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i would like to know what firetrucks in rural areas can carry on there trucks as far as medical supplies to be able to meet there needs on the call until ems arrives

Oxygen is inexpensive, easily obtainable, ad widely utilized as to impede and prevent the effects of hypoxia. Since it's discovery in the late 1700's oxygen has remained one of the most effective therapeutic agents known to the medical world. However, currnent literature suggests this medication is all too commonly administered at extremely high doses, causing hyperoxia. But oxygen is harmless right? Hyperoxia induces bradycardia and a reduction in cardiac output, which partly offsets the otherwise increased oxygen delivery. below are several different articles or studies regarding potentila risks of high flow oxygen. A publication in the October 2003 issue of Chest confirm that 100% oxygen can be harmful for asthmatics and support recommendations to use the minimum concentration required to maintain target O2 saturation. Retinopathy of prematurity Dr. Bledsoe on "the oxygen myth" -http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_myth.html oh and, apparently concentrated oxygen is ineffective at harming or killing cancer cells(an interesting read) -http://www.cancer.org/docroot/eto/content/eto_5_3x_oxygen_therapy.asp hope this provides some insight for you.

My FD runs a fully staffed BLS Non-Transporting Heavy Rescue Truck. It includes all the equipment that a BLS ambulance has, with the exception of a cot. We have all the backboards including a pediatric one, scoop strecher, vacuum splints, KED boards, LifePak 12 (with 12-Lead ECG, NIPB, SpO2 and AED defult mode with ALS manual mode with pacer), jump bag, trauma kit, pediatric kit and all the other equipment that the state requires a BLS rig to have. We have one engine that we run as a BLS rig and it is much simpler. Jump bag that has airway kit, OB kit, suction, c-collars, meds and other misc equipment. We even have a LifePak 12 that only has SpO2, four lead ECG (no 12-lead), defaults to AED but can be changed over when ALS arrives to be maual defib and pacer. We have no backboards or splints on this rig. We have this since it is second out to MVC's and first out for fire's and haz-mat. The reason we have the Rescue Truck is because we respond on 100% of 911 calls that our ambulance has. Hope this helps.

I am the service director for a first responder unit, and we are thinking of upgrading our service to emt-basic non transport. i was wondering how many emt-basics your department has to make 24/7 coverage possible. im not talking members on your roster, but how many emts actually do the work to keep your service 24/7 compliant. I cant find a definate or estimate answer anywhere with the state, but was hoping everyone on here could help me get a rough number.

hello everyone...my names Jim and some of you might recognize my name from another forum, I am a new paramedic from RI...so hello from the east coast

A watch is a personal choice. It should be functional with being easy to clean and I prefer the band not to conduct heat. It should be easy to see for your work environment and eyesight. It should stand up well to your work environment. I live, work and play around water so being water proof is a plus. I also don't like to switch watches a lot between work and play. The times I do change are for those occasions when only a Rolex will do to go with the shoes.

He is what North Carolina is saying about using the King airway for emergency situations. NC-KingAirwayFDAOpinion.pdf

Greetings and welcome !

Nice to see you again piranah!

