# A neat call last night, I want your advice



## Ms.Medic (Apr 4, 2009)

So its 11pm, I was riding my first paramedic shift for the service Ive worked as a basic in for a few years. I had my paramedic partner with me, along with a basic. We were dispatched to a call where the dispatcher stated the caller was a 76 y/o m stating he "was having a heart attack". My paramedic partner looks at me as we were walking in and says, "its all you girl, Im not even here". Holy crap, now Im about to be the one in cardiac arrest. Anyway, I walk in and the woman says he was in the bathroom having "loose bowels". I knock on the bathroom door and ask him if he is okay, he says he'll be right out. He walks out and immediately I could tell he wasnt lookin good. He looked sick. So my findings and treatment are below, and this being my very first als call to do by myself, I want you guys to look over it and see what I could have done better, or differently, or anything that would be some neat advice.

Initially: We walk into the call with cardiac on the brain, but not ruling out anything.
BP  108/52 manual 110/48 auto
PR  68
rr   16
SPo2 97 placed on 15lpm via NRB
bgl 119
lung sounds clear
3 lead occasional PVC's 
12 lead  NSR
etco2 36
hx=htn x2 yrs, 6 months ago had a ct scan due to possible stroke, but no diagnosis/findings to suggest a stroke, no cardiac hx at all
meds=lisinopril, trazadone, asa
Physical/mental assessment= EXTREME diaphoresis, pale, cool, A+Ox4, neurological exam= perfect 
Okay, we let dispatch know we were out with one stable patient, and would advise on transport decision asap


As I continue my assessment, and reassessed vitals approx 3-5 min later, things started to change:
BP 114/58 manual 114/64 auto
PR 76
rr  18
SpO2 97 O2 same
12 lead, NSR
etco2 38
A+Ox4
When assessing his pupils again, I could see a slight sluggish response on the right, but very slight, I had to look 6 times before making my decision that yes, for sure there was a slight sluggish response, I check for neuro deficits, again VERY slight weakness on left side. HOLY CRAP, now Im kickin it into oh :censored::censored::censored::censored: mode, there is an onset of a stroke happening right before me. How neat is that. I start explaining to the patient what I feel is going on and that time is everything when dealing with a stroke, and that I really would appreciate it if he would let me put him on a helecopter to fly him downtown, but that it also could be nothing, at least it would be "peace of mind". The man was very calm, very appreciative, and accepted my suggestions. I get on the radio and call for county to dispatch phi, we load him into the back and head for the airport. I work in a very rural area, and the closest appropriate facility is Hermann Memorial downtown. We were also in an area that no aircraft would be able to land in (trees everywhere), but anyway, in route I start bilateral IVs, explain to the patient what was about to take place, and then I reassess his neurological deficits, heres what I find:

A more defined sluggish right pupil, more defined left sided weakness, a right side facial droop ?.? unexplainable. I tell him to stick out his tongue and it deviates to the right side, BP is now 149/62, PR is 82, and now the patient is starting to repeat himself, and is slow to respond to questions, looking a little confused on how to answer me. HOLY CRAP. This is awesome, not for the patient, but for me to get to witness and treat. The flight crew is here now, I give him the report,and send them on their way.

The flight medic that was on the aircraft also works for us part time, so when he got the report he called me and told me that when they did the scan, the found a bleed on the right, but closer to the middle, parietal lobe of the brain. Very small, very deep in the brain, but it was definately there... WOW.

Its not very often that you get to witness the onset of a stroke like that and watch the detioration, in 7 years, Ive never been able to, but that was absolutely amazing to watch and treat, not that there was much I could do for him, but I did however get to recognize it and get him to an appropriate facility well within our 90 minute range. He was at the hospital in approx 50 minutes from onset.

Given the info, I was wanting to know from you experienced guys, what could I have done, assessed, or treatment wise, done differently. I think I did well, but theres sometimes a lot of things you could have missed doing that would have helped, or thought about something else too. AND, I also wanted to share a really neat call with you.


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## 8jimi8 (Apr 4, 2009)

Great assessment.  The only questions I would have is: "Did you take your aspirin today?  How long have you been feeling this way / how long ago did you notice he was acting differently" and What was his PsO2  w/o O2 15l/min NRB.  (and also possibly, did you do your repeat blood pressures on the same arm?)

Good Job.  You saved this man some brain.


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## TransportJockey (Apr 4, 2009)

Sounds like a good call. I would like to see something like that when I go out to internship this week


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## Ms.Medic (Apr 5, 2009)

jtpaintball70 said:


> Sounds like a good call. I would like to see something like that when I go out to internship this week



Well that was a first for me, Im sure there will be more to come, but all day Ive been thinking about how neat it was to actually get to see all of it start right before my eyes.


