VentMedic

SAN FRANCISCO — Paramedic TV drama "Trauma" will be returning to the air after NBC reversed its decision to cancel the show, it emerged Friday. The network has requested three more episodes after saying last month production would be halted after the initial 13-episode order, according to reports. It has ordered additional material following a recent spike in ratings and may order more in the future if the show continues to attract viewers. Despite high production costs for on-location filming and special effects, "Trauma" attracted just 6.9 million viewers for the season premiere and maintained less than a 2.0 rating shortly before cancelation. It has faced strong criticism from much of the EMS community, with both NAEMT and the IAFC’s EMS Section sending letters to show producers protesting the creative direction of the drama and labeling it an "injustice" to those in the profession. On Thursday, it was also announced that the show will air in the UK after cable network Virgin1 agreed a deal with NBC. http://www.ems1.com/ems-news/606015-nbcs-trauma-revived-after-cancellation/

Those who post stuff like that probably have neither a wife or a girlfriend and are living in a fantasy world. I have not seen posts like his on any of the popular FF sites so there is a good chance he is just messing with us here as he knows what would happen if he started posting crap on the FF forums. There are still a lot of FFs who do put their families first right along with their jobs. There are also a few good FF/Paramedics in Southern CA that do try to make the EMS side better and really don't need people like him, if he is one of them, making their job out to be nothing more than a paycheck. Since there have been so many inconsistencies in his posts, there is a good possibility he is not a FF at all but some wannabe who didn't even make it through Paramedic school and is probably working for some private ambulance in L.A. rather than with the FD since he seems to know more about them than FDs, FFs, Paramedic protocols and medical directors.

The only reason it doesn't feel like a real national exam is due to the fragmentation of EMS with the 50+ different levels and each state trying to please everyone, mostly at the lower end, by handing out a patch for just one skill and calling that a "level" for that state. Hopefully the new levels will bring some unity to EMS and eliminate some of the mess this piece mill patch to pacify has created.

What a novel idea! Transport to the most appropriate facility! I wonder why someone hadn't thought of this before? Oh wait! The rest of the country has been doing this for several years even if it didn't have a fancy name to it. For at least 25 years we took suspeceted cardiacs to hospitals with cath labs and anything that appeared to be neuro to a center with a neurologist available. We have even been taking trauma patients to trauma centers for over 20 years. The county also kept us updated at to what hospital offered what services incase there was a diversion or a need for an alternate hospital.

Am I reading this right? The unfortunate MVA patient who happens to fall on the FD's 3rd rotation or "all MVAs" gets only BLS. That sucks for the patient if they need pain management or a pneumo decompressed. Extra 10 minutes? That's what I call a dump and run. Sounds like the residents of that area or those who have the misfortune of having a car crash there are going to be paying only for an expensive taxi ride and little else.

Exactly. It is like those who freak out when they have a pedi patient but realize all they have is an adult BVM. Learning the basics of how your equipment works should enable you to adjust for many different situations. This is something I have tried many times to stress with even simple things like the NC. I can not give someone the standard blanket recipe since every patient will be different. I will elaborate a little more on the low VT ventilation. For the cardiac, the theory is not to hyperinflate and do smooth even flows with low pressure. For ARDS, we may do a very rapid flow to hold similar to a square wave pattern to increase airway MAP and thus, hopefully increase oxygenation. However, that may require much pharmacological support to accomplish this as a high PEEP is also used in conjunction with the low VT to improve oxygenation and reduce atelectasis.