Bledsoe did provide some misleading information in that article. From the AAP and the 2005 NRP guidelines which were in effect when he published that articls: For babies born at term, • The Guidelines recommend use of 100% supplemental oxygen when a baby is cyanotic or when positive pressure ventilation is required during neonatal resuscitation. • However, research suggests that resuscitation with something less than 100% may be just as successful. It does not say room air. Some do start at 40%, 50% or 60% but not room air. • If resuscitation is started with less than 100% oxygen, supplemental oxygen up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth. You do not wait for "failure". • If supplemental oxygen is unavailable, use room air to deliver positive-pressure ventilation. This article did more to explain the death of the hypoxic drive theory by way of the release of hypoxic pulmonary vasoconstriction and ventilation/perfusion mismatching. http://chestjournal.chestpubs.org/content/124/4/1312.full'>http://chestjournal.chestpubs.org/content/124/4/1312.full From the article (if this is the article you referenced): But then for asthma, oxygenation is generally not the issue but rather ventilation which is why 80/20 and 70/30 HeliOx mixtures are used. However, when 21% or 100% O2 can not be ventilated for gas exchange and no heliox is available, you use what you have available to maintain SpO2 even if that means 100% oxygen. For all the other situations, there are variables in each situation that must be examined. No blanket statment should be made for any one situation at there are some situations where 100% O2 will be necessary. Prehospital just hasn't gotten so far as to running SvO2 or StO2 monitoring on everyone to see the tissue oxygenation. Also, many of the studies were done on long term effects and not for the 15 minutes an EMT(P) are with a patient. Right now StO2 monitoring is becoming more populat if SvO2 is not immediately available although one can be obtained by iSTAT or other POC as soon as central venous access is available. Thus, the patient is then treated by that rather than the SpO2 or SaO2. If the patient is septic, there are also guidelines and protocols in place for 100% O2 to be initiated. Pulmonary HTN is also an issue after a traumatic event as is ARDS and both may require 100% O2 until the patient can be placed on the proper gases, ventilator and medicine. The same is true for PPHN of the neonate. Right now, O2 is used with caution and maybe not at all or even subambient for ductal dependent cyanotic heart lesions. For others, research is still being done in a very controlled environment. However, I think it is great that you are reading the journals. The further you advance in college, the more all of this will start to make sense. But, in medicine there are very few concrete answers which makes it an exciting field to be in. Just when we think we've got all our guidelines and protocols working smoothly the patient decides to toss us another issue just to see if we're paying attention. It is those who take everything in their protocols as "the word" and fail to look at the whole picture that miss what the patient's body is trying to tell you. When reading an article, look at the whole study to see similarities and differences. They may be focused on proving just their one theory when they have actually supported something else. Thus, that leads to another research article to be written. CEHST is a great journal for those who want to know what is happening in the world of Cardiopulmonary Science: http://chestjournal.chestpubs.org/ The Journal of Respiratory and Critical Care Medicine is also a great journal. http://ajrccm.atsjournals.org/ For prehospital: Prehospital Emergency Carehttp://www.informaworld.com/smpp/title~content=t713698281~db=all Resuscitation Journal also has some great articles from an international perspective. http://www.elsevier.com/wps/find/journaldescription.cws_home/505959/description#description For those interested in neonates and pediatrics: AAP http://www.aap.org/ NRP http://www.aap.org/nrp/nrpmain.html Johns Hopkins Neonatal Newsletter http://www.eneonatalreview.com/ Journal of Pediatrics http://www.jpeds.com/ Annals of Pediatric Cardiology http://www.annalspc.com/ Also, after reading the many articles in the various journals, one can easily see why "scenarios" are not always as simple as they appear. You may have treated an obvious symptom but have not actually diagnosed the cause but rather assessed for a working diagnosis to run the protocols you have available. The more knowledge you acquire, the more protocols or guidelines you may have to go with your assessments when working in different areas as a Paramedic such as Flight, CCT or Specialty transport. Keep researching the journals. They'll open you eyes even more to the vast information out there and hopefully inspire you to take your career to a higher level regardless of what title you work under. I almost forgot to reference the Canadians. They've been known to do some fine medical research also. Canadian Respiratory Journal http://www.pulsus.com/journals/journalHome.jsp?HCtype=Consumer&jnlKy=4&/home2.htm&

Each position that has to be covered 24 hours a day means about 720 hours per month (30 x 24). A well-run business does not rely on overtime for day-to-day operations, so when calculating how many employees you need for that post, simply divide 720 with the number of hours that (in your area) constitute a full-time job without overtime. Around here, a full-time job is 8 hours a day, five days a week. In an average month, you have 22 working days, so that's 176 hours (22 x 8). This means that in my area, a post that has to be covered 24 hours a day needs 4.1 employee. Now, in the real world, things aren't that simple. Employees take time off. They need their summer vacation (here that's at least 4 weeks paid vacation per year). There's holidays like Christmas, Easter, Independence Day, etc. There are maternity/paternity leaves (here that's 3 months per parent plus another 3 months the parents can divide between the two of them as they see fit). Then there are sick days (especially if the employees have young children). It's really hard to believe how much time employees do take off until you see it with your own eyes. I would go by 5 employees per post. That should cover day-to-day operations, even with all the time off. Also, that may give you some elbow room for those extra shifts that always seem to come up. In some months, you may not strictly need five full-time employees per post, but I believe you will benefit from it in the long run. You'll avoid burn-out, be able to minimise employee turnover, and probably also, on a yearly basis, save money - it's expensive to have to pay overtime every time something comes up.

we have a heavy rescue and a light rescue. each truck carries a jump bag with all the basics. c-collars. long boards, scoop stretcher,and the same stuff for pedi. all except a stretcher. but the difference is that we only roll when there is a rescue call. the ambulances all respond by themselves and we'll call for rescue for extra hands..lifting, code. we have medics that respond only to certain calls as per protocall that is set up with the 911 center. southern nj is run that if you bill for your services which in no way does it mean that we get paid. just we bill the insurance we need 2 emts...but if you your squad dont bill then you just need one emt and a driver.. crazy i know but that's nj.

Do any of you have any experience with negative pressure ventilators? Are they still in use, and what would indicate their use over positive pressure ventilators?

Thank you all for your much valued responses. For any other members interested, I think the following article also answered some of the other questions I had regarding negative pressure ventilations. http://chestjournal..../2217.full.html

Two districts in our county have BLS ambulances that role, every other VFD has a rescue truck equiped with everything a BLS ambulance would have minus the transports capabilities. The VFD usually gets on scene 5-10 mins prior to the ambulance. We also have an ALS quick response truck that responds by the paid crew unless there is a fire. They can usually get there about 5 mins prior to ambulance.

Here , when an EMS calls comes in , the fire station door opens and we respond with an ALS transport ambulance. For MVC's and water rescue calls , we also have a heavy rescue truck which has all the same equipment as the ambulance except the stretcher. it also carries all the cribbing & extrication gear.

