VentMedic

Again the Case Manager who was overseeing his case is accountable to ensure this person has a safe environment. At 83 y/o he is eligible for Medicare and a supplemental insurance. While options are often limited, no hospital wants the publicity of "kicking out the elderly" although many do fall through the cracks of the health care system. The person's living situation may not have been mentioned. We have had a few frequent fliers brought in from home several times by ambulance with no mention of the patient's living conditions until ONE lone EMT makes a report and a check is made. That one person was able to initiate a change for that patient and get the needed services. The others just hauled with blinders on because they didn't know the process, didn't want to take the time or didn't think it would make a difference.

If the patient was in total control of his life you might say he has the right to live however he chooses. For this situation it would depend on how much control and responsibility the primary care giver has. That would also determine how the Elder Abuse is viewed. However, it still requires a Social Services and welfare check to follow up. That report should be made as soon as possible as in immediately with the ambulance service supervisor to contact the Case Manager who was involved with the patient's discharge. Their name and number may be on the patient's paperwork. As far as the A&O x 4 issue, even if this person is well oriented they will probably still tell you to leave them regardless of how bad the living conditions are as the unknown to them might be worst. At 83 y/o with failing health, few are going to say they don't want to be in their own home. As bad as this place might be, it is their security and still represents their independence or what is left of it. Social Services may be able to arrange for home health visits to ensure the patient's living conditions are better as the primary care giver will then know someone is watching.

Some of our LVAD patients have been DNRs but they are still treated within reason. It only means they want no further heroic measures if they code especially outside of the hospital environment. Others who are a DNR are those that are no longer on a transplant list for whatever reasons. A DNR of any type can be reversed for surgery and some DNRs are also of a limited type depending on the state and local paperwork.

Here's another study with sabutamol It does help with the search when you enter the name for the drug most commonly used in countries other than the U.S. Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe asthma: a randomised controlled trial Thorax 2003;58:306-310; doi:10.1136/thorax.58.4.306 http://thorax.bmj.com/cgi/content/abstract/58/4/306 Unfortunately I'm not coming up with too many recent articles. However, here is a very recent article on SARS and MDIs. There was a lot learned from SARS and most of it was what was done wrong or could have been done better especially for the respiratory isolation issues. But then other parts of the world don't always have the expertise of Respiratory Therapists. http://www.rcjournal.com/contents/07.09/07.09.0855.pdf

What make and model? Continuous flow or pulsatile? Battery pack? Ejection fraction before implantation and after? Mobility restrictions? Full time knowledgeable caregiver and/or instructions to EMS accessible? Specific EMS considerations for your situation such as medications? Future plans? Don't feel obligated to answer any questions you consider too personal.

Not alot of compelling evidence out there. Terbutaline is still a decent medication but had its place in the spotlight in the late 70s and 80s where a couple of your studies are from. However, there have been several articles showing albuterol or salmeterol to be more effective. One article you cited is inconculsive: Again, there are going to be some factors to consider if this is to be used on flu patients. Unless they have bronchospasm from an underlying pulmonary hx, IV may not be as effective nor would a bronchodilator be always indicated with PNA or infiltrates with ARDS. Also, if the patient is experiencing all the flu symptoms, you may have dehydration, hypovolemia, tachycardia and electrolyte imbalances to consider before introducing something IV such as Ventolin which is already noted for hypokalemia and known for Diabetes Mellitus exacerbations. Either medication can enhance the overall presenting situation. Thus, for flu patients, working with a filtered neb (or MDI) and the provider wearing the N95 mask may be a better alternative to target specific receptor sites and minimalize systemic side affects. Now for the asthmatic patient, that might be beneficial. However, the literature has so far no proven the benefits across a broad range for even the countries where IV Ventolin is an option. Here is a fairly recent (2002) study for pediatrics: http://findarticles.com/p/articles/mi_m0689/is_7_51/ai_88999791/?tag=content;col1