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## Ms.Medic (Apr 5, 2009)

8jimi8 said:


> Great assessment.  The only questions I would have is: "Did you take your aspirin today?  How long have you been feeling this way / how long ago did you notice he was acting differently" and What was his PsO2  w/o O2 15l/min NRB.  (and also possibly, did you do your repeat blood pressures on the same arm?)
> 
> Good Job.  You saved this man some brain.



He did have all of his daily meds that morning, which included the asa. And as far as the bp goes, I did not take it on opposite arms, which I thought about after the fact. His spo2 fluctuated between 97-99 the entire time, so it stayed good. And he fell out when the wife called 911. So he wasnt feeling like this until a few minutes before our arrival.


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## vquintessence (Apr 5, 2009)

Being a complete ball busting, nit-picking armchair quarterback here, but the only thing's I'd comment on are:

Unifocal or multifocal PVCs?  Perfusing or not?
and
Probably wouldn't initially have given 15L/min O2 c sp02 97%+, -SOB and clear bilat.

Job well done.  More testament to why you don't just sit back and zone out on the tech seat once the trucks rolling and you have a working dx.


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## Veneficus (Apr 5, 2009)

Looks like strong work to me. 

Keep up the good work.


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## emtfarva (Apr 5, 2009)

I am only a basic, But great work, don't let it go to your head. Always ask what you could have done differently. That is how you become a better provider.


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## bstone (Apr 5, 2009)

Your description was excellent. It taught me something! Bravo on the good work. You likely saved his life.


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## Ms.Medic (Apr 5, 2009)

bstone said:


> Your description was excellent. It taught me something! Bravo on the good work. You likely saved his life.



Id like to know what you learned from it.....and thank you, but I dont know about saving his life, maybe some brain matter.


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## Shasta (Apr 5, 2009)

*Great Job*

Sounds like you are the medic I want taking care of me if I ever travel to Texas Great Job.


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## Ms.Medic (Apr 5, 2009)

Shasta said:


> Sounds like you are the medic I want taking care of me if I ever travel to Texas Great Job.



LOL, well thank you, but Im still way to new, and still have waaay to much to learn to take that much credit. I mainly just wanted to share an awesome call with you guys.


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## Melbourne MICA (Apr 5, 2009)

*Left turn*



Ms.Medic said:


> I had my paramedic partner with me, along with a basic.



Sorry for the tangent - but I'm curious about your crewing level - are you saying here you have two Paras and one basic in your truck?

Well done by the way - trends are very important as are ongoing reassessments - you have now seen this first hand. 

Out of interest - what might you have surmised at first glance from a pt who is diaphoretic, has just been for number twos and has a marginal BP 108/sys?

A good time frame at least for the pt - early on in the piece. Does your destination hospital manage strokes well?

MM


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## emtfarva (Apr 5, 2009)

Ms. Medic,
you saved more than brain matter. you probably saved his quality of life too. I think you did a great job. Like i said before, always ask what you could have done better. I have one question, What did your senior medic say? Did he say you did a good job?


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## 8jimi8 (Apr 5, 2009)

brain = quality of life.  You did save his.


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## TransportJockey (Apr 5, 2009)

Melbourne MICA said:


> Sorry for the tangent - but I'm curious about your crewing level - are you saying here you have two Paras and one basic in your truck?
> 
> Well done by the way - trends are very important as are ongoing reassessments - you have now seen this first hand.
> 
> ...



I'm thinking there might be three on that truck because IIRC Ms. Medic is still a newer medic. But I can't remember correctly.


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## Ms.Medic (Apr 6, 2009)

Melbourne MICA said:


> Sorry for the tangent - but I'm curious about your crewing level - are you saying here you have two Paras and one basic in your truck?
> 
> Well done by the way - trends are very important as are ongoing reassessments - you have now seen this first hand.
> 
> ...



Yes, I was riding being observed by a senior paramedic for our service. So basically a senior paramedic watches and doesnt get involved to see if Im ready to be cut loose to ride by myself.

The hospital is a level 1 in downtown Houston


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## Ms.Medic (Apr 6, 2009)

emtfarva said:


> Ms. Medic,
> you saved more than brain matter. you probably saved his quality of life too. I think you did a great job. Like i said before, always ask what you could have done better. I have one question, What did your senior medic say? Did he say you did a good job?



