A Reply for Coloneldom.

Last week in day two one of the pts was described as having an opiate overdose and coloneldom has asked whether I administered Naloxone (Narcan). Lets review firstly the job as I posted it.

'40F, OD on opiates, interesting because it's not her fault in my opinion. She has been prescribed by the one GP over ninety milligrams of a pain killer daily and therefore some days depending on her metabolism, other medication use and even stimulants like coffee she appears to OD.'

Naloxone Opioid Antagonist, reverses respiratory depression, sedation and hypotension caused by opioid analgesia.

Apart from the reversal of say Heroin ODs it can also be used to just back off on Opioid Pain relief with Pts.

My choice as a Qualified (the buck stops with you unless you call for Intensive Care Paramedics [Frogs - because everything they touch croaks]) Paramedic was not to give any Naloxone.

1. Pt was conscious.
2. Pt was fully ambulant.
3. Pt was not, while with us, in any life threatening danger.
4. Pt had refused transport and treatment initially which was her legal right as a pt who may have been under the influence of drugs but did display a competency and capacity to make decisions, even a bad one.
5. Pt only changed her mind after a short discussion with a staff member of the sanctuary she was was staying in. I did not hear any of the content but I believe it may have been coercion, but not by me.
6. I didn't wish to expose the Pt to possible infection from an IMI.
7. I didn't wish to expose myself to a possible needle-stick injury.
8. I wanted the Triage and ED Registrar to see with their own eyes the Pts true condition for assessment also of the GPs medication regimen.

Some of our allied Health Staff don't always believe what 'we saw' on the scene once a nicely package Pt is presented in the calm, controlled, well light, post any interventions by us, triage corridor.

So there you have it,

Simple short answer NO which doesn't explain the thought process to arrive at that answer.
It leaves me open to some prick thinking that I'm just a slack arsed ambo.
And doesn't provide direction to any Padawan reading the post.

I'm off back to bed for night shift tonight.

Be careful out there and I'll see you at the Big One.

Taz

For Jinx.

Hello Jinx,

Welcome to the world of Aussie Ambo Blogging.

F.A.S. now this is not a cultural slurr but you will notice that with some of our patients from this ethnic background they just go floppy on you after their family member tells you about their current illness.

Now I've observed this to happen after vomiting and diarrhoea as well as non de script sore legs and sore finger and all kinds of other stupid conditions.

Beware they will also walk for about half the hallway and then collapse causing a sudden rush of family to pat, stroke and fan the patient.

I have also seen plenty of others deny the pain that is obvious to me and struggle to assist with their loading even though it pains me to see them do it..

With the transgender I communicate to them in the preferred style (feminine) but the paperwork I do ask the straight up, 'what sex are you legally?' and record that.

Hope this makes sense to you, we only did a normal twelve hour shift today that I will post about later but one of my dear friends and peers from station is moving to the quiet life up the cost and we had drinks after work and I'm a bit blurred!!!!!!

Be careful out there and I'll see you at the Big One.

Taz

What did I do on the days off?

Not much,

We had visitors from Tassie for three days.

Ambowife's birthday is coming up and I have to get something (can't say too much because she reads this to check that I'm telling her all the things I have on my mind), So I went off on the bike on day four to do some shopping or browsing.

Day five was a beautiful day so we hopped on the bikes and went for a ride together, she even did some of the pace setting. Quicker than we have done this ride before, the final stats are;

Distance of 45km or 28m
Time moving of 2h, 44m.
Ave speed of 16kph or 10mph

Be careful out there and I'll see you at the Big One.

Taz

Night Two.

Hospital to Hospital transfer of a young one in the child capsule with Grandma escort.

94F, Head Lac, those damn throw rugs on slippery tile floors.

Unable to locate.

Some Floppy Asian Syndrome (FAS) with abdo pain.

43M, Psych transfer, nice fella just lost all idea of who he was!

52M/F, Transgender, a legend around my patch whom I had never had the pleasure to attend. We, as I was to learn, were the third crew to have responded to the pt this evening. The pt had been escorted from A&E previously for verbal abuse to staff and other normal pts.
At two AM when we were responded to the same pt again, I must say I slipped the angry ambo suit on. A direct, blunt instruction and dressing down of the alleged pt occurred until the pt had indicated three times that they understood.
We then transported them to the next nearest hospital for their abdo pain.
Pts main fluid intake is Metho.


