Around the middle of 2004 I found myself sitting at a desk in a huge hall with about five hundred other people. They fidgeted and sweated and nervously chatted amongst themselves. I tried not to get sucked in, but I was nervous too. You see, it was the first of several rounds of testing that I had to undergo to be employed as a paramedic.

The three-part exam was unsurprising. There was a maths component, an English-language literacy component, and a short essay. I was told that the essay was designed to test my ability write coherently, but the topic suggested that there was more to it: “Why do you want to be a paramedic?”

Why indeed?

I knew what I was meant to say – I was meant to bang on about how I wanted to help people or something to that effect, and so away I went. I wrote three pages on healing the sick, comforting the wounded, and generally being Nightingale-esque. It was a little cynical, but it got me the job.

Recently I brought this event up in conversation with a very senior and experienced paramedic. He told me that when he started it was completely normal and routine that people would apply to work for the ambulance service chiefly because they wanted to serve their community. He told me that the idea of service was people’s key motivation when he started, and that idea was reflected in my exam paper.

The idea of community service as a main motivation seems quite exotic now, and my colleague’s concern was that junior paramedics are now far more ego-focussed and selfish than they used to be. I can’t comment on that directly, but he also made the point that mainstream values have sharply shifted away from communitarianism towards individualism over the course of his career, and that it makes sense that junior paramedics internalise those values.

That may or may not be true (I suspect that it is), but I want to make the point that even though it’s unfashionable, service to one’s community is absolutely critical to your career as a paramedic. It is what will keep you functioning when you’re in hour 13 of your shift and are desperate for sleep. It will keep you turning up, week after week when you’re not feeling it. It will keep you from dreading Mondays. Service and duty will allow you to function in a difficult job, even when things aren’t going your way.

Service is not only at the core of what we do, it’s at the core of how we keep ourselves sane. Our work has intrinsic value independent of the money we are paid or the prestige we believe ourselves to have. Without a feeling that you’re helping your patients, you might as well be working a customer service job – the hours are better, after all. The worst times of my career have been when I have lost sight of the idea of patient care and have felt myself to be an ambulance robot, going through the motions. I became unmoored from the purpose of my work, and had to try to find it again.

Service is hard. No-one is denying that. You will have to make decisions about how to spend your limited time and emotional resources. But, for better or for worse, a feeling of service to the community and a focus on patient care is what will buy you longevity and happiness as a paramedic.

This may seem like harnessing a communitarian value for your own individual psychological benefit and that this might be somehow dishonourable or dishonest. But isn’t that the core of all community work? Regardless of motivation, both the individual and the community benefit. Think about the unhappiest people you know; I would lay money on the idea that they are also the people who have the least engagement with the people around them.

Did I believe all that when I wrote that exam paper? Not really – I was mainly motivated to gain employment in a job that excited me. But after I sat that exam I went home and had a big think about why I wanted to do the job. I hadn’t felt that I’d told an untruth but I felt I needed to refine my ideas more. When the time came for me to be interviewed for the job, I was asked the same question.

My reply was this: “I want to be a paramedic because I want to work in a job where even if I only treat one patient, I am able to go home at the end of the day feeling that I left the world better than I found it”. Then and now, it remains the truth, and I hope that if that ever changes I’ll find something else to do with my time.

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Paramedic Burnout.

There is a growing awareness that working in healthcare is hard not just on the body, but on the mind as well.  However there is relatively little published research into the effects of burnout on Paramedics.

Dr Liz Thyer (@lizthyer) from the University of Western Sydney is trying to change that, and you can help.  Click the link to head over to SurveyMonkey and take a brief survey to help determine the prevalence of burnout amongst paramedics in Australia.  If you are an Australian paramedic, 15 minutes helping Liz help you will be time very well spent.

Posted in Mental Health | Tagged , | 1 Comment

Let’s be clear! Not all trauma patients must be treated with spinal immobilization during prehospital resuscitation and transport.

