VentMedic

Lactate level? Increasing or decreasing? BNP? Sputum C&S? Influenza swap with H1N1 specifics? Central line for IVs and CVP? CVP reading? Monitor fluids and BP MAP per sepsis protocol. SvO2? http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf We try to avoid CPAP/BIPAP on patients such as these especially if they have had extensive grafting both internally and externally. They may also have TE fistulas which will creative more abdominal problems even if the G-tube can be vented. Also, many ALS/EMS CPAP machines can not achieve the FiO2 and flow necesary to maintain a patient like this for very long. One would also have to consider the CPAP pressures and what the ALS team is capable for meds and titration (U.S. concerns more than Canada). The ABG indicates a large A-a gradient which will make this patient unstable for transport by ALS without a definitive airway. The patient is attempting to maintain his own homeostasis with a high RR and will evenually fatique. If the patient wants to be a Full Code, a definitive airway via fiberoptic would be the tool of choice. This can help identify anatomical defects from reconstruction and possibly the fistula. A trach of some type will probably be in his future. Once ETI is established the ventilator and pressors can be adjusted for a modified ARDSnet protocol depending on the ventilator used. If ALS only has an ATV, a specialty team (RN/RRT) may need to accompany with their equipment. This may also be an issue for the CVP monitor and hopefully and A-line can be established as well. If the patient is on the ventilator, sedation and possibly paralytics might be considered. Diprivan (propofol) would be our drug of choice for a Specialty team transporting a high level ventilator patient. Again, right meds, right equipment and right team. Plateau pressure on the hospital ventilator if the decision is made to intubate? The other Dx to consider would be more involved and concerning his CA. Many of these patients will require some type of surgical procedure at least once a year. Another warm body, no matter how educated they are, would be of little use unless they have the right equipment and the right expertise. This would only get you a request for a really fast transport with the L&S thing.

Again Atrovent liquid did not present an allergy issue for those allergic to peanuts or soy. The lecithin base used in the CFC propellant MDIs of Atrovent and Combivent (which is Albuterol/Atrovent combo) did present a potential problem. Atrovent is now HFA and the lecithin is no longer used in the product. Unfortunately Combivent still has not been able to reformulate so it still is CFC with lecithin making it a problem for those with peanut or soy allegies. New Atrovent HFA MDI insert: Note there is no mention of peanut/soy allergies. http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdf general pt info http://fdb.rxlist.com/drugs/drug-93239-Atrovent+HFA+Inhl.aspx?drugid=93239&drugname=Atrovent+HFA+Inhl&source=0 The link I posted earlier. http://www.aaaai.org/patients/resources/medicationguide/saba.stm Note the Combivent information. There have been numerous changes to Respiratory medications during the past 3 years to be in compliance with the 1987 Montreal Protocol (treaty) which is why I posted the earlier links. In fact, just about every MDI had to reformulate. Combivent has been granted a stay of termination for now as it attempts to produce an HFA product. There is a chance that none of the MDIs are as they were presented in your Paramedic text book. I am actually still seeing EMS information with Bronkosol listed as a frontline med.

The FiO2 will be dependent on the pt's RR and VT on the flow you pick. http://www.vitaid.com/usa/boussignac/resources/FiO2_Delivery.pdf

The Boussignac should give the patient a fairly high FiO2 since it doesn't dilute with a venturi. However, if you want 10 cmH2O of CPAP, that will be 25 liters of flow off your tank. Thst means less than 15 minutes on a D tank and not much more with an E.

Or, they need some more experience with many types of patients. Necrotizing Fasciitis is not that rare and we often see patients that smell rather foul like they died days ago but somehow manage to be treated or at least made comfortable when treatment is not possible.

