VentMedic

The first lawsuit came when we were being shot at during the riots and the boatlifts in the early 1980s and another one later in the 80s/early 90s. Some of us felt strongly about carrying weapons as I always had a gun while in my POV to and from work. The ambulance companies and a few FDs did provide the employees with secure lockers to store weapons while on duty. During these bad times, the Guard and PD stuck by us even though our trucks took a few bullets. In a way I was glad I didn't have a gun because in the confusion, I don't know who I might have shot. The good guys and the bad guys were all starting to look alike and everyone on the street was carrying some type of weapon. We had enough to do with the medical aspect of the job treating patients who were victims of the violence and getting out of the riot zone to safety.

For patients with known respiratory problems, we treat the lungs and monitor the HR as we are sorting out the other signs or symptoms. If you don't fix the respiratory stuff, the heart will continue to work harder. Albuterol and Atrovent would both have been indicated with a previous history of COPD. I also would not have worried about that "hypoxic drive" thing and give the patient some O2. What was the BP? What the patient also on a diuretic? What was his BGL? Steroids recently? Were the crackles localized to one lobe or multiple? What type of inhaler? Long Acting, Short Acting, Steriod, Mast cell inhibitor? How many puffs? Definitely want to know how many puffs if it was a LABA. PNA vs CHF with exacerbation of COPD. Rarely are these patients just one simple disease process to treat. Did they do a BNP at the hospital? Lactate level? Don't get too excited about the calm respiratory effort. With some older COPD patients it is the calm before the storm as their CO2 is rising from impending failure...not the O2 being given.

That lawsuit thing against employers didn't fly in Florida by the EMT(P)s and it probably hasn't held water in Texas either since there is a long list of no carry zones. This is from the Texas statutes for Concealed Weapons.

Here are a couple of states that have addressed this: Oregon http://www.oregon.gov/DHS/ph/ems/docs/2009...onsLetter4a.pdf MN http://www.emsrb.state.mn.us/docs/May_2003-31.pdf So before one tells someone else it is their right to bear arms, one should know that state's laws and how they pertain to EMS or the employer of the person you are advising. Unlawful carry can also be a career ender and I doubt seriously if anyone on this anonymous forum who told you otherwise will pay your court expenses. My advice to the OP is to ask your EMS office, your employer and the state office that administers Concealed Weapons permits. Don't just take advice off the internet from people who have strong feelings about certain issues regardless of whether they are right or wrong.

Hospitals are not the only no carry zones. For many states, including Florida, if you have a concealed weapons permit and it is of nonprofessional status, there is a long list of public places that a weapon can not be carried. If your company is aware of you carrying, they will be held liable for your actions while you are wearing their uniform. If you are carrying it for personal reasons and have not made your company aware, the company and union may leave you hanging to pay your own legal expenses if something goes wrong or you are caught carrying the weapon in a no carry zone. This has already be tried in Miami back when the violence in the streets may have justified a gun. You get caught with a gun while in uniform, either Fire or EMS, you lose your weapon and face the penalities for carryng in a no carry zone as well as whatever state laws you have broken for the concealed weapons permit. Also, if you fail to secure your weapon properly when not carrying, you may be held severely responsible for the consequences. Put serious thought into it before you carry a gun. Just because you think you can doesn't mean you should. Good video which has been playing alot on TV: If I Only Had A Gun http://abcnews.go.com/Video/playerIndex?id=7310933

akroeze, I believe the key word here is hospital. IFT transports should be held to a level of higher expectation. No hospital should ever allow their equipment to be loaned out to anyone if they do not have some idea about that person's knowledge of that equipment and even then it is a huge liability. Anytime hospital equipment that is providing some form of life support either meds or ventilation, a member of the hospital staff should accompany. Too often some do not know what they don't know and assume an IV pump is just a couple of buttons. Thus, when they can not get the pump restarted during transport, they end up diverting to another facility because the med is not running or their "eyeball" technique ran too much med and dire consequences have occurred. Receiving hospitals do take note of these muck ups and eventually file a complaint against the sending facility if it happens too often. Those with the higher licenses should have known better. Also, if this occurs during an ED transfer, the sending hospital may have to answer to EMTALA regulations as to why they allowed a poorly prepared team without proper equipment transfer a patient. That is a huge offense and again those with the higher licenses should have known better since obviously by some of the comments here, some Paramedics don't.

