VentMedic

Until you've seen a FF/medic try to start an IV with their fire gloves on, you won't understand.

I can see pulling the line immediately if it was infiltrated or otherwise not usable. That would prevent others from wasting time trying to put meds into it. The issue for the OP is to educate the staff about waiting until a line is in place. If the doctors and nurses are young, they just need a little guidance. We get over eager residents also who sometimes have to be reminded of the P&P or a timeout until they can get themselves oriented to the tasks and their proper order. Also phlebitis probably won't show up in just 15 minutes after insertion so it is not a valid argument "to not see phlebitis". EMT(P)s themselves are the ones who have shown their own issues against IVs started in the field. "We're EMS. We don't have time to do it like you do in the hospital." We've even had issues with Paramedic students in our ED wanting to start IVs like they have been told they would in the field and not by the standards of the hospital. A few students were noted to not even give the site one swipe with alcohol. They were betting with each other who could get the IV in the fastest and cleaning took too long. If this becomes an issue again, the schools may have to look for another ED for IVs. We already have banned intubation by Paramedic students from these schools in our ED. Again, it is hard to maintain quality control for many different schools and many different departments. Of course, you may not have seen the look on some Paramedics' faces when we do a quick tube change out in the ED.

You should also do a thorough assessment since the marijuana may or may not have exacerbated another situation. Don't just get distracted by what seems to be the obvious.

One of the hospitals I moonlight at is a medicinal marijuana center. I posted the drug information earlier because just like any other medication we monitor for reactions and interactions. First time users can react in many different ways. The medicinal marijuana is grown just like the good quality street stuff and will give people the same high. Marijuana has a lot of different chemical properties that will react with different people differently without being laced with another street drug. I do not believe the FDA has put their seal of approval on it due to the various side effects as well as benefits. It is also difficult to study something even for medical benefit if it is illegal. Regardless of whether a drug is street or legit, assess it from its chemical properties and what systems it normally affects. Look at it as you would any drug rather than just a "street" drug. The same for heroin and cocaine. You should have a general idea about what systems they affect when you are assessing your patient and planning your treatment.

This is not a new question and it comes up occasionally in the EDs. This information pertains to the U.S. Differences in education/training and oversight must be factored in. First you need to work with your infection control officers and find out the references by which their policies were written from since this is also a CDC recommendation. Medicare and accrediting agencies also like to follow the CDC guidelines. Then, you need the written policies of every EMS/Ambulance that transports to your facility and their competency sheets. You may be surprised to find some services do not have all their data in order. If all services transporting to your ED can not satisfy general documentation and competency data, you may be hard pressed to change any policies. That has been one of the biggest stumbling block along with EMT(P)s themselves bragging about their "prehospital techniques". Also, what levels of prehospital providers are doing the IVs in your area? How much initial and continuing education do they get on technique and infection control? That also will have to be documented when you present your position. National studies with a limited sampling area may not be enough. The IHI also has been incorporating various data bases and may be of some help or find out where the weak areas are and you can assist the prehospital agencies in achieving compliance. I do believe an antecubital IV should be placed in a better location if it is not being used for resuscitation. Some hospitals have extended their prehospital restart to 48 hours which is just one day shy of the in hosptial policy for site rotation of 72 hours. We also change out prehospital ETTs whenever possible if the patient is going to be on a vent for more than 24 hours. We take the infection control issues and the mandates from Medicare very seriously. So far out overall hospital infection rates have decreased dramatically with 0 for VAP and central lines so far. Peripheral IV lines have not been an issue but the hospitals have almost always had the 24 hours change out policy. You may be the only EMS provider in your area and you may be able to provide the hospital with all the necessary paperwork if ever asked. However, when one facilty is on the rec'g end of over 15 different EMS/ALS services, many of which have their share of problems, the hospital has gotta do what it must to ensure quality.

Since there are over 400 different chemicals documented in marijuana, it is very possible one could have a reaction from something. Marijuana has had a lot of research done since it is now used for medicinal purposes. Everybody will reacts a little differently to some outside chemicals and that includes marijuana. Even oxygen can have different effects on a patient depending on the chemical and cellualar make up of that person. This also varies with race and sex. http://www.drugs.com/npp/marijuana.html

See my previous post. This is not new. They have already been tested over a year ago. They have since made other headline blunders. And, it has been awhile since the David Rosenbaum family made their offer of good faith by not accepting a settlement if the Washington DC department would get its act together. Their EMTs have also been tested with a 28% fail rate and the others are accused of cheating. Does anyone know if this department provides the initial EMT(P) training inhouse or at a contracted "mill"? Some of the mistakes made appear that their initial training sucked so there is little foundation to build from without sending some back to the beginning of EMT class and then all the way through a real Paramedic program. A lot lacks here including integrity and pride of providing quality patient care. This appears to be a created culture of indifference and not just a few very bad providers.