The specs on it look better than some so it might be able to do decent CPAP and ventilate post code on an unresponsive patient. The thing with ventilators, if the patient is trying to breathe spontaneously and the machine isn't sensitive enough or doesn't have the capability to meet flow demands, few 911 ALS or even some CCTs have the ability to provide adequate sedation. In the hospital, we occasionally use the ParaPac portable ventilator for MRI. http://www.smiths-medical.com/upload/products/PDF/Respiratory.pdf (specs near the bottom - the specs for the Carevent are on the links above) It is a little work horse and can achieve a decent flow but we often have to give a good dose of something to chill some patients. Luckily Diprivan (Propofol) is usually hanging. I have quizzed patients who have been transported many times which they prefer and it usually the LTV 1000 or 1200 with a real liking for the 1200. The internal turbine in the LTV is hard to beat among the transport vents. I like the valving also for its responsiveness and ease of acceleration to meet the patient's demand. It is fairly rugged and handles the rough terrain of HEMS. The sleek design allows it to hug the curves to travel just about anywhere including cramped CT Scan rooms. Nice option package with can include a good monitor makes it versatile for CCT. It handles most critical care respiratory patients very well when taken for a long distance transport. Gas consumption gets decent mileage also. And, it was the ventilator choice of Superman. But, it is impractical for most 911 ALS unless they also do "real" CCT and have adequate training. I'm spoiled. After growing up with Elder demand valves, it is time for some luxury. BTW, my opinion of the Oxylator is that it is a Elder demand valve that they attempted to give some "thinking ability" to but the limited feedback data capabilities can fool it and the health care provider. http://www.lifesavingsystemsinc.com/documentation/LSI-Oxylator-BPM%20Rate%20Changes%20&%20Indications%20EM-100,%20EMX.pdf

You may have been introduced to CPAP. Here are a few I've seen in use with a couple of agencies or have heard being used. Carevent BLS http://www.otwo.com/prod_hhar.htm Carevent ALS (near the bottom of the page) http://www.otwo.com/prod_atv.htm Autovent 2000 http://www.buyemp.com/product/1020801.html Autovent 3000 https://www.med-worldwide.com/prod/allied-autovent-3000-al-l461-113

That is cause for some concern. A ventilator still needs to be assessed as this is just a piece of plastic with O2 powering it and no monitoring capabilities except for manometer which could care less where it is getting its pressure measurement from. Not if they do IFT or critical care patients. This ventilator, and I use that term "loosely", is good for ventilating the living dead post code. It frees up your hands but that doesn't mean you do not monitor the airway. It is an automated BVM and should not be used on IFTs for patients requiring more precise monitoring and settings with some options. For those of you who don't know what a VAR is: http://www.floteco2.com/htm/Products/B-VOR_Automatic_Resuscitator.htm Unfortunately for 911 EMS, an ATV may be all the education, training and budget will probably allow for. However, one needs to know a little something about the pulmonary system to make these little ATVs work as well as they can for the patient. The generic settings I've seen in some of the protocols are...well.......okay I'm at a lost for words. If one understands the settings they have chosen for THAT patient and physically monitors the patient closely, the ATV has benefits over the bag for not causing flutuations in pH by varying the CO2 with irregular bagging or drastic changes in hemodynamic status with over zealous bagging. It is now recommended by the AHA for those reasons since counting while bagging with consistency for rate/volume is a difficult skill in an emergency for some. And, it does free up the hands but the ventilator should not be forgotten when it comes to continous assessment. kohlerrf I saw you post on the H1N1/Ventolin thread. Don't forget to put a good filter on this VAR to keep from getting aerosolized particles coming at you from the patient's lungs.

Look at the oxyhemoglobin dissociation curve to see the correlation between mmHg and SaO2. One might expect the PAO2 to be at 450 mmHg and the PaO2 to be 440 mgHg on a healthy patient on a NRBM. If the PaO2 is at 90 mmHg, that is what one might expect on a healthy person on room air and would give you an SpO2 in the high 90s. However, if the patient is on a NRBM with an FiO2 of 0.90, that gives you an A-a gradient of 350 mmHg which is very significant. Intubating may not immediately fix the problem. The patient may even die because of the oxygenation problems such as what we are seeing with the Influenza A patients and ARDS. This is part of the discussion Tnuigs and I were having on the Ventolin/H1N1 thread. It may take the serious RT technology such as High Frequency Ventilation, Nitric Oxide or ECMO to oxygenate a patient. But, we would hope that the direct route to the lungs with a closed circuit, PEEP can do its job to improve oxygenation. Check out the Respiratory Failure link here: http://www.ccmtutorials.com/ In the All about Oxygen section, you'll find some information on absorption atelectasis and that will explain about nitrogen. Read about ARDS under Acute Lung Injury and you will learn about damage to the various cells. There is also the O2 toxicity concern from high concentrations of O2 for a long period of time. Usually we try to lower the FiO2 within 24 hours to below at least 0.60 with 0.50 being preferred. However, we must also look at other factors that may still require significant O2 to maintain adequate PaO2 or SvO2 which is venous saturation. Patients with sepsis and some TBIs are monitored closely and may need more ventilatory support, pressors or fluids to maintain an adequate range. For some patients such as those with PNA from Influenza A, they may be on special ventilators for several days or even weeks until the lungs heal well enough to have the FiO2 at a reasonable number. The same for patients that develop ARDS due to trauma or sepsis.

