VentMedic

Another "we are a young profession" excuse. That still does not excuse individual behavior or a lack of supervisory oversight in their company. EMS is more like middle-aged with 40+ years. Several other healthcare professions have reached maturity in less then 20 years. Several licensed healthcare professions can say that. What about the partner? Do they approve or just wish to avoid a confrontation or be known as a tattler? Do those supervising the few that do this spiteful things just look the other way and establish it as "accepted"? Do the medical directors not hear about these things from their communications with the ED physicians?

It is a little manual that is now passed out in some CCEMTP classes for RN and EMT-Ps who have little knowledge of ventilators and is horrifying to read for anyone that has an education in the principles of ventilators. We usually send one of our own hospital staff if we know that is all the training the have when transport of an ICU ventilator patient is required. Idiots don't need to be touching ventilators or anything else that resembles critical care. These patients get a trach so that Speech Therapy can start working with them to regain some function for swallowing and speech. NTI will only prolong and enhance the problem since the tube still goes through the cords. Are they going to be on a ventilator? Alert and conscious may not be the best to start their ventilator stay. How do you know you'll have any success blindly do NTI? FiberOptic scope and oral is a more direct route. The patient may also have sinus problems if their face has been damaged. I'm not picking on you but just pointing out somethings that you should be researching and thinking about before doing NTI on some patients. If you are not working in the ICU you may not be aware of the long term potential problems. I'm just telling you have we treat various situations to get the patient back to some type of normal life with the least complications. You also don't seem to think there are many hospitals that have advanced enough to have the appropriate equipment to intubate in ways that may be best for the patient. I hope you don't think this is all science fiction. If you don't like the links, too bad. If you have reached the Paramedic level, even at Florida's standards, you should be able to do some reading on your own especially since I did give you a start by posting the links. I shouldn't have to copy and paste every article or spoon feed you. The discussion moved away from EMS slightly and yes, for the areas we are discussing credentials are important.

When the patient is on anticoagulants or their platelets are low, which these are concerns of many patients with chronic illnesses, it will be difficult to prevent bleeding. Quite often, the patient with the field tube will have the nare packed for a couple of days after the tube is removed. No one disputes the use of NTI in prehospital care unless the Paramedic is doing it out of laziness.

For prehospital intubation, yes. However curse still didn't see issues for long term nasal intubation or infection in the ICUs. As far comfort, since Spock also mentioned the OR tubes, the surgeons will often suture these to the nare. Very little compares to watching someone levitate off the bed when the vent circuit or NT is bumped.

If you work in a hospital then the information about VAP and the CDC's stance on NTI should have already been covered somewhere unless you hospital is one of those I may have insulted in an earlier post which would be why you are continuing with further insults. You haven't read the articles in the link I posted? There were 12 pages of links pertaining to VAP and sinusitis. Sinusitis and VAP wsa the title of the search that brought up all of those links. I think this statement sums up why you are having a difficult time understanding these concepts. There is much more than that little guide which even the nurses laugh at when they see it. Yes, there is a big world outside of my hospital and even EMS. That is why we link to other facilities with our research data. I also spend part of my time on another coast in another hospital system that is involved in research. This is besides the numerous seminars and conferences that I attend and may even lecture at occasionally. I never said you were in EMS. You stated something about an ICU and hospital but yet are unaware of the common causes of problems associated with ventilators and tubes so it is hard to tell what training you actually have. The data is for you. You seem to have a difficult time with the Yahoo search for good literature. Yes, I do have lots of first hand experience with ventilator patients who have tubes of all types. I have often pointed out on the forums that there are over 300 different airways to choose from. Then you may not understand the various treatments that must be made available for sinusitis when systemic antibiotics are creating more problems than they are solving. I also see you have missed the point about dialysis and antibiotics. I don't know what you are or what position you have, but your posts have not been the most convincing that you have adequate ICU experience to be judging such issues as VAP, ventilators or even NIT in the critical care setting.