Here's a little freebie full of good info for Niftymedi911 and Richard B the EMT. http://www.sleepreviewmag.com/

I just don't get it. They know they have been under the watchful eyes of the public who is now all too familiar with their screw ups. They know they are being tested. And yet, they manage to muck it up each time. Do they not know what that Paramedic patch means and the responsibility that comes with it? By the comments in the article, it seems they totally expect to be spoon fed the test and take no responsibility for their license themselves. Shameful. I also thought these medics were already tested last year. DC medics to be retested Wednesday, February 27, 2008 http://emergencymedicaltechnician.blogspot...01_archive.html In an unusual and sweeping move, Washington, DC Fire Department will retest all of its 250 paramedics for "competency." The testing has been contracted out to the Maryland Fire Rescue Institute (MFRI). This is a bold move in a troubled department. You may recall the lawsuit filed by the family of David Rosenbaum, the journalist who died in DC after a series of errors. Looking between the lines it seems quite a bit of power is held by Dr. Michael D. Williams, the DC medical director. After all, the medical director is ultimately responsible for the clinical aspects of an EMS system. But other angles (Rosenbaum lawsuit, legal maneuvering around union issues, politics, etc.) make the medical director the ideal person--and the most bulletproof--to make decisions stick. He says: "I expect there will be people that fail this process," Dr. Williams said yesterday. "And I think I will be saying, 'You're really not functioning as a paramedic, so we're going to pull you out.' " Dr. Williams said the policy could create difficulties for the department official who assigns crews to ambulances, but "my obligation sort of trumps his on this one." Using an outside agency was also wise. MFRI is respected in the area. Offering remediation to those on the edge prevents this being an outright slaughter. I am not sure whether ousted medics will be any better as EMTs. Time will tell.

Which model are you using? I am just amazed at the technology available for that "industry". Right now the Sleep Lab is still a nice cash cow for the RT department. It is also a healthcare profession that quickly saw that proper education, certification and licensure are being obtained to work with these labs and the CPAP machines. Many places now require at least a two year degree.

Critical Condition: D.C. Paramedics Up to Par? Evaluation of video leads to questions posted 04/24/09 http://www.nbcwashington.com/news/local/Ar...-Up-to-Par.html (The video is at this site.) Video never seen before by the public shows paramedics reacting to a life or death situation -- a simulation used to evaluate their performance in an emergency. These assessments were performed last year at the Maryland Fire and Rescue Institute at the University of Maryland. It's known as MFRI. Where the assessments took place looks like an ambulance, but it is an advanced life support simulator. A mannequin displayed certain health problems that led to a heart attack. The faces of the paramedics are not shown to protect their identities. To evaluate their performance we asked an nationally-recognized expert to choose and review some of the videos. Professor Paul Werfel is the director of the EMT/paramedic program at the Stony Brook University Medical Center in New York. "Of the videos that I saw, solely on the videos that I saw, the mistakes that these folks were making were huge," Werfel said. "The performance across the board was substandard. "I looked at 16 videos and of those 16 videos only one of which would have passed an entry level exam for competence on fundamentals," he said. The D.C. Fire and EMS Department contracted with MFRI to assess approximately 250 paramedics to see how D.C. emergency medical personnel measure up to national standards. "It is not an exam, it is not a test," said Steven Edwards, director of MFRI. "There was no pass-fail mark. It was simply a way to determine in a general way -- not a specific way -- where additional training should take place in the paramedic service." D.C. Mayor Adrian Fenty and Fire Chief Dennis Rubin released a written statement to News4 saying: * The assessment is one of the many efforts that the department is undertaking to improve the quality of EMS. * They have used their initial findings to improve medical protocols. * Several areas for systemic training improvements have been identified. * All paramedics have begun receiving specific focus-area training. But Ken Lyons, president of AFGE Local 3721, the union representing many D.C. paramedics, said only a few individuals have received additional training so far. "Let me describe to you what remedial training was ... here' s your book, go into the room and self study," Lyons said. "That's the extent of remedial training." The union wants training to avoid embarrassments like the 2006 death of New York Times reporter David Rosenbaum, who was found lying in the street, misdiagnosed as being drunk and died of a brain injury from a beating he suffered during a robbery. And last December, Edward Givens complained of chest pains. He was diagnosed with a stomach problem, was given an antacid and later died of a heart attack. Are D.C. residents well served when they dial 911? "Absolutely not," Lyons said. "They're not well served when they dial 911 and they are not well served when they pay their tax dollars to a system that for the most part has become a fraud." Are they in danger? "You know," Lyons said, "I think they roll the dice." The DC Fire and EMS Department said it is committed to reforming the system, and that the community should feel confident that they will receive high-quality emergency medical treatment and transportation. Click here for the Washington Times' report. http://www.washingtontimes.com/news/2009/a...ures-by-dc-ems/ On Friday, News4 gets reaction to this report from the family of Edwards Givens, the man who was diagnosed with acid reflux but died of a heart attack. D.C. Fire Probes Allegations of Cheating on EMT Test posted 04/24/09 7:51 am http://www.wjla.com/news/stories/0409/616183.html WASHINGTON - All D.C. firefighters have been ordered to cease using the Pearson VUE Facility at the College of Southern Maryland for EMT testing after allegations surfaced that tests performed there could have been compromised, perhaps by cheating, a department spokesman confirmed to ABC 7 News Thursday. According to a statement, the allegations are "that members utilized outside materials during the National Registry Emergency Medical Technician examination process." More at: http://www.wjla.com/news/stories/0409/616183.html and City Investigates Alleged Cheating on EMT Test - Washington Post http://www.washingtonpost.com/wp-dyn/conte...9042304902.html