So 7.25 pts on average for the four shifts

Be careful out there and I'll see you at the Big One.

Taz

Night One was one for the ladies!!!

Or rather they made up the majority of our pts.

Assault - Unable to locate.

34F, 3/24 of Diarrhoea.

16F, Intoxicated, Mum had been called so we waited, she was more than happy to take pt home.

44F, Intoxicated, friends called but pt wanted to go home, they were staying with her so they did.

64M, Has two inner ear conditions and had a syncope after leaving a club with live band, wonder why?????

18F, Decreased LOC, not intoxicated, history of similar idiopathic.

25M, Intoxicated found by police. They told me as we approached that they tried the sternal rub I showed them to nil effect, showed them a new one 'Chinese Ear Rub'. Lay flat of hand on the external ear and move back/forward real quick, older brothers have been doing this to little brothers for years. It worked and out of the kindness of their hearts they were going to drive him home until he pulled out the ol' fella and pissed over himself and the back of the cage truck he was in. New destination the charge room.

25F, # foot, dumb ox B/f stood on it. The swelling was that tight I couldn't even check for pulse.

35F, Osteogenisis Imperfecta underlying condition, suspected # post fall.

Finished up with a job that I still feel uneasy about, the transport of an alleged sexual assault victim. The victim can be male or female but the aggressor is nearly always a male.
I am very mindful of the respect and trust for my profession by the victim and ashamed to be a man.

Be careful out there and I'll see you at the Big One.

Taz

Day Two

21F, MVA, no injuries.

40F, OD on opiates, interesting because it's not her fault in my opinion. She has been prescribed by the one GP over ninety milligrams of a pain killer daily and therefore some days depending on her metabolism, other medication use and even stimulants like coffee she appears to OD.

21M, First ever witnessed seizure, couldn't link a trigger either, none of the usual ones like illness, fatigue, drug use, etc.

Early elderly Pt who was visiting a Dr about a broken arm and tumbled and may have broken their hip, some days you just can't catch a trick.

96F, Bright as a box of sunshine too but with a nasty case of cellulitis in the legs.

73M, Dystonic gate, possible Parkinsonian Syndrome has had his meds increased but they seem to have left him even more immobile.


Interesting enough day except that 'Dorothy' (new affectionate nickname for Padawan) and I where definitely not in Kansas any more as we had slowly been dispatched further west with each case.

We also again had not received and lunch or crib break and without the aid of a twister we had to drive all the back to station making it a thirteen and a half hour shift.

Same last comment as previous post!!!!!!!!

Be careful out there and I'll see you at the Big One.

Taz

Day One.

The system has been very busy when I talked to the staff finishing the nights so I looked set to continue the same for us.

Regular Pt doing to dialysis.
60F, misjudged the depth of the gutter and took a tumble, Left upper arm injury.
83F, Fell out of bed, Right wrist fracture very obvious and she kept trying to wave it around.
84M, Abdo Pain.
88F, Everything hurts, High maintenance Pt this one wasn't even hiding the pleasure of the attention.

84yo, Cerebral event. This one is worth a bit more of a story, called to a CVA but the history tells of symptoms as old as two weeks ago but not constant and then today some kind of a fall in the AM and six hours later dysphasia, semi obstruction of own airway by tongue, equal strength but no coordination.
On the way left deficit occurs, right upward gaze and decreased GCS.

As normal we didn't get to follow up that day but the next we got to see the scans. It appears to them that there was a slow bleed over the last two weeks and the fall opened the flood gates and the final presentation. Prognosis, not survivable.

Finished the day with a 30 something M with a hypo, GCS 15 with something like a 2.1BGL, sugared him up, he signed the PHCR and off back to the Ranch we went.

No lunch or crib break all day and it was a twelve and a half hour shift.

It buggers me as to how some old fart in the IRC or our own ivory towers can think that the extra two hours and still no breaks makes for an easier dayshift.

Be careful out there and I'll see you at the Big One.