If you work 24's you could have 3 basic emt's and 3 first responders if you choose to do it that way and your state allows it. If not, then it's a minimum of 9 emt's. However, if you choose to work 12 hour shifts, 3 or four a week, you still will be roughly looking at the same amount. If a non transport service, are you even required to maintain a full crew? Could you just get by with 3 potentially (and PRN personnel to cover when not available). That is something you would need to get in touch with the state and ask if you are requesting 24 hour coverage. You don't specify what state you're in so that makes it a bit tougher as you have people all over the nation (and some international) and each state obviously has it's own rules. Take care and good luck !

I'm going to make this short. I don't really want to get into a big discussion on this on the open forum. If anybody needs further clarification or would like to discuss this issue further with me, just PM me please. Earlier this year we were called to an accident with a possible head injury. I was not required to respond to this call but could have. I didn't (2-3 years ago I probably would have). It turns out that the victim was a member of our department and a friend of mine. There were mistakes made on this call that reduced whatever chance the victim had in the first place. Meanwhile, I listened to this cluster on the radio rather than responding. My friend died about 4-5 hrs later at the trauma center. There's a lot more to this story but, this pretty much sums up the events. I have been a career EMS provider for about 6 years and have dealt with crappy calls (including family members that have died) in the past. This incident though just won't leave me alone. I just don't know what to do. It's the call I didn't respond to that is giving me more trouble than any I have responded to. If anybody has any suggestions please PM me. If you need more details, I can get into that too via PM. I just don't feel like getting into all the specifics on the open forum. Thanks in advance to anybody who responds to this.

My BLS Non-transporting Fire Department currently has (5) NREMT-B, (3)NREMT-I/98 and (3) NREMT-P/98. My ALS transporting ambulance has (6)EMT-Basics, (4) NREMT-I/85,(3)NREMT-I/99 and(5)NREMT-P/98. Both are rural volunteer services.

Negative pressure ventilation is still around. The following is an article from 1996 that is dated as far as current literature; however, many of the conditions and potential conditions that can benefit from NPV modalities are covered. http://www.erj.ersjournals.com/cgi/reprint/9/7/1531 The following is a newer review of prospective literature. It is actually somewhat limited for NPV when considering using NPV for acute conditions; however, it does appear that NPV could have a role. Clearly, I think a modality that helps the patient and prevents intubation has potential. However, I am not sure how NPV would compare to less invasive positive pressure techniques such as CPAP and BiPAP. I have even seen literature stating good results when patients were liberated from the ventilator by extubating and transitioning to less invasive ventilation techniques. As I remember, many of these patients did not undergo traditional spontaneous awake breathing trials. Therefore, I suspect it takes a massive pair to simply extubate and trust the less invasive modality to do the rest. I will try to pull the literature. Dr. Jeffrey Guy actually presented these studies in a recent podcast from his ICU rounds series. Free iTunes download. I will try to find the exact podcast. http://www.erj.ersjournals.com/cgi/content/full/20/1/187 Take care, chbare.

... paging Ventmedic - Ventmedic to the forums please.....

Great to see you! I know you will be a tremendous asset to this site. We could use some new blood around here to shake up some of the old timers... we all do get into our ruts you know. I am delighted to see you and some of the others that are migrating over. The more the merrier!

My question is, was this your scheduled shift off? If it was then you can't truly blame yourself, we can't be everywhere all the time. As care providers we do need "me" time occasionally. I tried that life once where you show up to everything whether on shift or not and it can have a negative effect on you and your family in time. I also agree with the above posters in that it may be time to seek professional help dealing with this, both for your sake and that of your family's. Since I don't know all the details I won't claim to know what you are feeling but I will say stay strong and good luck with this.

I suppose the theoretical answer is that if a patient is hypoxic without being hypoxemic, their O2 sat will not reveal their true level of cellular distress.

I just finished my intermediate class, and I'm just barely hearing many of these concepts for the first time. Why aren't they addressed?!?!? Now I feel like the idiot. Anyways, its been great reading through all this. Question for chbare, or anyone really; I understand the difference in definitions between hypoxia and hypoxemia, but how is this actually going to play out on a patient?...in the field?

Firstly: I am sorry I asked now, point being that one can not quantify "HELPED" one unless using controls as Ventmedics post using Compressed Air vs O2, its ALL anecdotal there is no science in the OP original question, just opinion and conjecture only. as for the home fed, HUH ? There is no possible way to deliver an FiO2 with just a SVN or NRM btw and return to what baseline ? Do you mean Homeostasis ? and sinus brady is a sign of Hypoxia. So then and Peads Brad and the Elderly Brad before becoming tachycardic when they are Hypoxic ? Or am I reading this incorrectly ? So your saying you treat symptomatic Bradycardia with O2 and this improves Heart Rate? If I a correct in my reading skills, just where did you get your Paramedic licence out of a box of corn flakes ? Again how can one in the field "Quantify" please note that in Kevkie attachment on the use of thromblytic protocol the target SPO2 ie Keep Sats > 92%. I have yet to see any protocol that does not state use supplementary O2 for any CP or SOB. A better question could be can one PROVE that Oxygen in the field is detrimental, just saying The FREE answer to that is in the Sickle Cell Patient they are at a far greater risk of sickling with PaO2 < 50 mmhg or bedside SPO2 < 85% (more or less, and quite dependent on the ODC shift) that may "help" to explain the other queries in regards to the ODC, that little sigmoid shaped graph is far more complex than most would imagine. Preaching to the Choir mate, higher operative word in the above statement (but a good point never the less)The meat of that statement is in any suspected cases of Hypovolemia "higher flows" should be delivered to improve content and capacity of to saturate remaining HGB. So an Oxygen DEBT does not not come into play in a Metabolic Lactic Acidosis ? Simply stated: The Krebs Cycle (anerobic respiration and production of lactic acid) this is just PART of the SUM "of the PART's" when hypoxia is present. Bless you, btw none of my queries were aimed at chbar well other than ODC.

