Medical Song 71

Open Your Heart – Madonna: Thoracotomy

Medical Song 72

Listen to your heart – Roxette: Heart auscultation

Medical Song 73

Shake Your Body (Down to the Ground) – Jackson 5: Seizures

Medical Song 74

You’re so Vain – Carly Simon: Venipuncture/cannulation

Medical Song 75

I’m Not Crazy – Matchbox 20: Delusions of grandeur

Medical Song 76

Wake Up – Arcade Fire: Trying to rouse patient with decreased LOC

Medical Song 77

Pins & Needles – Killing Heidi: Spinal Trauma/stroke

Medical Song 78

The Remedy – Jason Mraz: Patients wanting symptomatic relief

Medical Song 79

Cigarettes Will Kill You – Ben Lee: Emphysema/COPD

Medical Song 80

Haemorrhage – Fuel: Arterial bleed

Medical Song 81

Swallow – Bush: Speech path song

Medical Song 82

You fucked up my life – Blink 182: Psych patients/unsuccessful resuscitation

Medical Song 83

Oxygen’s Gone – Die Trying: Respiratory arrest

Medical Song 84

Lets Talk About Sex – O&G Doctors

Medical Song 85

Shout – Tears for Fears: Demented screamers/waiting room

Medical Song 86

I Gotcha – Jimmy Barnes: Security guard catching scheduled patients

Medical Song 87

We Don’t Need Another Hero – Tina Turner: GS song

Medical Song 88

2/3 Ain’t bad- Meatloaf: Mortality rate

Medical Song 89

Joyride – Roxette: Ambulance psych patient transfer

Medical Son 90

Freeway of Love – Aretha Franklin:CDA

Medical song 91

Quit Playing Games with my Heart – Backstreet Boys: Cardioversion song

Medical Song 92

Dirrrty – Christina Aguilera: Code Brown

Medical Song 93

Razors Edge – ACDC: Self-harm/Bearded lady

Medical Song 94

The Wheels on the bus go round and round: Ambulances

Medical Song 95

Freak – Radiohead: Freak patients

Medical Song 96

Hit me baby one more time – Britney Spears: Alleged Assault

Medical Song 97

I Believe I Can Fly – R. Kelly: Suicidal jumpers

Medical Song 98

Tubthumping (I get knocked down) – Chumbawumba: Alleged assault/Ped vs car

Medical Song 99

Elevation – U2: ST elevation on ECG

Medical Song 100

Vertigo – U2: Dizzy patients/Meniere’s disease

Medical Song 101

I Still Haven’t Found What I’m Looking For – U2: Sudden loss of vision

Medical Song 102

Because I Got High – Afro man: Patients on illicit drugs

Medical Song 103

Flashdance (What a feeling) – Irene Cara: Post Morphine/Ketamine administration

Medical Song 104

I Will Survive – Glora Gaynor: Patient vs NFR order

Medical Songs 105

Saltwater – Julian Lennon: When someone squirts saline in your face

Medical Songs 106

Start me up – Rolling Stones: Starting IV infusion

Medical Song 107

The Prayer – Anthony Callea: Last rites

Medical Song 108

The Drugs don’t work – The Verve

Medical Song 109

Crazy – Seal: Psych patients

Medical Song 110

Get Up – Technotronic: Mobilising patients with back pain/getting patients to ward

Medical Song 111

Freeze Frame – J. Geils Band: X-ray

Medical Song 112

From a Distance – Bette Midler: The Bryan Byers song (because he can’t see!)

Medical Song 113

U Can’t Touch This – MC Hammer: Patients refusing PR

Medical Song 114

Stand By Me – John Lennon: The special song

Medical Song 115

Blowin’ in the wind – Bob Dylan: Passing flatus

Medical Song 116

You keep me hangin’ on – The Supremes: Suicidal/attempted hanging

Medical Song 117

Hang On – Help is on its way – Little River Band: CDA

Medical Song 118

Pussytown – Machine Gun Fellatio: O&G Review

Medical Song 119

New Sensation – INXS: Spinal cord patient getting feeling back in legs

Medical Song 120

Don’t leave me this way – Thelma Houston: Grannies sent back to nursing home

Medical Song 121

I like to move it – Reel 2 Reel: Constipated patients

Medical Song 123

Manic Monday – The Bangles: Mondays

Medical Song 124

I Can See Clearly Now – Jimmy Cliff: Glaucoma/post cataract surgery

Medical Song 125

Always look on the bright side of life – Monty Python: Depression

Medical Song 126

I Feel Good: James Brown – Patients on ketamine

Medical Song 127

Stay with me – Shakespeare’s sister: Patients who are sooks

Medical Song 128

Push the button – Sugababes: Arrest buzzer/ambo exit door/radiographer’s song

Medical Song 129

Feelin’ hot hot hot – Buster Poindexter: Febrile patients

Medical Song 130

All Night Long – Lionel Richie: Category 4/5 patients waiting after midnight in the waiting room

Medical Song 131

Will I ever see your face again – Angels: frequent flyer patients

Medical Song 132

Milkshake – Kelis: The ED Tony Ferguson diet

Medical Song 133

Can’t Get You Out of My Head – Kylie Minogue: Paranoid psych patients

Medical Song 134

Goldfinger – Shirley Bassey: Doctor after a PR

Medical Song 135

Ring Ring – ABBA: Team leader phone/PR song

Medical Song 136

It’s In Your Eyes – Kylie Minogue: Foreign Body in eye

Medical Song 137

Shut Up – Black Eyed Peas: Triage patients

Medical Song 138

Seen Better Days – Pete Murray: For the patient being intubated

Medical Song 140

Everybody Hurts – R.E.M: Depressed patients/song for triage nurse to sing at triage when the patient is in pain

Medical Song 141

Don’t give up – Peter Gabriel: Resuscitating patients/Unsuccessful cannulation/ABG

Medical Song 142

Caught Up – Usher: When doctors/nurses are too busy

Medical Song 143

ABC – Jackson 5: Primary Survey

Medical Song 144

Fever – Michael Buble/Kylie Minogue: Self explanatory

Medical Song 145

Chains – Tina Arena: Patients shackled to the bed

Medical Song 146

Watching You (I See You) – Rogue Traders: Paranoid patients/ Intensive Care Unit (ICU)

Medical Song 147

Dangerous – Roxette: Violent psych patients

Medical Song 148

The Only Way Is Up – Yazz: Hypotensive or bradycardic patients

Medical Song 149

Touch It – Monifah: Getting a stool sample

Medical Song 150

My Neck, My Back – Khia: Trauma patients getting a log roll

Medical Song 151

This Is How We Do It – Montell Jordan: The educator song

Medical Song 152

Shocked – Kylie Minogue: Internal defib going off/defibrillation/cardioverson

Medical Song 153

Do You Really Want To Hurt Me – Culture Club: Patients who we restrain and give Midazolam to

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Medical Music

August 25th, 2010

More medical music…

Push the button – Sugababes: Arrest buzzer/ambo exit door/radiographer’s song

Feelin’ hot hot hot – Buster Poindexter: Febrile patients

All Night Long – Lionel Richie: Category 4/5 patients waiting after midnight in the waiting room

Will I ever see your face again – Angels: frequent flyer patients

Milkshake – Kelis: The ED Tony Ferguson diet

Can’t Get You Out of My Head – Kylie Minogue: Paranoid psych patients

Goldfinger – Shirley Bassey: Doctor after a PR

Ring Ring – ABBA: Team leader phone/PR song

It’s In Your Eyes – Kylie Minogue: Foreign Body in eye

Shut Up – Black Eyed Peas: Triage patients

Seen Better Days – Pete Murray: For the patient being intubated

Everybody Hurts – R.E.M: Depressed patients/song for triage nurse to sing at triage when the patient is in pain

Don’t give up – Peter Gabriel: Resuscitating patients/Unsuccessful cannulation/ABG

Caught Up – Usher: When doctors/nurses are too busy

ABC – Jackson 5: Primary Survey

Fever – Michael Buble/Kylie Minogue

Chains – Tina Arena: Patients shackled to the bed

Watching You (I See You) – Rogue Traders: Paranoid patients/ Intensive Care Unit (ICU)

Dangerous – Roxette: Violent psych patients

The Only Way Is Up – Yazz: Hypotensive or bradycardic patients

Touch It – Monifah: Getting a stool sample

My Neck, My Back – Khia: Trauma patients getting a log roll

This Is How We Do It – Montell Jordan: The educator song

Shocked – Kylie Minogue: Internal defib going off/defibrillation/cardioverson

Do You Really Want To Hurt Me – Culture Club: Patients who we restrain and give Midazolam t

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Ambulance Songs

August 25th, 2010

These are more emergency or Ambulance Songs

Help – The Beatles: Depressed patients

Gloria – Laura Brannigan: Old grannies who are named Gloria

Come on Eileen – : Old grannies who are named Eileen

Fallin’ – Alicia Keys: #NOF’s/falls patients

Pump Up The Jam – Technotronic: Pumping the bed up/CPR song

If I Could –1927: For patients born in 1927

I Feel The Earth Move – Martika: Fat truck/obese patients

People=shit: Slipknot:…..

Hungry Like The Wolf – Duran Duran: Patients complaining of not getting food

Blister in the Sun – Violent Femmes: 1st degree burns

Wake Me Up Before you go go – Wham: Unconscious patients/sedated patients

Broken Bones – Love Inc.: Fractures

Hold The Line – Toto: Propofol priming/CDA fluids/Ward clerks

All Fired Up – Pat Benatar: Triage nurse song

(I can’t get no) Satisfaction – Rolling Stones: Category 4/5 patients in waiting room/impotence

Heaven Help my heart – Tina Arena: AMI

What’s The Story Morning Glory? – Oasis: Handover song/priapism

Dressed for success – Roxette: Discharged patients

What About Me – Moving Pictures: Category 4/5 patients in waiting room

It’s All Been Done – Barenaked Ladies: When a nurse has done your work for you (doctors)

Rollin’ Like a River – Credence Clearwater Revival: Rolling off NART stretcher onto bed/urinary incontinence

Should I Stay or should I go – The Clash: Patients in waiting room

Disease – Matchbox 20: Infectious patients

Catch my disease – Ben Lee: Patients who cough in your face/isolation room

Patience – Guns n Roses: Whingeing relatives/patients

Reach Out – The Four Tops: Transferring patient’s via patslide

Achy Breaky Heart – Billy Ray Cyrus: Chest pain

Cheap Wine – Cold Chisel: Intoxicated patients

Yellow – Coldplay: Jaundiced patients

Knocking on heaven’s door – Guns n Roses: Bed 30/Code 4 song

Rescue Me – Aretha Franklin: Rescue truck

Stupid Girl – Garbage: Psych/OD patients

Pump It Harder – Black Eyed Peas: Cardiac arrest

The Nartbush – Tina Turner: NART

Looking out my backdoor – Credence Clearwater Revivial: PR check/polyps

Cuts like a knife – Bryan Adams: Chest tube/self harm

I Just Died In Your Arms Tonight – Cutting Crew: Self explanatory

Electric Blue – Icehouse: Song for VF arrests

Burn For You – John Farnham: Burns patients

Should Have Known Better – Richard Marx: Patients who have accidents/Drink drivers/unplanned pregnancies

The Key – Urban Cookie Collective: Buzzing for blue keys

Ring of Fire – Johnny Cash: Haemmorhoids/7/7 history of diarrhoea

Suspicious Minds – Elvis: Paranoid schizophrenics

Survivor – Destiny’s Child: Patients surviving arrests

They don’t care about us – Michael Jackson: Patients in waiting room

We’re Not Gonna Take It – Twisted Sister: Patient refusing meds

You’re The Voice (try and understand it) – John Farnham: Expressive dysphasia

Bring Me To Life – Evanesence: Arrested patients/heroin OD

I Want Candy – Aaron Carter: Hypoglycaemic patients

Bad Medicine – Bon Jovi: DD drugs

Hit Me With Your Best Shot – Pat Benatar: Gun shot wound/IM injection

Open Your Heart – Madonna: Thoracotomy

Listen to your heart – Roxette: Heart auscultation

Shake Your Body (Down to the Ground) – Jackson 5: Seizures

You’re so Vain – Carly Simon: Venipuncture/cannulation

I’m Not Crazy – Matchbox 20: Delusions of grandeur

Wake Up – Arcade Fire: Trying to rouse patient with decreased LOC

Pins & Needles – Killing Heidi: Spinal Trauma/stroke

The Remedy – Jason Mraz: Patients wanting symptomatic relief

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Medical Songs

August 25th, 2010

On nights shift one night some emergency nurses and I started to come up with a list of songs which could be considered the sound-track for any Ambulance or Emergency Department… hope you enjoy… some of them are a little wrong… but entirely in good spirit.

Shackles – Mary Mary: When psych patients are shackled to the bed

Venus – Bananarama: When arterial blood gas sample is venous

Harder to Breathe – Maroon 5: Short of breath patients

Breathe – The Prodigy: Specific to patients on Bipap (Breath the pressure)

Pressure Down – John Farnham: Hypertensive patients or letting air out of the pressure bags

Check On It – Beyonce: Nurses needing a drug checked

DOA – Foo Fighters: The white meat truck

Confide in Me – Kylie Minogue: Psych registrar song

Push It – Salt ‘n’ Pepa: Wardsperson/porters song/pushing IV drugs

No Scrubs – TLC: Soiled uniform and need to change into scrubs

Dizzy – Spin Doctors: Dizziness

Hot In Here – Nelly: Trauma gown songs/failure of air conditioning

Hot Stuff – : Skanky psych/D&A patients

I Want That Man – Deborah Harry: Skanky psych/D&A patients

Can You Feel It – Jackson 5: Testing neurovascular status

Stayin’ Alive – The Bee Gees: Arrest song

Night Fever – The Bee Gees: Nocturnal Diaphoresis

Purple Pills – Eminem: Epilim song

All By Myself – Jamie O’Neal: When you sign on and there is no one to work with

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Evidence Based Practice in Paramedics

August 25th, 2010

The need for evidence based practice in paramedics

Introduction into evidence based practice for paramedics

The following paper will explain why researchers and health bureaucrats have enthusiastically embraced evidence-based practice, while critics have argued that the evidence on which the evidence-based practice philosophy rests has inherent weaknesses that allow it to be capable of harm as well as good. Evidence based practice will be defined, followed by an explanation of the principles and processes of evidence based practice. The proponent’s argument developing the need for EBP will then be determined by discussing the four main driving factors of EBP, followed by the critic’s argument against EBP. Lastly, an objective view of both the strengths and weaknesses of EBP will be addressed.

Evidence-based practice defined

According to Sackett, Richardson, Rosenberg & Haynes EBP is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of your client’ (1997, p. 2).  EBP integrates individual clinical expertise with the best available external clinical evidence from systematic research; the evidence, by itself, cannot make a decision for you, but it can help support the patient care process. The initial definition of EBP was within the context of medicine, where it is was well recognised that ‘many treatments do not work as hoped’ (Doust and Del 2004, p. 474-5).  EBP is a total process beginning with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence then must be applied by a clinician with expertise in considering the patient’s unique values and needs. The final aspect of the process is evaluation of the effectiveness of care and the continual improvement of the process (Sacket et al, 1997, p.3).

Principles and processes of evidence-based practice explained

According to Sackett et al, the principles of EBP are based on a ‘process of lifelong, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues’ (1997, p. 3). By basing one’s clinical practice on the conscientious and judicious use of best evidence, one may enhance his or her clinical capabilities and ultimately the health outcomes of their patients.

According to Cook, Jaeschke, Guyatt, the ‘five steps of EBP were first described in 1992 and most steps have now been subjected to trials of teaching effectiveness’ (1992 p. 275-82) The process of EBP includes the following steps:

1.            converting information needs into answerable questions;

2.         tracking down, with maximum efficiency, the best evidence with which to answer them (whether from clinical examination, diagnostic laboratory, research evidence or other sources);

3.            critically appraise that evidence for its validity and usefulness;

4.         apply the results of this appraisal in our clinical practice; and

5.            evaluate our performance

(Sacket et al 1997, p. 3).

This five-step model forms the basis for both clinical practice and teaching EBP, and as Rosenberg and Donald have observed ‘an immediate attraction of evidence-based medicine is that it integrates medical education with clinical practice’ (1995, p. 1122- 3). Good practice including effective clinical decision-making, step 4 of the EBP process, requires the explicit research evidence and non-research knowledge (tacit knowledge or accumulated wisdom). Clinical decision-making is the ‘end point of a process that includes clinical reasoning, problem solving, and awareness of patient and health care context’ (Maudsley 2000, p. 63).

Since 1990, when EBP was introduced, it has broadened to reflect the benefits of entire health care teams and organisations adopting a shared evidence-based approach. This emphasises the fact that evidence-based practitioners may share more attitudes in common with other evidence-based practitioners than with non evidence-based colleagues from their own profession who do not embrace an evidence-based paradigm (American Medical Association 1992, p.4).

The need for EBP

Proponents of EBP argue the need for EBP with four main points. These are: ‘the research-practice gap, poor quality of most research, information overload and practice which is not evidence-based’ (Trinder 2000, p.3-4).

During the last century there has been an exponential growth of research and knowledge (Humphreys, McCutcheon 1994, p.18). The growth of health care information has been particularly rapid in diagnostic and therapeutic technologies, with the sheer volume of medical papers published doubling every 10 to 15 years (Hook 1999, p.3) and electronic access to full text articles and journals available since 1998 (Delamothe and Smith 1998, p.1109-10). Although, with all this research it was still argued that many medically based practitioners have a research-practice gap, which basically means that there is a limited extent to which they utilize and draw upon research finding to determine or guide their actions. Ultimately, they rely on indicators such as ‘prior knowledge, prejudice, outcomes of previous cases, fads or fashions, and advice from senior colleagues’ (Trinder 2000, p.4). With this expansion of information, our knowledge should be greater and our practice should be more effective. Unfortunately this is too often not the case (Walker, Grimshaw , Johnston, Pitts, Steen , Eccles 2003, p.19). This recognised gap between best evidence and practice is one of the driving forces behind the development of EBP.

Furthermore, it can be seen that many of those who do utilise research findings note that most research is methodically weak and of a generally poor quality. For example, the studies have not utilised the ‘gold standard of research, such as a well conducted randomized controlled trial (RCT)’(Trinder 2000, p. 4).

Those who do find research papers often discover information overload, which relates to the sheer amount of research papers available. According to Hook the volume of medical papers published doubles every 10 to 15 years (1999, p.3). Therefore the task of distinguishing between rigorous and useful research and poor or unreliable research has become a much more difficult task for clinicians and practitioners (Trinder 2000, p. 4).

Lastly, it can be seen that many practitioners are utilising techniques that are not based on evidence. The consequences of these previous factors result in the continual utilisation of medical interventions that have ‘been shown to be ineffective, harmful, slow or limited adoption of interventions which have been proven to be effective or more effective, and there continue to be variances in practice’ (Trinder 2000, p.4).

Critics view against EBP

Critics have argued against EBP on the basis of many common misperceptions of EBP as well as many correct failings associated with EBP. These primarily include: the argument that many doctors were already doing these things; that good evidence is often deficient in many areas; that lack of evidence and lack of benefit are not the same; that the more data are pooled and aggregated the greater the difficulty in comparing the patients in the studies with the patients presenting; that EBP is a covert method or rationing resources, is overly simplistic and often restrains professionals; that many clinicians lack the time and resources to practice EBP and require new skills to utilize EBP (Guyatt, Cairns, Churchill 1992, p.268; Trinder 2000, p.2; and Straus 2000, p. 837-9).  Furthermore, those who agree that ‘EBP makes good sense in theory, have quite appropriately demanded evidence for whether it improves patient outcomes’ (Miles, Bentley, Polychronis and Grey 1997, p. 83-5). Although, the ethical and moral implications of such a randomized controlled trial, relating to withholding evidence in the clinical treatment of patients may never be appropriately justifiable.

In developing the EBP some have argued that the new paradigm is sometimes misinterpreted. For example, many have argued that EBP recognition of the limitations of intuition, experience, and understanding of pathophysiology in permitting strong inferences are a rejection of these routes to knowledge altogether.

A common critic misperception or argument against EBP is that it ignores the clinical experience and clinical intuition of the practitioner or clinician.  In many ways it is important to expose learners to exceptional clinicians who have a gift for intuitive diagnosis, a talent for precise observation, and excellent judgement in making difficult management decisions. Untested signs and symptoms should not be rejected out of hand. They may prove extremely useful, and ultimately be proved valid through rigorous testing. The more experienced clinicians can dissect the process they use in diagnosis, and clearly present it to learners, the greater the benefit. Similarly, the gain for students will be greatest when clues to optimal diagnosis and treatment are culled from the barrage of clinical information in a systematic and reproducible fashion (Craig, Irwig and Stockler 2001, p. 1-3).

Institutional experience can also provide important insights. Diagnostic tests may differ in their accuracy depending on the skill of the practitioner. A local expert in, for instance, diagnostic ultrasound, may produce far better results that the average from the published literature. The effectiveness and complications associated with therapeutic interventions, particularly surgical procedures, may also differ across institutions. When optimal care is taken to both record observations reproducibly and avoid bias, clinical and institutional experience evolves into the systematic search for knowledge that forms the core of evidence-based medicine (Straus and McAlister 2000, p.839).

Another argument is that the understanding of basic investigation and pathophysiology plays no part in evidence-based medicine. The dearth of adequate evidence demands that clinical problem-solving must rely on an understanding of underlying pathophysiology. Moreover, a good understanding of pathophysiology is necessary for interpreting clinical observations and for appropriate interpretation of evidence. However, numerous studies have ‘demonstrated the potential fallibility of extrapolating directly from the bench to the bedside without the intervening step of proving the assumptions to be valine in human subjects’ (Echt, Leibson, Mitchell, Peters, Obias 1991, p. 781).

Some critics have argued that EBP ignores standard aspects of clinical training such as the physical examination. A careful history and physical examination provides much, and often the best, evidence for diagnosis and directs treatment decisions. The clinical teacher of EBP must give considerable attention to teaching the methods of history and clinical examination, with particular attention to which items have demonstrated validity and to strategies to enhance observer agreement (Echt et al 1991, p. 781-2).

Large randomized controlled trials are extraordinarly useful for examining discrete interventions for carefully defined medical conditions. The more complex the patient population, the conditions, and the intervention, the more difficult it is to separate the treatment effect from random variation. Because of this, a number of studies obtain insignificant results, either because there is insufficient power to show a difference, or because the groups are not well-enough ‘controlled’ (Straus et al 2000, p.839).

Furthermore, the critic may argue that EBP has been most practised when the intervention tested is a drug. Applying the methods to other forms of treatment may be harder, particularly those requiring the active participation of the patient because bliding is is more difficult (Stephenson and Imrie 1998, p.1). The types of trials considered ‘gold standard’ (i.e. randomized double-blind placebo-controlled trials) are very expensive and thus funding sources play a role in what gets investigated. For example, the government funds a large number of preventive medicine studies that endeavor to improve public health as a whole, while pharmaceutical companies fund studies intended to demonstrate the efficacy and safety of a particular drugs, so long as the outcomes are in their favour (Coats 2004, p.2-3). Furtheremore, ‘determining feasibility and relevance to the real world is often difficult’ (Stephenson and Imrie 1998, p.2).

One of the fears of EBP is that purchasers and managers will control it in order to cut the costs of health care. This would not only be a misuse of EBP but suggests a fundamental misunderstanding of its financial consequences. Doctors practising EBP will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care (Straus et al 2000, p.839).

Many of the studies that are published in medical journals may not be representative of all the studies that are completed on a given topic (published and unpublished) or may be misleading due to conflicts of interest (i.e. publication bias); therefore the array of evidence available on particular therapies may not be well-represented in the literature.

Strengths of evidence based practice

Some of the many strengths of EBP include: finding better procedures, stopping negative procedures, learning from other people’s mistakes, providing a basis for clinical judgment, legal protection, best utilization of resources and ultimately best clinical practice (Straus et al 2000, p. 837-40; Trinder 2000, p. 2; ).

By utilising the evidence to provide the best practice possible, a clinician or practitioner is capable of reducing if not removing the possible harms of treatment. According to Trinder ‘EBP remains firmly committed to the modernist promise that risk can be assessed and controlled by expert knowledge and that potential harm of interventions can be minimised and the potential benefits maximised’ (2000, p. 7-8).

EBP is an approach that ‘promotes the collection, interpretation, and integration of client-reported, clinician-observed, and research-derived evidence’ (McKibbon, Wilczynski, Hayward, Walker-Dilks, & Haynes 1995, p. 4). It does not command your clinical decisions, but may be utilised to ensure that through the ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of your client you have developed the most effective and efficient treatment decision for your patient (1997, p. 2).

EBP may help identify procedures that are not cost-effective and may be dropped. This is not to say that it will drop procedures and change the management plan of a patient based on economic restraints, but that it will look for more effective methods of providing treatment (Straus et al 2000, p.839). Likewise, EBP may help identify new procedures and justify their cost. According to Trinder ‘supporters and advocates of EBP claim that the approach results in the best practice and the best use of resources’ (2000, p. 2).

EBP may become the common language through which different healthcare disciplines communicate, such as the medical, physiotherapy, nursing and paramedical disciplines (Sackett et al, 1997, p.17). Furtheremore EBP principles do not change from undergraduate to post-graduate education and hence are a greater advantage to the life-long process of study associated with any professional clinician or practitioner (Echt et al 1991, p. 781-2).