DuoNeb is ONE vial of medication but is formulated in combination. Thus, you document DuoNeb with the understanding by your formulary (or protocols) that it is a DuoNeb. Also, if you look at the meds in DuoNeb you will find it states 3.0 mg Albuterol with the atrovent where as your standard Albuterol dose will be 2.5 mg. However, there is a notation on DuoNeb is that it is equivalent to the 2.5 mg base. Again, it is a difference in the formulation. If you were in a system that held you accountable for your medications, you would come up short if you document Albuterol and Atrovent as two separate medications but give DuoNeb. Your company could also not justify charging for a more expensive "DuoNeb" if you did not charge it as given. If you look at the links I posted you will find that many of the medications are combinations such as Advair and Symbicort. You must know the combo name and the medications each contain to know what you are giving. As far as allergies, liquid Atrovent has NEVER had the peanut issue. It was only a concern with the CFC propellant formulation with a lecithin base for MDIs with Atrovent and Combivent. Atrovent MDI now has the new propellant formulation (HFA) and is not longer an issue. Combivent, at this time, still has the CFC propellant and lecithin base which makes the peanut allergy still valid.

Let's start off with a clarification of "Duoneb". It is not meant to be Duo Neb as in two med neb although it is a catchy name. DuoNeb is the brand name for a combination medication of albuterol and ipatropium bromide and is from Dey Pharmaceuticals. Not every person will know what you mean since some use the generic formulation and I don't believe DuoNeb is available in most of Canada. In fact, here in the U.S., there are many hospitals and EMS agencies that do not use DuoNeb because of the cost. It can also be mistaken for "Dual Nebs" which is a therapy term in respiratory for certain high flow device setups. If you are going to use rescue therapy, you might as well hit the patient with the Albuterol/Atrovent combo first since Atrovent is technically not a rescue medication but can be considered one if used as frontline in rescue. Its action is also not as quick as albuterol so if you are going to use...get it in right away. Albuterol and Atrovent are two very different medications in different classifications and it is not "if one doesn't work try the other".

Does that mean I have to write out SpO2 as "Oxygen Saturation by pulse oximetry" each time?

There are certain standardized abbreviations/acronyms that must be used which you will commonly see in hospitals and long term care facilities. There is also a list of abbreviations that must not be used. JCAHO "do not use" list: http://www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/0/dnu_list.pdf Some disease processes such as pneumonia (PNA), cystic fibrosis (CF) chronic obstructive pulmonary disease (COPD) and Amyotrophic lateral sclerosis (ALS)have accepted abbreviations. Chronic obstructive lung disease is sometimes used but not as often as COPD. A patient may be more likely to use the term if the physician brought the language into simpler terms. Chronic lung disease (CLD) is sometimes used in describing infant and pedi pulmonary disease such as bronchopulmonary dysplasia. Of course each profession has its own set of terms and abbreviations. You will see me use some of the above from my RT profession and feel free to ask questions. I may also use "ALS to mean Amyotrophic lateral sclerosis and not Advanced Life Support but then the context of the statement should indicate that. Examples of different abbreviations for other professions (most are recognized internationally): Respiratory Therapy http://www.rcjournal.com/guidelines_for_authors/symbols.pdf Physical Therapy http://physicaltherapy.about.com/od/abbreviationsandterms/a/PTabbreviations.htm Radiology http://www.rtstudents.com/radiology/radiology-abbreviations.htm EMS sometimes falls outside of some standardized abbreviations. Example: DIB may mean Difficulty in breathing to EMS but is rarely used in the hosptials. The hospital staff may use SOB or DOE which can be more descriptive. Thus, the abbreviations that are literally made up (and some do have a habit of doing that) and not listed in YOUR own policy manual are the ones that are truly invalid for your charting purposes. However, it is wise to follow the "do not use" list especially when it comes to medications. Write out what you can. However, if you do a thorough lung exam, it might take up alot of space to write out each lobe or segment. That being said, I will try to write out some of the abbreviations. However, I suggest you get into the habit of reading medical literature (other than JEMS) which will generally have a list of many different terms and abbreviations included with each article. This will also help you when reading medical reports in patient charts.

