VentMedic

This is my point Herbie1 You are only looking for the acute emergent situation like CHF when you see these patients and if you don't see something emergent, you may blow them off as BS. Many patients themselves don't realize what problems they have. They just know they don't feel good. Some are passed off as having the flu or hungover when actually they are working on sepsis. The other issue you seem to be seein is only a social problem with alcohol and not the illnessness that can be very emergent but are not adequately covered in EMS education since it actually does not cover medical emergencies, either acute or evolving, to any great depth. These patients need a doctor first and then maybe a chaplain. docharris gave a great outline of things that can be addressed. I mentioned systems that are also doing this. It doesn't take much to set up a database or paper trail of repeat offends or to have your agency establish referral forms for a welfare check by some social service agency. It can either be turned into the ED or to your supervisor who can deliver it to the appropriate agency. This may not be much but you might be able to make a difference for one patient. I don't try to change the whole world. I just try to see if I can make a difference one patient at a time. What do you want to do? Have an intubation competition? See who can start the most IVs in 10 minutes? There is so much more to being a healthcare professional than just "skills". When you have chosen not to see beyond just the skills and perceive those as what is limiting you, there is not much more agruing anyone can do with you. You yourself have placed yourself in your own little world with a limited view of how times and medicine are changing.

It doesn't sound like you have much respect for anyone unless they fit your "type" of patient. You seem to be stereotyping homelessness and addicts. Have you looked at the homeless population lately? You may even find a few EMT(P)s in the crowd. Many of these people call because they don't know what else to do. When you have lost everything including your dignity, there isn't much left. Get your head out of your arse and take a good look at the world around you without such jaded opinions on humans who are less fortunate then you and enough with the "not my job" crap. The other posters have given good examples and I gave one example but I can come up with a lot more. We are in the health care profession and not just in it to thump our own egos by picking and chosing who we decide to save today.

No bleeding heart, just years of working in a city with these problems and trying not to add more to the existing problems. There are EMS systems that do get involved in community issues even if you don't give a crap about healthcare issues. Lee County FL has a great model for them. When they call, they area still your patients. You can ask many in EMS what alternative services there are and few know what happens outside the walls of their truck. Few could even provide a taxi number as an alternative. Again, there are just as many EMT(P)s sucking up funds for smoking and obesity that also refuse to take care of themselves or take responsibility for their lives. That says it all about you. It is a shame your type even deals with patients.

That's just it. Some in EMS take only the obvious problem into consideration which might be the intoxication issue. Few will do a thorough enough exam to see the ulcers and other signs of chronic disease processes that are occuring. Some in EMS will also refuse to transport these patients. Then, instead of what could have been a little patch up and buff up of the electrolytes in the ED will later become an extensive ICU stay tying up a bed possibly for weeks and then to a stepdown unit, med-surg and a SNF until well enough to be released. Some cities have RNs roving the streets looking for homeless people with medical problems that need to be identified and referred to a clinic where NPs and PAs are taking the load off the EDs. At this time EMT(P)s in the U.S. are not educated or trained to recognize things other than emergent conditions. The idea is to get these people into the system with followup to while they don't become a problem for EMS. Often if they know someone is there to look out for them, they are no longer relying on 911. The national associations for NPs and PAs (as well as RTs and RNs along with many others) are addressing these issues and are working, sometimes even together, to broaden the reach of services. EMS is still searching for an identity and more letters in the alphabet to put behind EMT.

To many fail to recognize a difficult airway and just do the poke and jab method until the airway is mangled. Then they plop the patient in the ED with a bloody and swollen airway. The ED staff of course will now have serious a problem to deal with while the EMS crew snickers that "they can't get it either". What they don't realize is that if they had recognized this earlier, the damage could have been avoided and a less serious intubation alternative might have been used as well as saving the patient many vent days. Often a patient may recover from whatever caused the respiratory problem such as COPD exacerbation or CHF quickly to where they should be off the vent in 24 hours. However, if the throat is damaged and the patient fails a leak test, they could be on another week or two or until they get a trach and/or peg. The unfortunate thing is some did not understand the anatomy of a difficult airway to even describe what they saw when attempting to intubate. Others may not admit it took them 6 tries with the tube and will also not tell the ED staff of potential problems although the ED will do their own assessment. It would however be nice to know a few things that could have been seen easier before the tube. Even when we get a patient from the OR in the ICU we look at the notes from the anesthesiologist just in case the patient may need to be reintubated in the future.

Are you serious? They don't teach how to identify a difficult airway? There are certain factors one must be aware of which will prevent you from making hamburger out of the airway which could result in a cric, trach or permanent damage to the voice.

