It’s been such a long time since I’ve posted to this blog. I apologise to our regular readers from the bottom of my depressed heart.

You see, there’s been some union-ing goin’ on. And it’s been makin’ me sad.

In fact, of all of the workplaces I’ve ever worked in (and there’s been more than a few), I have never seen such low morale.

Paramedics are just fed up with the enterprise bargaining process and how hamstrung we’ve been by Free Work Australia (FWA) or whatever it’s called.

Unlike just about any other occupation or field of work we paramedics can’t express ourselves with any form of industrial action. No strikes, no stopworks, no overtime bans (despite overtime being voluntary). Even our MICA paramedics have been threatened with mass sackings for expressing their concerns.

Anyhoo, this has been an ill-worded, grammatically rubbish post but I think you get the point.

So in a nutshell:

We, the paramedics of Victoria, feel shafted by the Victorian Government and by our own union, and there’s nothing we can do about it.

Cheers!

The, and I repeat, the most scary “job” a paramedic can attend (aside from the knife wielding nanna) is the woman in labour. These scary, messy cases start with one patient and often end up with three patients if you include the husband that’s just fainted.

I’ve always had anxieties about these cases because they can be so intense. What do I ask? What do I look for (aside from the crowning head that is)? Is the mum really in labour? Why couldn’t we be diverted to another job? And lastly, the most important question to answer – can I get to the hospital before the screaming package arrives?

So here are some of the basics answered:

Is mum in labour?

Probably. Although she may be having Braxton-Hicks contractions. These are an irregular tightening of the muscles around the Uterus. And irregular is the key word here.

If the contractions are regular then it’s likely to be labour time.

How far along is mum?

As you may know, labour has three stages:

• 1st – This is when the regular contractions start and ends when mum’s fully dilated. This length of time varies from 6 hours (or less) to 12 hours (or more) depending upon whether mum’s done this before.
• 2nd – Or scary stage. This is from full dilation to the precious package being delivered. This can be quick for the expert mums. Times vary from less than 30 minutes to 2 hours or more.
• 3rd – This stage is from the birth to the delivery of the placenta. This can take from 5-60 minutes (more or less). Remember to keep the placenta. This will need to be checked to make sure it’s all there. Retaining of parts of the placenta can lead to post-partum haemorrhages.

Should I stay or should I go?

This is a tough question. The first guide is to look at how far apart the contractions are. The interval if you will. To calculate the “interval”:

Interval = the beginning of one contraction to the beginning of the next.

If the interval is > 5 minutes you should be okay to transport. However intervals of less than 2 minutes are the tipping point. You’ll be looking for the signs of imminent delivery at this stage. These signs include:

• Regular contractions with an interval between 45 seconds and 2 minutes.
• The need for mum to open her bowels (do not let her go to the toilet), anal pouting, or the need to bear down.
• A large bloody show.
• Mum says that delivery is about to happen (always listen to the mum).
• The head is crowning.

What do I do, what do I do?

• Find a private spot. This aint a spectator sport. Get anxious bystanders to chop firewood or boil water.
• If you have then, pop a pillow or a blanket under mums buttocks. This can help with the delivery of the head.
• Get some baseline obs (HR, BP). This isn’t a medical emergency but they’re nice to know.
• Coach mum to bear down or push with the contractions.
• Tell mum to rest between contractions. This in not a race, mum needs to pace herself. If she won’t relax, get her to pant between contractions.
• Remember that you (the paramedic, remember) are there to assist a natural process and to prevent an uncontrolled delivery.
• When crowning occurs apply gently pressure to the bubs head to prevent mum tearing and the baby to exit too fast.
• If the membranes are still intact, tear them with your fingers.
• After the head delivers check the neck for cord looping. If it’s looped slip it over the bubs head.
• The baby is going to restitute. Support the babies head as it rotates in preparation for the delivery of the shoulders. The shoulders will move from the east-west position to a north-south position (anterior-posterior).
• Apply gently pressure downwards to deliver the anterior (north) shoulder and then upward to deliver the posterior (south) shoulder.
• Make sure you grasp the baby securely as the rest of the baby is delivered.
• Most importantly the baby must be dried and wrapped to keep warm.
• Do not risk the wrath of a midwife for bringing in a cold baby.
• Record the gender of the bub and the time of delivery.

