The state of play, with regards to Ambulance Victoria, is that on AFL Grand Final night Melbourne is missing over 20 ambulances from our streets.

Frightening to say the least!

Is this because of union/eba issues, disillusioned ambos, people “chucking sickies”, or what?

Any way you paint it – don’t get sick.

Such is human nature.

Solidarity. Mutual goals. And then it all crumbles. Or has it?

So the Ambulance Victoria enterprise bargaining melodrama continues. This time in a more surreptitious manner. Ambulance Victoria has struck an agreement of sorts with the Victorian Ambulance Union (AEAV), a last minute face saving exercise, apparently.

Next came the MICA mass resignations and another last minute agreement between the MICA paramedics and Ambulance Victoria. This assured an improved package for MICA paramedics.

En masse there has been a collective “fair enough too”. But this has left the Victorian work-horse paramedic in an unenviable position.

They can now accept an agreement that has been universally seen as  degrading  pay and conditions or they can say no and go to arbitration.

There are three major problems with arbitration. Number one is that it puts in jeopardy the gains made by MICA paramedics. Secondly the arbitrator could strip the hard earned and required benefits that all paramedics enjoy. And thirdly paramedics could be seen, by Joe Public, as being greedy and ungrateful.

These are interesting and confusing times.

Greed, human nature, comradeship, and so on. A true melodrama is playing out.

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.

If there is one thing in life that I’ve learnt. People over complicate things.

Back in the day I had a hell of a time passing my university degree. I always had questions floating around in my head about everything I’d learned. To many whys and not enough acceptance. All this did was to brick up any further learning. Then I’d start falling behind.

I vowed never to go back.

Then I did.

This time I accepted what I was told. I kept up. I went home and read. I answered those questions in my head, in my own time, at my own pace. The simplicity of it all just clicked.

This is why, if I can, I break everything down to its most simple form. Even being a paramedic.

So here’s the theory:

• When you meet the patient find out first if they’re alive, dying or dead. This should be fairly obvious.
• If they’re gasping give them oxygen. If they’re not breathing, start CPR and pop the defibrillator on. If they look like they’ve had a big trauma, have someone stabilise their neck. If the blood’s pouring out, stop it. Otherwise take a breath.
• The next step is to find out what’s wrong. I reckon the best way is to ask them. See, simple is nearly always the best.
• Get a baseline. Conscious state, blood pressures and heart rates, see how well their breathing is. This’ll give you an idea as to whether they’re getting worse or if your treatment is working.
• Treat what you can treat and transport.
• Done, QED, keep it simple stupid.

This is just the standard clinical approach. Don’t over complicate it.

You’ll fix the diabetic hypos, and the heroin overdoses. But if they’re sick I say leave it to the folks that earn the big bucks. There’s only so much you can carry anyway.