Now to get a little more specific. Albuterol is the cure all for everything or so it would seem. If you don't know what is going on in the chest, they get an Albuterol neb in hopes of sorting out the sounds left or that appear after the treatment. Atrovent (Ipatropium Bromide) is generally more effective in COPD patients. However, since asthma can also fall into the broad category of COPD and the lung remodeling that occurs, Atrovent may also be a good med to use with the Albuterol. For PNA, it depends on the history, type and site of the PNA as to whether Albuterol can be effective. Sometimes patients may have a bronchospasm present with the PNA and sometimes not. However, if a neb is given that is powered by O2 from a tank, the patient will probably rave about how good they feel just because of the extra O2. The extra flow may also enhance the intrinsic PEEP effect that may splint some of the airways. This is one of several reasons why I prefer a mouthpiece neb over the mask. CHF is also controversial. If the patient has an underlying PNA or pre-existing lung disease which could also have been an initiating factor for the CHF, Albuterol or Albuturol/Atrovent may help but I would not delay initiating other therapy such as CPAP. For pulmonary edema post operatively following lung surgery and early stages of ARDS, we have been conducting studies for Albuterol (Salbutamol studies in Canada). We have noticed some improvement with the Albuterol and not as much with the Atrovent (Ipatropium Bromide). But, there are many factors to consider with each patient.

Thank you for that introduction Jake. It is important to find out when the patient started using nebs/MDIs and what type. Some people are given MDIs at their GPs office but are not given any clear instruction about why or when. Thus, we now have very good medications that are under scrutiny due to fatal incidents when the problem is actually a lack of communication. The LABAs fall into this category unfortunately. It would be important to note if the patient is mistakenly using an LABAa as a SABA or rescue inhaler. I personally have seen at least 5 emergencies involving LABAs recently. One was from EMS who had the patient on a "Duoneb" while the patient was holding an empty Symbicort canister which their had just gotten a script for on previous day. The HR was 250+ but that was not known since the patient was not hooked up to a cardiac monitor until they reached the ED. Palp HR by radial was 80. The patient was also told by the Paramedics to take "another hit" off the LABA while they sat up a nebulizer. So the Paramedics has assumed the patient was holding a rescue inhaler (SABA) and did not check what med they had just told the patient to take. Rookie mistake or one of extreme carelessness that can be potentially fatal. Here are some links for all the new meds out there. Note that Albuterol is not yet available by the generic name of "Albuterol" with the HFA formulation. If you see a generic canister of Albuterol (CFC propellant), check the expiration date. However, there are brand name "Albuterol" MDIs on the market. SABAs http://www.aaaai.org/patients/resources/medicationguide/saba.stm LABAs http://www.aaaai.org/patients/resources/medicationguide/bronchodilators.stm Cromolyn and theophylline http://www.aaaai.org/patients/resources/medicationguide/cromolin_theophylline.stm Inhaled Corticosteroids (not Advair and Symbicort which contain a LABA) http://www.aaaai.org/patients/resources/medicationguide/inhaled_corticosteroids.stm Leukotriene Modifiers http://www.aaaai.org/patients/resources/medicationguide/leukotriene_modifiers.stm Immunomodulator http://www.aaaai.org/patients/resources/medicationguide/immunomodulator_medications.stm Also, many of the nasal sprays will have similar names as the MDIs including the corticosteriods and Atrovent (Ipratropium bromide) and can easily be confused at first glance. http://www.aaaai.org/patients/resources/medicationguide/nasalmedication.stm Sidenote: Duoneb may not be the name seen as often since the generic Albuterol/Ipatropium bromide is readily available now and a little cheaper.

As I mentioned earlier, I like the way Orebaugh's book shows the positioning of the Combitube for changing out to the ETT. Kings, LMAs and Combitubes much come out as soon as possible once the patient is stable. If not, one of the complications is the tongue becomes engorged to where fiberoptic or even a trach may be necessary. If your service just started using these devices on a regular basis, it might be a great idea to inservice the ED doctors in your area especially in the more rural regions. You may even have to assist changing them out. Definitely warn the doctors of the aspiration risks and the potential for trauma especially with the Combitube. For those using the Combitube, it would really be helpful if you bring the large (140 ml) syringe in with the patient at the ED and personally hand it to whoever will be managing the airway. Not only will this be a great help when they change out the tube but also, if they give you a "deer in headlights" look, you know a quick inservice may be necessary.