Ok, sorted. What now?

Remember what we said earlier. Don’t mess with the midwife – rug the baby.

Checking the baby is a good idea. APGAR scoring should be done at the 1 minute mark and the 5 minute mark.

An APGAR score of 7+ is good. Scores of less than 6 are cause for concern and the bub may need some resuscitation or assisted ventilations.

According to Ambulance Victoria’s guidelines, the newborn’s obs should be sitting with a respiratory rate of 40-60 breaths per minute and a heart rate of 120-160 beats per minute.

For infants and newborns, a heart rate of less than 60 is the point cardiac compressions should be commenced (40 for children). The head and neck should not have any flexion or extension as in the adult. A blanket can be placed under the body to correct for their abnormally large heads.

What other questions should have been asked?

This is far from an exhaustive list but you should be thinking about asking mum and dad:

• Is this your first bub? No, how many have you had and have you ever lost one?
• What are the contractions like? Regular? Increasing in intensity? Decreasing intervals between contractions?
• Have you had pre-natal care? No, this can increase the chances of complications.
• When is the baby due? Premis have an increased chance for breech or prolapsed cord.
• Have your waters broken or have you had a show?
• Any previous cesareans? This could increase the chance of a ruptured uterus.
• Is mums BP high + hands or face puffy? Could be pre-eclampsia – watch for seizures and decrease the stimuli mum is experiencing (dim the lights).

Other terms and things?

Para – number of children delivered after 28 weeks (alive or miscarried).

Gravida – number of times the uterus has contained a pregnancy.

If mum is involved in a trauma/accident she must be evaluated at hospital (regardless of the injury). The foetus will be sacrificed to save the mother.

Post-partum haemorrhage:

• >500ml of blood loss after delivery.
• This will normally occur in the first few hours after the delivery.
• As stated before this could be due to retention of the placenta or parts thereof or the incomplete contraction of the uterus.
• Treatment involves controlling external bleeding (tears), fundal massage (support uterus @ symphysis pubis and massage the fundus), encourage breast feeding, and transport.

Some days you just wish you hadn’t put the right shoe on the left foot when you woke up.

“The other day” was one of those days.

My partner and I received a job just around the corner. Looking at the pager I knew it was the local skate park. Some winner had taken the plunge off the edge of the bowl and hurt himself. We soon earned an upgrade to bells and whistles when the caller said his mate had fallen a couple of metres on to his head and then had a seizure.

We pull up and peroxide boy says his mate is awake and talking. “He’s sittin’ o’er on the chair ma’e”.

That’s when my day went south. Fast.

Firstly I got three stories. “He was unconscious straight away”, “Nah mate, he crawled out and sat on the chair”, “he was shakin’ for ages”, “mate, I tell ya, he was awake when he was shakin’, mate”, “hang on let me get another photo”, “this is goin’ to MySpace tonight”, “oh yeah I ‘fink he had somfin’ comin’ out ‘is ear, like water”.

We just went around in circles.

We checked his spine and grips along with his conscious state. We put a collar on him to support his neck, just in case and popped him onto the stretcher. He had no base of skull fracture signs. His pupils were a-ok. His vitals were fine and he just wanted to go home.

We just couldn’t put him into a category. He’d possibly had a seizure and possibly been unconscious at some point in time, so we spinally immobilised him. His injuries didn’t fit out time critical guidelines so I felt he’d need a hospital that could do some CT scans, just in case. My partner was undecided but did feel concerned by parts of the story, understandably.

So we threw the ball to the captain and got some external thoughts.

The clinician felt the major trauma hospital in the city was the way to go. Just in case.

Sorted.

He got a cannula (which he hated), ECG, O2, a trickle of fluid, a big time secondary survey (examination), and we made sure he was strapped down tight, just in case. I suppose that’s what it’s all about. Just in case.

