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.

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!

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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!

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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!

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.

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.

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.

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.

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.

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).

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

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.

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.

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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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?”

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.

Want to learn the paramedic management of anaphylaxis?

Return to paramedic notes page.

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.

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

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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!

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:

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

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

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).

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.

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

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.

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.

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.

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.

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.

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.

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?

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?

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

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.

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).

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.

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.

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.

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.

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!

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.

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.

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. 

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.

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.

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.

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. 

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.

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.

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.

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.

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 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.

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 Signs and Symptoms

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

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.

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.

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.

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.

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.

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Ventricular Escape Rhythm

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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!

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.

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

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!

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.

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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).

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

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.

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

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.

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).

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.

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The Normal ECG

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

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:

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.

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:

(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.

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Blood Flow Through the Heart.

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:

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.

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Phases of the Cardiac Action Potential

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:

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.

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Coronary Artery Blood Flow

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.

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.

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.

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.

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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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.

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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.

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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.

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

(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 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.

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Sinus Rhythm

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).

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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!

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.

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).

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.

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.

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.

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.

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.

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.

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!

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

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….

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.

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.

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

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. 

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.

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.

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.

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.

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…”

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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…

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.

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…

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.

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.

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.

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).

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.

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.

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.

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.

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 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.

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).

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.

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.

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.

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.

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%.

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.

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.

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.

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).

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.

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.

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.

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.

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)

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.

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.

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!

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.

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.

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.

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.

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

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

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:

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.

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 )

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.

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.

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

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.

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.

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:

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

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.

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

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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).

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.

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.

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.

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.

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.

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?

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.

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.

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.

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.

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?

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.

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?

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  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.

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.

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.

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.

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.

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).

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.

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.

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).

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.

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.

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.

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).

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.

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.

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.

The number to call in an Emergency in most of the countries of the European Union is 112.

The number to call in an Emergency in New Zealand is 111.

The number to call in an Emergency in the UK is 999.

The Number to call for Police, Fire or Ambulance in Australia is 000.

Please save it for emergencies only!

The number to call in an emergency in the USA for an Ambulance is 911

The number to call for an Ambulance, while in India is 108.

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.

The maximum inspiration volume is the most amount of air/gas that a person can inhale. On the average male, this is 6000 ml.

The normal tidal volume (TV) during respiration is 500 mls; however, this may be greatly increased in times of exertion and stress.

Expiration occurs when the diaphragm rellaxes, causing the intrapulmonary pressure to raise. Therefore expiration is a passive process.

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.

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.

The normal atmospheric pressure is 760 mmHg.

Although it should be noted that this is considerably less the higher you go from sea level.

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.

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!

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!

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 consequentl