Heather Moore responded to an emergency call with colleague Sharon Robinson when three-yearold Roma McAleese was hit by a car last year.

Yesterday Coroner John Leckey told Miss Moore: “What happened to you and your colleague was totally unwarranted, quite disgraceful.

“It is unacceptable that the emergency services seem to be attacked almost routinely.

“Instead of expressing gratitude for your arrival, this physical assault happened.”

Little Roma was playing feet from her family home in the Ashdale Park area of Coleraine, Co Derry, when tragedy struck last March.

Nicola Smyth, the driver of the Volkswagen Golf involved in the March 2009 incident, was never charged with any wrongdoing.

Miss Smyth, who was left traumatised by the incident, was excused from attending yesterday’s hearing due to health problems.

Instead the driver described to police what had happened after she left her friend’s house.

Her statement read: “The wee girl just seemed to appear out of nowhere. I slammed on my brakes and got out of the car but the body seemed to be rolling about.”

Senior scientific officer Damien Coll said there was nothing to suggest Miss Smyth was breaking the 30mph limit.

A postal van may have obstructed her view, the expert added.

Roma’s mother Andrea told the court how their lives had been ruined by the loss of her daughter.

Mrs McAleese said: “Our lives have been destroyed without her. She had a big sister who worshipped her. She was me and her daddy’s world.”

She explained she has not heard anything form Nicola Smyth since her daughter died and claimed that Roma was walking across the road in bare feet with her shoes in her hands when she was hit by the Volkswagen Golf.

Mrs McAleese, who cradled her injured daughter in her arms as she clung to life, said: “Roma was not running.”

Paramedics left another emergency to attend to Roma and took six minutes to reach the scene.

They worked on her while on the ground and transported the toddler to the Causeway Hospital Coleraine, where staff continued to try to resuscitate her. She died around three hours later at 9pm.

Mrs McAleese also paid a dignified thank you to the paramedics, neighbours and hospital staff who tried to save Roma and explained the entire family was very grateful for all the efforts made during the worst moment of their life.

She explained how a playhouse is being built at St Malachy’s Nursery named after Roma.

Mrs McAleese added: “The whole community at that time, we would not have gotten through this without the support from the people.”

The coroner ruled Roma died from head, neck and chest injuries sustained when she was knocked down while crossing the road by a car being driven within the speed limit.

No paramedic should need to be told that they constantly face the potential for violence.  That violence can come from bystanders, family or from the patient themselves. 

We have all been on a call that later we thought to ourselves: “That got out of hand fast!”  Sometimes the patient doesn’t want us there (i.e. the sicidal patient that family/friends wanted to surprise with our visit).  Sometimes family and bystanders feel that they know how to do our job better than we do and get angry when we don’t follow their intructions to “Just give them somthing!”

The violence that ensues does not necessarily need to the brandishing of a knife or firearm.  A simple strike or push backwards that causes you to lose your balance and fall hurting your back, twisting your knee, tearing your rotator cuff etc. are more than enough to potentially end your career.

Before the violent episode or confrontation happens there are always warning signs or cues that the situation is escalating.  As a paramedic, you should be a keen observer of character and as your years on the job progress so should your ability to “read people”.  When you feel that your scene is starting to get out of hand you need to act quickly.  It is imprtant to recognize the cues that tell you a person is escalating towards violence and act on them.

I cannot stress how improtant it is that we be able to de-escelate a potentially volotile situation before it becomes physical, for so many reasons.

When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation is appropriate.
There are two important concepts to keep in mind:

1. Reasoning with an enraged person is not possible.  The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible.
2. De-escalation techniques are abnormal.  We are driven to fight, flight or freeze when scared. We need to change this mindset. We must appear centered and calm even when terrified.  Therefore, these techniques must be practiced before they are needed so that they can become “second nature.”

There are 3 parts to be mastered in verbal de-escalation:
A: THE WORKER IN CONTROL OF HIM/HER SELF

• Appear calm, centered and self-assured even though you don’t feel it. Relax facial muscles and look confident. Your anxiety can make your aggressor feel anxious and unsafe which can escalate aggression.
• Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
• Do not be defensive, even if the comments or insults are directed at you.  Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
• Know that you have the choice to leave, tell your aggressor to leave or call the police (or even 10-200 if necessary) should de-escalation not be effective
• Be very respectful even when firmly setting limits or calling for help.  The agitated individual is very sensitive to feeling shamed and disrespected. We want him/her to know that it is not necessary to show us that they must be respected.  We automatically treat them with dignity and respect.

