VentMedic

Here you can run into some problems with "interpretation". The NRBM manufacturers have provided recommendations for safe liter flow when using their product. Many publications and protocols have published their recommendations for the usage of O2 devices and liter flow. Do you have the medical director's suggestions in writing? If not, when an adverse incident occurs, the MD might say in the depo "that's not what I said and especially not in that circumstance". Your charting and that of the rec'g ED will have the documentation to which you may have to defend your actions.

Now for the IV Ventolin question again. Would flu symptoms with no history of pulmonary problems be an indication for Ventolin? Is Ventolin indicated for PNA with the absence of pulmonary disease history? Isn't this similar to the CHF and ventolin debate?

Now you have 3.

We will sometimes do O2 by SpO2 and titrate from there unless there are other immediately obvious factors. Short term O2 should not present a problem. Quite often that STAT ABG upon arrival to the ED will reset the breathing or be enough push them over the edge. Either way it gets "results". I just make sure they are on the stretcher when I poke them. The presenting SpO2 and symptoms did warrant oxygen. A 24 y/o with the initial SpO2 of 89% would deserve a closer look regardless of what emotional issues were going on. The drama is important information but the onset, length and presentation should be emphasized more than the nitty gritty details. Too many distractions can skew an assessment which is why I do fault the RN here for assuming without at least a closer look. O2 can be titrated as the symptoms and vitals stabilize. However, allowing a patient to remain with a low SpO2 could be worse. I have also seen patients with an SpO2 of 100% on a NRBM come back with an A-a gradient of 300+ mmHg and get intubated. Hence, the reference to the flu and the PNA associated with it.

The hospitals have been switching to the Oxymask. You can start high at 15 - 20L and wean down to 1 L without changing the device. The patient can also be suctioned, have a bronchoscopy or eat and drink without removing the mask. http://www.southmedic.com/products/oxymask-adult.php Comparison of Oxymask and VentiMask http://www.pulsus.com/journals/abstract.jsp?jnlKy=4&atlKy=6894&isuKy=365&isArt=t&HCtype=Consumer

True. I would have said tachypnea with decreased SpO2 as presenting and then go from there. However, right now if a 24 year old has similar complaints in our ED they will immediately get a nasal swab up the nose and a filter mask until the determination is made they do not have the flu.

You made the diagnosis of "hyperventilation" and stated that to the nurse. You actually had no idea if it was hyperventilation without knowing the PaCO2. You only knew the patient was tachyneic and has an SpO2 of 89% on RA. Sometimes it is best to just give the signs and symptoms without the diagnosis. Too many have put themselves in the BS state of mind when they hear or presume "hyperventilation". As well, there should be a distinction made with "hyperventilation" by physiological definition and "hyperventilation syndrome". The syndrome, can also be chronic and have physiological changes that may not always follows the rules of "hyperventilation" by definition. So, assuming "hyperventilation" can lead on down the wrong assessment pathway and that includes the nurse you said this to. This patient could also have a true diagnosis of "hyperventilation syndrome (HVS)" other than the one that is just associated with a momentary anxiety attack can become chronic which needs the assessment and treatment of a specialist. A good read on the subject: Overview http://emedicine.medscape.com/article/807277-overview Differiential diagnosis http://emedicine.medscape.com/article/807277-diagnosis Treatment and medication http://emedicine.medscape.com/article/807277-treatment Follow-up http://emedicine.medscape.com/article/807277-followup There can be many reasons for him to have a tachyneic episode. He may even have a RAD sensitivity that has yet to be determined. We see a lot of those in the PFT labs and try our best to recreate the symptoms. He might also have periods of SVT from something like LGL or WPW that might bring on a "panic like attack" and resolves. He might even have runs of VT that are transient but can be a strange feeling. Emotional states can exacerbate whatever underlying there might be and the etiology may yet to be determined. Also, the liter flow of the NRBM is set by the patient's minute volume or dept of each inspiration and one should not be thinking of regulating the FiO2 by the liter flow. Hypoxia can cause aggitation and the degree may also be dependent on the patient's O2 carrying capacity. A shift might be seen if the patient truly got his pH on the high alkalotic side which can explain other mentation disturbances. However, the body usually responds to that by shutting down momentarily to "regain control" if there is not a true physiological reason at that moment for the body to be "hyperventilated".