Weaknesses of evidence based practice

The weaknesses of EBP include: the limitations to samples in research, the required need to still make clinical judgments (EBP is only a guideline), the fact that information develops rapidly and beyond one person therefore protocols are useful, the fact that it requires new skills from clinicians, may in fact raise and not necessarily lower the cost of health care, it cannot replace experience, and the paucity of proof that EBP actually works (Straus and McAlister 2000, p. 838; Trinder 2000, p. 2).

EBP requires new skills of the clinician, including efficient literature-searching, and the application of formal rules of evidence in evaluating the clinical literature, such as the five steps in the process of EBP as described by Sacket et al (1997, p. 3).

EBP is also not an ivory tower or armchair medicine but a way of staying on top of a busy professional life. It is not an alternative to experience.

EBP is not cook-book medicine imposed from above and slavishly followed but an active process which integrates the doctor’s own expertise, the external evidence and the patients’ preferences. Clinical guidelines are similarly subject to this flexible approach. External clinical evidence can inform but never replace individual clinical expertise and it is this expertise that decides even whether the external evidence is relevant to the patient at all (Howizts 1996, p. 320).

EBP is not necessarily a cost-cutting exercise but a method of looking for the most effective ways to improve the quality and quantity of patients’ lives. This may in fact raise, not lower, the cost of care (Straus et al 2000, p.839).

Because EBP requires an upwards approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision (Coats 2004, p.4-5). Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient’s clinical state, predicament, and preferences, and thus whether it should be applied.

EBP involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a ‘diagnostic test, a clinician needs to find proper cross-sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial’ (Oxman, Sackett, and Guyatt 1993, p. 2). For a question about prognosis, a clinician needs a proper follow-up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence required will come from the basic sciences such as genetics, immunology and basic pathophysiology. It is when asking questions about therapy that one should try to ‘avoid the non-experimental approaches, since these routinely lead to false-positive conclusions about efficacy’ (Coats 2004, p.2-3).

Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the ‘gold standard’ for judging whether a treatment does more good than harm. However, according to Straus et al, even though ‘randomised clinical trials are considered to be the ‘gold standard’ for establishing the effects of an intervention, they are not necessarily the best sources for answering questions about diagnosis, prognosis or harm’ (1997, p.839). Furthermore, some questions about therapy that would ordinarily require randomised trials, may not require randomised when trials of successful interventions would prove otherwise fatal or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient’s predicament, a clinician should follow the trial to the next best external evidence and work from there.

Despite its ancient origins, evidence-based medicine remains a relatively young discipline whose positive impacts are just beginning to be validated and it will continue to evolve (Oxman et al 1993, p. 2). This evolution will be enhanced as various undergraduate, post-graduate, and continuing medical education programmes adopt and adapt it to their learners’ needs. These programmes, and their evaluation, will provide further information and understanding about what EBP is, and what it is not. As yet, however, there is ‘no good evidence to suggest that EBP actually works (Trinder 2000, p.4).

Critical appraisal of clinical practice involves additional time and effort, and may be perceived as wasteful; however, this time and effort may be reduced by clinicians developing effective searching skills and simple guidelines for assessing the validity of research papers. In addition, one can emphasize that critical appraisal, as a strategy for solving clinical problems is most appropriate when the problems are common in one’s own practice (Oxman et al 1993, p. 3).

Conclusion

This paper has explained why researchers and health bureaucrats have enthusiastically embraced evidence-based practice, while critics have argued that the evidence on which the evidence-based practice philosophy rests has inherent weaknesses that allow it to be capable of harm as well as good. EBP has been defined as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of your client’ (Sackett et al 1997, p. 2). An explanation of the principles and processes of EBP were then discussed. The proponent’s argument developing the need for EBP was then determined by discussing the four main driving factors of EBP, followed by the critic’s argument against EBP. Lastly, an objective view of both the strengths and weaknesses of EBP were addressed, and in doing so, it was determined that in theory, EBP is an excellent idea, and there is a definite need for it within the medical context, as well as many other professions; however, while it is still early in its practice, there is no substantial evidence to suggest that EBP actually works.

References:

American Medical Association, 1992, Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine, Centre for Health Evidence, http://www.cche.net/usersguides/ebm.asp#Paradigm, Last updated, 11/7/2005, viewed on the 16/9/2005

Coats, V. 2004, Randomised controlled trials — almost the best available evidence for practice, Journal of Diabetes Medicine

Cook, D. Jaeschke, R. Guyatt, G. 1992: Critical appraisal of therapeutic interventions in the intensive care unit: human monoclonal antibody treatment in sepsis. Journal Club of the Hamilton Regional Critical Care Group.J Intensive Care Med 1992, 7:275-282.

Craig, C Irwig L and Stockler M 2001, Evidence-based medicine: useful tools for decision making, MJA

Delamothe, T. Smith R1998: The BMJ’s website scales up evidence based practice

British Medical Journal

Doust, J. Del-Mar, B. 2004: Why do doctors use treatments that do not work? British Medical Journal

Echt, D. Leibson, P. Mitchell, R. Peters, B. Obias, R. 1991, Mortality and Morbidity in Patients Receiving Encainmide and Flacainide or Placebo, New England Journal of Medicine

Guyatt, G. Cairns, J. Churchill, D. abd Evidence-Based Medicine Working Group, 1992,  Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA

Hook, O 1999: Scientific communications. History, electronic journals and impact factors, British Medical Journal

Howitz, R. 1996, The Dark Side of Evidence Based Medicine, Journal of Emergency Medicine

Humphreys, L. McCutcheon, E.1985: Growth patterns in the National Library of Medicine’s serials collection and in Index Medicus journals, 1966-1985.

Bull Med Library Assoc

Maudsley, S. 2000, Science, Critical Thinking and Competence for Tomorrow’s Doctors. A review of Terms and Concepts, Journal of Medicine Education

Miles, A. Bentley, P. Polychronis A. and Grey, J. 1997, Evidence-based Medicine: Why all the fuss? This is why. J Eval Clin Pract

Oxman, A Sackett, D and Guyatt G 1993, EBM: How to Get Started, JAMA,

Rosenberg, W. Donald, A. 1995: Evidence based medicine: an approach to clinical problem-solving, British Medical Journal

Sackett, L. Richardson, S. Rosenberg, W. and Haynes, B. 1997, Evidence-based medicine: how to practice and teach EBM, Churchill Livingstone, New York, USA

Sackett, L. Rosenberg, W. Gray, J. Haynes B. Richardson, W. Evidence based medicine: what it is and what is isn’t, British Medical Journal

Straus, E. and McAlister, A. 2000, Evidence-based medicine: a commentary on common criticisms. Cannadian Medical Association Journal

Stephenson, J. and Imrie, J. 1998, Why do we need randomised controlled trials to assess behavioural interventions?, British Medical Journal

Trinder, L. 2000, Introduction: the context of evidence-based practice. In Evidence-based practice: a critical appraisal, Blackwell Science, Oxford

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Ambulance Billing

August 23rd, 2010

How do Ambulance Services bill their patients? How do they run in Australia?

Although Australia has some private companies which provide paramedic and first aid at sporting events or special events, fundamentally, all state Ambulance (Emergency) Services are government funded. Now, the level of governement funding differs in each state, and as a consquence, the billing requirements and need for customer costs differ. 

In Western Australia, I believe that it is almost fully funded by patient Ambulance Billing, donations and volunteers. In most states on the East Coast of Australia are funded primarily by the government, and then create revenue through a certain level of billing. Although this differs from state to state – most Ambulance Services charge around $250 to respond to an emergency in which paramedic treat and transport a patient. However, this bill may increase if the patient requires long transfers or other specialised care. In virtually all cases though, the bills are low enough that virtually all patients can afford safe, effective, emergency Ambulance treatment.

Does everyone have to pay for an Ambulance?

No, generally, most of our patients don’t end up having to pay for their Ambulance service or treatment. In Australia, health (at least for the time being – thank goodness) is still fundamentally the right of every person regardless of their financial situation.

The following people don’t usually have to pay for Ambulance (although this may differ from state to state):

1. Pensioners

2. Patients on welfare concessions

3. Hospital to hospital transfers are often paid for by the hospital

4. Most school age kids at school have Ambulance Cover provided by their school (although most schools have this, it is not compulsory and not all schools have it)

5. In QLD (I believe) the bill for the Ambulance Service is taken out as a levy in every person’s electric bill and consequently, the users of the Ambulance Service do not have to pay for each service.

6. In most states you can organise Ambulance Insurance or Ambulance Cover for about $25-50 per year, which covers all Ambulance Billing

7. Most private health insurances cover Ambulance use – however, some insurance companies have in their “fine print” the proviso that they will only cover Ambulance Bills in “life threatening emergencies”

8. If you have a injury at work, you should be covered by work-cover and consequently not have to pay for your Ambulance Bill

9. If you have a car accident in Australia (so long as the car is actually registered) you are covered by the compulsory accidental injury insurance.

At the end of the day… if you need an Ambulance – call an Ambulance! For the sake of a few hundred dollars (generally worse case scenario) there is no reason why you should not have the best level of emergency prehospital care capable in your area! The Ambulance Billing can always be fixed later…

We’re here to help people – so if you need our help, call us.

In Australia you can call for an Ambulance by call “000”  and asking for Ambulance – this is a free call and works from a pay phone or any mobile (even if you do not have credit).

Take care,

Australian Paramedic

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Ambulance Analgesia

August 23rd, 2010

This paper will compare and contrast the use of morphine and fentanyl as pre-hospital analgesia.

Pharmacokinetics and pharmacodynamics of fentanyl.

Administration and absorption

Fentanyl can be administered intravenously (IV), subcutaneously (SC),intranasally (IN), as a transdermal patch (TD) and as an oral transmucosal lollipop (OTM) (MIMS 2003, p 4-359; Bryant and Knights 2003, p. 247). IV administration has the most rapid onset of action, followed by OTM, IN, SC and TD being the slowest. Unlike most other opioids, which have to be primarily administered parentally, fentanyl can be administered via both the parental and enteral routes, without any major reduction in bioavailability as a result of a first pass metabolism within the liver (Galbraith, Bullock, and Manias 2001, p. 366).

IV and SC administration may be useful when analgesic requirements makes oral dosing impractical as well as patients who require rapid titration of opioids for pain relief. Medications may be given as repeated intermittent bolus doses or by continuous infusion (Bryant and Knights 2003, p. 247). IV administration provides ‘almost immediate analgesia where as SC may require up to 15 minutes for full effect’ (MIMS Annual 2003, p. 4-365). Bolus IV dosing provides a shorter duration of action than other routes, while continuous infusions provide steady blood levels (Weiner 2002, p. 482). Because of its high affiliation with lipids fentanyl is readily absorbed via the skin.  Bryant and Knights states that: ‘fentanyl is highly lipophilic making it easily administered TD’ (2003, p. 247). Plasma levels rise slowly over 12-18 hours after transdermal patch placement and slowly fall off 20-24 hours after removal (Oh 1998, p.681), making it very easy to use, and ‘practical for chronic pain disorders, especially cancer’ (Galbraith, et Al 2001, p. 366). 

When fentanyl is administered in the oral transmucosa, in the form of a lollypop, it acts in a ‘combination of an initial rapid absorption from the buccal mucosa (parenteral absorption) and a more prolonged absorption of swallowed fentanyl from the gastro-intestinal tract (enteral absorption)’ (Loeser 2001, p. 98). Both the blood fentanyl profile and the bioavailability of fentanyl will vary depending on the fraction of the dose that is absorbed through the oral mucosa and the fraction swallowed. Fentanyl is metabolized primarily in the liver and intestinal tracts which would suggest that any enteral administration of the drug would be ineffectual due to a first-pass mechanism. However, according to Evan, Kharasch, Whittington and Hoffer the ‘first-pass metabolism has little effect on fentanyl’s bioavailability from oral transmucosal fentanyl’ (2003, p1). Furthermore the buccal absorption, bioavailability, and permeability of fentanyl are markedly increased as the pH of the fentanyl solution becomes more basic. This is because of ‘an increase in the fraction of unionized fentanyl’ (Streisand, Zhang, Suyi, McJames, Remco, Pace 1995, p. 759). Intranasal fentanyl is an alternative route when the oral route is unavailable.

The IN route provides for rapid absorption and onset of action. According to Striebel, Kramer, Luhmann, Rohierse-Hohler and Rieger: ‘intranasal fentanyl seems to be a promising, non-invasive and rapid-acting new mode of opioid administration that is especially suitable in acute pain syndromes’ (1993, p.1). Acording to Hill ‘intramuscular injections should be avoided because injectionsare painful, inconvenient and absorption is erratic, meaning that the benefits do not out way the negatives’ (Hill 97, p. 3).

Distribution

According to the MIMS Annual the ‘distribution time of fentanyl is 1.7 minutes, redistribution is 13 minutes and the terminal elimination half-life is 219 minutes’ (MIMS Annual 2003, p. 4-359). According to Weiner ‘fentanyl is highly lipid soluble, causing it to have a rapid onset of action with a large volume of distribution and a relatively short duration of action’ (2002, p. 482). The mean volume of distribution at a steady state is 4 L/kg (MIMS Annual 2004, p.4-359). The analgesic effects of fentanyl may appear before the adverse effects, when administered IV. According to MIMS annual: ‘the onset of action may be immediate when administered IV; however the maximal analgesic and respiratory depressant effect may not be noted for several minutes’ (MIMS Annual 2003, p. 4 –359). 

A proportion of all drug molecules entering into the blood stream bind to proteins to form drug-protein complexes. ‘Acidic drugs bind mainly to albumin, while basic drugs bind to acid glyco-proteins contained in the blood’ (Bryant and Knight 2003, p.108). Because of the size of the molecules formed by plasma protein drug complexes, drugs which are bound to proteins cannot pass through the plasma membrane of the vascular system, and are therefore unable to cause their desired effects on their target cells or organs. Galbraith et al states: ‘the stronger the protein binding, the less of the free drug that will be present in the plasma and the longer the drug will remain within the vascular system increasing the drugs ½ life’ (1998, p.1081). Therefore, one would determine that because fentanyl is highly plasma protein bound at 85% it would remain within the vascular system longer than morphine, which is only 35% protein bound (MIMS Annual 2003, p. 4-359). However, due to its highly lipophilic nature and the fact that it has a pKa (ionization) of 8.2 its rate of distribution and onset of action is more rapid than morphine, causing its half-life to be considerably shorter (Streisand et al 1995, p. 759).

Metabolism

Fentanyl is highly metabolized by the liver, decreasing the effect of any orallyadministered but not leaving it ineffectual. Fentanyl is primarily (more than 90%) eliminated by biotransformation to inactive metabolites (MIMS Annual 2003, p. 4-359).

Excretion

The metabolites are mainly excreted in the urine while fecal excretion is lessimportant. The total plasma clearance of fentanyl is 0.5 L/hr/kg (MIMS Annual 2003, p. 4-359). The terminal elimination half-life after OTM administration is about 7 hours. Approximately 75% of an IV dose is excreted via the kidneys in urine as metabolites with less than 10% representing the unchanged medicine. Approximately 9% of the dose is recovered in the faeces, primarily as metabolites (MIMS Annual 2003, p. 4-359; Bryant and Knights 2003, p. 244-5).

Pharmacodynamics

Similar to other opiates, fentanyl acts as an agonist to bind with specific receptor sites in the brain, spinal cord and many other tissues, called opioid receptors. The body’s endogenous opiate receptor sites are known as ‘delta, epsilon, kappa and mu’ (Galbraith et al 2001, p.336). These are inhibitory neurotransmitters, which suppress pain messages to the CNS from the periphery. Fentanyl exerts its primary effect on the central nervous system (CNS) and organs containing smooth muscle. Effects include: ‘miosis, respiratory stimulation followed by depression, bradycardia, hypothermia, and a decrease in nociception’ (Loeser 2001, p. 99). There are high concentrations of receptors for the body’s natural opioids such as the endorphins and enkephalins in many areas of the CNS, particularly in the ‘grey matter of the midbrain, the limbic system and at the interneurons in the dorsal horn areas’ (Bryant and Knights 2003, p. 235). These areas are known to be involved in pain transmission or perception.

Fentanyl acts by binding to the mu and kappa receptor sites and in doing so blocking the transmission of the theoretical substance P (pain) through a variety of inhibition processes. According to Loeser the opioid receptor is ‘a gene-protein- coupled (G-protein) receptor that can work via a number of effectors and second messengers to influence a variety of neuronal processes’ (Loeser 2001, p.101). This leads to an inhibition both presynaptic and postsynaptic of transmitter release, and hence a decrease in nociception. Through G-protein coupling, opiate receptors can ‘activate potassium (K)channels, close calcium (Ca) channels or both’ (Loeser 2001, p. 102). In doingso, they cause a decrease in intracellular cyclic Adenosine Monophosphate (cAMP)levels and therefore result in a ‘reduction of chemical transmitter release and hencea blockade of synaptic transmission’ (Munson 1998, p. 408). Opiate receptors can also act on the O and I alpha G-protein subunits to inhibitadenylate cyclase and thus reduce the production of cAMP from adenosinetriphosphate (ATP). This, in turn, causes an inhibition of cAMP-dependant proteinkinase (PKC) and the transmission of substance P (Appleyard 1998, p. 14; Galbraith et al 1997, p.335). Decreased cAMP levels lead to a decrease in ‘neuronal excitability leading to inhibitory effects at cellular level; effects that appear to be excitory are actually due to the suppression of firing of in inhibitory neurons’ (Bryant and Knights 2003, p. 245).

At the spinal level fentanyl stimulates the ‘opioid mu receptors in the dorsal horn of the spinal cord’ (Galbraith et al 2001, p.362) and thus inhibits the release of substance P from the dorsal horn neurons. At supraspinal levels ‘opiates act to close the gate in the dorsal horn, thus inhibiting afferent transmission of the substance P’ (Bryant and Knights 2003, p 245). It is also capable of altering perception and emotional responses to pain because opiate receptors are widely distributed in the CNS, especially in the limbic system, thalamus, hypothalamus and midbrain (MIMS Annual 2003 p. 4 –433). When pain perception is inhibited the analgesic effect of an opioid is enhanced.

Fentanyl rarely causes a clinically significant histamine response such as morphine. Because of this, adverse effects such as hypotension are not as likely, making it a more suitable drug for patients who are haemodynamically unstable. OH states that ‘fentanyl has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680).

Contrasting the pharmacology of fentanyl and morphine

 Fentanyl absorption Fentanyl can be administered IV, SC, IN, TD and as an OTM (MIMS 2004, p. 4- 359; Bryant and Knights 2003, p. 247). Unlike most other opioids, which have to be administered parentally, fentanyl can be administered via both the parental and enteral routes, without any major reduction in bioavailability due to the first pass metabolism within the liver (Galbraith et al 2001, p. 366). Morphine absorption Morphine can be administered via ‘SC, IM, IV injection and as an oral tablet; however due to the fact that it is highly metabolism by the liver, its first pass mechanism reduces its bioavailability to all but 40% of the ingested dose (MIMS Annual 2003 p. 4-433).

Fentanyl distribution According to the MIMS Annual the ‘distribution time of fentanyl is 1.7 minutes, redistribution is 13 minutes and the terminal elimination half-life is 219 minutes’ (MIMS Annual 2003, p. 4-359). According to Shoemaker, Ayres, Grenwick and Holbrook, ‘fentanyl is approximately 500 fold more lipophilic than morphine’ (2000, p.300), which is the cause for its rapid onset of action. The plasma protein binding of fentanyl is 80-85% and the free fraction of fentanyl increases with acidosis. The mean volume of distribution at a steady state is 4 L/kg (MIMS Annual 2003, p. 4-359). The analgesic effects of fentanyl may appear before the adverse effects, when administered IV. Fentanyl reaches its peak effect in 2-3 minutes, which not only brings very rapid pain relief, but also allows safer titration. Morphine distribution Morphine is not particularly highly protein bound at ‘35% being bound to plasma protein’ (Bryant and Knights 2003, p247) and is relatively hydrophilic when compared to fentanyl, so it crosses slowly into the CNS. Because of this, its distribution time is relatively long. Approximately 20 minutes post IV administration (MIMS Annual 2003 p. 4 –364). Plasma half-life is achieved between 2-3 hours after administration (MIMS Annual 2003 p. 4 –433). IV morphine does not reach its peak effect until about 15 minutes, meaning that pain relief is relatively slow, by comparison to fentanyl, and the chance of opioid overdose through poor titration is more likely.

Fentanyl metabolism Fentanyl is highly metabolized by the liver, decreasing the effect of any orallyadministered fentanyl but not leaving it ineffectual (MIMS Annual 2004, p. 4-359). Morphine metabolism Morphine is metabolized by the liver to form ‘morphine-3-glucuronide (M3G) and morphine –6-glucuronide (M6G), which are both inactive metabolites’ (Bryant and Knights 2003, p. 249). 

Fentanyl excretion The metabolites are mainly excreted in the urine while fecal excretion is less important being less than 0.01%. The total plasma clearance of fentanyl was 0.5 L/hr/kg. The terminal elimination half-life after OTM administration is about 7 hours. Approximately 75% of an IV dose is excreted in via the kidneys in urine as metabolites with less than 10% representing the unchanged medicine. Approximately 9% of the dose is recovered in the faeces, primarily as metabolites (MIMS 2003, p. 4-359). Morphine Excretion Morphine is primarily excreted via the kidneys, and small amounts are excreted as bile and faeces (MIMS Annual 2003 p. 4 –433). Because both fentanyl and morphine are principally excreted via the kidneys any decrease in the glomerulus filtration rate (GFR) due to young age, old age or nephological disease may result in ‘maintained  higher serum levels and a longer duration of action than intended’ (Sanders 2001, p.261).

Fentanyl and Morphine pharmacodynamics

Fundamentally, because both fentanyl and morphine act on opioid receptors as their primary mechanisms of action, many of the pharmacodynamics between the two drugs are similar. Both fentanyl and morphine act as an agonist to bind with specific receptor sites in the brain, spinal cord and many other tissues, called opioid receptors. The body’s endogenous opiate receptor sites are known as ‘delta, epsilon, kappa and mu’ (Galbraith et al 2001, p.336). These are inhibitory neurotransmitters, which suppress pain messages to the CNS from the periphery. However, where fentanyl and morphine differentiate is by the specific opioid receptors that they bind with, and how much of a reaction they cause. Specifically, fentanyl stimulates the mu receptor sites +++ and the delta receptor +, with no effect on the kappa or epsilon receptors. Morphine, however, stimulates both the mu and delta sites similarly to fentanyl, but also acts on the kappa receptors sites + which may be the cause of some divergent pharmacodynamics as a result of choosing between the two forms of analgesia (Rang, Dale, and Ritter 1999, p.593).

Fentanyl and morphine exert their primary effect on the CNS and organs containing smooth muscle. Effects include: ‘analgesia, drowsiness, alteration in mood (euphoria), reduction in body temperature, depression of the respiratory drive, cough suppression and miosis’ (Hollinger 1997, p. 384). There are high concentrations of receptors for the body’s natural opioids such as the endorphins and enkephalins in many areas of the CNS, particularly in the ‘grey matter of the midbrain, the limbic system and at the interneurons in the dorsal horn areas’ (Bryant and Knights 2003, p. 235). These areas are known to be involved in pain transmission or perception. Although the delta, epsilon, kappa and mu receptor sites have all been associated with producing nociception, the mu receptor site is the most prominent in the reduction of pain. It is primarily the mu receptor sites that both fentanyl and morphine act upon to produce analgesic effects. By binding opioids to the mu receptor sites the transmission of the substance P through a variety of inhibition processes occurs.

According to Loeser the opioid receptor is ‘a gene-protein- coupled (G-protein) receptor that can work via a number of effectors and second messengers to influence a variety of neuronal processes’ (Loeser 2001, p.101). This leads to an inhibition both presynaptic and postsynaptic of transmitter release, and hence a decrease in nociception. Through G-protein coupling, opiate receptors can ‘activate potassium (K)channels, close calcium (Ca) channels or both’ (Loeser 2001, p. 102). In doingso, they cause a decrease in intracellular cyclase Adenosine Monophosphate(cAMP) levels and therefore result in a ‘reduction of transmitter release and hencea blockade of synaptic transmission’ (Munson 1998, p. 408). Opiate receptors can also act on the O and I alpha G-protein subunits to inhibit adenylate cyclase and thus reduce the production of cAMP from AdenosineTriphosphate (ATP). This, in turn, causes an inhibition of cAMP-dependant proteinkinase (PKC) and the transmission of substance P (Appleyard 1998, p. 14;Galbraith et al1997, p.335). Decreased cAMP levels lead to a decrease in ‘neuronal excitability leading to inhibitory effects at cellular level; effects that appear to beexcitory are actually due to the suppression of firing of in inhibitory neurons’ (Bryant and Knights 2003, p. 245). 

Although both fentanyl and morphine act on the mu receptor sites fentanyl rarely causes the clinically significant histamine response seen in the administration of morphine. Because of this, adverse effects of hypotension are not as likely and may be more suitable for patients who are haemodynamically unstable. Oh states, that ‘fentanyl has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680).

