Are you for real. Let me address your examples individually.
Where do I start. This patient is now in your care & en route to hospital with a transport time of up to 90 minutes - is there really going to be a difference in administering antibiotics en route. NO. Wait, let them administer in a hospital environment. The only exception is for meningococcal septecaemia where we carry IV antibiotics oin the kit.
That's my thought too because it has been documented that once we deliver antibiotics ... ie kill the bacteria they will release endotoxin which can cause even more problems.
The services that have introduced IV antibiotics for meningcoccal disease or sepsis have found thier use to be very, very rare.
Maybe not the best example but in very remote areas of Northland with significant transport times our standard procedure is to seek pre-hospital administration of penicillin from a local GP.
WTF????? You are unable to make this decision yourself knowing what the condition of your patient is? Surley anyone with HALF a brain should know this. I am assuming you have half a brain here. You should know through your dispatch if one hospital is busier than another, & make a transport decision from there. Hell we have crews that sit in the ER on bed block for hours. Esp with ortho cases because, in general they are not life threatening.
We don't know how busy the hospitals are it is not inherent capability we have, can't mind-read how busy the ED or cath lab is or if they have an orthopeadic surgeon at the hospital or not or whatever.
Early consultation and notification allows them, for instance, to arrange for the on call thoracic or cardiovascular surgeon (there is are always surgeons at the hospital but at night or the weekend the specialties are not there) or whoever to come back rather than waiting for us to radio up we are five minutes away with a patient who needs somebody that will take half an hour to get to the hospital, scrubbed and ready to operate when we could have called and asked "hey, do you want us to take this guy to hospital A or bring him to you?" and they would have said "oh sure bring him here we will get the ortho surgeon out of bed for you guys when you get here in 20 minutes".
I am assuming that you use the term Really Whacky as a medical term. Did you read what I wrote last time. The patient will have some SYMPTOMS. TREAT THEM. You dont need a doctor for any of what you have described. Now to prove you are not a complete moron. Would you like to try again?
Our first line of recourse it
not to a physician; it is to an IC Paramedic or our Watch Manager. I am in an urban area with IC Paramedics and a trauma facility ten minutes down the road and have
never spoken to a physician in my on-road life to ask them what to do or to do something for me as I can think for myself.
Some people here in the boonies are not that lucky. They have no IC Paramedics or backup and they are volunteers who know how to package a patient and dish out five drugs they cannot screw up that bad (GTN, ASA, IM glucagon, paracetamol and methoxy). In small towns with single crewed officers (even tho this is not always the case) it is
much easier to get the local GP to give morphine rather than wait around for backup which in some cases will be an hour, or more, away.
You dont need a doctor for any of what you have described
You presumably work in one of the states where the ambulance service is a well funded, well resourced, well educated and well trained third-service run by the state as a core health activity. Most states I have seen in Australia use only two levels. We are not that lucky mate, St John is atrotiously under-funded and we have four different levels; many ambulance crews here are not qualifed to give IV analgesia and many more are volunteer officers who have never been exposed to the same volume of peer review, peer critique and generally, patient encounters that our urban staff have.
We aim to shift to a new two-level model of care by 2011 where all staff who are not volunteers will be qualified in things like IV analgesia and have a much better education because we are putting them through the Bachelors Degree which will become mandatory for practice for paid staff because of exactly this reason.
Until then, if we need to talk to a doctor (which is
extremely rare) then we will do so.
Understand that some systems work differently than yours because it is the practical reality of the situation we are faced with rather than being a wanker and saying we should not require it.
Methoxy will go away due to the nephrotoxicity. St Johns will be one of the last to get rid of it because they want to do everything on the cheap, if their people are not intelligent enough to use narcotic analgeasia, then they need new people.
Yes they do. You have to remember the Johnnos here have over 5,000 "clinical people" the majority of which are old farts who do nothing more than sit on the sidelines at the rugby. They will never, especially in our new system, never ever get anywhere near narcotic analgesia in a million years.
Even our volunteer ambulance officers are
not that well educated; they are taught the fundamentals of managing acute symptoms using a small number of drugs and to package and transport a patient.
If you want to talk about not reading; then read what I wrote before
It's not generally something that our crew make habit of talking with a physician about what to do ...
It happens about once a day nationally for over four million people. Road crews
are able to talk to an emergency department physician or St John medical advisor for
advice for the best way to manage thier patient -- 99% of cases this is "which ED do I take him to?" (i.e. which is MOST appropriate); we do not carry some sort of telepathy device which lets us know if there is a cardiovascular surgeon at the hospital to the left or to the right; there might be one there but hey he might be busy with cases all day so I cannot call him out of surgery for an emergency and leave his patient half operated on!
There is also some use of GPs here rurally for things like morphine ... but this is really a symptom of the wider disease that rural crews aren't that well qualified and can't give IV analgesia. It's often again, easier to whip round to the local GP clinic and have the doctor give some morphine then take the patient into ED than meeting backup on the way because in some cases there is no backup.
I would rather nick round to the GP clinic and say "hey doc I'm gonna transport this guy into ED and it'll take an hour, can you top him up with some morphine?" rather than having to pee around trying to arrange for somebody who can give IV analgesia to come meet me enroute; which could be in the other direction or it could be that backup is busy with something else.
I don't see the problem in making use of a physician if I need one, I'm not a wanky egotist who thinks "hey I don't need a doctor". No, in 99.9% of cases I do
not require a physician to tell me what to do or to do something for me.
But if I am working in a rural location and need to use the GP to administer some pain relief because I am a volunteer officer who is not qualified to give it then I do not see the problem.
(actually, I'm curious, how do you propose that we teach doctors instead? Give them some special K to get high on? How is it that you are expanding your knowledge? Or as a paramedic student do you not need to?)
) I'm completely aware of the dubious level of evidence I have regarding my bad feeling about ketamine, which is why I call it nothing more than a bad feeling. As I said, if I was to use it clinically I'd do my best to ignore it. I just think its an issue worth some further investigation.