In the case of the home fed asthmatic 100% FiO2 fed nebulizer will help the pt return to their baseline faster and in the case of uncomplicated sinus bradycardia with pure oxygen administration the rate will often times will increase to a sustainable 60 or 70bpm and the B/P will normalize as well. Remember a sign of hypoxia (more prominent in the very young and the very old is bradycardia)

I agree, the only 2 situations I can say the administration of specifically oxygen truly helped my pt is; 1)Arriving to the home of a patient on a home room air nebulizer giving themself an albuterol treatment. When I repeat this with 100% O2 off my D tank the pt seem to recover faster. You could say that this is just the effect of the previous medications kicking in, but I don't think so because over the years I have gauged reaction times with initial tratment on Oxygen and initial treatments using room air. 2) The second situation is, believe it or not, Oxygen is my initial drug treatment for un-complicated sinus bradycardia! and it works.

However, for the benefit of the new EMT(P)s, if you read or hear "history" of anemia, that does not necessarily mean it is still true in present day. Many medical conditions can cause anemia and then improve as that condition has been treated. As well, they may be receiving regular treatment or even blood transfusions to deal with this problem. Don't let that word "anemia" distract you from still attempting to treat the shortness of breath and for doing a thorough assessment to look for acute causes.

Going to have to agree with John here, valid point as it may be, the idea of Oxygen in any amount being enough to even temporarily fix an anemic state is almost obsurd, If your patient needs oxygen give it to them wow what a post

A tutor assisting us with some giving sets the other day followed up a talk we had from a nurse on drip calculations, by saying in the broadest accent I've heard in a while (roughly equivalent to Bubba's southern drawl) "Now, forget all that crap. In Ambulance we have two drip rates: s**t loads..and none". I laughed and thought of you for some reason.

It becomes difficult when teaching CPAP or mechanical ventilation to those who have no college A&P and who don't understand the concepts of preload or afterload. I can explain alot of concepts relying on some of the principles FFs learn in the fire academy but when only given 30 minutes ot 1 hour to teach them everything they should know about CPAP or basic pharmacology, I still refuse to over simplify. It just gets tiring hearing "I've always heard this" or "This is what our instructor said". Usually the word instructor says it all as the person may not have any education beyond the certificate they are teaching and thus, they do not know how to explain basic hemodynamics or pharmacological principles themselves. Teaching over all the hearsay or "the way we learn it in the street" can be challenging. Let me toss back your earlier comments about how the basic O2 calculations are not useful in EMS education. This is now something I will have tossed back at me when teaching a class as "don't need that crap as EMS providers". Some will now get this idea that these fundamental explanations of showing how O2 affects the body are pointless as you with some impressive education said so and they will shut off the learning process for these basic concepts as just extra BS. It is through the lack of understanding of a few basic concepts that lead to a break down in EMS education. Instead knowing how O2 is carried, O2 content, the difference between delivered O2 and that in the blood, and the basic formulas for how O2 devices deliver an expected amount of O2, some will just rely on memorizing note cards. Example: 2 L NC = 28% O2. Unfortunately that note card fails to mention "at rest for a 75 kg person breathing normal VTs of 500 at a rate of 12". These simple forumalas can also disprove the "placebo" effect. If one was just using compressed air, you might have an argument for the placebo effect but even 1 liter of oxygen can change the content for PaO2 in the blood. When one reads the literature, they will notice that we categorize or measure with relatively small increments when discussing some FiO2 and PaO2 relationships. This is expecially true with neurological studies as we run tight parameters for PaO2, FiO2, BP and SjvO2. But, many will now call O2 a "placebo" and that will not be correct as more research would be needed to know if even a small increase in PaO2 could have a calming effect on someone by affecting other physiological factors since we do know O2 can bring about various chemical/physiological changes in the body. The study would have to be done against a true "placebo" of compressed air. Thus, we now have one more piece of hearsay about O2 being a "placebo" or "a couple of liters does nothing" that will have to be explained to EMS providers.