Because both fentanyl and morphine act on the mu receptor sites they cause a decrease in gastric intestinal motility and an increase in the desire to vomit (Rang, Dale, and Ritter 1999, p.593); however, according to the MIMS Annual ‘fentanyl appears to have less emetic activity than morphine’ (2003, p. 4-359) which may be very beneficial in patients in the prehospital care setting who may already have unstable airways, and have not fasted. Fentanyl may be the drug of choice to avoid the risk of the likely emetic results stimulated by such analgesia as morphine. The exact probability that a molecule will be protonated or deprotonated depends on the pKa (ionization) of the molecule and the pH of the solution. Fentanyl has a pKa of 8.2 where as morphine has a pKa of 7.9 (Sansom 2004, p.284). Therefore, by having a higher pKa (and a greater affiliation with lipids) fentanyl crosses over the plasma membrane more rapidly than morphine. Investigating the risks and benefits of fentanyl for analgesia in thepre-hospital care setting  Risks Like all opioids the major adverse effects of fentanyl are respiratory depression and sedation.

Fentanyl causes ‘a diminished sensitivity to CO2 resulting in a depressed respiratory drive’ (MIMS 2003, p. 4-359). Because of this, the use of fentanyl as analgesia in patients with limited respiratory reserve, such as those with chronic airway limitations (CAL) or chronic obstructive pulmonary disease (COPD) should be tentative and with close monitory of the patient’s conscious state, effectiveness of respirations (rate and depth), O2 saturations, skin colour and HR to ensure adequate perfusion is maintained.

 According to the therapeutic goods administration, due to its ‘cholinergic stimulation’ fentanyl may ‘produce bradycardia and possibly asystole’ (TGA 2003, p.2). This resultant bradycardia may be treated with atropine; however, ‘fentanyl should be used with caution in patients with cardiac bradyarrhythmias’ (MIMS Annual 2003, p. 4-359). This is a result of possible cholinergic stimulation, which is why atropine may be used in its treatment. According to the TGA ‘the inclusion of atropine or other anti-cholinergic agents in the pre-anaesthetic regimen tends to reduce the occurrence of bradycardia and other unwanted cholinergic effects (TGA 2003, p.1). According to the TGA ‘severe and unpredictable potentiation by MAO inhibitorshas been reported with opioid analgesics and the use of fentanyl in patientswho have received MAO inhibitors within 14 days is not recommended’ (TGA 2003,p.2). One of the more common adverse effects when administered with MAO inhibitors is a hypertensive crisis leading to cerebral vascular accidents (CVAs) and death (Jarvis 2005, p. 2).

Fentanyl is an synthetic opiate derivative, and therefore may cause physiologicaland psychological dependence commonly associated with the use of opioids (Galbraith et al 2003, p. 350-2; Oh 1998, p.679-83). However, judicious use of fentanyl in the treatment of actual pain should not be withheld due to an inherent risk of physiological and possible psychological dependence. ‘Patients on chronic opioid therapy or with a history of opioid abuse may requirehigher doses to achieve an adequate therapeutic effect’ (TGA 2003, p.2). Because 75% of fentanyl administered IV is metabolized by the liver and primarily excreted by the kidneys, its dose must be decreased to compensate in patients with hepatic disease or renal failure who fail to metabolize and excrete fentanyl as rapidly as healthy patients (MIMS 1998, p. 4 –359). Myasthenia gravis (MG) is one of a group of neuromuscular diseases. Neuromuscular diseases effect how your nerve pathways communicate with your muscles. With MG, the muscle does not always get messages to move parts of your body. According to MIMS Annual fentanyl ‘may cause muscle rigidity in patients with myasthenia gravis’ (MIMS 1998, p. 4-359). Alcohol and other CNS depressants potentiate effects, making it possible for overdoses, leading to respiratory failure and death.

Benefits

Fentanyl rarely causes a significant histamine response, as seen in the administration of morphine (Marik 2002, p. 706), therefore does not have such adverse effects as hypotension and may be more suitable for patients who are haemodynamically unstable. According to Oh, fentanyl ‘has fewer adverse effects on the cardiovascular system, and can be used in patients with haemodynamic instability in whom morphine may cause severe hypotension’ (Oh 1998, p. 680). Fentanyl is unlikely to provoke nausea and vomiting. According to the MIMSAnnual ‘fentanyl appears to have less emetic activity than morphine’ (MIMS 1998, p.4-359). This is specifically beneficial in patients with trauma, head injuriesand an unstable airway. By avoiding drugs with the high likelihood of emetic results, one avoids vomitus blocking the airway, the possible raised intracranialpressure (ICP) caused by vomiting, and the unnecessary use of anti-emetic agents such as metoclopramide and their potential adverse effects (Marik 2002, p. 702-7).

According to Weiner ‘due to fentanyl’s lipid solubility, it has a rapid onset,large volume of distribution and a relatively short duration of action’ (Weiner2002 , p.482). This may be very beneficial because it allows for rapid onsetof analgesia and safer titration. Because it is an opioid it may be antagonized rapidly with the use of naloxone,which acts by ‘competitively blocking opioid receptor sites’ (Oh 1998, p. 681). Therefore, any overdoses may be rapidly corrected. Special Forces medics administration OTM fentanyl during operation Iraqi Freedom to 22 patients with trauma and in that time found that ‘oral transmucosal fentanyl is an effective analgesic with a rapid onset, and limited adverse effects’ (Kotwal, O’Connor, Johnson, Mosely, Meyer, Holcomb 2004, p.1).

What analgesia would work best for paramedics in providing prehospital care?

According to Lord: ‘it’s crucial for members of the health care team to acknowledge and support the expansion of the paramedic’s role as a frontline pain manager’(Lord 2004, p.52). In order to do this successfully more rapid and effective methods of analgesia must be available for pre-hospital care (PHC) workers. Drugs such as IV, IN and OTM fentanyl should be made available to PHC workers and their educational and training levels brought up to a level that they know exactly how to use it effectively without fear limiting their use of it. To this day, apprehensions about adverse effects arising from analgesic use and the influence that administration of analgesics may have on the diagnostic process have been indirectly implicated. According to the National Health and Medical Research Council, evidence that the ‘relief of pain may actually enhance the diagnostic process refutes the contention that opioids mask symptoms andcomplicate the diagnosis’ (NHMRC, 1999). Therefore the only way to decrease such fallacies is to promote education and training so that PHC workers feelcomfortable in administering the type of drugs and enough of them required toactually treat the pain.

References:

Appleyard S. 1998, Agonist Dependant Desensitization and Opioid ReceptorsPhosphorylation: a Potential Role in the development of opioid tolerance.Universityof Washington Doctoral Thesis, Seattle

Bryant B and Knights K 2003, Pharmacology for Health Professionals, Mosby Medical Textbooks, Sydney Australia

Conyers V & Hamilton L, 2001 Foundations of Paramedical Science 2 – Module 4, Learning Materials Centre, Charles Sturt University, Bathurst, Australia

 Evan D. Kharasch R. Whittington D. Hoffer C.2003, Minimal Influence of Hepatic & Intestinal CYP3A Activity on the Acute Disposition & Effect of Oral Transmucosal Fentanyl (OTFC), American Society of Anaesthesiologists,

Galbraith, A. Bullocks S. Manias E. 2001, Pharmacology 3rd Ed, McPherson’s Printing Group, Sydney, Australia

Hill, C. 1997, Guidelines of the Treatment of Cancer Pain, 2nd Ed, Texas CancerCouncil, Texas, USA

Hollinger M. 1997, Introduction to Pharmacology, Taylor and Francis Publishers, Washington, USA

Kotwal R. O’Connor K. Johnson T. Mosely D. Meyer D. Holcomb J. 2004, A Novel Pain Management Strategy for Combat Casualty Care. Annals of EmergencyMedicine. Vol 2.

Loeser J. 2001, Bonica’s Management of Pain, Lippincott Williams and Wilkins, Philadelphia, USA

Lord B. 2004, The Paramedic’s Role in Pain Management: A vital component inthe continuum of patient care, American Journal of Nursing, Volume 104 Number11, USA

MIMS Annual 2003, MIMS Australia, Sydney, Australia Munson P. 1998, Principles of Pharmacology – Basic Concepts and Applications,Chapman and Hall Publishing, New York, USA

National Health and Medical Research Council 1999, Acute Pain Management: Scientific Evidence. Canberra: Commonwealth of Australia

Oh, T.E 1998, Intensive Care Manual, 4th Ed Reed Educational and Professional Publishing Ltd, Jordan Hill, Oxford

 Rang H. Dale M and Ritter J 1999, Pharmacology, 4th Ed. Churchill Livingstone, Philadelphia, USA

Sanders M.J. 2001, Paramedic Textbook, Mosby’s Inc, St. Louis, Missouri USA

Sansom L. 2004, Australian Pharmaceutical Formulary and Handbook, 19th Ed. Pharmaceutical Society Australia, Sydney, Australia

Shoemaker, Ayres, Grenwick and Holbrook 2000, Internal Medicine, W.B Sounders Printing Company, Philadelphia, USA

Streisand J. Zhang J. Niu S.  McJames S. Natte R. Pace N. 1995, Buccal Absorptionof Fentanyl is pH-Dependent in Dogs, American Society of Anaesthesiologists,Inc. All rights reserved. Published by Lippincott Williams & Wilkins, USA

Tintinalli J. Kelen D. and Stapczynski J. 2000, Emergency Medicine 5th Ed, McGrawHill Publishing, Sydney Australia Weiner R. 2002, Pain Management – A Practical Guide for Clinicians, 6th Ed,CRC Press, London

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Subarachnoid Haemorrhage

August 23rd, 2010

 

 

Managing Subarachnoid Haemorrhage

 

The following paper will examine the pathophysiology, diagnosis of, and management of, a subarachnoid haemorrhage (SAH), from both an acute and holistic perspective. A SAH will be defined. Cerebral anatomy and physiology will then be reviewed in order to determine the pathophysiology of a SAH. Clinical manifestations of a developing SAH will then be discussed, followed by the development of its diagnosis examined. Current nursing and medical management of this condition will then be examined by assessing a wide range of journal articles and research papers. Lastly, complications with management will then be discussed.

A subarachnoid haemorrhage defined

So what is a subarachnoid haemorrhage? According to Mosby’s Medical, Nursing and Allied Health Dictionary a subarachnoid haemorrhage is ‘an intracranial haemorrhage into the cerebrospinal fluid (CSF) filled space between the arachnoid and pial membranes on the surface of the brain’ (Anderson, Anderson, and Glanze 1998 p. 1554). It is further identified by Oh as refereeing to a bleed ‘primarily within the subarachnoid space, rather than into the brain parenchyma’ (Oh 1997, p.389).

Cerebral anatomy and physiology

In order to further understand the concept of a SAH a health care professional must understand both the cerebral anatomy and physiology so that the underlining pathophysiology may be understood. The brain is divided into four main sections: the brain stem, cerebellum, diencephalon, and cerebrum (see appendix A). The brain is protected by cranial bones, which make up the cranial vault and cranial meninges, which surround and encapsulate the brain (Tortora and Grabowski 1996, p.392). The cranial meninges, which surround the brain and spinal cord, include the dura mater (outer layer), arachnoid mater (middle layer) and the pia mater (inner layer) (see appendix B). The brain and spinal cord are nourished and further protected against physical and chemical injury by cerebrospinal fluid (CSF)(Tortora and Grabowski 1996, p. 393). This fluid circulates within the subarachnoid space, which is located between the arachnoid and pia mater. Blood and nutrients are then supplied to the CSF via two main arteries: ‘the internal carotid arteries (anterior circulation) and the vertebral arteries (posterior circulation)’ (Brown and Edwards 2005, p. 1529). The ‘anterior and posterior cerebral circulation is then connected at the circle of Willis and the anterior and posterior communicating arteries’ (Brown and Edwards 2005, p. 1529)

 

With a SAH, blood escapes from a defective or injured vasculature into the subarachnoid space. When the cerebral vasculature tears, most commonly through a berry aneurysm (Bendok, Getch, Malisch, and Batjer, 1998, p. 521) or arteriovenous malformation (AVM), blood under pressure is pumped into the subarachnoid space. This blood irritates the meningeal and other neural tissues and so produces an inflammatory response (Brown and Edwards 2005, p. 1529) Furthermore, this blood covers the nerve roots, and blocks arachnoid granulations, which impairs CSF reabsorption and clogs the foramina within the ventricular system, thus impairing CSF circulation. This results in an increase in intracranial pressure (ICP), while cerebral blood flow (CBF) and cerebral perfusion pressure (CPP) decrease. According to McCance and Huether, ‘the expanding haematoma acts like a space-occupying lesion, compressing and displacing brain tissue’ (2002, p. 512). As granulation tissue forms, scarring of the meninges occurs, resulting in a further decrease in CSF reabsorption and therefore secondary hydrocephalus may occur (Al-Shahi, White, Philip. Davenport, and Lindsay, 2006, p14). If this continues, the reduction in CPP will lead to insufficient cerebral perfusion, hypoxia and subsequent cerebral infarction, due to the anaerobic production of adenosine triphosphate (ATP).

Furthermore, if left untreated, ‘the pressure within the subarachnoid space may become so great that it will actually force the brain parenchyma through the foramen magnum, causing a brain stem herniation’ (McCance and Huether 2002, p. 513).

Clinical manifestations and Diagnosis

According to Van Gijn and Rinkel a ‘definitive diagnosis of a SAH is done through clinical presentation, lumbar puncture, and a non-contrast computer tomography (CT) scan (2001, p. 249). Although, there may be other diagnostic measures.

Through a thorough examination of clinical manifestations, medical staff may identify specific clinical signs and symptoms of a SAH, because these signs and symptoms often result from the pathophysiology of a SAH. Although these may not determine a definitive diagnosis of SAH, they may be used as warning bells to the clinician to perform a lumbar puncture and non-contrast CT to confirm a diagnosis of a SAH. According to Linn, Wijdicks, Van der Graaf, Weerdesteynvan, Bartelds, and Van Gijn,  ‘a sudden severe headache, which maximizes in intensity immediately or within minutes, and lasting an hour or more (usually days) is a classic first sign of a SAH’ (1994, p. 590).

According to McCance and Huether, common clinical manifestation of a SAH include ‘episodic headache, transient changes in mental status or level of consciousness, nausea and vomiting, focal neurological defects, including both visual and speech defects, facial palsy and a stiff neck’ (2002, p. 512). Many of these signs and symptoms may be directly related to the rise in ICP and meningeal irritation. For example, an episodic headache may result from an increased ICP irritating the meninges, altered conscious state may directly be related to altered ICP, while visual, speech and facial nerve palsy, are the direct result of a raised ICP placing pressure on the optic nerve (2nd cranial nerve), oculomotor nerve (3rd cranial nerve) and the facial nerve (7th cranial nerve) (Brown and Edwards 2005, p. 1482-3).

By performing a lumbar puncture, medical staff can measure CSF pressure, and perform a chemical analysis, which may suggest the presence of a SAH (Whitfield and Kirkpatrick 2002, p. 17). Unless there is any suspicion of an alternative diagnosis such as meningitis, it is agreed that a ‘delayed lumbar puncture for at least six hours, preferably 12 hours, after headache onset, will give the most accurate diagnostic reading for SAH’ (Van Gijn and Rinkel 2001, p. 249). This allows sufficient time for haemoglobin to degrade into oxyhaemoglobin and bilirubin. According to Williams, ‘Bilirubin signifies a subarachnoid haemorrhage because it is only synthesised in vivo, unlike oxyhaemoglobin, which may result from a traumatic tap or prolonged storage or agitation of bloodstained cerebrospinal fluid in vitro’ (2004, p. 174).

According to the UK National External Quality Assessment Scheme for Immunochemistry Working Group, ‘the opening pressure of cerebrospinal fluid must be recorded as an early indicator for likely changes in ICP’ (2003, p.481).

Definitive diagnosis of a SAH can only be determined by performing a non-contrast CT scan. According to McCance and Huether an ‘arteriographic examination is the definitive diagnostic measure used for identifying an aneurysm or AVM’ (2002, p. 513) (See Appendix C). Multi-slice computed tomography angiography (CTA) is able to determine accurate diagnosis’ of a spontaneous SAH because of its ‘speed, tolerability, convenience, and the ability to provide three dimensional reconstructions’ (White, Wardlaw, and Easton 2000, p. 361). The ‘accuracy of this procedure for identifying aneurysms greater than 3 mm diameter is about 96%,’ (White et al 2000, p.368) but poorer for smaller aneurysms (Van Gelder 2003, p. 598). Further studies may include four vessel catheter angiography if aneurysmal SAH is strongly suspected but the CTA is normal (White et al 2000, p. 368). Repeated cerebral catheter angiography, spinal catheter angiography, or magnetic resonance imaging may be necessary to identify alternative causes in some cases. For people with a purely perimesencephalic distribution, a normal, good quality computed tomography angiogram allows a diagnosis of idiopathic perimesencephalic subarachnoid haemorrhage without the need for further investigation (Van Gijn and Rinkel 2001, p. 249).

Current management

Current medical and nursing management is influenced by the SAH grading of the client, and its relationship with the client’s pre-existing medical history. Management often utilises various SAH grading classification systems and actual grade. According to Bendok, Batjer and Hunt, ‘there is still much debate amongst neurologist as to the best SAH grading systems, and therefore universal diagnosis and treatment varies considerably around the world’ (2006, p. 2).

The most popular systems include the: Hunt and Hess SAH classification scale (see appendix D) the World Federation of Neurological Surgeons (WFNS) grading scale (see appendix E), the Fischer Scale (see appendix F) and the Glasgow Coma Scale (see appendix G). In Australia the Hunt and Hess SAH scale is currently the most common  classification scale used, primarily because ‘it is what neurologists know and are used to, not necessarily because it is the best practice’ (Sepelt 2005, p. 2).  

Medical and Nursing management of the patient with a SAH can be divided into pre-operative, surgical and post-operative care (Oh 1997, p. 391).

Pre-operative nursing care involves bed rest with oxygen, sedation and analgesia as required (Oh 1997, p.391). Basic care of the unconscious patient if his/her condition has reached this stage, including appropriate attention to the client’s: Airway, Breathing, Circulation, Disability and Exposure’ (Sepelt 2005, p. 1). Further pre-operative nursing care involves maintaining regular and thorough neurological, cardiovascular and respiratory assessments, and developing interventions to maintain homeostasis.

A neurological assessment of: GCS, conscious state, pupillary responses and extremity movement and strength should be regularly completed because, ‘a change in any of these may indicate an increased ICP and the need for an immediate intervention of both nursing and medical for the benefit of the client’ (Brown and Edwards 2005, p. 1542).

A cardiovascular assessment of: heart rate, heart rhythym, BP, MAP, CVP, fluid intake and output is paramount to good outcome and should be ‘aimed at maintaining cardiovascular homeostasis’ (Brown and Edwards 2005, p. 1542). According to Sepelt, ‘all SAH patients should have an arterial and central venous line inserted as soon as practically possible’ (2005, p1) in order to maintain accurate BP and CPP monitoring. Inatropes such as nor-adrenaline or vasopressin should be used to maintain a MAP of 80 mmHg (Sepelt 2005, p. 1). 

A respiratory assessment of: respiratory rate, tidal volume, minute volume, oxygen saturation (SaO2) and end tidal carbon-monoxide (ETCO2) should be continuously conducted. According to the Brain Trauma Foundation, ‘patients with a suspected SAH should be kept normocarbic at a Partial Pressure of Carbon Monoxide (PaCO2) of 36-40 mmHg or an End Tidal Carbon Monoxide (ETCO2) of 31-35 mmHg’ (2000, p. 451).

Medical administration of antifibrinolytics, which inhibit clot lysis, ‘have been shown to reduce the rate of recurrent haemorrhage, but because of their disadvantages in overall health care of the client, their usefulness has been questioned’ (Roos, Y. 2002, p. 2).

Surgical clipping of the aneurysm is currently the preferred definitive treatment, with trapping, proximal ligation, bypass graft and reinforcement of the sac (Oh 1997, p. 391). However, according to Van der Schaaf, Algra, Wermer, Molyneux, Clarke and Van Gijn, ‘Although neurosurgical ‘clipping’ has become the standard treatment of aneurysms in the 20th century, endovascular occlusion of ruptured aneurysms using detachable coils is now superseding clipping in survivability’ (2005, p. 85) For aneurysms suitable for either treatment, coiling confers an absolute risk reduction over clipping of about 7% (25% relative risk reduction) for dependency or death at one year, with benefit sustained to seven years (Molyneux, Kerr, Yu, Clarke, Sneade, and Yarnold, 2005, p. 809) the number needed to coil to prevent one poor outcome is 14 (95% confidence interval 10 to 25) (Van der Schaaf, et al 2005, p. 85).

Surgical aneurysm clipping should be attempted as soon as practicable (within 3–4 days) after onset of SAH to prevent re-bleeding. It is believed that ‘morbidity seems to occur more often after clipping in the second week after haemorrhage when the risk of delayed cerebral ischaemia is greatest (Whitfield and Kirkpatrick 2002, p.3). Immediate evacuation of some intracerebral haematomas caused by aneurysm rupture, with concomitant aneurysm clipping, is supported by one small randomised trial (Dorsch, N. 2002, p. 128).

Postoperative medical and nursing management of SAH includes analgesic and general supportive care. Nursing care should be focused on continuous assessment of respiratory, neurological and cardiovascular systems as well as ICP and CPP monitoring, and implementing interventions that act to maintain these at homeostatic balances (Brown and Edwards 2005, p. 1542).

All patients with a ‘SAH should be positioned and nursed at 30 degrees head up, unless haemo-dynamically unstable to maximise venous drainage and minimise ventilator associated pneumonia’ (Sepelt 2005, p. 1)

Maintaining electrolyte homeostasis is important. The important electrolytes to monitor in SAH primarily include: sodium, potassium, calcium and magnesium (Huether and McCance 2002, p.513), with magnesium being important in neuroprotection. The optimal plasma magnesium concentration for neuroprotection remains uncertain at this moment in time. A study in 2005 suggested that a higher than normal level of magnesium is required for neuroprotection. According to Westermaier, Zausinger, Baethmann , and Schmid-Elsaesser  ‘a continuous infusion of magnesium sulphate (MgSO4) to maintain a plasma magnesium concentration between 2 and 3 mmol/L appeared to produce maximal protection against transient cerebral ischemia  (2005, p. 55).

Early mobilisation post SAH may increase positive outcome. In a randomised study between early mobilisation out of bed (3 days) compared to late mobilation (>6 days) post cerebral vascular accident (CVA), Diserens, Michel, and Bogousslavsky found that ‘early mobilisation as part of routine stroke unit care does seem to contribute to good long-term outcome’ (2006, p.190).

 

According to Rebuck, ‘ increased ICP is related to higher mortality rates and poorer functional outcomes’ (2000, p.38). Therefore, nursing management of the patient with a SAH should always include ICP monitoring and, if available, ‘ventriculostomy ICP monitoring should be used as this allows the therapeutic option of CSF drainage if required’ (Brain Trauma Foundation 2003, p. 4).

Once an ICP monitor has been implanted fluid and inatropes should be used to maintain a CPP (which may be calculated by MAP minus ICP) of greater than 60 mmHg. Although severe hypertension is not beneficial, hypotension dramatically affects the likelihood of a good health outcome. According to the Brain Trauma Foundation, ‘a single episode of hypotension dramatically worsens prognosis’ (2003, p. 2).

 

Complications with management

There are multiple complications associated with SAH both preoperatively and postoperatively. Complications can be both neurological and non-neurological in aetiology.

According to Harrod, et al, ‘cerebral vasospasm is a devastating medical complication of aneurysmal SAH that is associated with high morbidity and mortality rates, even after the aneurysm has been treated’ (2005, p. 1) A Transcranial Doppler (TCD) sonography is a well-established technique for investigating changes in cerebral hemodynamics (Compton, Redmond and Simon 1987, p.1499). The TCD technique can detect increased velocities in the proximal segments of the internal carotid, middle cerebral, anterior cerebral, posterior cerebral, vertebral, and basilar arteries, which are presumably caused by vessel lumen reduction. A rise in TCD velocity in the basal cerebral vessels occurs in nearly all patients after SAH, and a rapid rise to high levels is frequently associated with clinical deterioration caused by vasospasm and subsequent delayed ischemia (Harrod et al 2005, p. 3).

Current management of vasospasm includes the use of cerebroselective calcium channel blockers or hypervolaemic, hypertensive, haemodilution (HHH) therapy (Brain Trauma Foundation 2003, p. 4). Management with the cerebroselective calcium channel blocker ‘nimodipine’ acts to produce mild volume expansion while minimizing the effects on systemic arterial pressure; this is designed to prevent signs and symptoms of vasospasm. If, however, these signs and symptoms develop despite this regimen, patients are then often treated with aggressive HHH therapy. According to Rebuck ‘HHH therapy is used to elevate the cerebral perfusion pressure and thus provide blood to regions of the brain with marginal perfusion because of arterial spasm’ (2000, p. 39). By clipping the aneurysm early, one can be more aggressive with this therapy without concern of aneurysm re-rupture and subsequent rebleeding. Some neurosurgeons advocate prophylactic HHH therapy in patients at high risk for spasm (for example, thick subarachnoid blood clots). Thus, prophylactically one raises the blood pressure (in the range of 160-200mm Hg systolic with inatropes or vasopressors and volume expansion while monitoring the central venous pressure (CVP) or pulmonary capillary wedge pressure (PCWP) (Fujii, Takeuchi, Sasaki, Minakawa, Koike, Tanaka 1996, p. 84).

Acute hydrocephalus with large amounts of intraventricular blood is often associated with a poor clinical condition from the outset. If such patients are left untreated, >90% have a poor outcome. An indirect comparison of observational studies suggests that insertion of an external ventricular catheter is not very helpful in these patients, but that a strategy where such drainage is combined with fibrinolysis through the drain results in a good outcome in half the patients (Nieuwkamp, Gans, Rinkel, Algra 2000, p. 247).