If you look at CCTs, Flight and Specialty transport teams in Canada and other countries where education is higher, you will find they are Paramedic/Paramedic teams. Here in the U.S., the team often includes an RN or will be RN/RN or RN/RRT especially if there are "expanded" protocols. The RN is also usually the higher ranking team member if the partner is a Paramedic and that is often due to the vast differences in education as well as the ability to do advanced protocols especially where medications are concerned. The U.S. Paramedic has not really given education a chance to see what the possibilites could be. Other healthcare professions have and are making great strides in advancing their scope as well as the level and quality of patient care.

He was a physician who lives in Florida and is now a consultant. I also believe his experience comes from being an EMT(P) more than being a medical director. So, for some being an EMT-P is so easy.... Sometimes those in the profession are our own worst enemies. Minimum hours for the Florida Paramedic is 700 and has its own state exam which many other professionals can challenge. But, Florida did enforce the rule for no sleep overs on ALS engines for clinicals. I do consider that a major step forward. Actually, some of us enjoyed a more expanded scope of practice, especially in Florida, in the earlier years than we do now. I'm not just talking about all the "skills" we used to do either. There was a time when physicians were enthusiatic to support EMS. But, somewhere down the road we changed their minds. Failure to monitor the profession amongst ourselves and lax oversight have eroded the "skills" we do have and are putting them into question. Would Medic One in Seattle be able to be innovative in their skills/protocols and research if they had to rely only on 600 hours of training? Others such as Ada County (croaker260) have managed to maintain advanced skills/protocols because they have demonstrated a need and have put forth the effort. Dust has probably seen this article many times since it is still mentioned occasionally 10 years later by certain unions and EMT(P)s who feel education is an invasion of their rights. This, of course, pertains to the U.S.

Again, have you contacted Oregon or any of the countries that have higher education levels to see where they have gotten their data before you say there are no studies? Just because you can not find it on a GOOGLE search doesn't mean it doesn't exist. Lobbyists usually have their ducks in a row when they petition a state for increased standards. The reasons for not increasing education standards usually have little to do with patient care.

That is because higher education at a degree level is not a requirement for Paramedics in 49 of the 50 states. The stats may not give a true reflection for level of care if only one or two Paramedics in each agency have a degree in EMS or some health science. Some states only require a minimun of 500 hours of training. Some of the states have limited protocols either at the state level or the reluctance of Medical Directors to allow more responsibilty may also be a reflection of inadequate education standards. California can be used as an example for that. You might try researching the Oregon website since they do require a degree for their Paramedics. Also some agencies such as Seattle's Medic One that have a more extensive education program could be of some assistance for your research. Canada and other countries are also a good source for research since they have required much higher education levels for their Paramedics. This also makes their Paramedic better candidates for their Critical, Flight and Specialty transport programs which also has more extensive training then the 3 hour backroom CCT program at many ambulance services or an 80 hour overview of CCT that is so popular in the U.S. and often taken as the end all to Critical Care education for some. Other healthcare professions have kept stats on higher education and do use them as bargaining factors when petitioning for more reimbursement and privileges. However, if you are against higher EMS education, you might email the author of this: 2,000 Hours to train a Paramedic? http://www.fd-doc.com/2000Hours.htm http://www.fd-doc.com/

Believe it or not this scenario has been played out several times since HIV/AIDS has become known. The adult patient will initially not tell their parents or even the family physician of their diagnosis. Thus, the parents are then in the dark for some medical decisions. It doesn't even have to be HIV/AIDS. Adults may not tell their parents everything they have been doing in their life. As well, adults are known to have more than one doctor who don't always know about each other. We recently had a patient visiting from another state who did experience a seizure and was brought to our ED. The S.O. and parents of the patient stated the patient had just been diagnosed with HIV but later the patient admitted to having HIV for 10+ years and was now presenting with the signs and symptoms of AIDS. Adult patients should make their own decisions unless there is paperwork to state otherwise. I would have let med control handle this one.