Vent, 1. So, curious, what exactly do you say to those people when you hear the above highlighted responses? Yes it does.......I have no problems asking her opinion. Why would I? Cardiac Physiology background, Medical School, Anesthesia Residency, managed the TICU.....Deals with Respiratory Physiology every day of the week! .Wealth of knowledge. I know where my comfort zone is and where it is not.....( NICU is not ) That is why they have NICU nurses and RRT's! I respect those professionals immensely.... Respectfully, JW

Because one is an EMT-B using a textbook written at the 8th grade level does not mean one has to think like an 8th grader. And that goes for the 10th grade level Paramedic text book also. Unless you have the education, assessment skills and diagnostic, your medical director will not be able to write complex guidelines for you and thus you will have to make do with the protocols he/she gives you. Unless you can assess for certain the patient with a broken extremity is "hyperventilating" due to anxiety and not a fat embolism, you may have to error one providing significant O2 in attempts to alleviate their feeling of not being able to catch their breath. The same might be true for the patient with a headache. Imagine what would happen if there is already some cerebral swelling and we not put their face in a paper bag or a plastic mask with little to no O2 flow. Imagine what rebreathing CO2 could do to that person's brain. There are also many theories of thought of the various types of cerebral ischemia and O2 therapy. It is sad when some do want to over simplify some concepts and that my post is considered over the top by the Herbies of EMS. Is it little wonder why we get such "education" in EMS as "CPAP pushes lung water" and "lido numbs the heart". We also get all those great EMS/Fire station stories like "I've never seen it work on this or that". Yet, they are only with the patient for a few minutes and have no lab values to support what they are saying. Most don't know what happens to the patient 5 minutes after they are dropped off at the ED. Thus, are their "observations" useful for those who may have 30 - 60 minutes to spend with the patient for transport? The other factor to consider is the research itself. Often when forming the bases for one concept something else pops up. Look at how NaHCO3 was deemed not useful in the primary phase of ACLS nor did it change the acid/base balance when given down the ETT but did find uses elsewhere. What about NRBM and decompression sickness? Hasn't that concept been revisited but after extensive research on other applications? How about Albuterol and hyperkalemia? Who would have thought a side effect could become a treatment? What about acetylcysteine, the anedote for Tylenol overdose? Who would have thought it had so many uses and some of which were discovered through research for something else. Sometimes we look at research with tunnel vision and don't always see what it has actually proven. If some were to start recognizing there is a whole lot more to medicine, even at a very basic (not meaning EMT- level, there would be little argument against advancing the education for EMS providers. We need to stop dummying down the material and get EMS providers to become thinkers rather than just recipe readers. Getting one to think about basic concepts such as the formula for oxygen carrying compacity lays the foundation for you to critically consider the literature and what others are talking about. If you understand a few of these basic concepts you can then ask the appropriate questions of other healhcare professions including your medical director and know when some are just spouting what they saw on TV with such great shows as Third Watch or Trauma and believe that to be science. Too often some in EMS fail to establish a line of communication with their own medical director to find out why he/she wrote the protocol in such a way that you are questioning it. It is your medical director's license you are working under, not mine. I am just giving you a broader picture to think about. It also helps if your wife, the Anesthesiologist, is there.

To the OP: The IMPROVED OUTCOMES in the very short time that one attends to this or that patient in EMS is going to be VERY difficult to prove or disprove as most studies are "To Door" discharge, involving a huge cascade of Health Care Providers. To answer the question for the BASIC look to the pulse ox (if you have one) If you improve saturation you doing something for whatever the "slot" the patient one believes, ie say a COPD, with a Cardiac PmHx and throw in a community acquired pneumonia. But then withholding O2, with some study in hand and you may find your head in a guillotine for not following accepted practice, just saying. http://www.google.ca/search?hl=en&rlz=1C1CHMA_enCA347CA347&q=controversy+in+Oxygen+therapy+scholarly+studies&btnG=Search&meta=&aq=f&oq= As Vent notes: It would be a full time job just to read all the latest research about oxygen as it is used in various specialties and disease processes. Then introducing the PLACEBO effect, a hotly contested subject in latest issues of NEJM and the conclusions draw from meta studies vs some of the more dated studies that state empirically that this is even measurable. One certainly opens up a can of worms for the ethics types as delivery of Oxygen Therapy has never been studied, just medication(s) In regards to sword rattling, I provided for you as requested an anecdotal comment AND provided as much information concerning Pulmonary Physiology and the physics behind the rationale. I am and will continue to throw a gauntlet down in the spirit of an interesting debate, but taking it to my friend said level and emotional level ... FAIL. I do not have a degree I just make stuff up Mixing an "ethical dilemma" and the asking for "anecdotal comments" and toss in "human physiology and physics" you are going to get more conjecture than science. http://en.wikipedia.org/wiki/Ethical_dilemma

That's great, Vent. And I do appreciate the complexities involved with everyone's favorite little diatomic inhalant. But pending my training as an RT, if you hand me a patient, I still have to either give them oxygen or not; the pathophysiology involved may be largely over my head, but there's still only two options available to me. Can't we reduce these things to a somewhat easier set of principles or rules of thumb based on the brief time the patient will be under my care -- i.e. in the 8-15 minutes it's going to take me to back into the ER, I'd like to help some, but I probably don't need to work any miracles... just palliate a little. Or are you advocating the old everyone-gets-it strategem as the safest scheme for a low-level prehospital provider with a limited period of patient contact?