It is great that you want a good retirement but money should not be the only motivator. I could work in the coal mines in the midwest and make more than a FF while building a decent retirement. However, I do not want that job regardless of the pay and retirement. The same for the FD. I did it for 10 years and found it did not fulfill what I wanted to do as a Paramedic even though it was a decent department. I also knew things would change as they now have with the mega county wide mergers. You go from a department of 50 Paramedics oto of over 2000 in a couple of years and the system is stressed. I will not work at a job just for the money. Being stuck in a job that offers you little in satisfaction or your heart is not in it does a disservice to you, your family, your employer and the people you serve. I am fortunate that my education, the A.S. in EMS, got me a lead into CCT/Specialty and Flight. Without it I may not have been able to have the advantage over 200 other applicants with just my "fire medic" patch and experience to rely on since they were looking for people who understood the basic priniciples of pharmacology and disease processes and not just someone who can memorize a recipe book. Also, you went on and on about teamwork and dedication in the OCFA thread. Yet, you say you joined the FD primarily for the money and benefits like Diazepam did also. If I was a FF, I would say BS to your "teamwork" comments when you tell me over and over again about being in it for the money. You seem to miss the fire fighting aspects of the job like you did the patient care part with being a Paramedic. Thus, I would never trust you as a FF to watch my back even if you got to the Academy at 0300 to show how enthusiastic you are...to get a paycheck...and not fight fires or save lives. I would also cringe if I was still in the FD with all those FFs coming in just because they want to make money. How safe is that? They know once they get in the union will protect them regardless of how lazy and what screwups they are. Before long FDs as well as the EMS side of it will be in shambles with all those who are in it for the wrong reasons just as some have in EMS. The 18 week Fire Academy might seem tough and only a few are selected. But, when Oakland, CA got over 10,000 applicants, they had a difficult time finding 20 qualified people out of those to send to the Academy. Thus, when some say the "best of the best" what they actually mean is the "best in comparison to the rest". Now, back to education. You would be amazed at the number of opportunities that appear if you have an education to your name even if you don't immediately use it. I would never tell a young person to get a well paying/benefited factory or even FD job and pass up the opportunity to get an education when they are young whether it is in EMS or not. Later when the familly comes along they will be in the same boat at you. You can't find time and have all the "grown up" excuses for not advancing your education. Thus, your income is stuck at what the FD says it is and if you become disabled which can easily happen on or off the job, you will be trying to exist on a fixed income and your pension counting days will be over. You will not have anything to show for all that math you've been doing. I've seen this happen way to often in FDs and EMS providers. An education is something no one can take away from you and you can usually make use of it sometime in your life even if it is just to climb the ladder at the FD for a better pension. It beats being stuck in one pay class your entire life and just moving with the herd. People who are medically inclined usually want more from their lives and career than just settling for a job. There are still a lot of opportunites out there for those who don't just want to settle for a job at the FD where EMS is not all that great in some places...probably because few are in the FDs now to be either a FF or Paramedic by true ambition. There is also a work ethic that you must pass on to your kids and I truly hope you won't try to steer them away from education to settle for a job that they will be unhappy with and regret doing for the rest of their lives regardless of how big the pay check is. While in college they are given a chance to explore who they are and not the image you think they should be because it was good enough for you. Don't stall or destroy their ambitions or potential. Self worth is sometimes of a greater value. Excelsior? Here again you contradict your penny wise comments by wanting to go through an expensive program like this that is always under scrutiny. Since you are now in Virginia, to still consider Excelsior, you would either have to move back to NY or use that as an excuse as to why you didn't get your RN. You need to investigate your education alternatives as well as you do your checkbook. From the Excelsior website: Virginia Effective May, 2008: Virginia Board of Nursing has passed a new regulation that says anyone not enrolled with Excelsior College by April 2 of 2008 will not be allowed to sit for state boards. Those who were enrolled as of April 2, 2008, will have to complete their degree by December 31, 2009.