Just remember that while protocols or recipes are good, you still need a thorough understanding of the disease processes and a good device rep to get you started correctly as to how to use it.

Emphysema? What level are you? How much education have you had with the above diseases? How much do you know about CPAP? What additional education will your medical director provide you? CPAP has been around for well over 50 years and its results are fairly well documented in the medical literature. However, prehospital devices do vary in their performance to meet patient demand. Here is an educational website from Respironics. The sign on is easy and free. Look for NPPV courses under the CE modules as well as the training video of their product the WhisperFlow. http://elearning.respironics.com/index_f.asp

That is amusing and such cute names for Viagra. For some of us who work with neonates and pediatrics, we do not use the name Viagra (sildenafil) as it does cause parents to be alarmed just from this drug's stigma. However, we must explain that is the medication being given to their child. It is true that it is easier to get a grant to do research for erectile function (performed in the Sleep Study Labs) than it is to study pulmonary hypertension in children. BTW, it might be wise to learn the various names for Viagra since babies, peds and adults do use these meds in various forms/routes and some of the same precautions will apply. Now, back to the funny stuff.

That is a website JPINFV started when there was a discussion about the 50+ different certs. Even that site has become outdated as states change their certs to a different name by adding "one more skill". EMS magazine also has a difficult time keeping its data base updated quickly enough, croaker260 That would be interesting especially with their 8 different cert levels. They might have to add a couple more for those that don't want to be a paramedic but just like one in "skills".

I had only known of Oregon requiring a 2 year degree for a Paramedic license. Texas has a license for degreed but it is not required. I just found out about Kansas but with their use of the title MICT instead of Paramedic, I tend to overlook that state. Any others?

I think the term is middle-aged. Respiratory Therapy has had a couple of serious muck ups in the profession. Of course, one was in Florida and one was in California. Efren Saldivar was an Angel of Death in Calfornia who was convicted of 6 hospital deaths but claimed to have killed over 100. He stated he lost count after 60. The Florida incident involved a CRTT (Certified not Registered) shutting off the wrong ventilator for end of life or a "terminal wean". This was contributed to postpartum stress and the failure of the hospital to review P&P after an extended leave. But, from both of these situations, the profession in each state took action. California RTs will have to do a 3 hour Ethics class for each certification. The theme of it is essentially "Thou shall not kill". I kid you not. It also sucked for the RTs at Glendale Hospital and still does. In Florida, most of the hospitals only allow Registered RTs work the ICUs. As well, many do have policies that one must go through a review with a preceptor before taking an assignment after a long leave of absence. Nurses are also quick to put more performance monitors in place when one of their own screws up. EMS has already had numerous incidents where patients have been wrongly declared dead. Yet, some seem to not pay attention to the mistakes of others and learn something.