To Brandon Oto, Your questions: Your questions can not be simply answered with a yes or no. The subject of oxygen and the many patient care applications is a very broad subject. It may require some intense physiological explanations complete with formulas to express the many different conditions one could encounter with patients. It is not about just boasting knowledge and most of what has been explained so far is basic Respiratory 101 or what you might find in a decent college level A&P class. This is not about whose "sword has a bigger rattle". The posts are from people with many levels of education and expertise as well as many years of EMS experience to show you there is no one recipe fits all patients when it comes to oxygen therapy. I have advanced college degrees in subjects pertaining to oxygen and it is just enough education to show me how much I still don't know about the subject. It would be a full time job just to read all the latest research about oxygen as it is used in various specialties and disease processes. Unlike the MAST which was a man made device intended to serve one purpose, O2 exists in the air and affects many organs at a physiological level. When the body is deprived of it at the alveolar or tissue level, changes to occur. However, as others have demonstated, without certain diagnostic tests you may not know the extent the body is being deprived. The intent is generally to keep the PaO2 of the body at a normal level but it may take a higher FiO2 to do that depending on the disease processess and cardiac function of the patient. Even in the hospital, we know the patient should be off an FiO2 of 1.0 and below 0.60 (or 0.50) depending on which studies) before 24 hours. Unfortunately if a patient is also septic, the rules of weaning the FiO2 may take a backseat to seeing the tissues get oxygen. However, another septic patient may respond quickly to fluids and other therapies quickly and we can continue with weaning the FiO2. But, some patients with ARDS such as what we are seeing with the H1N1 flu may be on very high FiO2 with serious technology attached for 1 - 3 weeks. Those that survive may have some reduced pulmonary function but it will from the scarring caused by the disease. The extensiveness of it may prevent us from finding out what the O2 did to the lungs unless a biopsy is done either living or post mortem. For the research and literature, there are many, many specialties with a vested interest in the subject of oxygen. Even with good theories about the right way to use O2, the patient's body may dictate another way. Hospitals do have the luxury of knowing the disease processes and run O2 protocols bases on those diseases such as pulmonary hypertension and sepsis. Thus, in the short term, assessment is key. Once you take more classes to understand the disease processes and the body's physiology, you will be able to justify why you did or did not use O2 once your level allows you to make that judgement. However, even if you do advance, your agency's protocols may have to reflect the weakest link or the minimally educated. That also includes some Paramedic level agencies in the U.S.

The situation described by Tnuigs is something we are concerned about in the hospital and especially post op. Even at that, standing orders from surgery usually say O2 for 24 hours. In my role in the hospital, unless there is a sepsis or wound care issue, I can override that order with those from my medical director to make that O2 go away by just following a few guidelines for the various surgical patients. Thus, in many hospitals, RT knows about every O2 patient in the hospital. RNs are sometimes too busy for the old fashioned cough and deep breathe exercising of their patients and would rather put O2 on. Whenever I find a patient with lower SpO2s and I know some of the history, I see what their SpO2 will do if they take a couple deep breaths with a slight hold. That may also tell me a little about what I'm dealing with for the next step in their pulmonary or cardiac treatment. Some patients you see in the field are chronic hypoventilators. Without any lung disease they retain CO2 and buffer for high CO2. History and physical assessment can often tell you if they may have a tendency to hypoventilate. Some will see a sleep apneas machine and assume it is for OSA when it might be a bilevel (BiPAP) machine for hypoventilation. You can ask the patient "do you have a tendency to not breath deeply at night" or "do you snore or obstruct". Is your machine straight CPAP or does it offer another pressure when you breathe in?" Is the patient obese? Do they have a history of paralysis or loss of muscle strength from something like Gullian Barre? Do they have ALS or MS? You can watch their tidal volume movement and respiratory rates. Some breathe shallow and may have a higher RR to give an overall decent Minute Volume. At sleep, their RR may slow and their CO2 rises. That is why I caution people not to use the term "hyperventilate" when assessing a patient with a higher than normal RR. Tachypnea and tidal volume observations should be noted instead of just stating "hyperventilation" when the PaCO2 may actually be 70 mmHg. These patients I am a little more anxious to get their PaO2 back to normal once the underlying are identified. Remember the difference between Aveolar ventilation (PAO2) and that which makes it to the blood stream (PaO2) to give us a view of the A-a gradient. If they do require prolonged O2 therapy and it isn't just because of a pulmonary disease process like PNA which lowers the PaO2 or even if it is, this patient may need BiPAP during their time on the oxygen. But again, this will be for an extended period of time. Often in the ambulance and ED, the SpO2, history of past and acute illness/injury, breath sounds and physical assessment for work of breathing will give you some direction to follow until diagnostic tests (and philosophy of the specialist attending MD) steer the course.