We've got two very different applications and theories of thought going here. Low volume ventilation of 5-7ml/kg, which was included in the google link, is at the low end of the ARDSnet protocol scale. We rarely go below 6 ml/kg in the ICU and probably would not attempt very low VT ventilation if we do not know circuit compliance or the automated system does not do compression compensation as you might be ventilating with <3 ml/kg. (Fatal mistakes made by some CCTs and Flight teams) Of course the standard self inflating bag should not have that problem but monitor VTs might be an issue. Also, for that literature, this protocol takes into effect when lung compliance is very low and the plateau pressure is over 30 cmH2O. Thus, the PIPs will be high and the goal it to spare the lungs that are already damaged which can be sensitive to both volutrauma and barotrauma. The cardiac arrest will usually not have lung issues that will decrease compliance to where the PIPs and Plateau pressures will be as high. Thus, we are not thinking low VTs for the sake of ARDS. Instead, the AHA is, and quite possibly the theory behind the low tidal volume BVM, is to lower the pressure by limiting flow and VT in hopes of giving a more laminar flow and effective ventilation. This is also why the AHA is now support devices such as the Oxylator which are like tricked out Elder valves. In summary, the low tidal volume theories (or implimented protocols) for ARDS or ALI (acute lung injury) must not be confused with the low volume/low pressure/flow limited objectives of the AHA which is to lower pressures to prevent over inflation and increase coronary artery perfusion. These low VTs will work until the patient is spontaneously breathing and demands more VT and overall minute volume. For the OP, it sounds like that researcher is trying to build a better mouse trap with the BVM to achieve lower VTs, limited flow and lower pressures when some of the automated devices like the Oxylator are not available. Here is one decent article and of course it is from Toronto. It is the theory using pigs. The results of the human trials should be presented in early 2010 when the new AHA guidelines will be discussed. The Oxylator http://www.lifesavingsystemsinc.com/em100.htm Here's another one from CareVent. http://www.securityprousa.com/careventemt.html Below is just a little extra rambling about ARDS which again this ventilation protocol is not to be confused with low VT ventilation of the cardiac arrest. Those discussing ventilation on this thread have demonstrated a higher knowledge so I am taking it to that level and making that clear before someone accuses me of using medical terms that aren't appropriate for EMS providers. If the patient presented with ARDS and not as a cardiac arrest patient we would be running pressors, serious sedation and possibly a paralytic. We also wouldn't be using a little Elder Valve or ATV to ventilate. If you didn't have the technology like the LTV ventilator, you would be leaning into the BV/ETT. Manually ventilating them is a hefty task. Prepping for ETI, we may run the patient on a HFNC (high flow NC) at 40 l/m with a NRBM or Oxymask at 15 l/m. The HFNC may definitely be needed or at least an additional 6 L/m NC since the NRBM is not a high flow device and won't meet patient demand if the patient is in ARDS like what is now associated with the H1N1 flu. This is also when I like the flow inflating bags to give the patient the flow they need. Then, as soon as the RSI meds are in, intubate. Using a self inflating BVM is difficult at best with very high PIPs and the flow wanting to follow the path of least resistance which definitely is not in the lungs. Hopefully these patients will be in the ED before they fully crash although I've had a few that just made it. Intubation was initiated within 15 minutes of arrival or as soon as the CXR confirmed how the patient looked which nixed messing too long with CPAP/BIPAP even with the capabilities of the hospital machines.

Who are you comparing them to? If you have only a basic Paramedic cert and do not know what the benefits of an education will do, how can you make that comparison? Imagine how impressive they could be if they actually had some education to back up their "street smarts" and field skills. I think you are seriously missing the bigger picture of why EMS will have to eventually evolve as a profession. Even the FDs will have to justify that they are providing more than just a taxi ride to the hospital. That is because they are considered careers and not just jobs. If you only want to find extra income, there are plenty of other "trades" you can pick up in a short time and even on a part time bases at a tech school. Don't go into nursing or RT just for the money. Both professions involve alot of patient care.

Diazepam618 (or whatever name he happens to use on the other forums) is probably just trolling to get responses since he has had difficulty in keeping his statements consistent. I also have not seen him spouting such stuff on a FF forum. I seriously doubt if his FF buddies would be as receptive of him for presenting them as a bunch of uncaring, unprofessional EMS providers or FireFighters who care very little for the public they serve. There is also a good chance he is not with a FD or he would already know this.

It would be pointless to argue anything medical with you since you seem to have missed the 80% EMS calls in your own post. Since I have spent 30 years in EMS, your comments really don't scare me "out of EMS". You scare me for knowing you and others like you are allowed to do come near patients. As for the out of state applications, you are in California. We get the out of state applications also but very much like California, once an applicant realizes why our wages are higher and that their chances of raising a family complete with a house and car are slim to none, few stick around. It truly has nothing to do with your FD especially for those who are serious about being a good Paramedic. Those out of state applicants have probably blanketed the state with their applications to every FD. Seattle is more highly sort after since it is a challenge to get a job that requires dedication, ambition, intelligence as well as the physical fitness of a FF. There are also many other outstanding FDs that take EMS seriously. However, in Southern CA that in not the case and usually the studies done in your area are to show your Paramedics can not perform some of the basic skills in EMS such as intubation or 12-lead ECGs which are then used to reflect negatively on EMS. Other FDs and EMS agencies such as Seattle and Wake County have shown quite the opposite. I am sure there are a few really good Paramedics in your FD but as you said "strength in numbers". Thus, for those for good Paramedics, it would be difficult to soar like an eagle when you are working with a flock of turkeys.

You have changed your pay and hours worked way too many times in the various threads and forums for any of your statements to have much credibility. It is not that difficult for anyone to check your base pay on the FD's website.