Sometimes it is hard to regulate stupid. Night vision goggles unused after 4 years Last updated on: 4/8/2009 6:40:03 PM by Kara Kenney http://www.nbc2investigators.com/articles/...d=28034&z=5 LEE COUNTY: Lee County EMS spent $59,000 on night vision goggles that experts say reduce crashes and save lives, but NBC2 discovered despite purchasing the goggles four years ago, they are still setting on a shelf unused. In a life or death emergency, Lee County's MEDSTAR can make the difference, but flying medical helicopters comes with a risk. In 2008, 14 medical choppers crashed killing 28 people and injuring 9. In the bulk of the accidents, the pilots were not wearing night vision goggles, equipment experts say reduces crashes. Lee County MEDSTAR bought night vision goggles nearly four years ago. According to invoices, they spent $23,056 on two pairs back in 2005. Then in October 2008, they spent $35,845 to outfit the aircraft for the goggles. That's a total of $59,000. The goggles have never been used. NBC2: You're still not using them. What has taken so long? Rick O'Neal: It hasn't taken so long, it's a matter of perspective. O'Neal is the manager of air operations for MEDSTAR. He says in 2005, Lee County had the money for the goggles, and they were available. "That's why we bought the goggles when we did because the war in Iraq and Afghanistan was pulling all the night vision goggles. We knew we wouldn't be using them when we bought them. But we also knew that if we didn't buy them we may not be able to buy them in the future," said O'Neal. And as for why they waited years to outfit the helicopter, O'Neal says the county had a hard time finding a company that could do the work. "When we bought the goggles there was no one in the nation that could modify our aircraft-- so we knew we'd be waiting," said O'Neal. We called the Federal Aviation Administration who told us Lee County hasn't even applied to use the goggles. FAA approval is required when transporting patients. NBC2: Why haven't you applied to the FAA to use these goggles? O'Neal: I don't know what you mean when you say apply to the FAA. Certainly we have talked with the FAA. The FAA is aware of this, and they're working with us daily. To get FAA approval, the county has to submit a written plan on how they'll use them. The county says they have one, but wouldn't give us a copy. NBC2: Why haven't you submitted it yet? O'Neal: Because we haven't gotten everything together where we should be ready to submit it. There's a lot going on. I think we're right on schedule where we should be. O'Neal points out MEDSTAR already has a night vision enhancement system which is similar to night vision goggles, except the camera and screen are fixed. That means pilots are limited in what they can see at night. Lee County EMS says having both the night vision enhancement system and the goggles will keep patients safe. "Combining the two is going to give us the ultimate in safety and that's our goal," said O'Neal. We asked O'Neal if the purchase of the night vision goggles was a good use of tax dollars. "Absolutely. It was the right purchase at the time and the right thing today," said O'Neal. Lee County EMS estimates pilots will be using the night vision goggles within the next 6 months. They bought 2 pairs in case one pair breaks during flight. **********************************************************8 This was just released: HEMS: Industry Risk Profile http://www.flightsafety.org/pdf/HEMS_Indus...isk_Profile.pdf

Yet one should not leave a person to die on the curb like some animal that is road kill. Head injured patients can live for days and their organs can go on to live for many years in the bodies of others. The article said single gunshot to the head which does not necessarily mean the head was blown off for an obvious sign of death. That may mean one may have to go through the motions of confirming death by checking for vitals and an ECG. The ambulance crew checked so it is possible the head was still intact. I've seen some serious head injured patients survive to make it to rehab for some surprising recoveries. Those that have been suicide attempts even get a new lease on life once they have been that close to death.