AnthonyM83, I would blame that one on the spell check. Sometimes it thinks it knows what you mean but gives you similar but wrong choices.

I have grown up with Fire based EMS and have seen the very best and the very worst. However, when it concerns education and cheating, I lose all respect for the associations whatever they may be when they try to defend or excuse the behavior in this article. It puts the profession in a bad light and creates a serious public safety issue. Shame on the union for promoting such behavior by protecting those who abuse a public trust. A new test with both practicals and oral testing should be administered to all of those involved. Grand Jury Investigates Cleveland Paramedic Cheating Posted: Wednesday, April 15, 2009 http://www.emsresponder.com/article/articl...p;siteSection=1 Mark Puente, Plain Dealer Reporter Plain Dealer (Cleveland) Twenty-seven Cleveland firefighter/paramedics were called to testify before a Cuyahoga County grand jury Monday about cheating on a life-saving skills exam. City officials believe a firefighter smuggled a copy of the Paramedic Functioning Test from the Fire Training Academy in October 2007. The grand jury proceedings are meant to identify who took it. Cleveland police began investigating possible cheating on the exam in July after Emergency Medical Services officials received a computer disc that included a copy of the test. The disc indicated when and where the test was copied and could help police confirm who made the copy. The city-administered test, which paramedics and other EMS workers are required to pass every three years, emphasizes the most current medical protocols and procedures and goes above what is required for a state certification. Firefighters who fail the test can't do paramedic duties but don't lose their jobs. Chester Ashton, head of the fire union, said it's a waste of money to pay overtime for 27 firefighters to stand in a hallway waiting to be called. He believes the proceedings are motivated by politics at City Hall. "This is a witch hunt," Ashton said. "I don't see any need for this." The firefighters milled around and talked about taking the Fifth Amendment if called to testify. Ashton said the firefighters appeared before the grand jury but exercised their Fifth Amendment right not to answer some questions on the advice of union lawyers. More firefighters could be called to testify next week. County Prosecutor Bill Mason and city Safety Director Martin Flask declined to comment on the investigation. Grand jury hearings are secret. Cleveland officials created the test with help from the city's Physicians Advisory Board and the Public Safety Department's medical director.

Let me give some examples of how pH can affect the PaO2 and SpO2. You can also work the numbers for yourself on an interactive oxyhemoglobin dissociation curve website. http://www.health.adelaide.edu.au/paed-ana...gen/oxygen.html I will also be using SaO2 and not SpO2 for the examples. Using SpO2 may still not be an adequate reflection of PaO2. Quoted textbook values for SaO2 and PaO2 are usually at a pH of 7.4. SaO2 97% PaO2 at a pH of: 7.4 is 92 mmHg 7.3 is 101 mmHg 7.5 is 84 mmHg SaO2 91% PaO2 at a pH of: 7.4 is 60 mmHg 7.3 is 64 mmHg 7.5 is 51 mmHg A person with an acidosis may have a higher PaO2 for the same saturation but O2 delivery at the tissue level may be an issue. A person can have an alkalotic pH such as what you might get with some that hyperventilate but will lower their PaO2. A person can also increase their MV by breathing faster to raise their PaO2 but not enough to dramatically shift the curve. Deadspace ventilation can play a role in this. Here is a good site to explain tachypnea and deadspace ventilation. http://www.ccmtutorials.com/rs/mv/strategy/page16.htm I am willing to bet Dustdevil and Tniugs remember when we used to add deadspace to the older ventilator circuits to change ABG values before the newer technology appeared. Also as Tnuigs mentioned, the A-a gradient will also determine how sick a patient is. If the patient is on an FiO2 of 1.0 and has a PaO2 of 65, even with a decent SpO2 or SaO2, I would say that person has a problem. Here's another link about acid/base and ABG interpretation. http://www.rcsw.org/Download/2006_RCSW_con...%20Analysis.ppt