B: THE PHYSICAL STANCE

• Never turn your back for any reason!!!!
• Being at the same eye level helps de-escelate the situation but you need to aware of your vulnerability to physical violence from this position.  Encourage the client to be seated, but if he/she needs to stand, you stand up also.
• Allow extra physical space between you – about four times your usual distance.  Anger and agitation fill the extra space between you and your client.
• Do not stand full front to client. Stand at an angle so you can sidestep away if needed.
• Do not maintain constant eye contact.  Allow the client to break his/her gaze and look away.
• Do not point or shake your finger.
• DO NOT smile. This could look like mockery or anxiety
• Do NOT touch, even if some touching is generally culturally appropriate and usual in your setting.  Cognitive distortion in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
• Keep hands out of your pockets, up and available to protect yourself.  It also demonstrates non-verbal ally, that you do not have a concealed weapon
• Do not argue or try to convince, give choices i.e. empower.
• Don’t be defensive or judgmental.

C: THE DE-ESCALATION DISCUSSION

• Remember that there is no content except trying to calmly bring the level of arousal down to a safer place.
• Do not get loud or try to yell over a screaming person.  Wait until he/she takes a breath; then talk.  Speak calmly at an average volume.
• Respond selectively; answer all informational questions no matter how rudely asked.  DO NOT answer abusive questions.
• Explain limits and rules in an authoritative, firm, but always respectful tone.  Give choices where possible in which both alternatives are safe ones (e.g. Would you like to continue in a calm manner or should we have the police join us?)
• Empathize with feelings but not with the behavior (e.g. “I understand that you have every right to feel angry, but it is not okay for you to threaten me or my partner.)
• Do not solicit how a person is feeling or interpret feelings in an analytic way.
• Do not argue or try to convince.Suggest alternative behaviors where appropriate e.g. “Would you like to take a break and have a cup of coffee (tepid and in a paper cup) or some water?
• Give the consequences of inappropriate behavior without threats or anger.
• Represent external controls as institutional rather than personal.
• Trust your instincts.  If you assess or feel that de-escalation is not working, STOP! You will know within 2 or 3 minutes if it’s beginning to work. Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the police.

There is nothing magic about talking someone down.  You are transferring your sense of genuine interest in what the person wants to tell you, of calmness, and of respectful, clear limit setting in the hope that the client actually wishes to respond positively to your respectful attention.  Do not under any circumstances try de-escalation when a person has a knife or a gun.  In that case, simply comply.

Oakley Canada is proud to offer our Forces program in Canada for ten years and counting. It is our privilege to extend a special selection of product to EMS at a “Forces” price.

https://www.oakleyforces.ca/

Props Peel Paramedic Union for finding this out!

OM PARAMEDIC FIELD GUIDE: Ontario Provincial Standards Version

The new OM Paramedic Field Guide has been a great success!

We have gotten alot of requests outside the SWORBHP region for a generalized version.  Well ask and ye shall receive.  All base hospital programs in Ontario are required to follow the standardized Ontario Provincial Protocols. We have put together an Paramedic Field Guide that encompasses these Ontario Provincial Standards and covers both ALS and BLS protocols in the same guide.

The OM Paramedic Field Guide the first of it’s kind.  This guide focuses on the information that you need and omits the fluff that you know like the back of your hand. 

This guide contains the current 2011 Ontario Provincial Standards protocols! 

In this guide you will find:

• Ontario Provincial and SWORBHP BLS Symptom Relief and Cardiac Arrest Protocols, including TOR
• Ontrio Provincial and SWORBHP ALS Adult and Ped Cardiac Arrest  Protocols
• PALS Cardiac Arrest and Drug calculations (already done for ages neonate through 11 years of age)
• Rapid ECG Intereptation and STEMI Bypass
• Cardiac and Medical Emergencies
• and a lot more.

This guide is only $20 and you can order online with PayPal or by sending us an email here at mail@OntarioMedic.ca.

As always, if your service or BHP has specific notations that you would like to incorporated into a more customized Field Guide (as we have done with the SWORBHP version) we would be more than glad to accomodate.

S A M P L E    P A G E S

Background

Febrile seizures are the most common type of seizures observed in the pediatric age group.

Although described by the ancient Greeks, it was not until this century that febrile seizures were recognized as a distinct syndrome separate from epilepsy. In 1980, a consensus conference held by the National Institutes of Health described a febrile seizure as, “An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or defined cause.”¹ It does not exclude children with prior neurological impairment and neither provides specific temperature criteria nor defines a “seizure.” Another definition from the International League Against Epilepsy (ILAE) is “a seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures”.²

For other information, see Medscape’s Pediatrics Specialty page.