You have made very broad statements and assumptions about hospital practice. Where and how have you studied ventilators in the ICU? Or worked extensively in ICU which if you have and do you would not be questionly VAP issues and ventilators. This is one subject I rarely joke about since it is my specialty and I have seen the consequences of what happens when people don't understand ventilators, tubes or meds such as paralytics. I could take time to give you individual links or spoon feed you as I do for some in EMS but you stated you know how to search. I did post Google Scholar link which if you look at all the many pages of studies listed they pertain also to nasal intubation and are current. If you look at the CDC updated guidelines you will also find a list of references they use. Also, the infection control office at a hospital that you may be working at or transport you to can give you their policies and references. If you really insist on a bunch of individual links I can post and I many anyway later as those that know me here usually expect to see my latest data. Over 10 years ago, we may have seen 10% or 10 out of 100 ventilator patients in the adult world with NTI. Now, it will only be seen from the OR for specific surgeries that will not be intubated for more than 48 hours. It was banished in peds and neo before the adults. Yes I still see short term NTI either from the OR or a field intubation. I still know how to do NTI but prefer not to if at all possible. I also see those that get shipped to my hospital for specialty ventilation and reconstructive surgery as the result of NTI or mucked up ventilator management. I also see those that require nasal antibiotics long term and those that need dialysis from long term IV antibiotic use.

Wow! You have managed to try to make this a pissing match. I presented a fact about how we now ventilate patients differently and you found cause to be sarcastic. Have you studied the various methods of ventilation in the ICUs extensively? Do you know how ventilation and oxygenation practices have evolved? This is not about getting "gold stars" but improving the ways of medicine for advancement. Long term paralytics are not longer used extensively in the critical care units. I really don't see a need for sarcasism if you disagree. However, I would like to know why you disagree about the long term use of paralytics and prolonged vent days. NTI was promoted by some because it was easier and more convenient for the provider regardless of the patients' opinions. After all, we tell people it is for their own good when we are inflicting pain. I don't have to rely just on articles since I have has first hand experience with NTI and the patients. The articles you pulled up are from European sources and pertain to specific situations in the OR which I have already said the RAE tubes are used for NTI when the vent days will be limited. It is difficult to compare a few cases requiring such intensive knowledge of intubation in special precedures with what is done everyday in critical care units. Yes, case studies are abundant and it is important to understand these as well. However, I am talking in broad accepted practices and not the rare ones which can be successfully implimented in common practice in the many ICUs across the country. I also see you have wasted alot of time finiding articles about the rare situations instead of looking at what is accepted practice in the United States. I think you could have an easier time researching the correlation between sinusitis and lung infection. But, let me help you out: (multiple pages) http://scholar.google.com/scholar?q=VAP+si...p;hl=en&lr= Here is a good link to help with your search if you don't have access to a good medical search engine. http://scholar.google.com Again, I am not talking about "sticking holes in necks" (your words) as done emergently in the field. Please try to see the difference between this emergency procedure and a tracheotomy or tracheotomy that is done in the hospital to facilitate weaning and give them back their voice. Also, do not confuse the "holes" with the stoma made for laryngectomy patients. Those are very different as is their purpose.

Have you even been nasally intubated? You will not find much current information about NTI since it is no longer accepted in the hospitals except under rare circumstances. The way we venitilate patients have also changed. We no longer paralyze and sedate for 7 days and then trach. We try to get patients off the vents in as few days as possible. To say NTI is more comfortable is in the same ball park as saying babies don't feel pain which was the reason for doing surgery without sedation for many years. I think medicine has advanced enough to move on from some of the old "traditions" and ways of thinking. A trach done in the hospital in not like the ones done in the field. I am talking about critical care medicine. You need to see a broader view. My stance on NTI is because I have done this for a long time and have participated in the research that has gone into making the guidelines. I do stay current with the medical literature because that is an expectation of my employers. I do understand the many reasons why it is avoided if at all possible in the hospital. I don't need passion one way or another when I have current medical science and examples of patients before me. It could be said you have an adversion to trachs when they have been around for centuries.

You are very misinformed about the hospital advantages of nasal intubation. Do you not understand the complications of nasal intubation especially if the tube is left in for extended periods of time? It is definitely not more comfortable and will increase ventilator days with the increased work of breathing that causes failure to wean by the smaller tube and resistance through the nares. More sedation may be required to relax the patient to allow the ventilator to do the majority of work. That is not a good thing. As I stated, I have not seen NTI done except in very special surgical cases and even those may get a trach to avoid prolonged nasal intubation. It is not a difficult decision to do what will benefit the patient in the healing process without additional risks the nasal intubation will cause especially with infections and prolonged antibiotic use. This is a recommendation with guidelines issued by the CDC when the VAP campaign started over a decade ago. This is also one thing that Medicare will look at and will not reimburse the hospital for. Hospitals should not have to resort to nasal intubation with the other technology they have. Granted, there are some very bad hospitals out there that should be scrutinized closer when they can not provide decent care to their patients. Even the worst rinky dink hospitals should know about the various infection control protocols in place throughout this country for the year 2009.