So what is your agency doing about it? Establishing communications with your local Social Services? Leaving a paper trail for easier followup? Or, are you just dumping the problem into the ED and bitching about it? Maybe you're not even bothering to fill out the PCR appropriately for tracking? Do you just expect the ED and Case Managers to do everything? The Case Managers have their hands full trying to prevent others from becoming homeless. As far as the disgusting part, I feel the same way about obese, chain smoking EMT(P)s who suck up sick days, increase out of pocket insurance rates for everyone and then expect the government to support their fat, short of breath arses when they go out on disability from a line of duty injury they received while reaching for that last powdered sugar donut.

Don't forget cricoid pressure (Sellick) is contraindicated in patients with suspected cricotracheal injury, active vomiting, or unstable cervical spine injuries. You've also got: OELM: Optimum External Laryngeal Manipulation BRUP: Backward, Upward, and Rightward Pressure As well, you can practice difficult airway scoring on friends and familly or just by people watching at the mall.

I disagree. How do you now determine the effectiveness of CPR in the field moment to moment? Feel for pulses? Check pupils? The presence of femoral or carotid pulsations, pupillary signs, and arterial blood gas (ABG) results have not shown to correlate with successful CPR. In the hospital we may draw labs but even an ABG has its limitations and may be misleading with the gradient recognized by V/Q mismatching and venous paradox. During cardiac arrest the partial pressure of end-tidal carbon dioxide (PetCO2) falls to very low levels, reflecting the very low cardiac output achieved with CPR. It has been shown that the PetCO2 achieved during advanced cardiac life support reliably predicts an outcome of cardiac arrest. Higher levels of the PetCO2 indicate better cardiac output, higher coronary perfusion pressure and a greater likelihood of successful resuscitation. After the onset of cardiac arrest caused by ventricular fibrillation, the PetCO2 abruptly decreases to nearly zero and then begins to increase after the onset of effective CPR. Further increase is detected upon return of spontaneous circulation (ROSC) to normal or above-normal levels. For long transport the ETCO2 should not be the only observation relied on. In fact, we may not always use the ETCO2 monitor if the tube is secure and the ventilator settings are not being messed with. Our ventilators give us excellent wave forms and measured values. Correlated with other VS and a physical assessment, the pulmonary status can be well represented. Of course if it is an unstable CCT or HEMS, an ETCO2 monitor will be used. But even with that the PetCO2 number must be correlated with pt hx and assessment. The norm of "40" may not always be correct or appropriate for that patient. Experience may also need to be relied on that the ventilator settings are adequate for that patient and the number may be close to the PaCO2. Now of course if all you have for a vent is an ATV you had been have some serious assessment skills. While it is designed to be "idiot proof", its simplicity has led to some very under educated providers using it. Capnography should also be able on any truck that does RSI or other medication assisted intubation.

Decent powerpoint with reasons for increased and decreased PetCO2 pr P(a - et)C02. http://co-5.college-online.com/lisa_conry/...%20OXIMETRY.ppt Free and easy registration. http://elearning.respironics.com/index_f.asp Under CEs, you should see these titles. You may have to register as "other" instead of EMT(P) to see all the courses. Capnography: Principles and Clinical Application (very good) Respiratory Monitoring: Principles and Clinical Application Of Volumetric Capnography NPPV: Across the Continuum of Care Clinical Application of Ventilator Waveforms and Trending Appropriate Handling in the Neonatal Intensive Care Unit Noninvasive Ventilation in the Home CEU Under products: BiPAP S/T® Training BiPAP® AVAPS™ Training BiPAP® Focus™ Training BiPAP® Vision® Training Cadence® Training Esprit® Ventilator French Esprit® Ventilator NICO2® Respiratory Profile Monitor Philips Respironics V60* Ventilator e-learning program WhisperFlow®, Criterion® 40 and 60 Monitors and Criterion® OxyCheck™ Oxygen Analyzer Training

That's because there are no helipads at the hospitals in SF and that includes its trauma center. In fact at every community meet where the trauma center and another large hospital system had wanted to get support for a helipad, crashes were mentioned. Those who favored the helipad reported very low instances of this happening although they may have to change their stats on that after the past two years. However, those that oppose will get to see exactly what they have been talking about and their worst fears displays on TV even though it is fiction. Also, CA usually two member helicopter crews so they don't need the mother's assistance to cut her kid's throat open. The helicopter crews are usually RNs since the Paramedic scope of practice is rather limiting in CA. So for those that live in CA, this is more like a dream or their fantansy.