She said I did awesome, but that I should delegate to my basic a little more. I was trying to do everything myself, and that I was doing things a little disorganized due to that. But overall, a good job.


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## TransportJockey (Apr 6, 2009)

Ms.Medic said:


> She said I did awesome, but that I should delegate to my basic a little more. I was trying to do everything myself, and that I was doing things a little disorganized due to that. But overall, a goos job.



I'm noticing that in scenarios it seems like the hardest thing is to run the call and delegate.


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## Ms.Medic (Apr 6, 2009)

jtpaintball70 said:


> I'm noticing that in scenarios it seems like the hardest thing is to run the call and delegate.



Well Im glad that Im not the only one that cant get it down. Im sure it will come in time.


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## HotelCo (Apr 6, 2009)

Sounds like you did a great job. Excellent assesment skills. It's a good thing that you went and re-checked the pupils. Not enough people do that. That definetly saved some brain matter.


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## mycrofft (Apr 6, 2009)

*Show off...Advice indeed!*


Ask about facial pain if there is a recurrent or recent droop (Bell's Palsy), and be cautious with all that fluid if you think cardiac insufficiency. Well-played down the middle of the course, and good on you for not giving ASA as a knee jerk, since it might worsen a bleed.


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## Ms.Medic (Apr 6, 2009)

mycrofft said:


> Ask about facial pain if there is a recurrent or recent droop (Bell's Palsy), and be cautious with all that fluid if you think cardiac insufficiency. Well-played down the middle of the course, and good on you for not giving ASA as a knee jerk, since it might worsen a bleed.



Oooh, nice. I didnt even think about the asa situation (not giving it for the chest pain). Yeah, I guess Im glad that wasnt givin huh.


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## Melbourne MICA (Apr 6, 2009)

*Mixed crewing*



Ms.Medic said:


> Yes, I was riding being observed by a senior paramedic for our service. So basically a senior paramedic watches and doesnt get involved to see if Im ready to be cut loose to ride by myself.
> 
> The hospital is a level 1 in downtown Houston



Thanks. I take it a level 1 facility is top notch and can well manage a stroke pt. 

But do you have mixed crewing? ie one EMT-B and one EMT-P and is that standard for your county/region/state? The reason I ask is because crewing is the latest target of many services looking to cut corners and at the same time sell reduced services (in overall quality) but expanded (because they can claim they have "more").

Here in Melbourne our elite staff were so badly managed that they left in droves over recent years to the point where our management (and government) are now going to sell a (mostly -about 65% of the total) ALS single responder system as the equivalent or better of the system we had. 

By splitting the crews they now have twice as many staff for the same number of rostered shifts. A very neat trick and one many services are now pawning onto an unsuspecting public.

I see there have been many threads on this and other forums about the subject. 

(Sorry for the political distraction) and once again well done and enjoy.

PS Wait till you do a pediatric arrest as the top gun and watch that old sphincter tighten up!!!!

MM


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## Melbourne MICA (Apr 6, 2009)

mycrofft said:


> "Well-played down the middle of the course".



Nice turn of phrase mycroft and very appropriate as a descriptor for a management approach - I'll remember it.

MM


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## emtfarva (Apr 6, 2009)

Ms.Medic said:


> She said I did awesome, but that I should delegate to my basic a little more. I was trying to do everything myself, and that I was doing things a little disorganized due to that. But overall, a good job.


If you had a great basic, you wouldn't have to delegate, it would have been done. When you are on a truck with a regular partner you will learn what to expect from your basic. Right now you are riding third, when you are by yourself you will be better off. Plus you can mold your basic to the way you want him/her. My partner and I review each call after. It works, because I learned over a few calls what she wanted done while in the back of the truck, also we review while driving to the call. I don't know if this will help. I always drive, so my partner has time to read our protocols before we get there too.


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## Ms.Medic (Apr 6, 2009)

emtfarva said:


> If you had a great basic, you wouldn't have to delegate, it would have been done. When you are on a truck with a regular partner you will learn what to expect from your basic. Right now you are riding third, when you are by yourself you will be better off. Plus you can mold your basic to the way you want him/her. My partner and I review each call after. It works, because I learned over a few calls what she wanted done while in the back of the truck, also we review while driving to the call. I don't know if this will help. I always drive, so my partner has time to read our protocols before we get there too.