If you are going by SpO2 you can be fooled. Look at my comment concerning this in my previous post or review the factors that influence SpO2. You might also review the oxyhemoglobin dissociation curve. This is exactly why a true diagnosis of hyperventilation is not possible. Tachypnea can be caused by rising PaCO2 as in impending respiratory failure. Too many confuse all tachypnea as "hyperventilating". I have no problem with the statement about not telling a patient to slow down. I stated: in response to your statement:

Michigan is a little different than other states for their expiration date. http://www.legislature.mi.gov/(S(es0cwl45t...e=mcl-333-20954

No. If a person has a Pulmonary Emboli, they will be tachcypneic with a measured low PaCO2 and not have an abundance of O2. You also do not know their carrying capacity for O2 such as Hb, CO exposure and MetHb from some nitrates. No, not necesssarily. You do not kow the PaCO2/PetCO2 gradient. There are several causes for a low ETCO2. Air entrainment by tachypnea will dilute the ETCO2 measurement. Deadspace ventilation, low tidal volume ventilation, hypovolemia, hypothermia, lung parenchymal destruction and low cardiac output will give a low ETCO2. Of course you can always have the issue with poor equipment maintance and failure to calibrate. This is often the mistake some who don't understand V/Q mismatching will make on CCT when they try to "normalize" the PaCO2 of a ventilator patient by just looking at the ETCO2. Thus, the rec'g hospital ends up with a very acidotic patient. A DKA and some sepsis (or whatever metabolic acidosis) patients can get their PaCO2 into the single digits and still be very acidotic. This I definitely agree with. I will do a thorough assessment for organic problems of the patient before I write them off as anxiety and it is doubtful if I will even assume it then until all lab data is in. We have had many young people with new onset diabetes and their body will not let them slow down. One should consider an organic cause quickly during the initial examine and move on with further assessment to find the organic cause.

Whose responsibility is it to "get the patient to refuse"? Who should explain why going to the hospital is important...or not? EMT(P)s who just crawled out of bed and have a bad attitude due to it being 0300 and they already had made up their mind it was a BS call before entering the facility? The RN (and doctor) who may have known the patient for several months or even years? What influence will the EMT(P)s attitude have on the decision if the patient senses they are a "bother" to the ambulance crew? The patient may even feel they have no choice but to say no if they feel they are a bother just by the actions of the EMT(P)s. Of course, if the patient doesn't refuse, the trip to the ED can be very unpleasant for a frightened elderly person with two pissed off EMT(P)s in the ambulance talking crap about the nursing home, nurses and the doctor all the way to the hospital. Or, the patient gets stone cold silence and treated as an object and not a patient. Many of us have seen examples of that come into an ED whether it is from a nursing home or any call that the EMT(P)s feel is not worthy of their service.

You set if up for a bash and thrash of nursing homes, nurses and old people. By not other complaints, was the patient tracking his/her own lab levels? While some patients may feel ill when their labs are out of whack, those with chronic illnesses may not immediately notice a difference. Some may have a K+ of 8 or higher and not notice a thing until the heart notices it. I would take the patient to the hospital for the labs. Their next dose of meds may be dependent on those results. Interrupting the cycle or having/creating a toxic level may not be in the best interest of the patient. There may be a bigger picture here that you are not seeing. Unfortunately, illnesses don't function 9-5 so sometimes a 0300 call is necessary. The RN has to explain his/her actions as every transport from a facility requires documentation that must be signed by the physicians and the adminstrators. They are working on a budget and must answer to the payors and accrediting agencies. Again if you feel it is fraud or abuse, document and write a report to the appropriate authorities. Don't just turf it to the ED nurse to do your work. Just because someone isn't coding or bleeding doesn't mean their continued care is not important. Maintaining fragile patients for the long term is a delicate balance. Yes, what a shame sometimes things get over looked but healthcare providers are human. If EMS was absolutely perfect, let them throw stones. But we know that not to be true for some ambulance services and providers. Again, if you understand everything about healthcare and all the business aspects at several levels, excellent. You should then know how to make a point through the proper channels. When EMS providers put M.D. behind their name they can then over rule the other M.D. issuing the orders. If you want to converse with the physician, great. Just remember there will be those taking notes for the next contract negotiations if your area has competitive services.