Seizures may result in up to 6% of patients post development of a SAH (Al-Shahi, White, Philip, Davenport, and Lindsay, 2006, p. 14). Prolonged seizures may result in hypoxemia and cerebral infarction due to cerebral hypoxia. Therefore, patients who have started to have seizures should routinely be treated with phenytoin at a dose of 15mg/kg IV (Sepelt 2005, p. 2).

Non neurological include: ECG changes and arrhythmias, as a secondary result of hyponatremia and hypomagnemia commonly associated with SAH (Oh 1997, p. 389).

Deep Vein Thrombosis’ (DVTs) as a result of prolonged bed rest may occurs, so nursing interventions should include DVT prophylaxis, such as: TED stockings, sequential calf compressors, and early mobilisation (Sepelt 2005, p. 2). Furthermore, after a discussion with the neurosurgeon, heparin 5000 units subcutaneously (S/C) twice daily (bd) may be considered if no intracerebral bleeding has occurred for 48 hours after surgical haemostasis has been achieved.

 

Conclusion

The following paper has examined the pathophysiology, diagnosis of, and management of, a subarachnoid haemorrhage (SAH), from both an acute and holistic perspective. A SAH has been defined. Cerebral anatomy and physiology has then been reviewed in order to determine the pathophysiology of a SAH. Clinical manifestations of a developing SAH have then been discussed, followed by the development of its diagnosis examined. Current nursing and medical management of this condition have been examined by assessing a wide range of journal articles and research papers. Complications with management has then be discussed.

Reference List

Al-Shahi, R. White, Philip. Davenport, R. Lindsay, K. 2006, Subarachnoid Haemorrhage: A Clinical Review, Institute of Neurological Sciences, Southern General Hospital, Glasgow

Anderson, K. Anderson, L. And Glanze, W. 1998, Mosby’s Medical, Nursing, and Allied Health Dictionary, 4th Ed. Mosby Inc. Sydney, Australia

Bendok, B. Getch, C. Malisch, T.  Batjer, H. 1998, Treatment of Aneurysmal Subarachnoid Hemorrhage, Seminar Neurology, Vol. 18

Brain Trauma Foundation 2003, Update Notice, Guidelines for the Management of Severe Traumatic Brain Injury: Cerebral Perfusion Pressure, Vol 1.

Diserens, K. Michel, and P. Bogousslavsky, J. 2006, Early Mobilisation after Stroke, Cerebrolvascular Diseases, Vol. 22 (3) July

Dorsch, N. 2002, Therapeutic Approaches to Vasospasm in Subarachnoid Hemorrhage, Current Opinion Critical Care, Vol. 8

Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R Jan 1996, Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. Journal of Neurosurgery, Niigata, Japan

Harrod, C. Bendok, B. Batjer, H. Hunt, H. 2005, Prediction of Cerebral Vasospasm in Patients Presenting with Aneurysmal Subarachnoid Hemorrhage: A Review, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Huang, J. Van-Gelder, J. 2002, The Probability of Sudden Death from Rupture of Intracranial Aneurysms: a Meta-analysis. Neurosurgery, Vol. 51 (1101)

Linn, F. Wijdicks, E. Van der Graaf, Y. Weerdesteynvan, F. Bartelds, A. and Van Gijn, J. 1994, Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage, Lancet Journal, Vol. 344

Huether, S. and McCance, K. 2002, Pathophysiology the Biologic Basis for Disease in Adults & Children 4th Ed, Mosby Inc, St. Louis, Missouri, USA

Molyneux, A. Kerr, R. Yu, L. Clarke, M. Sneade, M. Yarnold, J. 2005, International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping Versus Endovascular Coiling in 2143 Patients with Ruptured Intracranial Aneurysms: a Randomised Comparison of Effects on Survival, Dependency, Seizures, Rebleeding, Subgroups, and Aneurysm Occlusion. Lancet, Vol. 366

Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A. Feb 2000, Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. Journal of Neurosurgery, Utrecht, Netherlands

Nieuwkamp, D. Rinkel, G. Silva, R. Greebe, P. Schokking, D. Ferro, J. 2006, Subarachnoid Haemorrhage in patients >=75 years: clinical course, treatment and outcome, Journal of Neurology, Neurosurgery & Psychiatry. 77(8):933-937, August 2006.

Oh, T. 1997, Intensive Care Manual, 4th Ed, Reed Educational and Professional Publishing Ltd, Jordan Hill, Oxford

Rebuck, J. 2000, infection relatd to intracranial pressure monitors in adults: analysis of risk factors and antibiotic prophylaxis. Journal of Neurology, Neuroscience andPsychiatry, Vol 69

Roos, Y. 2002. Antifibrinolytic Therapy for Aneurysmal Subarachnoid Haemorrhage: A Cochrane Review, Cochrane Library Issue 1

Sepelt, I. 2005, Management of Severe Head Injuries in Adults, Department of Intensive Care Medicine, Nepean Hospital, Australia

Tommasino C, Moore S, and Todd M 1988, Cerebral effects of isovlaemic haemodilution with crystalloid or colloid solutions, Critical Care Medicine Volume 16 (OH p.393)

Totora, G. and Grabowski, R. 1996, Principles of Anatomy and Physiology, 8th Ed Harper Collins Biological Publishers Inc, New York, USA

Westermaier, T. Zausinger, S. Baethmann, A. Schmid-Elsaesser, R. 2005, Dose finding study of intravenous magnesium sulphate in transient focal cerebral ischemia in rats. Acta Neurochirurgica, Vol. 147, 525–532.

Whitfield, P. and Kirkpatrick, P. 2002, Timing of surgery for aneurysmal subarachnoid haemorrhage, Cochrane Library, Issue 1

Van Gijn, J. Rinkel, G. 2001, Subarachnoid Haemorrhage: Diagnosis, Causes and Management. Brain, Vol.124:249–78

Williams, A. 2004, Xanthochromia in the Cerebrospinal Fluid, Practical Neurology Vol.

UK National External Quality Assessment Scheme for Immunochemistry Working Group, 2003, National Guidelines for Analysis of Cerebrospinal Fluid for Bilirubin in Suspected Subarachnoid Haemorrhage, Annual Clinical Biochemistry, Vol. 40

Van Gelder, J. 2003, Computed Tomographic Angiography for Detecting Cerebral Aneurysms: Implications of Aneurysm Size Distribution for the Sensitivity, Specificity, and Likelihood Ratios, Neurosurgery, Vol. 53

White, P. Wardlaw, J. Easton, V. Can Non-invasive Imaging Accurately Depict Intracranial Aneurysms? A systematic Review, Radiology, Vol. 217

The Brain Trauma Foundation 2000, Management and Prognosis of Severe Traumatic Brain Injury, Journal of Neurotrauma, Vol. 17

Van der Schaaf, I. Algra, A. Wermer, M. Molyneux, A. Clarke, M. Van Gijn, J. 2005,  Endovascular Coiling Versus Neurosurgical Clipping for Patients with Aneurysmal Subarachnoid Haemorrhage. Cochrane Database System Review, Vol. 4

Appendices

Appendix A – Totora, G. and Grabowski, R. 1996, Principles of Anatomy and Physiology, 8th Ed Harper Collins Biological Publishers Inc, New York, USA, p. 392

Appendix B – Totora, G. and Grabowski, R. 1996, Principles of Anatomy and Physiology, 8th Ed Harper Collins Biological Publishers Inc, New York, USA, p. 393

Appendix C – Huether, S. and McCance, K. 2002, Pathophysiology the Biologic Basis for Disease in Adults & Children 4th Ed, Mosby Inc, St. Louis, Missouri, USA, p.511

Appendix D – Harrod, C. 2005, Hunt and Hess Grading Scale for Subarachnoid Haemorrhage, Neurosurgery, Volume 56(4).April .p.633

Appendix E – Harrod, C. 2005, World Federation of Neurological Surgeons grading, Neurosurgery, Volume 56(4).April .p.633

Appendix F – Harrod, C. 2005, Fischer Scale, Neurosurgery, Volume 56(4).April .p.634

Appendix G – Harrod, C. 2005, Glasgow Coma Scale, Neurosurgery, Volume 56(4).April .p.634

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Chainsaw Sharpening

August 21st, 2010

Warning… this story has some drastic repercussions and lessons to be learned for those of you who wish to do some “once off” amateur branch trimmings with a chainsaw…

Several years ago now… I attended this patient who had spent the morning sharpening his chainsaw so that he could somehow “hack” at a branch that was obviously, just slightly, out of reach up the top of a tree. He’d tried a few months earlier, but was unable to reach it, and eventually decided to sharpen the chainsaw so that it was almost brand new and that way, he only “just” need to touch the branch to cut it off.

Needless to say… it didn’t happen the way that he had planned and it ended in him slipping, and amazingly enough, having the newly sharpened chainsaw falling after him, and landing half imbedded in his shoulder. When we arrived…

The man was still conscious (barely) and had the chainsaw imbedded deep inside his shoulder… I looked at my partner as if to say “surely he isn’t still alive!” He was, and he was working very hard to breath. We knew that if there was ever a time to “load and go” in the world of Ambulance, this was it! My partner got the stretcher, and we lifted him straight on the stretcher with the chainsaw insitu. There wasn’t a lot of bleeding, considering the massive amount of trauma and damage to his shoulder, chest and torso. I could hear any air movement in his left lung (the side the chainsaw was now lodged within), but he was still moving air in his right, so I was happy. A major trauma hospital was very close, and there really wasn’t time to do much more than insert a large cannula enroute and drive as fast (but safe) as we possible could. This person needed urgent surgery. By the time we arrived at the hospital, he was unconscious, but he still had a pulse, and his right lung was still moving air.  The hospital had been notified, and an emergency surgical team gathered together. We were advised by the ED (emergency department) upon arrival to bypass the resuscitation beds and keep going straight to surgery. We walked into surgery with our patient on the stretcher and rapidly assisted to get the patient across onto the surgery bed. 

By this stage, the patient was looking morabund (near death) and the surgical doctors worked quickly. The patient was intubated, chest drains were inserted, fresh frozen plasma and packed cells (blood) were given continuously. Within twenty 20 minutes of arrival at the hospital, and only 35 minutes since we had first received the call that a person had fallen with his chainsaw and sustained bad injuries, the patient went into cardiac arrest – that was all that his body was capable of compensating for. An arrest drill was run for approximately ten minutes before the patient was finally pronounced deceased.

It was one of the most dramatic trauma scenes I’ve ever attended as a paramedic (in which the patient was still alive when we got to hospital)…. the hospital theatre was quiet, and solemn as is often usual after such a serious accident goes so well, only to have the patient eventually die anyway… and then, all of a sudden… on of the surgions started to laugh…. and then another one… all of a sudden, I felt as though I was the only person in the room who was missing something that was blaringly obvious to everyone else…

“What?” I ask…

And then one of the surgeons started to point out all the little nicks, cuts, scrapes… on the man… evidence that this poor man had been trying for some time to cut this branch with his chainsaw, even though it was just too far out of reach from him. It even became clear, that he had cut himself with the chainsaw as recently as that morning (on two occasions) only to doggedly continue in a vain attempt to “jump” high enough to just nick the branch…

The moral of this sad story applies to many things, but especially when working with sharp chainswas – NEVER KEEP GOING WHEN YOU KEEP INJURING YOURSELF! Take a step back, have a look at what you’re doing, re-evaluate, and make sure that you’re going to survive this! Few people get a second chance with chainsaws – so make sure you take it and learn from it if you’re given one!

Australian Paramedic

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Chainsaw Accident

August 21st, 2010

 

I treated a patient who had fallen while he was using a chainsaw to cut a branch off a tall tree. When we arrive we found him with a half severed right leg, and a major arterial bleed from his femoral artery, which he was vainly struggling desperately to contol with both his hands. His wife was there, but she was trying her best to keep her young children away from the excitement. As we started to treat the badly injured man… we noticed that he started laughing… almost hysterically… at first, we continued working without asking him anything about it – often people react in very strange ways to terrible accidents such as these, and sometimes it’s just a response to the low blood preasure and decreased cerebral perfusion (blood to the brain). We applied an arterial tornequet and raised his leg… it didn’t completely stop the bleeding, but it slowed it down. Severed arteries are virtually impossible to control. We applied a second tourniquet to stem the bleeding. This seemed to do the job… the patient was still laughing, but he was conscious and the bleeding had stopped… so we figured we weren’t doing too bad a job. We still knew we didn’t have time to muck around on seen and basically this was one of those ‘load and go’ situations. The man was still laughing, and throughout all the excitement, I hadn’t really given any thought to what in the world he could be laughing at. We rapidly got him loaded in the back of the ambulance and inserted 2 large bore cannulas (one 16gauge and one 14 gauge) enroute to hospital. It was only at this point that I finally thought I had enough time to ask the obvious question…

“You just nearly killed yourself… what could possibly be so funny?”

The man looks at me… starts laughing hysterically and says… “Its just that… I just can’t  stop….”

I let him keep laughing a little while longer… eventually he settled down…. and told me…

“I had been meaning to trim a few branches off that tree for months now… I had my children there and my wife… and I had told them all to stand back while I used the chainsaw… now, when I fell… and I immediately saw how much of my leg I had taken off… and I realised I was probably going to die… I should have been thinking about my wife and kids, about my own life, about what its going to be like if I don’t make it through this… but you know the only thing that came through my head was?”

I look at them as though he’s a little mad… and shake my head…

“All I could think of was that stupid movie by Monty Python and the “Black Knight” and all I could see in my own mind was me standing there, like the “Black Knight” and yelling “Its only a flesh wound!”

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How To Assess Perfusion

August 20th, 2010

Many younger paramedics (and some of the older paramedics too) find that with the invention of more and more brilliant medical diagnostic machines, such as Saturation Probes, ECG/EKG monitors, Glucometers, End Tidal CO2 Monitors, 12 Lead ECGs (that self analize ST segments and possible dysrythmias) that they forget the most important part of any Ambulance job – look at your patient!

How are they looking? This will generally tell you much more than any machine.

When I first started as a student paramedic my training officer told me to remember one thing and one thing only

“Perfusion determines treatment…”

But how do you determine perfusion?

You can assess perfusion by assessing the patient’s Level of Consciousness, Skin Colour, Pulse and very last their Blood Pressure!”

This emphasizes the fact that in Ambulance Practice the machines are the last diagnostic tools. Take a Blood Preasure after you have looked at your patient properly… talked to them, assessed their skin… and manually felt their pulse.

Remember… by manually feeling a pulse you can assess the strength, rate, rhythym, regularity, and overall wellness of a person.

Australian Paramedic…

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Primary and Secondary Survey

August 20th, 2010

Primary and Secondary Survey

 

PRIMARY SURVEY

A: Airway – Check airway patency

B: Breathing – Check rise and fall of chest / symmetrical breathing etc

C: Circulation- How well perfused? Check pulse, cyanosis

D: Disability– Neuro – Are they conscious, can they talk to you?

Primary survey is a quick “eyeball” assessment of patient to ascertain priorities.

 

SECONDARY SURVEY

E: Environment / Expose– Unwrap and expose looking for obvious external trauma

F: Fahrenheit: – Assess body temperature- ? hypothermia

G: Get Vitals– Quick set of obs – BP,HR,RR, ?SpO2

H: History– Present History – Events related to current status

                    Related History – Things leading up to this event

                    Past History –Briefly Med / surg / Medication / Allergies / Last meal

                    Head to Toe or systems assessment – Depending on patient status may undertake a more thorough assessment of each system eg

Cardiac – Postural BP, Chest pain assessment, listen to heart sounds, JVP

Resp- Listen breath sounds, percuss lungs, peak flow

Other systems assessed are Neuro, GIT, Renal and integumentary.

I: Interventions– Reposition, Drug therapy eg oxygen,. Nitrates, nebs

I: Investigations- Depends on all of above findings but may range from ECG, BSL.

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Paramedic Murphy’s Law

August 17th, 2010

This page is dedicated to our dear paramedic friend, mr Paramedic Murphy and his very annoying laws, which visit and trouble all paramedics, EMTs, and EMS workers at some time or another. These are a list of paraemdic Murphy’s laws that I have come across and a testament to Murphy’s Law that basically says, ‘anything that can go wrong… will’ – Paramedic Murphy…

Paramedic Murphy’s Law 1.

Which ever piece of medical equipment which you’ve somehow forgot to bring into the scene with you is always going to be the one and only bit of equipment that you are going to find you really need on that particular ambulance case.

Paramedic Murphy’s Law 2.

You can be certain that whatever back up you have just cancelled as you arrive at the scene, based on your intial assessment, or ‘gut feeling,’ will be exactly the sort of assistance that you will be contacting despatch to request in the next five minutes.

Paramedic Murphy’s Law 3.

The most likely time to get called to a cardiac arrest is when you’re on your way back to station to get a new ‘full’ oxygen cylinder. The second most likely time is about 5 minutes before knock of time, when you have an important date to get to.

Paramedic Murphy’s Law 4.

If you plan on doing something after your shift – don’t. You can be certain that one hundred percent of the time that you plan to do something after work a major disaster will occur just before the end of shift and you will find yourself calling your date to explain that you wont be comming (unless he or she is willing to eat after midnight.

Paramedic Murphy’s Law 5

Haven’t refreshed a particular skill for a while? You can be sure that will be the skill required to save the day during this shift.

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Emergency Medical Services

August 13th, 2010

Emergency Medical Services means…

Sorry… page under construction… check back here soon!

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Paramedic Training

August 13th, 2010

What is involved in paramedic training?

Paramedic training is different in each state/country. In most states in Australia paramedic training is done through two main streams. I’m not certain overseas, in the US/Canada, South America, Europe, Africa, Asian and other areas… but in Australia, each state has its own Ambulance Service, and if you want to join, each state has different paramedic training  requirements.

There are two main streams in which you can become a paramedic. On the job traineeships and tertiery education with a graduate program afterwards.

To become a Student Ambulance Paramedic… or trainee Ambulance Paramedic…

You need to be keen, have a full (non-restricted) drivers licence (in some states you must have a Medium Rigid /truck licence) you can apply for a position as a Trainee Ambulance Paramedic or Student Ambulance Paramedic and actually be trained on the job over about a 3 year period with regular distance education and internal education packages. The competition is tough and some years the application process can take up to 12 months, while natural attrition and selection processes attempts to extract the best people for the job. Some years, positions may have as many as 8,000+ applicants for a position of 40-50 Student Ambulance Paramedics.

Depending on which state you apply for, testing will include: basic skills testing (writing, maths, vocabulary), adaptive learning skills (IQ tests), basic mechanical reasoning skills (can you take apart the oxygen -viva and put it back together again after being shown once), map reading, dictating tests (where someone tells you several things, and you must write everything down and repeat it). If you pass all this, you will most likely have a personality test of some description, where basically they will “get an idea” (sometime quite incorrectly) whether or not you have to right personality for the job. Then you will have a fitness/medical test – you can wear glasses, but need to be able to see well enough to drive, depeding on which state, you must not be colour blind. Then, if you survive all that, you will have an interview… and hopefully get a position… well done!

The second method, is to do a bachelor degree in Paramedics (such as Bachelor of Pre-hospital Care, Bachelor of Health Science/ Paramedic, Bachelor of Paramedical Science, or Bachelor of Clinical Practice /Paramedic). Universities in Australia that currently teach tertiery studies in paramedics include: Charles Sturt University (NSW), Hobart University (TAS), Flinders University (SA), Monash University and Victorian University (VIC), Brisbane University (QLD) and I believe there are more currently opening in their teachings of Pre-hospital Ambulance Care or Paramedic care. This acknowledges the current trend and changes in improving the skill and knowledge base of clinical practitioners (paramedics) from all around Australia.

Once you have gained your three year bachelor degree in some form of Paramedic studies (or in some states first 2/3 of a 3 year degree) you may then apply for a graduate position in an Ambulance Service. Most Ambulance Services in Australia now have graduate positions, which range from 10 months through to 2 years of an on-road “internship” which culminates in eventual certificate to practice as a Qualified Ambulance Paramedic. This is recognised on an indvidual state basis, and although generally interchangeable amongst different states, each service normally requires a RPL program (Recognition of Prior Learning) to be completed before achieving a Certificate to Practice.

Australian Paramedic…

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EMT Jobs

August 13th, 2010

So, you’re a qualified EMT and you’ve decided you’re bored of driving an Ambulance for a living? What other paramedic jobs are there out there? Depending on your back ground, clinical experience, interests, physical abilities, and education, these are some interesting paramedic/ EMT type jobs for you…

1. Extended Care Paramedic for those of you who work in an area where they have ECP paramedics. As an ECP you can utilise more holistic primary health care skills, such as managing chest infections, UTIs, basic sprains and strains, and other non-emergency health problems.

2. Mines rescues or mine medic. If you’re a qualified paramedic and you’ve had 2-3 plus years experience in pre-hospital care you can pretty much get any mines rescue or mine medic job.

3. Occupational Health and Safety Officer. Working as a paramedic or EMT is a fantastic background for someone wishing to get involved in OH&S.  Many mines or oil rigs double up their employees abilities by employeeing paramedics as their OH&S officers.

4. Paramedic on oil rigs. Most oil rigs like you to have a nursing background or Intensive Care background, but it isn’t always mandatory.

5. Ski paramedic. What better way to work than to spend your day skiing and looking after trauma patients? You’ve got to be a very good skier or snow boarder.

6. Advisory counsel for Medical TV shows. Most medical TV shows pay good money for people with real medical backgrounds to give advice on how things should occur “medically” on their shows.

7. Teach first aid. As a paramedic you are perfectly trained to share your experiences and teach first aid to others.

8. Teach wilderness first aid.

9. Be a paramedic on travel/adventure groups. Many adventure tour groups are required by law to bring wilderness first aiders/paramedics on their trips.

10. Paramedic research fellow. Have you thought that some things could be done better in Ambulance Practice? Considered spending some time proving it? Many Ambulance Services have research institutes attached. Alternatively, you may consider getting a scholarship to do a PhD.

Australian Paramedic

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Paramedic Jobs

August 13th, 2010

So, you’re a qualified paramedic and you’ve decided you’re bored of driving an Ambulance for a living? What other paramedic jobs are there out there? Depending on your back ground, clinical experience, qualifications, interests, physical abilities, and education, these are some interesting paramedic/ EMT jobs likely to be available for you:

1. Extended Care Paramedic for those of you who work in an area where they have ECP paramedics. As an ECP you can utilise more holistic primary health care skills, such as managing chest infections, UTIs, basic sprains and strains, and other non-emergency health problems.

2. Mines rescues or mine medic. If you’re a qualified paramedic and you’ve had 2-3 plus years experience in pre-hospital care you can pretty much get any mines rescue or mine medic job.

3. Occupational Health and Safety Officer. Working as a paramedic or EMT is a fantastic background for someone wishing to get involved in OH&S.  Many mines or oil rigs double up their employees abilities by employeeing paramedics as their OH&S officers.

4. Paramedic on an oil rig. All of shore oil rigs must have an Oil Rig Medic on board. Because of the remote location and distance to hospitals, most oil rig medics have qualifications in Nursing and able to communicate with medical practitioners in hospitals to provide various medications and treatments, such as suturing deep lacerations, intravenous antibiotic administrations, and overall all health checks. Preferably however, oil rigs like to employ RNs who have a background in paramedicine because paramedics generally have more experience in field diagnostic techniques and working on standing orders or clinical practice guidelines as opposed to doctors orders. If you are an RN and have qualified as an Intensive Care Paramedic, which means that you are capable of intubating, there will always be an oil rig medic job available to you. For more information on Oil Rig Jobs, there is a lot of useful information at Professional Oil Rig Jobs.

5. Ski paramedic. What better way to work than to spend your day skiing and looking after trauma patients? You’ve got to be a very good skier or snow boarder, but this will come with time. If you are a qualified paramedic and are a reasonably competent skier or snow boarder you should generally be able to get a job as a Ski Medic. The pay is generally quite low as a Ski Medic, but the quality of life and job satisfaction is pretty high.

6. Advisory counsel for Medical TV shows. Most medical TV shows pay good money for people with real medical backgrounds to give advice on how things should occur “medically” on their shows. This is your chance to stop the people at E.R. from shocking the poor patients who are in assystole!

7. Teach first aid. As a paramedic you are perfectly trained to share your experiences and teach first aid to others.

8. Teach wilderness first aid.

9. Be a paramedic on travel/adventure groups. Many adventure tour groups are required by law to bring wilderness first aiders/paramedics on their trips.

10. Paramedic research fellow. Have you thought that some things could be done better in Ambulance Practice? Considered spending some time proving it? Many Ambulance Services have research institutes attached. Alternatively, you may consider getting a scholarship to do a PhD.

11.

Australian Paramedic

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Best medical TV shows of all time

August 13th, 2010

Over the years there have been many paramedic and medical shows that have usually described every exciting medical emergency that’s ever happened and expressed them as “all in a day’s work.” This page is a tribute to some of the best medical shows of all time.  I don’t know if the order is right, but I do know that the best medical show of all time is definitely right.

These are the top 15 medical shows of all time!