If you enjoy what you do with the kids you just need to clarify whether the EMT is really part of your job description. The Florida statutes for the school systems are quite extensive and you should be able to function quite well under those guidelines. However, your school would have to adopt their P&Ps to those guidelines and not be in the belief that the EMT is some sort of independent health care professional. In this situation the EMT card is just a source of confusion and probably should not even be a part of your job description. Your focus should be on your position as an educator and that role has expanded as more children with medical problems enter the school systems. There are enough organizations backing these challenges to see the schools and the staff have the necessary support. Get your employer to tap into those resources.

Clarify what school staff can do under the Florida legislative guidelines and those for your county/school district. You may just want to go with the title of Teacher's Aide with "some first aid training" rather than EMT. Fireflymedic's post summed it up nicely. The asthma, allergy and respiratory therapy associations have been doing the same for breathing medicatons and epipens. However there are still a couple of states that have been reluctant to allow children to carry their inhalers or have them even easily accessible.

Whose medical direction are you working under as an EMT? Is there a School RN covering your area? Is there paperwork the family has filled out? In Florida, several associations fought long and hard to allow medications in the school system after we had 5 children die in school from not having their asthma medication available to them. I would really hate to see the EMT scope of practice limit the effort that has been put forth into the legislation for the school systems. There needs to be a clarification of the guidelines as it is possible the teachers may have a larger "scope of practice" than an EMT in the state when it comes to giving medication as a designated caregiver working under the supervision of an RN. I would definitely clarify your job description and medical direction since this situation will occur again as more medical needs children enter the school system. Suctioning a trach may not be an EMT procedure either but you may also be doing that as a teacher or aide.

This has nothing to do with you being an EMT if you are working as a teacher in Florida. This falls under the guidelines of the position you hold in the school system. Unless you are specifically hired to be an EMT with the school system and that is the title you are working under, don't confuse that cert with the job you are hired to do and the responsibilities that accompany it. If you are uncertain about your job description and responsibilities to the children, you can contact the education board in your county or FLDOE. You can also review the P&P for your school and that medication with the School RN. I also know it is unfortunate that the School RN is often covering several schools at one time and is not immediately available. http://www.fldoe.org/default.asp?flsh=false Example of Manatee county: Manatee County Good article this month in Pediatrics: http://pediatrics.aappublications.org/cgi/reprint/124/4/1244

Exacerbation of pre-existing conditions and other infections such as MRSA are expected with the regular Infuenza B season. Influenza A will quite often present with respiratory complications such as PNA of various etiologies and ARDS is now the issue in younger populations. If you have a patient with suspected flu that is having difficulty breathing to where you are considering IV Ventolin and no pre-existing pulmonary hx, there is a good possibility HFOV, Nitric Oxide and even ECMO could be in their future. A ventilator of sometype will probably be needed. This is where BiPAP/CPAP was thought to be of use in the initial phase to prevent intubation but the devices used by EMS and the single limb circuits with vented masks pose an infection control problem. While the numbers for deaths are relatively small compared to the total number of flu cases, they are significant for the cause and the targets. U.S. numbers so far: http://www.cdc.gov/flu/weekly/ http://www.cdc.gov/h1n1flu/updates/us/ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0710a1.htm Good case studies from Australia. http://www.mja.com.au/public/issues/191_03_030809/kau10748_fm.pdf Of course the challenge is getting patients from the less equiped hospitals to one with the resources safely for patient and crew. Thus, the filter conversation for the ventilators and masks for both patient and health care provider.

Another is: http://www.ccmtutorials.com/ All about Oxygen. http://www.ccmtutorials.com/rs/oxygen/index.htm Books http://www.aarc.org/bookstore/rc.html Respiratory Phyiology/John West http://www.amazon.com/Respiratory-Physiology-Essentials-Lippincott-Williams/dp/0781772060/ref=sr_1_3?ie=UTF8&s=books&qid=1255008119&sr=1-3 Egan's Fundamentals of Respiratory Care (the classic) http://www.amazon.com/Egans-Fundamentals-Respiratory-Robert-Wilkins/dp/0323036570/ref=sr_1_4?ie=UTF8&s=books&qid=1255008119&sr=1-4 Dana Oakes Series (all are great especially the hemodynamic monitoring for quick reference) http://www.amazon.com/s/ref=nb_ss?url=search-alias%3Dstripbooks&field-keywords=dana+oakes

I think it would be a great experience for EMT(P) students to spend a few hours in a Pulmonary lab donating their nares to research for new O2 devices and checking the FiO2 by sampling with a nasal catheter.