I'm sorry to hear that. It raises in interesting point for me, a student who is still wrapping their heads around these concepts. I was reading a chapter of Clinical Anesthesia (as all 21 year old university students should be doing during their holidays ) this morning and I came across the following passage, "However, a patient who is receiving minimal supplemental oxygen and has an acceptable oxygen saturation may have significant undetected alveolar hypoventilation". Other than using our knowledge of the particular problem that our pt presents with to infer that there may be a ventilation issue, is there a way of ascertaining this in the pre-hospital context (capnography?)? Its probably not a practical point considering that it may be enough for us just to keep their oxygen saturation up during the short time we see them (no capnography our AP trucks (our BLS), we don't even have pulse ox sometimes, but that's changing), but I'm interested none the less. Respiratory physiology is glossed over pretty briefly in my degree, which I don't agree with. Am I correct in assuming that the issue with masking hypo-ventilation with higher Fi02 is to do with reduced excretion of CO2 --> respiratory acidosis?

There will always be folks eager to show their expertise in a certain area. The thing about a diverse group as we have here is that everyone has their niche and will gladly share their sometimes extensive knowledge of a particular area. Nice to know- sure. Informative- absolutely. Practical and appropriate for this context? Not always. Just take what you need from the discussion, and if your question still isn't answered after all the sword rattling, ask it again. Threads frequently get side tracked.

Sorry buddy, but this is what starting a thread is all about. Each person has given you an answer/opinion and are attempting to back it up. Sit back, read, indulge, and lap up all the good info that is being discussed.

To echo what tniugs- and I- said, lacking definitive evidence that supplemental O2 does any harm to the average prehospital patient, I think the placebo effect is HUGE. A person calls 911 for help, and assumes we can help them, or at least help ease their fears. Not every patient will have a dramatic turnaround like a narcotic OD, a reversal of hypoglycemia, or treatment for chest pain or pulmonary edema. Think about how often people ask how their BP is. Diagnostically it may have nothing to do with their situation, but it's something that most people understand. Think about how often people ask us what we think is going on with them. (No, we don't offer a diagnosis, but many times we can alleviate concerns with simple things like a kind word, a reassurance, or offer a possible, less serious reason for their symptoms.) If we tell them the O2 should help their nausea, anxiety, weakness, etc, then often times they accept it, calm down, and feel better. They arrive at the ER hopefully in a slightly better state physically and emotionally than when we arrived. The ER takes over and provides definitive care, but with all our fancy toys, medications, and training, I think too often we forget that the little things are what patients and their family remember about EMS. The end result is what counts, and the patient couldn't care less how many initials you have behind your name, that you just finished training on a new piece of equipment, or just reupped your ACLS certification. They simply want to feel better, and isn't that what this is all about? We are the first step of a continuum of care and I think that starting off on the right foot is an important part of feeling better. Several people have mentioned the mindset of a patient, and I agree that there are some people who are simply just too stubborn to die. We've all had the patients who defy all odds and should not be walking this earth- they conquer and recover from seemingly impossible situations time after time. We also have the people who succumb to illnesses and problems that are minor by comparison. I had a regular lady around 60 years old who had diabetes, CHF, MI's, CAD, one leg amputee- and on a drug store full of meds. Every several weeks she would call, and we would find her in the same situation- standing on one leg with her head in the freezer(she was convinced this made her feel better), with audible rales heard down the hall of her building, struggling to breathe. I intubated her 3 times(Did not have CPAP), and treated her with medications at least a dozen more. Most of the time she was breathing normally by the time we reached the ER and she always thanked us profusely. Her heart finally did give out, but from what I was told, it was actually sepsis that did her in. On several of her close calls, she did indeed tell us she was too ornery to die yet, and that she was simply not yet ready. We believed her.