Pathophysiology

Febrile seizures occur in young children at a time in their development when the seizure threshold is low. This is a time when young children are susceptible to frequent childhood infections such as upper respiratory infection, otitis media, viral syndrome, and they respond with comparably higher temperatures. Animal studies suggest a possible role of endogenous pyrogens, such as interleukin 1beta, that, by increasing neuronal excitability, may link fever and seizure activity.³ Preliminary studies in children appear to support the hypothesis that the cytokine network is activated and may have a role in the pathogenesis of febrile seizures, but the precise clinical and pathological significance of these observations is not yet clear.^4,5

Febrile seizures are divided into 2 types: simple febrile seizures (which are generalized, last <15 min and do not recur within 24 h) and complex febrile seizures (which are prolonged, recur more than once in 24 h, or are focal).⁶ Complex febrile seizures may indicate a more serious disease process, such as meningitis, abscess, or encephalitis.

Viral illnesses are the predominant cause of febrile seizures. Recent literature documented the presence of human herpes simplex virus 6 (HHSV-6) as the etiologic agent in roseola in about 20% of a group of patients presenting with their first febrile seizures. Shigella gastroenteritis also has been associated with febrile seizures. One study suggests a relationship between recurrent febrile seizures and influenza A.^7,8

Febrile seizures tend to occur in families. In a child with febrile seizure, the risk of febrile seizure is 10% for the sibling and almost 50% for the sibling if a parent has febrile seizures as well. Although clear evidence exists for a genetic basis of febrile seizures, the mode of inheritance is unclear.⁹
 
While polygenic inheritance is likely, a small number of families are identified with an autosomal dominant pattern of inheritance of febrile seizures, leading to the description of a “febrile seizure susceptibility trait” with an autosomal dominant pattern of inheritance with reduced penetrance. Although the exact molecular mechanisms of febrile seizures are yet to be understood, underlying mutations have been found in genes encoding the sodium channel and the gamma amino-butyric acid A receptor. 

Frequency

United States

Between 2% and 5% of children have febrile seizures by their fifth birthday.¹³

International

A similar rate of febrile seizures is found in Western Europe. The incidence elsewhere in the world varies between 5% and 10% for India, 8.8% for Japan, 14% for Guam,¹⁴ 0.35% for Hong Kong, and 0.5-1.5% for China.¹⁵

Mortality/Morbidity

• Children with simple febrile seizures do not have increased mortality risk. However, seizures that were complex, occurred before 1 year of age, or were triggered by a temperature <39°C were associated with a 2-fold increased mortality rate during the first 2 years after seizure occurrence.¹⁶
• Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general population (2% vs 1%). Risk factors for epilepsy later in life include complex febrile seizure, family history of epilepsy or neurologic abnormality, and developmental delay. Patients with 2 risk factors have up to a 10% chance of developing afebrile seizures.^17,18

Race

Febrile seizures occur in all races.

Sex

Some studies demonstrate a slight male predominance.

Age

By definition, febrile seizures occur in children aged 3 months to 5 years.

Nooruddin R Tejani, MD

The recent flood in Pakistan is by far the worst natural disaster the world has seen in recent memory.  This disaster has had a more devastiting impact than the Haitian eathquake and Tsunami combined. 

Perhaps it is the rash of world wide plight that has kept this disaster out of the mainstream media.  The amount of relief being directed to Pakistan pales in comparision to previous disasters. 

From the onset of the disaster, Global Medic (headed up by Toronto pramedic Rauhl Singh) has been answering the call for help.  There are already teams of relief workers in Pakistan doing their best to bring back some of the necessities of life to the affected.  Now the Taliban has released a blanket threat agaist all relief workers in Pakistan yet Global Medic has voluteers ready to make the trip to lend their support. 

I am proud that many of these volunteers themselves are paramedics and several of them, my co-workers.  For those already there and those about to depart we wish you safe travels and a safe return.  You should be proud of the work that you are doing.

Atrial fibrillation describes an irregular and often rapid heart rhythm. The irregular rhythm, or arrhythmia, results from abnormal electrical impulses in the heart. The irregularity can be continuous, or it can come and go.

Normal heart contractions begin as an electrical impulse in the right atrium. This impulse comes from an area of the atrium called the sinoatrial (SA) or sinus node, the “natural pacemaker.”