Now that the entry for RT is a 2 year degree there is no difference in education. There are just two very different tests that must be taken; CRT and then RRT. Since RT had the 1 year tech with the credential CRTT and then CRT as the profession was preparing for the education change for several years, there were and are still many "technicians' that got grandfathered. As they become fewer in number and as the states start to recognize just the RRT, there will be a push to combine the information into one huge examine and just have the entry credential at RRT. The profession doesn't want to alienate some of the older original techs but eventually there will be no choice as change must move forward. The CRT covers mostly the technical aspects of the job and emphasizes basic knowledge of equipment and theory of the equiment such as venturi principles. The RRT deals with clinical data and application of theory to hemodynamics and disease processes. The RRT is a 2 part test with clinical simulations being one part. Some do both parts of the RRT on the same day and some do 2 days. Yes I was still with the FD. However, I also has a 2 year degree as a Paramedic from 1979, a few years before I got hired with the FD. It was still a 2 year course even though I had the prequisites done but it was a couple less classes each semester. This was before the mega mergers and the FDs at that time did support education by allowing some trading of hours. The nursing program: The better online programs keep you at the same pace with your other classmates for the diadetic. Clinicals should still be in the same time frame as some of the classes or close to it. There also should be no scrimping on the clinical hours and a good program should have no less than 1000 hours for just the clinicals.

If you do go for RT, the RRT is the way. After that you may want to specialize. However, the reasons for obtaining the higher level would be if you have any desire to work in a critical care unit, with ventilators and do transport. Again, if other states do start to recognize the highest level for licensing, the CRTs will have to upgrade. Right many CRTs have been faced with that to maintain their status in the hospitals. They were given 5 years to meet the 2 year degree requirements and get their RRT as the minimum education standard was raised. The hospitals had not obligation to maintain the lesser educated and credentialed providers in the critical care areas. Within the new few years there will only be the RRT and the differences in education of having either the 2 year or 4 year degree similiar to the options now for RN as the LVN has essentially dropped out of acute care. If the Bills pass as the AARC have planned, the 4 year degree will become more prominent and even expected by the employers. It will then be easy to increase the minimum education requirement for entry into the profession to a Bachelors. That will at least get RT closer to the other allied health professions when it comes to education and recognition with the insurances or medical community. It's not EMS where some argue for the lowest common denominator or cert of 120 hours. When you manage an ICU ventilator and critical patient, just showing you have the knowledge for "certified" is no longer enough. Of course nursing is now going through some of the same considerations for its profession as we are now seeing more BSNs especially in ICUs and specialties with that now being the lowest education level in some areas.

I am beginning to believe this show did such an overboard production with the first episode just to get attention. The second was not as ridiculous with some things toned down but enough over dramatization to keep people talking. This may be just part of their strategy to get viewers. How many have viewed the links for the show just to see what all the fuss was about? Who would have cared if the show stunk or not if a few big organizations hadn't got involved and all the forums hadn't been discussing it? How many bad EMS shows or shows with an EMS character (The Listener) have come and gone? Rescue Me got some of the same reaction when it debuted. The first few episodes really upset quite a few viewers, both FFs and the general public, who had placed FFs on a pedestal after 9/11. However, the characters and story lines are now strong enough to stand on their own with the fire station just being a place they happen to work and the show is not about fighting fires. If Tommy left the fire department his life's drama is still a decent story for a soap. In fact, those who want to see fire fighting are probably disappointed as that is no longer the emphasis. Those who get hooked on soaps do love this show. The title, Rescue Me, is also appropriate as it can imply FD and it can apply to the emotional turmoil or roller coaster each character is on. Will Trauma and its characters be able to pull it off? I personally don't think the actors in this show are strong enough to pull it off. As far the blonde, if a woman is going to do justice to the role of slut, she should have the beauty, class and some acting ability to do so. Rachel Welch managed to do that nicely in Mother, Juggs and Speed. Even if her acting ability was not always the best, her class made up for it. The blonde on Trauma has neither the class nor the acting ability to represent even the women in EMS who might be on the low side of professionalism.

COPD is a very broad category and quite a few conditions to isolate for variable factors in your study. Are you going to do the study on just CO2 retainers? And, in what disease category? What about those that are classified as hypoventilators with the COPD being a noncontributing factor but still present? Are you discussing long term or short term? For the hospital setting, are you going to include the interactions with the septic COPD patient and O2 management? Are you going to find a large enough sample size of just COPD patients without other complicating factors or disease processes? Sepsis? Pulmonary Hypertension? Acute lung infection with varying V/Q mismatch properties? Are you determining FiO2 by device or patient effort? Closed system? Continuous ABG monitoring? Expired ETCO2 with baseline knowns for hx and prior to administration? These are just a few of the issues we have faced in some of our studies on O2 delivery and COPD patients or any patient. These are also a few of the questions we ask at an article review to test for validity or rip it up.