15. Rescue: Special Ops

14. Trauma

13. Nurse Jackie

12. Rescue 911

11. The  Young Doctors

10. All Saints

9. Gray’s Anatomy

8. A Country Practice

7. The Flying Doctors

6. Emergency

5. Scrubs

4. Medivac

3. ER

2. House

And what I think is fairly safe to say the best medical show of all time… ever (but that’s just my view)…

1.  M.A.S.H.

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Funny Ambulance Jokes

August 13th, 2010

I warn you… Paramedics often use black humour to relax… most Paramedics genuinely want to help people and do not like to see people get hurt… sometimes this sort of humour is just a way of letting go, or settling after a very bad situation, or accident. Paramedics see bad things every day (okay, not every day, but often), and although they wear the uniform, they’re not Superman, they do sometimes go home and take things seriously…

These are some of the paramedic jokes that I’ve come across in my time… they are often macabre… and I’ve often found myself at a party telling them, only to find that I’m the only person who can see any sense of humour in them… now that you’ve been warned… I hope you enjoy…

1.

A friend of mine once went to a motor-bike versus truck at 100k+ and… needless to say, the truck came out better off than the motocyclist. As one of the Paramedic started assessing the scene and in doing so locating the various body parts of the deceased motor-cyclist, the Police Officer on the scene asked “How tall do you think this guy is…” The Paramedic looks around… looks at the legs in the bushes and then the head down the street “hmmm… he looks to be about 45 foot tall currently…”

2. 

Assume all Physicians on scene are proctologists until proven otherwise… and considering this, never turn your back on them!

3. Telling a patient “I’m just going to insert a very little needle in your arm…” followed by, “and I promise you… this wont hurt me a bit…”

4. I was called to a MVA which included a man who had been enjected from the vehical and thrown into a razor wire fence – this actually cut him in half around his waist. The patient was obviously deceased by the time we got there, and while looking through the car at the accident scene, we found dozens of bottles of empty beer in the car… I made the comment, “Hmm, guess this is what happens when you drive legless…”

5. I treated a person who obviously couldn’t help but lick the hand held cake before turning the power off… needless to say, the person ended up with a tongue that had amazingly managed to wrap itself around a million times and was now semi-permanently attached to the blender. When I was telling the triage nurse what had happened, she asked “did he tell you how this happened” to which, the response was “Ah… not really, he was a little tongue tied…” 

More jokes to come soon…

Australian Paramedic…

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Funny Paramedic Jokes

August 13th, 2010

I warn you… Paramedics often use black humour to relax… most Paramedics genuinely want to help people and do not like to see people get hurt… sometimes this sort of humour is just a way of letting go, or settling after a very bad situation, or accident. Paramedics see bad things every day (okay, not every day, but often), and although they wear the uniform, they’re not Superman, they do sometimes go home and take things seriously…

1. What did the paramedic say to the the left sided stroke patient? “You’re going to be alright…”

2. When I turn these lights and sirens on its my ‘invisibility cloak’ that makes it impossible for cars to get out of my way.

3. Did you know that the optimum rate of chest compressions in CPR is to the beat of “Stayin Alive.”

4. How do you know a paramedic has entered the room… they will tell you… 

5. At 11pm you are called to a high speed roll over…  on arrival at the scene you find a brand new BMW rolled on it’s side and a man trapped underneith screeming “My car! My beautiful car!” “Do you think they can repair it?” The paramedic looks down… and sees the man is missing part of his arm… “Mate… don’t worry about your car right now… look at your arm… you’re missing part of your arm!” The man looks more pale and more concerned than before and screams “My rollex, my rollex… I’ve lost my rollex!”

6. What’s the difference between God and an Intensive Care Paramedic? God doesn’t have delusions that he’s an Intensive Care Paramedic.

7. A doctor reaches for his pen and pulls out a thermomete instead… The doctor scratches his head and says “Hmm… I wonder which arse-hole has my pen?”

More to come…

Australian Paramedic

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Things you don’t want to hear from a Paramedic…

August 13th, 2010

As a paramedic I sometimes have to break some pretty bad news to people or tell them that I have to do something that might make them a little more than uncomfortable. As the years have gone by, I’ve gotten better at telling people what is happening and what I’m about to do with a certain level of honesty and integrity that just makes it work… However, somethings… a patient just never wants to hear.

This is a dedication to those things that you don’t want to hear from a paramedic:

1. “This my first day on the road… but I think I’m going to do really good!”

2. “Well, I guess I have to learn sometime…”

3. “A little more practice and I’ll be able to do this…”

4. “Have you seen how they do this on that Rescue Show?”

5. “Oh me… I’ve done this plenty of times before… no, not on a living person yet… but they say its very similiar…”

6. “Can you stop that thing from beating… its throwing me off my concentration…”

7. “Last time I gave this drug the patient died…”

8. “Does it really matter that I forgot to ad the decimal point to my adrenaline injection?”

9. “I hope this deffibrilator still works in the wet…”

10. “Sorry, we can’t come to you yet… it looks like that thing’s going to blow any minute now… we don’t want to get too close to you…”

11. “You might have that rare and deadly disease… of course I’m not going to come in and get it too…”

12. “You’re call is important to us… please hold…”

13. “Do you know how to get to the hospital from here?”

14. “On second thoughts… which funeral home were you thinking of?”

15. “Is there anyone you’d like us to contact…when… I mean if… the worst should happen?”

16. “I’m just going to attach these electric pads to your chest…”

17. “Oops”

18.  “I’m sorry, we just got a higher priority patient… we’ll probably come back for you soon…”

19. “I’m just going to put this white tag on your toe…”

20. Patient…”Have you ever seen a patient with these injuries before…” – Paramedic “Dozens of times… well, no, not on a living patient…”

21. “Wow…  I can’t wait to get back to school and tell them what they let me do on my ‘work experience day’!”

22. Now, I just need to inject this little needle… into… your heart…”

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Things you don’t want to hear while having surgery…

August 13th, 2010

These are just a few things that you really never want to hear while your having surgery (particularly because you probably don’t want to be awake while having surgery)!

1. “I wonder where this… thingie goes…”

2. “Did anyone see where my watch went?”

3.” Hey, Cleaner… you’ve seen this before… can you to finish this…  I have an important date…”

4. “We’re going to the mop for all this blood that I’ve spilt…”

5. “Which leg was I supposed to amputate?”

6. “Didn’t I have 5 forcepts before I closed him up?”

7. “I wonder if… there’s some way I can put this… part… back where it came from?”

8. “Oh this… nah…. she’ll probably be alright without  these extra parts”

9. “Hmmm… maybe I better put these parts somewhere… you know… in case we find out we need them or something…”

10. “Hang on a second… if this his spleen… then what did I just take out?”

11.  “You know… there’s a heck of a lot of money in kidneys… and, the guy already has two of them…”

12. “Sterile… smerile… the floors clean… I mean… the Cleaners mopped it, right?”

13. “Oops…”

14. “I sure wish my hands didn’t shake so much while I’m operating…”

15. “Hmm… I’ve stitched you up… but you’re going to have to come back tomorrow so we can finish where we’ve left off.”

16. “Can someone get me a text book…. or a diagram so I can see what I’m supposed to be doing?”

17. “Why are the directions always in Japanese?”

18. ” No, never seen or done this before… but once…. just once… I put together a whole Ikea Kitchen… this doesn’t look too complicated compared to that…”

19. “I think I put that in back to front…”

20. “Did your leg always move like that?”

21. “You better keep that… sometime the coroner likes to see it”

22. “Boy… I wonder if I should at least attempt to put these parts back together before the autopsy…”

23. “Don’t worry… I’ve worked with blunter instruments before…”

24. “Okay… so here’s the story… I never actually went to Medical School…”

25. “Will someone stop that thing from beating… its making it hard for me to think…”

26. “Wow… the other work-experience kids are never going to beleive that you let me do this…”

27. “Oh… his medical insurance is no good…. okay, I better take it out again…”

28. “What do you mean this isn’t my patient”

29. “Are you sure he didn’t want bigger boobs?”

30. “Remind me I need to pick up my glasses after this opperation…”

31. “So, I’m pretty good at taking all the parts out… its just putting them back in that I always have trouble with…”

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Paramedic Unions/Professional Associations

August 8th, 2010

These are some of our major paramedic unions/or professional associations in Australia… (I appologies for those I missed).

Emergency Medical Services Protection Agency (EMSPA) VIC http://www.vic.emspa.org.au/

Emergency Medical Services Protection Agency (EMSPA) NSW http://nsw.emspa.org.au/

Emergency Medical Services Protection Agency (EMSPS) QLD http://www.qld.emspa.org.au/

Health Services Union (NSW) http://www.hsu.net.au/

Australian Liquor Hospitality and Miscellaneous Workers’ Union (VIC) http://www.lhmu.org.au/

Ambulance Employees Association (SA) http://www.aeasa.com.au/

Australian Liquor Hospitality and Miscellaneous Worker’s Union (WA) http://www.amboswa.org.au/index.php?id=30&option=com_content&task=view

Australian Liquor Hospitality and Miscellaneous Workers’ Union (NT) http://www.lhmu.org.au/

Australian Transport Union (ACT) http://www.nswtwu.org/act/

Australian College of Ambulance Professionals http://www.acap.org.au/

Australian Paramedic…

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When you know you’re a Paramedic

August 8th, 2010

You Know You’re a Paramedic When: (the Definitive List)

1.      At social gatherings you drool at anyone with nice fat veins.

2.      You think anything less than 4 days off in a row isn’t worth having

3.      You see any person with a welfare card as your “employer”

4.      You at all your friends and realize they work for an emergency service or a hospital

5.      You marry a nurse

6.      It drives you absolutely nuts when someone calls you an “Ambulance Driver”

7.      For those of you who have worked on-call: when your 4 year old daughter knows the work phone as the “money” phone.

8.      You ask yourself “what should I have for lunch” while attempting to pick up an extra piece of a limb at a motor vehicle accident

9.      You start to match songs to different diseases

10.  You arrive at home in your own car after work, and attempt to mark yourself “At Station” on an imaginary MDT.

11.  You know that when a kid has been injured the person who will take up most of your time managing at the scene will be the parent, regardless of how sick or injured the child is

12.  You really believe that the Ambulance lights and sirens are in fact an invisibility cloak that makes it impossible for cars to see you and get out of your way

13.  You see sirens as an annoying sound… that you’d rather not have to use

14.  You attend a regular patient, and play the game “how much of the patient health care record can I complete before I get there”

15.  When you arrive at a call and your first impression is, Umm why am I here.

16.  You thrive on serious trauma.

17.  You have an entire closet dedicated to uniforms

18.  You lay your uniform, including socks, underwear, watch, shoes, and Ambulance keys out alongside your bed in case the “Big Job” comes in – even when you’re off duty.

19.  You spend many nights laying on a layzee boy!

20.  You have withdrawal from not wearing green on your days off!

21.  You know that Full Moon = Insanity.

22.  When you’re always checking out peoples’ veins for IV access.

23.   Unconscious = cooperative.

24.  You’re up at 2:00 am on Facebook, all in a day’s work.

25.  Random phones and buzzers send your heart into VF

26.   A few quiet days in a row equals an excellent call.

27.   When you and your partner are the only ones not panicking in the room.

28.   When you don’t let anybody get between you and the exit route at social gatherings.

29.   When you tell people to standby one.

30.   You get back pain just looking at really fat people!

31.   You answer questions with “Roger” instead of “Yes” regardless of whose asking them.

32.  Your dinner conversations often migrate toward that really messy trauma or explosive diarrhea call and you won’t lose your appetite.

33.   If, every time you drive somewhere, you ask your travelling companion “You wanna drive, or attend?”

34.   If you’ve ever conducted a practical joke using oxygen tubing.

35.  If you have use lignocaine gel on people’s phones, car handles or any door handle

36.  If you find skipping with an oxygen tubing a good form of exercise

37.  If you think getting off the layzee boy and answering the phone is a good form of exercise

38.  When someone needs a plaster and you pull out a trauma kit.

39.   When your home first-aid kit consists of OP airways, maternity kits and bag and masks!

40.  When your quick remedies kit for a hangover includes: 1L of Hartmann’s and a Maxalon

41.  When you’ve wanted to hold a seminar on ’Suicide – How to Get It Right The FIRST Time.”

42.   If you and your partner have discussed dinner plans over a dead body.

43.   When you have come to the conclusion that you are sicker than 3/4 of the people you take to hospital.

44.   You know you’re a paramedic when you wash your hands before using the bathroom.

45.   When you wipe your feet on the way out of people’s homes.

46.   When you back into parking spaces on your days off.

47.   When you are watching TV and get annoyed and point out all the inconsistencies of the TV medics.

48.   You spend your days off thinking about the calls the guys on shift are getting: the calls YOU are missing.

49.   All of your best stories start with “There was this one call where…”

50.  All your “funniest” stories are considered vulgar and disgusting

51.  You tell the best story ever, and you’re the only one who can see the humor in it

52.   You can put together a complete sentence using numbers and acronyms.

53.   “LOL” doesn’t mean “laughing out loud” but rather it means “little old lady.”

54.   You have at least one “things up people’s butts” story.

55.  You often finish a story with “and then he died”

56.  When you think you did a great job… even though the patient still ended up dead

57.   You’re covered in some bodily fluid or another more often than not and it doesn’t bother you.

58.  You’re tempted to use “oxygen therapy” on all annoying people, not just patients: an O2 tank over the head fixes everything (especially in combative patients).

59.   You find random pairs of gloves in every pair of trousers you own, whether they be uniform or civvies.

60.   You want to throw something at the TV when they shock asystole on some TV show.

61.   When hot spots are not areas of heat in a babies bottle.

62.   You refer to your ambulance as a “bus.”

63.   You have perfected the art of responding through rush hour traffic, with a burger in the one hand and a drink in the other.

64.   You hear a siren and you know exactly what service or vehicle it is.

65.   It drives you nuts when some ignorant fool calls you a first aider. (This is even worse than being called an ambulance driver.)

66.   You cringe when you arrive on scene and someone says you will need a chair or the patient can’t walk – umm… I will make that decision!

67.   When you come home in a clean uniform after a 24- hour shift and your spouse automatically becomes suspicious of your whereabouts.

68.   You and your partner are deciding what kind of burger to order after the call while your patient is projectile vomiting!

69.   You remember every patient by their injury or disease and not their name.

70.   You trample over people to get out of the coffee shop, fly through traffic for “SOB (shortness of breath) and chest pain” only to arrive on the scene to find a sharply-dressed senior citizen who walks up to the ambulance and says,” Good! I have an x-ray appointment in ten minutes!”

71.   You get called out for abdo (abdomen) pain at three in the morning to find your “patient” at the gate with their bag packed, and the whole family waiting to wave good bye.

72.   When hearing there is a doctor/nurse on scene, you consider it a bad thing.

73.   You’ve ever had an altercation on scene with a rubberneck.

74.   You crouch down in your car as you go past accident scenes so the crew already there won’t see you.

75.   You can’t put up IV lines unless everything is shaking around.

76.   You know at least 3 alternate routes to any place you are going.

77.   You’ve ever blown up a glove and drawn a face on it in the hopes it will stop your pediatrics patient from screaming.

78.   You can skip to the head of the line at the local Burger king or McDonald’s because you’re in uniform.

79.   It drives you nuts when a driver only says they’re a “Paramedic.”

80.  You resuscitate a regular patient and honestly question whether or not you have helped the community at all

81.  You don’t know how to operate all the nursing machines, but you can easily identify and utilize the silence buttons

82.  You describe a hospital gown as a “nice backless number”

83.  You know every party drug ever invented and what the “popular” ones are this week

84.  You believe that most occupants of an MVA don’t have a spinal injury

85.  You deliver a 17 year old’s baby and think “wow… she made to 17 before she got knocked up… good for her!”

86.  You’ve never worked out the importance of taking a diastolic blood pressure

87.  Believe all patients lie

88.  Although, unable to speak any other language, are adeptly fluent in all hand languages to signify that the patient can walk out to the Ambulance

89.  Know that its easier and more accurate to check a patient’s medications than to ask them what previous medical illnesses they have.

90.  Have been caught out at some stage by suggesting that you will decide if a patient can walk or not, only to find that they have a broken leg.

91.  You’ve looked at a drunken patient and thought “they called the wrong emergency service…”

92.  You often ask your patient to “wait in the waiting room” while you talk to the triage nurse

93.  You class CPR as one of your weekly exercise workouts

94.  You often take first note of what’s on another Paramedic’s shoulders

95.  You’ve walked into a patients house with just a BP cuff and argued that really, you’re over-prepared

96.  You’ve described a patient who has suddenly died as having made “a good innings”

97.  You’ve made jokes, which you have honestly thought were funny, about a funny way in which a patient has died

98.  You’ve had to explain to a triage nurse that the reason that you’ve come to their hospital is “because they’re a public hospital and you have a public patient

99.  You know that there’s no correlation between what you have been called to and what you are actually going to

100. You know that the only real use for the Ambulance lights and sirens is to entertain the kids who watch as you go by

 Australian Paramedic…

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Medical Jokes

August 7th, 2010

As a Paramedic I spend a lot of my day in the emergency department. These are some of the emergency medical jokes/doctors jokes I’ve heard in my time.. Enjoy…

1. A pregnant woman asks her gyneacologist how much labour hurts…

“Well… says the Doctor… that’s kind of difficult to answer… you see every woman is different… every woman feels pain differently, and pain by its very nature is hard to describe… you see…”

“I see” says the pregnant woman… “but is there anyway you can give me some idea?”

“Well… I suppose there’s one way… but its a little hard…”

“Okay… tell me… I want to know so that I can prepare myself…” says the woman…

“Well, first try stretching your upper lip a little upwards by pulling it with your fingers…”

“Like this….” she says ask she pulls it…

“Ah, yes… but a little more…”

“Okay, how about this…”

“Just a little more…”

The woman pulls her upper lip very hard…

“How about this?”

“How does that feel?” The Doctor asks…

“Its a bit sore… but I can handle it… is that what childbirth is like…”

“Now, just a little further and you will have experience childbirth pains…”

“Like this…”

“Yeah, just like that… now just pull your lip right over your head…”

2.  A 90 year old lady goes and sees her local doctor and asks for oral contraceptive pills… the doctor, a little concerned by the thought of “why” a 90 year old may think that she needs oral contraceptive pills… starts to explain that: “You really don’t need to take those to ensure you don’t get pregnant anymore…”

She smiles… “I know that… but I take them for my sleeping…”

“Oh… says the Doctor… I’m not sure why they would help you sleep better…”

“Well…” says the little old lady, “I spike my grand-daughter’s drinks with them and this makes me sleep better…”

3.

More to come…

Australian Paramedic

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Emergency Nursing Jokes

August 7th, 2010

Being a Paramedic means that you spend alot of your time in Emergency Departments… these are some of the nursing jokes that I’ve heard over the years…

1. When a Doctor is really annoying you and you can’t get rid of him/her… print a random ECG out and ask him to analyse it for you…

2.  If the Doctor is still annoying you… ask him to have a listen to all your patient’s chests…  

More to come soon…

Australian Paramedic

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Paramedic Jokes…

August 7th, 2010

I warn you… Paramedics often use black humour to relax… most Paramedics genuinely want to help people and do not like to see people get hurt… sometimes this sort of humour is just a way of letting go, or settling after a very bad situation, or accident. Paramedics see bad things every day (okay, not every day, but often), and although they wear the uniform, they’re not Superman, they do sometimes go home and take things seriously…

These are some of the paramedic jokes that I’ve come across in my time… they are often macabre… and I’ve often found myself at a party telling them, only to find that I’m the only person who can see any sense of humour in them… now that you’ve been warned… I hope you enjoy…

1.

A friend of mine once went to a motor-bike versus truck at 100k+ and… needless to say, the truck came out better off than the motocyclist. As one of the Paramedic started assessing the scene and in doing so locating the various body parts of the deceased motor-cyclist, the Police Officer on the scene asked “How tall do you think this guy is…” The Paramedic looks around… looks at the legs in the bushes and then the head down the street “hmmm… he looks to be about 45 foot tall currently…”

2. 

Assume all Physicians on scene are proctologists until proven otherwise… and considering this, never turn your back on them!

3.

Telling a patient “I’m just going to insert a very little needle in your arm…” followed by, “and I promise you… this wont hurt me a bit…”

4.

I was called to a MVA which included a man who had been enjected from the vehical and thrown into a razor wire fence – this actually cut him in half around his waist. The patient was obviously deceased by the time we got there, and while looking through the car at the accident scene, we found dozens of bottles of empty beer in the car… I made the comment, “Hmm, guess this is what happens when you drive legless…”

5.

I treated a person who obviously couldn’t help but lick the hand held cake before turning the power off… needless to say, the person ended up with a tongue that had amazingly managed to wrap itself around a million times and was now semi-permanently attached to the blender. When I was telling the triage nurse what had happened, she asked “did he tell you how this happened” to which, the response was “Ah… not really, he was a little tongue tied…”

6.

 A paramedic is called to a high speed MVA roll over. On arrival he finds a brand new BMW rolled on its side and badly damaged. He can hear a man screaming from underneath the car “My car, my car! What have I done to my beautiful car!” The paramedic comes over and finds the man is missing part of his arm after the car rolled on it… “Mate… forget about your car… what about your missing arm?” The man looks down and for the first time notices that his arm is missing… “My Rollex, my Rollex is missing!”

7.

Do you realise that the optimum speed for CPR chest compressions is about 100 beats per minute, which, incidently, is the same as the beat in the song “Stayin Alive” – true story.

8.

What’s the difference between a Paramedic and GOD? GOD doesn’t have a delusion that he’s a Paramedic! 

9.

I treated a patient who had fallen while he was using a chainsaw to cut a branch off a tall tree. When we arrive we found him with a half severed right leg, and a major arterial bleed from his femoral artery, which he was vainly struggling desperately to contol with both his hands. His wife was there, but she was trying her best to keep her young children away from the excitement. As we started to treat the badly injured man… we noticed that he started laughing… almost hysterically… at first, we continued working without asking him anything about it – often people react in very strange ways to terrible accidents such as these, and sometimes it’s just a response to the low blood preasure and decreased cerebral perfusion (blood to the brain). We applied an arterial tornequet and raised his leg… it didn’t completely stop the bleeding, but it slowed it down. Severed arteries are virtually impossible to control. We applied a second tourniquet to stem the bleeding. This seemed to do the job… the patient was still laughing, but he was conscious and the bleeding had stopped… so we figured we weren’t doing too bad a job. We still knew we didn’t have time to muck around on seen and basically this was one of those ‘load and go’ situations. The man was still laughing, and throughout all the excitement, I hadn’t really given any thought to what in the world he could be laughing at. We rapidly got him loaded in the back of the ambulance and inserted 2 large bore cannulas (one 16gauge and one 14 gauge) enroute to hospital. It was only at this point that I finally thought I had enough time to ask the obvious question…

“You just nearly killed yourself… what could possibly be so funny?”

The man looks at me… starts laughing hysterically and says… “Its just that… I just can’t  stop….”

I let him keep laughing a little while longer… eventually he settled down…. and told me…

“I had been meaning to trim a few branches off that tree for months now… I had my children there and my wife… and I had told them all to stand back while I used the chainsaw… now, when I fell… and I immediately saw how much of my leg I had taken off… and I realised I was probably going to die… I should have been thinking about my wife and kids, about my own life, about what its going to be like if I don’t make it through this… but you know the only thing that came through my head was?”

I look at them as though he’s a little mad… and shake my head…

“All I could think of was that stupid movie by Monty Python and the “Black Knight” and all I could see in my own mind was me standing there, like the “Black Knight” and yelling “Its only a mere flesh wound!”

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What is a Paramedic?

August 7th, 2010

According to the Australian Council of Paramedacine a Paramedic is “a Specialist Health Care Professional who responds to requests or attends to people who are suffering acute health crisis of any nature.” This includes providing health assessment, initial treatment, transport to hospital, and sometime treatment on scene that allows the patient to remain at home.  

At a more basic level Paramedic are problem solver, who people call when then they don’t know who else they can call to solve their problems. Sometimes these are medical problems, or medical emergencies, sometimes they’re emergencies of another nature, sometimes, they have nothing to do with medical emergencies or emergencies of any kind and the people just need help and honestly don’t know where else they can get it, so they call an Ambulance.  

Sometimes a Paramedic’s job is just to talk to someone… and sometimes refer them or suggest other avenues which are open to the patient so that they can get help.

Australian Paramedic…

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Do I want to be a Paramedic?

August 7th, 2010

Do I want to be a Paramedic? When I left school I was like everyone else (in short, I really had no idea what I wanted to be when I grew up)… I kind of just fell into a career as a Paramedic. Being a Paramedic is something that some people who you would never pick love it, and other, who you would make a perfect paramedic, hate it…. the only real way to find out is to give it a go..

Things to consider:

Have you got that sort of personality that makes you enjoy working as an Ambulance Officer – now, I don’t mean, can you handle blood, but, do you want to spend your day talking to old people, chronically ill people, and taking people to hospital who have been booked in for a week to have their routine urine catheter replaced… this is what we really do for a living… and every now and again, you get to have some excitement and treat someone who is critically sick or injured. Don’t get me wrong, I’ve been a Paramedic for about ten years, and I still love the job.

Do you genuinely want to help people? – (no… hmm, probably this is the wrong job for you). As a Paramedic, you are the ultimate public servant – you go into strangers houses an all times of the day/ night and do your very best to fix their problems (and this does not always mean medically problems).

Can you be patient with really stupid people? (when your job requires you to be)…

Can you compose yourself when you’re under a lot of stress and at least “fake” confidence? (Every good Paramedic does this from time to time).

Do you have to be busy all day… or are you just as happy to read a book and occasionally treat people in life-endangering emergencies?