I am only talking about the medical professions. However, I think you may find Accountants and quite a few other professions on the same page. Name one licensed health care profession that relies on a tech school cert. About the only one I know of is the LVN which is no longer utilized is some states. I haven't seen an LVN in the area hospital systems in over 20 years. The few that are still there are working as PCTs which are CNAs with a few more skills and a little more education. The title of LVN is no longer recognized or placed on any name badge. Upgrade piece mill? RT and RN did not put in a few extra piece mill patches between diploma and degree. They announced the degree would be the minimum and gave about a 5 year notice. LVN and CRTTs were put on notice that they get their advanced credentials or they would no longer find themselves working in their same job areas. A few RTs were grand fathered but the hospitals embraced the educational requirements but then, the hospitals actually started rerquiring a degree for employment long before it became official. Thus, there were not many nondegreed RTs still hanging around when the change occured. If you do a little researching you will find this is true for the other allied health professions and the coming NP education requirements. Why is it that every other health care profession has a degree? Many go into it for a career. If another professional wants to change careers they probably already expect some work to do so. An Accountant or Engineer would understand the importance of education. Have you ever heard of a 6 month bookkeeper tell a Graduate school Accountant that their college education is useless? Would I want a 6 month tech school bookkeeper representing me with the IRS? Should this be good enough for patients? Is patient care all about your leisure? Why waste time at an expensive tech school earning credits that transfer nowhere? Why would anyone then start over if when the college tells them they are not giving credits for half-arses A&P classes? You say you are not anti education but then are you anti Paramedic? Do you believe the Paramedic should not join the ranks of the other medical professionals for legislative recognition? Do you believe the Paramedic is nothing more than a first aider with a feel extra advanced skills and thus a tech school training will suffice? I know you have read my posts about how and why other professions have advanced their education and I am really puzzled that you claim to be pro EMS as a FF but can not seem to see them as medical professionals. If you do not want to advance with EMS then you really should consider if you only got the Paramedic patch for a few extra dollars from the FD for your pension and not for the patient care aspect of the job. Your posts lately have only been about what the job can do for your bank account and not what you can do for the patient. Even when you were talking about getting a degree as an RN or RRT in other threads, you mentioned very little about the job or the patient care aspect. Neither you or Diazepam618 are a credit to Fire Based EMS when you fail to realize there is a patient involved.

But, when it comes to being a medical professional, one should not just settle for the bare minimum especially when that minimum is measured in "hours of training". You are providing care to patients and not putting seats in cars. Patients deserve a health care provider who is there for them even though a good retirement plan is nice. There is not another health care professional that can now say a degree is not necessary. Many employers are now requiring at least one degree higher than the minimum. For RN, many positions are wanting a BSN as the 2 year degree is just not enough any longer for the fast pace of medicine in many places. The same for RRT. The RN and the RRT are also now way behind what the other allied health professions require. If one just wants to be a FF like Diazepam618 who has no interest in anything medical, then so be it. A few weeks at a Fire Academy should be enough and I do not agree that those like Diazepam618 should be made to take a Paramedic course. It just shows how ridiculously dumbed down the Paramedic patch has become in some areas and drags down the profession. Why should the degree only be for those who want to move on to RN or some other profession? Why is education not necessary for the "field" Paramedic? I find this rather insulting especially for those who have gotten a degree as a Paramedic to provide care at a more educated level rather than just from what is learned in a 10th grade text book. Again, this tech mentality has to go away for this profession to gain respect and take its place amongst the other professionals to gain any type of recognition from those that make the legislation for reimbursement. A mere 2 year degree is not much considering what other professions, medical and non-medial, require. You are truly a minimalist. The RN is but a 2 year degree. Right now the Paramedic cert in CA and most other states is only about "1000 hours of training". Do you really consider that too much or a whole lifetime of education and totally unobtainable? You have really been hanging out with some very unmotivated FFs way too long.