The ThermoFlo (ARC Medical), Drager TwinStar and the Hygrobac S (used to be Nellcor(?)) are so far the ones that seem to do the job with the less problems.

Here is a good reference with a visual for the oxygen masks and the potential for spreading disease. Dispersal of Respiratory Droplets With Open vs Closed Oxygen Delivery Masks* http://chestjournal.chestpubs.org/content/125/3/1155.full

Standard cannula starts at 0.25L for infants and goes up to 6L for adults. In home care you may find patient running their portable tanks at 8L, especially the demand flow models. In the hospitals, some nursing homes, SNFs and hospice facilites you may find high flow cannulas that go up to 40 Liters per minute. The prongs will look like a regular cannula but will be hooked through a heated water system to provide the humidity that closely matches that in the body. However, if you had said a nasal catheter, those could run at a slightly higher flow and were popular in the 80s and early 90s.

Newports? No real vents available in Canada? The U.S. is stockpiling LTV 1200s for their disasters. If anyone is interested, there is a decent 1.5 hour inservice on it at: http://www.aarc.org/headlines/09/09/webcast_training.cfm We do some serious filtering at the machine side and are using the HMEs that have a good micron filter rating for the exhalation to protect the HCWs. One CCT in California was discovered to be running dirty vents for antibiotic resistant microbes due to not using any filters to protect their ventilators. They also were doing NOTHING to protect their staff from exhalation gas, droplets or whatever. I still see many teams, including flight, that fail to protect their technology or themselves.

Florida and a few other states do have separate licenses with some differences in scope. CRTs don't always get to work the ICUs or do any of the "fun things" nor are they accepted to transport or ECMO programs. Rumor has it that California might finally do the right thing and only license RRTs. That would be great since CA was well known for its RT mills in the 80s and early 90s. If the legislation is passed that the AARC has been working on, the Bachelors program will become more prominent. The RT profession didn't wait for a mandate that they had to get a college degree in their profession. The RTs and employers just starting accepting it as the norm long before the legislation was passed for the 2 year degree. It was sorta common sense to see where a "cert" was not enough in the ICU just like the LVN. Now the 4 year degree is going the same route as more people are getting it to stay qualified in this job market.

A couple of the photos posted weren't viewable on my computer. Here's a link that might give some answers. http://antiquescientifica.com/archive.htm

The recommendations are for an N95 mask and not the surgical mask that had previously been used for the flu or droplet precautions. http://www.ama-assn.org/amednews/2009/09/14/prsa0914.htm#

The NRBMs offer NO protection at all and were actually mentioned as part of the problem for the spread of SARS at one hospital in China during the 2003 outbreak. Filtered nebs offer some protection but the healthcare providers should be wearing an N95 mask when near the patient. The neb can also be turned off briefly when moving through an area that exposes other patients or staff. For flu symptoms with no pre-existing pulmonary history, we find the nebulized bronchodilators do very little for breathing problems caused by the infiltrates. Patients that have influenza A are isolated. This is nothing new. If they require a NRBM or BiPAP/CPAP, they are put in a room that is capable of negative flow.

You do bring up a good topic as many are trying to come up with safe and effective delivery systems for nebulized meds and O2 without risking exposure to others. We do not have that many isolation areas in the EDs or even in some hospitals. IV Albuterol is approved in Canada and a few other countries but not in the U.S. I believe a few years ago IV Albuterol was part of EMS protocols in at least one area of Canada. There is some research for it, and that includes what was also done in the U.S., but it is inconclusive as far as it being a better bronchodilator than the nebulized or other IV medications. Of course the side effects such as hypokalemia are beneficial to some patients more than the nebulized form but also has other potential complications. Nebulizing meds and O2 devices allowing exhaled particles into the surrounding area has been especially controversial since the recent SARS and in years past with TB becoming prevalent in some areas. We do have filtered nebs which have been used for Pentamidine and some of the antibiotics which offer some protection. Simple masks, NRBMs and definitely BiPAP/CPAP devices are in question. There is a recent editorial in the Canadian Medical Journal concerning the use of BiPAP/CPAP as it may prevent intubation in some Influenza A patients. However, the patients I have seen lately need to go straight to a High Frequency Ventilator for ARDS. In the hospital we can use a closed limb system with filters for BiPAP/CPAP by using a nonvented mask with the ICU ventilators. We are also trying to determine which filter is most effective with least resistance for our transport ventilators such as the LTV which can also be used for BiPAP/CPAP.