Taz

Normal transmission is about to resume.

Sorry, I went a bit on the quiet side there didn't I.

I admit that I did have my focus somewhere else.

A little while ago we found a small lump on me in a place that only you or your wife should go.
It did appear to be getting a little bit bigger so I had it checked by my GP when I had my annual check up.

Having been reading Lance Armstrong's Biography "It's not about the Bike" didn't help with those unfounded thoughts you get with such things but after an ultra sound scan it appears to be a cyst.

So happy days.

Be careful out there and I'll see you at the Big One.

Taz

Livestrong!

So the new riding gear arrived this week from the US as pictured above.

Tracy wont allow me near her with the camera yet, something about needing another hundred or so km before she will allow a photo to be taken.

Be careful out there and I'll see you at the Big One.

Taz

Got an O/t on an ICP car.

Which means you allow one of the rostered officers first opportunity to step in and you do the GD work.

Didn't take me up on the offer so I got the ICP gig.

What a waste of time, I mean the GDs also didn't do anything 'BIG' but they were out doing work. I'm lying there waiting, waiting, phone rings 'it's for you guys', waiting, waiting, bloody waiting.

Three jobs.
Abdo pain and black diarrhoea - Hx of gastric ulcers, all Obs good.
Cardiac Chest Pain - due for a second angio in 3/7, all obs good.
Unwell - all obs good.

BORING, another reason I think why I'm not ready for ICP, I enjoy working too much (apologies to all known ICP who are still gungho!).

Be careful out there and I'll see you at the Big One.

Taz

What would you do on a hot winters day?

We went for a nearly four hour ride down into the Shire (Suburban area south of Sydney).
The length was only 45km(28m) which seems to be the length of most of our rides??? it just works out that way.

Forecast of 28 Celsius today but it only got to 26 so sunscreen was still a must.

Tracy did well with some of the route a little hilly and I believe she didn't abuse me once.

Still waiting on the riding gear I ordered from the Lance Armstrong Foundation, I might ring up the shipping company tomorrow and see where it is.

Be careful out there and I'll see you at the Big One.

Taz

Last night.

Better.

89F - Unwell, c/o decreased appetite but could have seen her LMO on Monday.

16M - Too young, and can't handle his booze, peaked around 2000hrs and was wasted.

66F - IDDM with high BGL (21.7) and a good fever (39.2 tymp), confused Dah!

20M - Cyclist traveling 25km run up the rear by a car at ?? 40km. Rear wheel of the bike was completely buggered, the helmet, on the rear right was cracked right through the foam. Landed on the windscreen of the car and walked to the footpath. Full spinal precautions, bat phoned it to the receiving hosp and the only pain was in the lower back and left shoulder.

47F - Exact same age as me, everything hurts. Interesting to see the difference alternate live choice decisions can have.

25M - Call came from the police, found at the front of what was his building but unable to remember where his keys were. We had a chat and then it came to him (the letter box) he retrieved them and disappeared inside.

The pick of the night,

28M - Assault, reports say 20+ beating him up. When I looked at him I flashed on another job I had done several months ago with a F police officer. His injuries oral trauma, large lac on the occipital, glass lac that you could put your finger into under the chin but not as far as the throat luckily, left orbit and zygoma just one huge contusion and gross swelling, amnesic to the event and perseverant questioning.

So yes I was happy with the night, Padawan and I talked about the trauma job, noted that the gelling and working as a team is developing along with his confidence.

Be careful out there and I'll see you at the Big One.

Taz

And the first night was like?

Well, unusual best described it for me.

Bedlock or Ramping to start the night.

One of the pts I was stuck with was a mental health emergency that I hadn't done a section on. I was trying to keep the pt voluntary, bipolar with probable schizophrenic undertones. A challenge to be able to keep a person so affected compliant and engaged.

The rest of the night was filled with pts who were all intoxicated.

Be careful out there and I'll see you at the Big One.

Taz

Steady for a second day.

Two of our station staff have got interviews for the team leader positions and I missed out so it seems my application lowered the bar enough.