For the rest of the shift I just felt, “wrong”. In some ways I felt that I’d lost control of the case. Perhaps if left to my own devices I would have gone to the wrong hospital and the patient could have deteriorated. I just don’t know.

Next time I’ll know. I think erring on the side of caution is the paramedics best option.

Somedays you look at a patient and just think to yourself, what is going on?

Most of the time it’s the humble chest pain. Is it their ticker or last night’s tikka?

You start of thinking that the pain’s a bit low, the patient ums and aahs about whether it’s their breathing causing the pain, and you just end up thinking – stuff it – treat for the worst case scenario.

I must say that I did visit a patient who had the classic chest pain after lawn mowing too much – and he just kept mowing – needless to say he got the stent that he was after. But things are always a lot murkier.

We recently received a call to a very dark path in a very dark park. The caller said that they couldn’t hang around but she’d seen a female in her 60′s unconscious on the gravelled path. Face down.

We pulled up and started wandering down the path. The 4 bystanders just stood arms crossed, chewing on fingertips. No one knew her and no one had turned her over to stop her pressing her nose into the dirt. That’s when we noticed the decerebrate posturing. Ooh, that’s not good.

We gathered some of the masses and, taking care of her spine, loaded her to our stretcher. We got her in out of the night and took a closer look. First glance said that she’d had a bleed in the cranium. Big haemorrhage in the brain. Stroke.

That’s when we got back to basics. The causes for altered conscious state? Number one – hypoglycaemia – low blood sugars. We felt it was a longshot, what with the decerebrate activity and all, but a drop of blood from a finger’s a quick test. And that would cross one thing off the list.

The reading was “LO” of the scale in a bad way. This looked like this ladies’ lucky day. As long as her brain wasn’t fried.

We got backup on the way, because they don’t trust us with IV sugars “yet”, and we gave her the Glucagon, popped a line in and waited for the cavalry.

Just as backup arrived she started to wake-up. A bit more magic juice from MICA and we trundled off to hospital.

She was itching to get home by the time we got to hospital.

I was going to verbal on a bit more about another job but you can only read so much before glazing over. Suffice to say the moral of the story is:

In ambulance things are never what they seem. Think outside the container.

I made my first big App store purchase “the other day”.

The ECG Guide by QxMD.

It’s starting to be a bit of a trend with this company, but hey if they’re putting out the good stuff then the flock will follow.

This time the good people of QxMD have packaged a pretty standard ECG guide for beginners and formatted it for the iPod touch and iPhone.

That’s all well and good. And that was all I was expecting from a $5.99 application. You’re looking at 6+ times that amount for a decent ECG book for beginners.

So what’s it good for:

• Learning the basics: lead positions and ECG interpretation including descriptions of the ECG segments.
• Learning about the effect chamber enlargements have on the ECG.
• Detailed descriptions of ischaemia and infarction.
• Learning about the ECG’s of arrhythmias: its mechanism, blocks, and a whole lot more.
• Showing that there are other reasons for ECG changes: Hypothermia, thyroid problems, pulmonary disease, and more.

The other bonus is the large amount of sample ECGs. Click on Atrial Fibrillation, turn the gadget on its side and blow up the sample for closer inspection. Nice.

The other little feature is the quiz. This brings up a random ECG for you to interpret. Click the info button to find out what it was. Then click next for another one. This quiz functionality could have been done with finesse but they’ve copped out a little. Multi-choice perhaps and a scoreboard to track your progress. Whatever.

Anyhoo, overall this is a neat little piece of kit. It’s just a re-badged basics of ECG book, but if that’s what you’re after then go for it. If you’re in the medical business it’s a tax deductible $5.79.

We’ll give it 3.5/5.

Pros: For a repacked basics of ECG book, it’s neat and comprehensive. Good selection of ECGs. Utilises the iPod/iPhones screen rotation functionality well. Cheap.

Cons: Not greatly useful on the road. The quiz could have been slicked up a bit.