Your numbers are impressive but he should also invest in his future in education. Tech education is almost nonexistent in the medial professions. If EMS ever gets its start at becoming part of the medical professions, those who skimped on education and just did the bare minimum may be severely penalized in the future. The old dogs may not have to worry if they are grandfathered and are ready to move on or out. However, the young people just starting out could have it rough if they graduate from a medic mill. Also, figure up the cost of that $12K loan at 10% over the next 15 - 20 years. And, you don't even get a degree or even transferable credits. You also failed to calculate what advancements in education can bring someone in terms of salary. You are essentially calculating on a blue collar basis. Someone who holds a degree can advance quickly through the FD ranks to an impressive salary toward their retirement, much more than a basic FF. Those wages that even a FF makes now may be small fry in 10 years. Also, as far as Southern CA, one can just pull all that OT just so long to make ends meet as a FF. They are by far not the better paid in that state when compared with other places. The FDs also do not know what the future holds for them. I truly believe those that advanced beyond the tech mentality will be the leaders to determine the destiny of EMS. It is a shame that some FDs really do want to keep EMS as just a trade school profession and not look to where even their own reimbursement dollars may have to come from when the taxpayors are not going to hand over their money so easily for so little when it comes to ALS care in their community. Not everyone wants or needs only a taxi ride to the hospital. I would never want to discourage someone, especially a young person, against college or tell them it is not a good investment or that they should just for for a tech cert and the money. There are too many people in the automotive industry that are kicking themselves for at least not getting a two year degree right after high school. Too many in several industries have lost their pensions and investments due to industry changes and that even includes some in health care. If you have nothing but a tech cert, you may be SOL.

I know you've had to have heard of AMR's chain of medic mills across the country. To the OP, Get your education at the local college which will probably be much cheaper than what a cert at NCTI is going for these days. NCTI will also try to hook you in with the EMT-I and other certs because they know their credits will transfer nowhere. This school may also try to hook you with a "package deal" that includes your EMT-B-I-P. It is essentially a used car salesman gimick as reputable schools do not have to use such tricks to get students. Also, DO NOT take their 1 week crash course entitled "Everything You Need to Know about A&P in 1 easy week". Take a real college level A&P class at a real college. Then, go straight for Paramedic.

Fortunately all Paramedic programs in California must be accedited by CoAEMSP. However, not all are created equal. If one reads the posts by Diazepam618, you may get an idea of the type of Paramedic Daniel Freeman might graduate. Interest in patient care is not a requirement. Disadvantages to a tech school is the lack of transferable credits. If you are accepted into a community college to do real college level A&P and Pharmacology, it isn't that much of a stretch to stay with a reputable school. You may want to advance your career by going into education or even get a promotion at the FD where a degree will be a head start. You also can get a certificate as a Paramedic at a local college without doing the whole 2 year degree. Someday EMS may even promote the 2 year degree as Oregon (and one other midwest state I can never remember) has already established and those college credits will have given you a good head start. Don't depend on any tech school credits to transfer and even if a few hours are given for the patch, they will fall very short. Also never look at a college education as wasting or locking up your life as some shortcuts may come back to haunt you severely later if you have any ambition for future endeavors. The price per credit hour at a California Community College is almost obscenely cheap at around $25/credit hour. Get your education while these prices last. Paying less then $3000 for a whole 2 year college degree beats a $12,000 medic mill cert. For that price you can have something more challenging at Loma Linda Medical University. Work experience is good but this "street smarts" attitude has also kept EMS providers as "trade" school techs and identified by a few technical skills rather than being recognized as EDUCATED MEDICAL professionals. This has held EMS back in legislative issues for reimbursement at state and Federal levels. One can get an education and then have the "street smarts" stuff make sense with a medical explanation rather than "this is the way we've always done it" or "just follow the recipe". Now if you just want to be a FF, ignor all advice here and follow the lead of the Diazepam618s who brag about making $100K while working well over 3000 hours/year with the FD and patient care is the furtherest thing from their minds. However, you can still be a FF/Paramedic but if you want to be a good Paramedic and not do a disservice to the patients and taxpayors, get a proper education.

For information about the NREMT, future testing levels and accreditation: http://nremt.org/nremt/downloads/Newsletter_2009.pdf NREMT website http://www.nremt.org http://www.ems.gov/ Accreditation by CoAEMSP http://www.coaemsp.org/ National EMS Scope of Practice Model http://www.nhtsa.gov/staticfiles/DOT...s/EMSScope.pdf The National Association of EMS Educators http://www.naemse.org/ The National Association of State EMS Officials http://www.nasemsd.org/ Implementation of the National EMS Education Agenda Web Site http://www.nasemsd.org/EMSEducationImplementationPlanning/index.asp 2009 National EMS Education Standards Gap Analysis Template 7/17/2009 A Comparison of EMS Knowledge and Skills to Assist the Transition and Implementation of the National EMS Education Standards for: Emergency Medical Responder (EMR) Emergency Medical Technician (EMT) Advanced Emergency Medical Technician (AEMT) Paramedic http://www.naemse.org/data/content/p...20Template.pdf National Association of EMS Physicians http://www.naemsp.org/

Have you checked your state website lately? http://kbems.kctcs.edu/ Changes coming for the NREMT and EMS: http://nremt.org/nremt/downloads/Newsletter_2009.pdf

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.