I have not seen Walls' book. The text we recommend for RTs is Airway Management: Principles and Management by Jonathan Benumof. I have the 1st edition (1996) but I believe there is a 2nd edition out now. It is a very indepth text of 1000 pages the covers some of the airway situations we see emergently, in the ED, ICUs, in the OR and post operatively. For easy reference with nice pictures, I use: Atlas of Airway Management; Techniques and Tools Steven L. Orebaugh It of course does not go into the detail of Benumof's text but still offers good examples of intubation situations, techniques and equipment. I also like it because if gives new intubators, including residents, a good visual for changing out the King and CombiTube which can be sometimes challenging. Yes in a vehicle that might be a problem. However, if I can get into a good position, I have not met a beard I couldn't tame with the BVM. Just don't puke before I get the NG placed. Depending on the situation, I can also adapt my portable ventilator, LTV 1000 or 1200, to do NIV (CPAP or Bilevel) and use a BVM mask with rubber straps that can be adjusted for a very tight seal. You probably won't like it unless it improves your breathing. If I have to intubate you, I can almost guarantee you'll be clean shaven when you wake up in the ICU and I'll swear that you gave me consent for the hair removal before the Versed.

I forgot to elaborate on this link. This course was taught after Volusia County Florida's intubation success rates averaged 44% for the county during 2004-2005. However, it was noted the ALS first responders that dragged the stats to that level. The Paramedics on the services that transported supposedly had an 88% success rate. There was some discrepancy noted in the data gathering. I believe their stats have improved OR they redefined some of their definitions to determine success statistics.

If the ETT can make it through the cords and you still have a problem oxygenating and/or ventilating, a cric may not make a difference. It is time, or should have already been done, to check chest wall integrity and restrictions. This may apply for the BVM and any supraglottic devices as well. Haste may make waste without examining all the possibilities. Some narrow their focus too much to where they miss the bigger picture. Also, as the higher patch on scene, I may want to be sure there is not a simple reason for the failure of a BVM or supraglottic device done by an EMT before I do a cric. This is not intended to offend the EMT. However, in reality few get little more than a couple hours of instruction and their only chance to place it is on a manikin. As well, most states that do allow EMTs to place a supraglottic device, the patient must be in a code situation or dead. Sometimes something much simpler than a cric, even if it is a "BLS" or EMT skill, can be used to maneuver the anatomy of the upper airway to where effective ventilation can be achieved. I would not discount any form of airway management whether it is labeled BLS or ALS. It also only takes a few seconds to examine the upper airway with a quick look at the anatomical structures and another quick check of the chest wall to see what you can expect especially once positive pressure is applied. In an MVC, you may also have to prep the chest for a needle or a tube depending on your protocols.

And the list keeps growing...