• As the impulse travels through the atrium, it produces a wave of muscle contractions. This causes the atria to contract.
• The impulse reaches the atrioventricular (AV) node in the muscle wall between the 2 ventricles. There, it pauses, giving blood from the atria time to enter the ventricles.
• The impulse then continues into the ventricles, causing ventricular contraction that pushes the blood out of the heart, completing a single heartbeat.

In a person with a normal heart rate and rhythm the heart beats 50-100 times per minute.

• If the heart beats more than 100 times per minute, the heart rate is considered fast (tachycardia).
• If the heart beats less than 50 times per minute, the heart rate is considered slow (bradycardia).

In atrial fibrillation, multiple impulses travel through the atria at the same time.

• Instead of a coordinated contraction, the atrial contractions are irregular, disorganized, chaotic, and very rapid. The atria may contract at a rate of 400-600 per minute.
• These irregular impulses reach the AV node in rapid succession, but not all of them make it past the AV node. Therefore, the ventricles beat slower, often at rates of 110-180 beats per minute in an irregular rhythm.
• The resulting rapid, irregular heartbeat causes an irregular pulse and sometimes a sensation of fluttering in the chest.

Atrial fibrillation can occur in several different patterns.

• Intermittent (paroxysmal): The heart develops atrial fibrillation and typically converts back again spontaneously to normal (sinus) rhythm. The episodes may last anywhere from seconds to days.
• Persistent: Atrial fibrillation occurs in episodes, but the arrhythmia does not convert back to sinus rhythm spontaneously. Medical treatment is required to end the episode.
• Permanent: The heart is always in atrial fibrillation. Conversion back to sinus rhythm either is not possible or is deemed not appropriate for medical reasons.

Atrial fibrillation, often called A Fib, is a very common heart rhythm disorder. 

• It affects about 1% of the population, mostly people older than 50 years. This amounts to more than 2 million people.
• The risk of developing atrial fibrillation increases as we get older. About 5% of people older than 80 years have atrial fibrillation.

For many people, atrial fibrillation may cause symptoms but does no harm.

• Complications can arise, but appropriate treatment reduces these risks.
• If treated properly, atrial fibrillation rarely causes serious or life-threatening problems.

Atrial Fibrillation Causes

Atrial fibrillation may occur without evidence of underlying heart disease. This is more common in younger people, about half of whom have no other heart problems. This is often called lone atrial fibrillation. Some of the causes not involving the heart include the following:

• Hyperthyroidism (overactive thyroid)
• Alcohol use (holiday heart)
• Pulmonary embolism (a blood clot in the lungs)
• Pneumonia

Most commonly, atrial fibrillation occurs as a result of some other cardiac condition (secondary atrial fibrillation).

• Heart valve disease: This can be something you are born with or be caused by infection or degeneration/calcification of valves with age.
• Enlargement of the left ventricle walls (left ventricular hypertrophy)
• Coronary heart disease (or coronary artery disease): This results from atherosclerosis, deposits of fatty material inside the arteries that cause blockage or narrowing of the arteries.
• High blood pressure (hypertension)
• Cardiomyopathy (disease of the heart muscle) leading to congestive heart failure
• Sick sinus syndrome (improper production of electrical impulses because of malfunction of the SA node)
• Pericarditis (inflammation of the sac surrounding the heart)

Atrial fibrillation frequently occurs after cardiothoracic (open heart) surgery, but often resolves in a few days.

For many people with infrequent and brief episodes of atrial fibrillation, the episodes are brought on by a number of triggers. Because some of these involve excessive alcohol intake, this is sometimes called holiday heart. Some of these people are able to avoid episodes or have fewer episodes by avoiding their trigger. Common triggers include alcohol and caffeine in susceptible individuals.

Atrial Fibrillation Symptoms

Symptoms of atrial fibrillation vary from person to person.

• A number of people have no symptoms.
• The most common symptom in people with intermittent atrial fibrillation is palpitations, a sensation of rapid or irregular heartbeat. This may make some people very anxious. Many people also describe an irregular fluttering sensation in their chests.
• Some become light-headed or faint.
• Other symptoms include weakness, lack of energy or shortness of breath with effort, and chest pain.

OntarioMedic is proud to announce that the OM Paramedic Field Guide is finally finished (and early too).  

The OM Paramedic Field Guide the first of it’s kind.  This guide focuses on the information that you need and omits the fluff that you know like the back of your hand. 

This guide contains the current 2011 Ontario Provincial Standards (and  SWORBHP) protocols!  Recerts are just about to begin but this guide refelects the current and 2011 protocols and directives.