This is a good example by what I mean as confusion for O2 terminology. This can also apply for differences in CPAP therapy or portable ventilator applications. One can not adequately compare all the data collected from ICU machines to most of the portable models. Thus, results may be different and misleading if one does not pay attention to the methodology and devices used in the studies. The below article, link at the bottom of post, is also a good example of that. After reading how this study was done, I can only say "WTF" and "why?" There are easier and more accurate ways to achieve flow and FiO2. It reads like someone just needed a paper to keep status. http://stroke.ahajournals.org/cgi/content/full/36/10/2066-a The article being referred to: A Pilot Study of Normobaric Oxygen Therapy in Acute Ischemic Stroke http://stroke.ahajournals.org/cgi/content/...pe2=tf_ipsecsha

To do a literature search on oxygen and ACS, those in EMS would have to learn new technical terms such as oxygen concentration and FiO2. "High flow" means little to other medical professionals since the percentage of oxygen delivered by the "high flow" device can be as low as 21% or even 16% for specific situations. But, if one sticks only with JEMS, the glamour magazine for EMS, one will have no problem since it does not use such scientific or medical terms. Happy now... quote AnthonyM83 Can you post the hospital data from these calls as to how many were admissiions and got "ALS" treatment of some type in the hospital? That could also include just an IV or a 12-lead EKG. As an educator for several different medical professionals, I would find this ridiculous. Medicine shouldn't just be about one's perception of labeling a patient as BLS or ALS. There are also several studies that have shown even Paramedics under estimate the illnessness of patients which is why some treat and release programs will not work. To present a paper that states patients will still live despite any interventions other than a taxi ride to the hospital defeats the purpose of arguing for Paramedic services in a city. Why would you even consider any other medical topics involving advanced interventions if you truly believe all the other stuff considered "reearch" in LA County. Their lack of preparation for many of their approaches to Paramedic interventions is flawed with the 12-Lead and intubation being good examples. Now that could be a good topic to show how you can not determine the success of a new skill, diagnostic tool or intervention without some preparation by way of adequate training and education. Are you doing an informative, research literature review or a political stance paper? How about a paper about how to search for medical literature and how to read it to form an opinion of its validity and/or how it pertains to EMS? But then, if this is college level, that should have already been taught in at least one of your classes.

For the U.S., this is a misleading study. 1. Its focus was on trauma. 2. The BLS level in this study had more education then many of the U.S. Paramedics. 3. The concepts studied should already have been evident for anyone with education of at least that length or as long as the "minimum" education for the U.S. Paramedic. Those that don't understand the theories and concepts emphasized in the study make the case for increased education...not less.

One little correction is due here. The BSN has been around alot longer than 20 years. The two year degree for nursing started to become required for licensure in some states in the 1970s. That doesn't mean there were not college degrees for nurses. In fact, it was the nurses with BSNs, MSNs and Ph.Ds that were teaching many of the Paramedic classes during the 70s and 80s. Paramedics make a working diagnosis because of the lack of data for a differiential diagnosis. Some may have to give it their best quess at times in the field to make it work by their protocols. Some protocols are also written so the Paramedic follows them to the letter with little thought or room for much fault when it comes to clinical judgement. I believe there is another recent thread where CPAP was thought to be indicated by several but by the protocols of the OP provider, it was not and one probably didn't dare to deviate from the protocols. Some also get so set on making a "diagnosis" in the field, they will "make the symptoms" fit what they believe, thus they may limit or overlook some very valuable assessment information. This is why other professionals also make a working diagnosis but leave enough room or keep an open mind to take another pathway as the assessment plays out. Nurses make a nursing diagnosis and it is adjusted to the situation they are working in be it an ICU, Flight team, Code team, Rapid Response Team or med-surg. The difference for RNs is they do have access to more protocols with guidelines that can give them more treatment pathways. A Paramedic will often have to "choose" a diagnosis from a very limited list in order to get a protocol initiated. The differential process comes when it is a toss up between two diagnoses that have similar symptoms. It would take considerable testing before the actual diagnosis is made and there there could still be other possibilites.

Are you thinking about Atrovent? Still, one Atrovent tx will not thicken anything very much. It is when we are giving it q4 hours for several days that we start to worry. Albuterol (or some bronchodilator) is required for mucolytics such as Mycomyst. explenture Yes, more education is needed to where clinical judgement can be used instead of following the recipe book. I would not be too keen on lasix for this patient. Which is why a BNP is used in the hospital along with a CXR and other data from the physical assessment/history. Not everything is "textbook".

Look up the state of Oregon. See how many Paramedics they have. Contact their EMS office and see what studies were presented as pro-education. You can look at the studies done in other countries. It is not that difficult to ask their EMS offices with a formal request in writing. Do some legitimate research if it really bothers you that much. You can also look at the many other healthcare professions that have documented patient outcomes and patient benefits by their increased education. The goverment and insuring agencies actually keep the stats on improved patient outcomes by increased professional education for some professions after the potential for money saved in healthcare costs was mentioned.