An EMT-B with 110 hours of training is going to judge licensed healthcare professionals, including doctors, about their competence? How about the administrators or the attorneys? How much education did that 110 hours provide for the legal contracts made between Federal, State and private insurances as well as those between the ambulance and 911 services? Few are even aware such agreements exist or believe they are the first to notice "routine" calls for things they may not know the reason to because they don't qualify as an "emergency". Yet, they may be the only option available. Some insurances won't pay unless it is this criteria. Some won't pay for that. Unless you are well versed in all the legalities and have read all the P&Ps for the nursing homes as well as the contracts made between your service and the LTC facilties, you may be just talking BS and showinng your own ignorance. My remarks are not necessarily directed at HERBIE1.

Here's a news flash for you: Other health care professionals don't get paid to sleep. You are actually very lucky that hospitals are understanding or just take it as "normal" for some in EMS to piss and moan every time they have to touch a patient. Maybe those professionals in the ED should complain more about some of the sloppiness of those in EMS so more can get weeded out and it might actually become a profession. Take a look at yourself from the other side and see what those in the nursing homes and hospitals have to put up when dealing with some of the bad attitudes of EMT(P)s with before you start casting stones to cause someone to lose their job. To want someone to lose their job because you were awakened while on duty or had your internet game interrupted is a harsh statement when you may not know all the facts from an incident that happened two years ago. You may also not have enough education as it pertains to various contracts between LTC facilities and ambulances services, including those that do 911, to even make that call. Get over the BS mentality and do patient care. It is a shame when those in EMS perceive they patients as just BS. It doesn't matter if you are just referring to the "call", there is still a patient involved. They are the ones who are caught up in a crappy healthcare system. If you are not in it for the patients, find yourself another job that doesn't deal with humans or animals.

Since this is a somebody told a friend of a friend of mine thing, pertinent facts could be missing. It could also be a crew from an ambulance, that may also do 911 calls as well as routine, that is pissed for being awakened from their paid to sleep time. They then only heard part of the reason why this "old person" needed labs and just thought they would bitch alittle to their friend at the ED who may or may not have anything to do with the patient. This happens occasionally in my ED but what the EMT(P)s don't always realize is they are seriously discredited because the NH RNs or doctor has already called a report with an assessment of things the EMT(P)s should have picked up on if they had only done a BP or checked a heart rate. If this is actually an abuse of the system, just doing a little verbal bitchin' isn't going to cut it. You will have to document everything and get it to the proper authorities. You must also be able to back up with proof that the NH is committing fraud or abuse. If the oversight agency calls the hospital and the "old person" was placed on life support as you were leaving, you may look like you just have a grudge or is uneducated about the many disease processes that require labs. You may also be in some trouble with your ambulance service which has (had) a contract with that NH if you can not back up your words. Many talk a big talk but some don't take the time to look past their attitude or hate for NHs, its staff, particularly nurses, and "old people". Some also exaggerate their stories to get attention when they are awakened from their sleep or need an excuse for not doing an assessment when they have already diagnosed it as a BS call long before they get to the nursing home and actually see the patient. It is your responsibilty to make the complaint to the appropriate agency. The nurses are not going to do your job for you. If they believe it is abuse, they may do their own reporting. However, just like the many threads on this forum, some are reluctant to second guess another provider's assessment since they were not there to see what the other person saw when they call for an ambulance. Many here don't want to criticize another EMT(P) for possibly being wrong either and especially in writing to an agency that will check up not only on the NH but also the person making the complaint. So, if you do file, make sure your own patient care report is perfect and without fault. You can also address your concerns to your medical director who may have a chat with the medical director or owner of the NH. Just remember, your medical director may have to also scrutinize your documentation of the call to be politically correct especially if there is a contract involved. If you really think you have a legitimate complaint against a nursing home, quit griping and find out how you can improve the system. Just make sure you are speaking out for the right reasons and not your dislike for routine "BS" nursing home calls, missing sleep or old people. I know there are those that abuse the system but some in EMS spend more time complaining than they do taking action or even finding out what can be done to make improvements.