Its not that we had a "bad basic", she is one of our very best, whos been in the service for 14 years. I just tried doing it all myself, I guess "delegate" was in some ways the wrong term to use.
For myself, its very hard trying to transition from basic to paramedic, when Ive been doing the basic for so long. I think what she meant was let them do their job/skills, and that way I can focus on mine as "paramedic role". I know we're supposed to focus on "basic first" even as a paramedic, but in some ways thats what I have her there for. If Im trying to do *ALL* of the basic stuff, theres nothing getting my partner involved to build that trust with each other, as well as getting them involved on calls.
I need to learn to work extremely well with my basic partner, and not leave them out in the wind, while I try to do every single thing, from holding c-spine down to bgl. 
Thank you guys for all of the input, as I go over it, its reminding me of a few things.


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## 8jimi8 (Apr 7, 2009)

could you give me an example of things that your preceptor was thinking you should have delegated?  Other than c-spine and BG?  I'm just curious what you were doing that excluded your partner?

i understand the scope of the basic, but are you talking about things like vitals, while you performed your assessment?


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## Ms.Medic (Apr 7, 2009)

8jimi8 said:


> could you give me an example of things that your preceptor was thinking you should have delegated?  Other than c-spine and BG?  I'm just curious what you were doing that excluded your partner?
> 
> i understand the scope of the basic, but are you talking about things like vitals, while you performed your assessment?



yes, exactly, along with trying to gather info, get the meds from family, talk on the radio, etc. 
And no, we did not hold cspine on this patient, I was just giving an example.


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## 8jimi8 (Apr 7, 2009)

ahh thanks!  that makes sense.  No worries!  You will get your routine down and streamline everything.  You have already gotten great assessments down, that is your cornerstone!


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## tydek07 (Apr 7, 2009)

Now that is a cool call, to be able to see it happening right in front of you! I have had a lot of CVA pts, but can count on one hand how many of those got to the ER in time for treatment. Most of the time its too late, so its always nice to have the couple you come across in time... but seeing it happening in front of you, now that is just awesome!

Good Job!,
tydek


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## maxwell (Apr 8, 2009)

This is why we do what we do.  
In the future (or you may have done this, just not written it)
-Did you take your drugs today?  (Should you have)?
-Ask the family if he's been weird/how long he's been weirder than normal?
-12 Lead ecg: were there neuro T's?
-Start the lytic checklist? (even though you wouldnt need it)
Nice work!


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## bonedog (Apr 8, 2009)

Melbourne MICA said:


> Thanks. I take it a level 1 facility is top notch and can well manage a stroke pt.
> 
> But do you have mixed crewing? ie one EMT-B and one EMT-P and is that standard for your county/region/state? The reason I ask is because crewing is the latest target of many services looking to cut corners and at the same time sell reduced services (in overall quality) but expanded (because they can claim they have "more").
> 
> ...


Hate to see this bean counter application to our form of medicine.
WE were a targeted paired system, however with MPDS, target's are hard to see. ( used to be they used basic's trained to dispatch and multitask, now they follow the cards and use the stunned closed ended questions that wouldn't be tolerated on car, consequently dispatched as rarely meets diagnosed as)
Pairing in my neck of the woods is fairly consistent, however, part of my province has gone to a nurse/medic trial.

Sorry for the hijack Ms.M. Sounds like you did a good call. Learning to delegate is an intregal part of the job, which will make life easier, once perfected. (knowing the partner is paramount so you know when and what to delegate)


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## nmasi (Apr 18, 2009)

How far is your transport time to a stroke facility?

I'm in the same position as you, we fly anything critical to Hermann or Taub.

I'm down in League City.


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## Flight-LP (Apr 19, 2009)

nmasi said:


> How far is your transport time to a stroke facility?
> 
> I'm in the same position as you, we fly anything critical to Hermann or Taub.
> 
> I'm down in League City.



You are aware that Ben Taub does not have a helipad?!? Patients flying into BT have to land at Hobby and are then ground transported by HFD to the ED. Not the most effective method by any means.

Also, that would be the LAST hospital I ever took a CVA to. Hermann, Methodist, or St. Lukes are all preferred stroke receiving facilities.

Do you routinely fly CVA pts.?


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## nmasi (Apr 20, 2009)

Ya, that was supposed to say Methodist...I was on the phone with someone talking about BT.  My mistake.

Flying a CVA is something that happens some of the times but not all, depends on what the circumstances are.  The transport time by ground to one of those facilities from our area is atrocious with construction and traffic so we fly a bit more than services that are closer and or have more efficient access to the medical center.


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## Melclin (Apr 20, 2009)

Melbourne MICA said:


> Thanks. I take it a level 1 facility is top notch and can well manage a stroke pt.
> 
> But do you have mixed crewing? ie one EMT-B and one EMT-P and is that standard for your county/region/state? The reason I ask is because crewing is the latest target of many services looking to cut corners and at the same time sell reduced services (in overall quality) but expanded (because they can claim they have "more").
> 
> ...