Have a think about it and become a Paramedic… it’s the best job on Earth…

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If I do a Paramedic Degree am I guaranteed a job?

August 7th, 2010

Am I guaranteed a job if a complete a paramedic degree? The short answer is: no, you’re not guaranteed a job once if you complete a paramedic’s degree.

If you complete a Paramedic degree you still have to apply for a Student Ambulance Paramedic or Graduate Paramedic Student position. Although it is much more likely that you will get a position once you have a degree in Paramedics, it is by no means certain that you will get a job. Most Ambulance Services are increasing their intake of Graduate Students each year and decreasing their intake of non-tertiary student intakes. This shows how much each Ambulance Service is committed to providing the best skill and knowledge base to its patients and recognises the fact that Ambulance Paramedics as a career really is becoming a profession, such as Registered Nurses, Doctors, Physiotherapists or any other Allied Health Professional

.

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How to Become a Paramedic

August 7th, 2010

How do I become a paramedic? Before you apply yourself to become a paramedic you need to first determine if becoming a paramedic is right for you. Being a paramedic is not always exciting or about saving lives. The best description of being a paramedic is this:

“Being a paramedic is about being bored 99% the time and then terrified for the remaining 1% while you use all of your training and experience to get you through some seriously emergency…” -Australian Paramedic.

Okay, so you’ve considered what paramedics actually do for a living and have decided to put your efforts towards becoming a paramedic. How do you do it?

In Australia, each state has its own Ambulance Service, and if you want to join, each state has different employment application requirements.

There are three main streams in which you can become a paramedic in Australia.

Options one: General Entry. Through this method you can study on the job through a student paramedic traineeship. This is where you manage to gain entry into a student ambulance paramedic training program (usually very competitive) through a specific Ambulance Service. In Australia, NSW, WA and QLD are the only States that still use general entry into their Ambulance Services. Once you gain employment, you will complete a selected period of theory training by your service (with exams) followed by a 3 year paramedic internship, where you will be trained on road by senior paramedics.

Options two: Graduate Entry. If you are willing (and able) to successfully complete a 3 year Bachelor’s degree in Paramedics/Clinical practice or Health Science, you can then apply for a position at most Ambulance Services as a Graduate Paramedic. Once you gain employment you will then undergo further training and development on road for a period of up to 2 years. This is a longer route to becoming a paramedic, but will place you in a good position for further development as a paramedic in the long run.

Option Three – RPL Paramedic Program. If you’re already a qualified paramedic interstate or overseas you may apply for Recognition of Prior Learning and gain employment as an RPL Paramedic. As an overseas paramedic you can generally get a paramedic job anywhere you want, so long as you are already qualified and have at least 3 years of experience as a paramedic.

Want to become a paramedic in the US?

To become a paramedic in the US you will need to pass the National Registry of Emergency Medical Technicians – Paramedic (NREMT-P). To apply to become a paramedic you will need to:

1. Be at least 18 years of age

2. Have an unrestricted drivers licence

3. Possess a current NREMT-B certification

4. Successfully complete and pass both the NREMT-P cognitive and psychomotor exams.

More information about the NREMT-P exam process can be found here.

Want to become a paramedic in the UK? Paramedics in the UK must meet the standards and gain registration as Paramedics under the National Health Professions Council. Becoming a paramedic in the UK generally requires tertiary study in Paramedic Science followed by on-road experience as a student paramedic. UK paramedic registration is held in very high regard around the world and consequently UK registered paramedics are highly employable globally.

Want to become a paramedic in South Africa? In South Africa there are three main levels of Ambulance Attendants and each have their own training requirements. These include: Basic Ambulance Assistant, which requires 160 hours of training; Ambulance Emergency Assistant, which requires 1000 hours of training; and the Critical Care Attendant, which requires a further 1200 hours of paramedic training and is considered equivalent to the US NREMT-P standard.

Want to become a paramedic in Dubai? Dubai regularly recruits paramedics from overseas. The main requirement to become a paramedic in Dubai is to have completed paramedic training and have 3 years of experience in a recognised government ambulance service.

Testing to Become a Paramedic

How do I become a Student Ambulance Paramedic?
You need to be keen, have a full (non-restricted) drivers licence (in some states you must have a Medium Rigid /truck licence) before you can apply for a position as a Trainee Ambulance Paramedic or Student Ambulance Paramedic and actually be trained on the job over about a 3 year period with regular distance education and internal education packages. The competition is tough and some years the application process can take up to 12 months, while natural attrition and selection processes attempts to extract the best people for the job. Some years, positions may have as many as 8,000+ applicants for a position of 40-50 Student Ambulance Paramedics.

Depending on which state you apply for, testing will include: basic skills testing (writing, maths, vocabulary), adaptive learning skills (IQ tests), basic mechanical reasoning skills (can you take apart the oxygen -viva and put it back together again after being shown once), map reading, dictating tests (where someone tells you several things, and you must write everything down and repeat it). If you pass all this, you will most likely have a personality test of some description, where basically they will “get an idea” (sometime quite incorrectly) whether or not you have to right personality for the job. Then you will have a fitness/medical test – you can wear glasses, but need to be able to see well enough to drive, depending on which state, you must not be colour blind. Then, if you survive all that, you will have an interview… and hopefully get a position… well done!

The second method, is to do a bachelor degree in Paramedics (such as Bachelor of Pre-hospital Care, Bachelor of Health Science/ Paramedic, Bachelor of Paramedical Science, or Bachelor of Clinical Practice /Paramedic). Universities in Australia that currently teach tertiary studies in paramedics include: Charles Sturt University (NSW), Hobart University (TAS), Flinders University (SA), Monash University and Victorian University (VIC), and Brisbane University (QLD) and many Universities are introducing this course. This acknowledges the current trend and changes in improving the skill and knowledge base of clinical practitioners (paramedics) from all around Australia.

Once you have gained your three year bachelor degree in some form of Paramedic studies (or in some states first 2/3 of a 3 year degree) you may then apply for a graduate position in an Ambulance Service. Most Ambulance Services in Australia now have graduate positions, which range from 10 months through to 2 years of an on-road “internship” which culminates in eventual certificate to practice as a Qualified Ambulance Paramedic. This is recognised on an individual state basis, and although generally interchangeable amongst different states, each service normally requires a RPL program (Recognition of Prior Learning) to be completed before achieving a Certificate to Practice.

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How to Provide Basic First Aid – A Paramedic’s View

August 5th, 2010

So, you come across an accident, or person lying down, unconscious, and they don’t look so well… what can you do to help?

Well, first… 

Make the decision to help them! Many people fear legal repercussions if they provide first aid and the person gets worse. In Australia this is impossible. There is an Act (Law) in Australia called the Good Summaritan’s Act, which basically states that so long as a person is attempting, in good faith, as a person with their knowledge and experience in this situation would, to provide assitance to a person who is injured they cannot be held accountable for any damages they cause incidentally during the attempt. I don’t know about other parts of the world, but I find it hard to believe that many people have ever been sued for attempting to help someone who has been injured.

Okay, so you’ve decided to help… now what?

Follow the basic pneumonic from first aid, which is: DRABC and try to fix each thing before you move on…

So,

D – Danger – Check for danger… if someone’s been electrocuted… the last thing you want to do is get zapped yourself… so, take a few seconds, have a look around, and have a think about how this person ended up where they are, so that you don’t follow them (Remember… you can’t rescue anyone if you get injured). If you can, remove the danger from yourself; then try and remove it from other people who are around and not quite as clever as you to have noticed the danger; lastly, try to remove the danger from the poor casualty…

R -Response – Check for a response… “Hey buddy, are you okay…” You never know, you may get lucky… they may turn around and say, “Yeah, I’m just sleeping… what’s your problem?” If this happens… its best to find out before you start trying to give mouth to mouth. If the person doesn’t wake up… give then a shake (not too rough here) and see if you can rouse them… if someone is completely unconscious (you can’t wake them up no matter how many times you shake them), they are significantly sick or injured.

A-Airway- Make sure that they still have an airway (this means some open pipes from which air can pass into their lungs). To do this, try to lay them on their side… open the jaw and see if they have anything stuck inside… unless you’re in a restauraunt, and the person was eating steak, chances are, they wont have anything in their mouth… better move on.

B-Breathing – Are they breathing? Yes, oh good! This is a good start… Keep them on their side and call an Ambulance (In Australia this is done by calling 000 – but every country has a different number)… No breathing… hmm, not a good sign. You better do this mannually for them. You can do this by tilting their jaw back (gently), squeezing their nose (so the air doesn’t go out), and providing two short breaths into the mouth… while you do this… you might want to feel for a pulse. The easiest place to feel a person’s pulse is to find the Adams Apple and move your fingers slight to the left or to the right into that little grove… you should feel a pulse fromt the carotid artery. If not, well, you better move onto C for circulation…

C – Circulation – If the person doesn’t have a pulse, you need to provide one for him or her… in fact, you’ll need to provide one for the patient until the paramedics arrive and hopefully manage to make the patient’s own heart start working again. How do you do this? By doing cardio-pulmonary resuscitation (CPR) – yes, like in the movies, but you don’t get to give up after thirty seconds and say “there was nothing we could do for him…” Basically, to do CPR, you place one of your hands just about and central to the chest as possible (don’t get overly concerned by this… no matter where you place your hands on the chest, you’re going to be doing more good than damage to the patient, than if you don’t do anything at all. Don’t worry when you hear the ribs break – this is normal… most people whose hear is sick enough to stop working, have very old or frail ribs… and many of them break… this isn’t a problem – keep going, you’re doing well..

If you’ve done all this… in fact, if you’ve done any of this, you will have provided the paramedics with the best possible chance of getting this person’s heart to start working again (that’s just their job); but you will have saved the casualties life. The paramedics have no chance if you don’t make a start…

Good on you…

Australian Paramedic…

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What drugs can Paramedics give?

August 4th, 2010

Paramedics can give a range of drugs to treat various illnesses or provide analgesia and comfort people.  Each state in Australian has a different Ambulance Service, and each service has its own set of protocols, procedures,  pharmacologies, or clinical practice guidelines. 

Paramedic cardiac drugs  include: aspirin, anginine (Glyceryl Trinitrate), morphine, lignocaine, adrenaline, amiodarone, atropine, and in some states throbolytics, such as tenecteplase.

Paramedic analgesic drugs include: ibrufen, methoxyflurane, fentanyl, morphine, ketamine, nitrous oxide.

Paramedics also carry a range of other drugs for managing asthma, such as: iprotromium bromide (atrovent), salbutamol and adrenaline. 

Paramedics can treat overdoses, with: naloxone, flumazenil, and sodium bicarbonate.

Paramedics can treat hypo/hyperglycaemia with drugs such as: glucagon, glucose gel, 10% glucose, 50% glucose, and hartmanns or saline solutions for hyperglycaemia.

Paramedics can treat nausea with a multitude of antiemetics, including: maxolon, ondansetron, promethazine, or stemetil.

Australian Paramedic….

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I Hate Blood… and I’m a Paramedic

August 4th, 2010

I’m providing moral support while my girlfriend has a tooth pulled out… I don’t generally like anything to do with teeth, but I make the effort and I hold her hand while the Dentist starts to pull the tooth… the next thing I know, I’m waking up, and the Dentist is telling me not to worry…

“Lots of young men don’t like the sight of blood…”

I look up… and realise I’ve just passed out… I respond “Yes, but you don’t understand… what I do for a living?”

The Dentist smiles at me and says… “Oh, what do you do for a living?”

“I’m a Paramedic” I answer sheepishly…

“Oh, I see your problem…”

I’ve always hated blood… and have always been prone to light-headness/episodes of dizzyness when I see blood… it wasn’t until I had been a Paramedic for a number of years, whenI finished a job in which a man had lacerated his carrotid artery, and I spent an intense 2 minutes trying to keep him alive until we reached a hospital (and had blood covering my goggles, face, uniform and entire back of the Ambulance, that I had this realisation… hey, I thought… “I hate blood! – In fact, I’ve always hated blood!”

So, how did I become a Paramedic? Well, I thought when I was younger that I couldn’t do first aid because I hated blood… so, I did a first aid course to get over it… unfortunately, it didn’t help… so I ended up volunteering at a local hospital during my last few years of highschool to somehow improve myself… and from that, I ended employed at the hospital, where, somehow… in an attempt to get away from all the blood one sees in a hospital, the only natural course of action was to become a Paramedic so I could leave the hospital…

Now,  seven years later, and I’m still a Paramedic that can’t stand blood… and yet I love my job…

How does this happen? I have no idea… I’ve passed out telling a friend about a job that I just attended… but while I was at the job, I can concentrate on my job… and don’t have time to really look at all that blood… and feel sick…

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What is it like to be a Paramedic?

August 4th, 2010

So, what is it really like to be a paramedic? Working as a Paramedic is a great job. You’re able to spend your day helping people, while doing something you genuinely enjoy. When the day is quiet, you don’t have to justify yourself to anyone, by “creating” work to do; but when its busy, the hours go quick, and work is often interesting. Its one of the very few medical jobs on Earth, where you can start the day treating someone for a cardiac arrest, then go to a bad MVA (motor vehical accident) and spend hours just trying to extricate someone, and then finish the day off by delivering a baby in someone’s very own bathroom… and in all those jobs, you’re the person in control, you’re the one making decisions, and you’re the one who everyone looks to in order solve their problems.  

Of course… that’s not every day…

So, what’s it really like being a Paramedic? Well, most of the time you spend at the station trying to come up with new ways of passing the hours of the day ( many paramedics have multiple degrees, hobies, or take up writing internet blogs to make the day go faster). The majority of the work is mundane, standard cases, which involve taking elderly or chronically ill patients to hospitals…  but every now and again… something happens… and you earn every penny you make by treating a very very sick patient…

Is it like the movies/TV shows? No, we’re much more competent at our jobs… and we actually know that you can’t shock assystole (the flat line that they always show people shocking in the movies)… In the ten years that I’ve been on road, as a Paramedic, I have only really “saved” about a dozen people’s lives… that’s not so much our job… if people are going to live, they’re generally going to live regardless of our interventions… except in the rare cases of anaphylaxis, severe asthma, or witnessed VF cardiac arrest. No, we don’t generally save lives for a living… we comfort people… the single biggest thing that we can do for our patients is manage their pain with good analgesia, whether this is through reasurance, splinting, methoxyflurane, fentanyl, ketamine, or morphine – this is where we can really make a difference to the lives of our patients.

More and more these days we’re having a role in welfare issues, such as domestic violence, poor nutrition, mental health related disorders – some Paramedics don’t like this… but, it is a large part of our job. 

If you like people, and genuinely want to help people, and occasionally like a little excitement… then being a Paramedic is a great job…

Australian Paramedic…

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What is an EMT?

August 4th, 2010

EMT stands for Emergency Medical Technician and is a term mainly used in American Ambulance Services or Fire Services to represent Paramedics who have completed training up to a certain level, but not has high as a fully qualified Paramedic. Depending on which state you work for or whether or not you work for a public or private Ambulance Service, most Ambulances use one EMT with one Paramedic. However, in some areas, they use two Paramedics together. With Fire services, often all Fire Personnel are trained up to the level of EMT, and one person is trained to the level of Paramedic.

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What is the difference between PTOs and Paramedics

August 4th, 2010

Paramedics and PTOs (Patient Transport Officers) both work to transport patients in an Ambulance to and from hospitals. However, Paramedics are utilised to attend emergency patients in the pre-hospital care environment, where as PTOs are primarily used to transport patients from one hospital to another or “pre-booked” patients from a nursing home or their individual address to the hospital. PTOs often have the medical background at a level of an Advanced First Aid Certificate, or a Industrial First Aid Certificate, as well as ongoing training in First Aid and basic resuscitation.

Some states in Australia use public Paramedics and public PTOs in the same organisation, some states however, like Victoria have privatised their PTOs so that private companies transport low risk patients to and from hospitals. This has resulted in more Paramedics and Ambulances to be available to attend patients in medical emergencies.

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What is the Difference Between Paramedic and ICP?

August 4th, 2010

Both Paramedics and ICP Paramedics are Paramedics highly trained in providing emergency care to ill or injured patients in the pre-hospital care environment. Depending on which country or state you live in, ICP Paramedics (Intensive Care Paramedic) provide intensive care to critically ill or injured patients.

In NSW the Ambulance Service has both Paramedics and Intensive Care Paramedics.

In Victoria the Ambulance Service has MICA, which stands for Mobile Intensive Care Ambulance.

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What is the Difference Between Paramedic and EMT

August 4th, 2010

Both Paramedics and EMTs work from Ambulances and spend their day medically helping sick and injured people. However, EMTs (Emergency Medical Technicians) are usually less qualified than Paramedics or Intensive Care Paramedics. Depending on which country you go to and even which state, EMTs have different levels of training ranging from short courses through to 1-2 year traineeships. Paramedics however, usually have completed a three year traineeship and often have tertiary qualifications to ensure that they can provide a very high level of care to their patients.

Both EMTs and Paramedics are qualified to diffibrilate and treat a patient during a Cardiac Arrest; however, Paramedics are often capable of providing advanced airway interventions such as endotracheal intubation and advanced cardiac drugs such as amiodarone, lignocaine, adrenaline, and atropine.

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You Know You’re a Paramedic When (Definitive List)

August 2nd, 2010

You Know You’re a Paramedic When: (the Definitive List)

1.      At social gatherings you drool at anyone with nice fat veins.

2.      You think anything less than 4 days off in a row isn’t worth having

3.      You see any person with a welfare card as your “employer”

4.      You at all your friends and realize they work for an emergency service or a hospital

5.      You marry a nurse

6.      It drives you absolutely nuts when someone calls you an “Ambulance Driver”

7.      For those of you who have worked on-call: when your 4 year old daughter knows the work phone as the “money” phone.

8.      You ask yourself “what should I have for lunch” while attempting to pick up an extra piece of a limb at a motor vehicle accident

9.      You start to match songs to different diseases

10.  You arrive at home in your own car after work, and attempt to mark yourself “At Station” on an imaginary MDT.

11.  You know that when a kid has been injured the person who will take up most of your time managing at the scene will be the parent, regardless of how sick or injured the child is

12.  You really believe that the Ambulance lights and sirens are in fact an invisibility cloak that makes it impossible for cars to see you and get out of your way

13.  You see sirens as an annoying sound… that you’d rather not have to use

14.  You attend a regular patient, and play the game “how much of the patient health care record can I complete before I get there”

15.  When you arrive at a call and your first impression is, Umm why am I here.

16.  You thrive on serious trauma.

17.  You have an entire closet dedicated to uniforms

18.  You lay your uniform, including socks, underwears, shoes, watch, and Ambulance keys down beside your bed in preparation for the “Big Job” – even when you’re off duty.

19.  You spend many nights laying on a layzee boy!

20.  You have withdrawal from not wearing green on your days off!

21.  You know that Full Moon = Insanity.

22.  When you’re always checking out peoples’ veins for IV access.

23.   Unconscious = cooperative.

24.  You’re up at 2:00 am on Facebook, all in a day’s work.

25.  Random phones and buzzers send your heart into VF

26.   A few quiet days in a row equals an excellent call.

27.   When you and your partner are the only ones not panicking in the room.

28.   When you don’t let anybody get between you and the exit route at social gatherings.

29.   When you tell people to standby one.

30.   You get back pain just looking at really fat people!

31.   You answer questions with “Roger” instead of “Yes” regardless of whose asking them.

32.  Your dinner conversations often migrate toward that really messy trauma or explosive diarrhea call and you won’t lose your appetite.

33.   If, every time you drive somewhere, you ask your travelling companion “You wanna drive, or attend?”

34.   If you’ve ever conducted a practical joke using oxygen tubing.

35.  If you have use lignocaine gel on people’s phones, car handles or any door handle

36.  If you find skipping with an oxygen tubing a good form of exercise

37.  If you think getting off the layzee boy and answering the phone is a good form of exercise

38.  When someone needs a plaster and you pull out a trauma kit.

39.   When your home first-aid kit consists of OP airways, maternity kits and bag and masks!

40.  When your quick remedies kit for a hangover includes: 1L of Hartmann’s and a Maxalon

41.  When you’ve wanted to hold a seminar on ’Suicide – How to Get It Right The FIRST Time.”

42.   If you and your partner have discussed dinner plans over a dead body.

43.   When you have come to the conclusion that you are sicker than 3/4 of the people you take to hospital.

44.   You know you’re a paramedic when you wash your hands before using the bathroom.

45.   When you wipe your feet on the way out of people’s homes.

46.   When you back into parking spaces on your days off.

47.   When you are watching TV and get annoyed and point out all the inconsistencies of the TV medics.

48.   You spend your days off thinking about the calls the guys on shift are getting: the calls YOU are missing.

49.   All of your best stories start with “There was this one call where…”

50.  All your “funniest” stories are considered vulgar and disgusting

51.  You tell the best story ever, and you’re the only one who can see the humor in it

52.   You can put together a complete sentence using numbers and acronyms.

53.   “LOL” doesn’t mean “laughing out loud” but rather it means “little old lady.”

54.   You have at least one “things up people’s butts” story.

55.  You often finish a story with “and then he died”

56.  When you think you did a great job… even though the patient still ended up dead

57.   You’re covered in some bodily fluid or another more often than not and it doesn’t bother you.

58.  You’re tempted to use “oxygen therapy” on all annoying people, not just patients: an O2 tank over the head fixes everything (especially in combative patients).

59.   You find random pairs of gloves in every pair of trousers you own, whether they be uniform or civvies.

60.   You want to throw something at the TV when they shock asystole on some TV show.

61.   When hot spots are not areas of heat in a babies bottle.

62.   You refer to your ambulance as a “bus.”

63.   You have perfected the art of responding through rush hour traffic, with a burger in the one hand and a drink in the other.

64.   You hear a siren and you know exactly what service or vehicle it is.

65.   It drives you nuts when some ignorant fool calls you a first aider. (This is even worse than being called an ambulance driver.)

66.   You cringe when you arrive on scene and someone says you will need a chair or the patient can’t walk – umm… I will make that decision!

67.   When you come home in a clean uniform after a 24- hour shift and your spouse automatically becomes suspicious of your whereabouts.

68.   You and your partner are deciding what kind of burger to order after the call while your patient is projectile vomiting!

69.   You remember every patient by their injury or disease and not their name.

70.   You trample over people to get out of the coffee shop, fly through traffic for “SOB (shortness of breath) and chest pain” only to arrive on the scene to find a sharply-dressed senior citizen who walks up to the ambulance and says,” Good! I have an x-ray appointment in ten minutes!”

71.   You get called out for abdo (abdomen) pain at three in the morning to find your “patient” at the gate with their bag packed, and the whole family waiting to wave good bye.

72.   When hearing there is a doctor/nurse on scene, you consider it a bad thing.

73.   You’ve ever had an altercation on scene with a rubberneck.

74.   You crouch down in your car as you go past accident scenes so the crew already there won’t see you.

75.   You can’t put up IV lines unless everything is shaking around.

76.   You know at least 3 alternate routes to any place you are going.

77.   You’ve ever blown up a glove and drawn a face on it in the hopes it will stop your pediatrics patient from screaming.

78.   You can skip to the head of the line at the local Burger king or McDonald’s because you’re in uniform.

79.   It drives you nuts when a driver only says they’re a “Paramedic.”

80.  You resuscitate a regular patient and honestly question whether or not you have helped the community at all

81.  You don’t know how to operate all the nursing machines, but you can easily identify and utilize the silence buttons

82.  You describe a hospital gown as a “nice backless number”

83.  You know every party drug ever invented and what the “popular” ones are this week

84.  You believe that most occupants of an MVA don’t have a spinal injury

85.  You deliver a 17 year old’s baby and think “wow… she made to 17 before she got knocked up… good for her!”

86.  You’ve never worked out the importance of taking a diastolic blood pressure

87.  Believe all patients lie

88.  Although, unable to speak any other language, are adeptly fluent in all hand languages to signify that the patient can walk out to the Ambulance

89.  Know that its easier and more accurate to check a patient’s medications than to ask them what previous medical illnesses they have.

90.  Have been caught out at some stage by suggesting that you will decide if a patient can walk or not, only to find that they have a broken leg.

91.  You’ve looked at a drunken patient and thought “they called the wrong emergency service…”

92.  You often ask your patient to “wait in the waiting room” while you talk to the triage nurse

93.  You class CPR as one of your weekly exercise workouts

94.  You often take first note of what’s on another Paramedic’s shoulders

95.  You’ve walked into a patients house with just a BP cuff and argued that really, you’re over-prepared

96.  You’ve described a patient who has suddenly died as having made “a good innings”

97.  You’ve made jokes, which you have honestly thought were funny, about a funny way in which a patient has died

98.  You’ve had to explain to a triage nurse that the reason that you’ve come to their hospital is “because they’re a public hospital and you have a public patient

99.  You know that there’s no correlation between what you have been called to and what you are actually going to

100. You know that the only real use for the Ambulance lights and sirens is to entertain the kids who watch as you go by

 Australian Paramedic…

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The Need for Paramedic ECG Interpretation Debate

August 2nd, 2010

The importance of paramedic ECG or IKG (in the US) interpretation is debated amongst clinical practitioners, doctors, paramedics, ambulance officers, EMTs and other members of the health community. There are multiple arguments that promote ambulance paramedics’ being capable and regularly thoroughly interpreting ECGs and similiarly many arguments stating that paramedics only need to know those ECG rhythyms that they can actually do something about. These are the arguments that have been debated over the years… I’ll let you decide:

1. There is the argument that the only real ECG rhythyms that paramedics need to interpret and identify are those, which paramedics can actually do something about, such as ventricular fibrilation (VF), ventricular tachycardiac (VT), and those which there is little that can be done for such as assystole. More in depth analysis of ECG rhythyms such as 1st, 2nd or 3rd degree heart blocks, wolf-parkinson white syndrome, etc, although interesting and useful to know, will not affect the paramedic’s treatment of the patient in the pre-hospital care setting, and the delay while the paramedic attempts to identify the rhythym may be counter-productive to the patient’s health outcome.