Let me spring a few more airway situations on you which is now seen more often in the field for EMT(P)s as there are more subacute facilities and home care patients with tracheotomies and tracheostomies or stomas. When you pick up a "trach patient" do you assume it is a "trach" like the one shown in the EMT(P) textbooks or do you examine for brand, model, size and if it has a 15 mm adapter? What if you have a patient with a false tracted trach? Do you know how to recognize it and how long would you attempt to recannulate (with another trach or ETT) before you moved to oral intubation? What if the trach was for tracheal stenosis above the trach site? Are you familiar with Blum-Singer (speaking) valves in stomas? Or, the fistula that may exist between the trachea and esophagus for speaking valves of laryngectomy patients? Can you immediately recognize a flesh colored stoma covering on a patient? This is a good mall people watching activity. These patients may be young and active. They may be in biking or motor vehicle accidents and anywhere else that you would not expect to be faced with an alternative airway situation. BLS: How do you manage the airway of a stoma patient? Sidenote: a tracheostomy/stoma may be found in pediatric patients who are in long term care and/or vegetative states to prevent aspiration. What about all the numerous tracheotomy/tracheostomy devices that don't have a regular 15 mm adapter for the BVM? Montgomery tubes, Singer laryngectomy tubes and Shiley trachs missing their inner cannulas are examples of this. Has anyone seen an innominate artery blow? Was this discussed in your cricothryoidotomy or trach class? Reconstructive surgery and/or radiation may make land marks difficult to identify if you do need to perform a cricothryoidotomy. Some interesting websites: Prostetic speaking valve and stoma/fistula coverings http://www.google.com/imgres?imgurl=http://www.epithesen.com/images/trach6.jpg&imgrefurl=http://www.epithesen.com/engl/tracheostoma.htm&h=283&w=368&sz=18&tbnid=BTBikyToolDgGM:&tbnh=94&tbnw=122&prev=/images%3Fq%3DBlom%2Bsinger%2Bvalve&hl=en&usg=__kBol3Gh-SpoB1ctYsCvxWM5n45o=&ei=sW-yS9GSOoyOswOUl6DMAw&sa=X&oi=image_result&resnum=10&ct=image&ved=0CCcQ9QEwCQ Speaking valve for laryngectomy patients http://img.medscape.com/pi/emed/ckb/otolaryngology/834279-883689-33.jpg Voice restoration for laryngectomy patients and the founders of the technology. (Some great information on this website especially under Educational Resources.) http://www.inhealth.com/Blom-Singer_30years.htm Larygectomy products and literature http://www.inhealth.com/literature.htm Montgomery Tubes (note that some look like dry wall hangers and may have been surgically placed.) http://www.bosmed.com/airway-management/montgomeryr-cannula-system.html These are just a few things to read about. RTs and ENTs get called almost every day to the ED by the ED doctors to identify and manage a funky looking device sticking out of someone's throat that was placed for some special reason by a Specialist. "Trach" is a catch all term but may not be the appropriate one to use when giving report. Others may "assume trach" and be caught off guard in an emergency by a specialized device.

This I would never advise anyone to do. We have a service in FL that purchased a 1968 Huey for a bargain price of $326,000. It ended up being a money pit with parts that were difficult to obtain and a couple of pilots out of a job when they raised a fuss about a little issue like safety. It was not reliable due to maintenance problems and another service had to be called from over an hour away to pick up the patient at the last minute when the Huey couldn't take off due to mechanical failure. This service has since purchased a 1982 Sikorsky for $3.7 million. But, there is still much controversy surrounding it for funding and tax purposes as well as what transport service is appropriate for the patient. The local hospitals still prefer to call the Children's Hospital and their helicopter or fixed wing for Specialty transports. Of course the local service gets its feelings hurt. There is also an issue with obtaining the contracts from the hospitals and liability issues for medical control as well as that of the flight team's medical director.

If the OP intended this to be a joke, his timing sucks. While the questions are somewhat...distant, I will provide some information on the topic. We might just have a genuine dreamer here or someone who has a friend with a helicopter he wants to put to good use. Of course if one did have a helicopter, he probably would already know where to look for some of the answers. If nothing else, some of the links might provide some reading for those who have an interest in Air Medical Transport. Here are the CAMTS guidelines which includes references to communication equipment or at least where to look with the FAA. http://data.memberclicks.com/site/nemsp/AccreditationStandards_-_7th_Edition_2006_1_.pdf Recent ammendments to the guidelines can be found here: http://www.nemspa.org/mc/page.do?sitePageId=91563&orgId=nemsp'>http://www.nemspa.org/mc/page.do?sitePageId=91563&orgId=nemsp CAMTS website http://www.camts.org/ NEMSPA (you will also find the NTSB recommendations on this site) http://www.nemspa.org/ READ all safety recommendations. In case you haven't noticed there have been several medical helicopter crashes resulting in the death of providers and patients. Of course the helicopter, licensing, insurance, crew and equipment are just a few issues. You will also have to petition your local government agencies for landing zone permits at the hospital or where you decide to land the helicopter. You may have to apply for a specific certificate of need for this type of service in your area. You will have to work out billing and taxation issues for IFT/scene response. You will have to get a cert for IFT and if you do scene response you will need one for that as well. You will have to petition for funding to maintain a LZ at your hospital. This may have to be done with the board of the hosptal, the local government officials and if any tax dollars are used from the area residents, a special election may need to be held for approval. This may also apply to have the tax payers pick up the costs of transporting the uninsured. One more serious note, make sure all of the employees flying get a copy of this: http://www.flightweb.com/filemgmt/datafiles/EMS_preparedness_guide_v3.pdf Of course the information is of value to ground EMS as well.