Melb, when you say ALS single responder, are you talking about the MICA singles or is there some new hair-brained scheme I haven't heard about, to have ALS singles as well? 

Also, out of interest (I live in Melb), which MICA van are you on? If you don't mind sharing in a public forum.


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## Melbourne MICA (Apr 20, 2009)

Melclin said:


> Melb, when you say ALS single responder, are you talking about the MICA singles or is there some new hair-brained scheme I haven't heard about, to have ALS singles as well?
> 
> Also, out of interest (I live in Melb), which MICA van are you on? If you don't mind sharing in a public forum.



I'm on Z2 at the Alfred

As regards you're query, the problem is in the non -  transferable job descriptions.

"Paramedic" in Australia now refers to any ambo as you know. In the US a "Paramedic" is an EMT-P - one of their highest levels roughly equivalent to our MICA types. 

"ALS" in Australia is the skill set our "Paramedics" now have - (remember not all our Paras (normal ambos) are signed off as "ALS" - its a skillset. 

In the US their highest skill-sets are roughly described as "ALS". It is also the skill level applied to certain types of clinical situations - but may not reflect the skill-set of those attending the patient. (At this point, corrections by some of my US EMT-Life friends are welcome if I have my definitions wrong) 

Confused? I am and I wrote it - thanks to the ambos in Australia who pushed for our name changes!!!).

Therefore I am referring to "ALS" single responders in the context of US EMS services in the same way as our MICA single responders.

Hope that clears it up.

PS There are many regional and state/private sector service variations but from what I gather there is roughly three general classifications of skill-set in the US.

EMT-B (Basic)
EMT-I (Intermediate) 
EMT-P (Paramedic)  

Once again I'm sure our local people here will tidy up my suppositions.

Cheers

PPS Do you like the forum? The boys and girls can get fired up at times but they're all pretty good types from my experience.

MM


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## Melbourne MICA (Apr 20, 2009)

bonedog said:


> Hate to see this bean counter application to our form of medicine.
> WE were a targeted paired system, however with MPDS, target's are hard to see. ( used to be they used basic's trained to dispatch and multitask, now they follow the cards and use the stunned closed ended questions that wouldn't be tolerated on car, consequently dispatched as rarely meets diagnosed as)
> Pairing in my neck of the woods is fairly consistent, however, part of my province has gone to a nurse/medic trial.
> 
> Sorry for the hijack Ms.M. Sounds like you did a good call. Learning to delegate is an intregal part of the job, which will make life easier, once perfected. (knowing the partner is paramount so you know when and what to delegate)



I agree totally. Our system has always been two tiered with a kind of intermediate level skillset as the "normal" ambos and our ALS MICA types as the second tier - supposedly to attend to time critical pts only. Not now.
Johnny on the spot, AMPDS, closest car, response times etc. You guys have suffered just as much from what I read and here.

Cheers bonedog

MM


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## Melclin (Apr 20, 2009)

Melbourne MICA said:


> I'm on Z2 at the Alfred
> 
> As regards you're query, the problem is in the non -  transferable job descriptions.
> 
> ...



Ah, small world. I was there last Thursday at the JEPHC symposium.

Yeah I understand. I can't say I agree with much about the American emergency health system. Not to insult anyone's ability, but I'm glad there's a MICA van 5 mins from my house and not a fire fighter with an AED. That sounds really harsh, I'm not having a go at fireies, but you know what I mean.

Yeah I really like this forum. Esp the case study type posts, and posts with interesting ECGs. And everyone is very helpful and knowledgeable.


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## Melbourne MICA (Apr 20, 2009)

Melclin said:


> Ah, small world. I was there last Thursday at the JEPHC symposium.
> 
> Yeah I understand. I can't say I agree with much about the American emergency health system. Not to insult anyone's ability, but I'm glad there's a MICA van 5 mins from my house and not a fire fighter with an AED. That sounds really harsh, I'm not having a go at fireies, but you know what I mean.
> 
> Yeah I really like this forum. Esp the case study type posts, and posts with interesting ECGs. And everyone is very helpful and knowledgeable.



Don't be gun shy. Stick your neck out if you have a query or point of interest. When the guys get past taking the piss out of you some of them actually have intelligent suggestions and remarks to make. A number are highly qualified and experienced in areas of EMS operations we don't yet utilize in sunny OZ.

Enjoy - stick you head in at Z2 some time and say hello. I'm on B roster at the moment.

MM


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