Clinical presentation and evaluation,and good observation in the field: Pallor, look to mucosal membranes (pull lower eye lid and observe the color) PMHX: say like a possible GI bleed upper or lower, sickle cell anemia,iron deficiency anemia,(a Pt. may be on iron suppliment (ask are they self medicating or are they prescribed by an MD and this some times is overlooked) heavy menstrual bleeding, in pernicious anemia (they receive Vitamin 12 on a regular basis)I could go on if you wish http://www.emedicinehealth.com/anemia/page2_em.htm hemacrit ok, lets understand that first, a pecentage of RBCs to Blood Plasma. http://www.google.ca/search?hl=en&rlz=1C1CHMA_enCA347CA347&defl=en&q=define:hematocrit&ei=jqb9Sq-PFIa0swPXs-WdCg&sa=X&oi=glossary_definition&ct=title&ved=0CAcQkAE So just what does your Board Certified MD wife do to correct this? If you go down the path before a clear understanding of terms well it could be a bumpy road ... just saying, again look to Vents Post re: types of Hemoglobin. I highly suspect you are referring my post split hairs or provide educational links and ask a simple question ? See Vents post: Where to start Ok I will do the leg work for you in regards to PaO2 this is an arterial sample, hence the a part, then analysed by a Clark electrode and actally measures the partial pressure of oxygen dissolved in the blood plasma a linear and direct relationship is made.(see chbare equation its the .0003 part) Then with all the factors ODC calculated and value is determined IN some ways bedside Pulse oximetry used to trending device is a extremely valuable tool, even in the light of an anemic hypoxia. http://www.google.ca/search?hl=en&rlz=1C1CHMA_enCA347CA347&q=pulse+oximetry+measures&meta=&aq=3&oq=pulse+oximetry http://www.google.ca/search?hl=en&rlz=1C1CHMA_enCA347CA347&q=pulse+oximetry&btnG=Search&meta=&aq=f&oq= One of the biggest concerns of mine In EMS is the serious misunderstanding between oxygenation and ventilation. So a little side bar, 2 years ago now RNs treated my mother post op major GI surgery, and even though I attempted to explain the difference of hypoventilation and oxygenation, studies indicate post op geriatric patient that supplemental O2 may increase mortality morbidity ... It did in My Mothers case, unrecognized Hypoventilation (but Pulse oximetry by their protocol, and all was good ) this lead to pre renal failure and my mother died, yes anecdotal but now clearly backed by EBM, btw the Board Certified MD Anesthesia did contribute in passing, urine output during surgery and post op (this on a RENAL unit to boot)then oxygen absorbortion atelectasis a post mortum finding. The RN said they were just following (protocol post surgery orders) (I was not in the employment as an RRT in that facility) the RNs have since received a very serious lecture since that time by the manager of respiratory department, the protocol has now been CHANGED, Respiratory Therapy department is now consulted. In part thanks to VentMedic an PM's I will always be in Vents Debt besides having a personal relashonship with the associate professor of ICU did not hurt either. There are much controversy now with researchers in regards to High levels of O2 vs Low levels in the CHF patient, just what I do is in cases of CHF and in Pulmonary odeama (when no anemia suspected) is watch the pulse ox trends. And as Ventmedic just touched upon many other areas, it boils down to this EMS initiates O2 therapy, RRTs then wean patients off O2, with all the hospital toys we get to play with: YES O2 is a toxic gas but not over the very short time in contact in the field, it has not been proven to be harmful (in vast majority of cases) that said the jury is not completely in lots of research to do yet. Did you note the time of my post? I get crabby when I am sleep deprived. Oh the O2 treats Nausea? Nope I disagree the EMS provider in that case used the gift of the GAB, body language, and confidence this relieved anxiety .... the placebo effect is huge and a tool in the EMS provider should NEVER forget. Anecdotally I have had some patients that have very seriously survived because they were convinced that they would, comments like hey I have seen way worse and their still walking and causing grief. One case comes to mind an elderly Woman on every Cardiac Med Know to man, in flash Pulmonary odeama ... 5 stents, LEF about 12% so I was honest with her, things are not looking great here: Her comment to me: cheers

Well, this goes back to evidence based medicine and as usual, we are at a disadvantage because our diagnostic options are limited. Without KNOWING what underlying problems are, in the case of supplemental O2, what harm could we do? Our routine medical care for an ALS patient has always included o2, monitor, TKO IV, and a glucose check. Over the years, thanks to real world concerns like costs of glucometer test strips, we are encouraged NOT to check a sugar on every patient unless there is a suspicion(or PMH suggests) an abnormally high or low reading may be likely. Our service is not exactly progressive, so discontinuing routine supplemental O2 because it MAY not be necessary is not likely to happen any time soon. Can things change- of course. Look at all the changes over the years we have seen in this business. It used to be many systems required permission from medical control to even start an IV. When I first started in this business, MAST suits were standard protocol on all cardiac arrests. We no longer use them, and the reasons have been well documented. We used to be encouraged to stabilize, splint, and work up trauma patients before transport. Then came the golden hour and everything possible is done enroute to definitive care at a trauma center. I think of all the medications that have come and gone over the years like Bretylium, and aminophylline. Remember when sodium bicarb was used very early in a cardiac arrest scenario, instead of for a renal patient or for an extended resuscitation? Some changes were because better treatments came available, some were because they were simply never used, and others caused side effects that were worse than the problems you were treating. Will the use of supplemental oxygen become less automatic? We'll see, but in the meantime, I still see no harm in it, and the potential to at the very least help alleviate a patient's fears and anxiety is reason enough to continue.

Thanks everyone for your responses. These numbers are exactly what i needed. Thanks again for your help.

To work a 48/96 1 ambulance requires 6 Paramedics. If you want to limit overtime you hire 2 part time Paramedics as well.

We have roughly 30 Ambulances, we work 12 hour shifts, 3 days on 4 days off, we require at minimum 360 persons per week. Assuming no one works over time. For 1 Unit we need approximately 12 EMT's per week. Supervisors, operations, billing, payroll etc... not included.

If your trying to cover one unit. you will need at a minimum of (9) nine emt-b's. That will give you one unit on call 24/7 with the personal on duty 24 hrs. on 48 hrs. off. If you add a supervisor you'll have 10 personal. From that point on if you add another uint you'll add 9 emt-b's for each unit you need the field. Plus one supervisor/shift. Unless your talking about one man units. That would mean you only need (1) person per 24 hour shift. With one man units you may be able to use less supervisors.------Hear endeth the lesson. Passin.

2 24hr ambulances. 8 f/t 4 casual 1 mangr

Depends entirely upon the educational qualifications of the firemen. It is my opinion that most of them could do just fine with nothing more than c-collars, oxygen, a BVM, and an AED. ABCD is really the only function of a first-responder.