The references sited at the bottom of wiki should also help. This was there which looks like it has some great info. http://www.dyscalculia.org/

He also had to do a ton of OT to get that $100K. For the base salary I wouldn't waste my time taking a contract there even if all expenses were paid. Definitely low by CA standards even if it is Southern CA. It's too bad he doesn't know what medical professionals can make without working almost 4000 hours.

There is nothing wrong with many online programs, especially those associated with a college, if done well. They should have access to an educator and student interactions via the internet occasionally. As well, they should be structured with the same time requirements for assignments as the classroom program. What go Excelsior is the lack of clinical hours. 1 or 2 weeks is not enough when the traditional nursing students are getting 1000 hours of just clinicals with strict guidelines for what must be achieved during that time. This is also where some of the online Paramedic programs fail. They may have a great online portion but might allow the student to pick a clinical site closer to home. That is where the control is lost and even though the paperwork that agency might send in, there is little way of knowing that is actually how the clinical situation will be. It could be an ALS Engine sleepover where the student will have minimal contact as an ambulance with Paramedics may take over the care as well as do the transport.

At least Florida doesn't allow Excelsior grads in until they get 2 years of working experience as an RN in another state. And that is getting harder to do with other states imposing restrictions on that program.

Everest is still running under provisional approval by the Florida Board of Nursing. Unfortunately RNs in Florida do not make that much. A Florida Fire Paramedic usually makes more.

http://jcn.sagepub.com/cgi/reprint/19/10/765 http://www.wjh.harvard.edu/~caram/PDFs/198...a_Basili_BC.pdf PDF version is in full. http://www.sciencedirect.com/science?_ob=A...a737b2a14368d69 http://books.google.com/books?hl=en&lr...2vDd_TKKoX_539s All found on Google Scholar.

I have shed more tears for the animals in our research and training projects than I have even thought about shedding for the human patients in our trials. BTW, the bunny rabbits didn't survive either.

I felt much better when we used ferrets aka weasels. But still an animal. I really felt bad when we used long floppy earred bunny rabbits for chest tube insertion training. This was for Neo/Pedi ICU/transport. But then in my early days as an RRT, in the research labs we used to drown dogs by pouring either fresh or salt water down their tubes to study the differences.

The outcomes of SCIs, noted by X-rays or not, will vary and it depends on the classification of injury. We have over 100 SCI patients in our hospital at any given time with the neuro ICU, Spinal Cord center and Rehab. No two are rarely the same. The HIV status would probably not be a factor unless he has already developed lesions somewhere within the central nervous system, including the cord, which could also be complicated by CMV.

True but is is also necessary to ensure nothing is missed that would also require surgical intervention. The other issue with MOI is some assume people are driving in picture perfect position and eyes forward. If you ever hang out at a busy intersection you will notice that is not always true. People are reaching for the radio, GPS setting, food, things dropped like their cell phone. They are turned to get a better look at the address they passed or the good looking pedistrian or car. They are looking down to text message someone. They may even be reaching into the back seat to get something or to slap the kids. The seat belt still allows for some mobility and has its limitations for different points of impact. We have had SCIs from very slow moving vehicles in a parking lot because the person should have gotten themselves settled and belongings in place before pulling out of the parking spot. The body is torqued and twisted to where just a few pounds of force can do serious damage just as some have learned from lifting even light objects.

Here's some links to case studies on Goolgle.Scholar. http://scholar.google.com http://scholar.google.com/scholar?hl=en&am...rognosis+adults Alot will depend on whether the injury is partial, complete or central. Here are SCI classifications: http://www3.umdnj.edu/stlibweb/dpts5312/maynard.pdf I believe there is an updated version but the info is basically the same.

Here's a link to a couple of sites for a decent overview of pharmacology. Of course it is not a substitute for a couple of college pharmacology courses. http://nursingpharmacology.info/learning2.htm http://www.pharmacology2000.com/learning2.htm

Spinal cord injury without radiographic abnormality (SCIWORA) SCIWORA is most common in children but definitely not that unheard of in adults and may be in the thoracic region. Being a spinal cord center we do see this occasionally and extensive testing may need to be done since the injury is not visible on regular X-Ray or CT Scan. An MRI has a better chance of spotting most injuries but even with that the integrity of white matter tracts within the spinal cord are not well demonstrated. Thus additional steps in MRI are done if this is suspected. On another note, it is sad to again see the numbers of the new HIV cases among the young.

This is not uncommon especially if the patient has had a full workup prior to surgery and has been continuously monitored throughout the surgery. The baseline has been established. However, I would hope they are checking some pulses manually if nothing else to check perfusion. We do check manually if the patient and assessment don't look like the numbers on the NIBP screen or A-line.