Originally posted on MEDEST:

ems-backboardsSpinal immobilization is performed in all trauma patients from the rescuers in EMS systems all over the world, regardless the mechanism of injury and the clinical signs.
This kind of approach is nowadays been rebutted from the recents evidences and the actual guidelines.
ACEP, in Jan 2015, released a policy statement entitled :”EMS Management of Patients with Potential Spinal Injury” clarifying the right indications, and contraindications, for spinal immobilization in prehospital setting.
The lack of evidence of beneficial use of devices such as spinal backboards, cervical collars etc… is in contrast with the demonstrated detrimental effects of such instruments: airway compromise, respiratory impairment, aspiration, tissue ischemia,increased intracranial pressure, and pain, consequent to spinal immobilization tools, can result in increased use of diagnostic imaging and mortality.

Already in 2009 a Cochrane review demonstrated the lack of evidences on use of spinal restriction strategies in trauma.

Recently the out of hospital validation…

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How not to end your EMS career

My EMS career nearly ended last week. Not once, but three times.

The first time I was treating an agitated patient, whether mental health related or behavioural we couldn’t tell. She required restraint from four police but continued to kick and punch with some force. Sedation had relatively little effect on her with the result that her extrication was a messy affair as she thrashed and fought constantly.

The second time I was treating a young woman who weighed north of 100kg who was suffering from a “seizure” or pseudo seizure. In order to effectively manage her we needed to drag her out of the cramped toilet cubicle she was in and across a small landing. When we finally managed to get her onto our wheelchair, she proceeded to have another “seizure” which destabilised the chair going over a number of steps and gutters.

The third time was the worst. I was transporting a patient on the stretcher to the ambulance, but the stretcher became unstable on uneven ground and toppled completely over. For a moment I fought to prevent it falling as one does instinctively, and when that battle was lost I was thrown into a concrete carpark by the momentum. Against my retrospective better judgement my partner and I then proceeded to hoist the stretcher back to standing position with the patient still attached.

Any one of these three incidents could have ended my EMS career with a back injury. With the possible exception of the last one, none of these are unusual circumstances in ambulance work. We often have to wrestle with patients in the line of duty and physically manoeuvring them into the ambulance is all in a day’s work. Every time we perform actions like this we are exposed to risk.

I can name a dozen friends who have injured themselves in far less dramatic circumstances. Some have had prolonged periods away from work with complications such as chronic pain, the need for surgery and often depression and anxiety. There is very little we can do to modify the environment we work in – it is by definition uncontrolled and sometimes actively harmful to ambulance workers.

Regular readers of my rantings will probably know where I’m going with this thought. If we can’t predict the environment and our ability to modify it is limited, we are left with only one way to minimise injury – we have to improve ourselves. And that means we have to make ourselves stronger. Much stronger.

I can’t prove it, but it is my belief that the only reason I was not injured on these three occasions is that I am physically quite strong. Nothing special by strength athlete standards, but certainly stronger than most people my age and size, and far stronger than I used to be. It was this strength which allowed me to do stupid things like lift up stretchers and feel completely normal the next day. Wrestling with a 100kg+ person is not my normal plan, but it’s what I have to do sometimes.

I have been lucky enough to have had great coaching from Kyle at ACE ( , and I pursue strength as a hobby, but it is not difficult to become plenty strong enough for what we do. More strength equals fewer injuries, easier night shifts, makes you harder to kill and an all-around better person. If you can deadlift and squat your own bodyweight in iron, that is probably strong enough. If you can use double your bodyweight, that is a game-changer.

I’ve run marathons, ridden a lot of bikes, done a bit of rock climbing and parkour, and not one of them prepared me as well for my work as 12 weeks of barbell strength training. I know I sound like a bit of a stuck record on this particular topic, but I’m quite happy to be boring if it means that a few of my colleagues aren’t forced out of the industry with chronic pain and permanent dysfunction. Strength training is the absolute best insurance that a paramedic can buy and frankly I think we’re mad not to do it.