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.

Try the links and contacts listed on this page: http://ccasmur.forumpro.fr/worldwide-emt-s-international-page-f2/who-are-we-in-france-t3.htm

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.

Where to start.... EMS generally does not have access to many factors like Hb (and different types), A-a, lactate level, SvO2 or even the ability to take the patient's temperature. Anxiety, "hyperventilation": Too many unknows as to if there is a medical underlying cause. Even electrolyte imbalances or an undiagnosed diabetic situation can cause a "mood swing" or "argument" to escalate out of control and what might appear as a "simple" anxiety could be a true medical situation. Thus, the word tachypnea should be used until a further exam is done. If the patient calms with O2, it could be because of comfort or because it is improving an underlying situation that is skewing the O2 consumption or Oxyhemoglobin Dissociation Curve. Pain Management: Does O2 improve the situation by alleviating the symptoms of increased O2 demand due to pain? Advanced practitioner should know this from critical care experience. There is now tons of lierature on this subject in Anethesia and Critical Care journals. Anyone that has worked with an ill or injured patient may see the O2 SpO2 plumment if not immediately but shortly there after if the pain issue is not treated. For EMT-Bs, treatment of pain is limited but the O2 may prevent the cascade of physiological events that occur with increase O2 demand and consumption due to pain. Once pain management is under control, O2 may not be required. Reseach: Again as I mentioned with pain management, there is an abundance of literature on the subject. However, everyone has a different theory and for every topic I can easily find 50 articles pro something and 50 articles con. For an Etomindate thread on this forum we had almost 50 articles just for a relatively short discusssion. In the larger Neuro ICUs, you may have 18 patients with different types of "Strokes" or head injuries and with them you may have 18 different O2 recipes to follow depending on whether a neurosurgeon, neurologist, Pulmonologist or Intensivist is following. It also depends on pre-existing or co-existing illness. Medical issues: There is now much research being done with Sepsis and many protocols run with a higher FiO2 depending on SvO2 which is again a factor that EMS providers do not have access to. Limitations: EMS medical directors that trained in large teaching hospitals got to see the philosophies of many different doctors managing patient in many different ICUs. Thus they also learned that one recipe may not fit all and due to limitations of training in EMS, if might be better to write protocols that error on a higher side of FiO2 rather than risk having EMT(P)s trying to figuure out the intricate details of a definitive diagnosis as it pertains to O2 consumption. EMT(P) training in the U.S. does not give much foundation for understanding sepsis, pain, neurological or many other medical issues. Even for those using a pulse oximeter, not many understand the Oxyhemoglobin curve, A-a gradient, sepsis or other disease processes that skew the abilities of a pulse oximeter besides the few obvious one taught in EMT(P) school. Some are mystified why we are intubating someone in the ED with a 100% SpO2 on a NRBM but don't understand that the A-a gradient of 400+ mmHg is bad. We also have had disagreements with ALS IFT teams who want to wean the FiO2 by SpO2 on a sepsis patient when the SvO2 is 50%. The same for the ETCO2 when there is a relatively large PetCO2 to PaCO2 gradient. There is also a lack of oxygen equipment education in EMS. A 4 L NC will not give the same FiO2 for someone with a MV of over 20 L/min as it will for someone with nice VTs of 500 breathing at a rate of 12. Also, the NRBM is truly not a high flow device by definition and has limitations. Thus, EMS medical directors, knowing the variations in current medical literature and research as well as that of the EMS providers, must write for what they feel may be the safest for the patient in the short term. Even if that agency has some very highly educated providers, for every 10 with education, there may be 50 more without. In the hospitals, we try to please everyone and I have probably 60 different protocols concerning the O2 management of various patients. This includes sepsis, ARDS, congenital anomalies, pulmonary HTN, neuro injuries, pneumothorax, post-op, pneumocephalus (including some caused by agressive CPAP on the wrong patient dx), cardiac of many types depending on pain, EF etc, and so on and so on. I really wish I could say that this recipe is better than that recipe but as soon as I do along comes a patient that demonstrates to me and others in the medical communities a differing opinion.