Your comments about the BSN grads knowing very little practical applications can also be applied to many ADN grads. Unfortunately not all programs and clinicals are created equal which depends greatly on the facilities they have access to as well as the educators or the nurses the students are assigned to. You probably would not give a BSN student much of a chance since your attitude is already negative and probably very little would change your mind when it comes to giving the students of a BSN program an opportunity to learn. If you only have the ADN and have never been through a BSN program, how can you fairly judge a BSN grad? I would in no way want to be precepted by someone that has such a skewed impression about someone who has gotten a higher degree. This is why some hospitals only put those with BSNs (or BSRTs) in preceptor positions. It is unfortunate that these educated professionals must be subject to your attitude towards them just because they have chosen to get an education. If you compare the programs for the ADN and the BSN, you will find they have the same sciences and require the same number of clinical hours. Of course the BSN has the option of requiring the higher level sciences and maths as well as introducing the student to the world of medical literature and research. Why do you find research to be a negative thing? I don't know if you have ever worked in EMS but unfortunately, research is an area that could use a boost but people must be willing to acquire enough knowledge through education about the research process to make a valid project. It is too bad you work in a hospital that does not have opportunities for the RNs to obtain professional growth and to have mentorship by those who take a different outlook on their profession and education. You would be truly amazed what well educated nurses and other professionals can bring to an ICU or any unit in a hospital.

Many hospitals do pay a little extra for the BSN as well as the MSN. (The same goes for the BSRT as well.) Many hospitals prefer the BSN for those in specialty units and on specialty teams including transport. Yes, being on a specialty team may also get you a little extra in your pay check. I have only seen a few RNs with anything less than a BSN in our ICUs. We also have 5 colleges in the county that offer the BSN and only one community college. Thus, I would say in my area, 80% of the grads are not from the community college. The BSN is also easily accessible at the community colleges which makes it an easy transfer. Community colleges are welcoming these arrangements to survive especially now in California. Florida learned this a long time ago and got the community colleges together with the universities. Many hospitals offer tuition assistance for completing a BSN. Many hospitals will reimburse a considerable portion of the RN's tuition from a BSN program including some of the more expensive ones in California which can cost around $50K. The Federal government has a reimbursement plan for nurses. Nurses now know where they stand amongst the other health care professionals that now require much more education with the RN and RT being at the bottom of the professional food chain with a mere Associates degree. And yes, RT is doing something about that. At this time there is not a great nursing shortage. Many new grads are struggling to find jobs and those with the BSN may win out over the ADN. Administrators see those that have put forth a greater effort and who have made an investment in their future as employees who want a career and not just a job that pays well. Thus, for a profession that still has hospitals and the government throwing money at their nursing students and RNs, one would be a fool not to take advantage of the many offers out there if nothing else then for personal gain for a professional goal. RTs were getting A.S. degrees for over 20 years before it became the standard. They were also getting BS degrees over the past 20 years knowing that some day a couple of Bills for their practice would come along for a few nice opportunities with professional growth and monetary gain. Nursing has many opportunities to put their BSN to good use even if it might not be in the hospital one is at now. One can sit and whine about their status and make excuses or one can take advantage of what their profession has to offer. A BS degree is not bullshit. Nor is it just for management. Those who believe education is bullshit will be and should be the ones downgraded to a lower status and left behind. They do little to promote their profession regardless of what it is. Imagine having this conversation with the many different professionals that go on to obtain higher education just to enter their profession such as Accountants and Graphic Artists. You need a Bachelors degree to be competitive in the world of drawing pretty pictures but you only have to be minimally educated to take care of patients and save lives.