In this guide you will find:

• Ontario Provincial and SWORBHP BLS Symptom Relief and Cardiac Arrest Protocols, including TOR
• Ontrio Provincial and SWORBHP ALS Adult and Ped Cardiac Arrest  Protocols
• PALS Cardiac Arrest and Drug calculations (already done for ages neonate through 11 years of age)
• Rapid ECG Intereptation and STEMI Bypass
• Cardiac and Medical Emergencies
• and a lot more.

$20

The OM Paramedic Field Guide is 115 pages and 4.5″ by 5.5″.  Everything is colour coded and organized to make it quick to find information and easy to read. 

You can order your Guide by sending us an email or online using PayPal. 

Have a look at some sample pages:

]]> http://ontariomedic.ca/2010/08/27/field-guide/feed/ 0 http://ontariomedic.ca/2010/08/26/siu-releases-final-report-on-pham-shooting/ http://ontariomedic.ca/2010/08/26/siu-releases-final-report-on-pham-shooting/#comments Thu, 26 Aug 2010 17:36:38 +0000 admin http://ontariomedic.ca/wordpress/?p=85 SIU Releases Final Report on Pham Shooting

SIU released it’s final officially clearing Const. Del Mercy.

The report gave details of the incident explaining that Fred Preston broke into his sister’s residence with the intent of harming her to retaleate for his wife leaving him.  Constable Pham and Mercy responded to the sister’s 911 call.  By their arrival, Preston had fled the scene.  Pham and Mercy were in seperate cruisers and Pham ended up stopping Preston’s pick-up truck shortly there after.

Pham radioed his position to Mercy who joined him at the traffic stop.  Pham exited his vehicle to approach Preston, Preston opened fire with his rifle.  Pham managed to return fire with only one round before being struck in the head.  Mercy returned fire as Preston now began to fire on Const. Mercy.  Preston was mortally wounded and died in hospital 3 days later.  Pham died 3 hours after the incident.

This has been a long ordeal for all the families involved.  We are so glad that SIU’s report is finally finished.

]]> http://ontariomedic.ca/2010/08/26/siu-releases-final-report-on-pham-shooting/feed/ 0 http://ontariomedic.ca/2010/08/24/off-duty-paramedics-jump-into-action/ http://ontariomedic.ca/2010/08/24/off-duty-paramedics-jump-into-action/#comments Wed, 25 Aug 2010 00:38:48 +0000 admin http://ontariomedic.ca/wordpress/?p=78 Off-duty paramedics jump into action

By IAN ROBERTSON, Toronto Sun

In a twist on the old saying “where is there a cop when you need one,” five off-duty Toronto paramedics stopped to help after a collision between a van and a tractor-trailer Friday.

Minutes later, the tractor-trailer burst into flames, said paramedic Rob Gillman who along with his four colleagues was en route to work when they came to the crash on Hwy. 401 around 6:30 a.m. Three of the paramedics were travelling alone in their vehicles, the other two were sharing a ride.

“Within 10 minutes, it was fully engulfed,” the 17-year veteran told The Sun.

The Whitby resident spotted fellow paramedic Jason Hess helping a man sitting on a barrier near his damaged van, and stopped to help.

“I didn’t have my uniform on, but Jason did, so I stayed with the guy while he went to help the driver of the truck,” Gillman said.

The trucker, who suffered a broken leg, had climbed out of his rig safely about 500 metres behind the van.

As eastbound traffic slowed during the drama, the other three paramedics heading to work, Norm Gray, Glynn James and Mike Wilson, pulled over and climbed the median barrier to render assistance before colleagues in ambulances joined police and firefighters.

“I saw smoke coming from it when I stopped,” Gillman said in an interview, recognizing from long experience the potential danger that can — and did — erupt.

The resulting inferno melted the top of the rig’s trailer and the fibreglass tractor cab.

“Things change on the drop of a dime and can get quite volatile,” he said.

Adding to the risk was that they lacked protective gear, “which is always a concern. If you’re hurt, you’re no use to anyone else.

“But when you see somebody hurt, sitting on the side of the highway, you want to help … it’s what we do,” he said after suiting up for the 7 a.m. start to his 12-hour shift.

Gillman has stopped to help at other accidents while off-duty, “but they don’t happen as frequently as you might think.”

Paramedics risk their safety and lives daily, but “don’t like to be called heroes,” Emergency medical services spokesman Kim McKinnon said. “They’re often unsung heroes.”

The trucker was driven to a hospital by on-duty paramedics. The van driver suffered a minor head injury.

Ontario Provincial Police are investigating the crash, which required the express lanes to be shut down for a portion of the morning rush hour.

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