42F - IDDM with a BGL of 9.2mmol/L. Who care? She had her mind set on going to hospital so with a family member rolling their eyes at me we had to take her to hospital.
72F - Syncope, witnessed even.
60M - ETOH withdrawal (the DT's).
23F - ??? had not taken psych meds and had buggered off, police were still looking for her.
60M - Parkinson Pt having a bad day.
60M - Hosp to Hosp transfer.
84F - who needed a repairman but got us. She needed a repair to her home O2 tubing.
79F - Scheduled by Community Health staff and they didn't believe she would come peacefully with them.

Again an 0700 start, one 30 minute break and signed off at 2005hrs.

Be careful out there and I'll see you at the Big One.

Taz

Busy Day for a change.

68M - SOB, Pluritic chest pain good chance of infection.
11M - ? # Toe, nasty contusion.
57M - Severe Sciatica, I suffer infrequently from the same, very painful.
45F - Lucky passenger in a Taxi, low speed MVA, nil injuries.
63M - Lucky Taxi driver from same with same.
59M - Chronic ETOH abuse, needs a lift back into his drinking seat. Spent a long time seeing if I could try to get him off the sauce and into rehab. No luck it's his life for now.
Unknown age, unknown sex, call from a public phone, from a stretch of CBD street that has numerous phone booths. Unable to locate.
36M - Renal colic, fourth episode within two months.

Started shift at 0700, one single 30 minute break and signed off at 2015!

Be careful out there and I'll see you at the Big One.

Taz

Another ring in the trunk.

That is a reference to the growth rings in trees too before you get the wrong idea!

Forty S*&%n years old.

DVD Box set series 1-4 of House,
Box of chocolates,
Lance Armstrong biography,
Pictorial history of the Tour de France.

And a wife who loves me for everything I do, even the mistakes.

To follow that theme we went on a ride to the bridge you cross to enter the shire (32k).

Be careful out there and I'll see you at the Big One.

Taz

Well, pulled an O/t shift at my local station.

A very quiet night for the weekend.

26F with non traumatic back pain, she really was in pain and a lovely girl to boot.
19M intoxicated in Police care. A cabbie had just dropped him in the street and left. Nice fella.
44F Two glasses of red wine and now vomiting (they ? drink spiked) I explained the reasons behind someone spiking your drink, and that no one would blow the cost of a drug just to watch you puke???
17M your elbow will never win an argument with a window. It will always come off second best.
58M Homeless, ambushed us in the station driveway, a direct request to be taken to a hospital. Shit, I have no option.
Drug overdose that saw me do my first DoCS report, not a nice job.



Be careful out there and I'll see you at the Big One.

Taz

So what were the nights like?

Bloody awful!

First one,

80+F with a gurgle in her upper airway post possible aspiration of puree food.

75M with persistent fevers - UTI

26F Epigastric pain.

41M who woke up after a night on the booze 4-5 days ago with a sore shoulder, he rotated it around to show me which one. He wondered if he should have got it checked out? ? ? ?
I calmly suggested that I could take him to a hospital if he wanted, he declined. We left.

Night two,

60F with a fractured arm, fall going to the loo.

80F dislocated hip, chronic repeat offender, she's done it four times in the last month or so.

24M Lac to wrist (G/F's, not worth it),

Near 40F, nutter B/F in another state, she doesn't answer his calls he rings police with a concern for welfare.

80+M Knee injury.

We managed to do some training after midnight each night as we had three Padawans there.



Be careful out there and I'll see you at the Big One.

Taz

Someone has a new joy!

Yes it's lovely,

But mine gets better fuel economy!

Be careful out there and I'll see you at the Big One.

Taz

Reply to Anonymous.