Once we get the H1N1 patients out of the ED and into the ICU they may not get another bronchodilator unless the do have a pre-existing pulmonary condition that might warrant it. We go straight for an ARDS protocol if there are infiltrates present and if the O2 index warrants, we go for the serious technology: HFOV 3100B http://lane.stanford.edu/portals/forms/High_frequency_oscillator_ventilation.pdf Once the patient is on this, we won't break the circuit for a nebulizer. Steroids are also controversial in ARDS.

And most don't understand the textbook "guessimate" values are for the 75 kg person breathing a calm 500 ml VT at a rate of 12 - 16. 2 L/M or 28% means little to someone who is tachypneic. 6 L/m means little to someone in respiratory distress and tachypneic who could seriously use a steady FiO2 of 0.40 but ain't gonna get it.

We don't use it for bronchodilation but rather for vasoconstriction of the inflamed area. We also do an epi with or without lido mix emergently for a traumatized throat from extubation if it wasn't planned or the cuff leak measurement fooled us. The epi properties we are hoping for are the same as when we use it for a site prep for a biopsy during a bronchoscopy or when the "bite" has bitten a bleeder. Steroids can also be given inbetween treatments as well as IV without enhancing side effects of the epi. Essentially we just want to buy time for the IV steroids to work without intubation which can get knarly when the airway is closing on a child. The kid has to go down and out with the tube in almost simultaneously and it will be a small tube which will make the ventilator period a B%&*h. Racemic Epi and my favorite...HeliOx http://pediatrics.aappublications.org/cgi/content/abstract/107/6/e96 Safety and Efficacy of Nebulized Racemic Epinephrine in Conjunction With Oral Dexamethasone and Mist in the Outpatient Treatment of Crouphttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4HG68T9-6&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1039306228&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=d9d361f2be196b2f01056a0661954a0c The management of croup http://bmb.oxfordjournals.org/cgi/content/abstract/61/1/189 Good overview with x-ray and decent references cited at the end. Viral Croup http://www.aafp.org/afp/20040201/535.html

For croup, Racemic Epi has been a frontline med. For RSV, it has been controversial but is in our protocols for rotation with either albuterol or levalbuterol.

For the patients' benefit, several of our EDs have gone to giving MDIs instead of the nebulizers. The ED can dispense meds so the patient doesn't need another script and then have to find the cash and pharmacy for another MDI. They will have their medication to last for a few days. Getting meds is often the problem here in the US with the lack of insurance especially now with the high unemployment rate. I also find I can give in a shorter time the same amount of medication and often much more with an MDI than with a nebulizer. Unless you are using a BAN (Breath Activated Neb), you are receiving a very small percentage of the medication. An MDI and spacer or holding chamber can deliver a larger percentage of medication. In the helicopter and CCT we do carry the MDI since the space is tight and we may be running a ventilator.

There actually have been many studies for many different routes since epi and theophylline days. The opinions are mixed for levalbuterol (Xopenex). Terbutaline is good and has a place. Epi vs Albuterol http://scholar.google.com/scholar?q=epinephrine+albuterol+IV&hl=en Levalbuterol http://scholar.google.com/scholar?hl=en&q=xopenex+levalbuterol Terbutaline http://scholar.google.com/scholar?hl=en&q=terbutaline+ http://scholar.google.com/scholar?hl=en&q=terbutaline+IV+asthma I personally think MDIs (Metered Dose Inhalers) would be a safer route provided the health care provider wears an N95 mask when near the patient. Of course, this might not be cost effective but it could be an alternative for suspected flu cases with a hx of pulmonary disease.

A-a is Alveolar to arterial What you expect for PAO2 at the alveolar level minus the measured PaO2 or arterial level. A-a gradient = PAO2 - PaO2 The normal difference should be about 10 mmHg. Alveolar equation: PAO2 = ( FiO2 * (760 - 47)) - (PaCO2 / 0.8) Now you can also relate the value for the PaO2 and SpO2 (or SaO2) via the Oxyhemoglobin Dissociation Curve. http://www.ventworld.com/resources/oxydisso/dissoc.html The SpO2 or SaO2 can still be near 100% but the A-a gradient might be very wide which could be the result of impaired diffusion or ventilation-perfusion inequality or mismatching (V/Q) or shunting. Of course, once removed from the NRBM the SpO2 will probably drop quickly.

Now, now... The A-a gradient thing is more likely to be an issue with a NRBM. I had thought the "dog in car" theory was like my "cat in carrier" theory when I lie to them. However dogs will believe anything their humans tell them and cats want evidence based proof.