That 5 week ventilator course just introduces you to what a ventilator is. The following semesters apply what you learned from that course to the courses for introduction to critical medicine and bring it all together later. You will also get a semester of specialty ventilation/critical care theory for Peds and a semester for neonatal. As well some programs may have electives in HBO, Cath Lab and ECHO. I did all three because I just couldn't get enough. I also repeated Cath Lab later when I did my B.S. in CardioPulmonary just to see how another center known for caths did it with technology. The first was in the 80s were we still did all the calculations and manual drawings. It is difficult to have a flexible schedule because the clinicals may actually be monitored by physicians along with the clinical educators. Most of my classes, especially ath the B.S. level, were taught by physicians. Nursing of course can have more opportunities but the RRT can have many also. I can travel on short or long assignments in any state I care to get a license in. I have also worked PRN as an RRT most of my career as a FT Paramedic. For specialty programs such as Neonatal, they did require a serious commitment especially if you wanted to work at a higher level of competency and be on transport. RT is a very active profession politically when it comes to lobbying for benefits for the patient and the therapists. The benefits for the patient includes home care payments from medicare for extended services. By that, whatever benefits the patient gets it helps the RRTs' future. But, the patient is always emphasized first which the profession took notes from NPs, PTs and PAs in that areas. They didn't use the "me, me, me" approach and have managed to make great strides in the past 20+ years. The biggest thing against the Excelsior program is the clinicals. You really need to know basic nursing skills and time management. Few RNs precepting you will want to talk you through gait management and the various lines when there are so many other things to learn about the facility. The clinicals also allow you to network for a decent job.

NAEMT? This organization has no power to suspend any cert since they do not issue any certs. This is an organization you join voluntarily and pay membership dues. California has been trying to clean up its act when it comes to screening and discipline. Other states also take some offenses very seriously. Many professional EMS companies do care about what their employees do when wearing their uniform. However, those that make the newswires are the most interesting for Hollywood to write their scripts around. I would also tend to believe that the consultants who advise the directors and producers may get a little full of themselves when talking about their life as a Paramedic just to make it seem a little glamorous. I might even compare it to what Bubba instructor does when teaching an EMT or Paramedic class to keep the students awake and make the profession more attractive. If Hollywood had wanted accuracy they would have called Dustdevil, spenac or RidRyder911 to be a consultant. Instead, they probably wanted just the dirt and fish tales so they called Bubba. BTW, I didn't include myself as a potential consultant because they already know me as the one laughing hysterically during one of the scenes when they were filming on location in SF.

We have had patients tell us that the EMT(P)s were on their cellphone the whole time they were in the back with the patient. We've had EMT(P)s take a call on their personal cellphone during report in the ED from a 911 transport and during IFTs by "CCEMT-Ps" picking up a patient in the ICU. Even our physicians do not answer their personal cellphones during a report or rounds in the ICUs. IPods are another pet peeve of mine as I removed one from an EMT who had transported my mother from a SNF to the hospital. It is rather difficult to take a BP with earpieces stuck in your ears or even listen to what the patient is saying. I gave the iPod to a nursing supervisor who was only going to release it to a senior supervisor for that ambulance service. Some might consider what I did an assault or theft by the way I demanded the iPod but on the bright side, I let him live despite his behavior and lack of care. It would also be these same fools who can not understand why some car drivers do not immediately move out of the way even with a siren blasting.

Lifetime immunity? No. The varicella (chicken pox) is an example. Those of us who had the disease as a child and then had high titers for many years may find our titers are barely detectable later. The same is being said of mumps which is why the MMR is given together and not separately more often than not. Smallpox is another example as those of use who got vaccinated prior to 1972 were told we had "lifetime" immunity but then were told differently in 2003 when Pres. Bush wanted everyone to get the smallpox vaccine. Our immunity has probably expired.

This is the problem I have with the FD's version of training and education. Do you realize how little that is when compared with even a mere 2 year health care degree? Other health care professionals also spend at least 6 weeks and usually a lot longer maintaining competencies and recert classes each year or at least every two years. In addition, those serious about medicine spend more each year learning new things and not just doing the "recerts" or mandatory stuff because the department says so. Many do this on their own time because they want to be a professional with some expertise in medicine.