This was a comment left on the post for the 'Second Night' from the 28th July

Taz, I just have some enquiries about your "Asthma in Extremis" Pt. You have clearly stated that the patient was anxious, so much to the point of being unconscious. You have stated that they have adequate tidal volume. There is no mention of respiratory rates or SpO2%. You have stated at no point did the patient have a wheeze. You have stated that the patient is not a known Asthmatic. I am wondering then how you have justified you use of Adrenaline and repeat doses of Salbutamol and Atrovent? There is no mention of chest hyperinflation. No mention of high inflation pressures. No mention of minimal air movement. No mention of perfusion. And why did you not attempt expiratory assistance?In fact there is little evidence to suggest that the patients condition is servere of extreme at all (which is clearly stated in the protocol). Or little evidence to suggest a mild Asthma attack at all.Let me put to you how you have described the patient's condition a different way.A non-asthmatic patient, hyperventilating to the point of a decreased LOC, no wheeze, still moving air, not cyanosed, not tachycardic.Can you justify Adrenaline or repeat Salbutamol and Atrovent?You have stated the patient had wide spread creps. And you stated you did not take a blood pressure. I want you to now consider the complications of a patient in APO, with a failing left ventricle, to whom you have administered Adrenaline.I will admit I was not there, but I don't think in any way can you justify your drug administration.


So I'm being called out by a peer, but I have already wanted to follow up this pt and been analysing the job because it wasn't any normal presentation.


This not a journal with complete case studies.

Remember Sp02% is a machine reading of the oxygen saturation in the finger the probe is attached to.

The pt never really got to the hyperventilating level, increased WOB & RR yes, but not the 30-40 pre min you normally describe as an anxiety attack.

The pt had dry crepes in the lungs, stated no cardiac Hx also other than controlled HT and had increasing respiratory difficulty for 2-3 days. I was happy to continue down the respiratory track.

So if a pt doesn't fit a protocol are we meant to not treat or to keep our head in a box and not investigate other possible conditions. Education is pushing guidelines not strict protocols.

But correctly you were not there and I have said that the post was not a complete report due to the complexity of the job.



So I had asked the Director of Emergency Medicine at the hospital if they would be able to review the case for me.

Six hours later I got a phone call,

Diagnosis - Respiratory Failure secondary to ASTHMA.
Pt's records also showed an admission six yrs ago for severe asthma.


The hospital still has the pt on a ward due to the overall complexity of their medical conditions. My actions were correct, I have been vindicated by an independent umpire and dear anon you were just a little to quick on your high horse.


So I have now had my say.



Self critique, self analysis is key to being a true professional.





Be careful out there and I'll see you at the Big One.

Taz

So what happened day two?

Bedlock that's what happened.

My opinion, circumstances and planets aligned to have an increased concentration of pts all ringing within a similar time period.

How can a hospital handle eight ambulances arriving within ten minutes and more turning up in the next hour and they are already nearly full in the A & E and the waiting room?

So this is a list of how I contributed to the problem,

50M, Suicidal, wanted Police to transport him??????????? that's a sick person!

23M, Abdo pain, heavy tackle playing sport on the weekend.

50F, Food allergies, being investigated, not anaphylaxis (because people love to use that phrase), some numbnut told them to not take the antihistamine because it reduces the symptoms!!!

86M, Decreased mobility, leg ulcers and needs admission for advanced care.

45M, Penile pain and that's as far as I'm taking this one.

73M, Vertigo, picked him up a week ago for the same, had CABG x 5 done five weeks ago too!

80F, Chest infection, 40 degree Celsius (104F).

And it took us fourteen hours without a break to do all of this.

Be careful out there and I'll see you at the Big One.

Taz

Rested up now.

I forgot to make a note of the day 1 jobs but these three I remembered.

79M with suspected NOF, while located in a multi level carpark it was on the first level so straight in with the stretcher, he was on a clean, flat, tiled surface so easy to get the scoop under him.

80+ Deceased. I knew this pt, not really well but as soon as I walked in the flat I flashed on my past visits so I felt that I was better able to here comfort the family member how lives there because I was a familiar face.

It was what I have called previously a good death, at home in their own bed, with family who love them and a good innings behind.

Mid 80's F presenting with Left Deficit CVA and a confirmed five minute window of onset forty minutes ago!!!!!!!!! how bloody good is that?
O2 therapy en route did relieve some of the symptoms a little, raised my hand at triage and the FAST track was opened to us, off we went to CT within five minutes of arriving.

A quick note to anonymous, I'm having that job reviewed too.


Be careful out there and I'll see you at the Big One.

Taz

Days finished.

No breaks,
No lunch,
12 hours the first day,
14 hours the second,

I'm stuffed,
Can't write anymore, I'm off to bed.

Be careful out there and I'll see you at the Big One.

Taz