2. Other other side of the debate, one may argue that the better the paramedic’s sound knowledge base, and diagnostic abilities, the better the treatment. Although the paramedic may not be able to treat atrial fibrilation, or a 2nd degree type I heart block, identifying it may allow the paramedic to recognise, or rationalise the patient’s other physiological findings, in order to differ treatment. For example, the paramedic may rationalise that the patient has a low blood preasure because the patient has AF and the heart is not fully filling therefore more intraveneous fluid will not actually help the situation. Furthermore, if the paramedic recognises that the patient is in a 3rd degree heartblock (where there is no correlation between the SA node firing and the Ventricals contracting) the paramedic will realise that administering atropine to increase the pule rate will not actually work.

3. Another concept has been proposed more recently as the term or role of a paramedic has changed to encompass much more community health over emergency health, and this is that by having 12 lead ECGs and a thorough understanding of the electrophysiology, a paramedic is more likely to be able to safely rule out cardiac problems, and may identify patients who do not need to go to hospital.

4. It has also been argued that by having 12 lead ECGs in the pre-hospital care setting, paramedics can realistic confirm an acute myocardial infarction (heart attack) and in doing so treat it with thrombolytics in the pre-hospital setting, therefore reducing treatment times, and myocardial damage. Although, where paramedics are not able to administer thrombolytics in an Ambulance, the increased scene time required to complete an accurate 12 ECG may be counter productive to the patient’s health outcome.

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Stories From a Rookie Paramedic

August 2nd, 2010

“Being a Paramedic means spending 99% of your time doing mundane, routine work, involving transporting patients who aren’t actually sick to and from hospitals and appointments, and the other 1% seeing things that most humans never see, and pretending that you’ve seen these things a hundred times before and know exactly what to do about them”  – Australian Paramedic

So this is what I expected for my first day on the job.

I had just finished my theory training, and it was my first day “on the job.” I started at the 0700 shift, and met my Training Paramedic Officer.  I was young, naive, eager to learn, and all too concerned with checking the Ambulance before we got the first “Big Job.” My Training Paramedic Officer was concerned with making a good cup of coffee and sitting down to read his newspaper, before we were rudely interrupted with the “Big Job.” At 0705 the phone rang. John, my Training Paramedic Officer looked over at my excited expression, and said: “That’ll be the sign on call.” It wasn’t…

We were called to a 16 year old boy, found unconscious in the backyard after apparently being involved in the consumption of a lot of alcohol the night before, not breathing, and without any pulses, while his brother was attempting CPR.

John looked at me, “Okay, here’s your orientation to driving lights and sirens… as the passenger, your job is to watch for cars coming from the intersections on the left (Australians drive on the left side of the Rd). Acknowledge “Clear” or “Stop” if you think a car’s not going to stop. I’m not going to be looking on the left side… so if you want to avoid being hit by a car on your side, you’d better pay attention…”

I paid a lot of attention.

As we rapidly progressed through the busy city streets, lights and sirens blaring, I felt as though I was on a roller-coaster ride for the first time in my life, and unable to interpret all the information that appeared to be buzzing in from all directions…

Overtaking cars, trucks, cyclists…

Driving through red lights, and listening to the multitude of cars, driven by people not yet fully awake, who are honking their horns, in complaint of the vehicle in front, which has stopped – for no apparent reason, oblivious of the Ambulance desperately making its way through.

Trying to weave our way through a large procession of early morning, city dwelling pedestrians on their way to work, with I-pods in their ears, blissfully ignorant of the Ambulance desperately trying to get through, John looks over at me “Do you want acknowledge all that?”

I feel like I’ve fallen asleep and just woken up in the middle of giving a speech at the point in which I’m about to identify the brilliant solution – completely unaware of what I was meant to say.

“Acknowledge what?” I ask, sheepishly.

John calmly looks over (as though he doesn’t have enough to think about/look out for while driving fast through the busy city streets)… “Weren’t you paying attention to the radio?”

While trying to interpret all the other excessive information… my ears didn’t mention to me that despatch was giving me specific information about my patient…

After all – I was still trying to remember how to set up the resuscitation equipment…

John grabbed the radio and acknowledged the information.

Suddenly, the ride stopped.

We were at the scene. There was a neighbour urgently waving both hands, as though his urging could somehow speed up our presence.

We grabbed our gear… and followed the man around to the back yard.

In the middle of the yard, we found a young man, stiff as a rock, cold, and very clearly deceased from the night before. My Training Paramedic started to explain to me that this patient had obviously died during the night and then proceeded to place the cardiac monitor dots on the patient. This was part of policy, with any deceased patient, to ensure that he/or she was in assystole (the flat line on the monitor that means there’s no electrical activity in the heart). We did this, even in patients who had clearly been dead for some time and no amount of resusciation efforts would ever help bring them back.

To our surprise… the monitor started to beep.

The rhythm was almost completely normal.  My Training Paramedic looked at me, as though somehow I had made a mistake putting the ECG dots on, as though it must be my fault – because obviously this patient was dead, and there could be no electrical activity anymore.

No…. the monitor doesn’t lie… this person’s heart was still firing its normal electrical currents – but the heart just wasn’t doing what its supposed to and actually beating (this is called EMD – Electrical Mechanical Disassociation-, or PEA – Pulseless Electrical Activity).

We immediately start CPR – with me doing chest compression, and my Training Paramedic ventilating the patient.

The Intensive Care Paramedics then arrived, and while one of them inserted an ETd tube into the patient’s trachea to breath for him, the other Paramedic inserted an intravenous cannula into the patient’s jugular vein (neck vein) and started to administer adrenaline.

Within five minutes the patient’s heart spontaneously started to beat on its own… and the patient had a good, strong, pulse…

We quickly loaded this patient into the Ambulance… he starts to moan… and with both arms reach for the ET tube…

Everyone talks about Ambulance Miracles… and this appeared to be one of them, because this guy was dead… I mean… his arms were that rigid when we got there that we couldn’t move them at all…. and now, we were fighting with him and trying to tell him not to pull the tube out because it was helping him.

About five minutes from hospital… the Ambulance miracle ceased… and the monitor shows that the patient is now in assystole (flat line, like the movies)…

CPR is immediately commenced – and the Intensive Care Paramedic says to me… “this is your baptism of fire mate… every Paramedic’s gotta learn to do CPR in the back of a moving Ambulance at some stage…”

The patient’s condition remained unchanged.

At hospital, the medical teams continued to work on the patient for another half hour and then pronounced him dead…

I talked to my training paramedic while I was given the rookie job of cleaning the Ambulance and re-setting all the equipment, and asked what he thought had happened to the young man…

“Mate… there’s another learning lesson for you… sometimes the srangest things happen in this job… and that’s all there is to it… no explanation no rhyme or reason why one patient dies and another lives…”

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Paramedic… I See Dead People

August 2nd, 2010

They say that the more you do of something the more that you will see it… for example, you decide you like the new model Audi… then wherever you go, you seem to see the new model Audi. The question then becomes, was the new model Audi everywhere in the first place, and you just didn’t notice it, or is it turning up everywhere now, just because you’re interested in it… I don’t know… and this all seems too wishy/washy a topic, but from my own experience and that of other paramedics that I know…

I find that since I became a paramedic and started to go to sick and injured people everyday, I seem to always see sick or injured people while I’m off duty.

This is a compilation of stories are some of the more ridiculous events I’ve had since I beaome a paramedic and have been off duty, around home or about. For a period I worried that I kept on killing everyone around me (or hurting), but I look at it more possitively these days, and believe that these people were going to die whether I was around or not, and it was good luck that I was there to help them. You decide…

1. Its a quiet day at work, and my partner and I take the Ambulance and go for a cup of coffee… an old lady walks in and looks at us, and then suggests that it must be a quiet day. I acknowledge her, and she sits down and orders a cup of coffee. Two minutes later, the waitress comes over and tells us that the same lady is feeling unwell and can we come have a talk to her. I come over and ask her what’s wrong, and if she’d like our help…  she looks at me, and says “I don’t feel very well…” and then immediately vomits, large, copious amounts of frank (arterial red) blood. She had undiagnosed oesophageal viracies, which had just ruptured. We did everything we could to make her comfortable and got her to hospital. Within ten minutes of arrival at hospital she died from blood loss. It all happened so suddenly, had we not been there when the oesophageal viracies ruptured she would have been dead by the time we arrived.

2. I’m driving back from a paramedic course… I’m wearing my uniform, only because I hadn’t gotten around to changing yet, and was on my way home in my own private vehicle. I’m flagged down by an SES person (State Emergency Services), who tells me I can’t drive through… there’s been a bad accident… he then tells me that there’s no phone reception and he can’t call 000 (the Ausralian emergency phone number)… he then suggests that I drive back about 15kms and try to call 000 from there… at this point, he notices the uniform that I’m wearing…

The off duty paramedic now recognised… the off duty SES worker decides to drive back to get help… so I find myself, without any equipment, in the middle of nowhere, with a car that has rolled off an embankment and is now laying 80 odd metres down the gentle mountain slope…

I tentatively wonder down the hill and calmly ask “is anyone’s in the car”… no- response… then yell as I get a little closer…” can anyone hear me?”

To this, I get the answer… “I’m okay, I’m just trapped… and upsidedown… can you help?”

I wonder down and find an older lady, upside down, and stuck by her seatbelt… fundamentally unscathed…

She looks down at me… “Wow… you guys got here quick!”

I inform her that I was just driving by…

After several failed attempts to free her… I wonder back up the hill… find a small knife (in my car tool kit… ) and come back down to free this damsel in distress…

She ended up virtually injury free (the car wasn’t so lucky)…

3. I’m doing my shopping on my way home from work (again, in my uniform… why do I wear this thing?)… I casually chatting to the check-out lady, who appears to be a little short of breath… I politely ask her how she is… and she tells me that she’s been feeling crook most of the afternoon… “oh, you poor thing… just a cold or something?” I ask conversationally… “no… I have had this funny pain in my chest…”

A small part of me thinks maybe I should stop there and politely avoid asking anymore questions that will inevitably lead to me having to call an Ambulance… but I was away at school when they were teaching young kids the value of discretion and leaving things alone…

So I ask “tell me abit more about this funny feeling in you chest…”

Within minutes I acknowledge the fact that this lady is having a heart attack and organise calling an Ambulance…

She was later taken to a major hospital, where it was confirmed that she was having a myocardial infarction (heart attack) and was taken to have an angiogram, where she had cardiac stents inserted and made a full recovery…

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Paramedic… I See Stupid People

August 2nd, 2010

This is a list of things that I have seen as a paramedic that identify “stupid people” – I make no appology to the stupid people in this article… I also wouldn’t worry if you think you were one of the people in this article, because most of the things that have occured here, have occured many times previously…

As I said before… as a paramedic… I see stupid people…

Paramedic  – Stupid People Story 1

I looked after a 45 year old female, who had only ten minutes earlier chided her son for wanting to lick the dangerous end of a electric cake mixing hand held blender. She then attempted to lick just a little bit, that was evidently irresistible. Unfortunately, the power was still on, and she ended up twisting her tongue around in positions that aren’t normally possible. It ended up taking more than 6 hours of surgery to remove all the bits of the little blade from her tongue and stitch her tongue somewhat back together again.

Paramedic – Stupid People Story 2

I looked after a 32 year old man who had been driving an enormous quarry truck – you know those trucks used at mines with wheels that are taller than most adults? Well, he had raised his dump tray (about 90 feet into the air) so that he could dump his load of dirt. And then, without lowering the tray, continued to drive away, until, several kilometres later, he tried to drive under a bridge at 80km/h – causing the up-right dump tray to collide with the bridge and flip the entire truck.

Paramedic – Stupid People Story 3

Patient walks into the Ambulance station, huffing and puffing… “I need an Ambulance”

Paramedic: “Okay, what’s wrong”

Patient: “I have terrible chest pain”

Paramedic: “Have you ever had this pain before?”

Patient: “Yes”

Paramedic: “What was it then?”

Patient: “The Dr said it was a heart attack”.

Paramedic: “Okay, when did this start?”

Patient: “About two hours ago…”

Paramedic: “Okay, so why didn’t you call us then?”

Patient: “I decided to walk to the Ambulance Station (about 3kms away).

Paramedic: “Why didn’t you call us, instead of walk here?”

Patient: “The Dr said that walking was good for the heart.”

Unfortunately, this poor patient  had a cardiac arrest and died two days later in hospital.

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Paramedic Medical “Attacks”

August 2nd, 2010

Paramedic Medical “Attacks”

Anyone who has ever worked for health, either as a nurse, doctor in a hospital or a paramedic, ambulance officer or EMT in the pre-hospital setting, easily recognises the severity and the difficulty of managing a paramedic medical “attack,” which often afflicts un-suspecting individuals, and almost no amount of paramedic intervention may resolve these ailments. This is a definitive list of paramedic medical “attacks:”

1. The “Asthma Attack”

2. The “Panic Attack”

3. The “Anxiety Attack”

4. The “Heart Attack”

5 The “Transient Ischaemic Attack”

6. Th

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Tricks of the Trade by Older Paramedics

August 2nd, 2010

After you have been a Paramedic for a few years you will have made mistakes and probably learnt from them. These are a few of the odd little tricks that I have learnt since I started as a Paramedic:

  1. If you’re going to administer GTN (Anginine) to a patient who has never had it or another nitrate (the class of drugs used to dilate coronary arteries) before, try to get them onto the stretcher if this is possible before administering this. Obviously, you do not wish to delay nitrate therapy in a patient with suspected cardiac related chest pain; however, if it is the matter of a couple minutes, it may work out in your favour to wait and administer it to them once they’re on the stretcher. This is because, unlike elderly patients who may have had nitrates hundreds of times before, if you administer it to a person for the first time, they are very likely to have a significant drop in blood pressure, and end up either laying down, or unconscious. It is therefore much easier to deal with this if you get them onto the stretcher first.
  2. If a patient tells you that they don’t have any previous medical problems whatsoever, ask them if they take any medications. Often, people don’t acknowledge that they have any medical problems, because they see the fact that they take medications for them, means that they no longer have the problems.
  3. If you’re having trouble differentiating between pleuretic and cardiac chest pain, ask them to point to the pain with one finger – if they point to one specific spot and describe it as a sharp stabbing pain, it is most likely pleuretic in nature, if they point to an area, not a specific point, it is more likely to be cardiac in nature. At any rate, if you’re unsure at all, treat the patient for cardiac chest pain.

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Most Annoying Questions to Ask a Paramedic

August 2nd, 2010
  1. Do they ever let you treat the patient? Or do you just drive?
  2. You must see some terrible things?
  3. Have you ever seen a dead person?
  4. Where did you study to become a driver?
  5. Did you ever want to study and become a registered nurse or doctor so that you can treat the patient?
  6. Have you ever been to a bad car accident> 

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Lies Told by Patients to Paramedics

August 2nd, 2010

The following are common lies told by patients to the paramedics who are treating them and trying to save their lives in an emergency. Paramedic are not the police, we really don’t care what drugs you have taken, or how stupidly fast you were trying to drive, we just want to know your mechanism of injury so that we can treat you appropriately.

  1. I’m not allergic to anything
  2. I’ve got no previous medical history
  3. I was unable to make an appointment with my doctor
  4. The pain is 10 out of 10
  5. I can’t walk
  6. I have pain in my neck
  7. My GP told me to call an Ambulance

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Lies Told by Paramedics to Patients

August 2nd, 2010

I would always advocate honesty first for any paramedic. But at times… paramedics are known to lie to patients (and other paramedics).

This page pays tribute to the worst and most common lies told by paramedics to their patients and colleagues:

  1. Oh, this… yeah, I see this sort of stuff every day
  2. I know where I’m going
  3. Yes, I re-stocked and checked the truck
  4. Its only a little wound
  5. Its okay, I’ll cut along the seems
  6. We wear these gloves, gowns and masks for every patient, to protect you, not us
  7. This will only hurt a little
  8. I’ve done this procedure before

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Hypothetical Paramedic Case Studies

August 2nd, 2010

I intend to publish regular hypothetic paramedic case situations as a means of sparking debate about how a patient should be treated in order to obtained optimum levels of care. If you enjoy this, you may wish to see my wish to follow my weekly paramedic ambulance case reviews.

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Knife in the Head True Story

August 2nd, 2010

This was one of the funniest paramedic stories that I can tell you about in my past decade working as a paramedic. What makes it particularly humorous is how serious it all started off.

Despatch: “Car 688 – we have a 92 year old female with a possible, accidental stabbing to the head with a large knife.”

Car 688: “Thanks, we’ll stand off until Police are on scene for this one”

Despatch: “Negative – patient is a 92 year old female, who has accidentally stabbed herself in the head – Police not required.”

Car 688: “Thanks, we’ll be standing off until Police arrive – if this person has a large knife and is disturbed enough to stab herself, she’s likely to stab us.”

Despatch: “Negative, this has now been confirmed as a definite accidental self stabbing to the head – please attend without Police.”

I look at my work partner, as though to ask, is this dispatcher an idiot? “What do you think?” I ask my work partner. He smiles, and says: “They must know something we don’t know… we’ll go have a look.”

When we arrive, we have cursory look around the scene from the safety of the Ambulance. There’s no-one around – so I tentatively approach the front door, with my first aid kit in hand ready to throw at any knife wielding crazy granny, I put part of my foot on the screen door to stop anyone bounding out with a knife. I then knock at the door and state: “Hello, Ambulance… Did anyone call an Ambulance?”

At this point, I’m greeted from behind the screen by a polite, softly spoken, 92 year old lady, with a face covered in blood, and a large kitchen knife stuck 8-10 centimetres into her skull. She smiles and says: “I’m okay, I’d just like someone to take this thing out of my head.” From the position that the knife is penetrating her skull, I believe it to be impossible for her to have done this to herself, so I ask “Is there anyone else in the house? Do you know where the person who did this to you has gone?” She replies: “No, no, there’s no-one here dear… would you like to come in for a cup of tea?” A cup of tea, she asks me? Is she kidding, does she not realise that she has a giant knife sticking out of the top of her head? 

Eventually, she convinces me that its safe to come in and I ask her to sit down, while I assess her. My partner has a look around the house and sees a lot of red throughout the kitchen – hmm, that’s not good… fortunately it’s a small house, and my partner is able to quickly determine that there’s no-one else in it.

So, I get to ask the number one question: “Can you tell me what happened?

She then proceeds to explain how: “It’s Australia Day dear… and I never had kids… and Patty, well, she died last week, so I don’t have many people left around… so, I thought, I’m going have a really nice bottle of wine by myself (Grange $500+ a bottle). But then, when I got home, I couldn’t find a bottle opener… so I tried to pry the cork out with this knife… I still couldn’t get it open… so I then got a hammer and tried to hit the knife with the hammer (lightly) so that the cork popped out… but I still couldn’t get it out and got frustrated… so I decided to hit the knife once, really hard and hope it would cause cork to pop out….

Unfortunately, as I hit the knife, and the cork popped out, the knife ricochet off the bench, into the air, and landed directly on my head… and now… dear… I can’t seem to get the knife out of my head!

The patient had the knife surgically removed later that day and was discharged from hospital with no complication in two days time.

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How to Work for Bureaucracy

August 2nd, 2010

I know it can be difficult working for a bureaucracy, and working as an Ambulance Paramedic, Emergency Medical Technician, is no different to any other major bureaucracy. So, if you’re a Paramedic, you’re likely to work for a Bureaucracy and have an incompetent Bureaucrat for a boss. Fortunately, there is a simple way of doing everything in a Bureaucracy, and these easy steps will actually make it easy to succeed in a bureaucracy:

  1. Find the policy – Bureaucracies love policies, procedures, or standard operating procedures (SOPS). If you want to get something done, you have to find the form that says you can do!
  2. Fill in the forms completely – nothing is easier for a Bureaucrat than stamping – “Denied” or “Rejected” on a form that has not been completely filled out! Even if the information is clearly not relevant, or redundant you must write N/A or repeat previous information, so that the form is completed.
  3. Follow the correct procedure in submitting the form – just as it is important to completely fill in the form, it is compulsory to follow the correct policy in submitting it. Now, every Ambulance Service is different – but from my experience, if I want to apply for anything, I have to follow a certain chain of command. In this case, I have to complete the application forms and send them to my manager who then sends them to his manager and so forth until someone either succeeds in rejecting my application, or fails and allows me to have what I have applied for.
  4. Lastly, Bureaucracies hate change (just don’t do it to them!). Therefore, if you want to change something, you have to find a form which somehow suggests that you should change something, and then slowly (always very slowly) you need to suggest to senior management that “they” are the ones trying to change a certain aspect of the work, and that “you” the Paramedic are willing to help “them” achieve “their” goal.  

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How to Safely Leave Your Patient at Home

August 2nd, 2010

Although our role as Paramedics has become more dynamic and evolved dramatically over recent years, fundamentally, our role has been and will always be to transport patients to hospital (even those who aren’t actually sick). Now, in certain circumstances, people genuinely just panic and call for an Ambulance, and once they have been assessed and reassured, are probably better off staying at home. These are the patients, more than any others you attend who have the potential to die, leaving you the difficult job of explaining to the coroner why you didn’t do your job and transport them to hospital. By following these steps, you will make this job a little easier:

  1. Don’t go into the case assuming that you’re going to convince the patient to stay at home – if they really want to go to hospital, you’re just creating more work for yourself trying to convince them to stay. You may as well start driving them to hospital. This is even more so the case on nightshift, when you’re tired, and you just want to go back to bed. Remember, patients who have been taken to hospital can’t call you again (at least not for the next few hours!).
  2. Make sure you’ve resolved whatever the problem was that they called you for in the first place – if they’ve called you about a rash that they’ve had for 3 weeks, but only now have called an Ambulance, its no good, just telling them that this isn’t an Ambulance case. Give them options on what they can do tomorrow or later, such as contacting their GP (Sometime, people call Ambulances simply because they honestly don’t know another way of solving a problem).
  3. Complete a thorough an full assessment of the patient (I know you want to go back to bed, but this is important). As a general rule, I will do a more thorough assessment of a patient I’m going to leave at home than one I will take to hospital. This includes: Pulse, BP, Resp Rate, GCS, ECG, BSL, Temperature, Pain Score, auscultate the lungs. If you assess all these, and nothing stands out as being un-usual – its pretty safe to say that they do not have anything acutely wrong with them that can’t wait until the morning. Also, it makes patients feel like they’re getting their money’s worth out of you – many probably wont have had this much of an assessment by their General Practitioners.
  4. Thoroughly document everything – more important than simply doing a thorough assessment of your patient, you must document that you have done so (the results of this assessment is your justification for leaving the patient at home). 

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How to Drive an Ambulance as a Paramedic

August 2nd, 2010

Driving an Ambulance as a paramedic is very different than driving your everyday car home from work or going for a Sunday drive in the country. The days of putting a patient in the back of the “Meat Truck” and racing them to hospital are over.

Don’t get me wrong… at times we like to scoop and run with the trauma patient, but ultimately, you have the patient and you’re partner in the back of the Ambulance and you’re not going to do them any benefits if you end up involved in a motor vehicle accident yourself.

Driving an Emergency Vehicle

These are the things that I think about when I drive to a patient (under lights and sirens in an emergency situation):

1.  First and foremost, at the end of this shift, I want for my work partner and I to come back home alive, well, and uninjured.

2. I determine why this job has been designated as an “emergency” that requires lights and sirens. I’m not going to start driving lights and sirens through the busiest parts of town if the patient has had a “stubbed toe for 3 days.” It just doesn’t make sense.

3. I then work out the fastest route to the patient (this not necessarily the shortest distance – think about highways and the streets that you know will have a lot of traffic at this time of the day, which you want to avoid. I don’t leave the station until I have worked out the fastest route to the patient. Often, if a paramedic tries to rush and looks up the address on the way, it takes longer than if they had spent the time required in the first place to work it out at station.

4.  At all times, I consider this: “Do I feel safe right now?” If the answer is no, or I find myself getting nervous, then I know that I’m going too fast, and taking too much of risk, irrespective of what the “emergency” is that I’m going to. Does my partner look comfortable? If he or she appears to be hanging onto their seatbelt around corners or trying to brake on an imaginary break – then you are probably going too fast.

5. While driving, if the road is not separated by a medium strip, I will position the Ambulance slightly to the wrong side of the road. This allows two things to occur. First, it forces people on the other side of the road to pull over, which often causes the cars in front of you to wonder what’s going on, hopefully look in their rear-view mirrors and notice you. And secondly, it gives you a little bit of extra room to manoeuvre, if the person in front of you all of a sudden jams on their brakes.

6. I never get too close to the cars and trucks in front of me, they are likely to do the most erratic and strange things in response to the lights ands sirens. Also, the closer I get to the truck in front of me the less I can see ahead and the less the oncoming cars can see me.

7.  I never forget that vehicles are driven by people, and people never react well to things out of the ordinary (such as Ambulances driving under lights and sirens).