Hyperventilation is by definition a decrease in the PaCO2. With normal lung function, an increase in MV should increase PAO2 and PaO2. The oxygenation level should rise to whatever the barometric pressure (Pb) allows for. Note I used PaO2 since other factors will affect the SpO2 and it may not give an accurate indication of oxgenation and definitely not where the brain is concerned. Only an SjvO2 will determine that. You can have an SpO2 of 100% and the brain can be starving for O2 due to inefficient uptake or inadequate perfusing pressures. Manually/mechanically hyperventilating (taking PaCO2 level lower) can also cause more problems if the PaCO2 level is lower too much or the pH is raised too high. Take home message: You will have to go beyond your EMT book to adequately understand "hyperventilation".

UMC is a Level 1 trauma center, Pedi trauma center, Level 3 NICU and a high risk OB facility. Not having the proper staff available inhouse is a violation of their accreditation for whatever specialty.

Because they are teaching questions to pass an exam. EMT-Bs or even some Paramedics rarely have enough A&P to even understand the definition of hyperventilation. Acid-base and lab value interpretation are not taught to any great depth even in Paramedic school. Misuse of the word will also lead some to make a very incorrect working diagnosis. While psychogenic hyperventilation can be seen occasionally, tachypnea can be described in many ways for many reasons. the quality of the tidal volume and other findings in an assessment must be made. The quality of the VT must be considered or "hypoventilation" will be missed regardless of the respiratory rate. Psychogenic hyperventilation should not even be considered until other causes are explored closely. There is also limited determination of hyperventilation in the field unless you have the ability to do an arterial blood gas. An ETCO2 might help but again you may not know the gradient for the PaCO2 - PetCO2. If the person states they "hyperventilate" frequently, they may need more indepth evaluation than what even an ED doctor can provide since chronic HVS can indicate very serious problems which even if psychological, they must be addressed or the chemical changes in the body will start to create other problems which are organic. Other examples: A baby or child will breathe rapidly as they are nearing failure. A chronic lung or asthma patient may also increase their RR when their CO2 is rising and will appear very anxious but are not "hyperventilating". A chronic lung patient can also hyperventilate but their PaCO2 level could still be well above the text book norm and yet have their pH increased dramatically. Patients with pulmonary emboli or PNA (especiallly PCP) will breathe rapidly and may reduce their PaCO2 dramatically. With their increase in MV, they may also be able to maintain a decent SpO2. But, without the increased MV, they would present with hypoxia. People with increased temperature will breathe rapidly. Sepsis and metabolic acidosis will the pH and the body will try to compensate by increased RR. Learning a term such as hyperventilation with such a vague or broad definition without knowing much about the A&P or even the mechanisms that are associated with head injury, dka, metabolic acidosis or other factors that affect acid-base or the body's receptors to compensate is useless when there are other things that should be taught to have a foundation for proper assessment. And, when the instructor may not have enough A&P background to effectively teach these concepts or doesn't have the foresight to review what he/she will be teaching before class, the students only come from these classes with answers memorized or more questions. So, "A" would be my best guess for this poorly worded question as it is also the answer if taken as stated to be the most dangerous for making a working diagnosis without considering ALL the organic possibilities.