The point here is that if you have a path from the mouth to the cords to where either digital intubation or a CombiTube could be done, you would not be justified in doing a cric. Just be cause you can isn't always the best route. Alternative airways can be a stable airway until the hospital is reached to where more equipment is available to intubate the patient without cutting open their throat. If a ground EMS crew has established a Combitube, King or even an LMA to where there is evidence of adequate ventilation and oxygenation, very few flight crews would ever consider changing out for an ETT or doing a cric. Even in the hospital, we wil have all of our ducks in a row before we put that alternative airway. I have also used a BVM for very long periods of time with no problem while waiting for the right equipment for a difficult airway.

In the U.S. that may be harder to regain the confidence of the agencies that govern quality control for labs. Too many foul ups with poorly trained individuals with improper specimen collection and handling techniques led to incorrect and sometimes fatal treatments from the lab results. Even labeling was an issue with some EMS providers failing to see that their specimen was correctly labeled in a timely manner to get the correct labs results on the right patient. The EMS agencies themselves could not provide evidence of any training or QA monitoring for this "skill". If they also fail to monitor intubation skills, lab draws probably won't be much of a priority either. Even for Specialty, Flight or CCT, we may have the lab at the sending hospital draw the specimens and fax or call the results to the MD at the base facility which can then be relayed to us during transit. If we have extra cartridges for the iSTAT to do different labs, then yes we may draw and run the specimens immediately for certain tests. However, if the transport is more than 30 minutes, we have to take into consideration the length of time, proper storage and exposure of certain specimens if we must transport them. At one time EMS prehospital lab draws were not an issue but as with anything, when you let the lowest common denominator represent the rest of the flock, eagles can quickly be viewed as turkeys when it comes to soaring to new heights. Even the hospitals and clinics have raised their standard to where the phlebotomist that had once been OJT must now have at least 140 hours of education/training in just phlebotomy and they now have a national certification gaining popularity that reflects the national lab standards. That's longer than the EMT-B in the U.S. Any licensed hospital employee (RN, RRT) must now show initial and yearly competency in lab specimen collection. There are also agencies that do check and ensure this process is carried out. EMS still has not achieved that level of oversight in many areas and there probably would be some union that would say any additional education or competency expectation is unfair and someone is picking on them or treating them like criminals (to quote the LA FF article).

This is a decent ppt of infant intubation and some of the situations one could come across. http://www.pediatrics.emory.edu/ccm/lectures/files/The%20Neonatal%20Airway.ppt Meconium is also something one should be aware of if there is a chance you might happen across someone giving birth. One should check their equipment and review the procedure with their current partner so there will be no fumbling when seconds count. Even in controlled situations, we take the new (experienced but new to L&D or NICU) RRT or RN after their NRP class and have them spend a day just getting the hang of neonatal resuscitation with procedures repeated over and over which includes the meconium aspirator, suction and ETI. It generally takes an RRT or RN at least 10 - 20 intubations in the NICU before they are allowed to be part of the L&D resuscitation team. Unfortunately Paramedics do not get that luxury and must find at least an infant manikin to practice on. Fumbling can sometimes be excused but not if it is because you are not familiar with your equipment and the basics of the procedure.

It can be either hyperthermia or hypothermia and staging may depend on the orgin of the sepsis and age of the patient. Where you take the temp is also of importance and few EMS providers are going to be able to do a core temp from the esophagus or be inclined to do a rectal temp. Hyperthermia > 38.3 °C (101.0 °F) Hypothermia < 36 °C (96.8°F) Here is a link to guidelines and some good reading on the topic of sepsis. Surviving Sepsis Compaign http://www.survivingsepsis.org/GUIDELINES/Pages/default.aspx Physiological Monitoring for Critically Ill Patients: Testing a Predictive Model for the Early Detection of Sepsis Am J Crit Care. 2007;16: 122-130 Karen K. Giuliano http://ajcc.aacnjournals.org/cgi/reprint/16/2/122?ijkey=59ca6a51e57bbd491e87b501b52032817438d99c