8. When I approach an intersection, I slow right down (almost to a stop), change the sound of my siren to project sideways instead of forwards so that the cars coming through the intersection have a greater chance of hearing them (if your Ambulance has this feature). Because I’m in Australia, and we drive on the left side of the road, my partner will look at the left window and either state “Clear” or “Stop,” depending on traffic. It is important that they do not say anything other than “Clear” or “Stop,” because this can easily confuse the issue. I look out the right side. And we slowly progress through the intersection. Once on the straight road again, I will change my siren to project forward.

When I arrive where the patient is, I park so that the Ambulance is facing in such a direction that, if required, I can immediately drive off again. This is a safety issue. I don’t want to be trying to do a three-point turn to get out when someone is attacking me.

These are the things that I think about when I drive a patient to hospital:

First and foremost, at the end of this shift, I want for my work partner and I to come back home alive, well, and uninjured. This is especially important when my partner may not be restrained in the back of the Ambulance.

Anyone in the back of the Ambulance should be restrained. In the case of the patient, the patient is always restrained with seatbelts. There’s no point taking someone with a broken arm to hospital and endangering their lives by not applying seatbelts. The Paramedic or Paramedics in the back of the Ambulance should primarily wear a seatbelt throughout the whole transport to the hospital. However, there are times where this is not possible, such as changing oxygen tubing, suctioning, getting more equipment or drugs which are stored at the front of the Ambulance, or while doing CPR. At these times, the drive must be especially mindful of their safety.

Unlike driving to the hospital in which both Paramedics are sitting in comfortable seats and get see out the front windscreen, on the way to hospital, you have a patient, who is most likely travelling backwards and a Paramedic who, at times may be standing up. Therefore, the goal is not necessarily to travel the fastest, but to travel with a stable platform. This means not accelerating suddenly, or breaking suddenly. Leaving a much greater “safety margin” between you and other vehicles on the road. Reacting to street lights and braking cars much earlier, by taking your foot of the accelerator much earlier, instead of braking at the end.

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How to Cannulate in the Back of an Ambulance

August 2nd, 2010

Like everything else you do as a Paramedic, you have to ask yourself if this procedure is necessary. Do I need to cannulate this patient? Sometimes they need a drug to be administered intravenously, sometimes they are at a high risk of deteriorating and need a cannula for precaution. Whatever the case, ensure that you do not spend excessive time at the scene attempting to cannulate at the detriment of the patient.

Once you’ve decided to cannulate the patient there are a number of steps you may take to make the procedure much easier for yourself. You should determine if you need the cannula before you can move the patient, or wether you can wait and cannulate him or her in the controlled environment of the back of your Ambulance. Ultimately, you must follow your own Ambulance Service’s procedures, but these are the steps that I  follow as a paramedic to make the process easier:

Reassure the patient and explain what I’m going to do and why I’m going to do it. One of the most important aspects to cannulating a patient is getting the patient’s consent and trust. The patient isn’t going to consent to a paramedic putting a cannula in because he or she needs the practice. So tell them why you need to insert it: for example, “I’m going to put a small needle in the back of your hand so that I can give you morphine and take away your pain.”

Make sure the environment is exactly as you want it – unlike a Doctor in a hospital, as a paramedic your environment is rarely controlled, so you have to modify it to make it easier for you to cannulate. If you can turn on extra lights in the room, or get someone to hold a torch on the side of the road that may help. I put a tourniquet on both arms, and get comfortable so that I’m not in an awkward position while I’m cannulating. Canulation involves some fine motor skills, and the easiest way to do this is to make yourself comfortable.

I continue chatting to the patient (or taking more of a history) while I get everything out of the drug kit and ready for use. This includes cannula, cannula reflux valve (bung), something to tape it in with, and of course ensure that the sharps container is open and easily accessible. If you’re going to cannulate in someone’s nice clean house it’s a good idea to put down a bit of cloth (bluey) or something to ensure that you don’t accidentally spill any blood on the floor, bed, or anything else (if this occurs, you will not only look un-proffesional or incompetent, but also they will remember the mess you made of their carpet and the cost, irrespective of the benefit you gave their family member). It is important to keep the patient focussed on something other than the fact that you’re about to put a needle into their arm, hand or leg. Also, it makes you look more comfortable with what you’re doing, and relieves the patient of the fear that this is the first time you’ve ever done this before (even if it is).

Okay, now I start to actually determine where I’m going to insert the cannula. The right arm is my preference if possible (only because this is closest to the paramedic seat and I get to avoid reaching over the patient). I then look for the back of the hand (this generally seems to hurt the least), followed by the forearm, which I like because it is a long straight part of the arm, that makes it less likely the patient will accidentally knock it out once I’ve put it in. Lastly, I’ll take the large veins of the cubital-fossa. I look for straight veins, wide veins, veins without bifurcations (separations into two veins), which often have venous reflux valves that cause nothing but trouble. If I’m really having trouble finding a vein that I like I will get the patient to leave their arms drooped as low as possible causing the venous blood to fill the veins. Personally, I have found that lightly slapping the back of the hand will help irritate the veins, causing a very mild inflammatory reseponse which releases chemical mediators which cause vasodilation and makes for easier cannulation (however, there is evidence to suggest that this ultimately makes it harder to insert the cannula; but in my experience this is a tried and true method of bringing a vein up). If I find a small vein that I don’t quite feel comfortable cannulating, I will follow it up and “milk” the blood into the vein so that I have a nice easy wide vein to cannulate. You will find some good paramedics who “never miss a cannula” -are so good because they always make sure that the vein is clear, striaght and has been prepared perfectly so that any paramedic can insert a cannula there.

Use the right cannula – it always amazes me that a paramedic will try to shove a large bore cannula in a little vein when they are planning on using it only to administer a medication that is very small. For example, giving morphine for pain relief.

Okay, so you are now ready to cannulate – generally speaking, if the road is relatively smooth, there is no difference in cannulating in the back of a moving Ambulance or cannulating in a hospital bay (although new paramedics may perceive the need to stop the Ambulance before cannulating. If the road is rough, I will set everything up, pick a vein, alcohol wipe it, and then, get the Driving Officer to pull over just before I actually insert the cannula – this should only take 10-15 seconds. And then you should be able to continue driving towards the hospital.

Depending on type of cannula and how you are comfortable holding it, hold the cannula by the insertion pads with the thumb and fingers to insert needle into skin. Vissually inspect the cannula needle to ensure needle bevel is pointed upwards (this means that the sharpest point is going to pierce the skin and hopefully the vein).

Anchor the vein with gentle skin traction. This can be achieved through a variety of methods depending on the site chosen for venepuncture. For the hand, I traction the skin by gently holding the hand into a fist, which naturatally brings the veins to the surface and anchors them; for the forearm, I will apply gentle lateral traction of the skin by holding the arm from underneath; for the cubital fossa, I still often use the non-dominant hand’s thumb to pull on the skin. These are my methods, but whatever works for you is good too.

Insert needle at a 15-30 degree angle and wait for flashback of blood (don’t forget this may take longer if the patient is peripherally shut down).

Once blood flashback occurs, advance the needle a small amount to ensure the entire needle bevel is in the lumen of the vein.

Then lower the angle of the cannula to 10-15 degrees and slowly advance the catheter.

Remove the tourniquet, and apply pressure to the vein just proximal (above) the cannula site to ensure that the blood doesn’t pour out the vein. If you do this properly, you can generally save yourself having to clean up the spilt blood that pours out the cannula.

Remove cannula needle and place it immediately in a sharps container.

Attach cannula reflux valve.

Tie cannula in according to specific Ambulance Service Paramedic policy – remember, the sign of a good paramedic is his or her ability to keep a cannula insitu, not just insert it. There’s no point going through all the trouble to insert a cannula only to have it pulled out or fall out a couple minutes later because the patient (naturally) moves their arms or rolls over suddenly. 

Write the time and date of insertion on the cannula cover – don’t forget that this may be the only cannula used in the patient while he or she is in hospital. As a general rule, cannulas shouldn’t stay in-situ for greater than 3 days in order to reduce the risk of infection.  Most Nursing and Medical staff in Australia will remove a cannula if there is no date of insertion on the cannula to identify how long the cannula has been in-situ.

Flush the cannula with saline to ensure that it is correctly positioned and patent.

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How to be a Good Paramedic

August 2nd, 2010
  1. Actually want to help people
  2. Treat people as you would like to be treated. You will never get a complaint from someone who believes that you’re doing your best for them, but if they get the idea that you really don’t care, or have something more interesting on your mind, they will complain. Like it or not, being a Paramedic means that you’re providing a customer (your patients) a service.
  3. Do all the diagnostic tests: this means physically measuring the patient’s pulse with your hand, taking a blood-pressure, assessing their GCS, looking at their pupils, measuring their Sp02, monitoring their ECG if they have chest pain, auscultating their lungs if they are SOB, take their temperature and assess the their blood sugar levels. This serves two purposes. Firstly, it makes them feel that you are interested in whatever they have wrong with them (most patient’s probably don’t get this much attention from their GPs). And secondly, after assessing all these things, their problems should be blaringly obvious, or not acute. Either way, you know you’ve done your job.
  4. Remember, you don’t actually have to be calm, all you have to do is convince the patient that you are calm and that you have seen this and looked after this a hundred times before.
  5. Check your Ambulance properly at the start of the shift. Without fail, the one thing that you will have need at the next “big job” is the one thing that you forgot to check, and happen to be out of.
  6. Genuinely be interested (or appear interested) in a patient’s problem. Although some things may appear simple for you, it may be a serious problem for the patient 

 

 Australian Paramedic…

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How to Avoid Meeting the Coroner as a Paramedic

August 2nd, 2010

 

“There’s no such thing as a bad Case, only a badly written Patient Health Care Record”  – Australian Paramedic

This is a saying that many Australian Paramedics have used, and it does not suggest that you don’t look after your patients, but that the only physical record of the fact that you have looked after your patient well is that what you have documented thoroughly in the Patient Health Care Record.

Most Ambulance Paramedics will recognize that many hospital Nurses and Doctors don’t even look at the Paramedic Case Sheets. On the subject of continuity of patient health care, the most important thing you can do as a conscientious Paramedic is give a good hand-over to the Nursing or Medical Staff. However, if something goes wrong, and the patient has a subsequent poor health outcome, Nursing, Medical, and Legal staff will all thoroughly read your Case Sheet. This is why you write a Case Sheet – to document the fact that you have treated your patient correctly.

Follow your Guidelines, Protocols, Procedures – even if you know of a better way of doing something, or a different drug that may actually be better for your patient, you are not covered by doing so! If you are adamant that the current policy is wrong, try to change it by providing scientific evidence – not by implementing it by yourself.

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How to Assess Pain

August 2nd, 2010

How to assess pain. Reducing pain is one of the most important things a Paramedic, Nurse or Doctor can do for his or her patient. In order to provide appropriate analgesia and make the patient comfortable, the Paramedic must gauge the patient’s level of pain so that he or she can determine if the treatment is improving the pain or making it worse. There are multiple methods of understanding pain levels, but regardless of which system you use, it is important to understand that it is only a gauge of where the patient’s pain started and whether it is better or worse now. If the patient is in pain he or she needs analgesia –its that simple.

These are the three methods I use for assessing pain:

  1. If the person is alert and orientated and able to understand the concept, I will ask them: “On a scale of 0-10, where 0 is no pain and 10 is the worst pain you have ever had, what would you rate your pain at now?” Some people will say 10 automatically, this doesn’t mean they’re soft, or that they’re not in pain, or that they’ve never experienced pain before. This is simply a measure of where the pain is going. Therefore, after giving pain relief, ideally the number should come down. If not, you may need to provide more analgesia.
  2. If the person does not speak a lot of English, or is already disorientated, I will simplify the process a little and ask: is it a little pain, medium pain or big pain. This may also be useful when talking to kids. Then I will ask after providing analgesia: is the pain better, worse or the same?
  3. Another useful tool that I often utilise while assessing a person’s pain is the OPQRST method of understanding the pain. This includes asking:

 

O – Onset – When did it start? What were you doing?

P – Provocation – Does anything make it worse? Does anything make it better?

Q – Quality – How would you describe the quality of the pain? Is it sharp, dull, ache?

R – Region – Where does it hurt? Does the pain radiate anywhere else?

S – Severity – How severe is the pain? Here you may use the 0-10 pain score.

T – Time – What is the duration of this pain? When did it start?

4. Don’t forget to look at the patient, look at the position he or she is in, are they guarding anywhere, can they mobilise?

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Funny EMT Stories

August 2nd, 2010

Paramedics often experience situations every day that are bizzare, funny, humorous, and often sad. I’ve watched medical take-off shows like SCRUBS, or MASH and know that people often think, “How do they come up with these crazy medical stories?” But the truth is… everything you see, does actually happen… and the truth is often dumber, funnier… and crazier than any possible fiction.

This EMT story starts three months ago….

It was a fairly quiet day at the office, as an EMT. Got the cup of coffee, had time to read the paper and eat breakfast at work.

At 1130 was called to a 3mth old fitting – not the sort of job that you want to go to, on any day… when we arrived, the infant had ceased fitting, and as is normally the way while attending paediatric patients as an EMT, the hardest thing to do is calm the parents down…

After checking and seeing that the infant was doing well and appeared normal for a post-ictal (after fitting) paediatric, I looked up to see mum, who was hysterically talking about how her baby was “dying.” I explained that everything was okay…  and she went outside to try and calm herself down… my partner followed her out to talk to her, and reasure her…

I look up at Dad who appears to be coping quite well… “I guess you’ve scored the ticket as the parent to come to hospital with us?”

“I guess so” he replies, and then, noticing that he’s still in his pyjamas, notes that he’d better get changed. I offer to take the baby, but am told that once she wakes up, she does not take to strangers very well and that he would prefer to look after her.

So, carrying the baby, he walks into his bedroom and starts to get changed, while one-handedly holding the baby. I tentatively look outside, and find that my partner is helping Mum, who has now fainted and is unconscious, laying on her side, on the ground, where my partner is trying to look after her. “I think she’s just fainted with the stress…” my EMT partner says, “she’s got a good stong pulse, and is breathing normally… do you want to grab me the viva (the oxygen device).” I grab him the viva, and at this point, her a blood curdling scream from inside…

I don’t normally run… ever…

But for some reason, this time, I did, what I would call as close to a run, or fast walk back inside, where I knew that the Dad and infant were the only two people inside the house.

I see Dad laying on the ground… wimpering… unable to speak, and the baby, appearing normal, but post-ictal on the ground beside him…

“Are you alright?” I ask…

He moves his legs closer to his stomach  in the foetal position… attempts to talk, but only an inaudible whimper comes out…

“I assess the infant, and am relieved that no changes in her condition has occured.

I look over again at Dad “Are you alright?”

He mumbles, “I need help… there…” and points to his zipper…

I don’t believe it… he’s caught himself in his zipper?

I cringe…

Do you want some pain-relief? I’ve got some good stuff in the Ambulance…

“No, this has happend before…” he looks at me… “the zippers caught on my penis ring… can you try and free it…”

I ofter some very minor assistance, but acknowledge early on that there is very little that I can do to free the zipper.

Ultimately, we required 3 separate Ambulances to treat 3 separate patients…

Mum: regained consciousness shortly after her fainting episode, and was transported to hospital for further assessment

Dad: spent two hours undergoing unsuccessful basic attempts to free his penis ring from the zipper… before undergoing a general anaesthetic and surgical interventions with success

Baby: had had her first febrile convulsion (hot seizure) and recovered fully within the hour.

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How to Interpret an ECG as a Paramedic

August 2nd, 2010

Okay, so you’ve decided that you want to learn how to interpret an ECG…

Interpreting an ECG as a paramedic is just that, an interpretation of the ECG. If you google steps in interpreting an ECG you will get thousands of different steps (all fairly similar, some very different)… but most will give you a basic interpretation of an ECG. In my careers as a paramedic I have often seen cardiologist review and debate the interpretation of the very same ECG. These are the steps that I use… if they work for you that’s great… if your ambulance service requires you to utilise a different technique than that is what you should use. This is just a guide.

But first… a little bit about ECGs and what you’re actually looking at.

At a very basic level, an ECG is just a graph representing the basic electrical flow of the heart, as seen by small (snap-shot) views of the heart. If you think of an ECG lead as a camera looking at the heart, each separate lead is a different camera angle of the heart. Therefore, multple leads will allow a better overall view of the heart. For the purpose of this ECG interpretation webpage, I will only discuss lead II.

So what normally happens with the heart? In a normal person there is an electrical impulse generated by the sino-atrial (SA) node in the right atrium of the heart. This impuse is conducted through the cardiac muslce fibre to the atrial-ventricular (AV) node. From here the impulse conducts down the right and left bundle branches and finally disipates in the purkinje fibers causing the ventrical to contract and thus creating the pumping action of the heart. These electrical waves can be measured by the ECG electrodes which are placed on the skin and record minute levels of electrical activity.

    Here is an example of an ECG

The first small spike you will see is called the P wave. It represents the firing of the impulse from the sino-atrial node and the subsequent contraction of the atria or the upper chambers of the heart. The space between the P wave and another wave called the R wave is known as the PR interval. This represents the time between the electrical signal of atria contraction and the signal of ventricle contraction. The R wave (represented by tall spikes) is in between a small dip called the Q wave and another small dip called the S wave. Together, the QRS complex (Q, R, and S waves) demonstrates the activation of the left and right ventricles of the heart.

On the other hand, the T wave represents the resetting (or repolarization) of electrically charged cells in the ventricles. This resetting occurs during the contraction of the ventricles, masking the signals so they will not appear on the waveform. When resetting finishes, the entire cycle repeats.

Similar to that of the PR interval, the waveform from the end of the QRS complex to the starting point of the T wave is called the ST segment. The waveform from the starting point of the QRS complex to the end of the T wave is called the QT interval.

When reading the ECG, the height of the waves denotes electrical signal strength and the overlap of the opposing signals. The space between the waves represents the time it takes for the signal to pass through your heart.

Okay… so you know a little bit about the the hear and the electrical activities now… how do you interpret the ECG?

Follow these steps:

1. Look at the QRS Complexes – Are they regular or regular? You can feel the patient’s pulse while you do this and see that the patient has a regular or irregular pulse and that this matches up with what you are seeing on the ECG or EKG if you’re in the US.

2. Determine the rate by counting the QRS Complexes in a 10 second strip. Is it fast (greater than 100 beats per minute), Normal (60-100 beats per minute) or slow (less than 60 beats per minute)?

3. Look at the P- Waves. Are they normal? A normal P wave should be upright in lead II and should be identical to all the other P waves in the ECG. A P wave should also precede a QRS Complex. If you can’t see a P-wave, the person most likely has Atrial Fibrillation – (see if this is normal for the patient, or new).

4. Look at the PR interval and the relationship between the P-Waves and the QRS Complexes. A PR interval should normally be between 0.12 and 0.20 seconds in length. If it is longer than this, there is a conduction problem between the SA node and the AV node. If it is shorter than this, the SA node is firing too quickly as is the case in Atrial Tachycardia.

5. Look at the RR intervals – are they regular? Are they identical in timings? In a normal sinus rhythym an RR wave should be consistent.

6. Look at the QRS Complexes – It is normally less than 0.1 seconds in length. If this is longer, there is a conduction problem between the AV Node and the Perkinje Fibres (this indicates a Bundle Branch Block).

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How to Auscultate Lung Sounds

August 2nd, 2010

Auscultating lungs is a vital skill that Paramedics need to develop to be good Paramedics. The easiest way to develop this skill is to listen to as many chests as possible. This includes good, health chests, as much as sick chests. Without listening to healthy lungs, how will you know the difference with un-healthy lungs? These are the steps that I use:

1.      Minimize the noise in the room. This includes: turning off the television and radio and if the Ambulance is moving, you may have to stop the Ambulance so that you can clearly hear the lung sounds.

2.      Explain to the patient what you are going to do.

3.      Make sure the diaphragm of the stethoscope is turned on. Put the ear pieces in your ears and gently tap on the flat diaphragm. If you can’t hear anything, turn the head of the diaphragm to turn it on.

4.      Have the patient sit upright if possible. Start in the upper lung fields. Place the diaphragm of the stethoscope on the patient’s upper back on the left side to listen to the posterior upper lobes of the lungs. Although a thin hospital gown or t-shirt should not interfere with auscultation, it’s best to place the stethoscope on bare skin.

5.      Instruct the patient to take a deep breath through her mouth. As the patient inhales, listen to the sounds in the lungs. Move the stethoscope to the opposite of the body, but at the same level. Always listen to both sides of the lungs to compare the sounds. Every time you listen to a new segment of the lung have the patient inhale. Follow this diagram to determine where to auscultate**

6.      Move the stethoscope down a few centimeters and listen to another segment of the lung on both sides.

7.      Put the stethoscope on the front of the patient’s chest to listen to his anterior lobes of the lungs. Repeat the same pattern as with the back, starting at the top and working your way down. Listen to one side of the body and move to the other.

8.       Identify abnormal lung sounds. The most common abnormal lung sounds include wheezing, stridor and crackles. Each has a distinctive sound and possible cause. Wheezing is often caused by constricted airways and is a high-pitched sound and may occur with asthma or emphysema. Crackles sound similar to snoring and can occur with fluid in the lungs caused by a condition such as congestive heart failure. Stridor may indicate croup and is a narrowing of the upper airway. It usually sounds like wheezing on exhalation over the trachea. Crackles sound like bubbles popping and can occur with pneumonia due to the fluid in lungs.

9.      Document what you have heard and re-evaluate to determine if your treatment has changed anything.

 

 

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Ambulance Paramedic Bureaucracy Stories

August 2nd, 2010

Ambulance Paramedic Bureaucracy Stories

Anyone who has ever worked for an Ambulance Service will understand the deranged incompetence of the Bureaucratic system. Here are some of the ultimate highlights of my experiences trying to improve a Bureaucratic Ambulance system as a Paramedic:

I used to work at a small, outback, country Ambulance Paramedic Station – most Paramedic Stations are stocked based on their Average Monthly Item Use (AMIU) numbers, and this is particularly regulated in small country Paramedic station that does a limited amount of cases per month and therefore more likely to have stock go out of date. At my Paramedic Station, our AMIU for cervical collars has been set at 5 of each size per month, and has been for the past 30 years. Now, as anyone who’s actually worked as a Paramedic would know, everyone, tall short, skinny, fat, will either take a No-Neck Cervical Collar or a Short Cervical Collar (even if they’re 7 foot tall, they still don’t seem to fit a Regular or Tall Cervical Collar!). So, as you can imagine, if we get 5 of each every month, but we only ever use Short or No-Neck, we’re going to always end up without and Short or No-Neck and we’re going to have about a million of the other sizes. So, after about 2 years of accepting there’s no chance of changing this, I find myself working as an Acting Station Manager, and decide (naively), that I will fix this problem, and order 20 of the Short and No-Neck Collars – and no Regular or Tall. This is how the conversation unfolded with both the Stores Manager, and then Eventually the Senior Paramedic Managers.

Paramedic: “Thanks, we’ve ordered 20 No-Neck Collars and 20 Short Collars, but have been sent 5 of each, and then 5 Regular and 5 Tall, which we didn’t even order…”

Stores Manager: “Yes, that’s correct.”

Paramedic: “If we send the excess Regular and Tall Collars back to you, will you exchange them for No-Neck and Short Collars?”

Stores Manager: “No, your AMIU is 5 of each.”

Paramedic: “I understand that, but, you see… we only use the two small collars, and we need more than 5 per month for those… and we already have an excess of the larger ones, so we don’t need anymore of those.”

Stores Manager: “Hmm… it says here that you get 5 of each… so you get 5 of each… good bye.”

I approach Senior Ambulance Management about the problem via mail, carbon copied to the Stores Manager. 4 weeks later, I contact Senior Ambulance Management to see if this has been resolved.

Paramedic: “Any luck with the issue of ordering more cervical collars?”

Senior Ambulance Management: “Yes, I resolved the problem.”

Paramedic: “Great, thanks for that… so we can now order more than 5 collars per month?”

Senior Ambulance Management: “No, you can order 5 of each size per month…”

Paramedic: “But you just said you resolved the problem.”

Senior Ambulance Management: “I did… I reviewed the orders for the past 20 years to determine if your AMIU numbers have changed at all – and over the last 20 years, you have ordered 5 of each size collars…”

Paramedic: “Thanks, we’ve ordered 20 No-Neck Collars and 20 Short Collars, but have been sent 5 of each, and then 5 Regular and 5 Tall, which we didn’t even order…”

Stores Manager: “Yes, that’s correct.”

Paramedic: “If we send the excess Regular and Tall Collars back to you, will you exchange them for No-Neck and Short Collars?”

Stores Manager: “No, your AMIU is 5 of each.”

Paramedic: “I understand that, but, you see… we only use the two small collars, and we need more than 5 per month for those… and we already have an excess of the larger ones, so we don’t need anymore of those.”

Stores Manager: “Hmm… it says here that you get 5 of each… so you get 5 of each… good bye.”

I approach Senior Ambulance Management about the problem via mail, carbon copied to the Stores Manager. 4 weeks later, I contact Senior Ambulance Management to see if this has been resolved.

Paramedic: “Any luck with the issue of ordering more cervical collars?”

Senior Ambulance Management: “Yes, I resolved the problem.”

Paramedic: “Great, thanks for that… so we can now order more than 5 collars per month?”

Senior Ambulance Management: “No, you can order 5 of each size per month…”

Paramedic: “But you just said you resolved the problem.”

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