Posted in Education, Uncategorized | 1 Comment

Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients

Robbie (@AmboFOAM):

Anyone who has to deal with the acutely agitated patient knows how difficult this cohort can be to manage. This is an interesting article regarding the use of everyone’s favourite drug, ketamine, as a means of safely dealing with these challenging situations.

Originally posted on PHARM:

photo (26)

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Originally posted on PHARM:

Courtesy of Dr Nicholas Chrimes & Twitter Courtesy of Dr Nicholas Chrimes & Twitter

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Mechanical CPR: Three CHEERS or a boo?

There has been a fair bit about mechanical CPR devices floating around the FOAMasphere lately, so I thought I should probably do a post.

These devices are not exactly new (check out the Thumper, in use in Victoria in the 70s) However, there seems to be a surge in interest in these devices, and I must say there seems to me to have been a largely positive buzz about them in spite of the evidence for their effectiveness being somewhat lacking to say the least.

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The AmboFOAM Google+ Community

Hi everyone.

I have a post in the works to follow up from the excellent SPA 2014 Conference from last weekend (as promised)  In the meantime, I have started a community on Google+ for ongoing discussion of stuff.  AmboFOAM, #FOAMed, #FOAMems stuff that is.

It’s kicked off with a fantastic conversation about mechanical CPR devices.

Sign up to Google and head over to AmboFOAM Discussion community and join in.

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Surviving your first year on road part 5 – Clinical Concepts

The clinical concepts that no-one teaches you about at university


You’ve spent the last three years or so getting to know the intricacies of morphine metabolism and the cardiac cycle.  Those things are all important as background, but in your operational life it is at least as important to have a collection of rules of thumb to fall back on until you’ve got a bit of experience.  Rules of thumb are formally known as heuristics, intellectual shortcuts which mostly work, most of the time – they’re not perfect but they can get you out of a lot of scrapes.  Here are some which I’ve found useful, both clinically and in learning to live the paramedic life.

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Necromancy and the law: step away from the corpse sir…

Robbie (@AmboFOAM):

As most of you know, I have a fairly strong view on how we go about resuscitating all and sundry, even when it does not appear to be the right thing to do. One thing I had not really considered in the past was the actual case law side of things in the jurisdiction in which I work. This is not to say that I had never considered the legal ramifications of the decisions I made, but I have always tried to do what I believe to be the best thing for the patient, rather than what will keep me out of court.

Fortunately in Australia, we have someone who does consider the actual legalities of providing care as paramedics – Dr Michael Eburn.  Dr Eburn runs a blog called Australian Emergency Law, and if you have not seen it before and work in Australia, you probably need to head there now.  Michael responded to a tweet of mine following some comments coming out of the NZRC conference last month with the following post on the legal view of starting, or withholding resuscitation when it is not in the best interests of the patient.

In a nutshell, it seems that in Australasia at least, resuscitating a patient in whom resuscitation is not in their best interests (for example the terminally ill or the terminally old) is probably a very bad idea:  “the law is clear, if treatment is not in the persons best interests it is not only appropriate to withhold that treatment, in Lord Browne-Wilkinson’s view it may be both a crime and tort to administer treatment that the practitioner has reasonable grounds to believe is not in the patient’s best interest”

Read the entire post below, and as always I welcome feedback, comment or criticism.

Originally posted on Australian Emergency Law:

I’m responding to an issue on ‘twitter’ (but a word of caution, I really don’t follow twitter and rarely look at my account, so this is not an efficient way to get in touch with me; but it worked this time).

The ‘tweet’ says

“NZ case law confirms no requirement to resus when medically not in their best interest. #nzrc2014” same in Oz? Ping @EburnM

The link is to, I think, the New Zealand Resuscitation Council.

The case law is clear and that may be because the key cases come from the UK. I’m not sure what NZ case law the speaker was referring to; but in Australia the law that justifies treating a person who cannot give consent is the principle of necessity.  In In Re F [1990] 2 AC 1 Lord Justice Goff set out the test for necessity.  He said (p 25, emphasis added):

… not only…

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