Nasal intubation has been frowned upon in hospitals for well over 10 years since the CDC posted their position on hospital acquired infections and complications by this route. The only time it is acceptable at many hospitals is for special facial surgeries where a RAE tube might be used. Any field nasal tube will usually be changed in the ED or ICU at most hospitals. I honestly can not remember resorting to a nasal intubation in or out of hospital in 15 years at least. But, I also have RSI capabilities.

This is a statewide effort that affects healthcare and many other industries. You will also have to sign this statement and pass a nicotine test at many of the hospitals. They are no longer tolerant of smokers. If you smoke, don't bother applying at many of the facilities, FDs or EMS agencies. Current employees are encouraged to go through smoking cessation programs.

The Fire Departments and the Sheriff's office run the 911 calls. Broward County http://sheriff.org/about_bso/dfres/ Hollywood http://www.hollywoodfl.org/Fire_rescue/history.htm Pembroke Pines http://www.ppines.com/fire/index.html and several more FDs. Barry University is an excellent school for nursing and produces some quality graduates. It is expensive but many hospitals are willing to reimburse the expenses for one of their graduates. Besides Broward Hospital District, there is Jackson Memorial Hospital - base for University of Miami Med school and Ryder Trauma Center. http://www.jhsmiami.org/ Cleveland Clinic - Weston - They recently has a job posted for ER tech. http://my.clevelandclinic.org/ccforms/flor...ortunities.aspx If you are planning on nursing school, don't limit yourself to just being an EMT(P). Think outside of the box and sell your skills/knowledge while playing up to who ever you are talking to. If it is a nurse manager, toss in the nursing school thing. Pick up a quick CNA and Phleb cert which can land you many different jobs and not just the stereotyped ones that are talked negatively about on the forums.

How often is LAPD doing this again? You would think that by now they would have elaborate protocols in place after the worldwide publicity this hold brought them. Besides the thorough phyical assessment already mentioned, I would consider transporting the person if the length of unconsciousness was 20 seconds or more regardless of the physical findings. Check out the pediatric subacutes and pedi nursing homes or the designated "peds wing" in your county LTC facility. You will find the results of kids "choking" themselves or each other. The lucky ones can get up and shake it off but there are some that don't.

Many companies do address this in their policies. Often it is up to a certain monetary limit when it is from a patient. A gift does not just have to be from a patient to fall into this category. I'm sure many here have accepted free meals at various restaurants. This is usually acceptable except if there is a polictical or business connection. It could also come into question if the restaurant owner had been a patient of yours and several meals have been consumed at that restaurant. Another area of concern is when vendors or competitors offer gifts. A vendor bringing pizza while giving an inservice may be acceptable. A vendor sending you gifts to sway your decision on a product may not. I believe AMR, as well as hospital based companies, has a corporate compliance program that specifically outlines what is acceptable or not.

You're right... That is a little long for only 110 hours of training.

Several reasons for the way things are done: 1. Who's budget? RT? Nursing? Or a separate ICU, ED, CCU, SICU, TICU etc? 2. Consistency of equipment... You might recall some of the problems hospitals have with adapting different defibrillator equipment if each department does its own thing. 3. Some ICU monitors may not be set up to give all the graphics required or have too much already connected and the ETCO2 display becomes a little number down in a lower corner. 4. Versatility for downloading and integrating with various research programs. 5. Some ventilators can have an ETCO2 package as an extra but costly accessory. 6. Biomed contracts. 7. Type of uses for the monitor. 8. Some ventilator patients may be in an area that does not have an ICU monitor or one that is compatible with that equipment. 9. Portability to be used on patients that are not on ventilators. 10. Vendors the hospital has contracts with which determines what equipment is easily approved for purchase. 11. May want a multifunction machine that also includes respiratory profile monitor. (You may be familiar with these if the Philips' reps have tried to up grade your equipment.) Sidenote: Philips acquired or "inhaled" Respironics a couple of years ago. 12. Level of expertise and knowledge of the doctors, RRTs and RNs. Like some Paramedics, they may just want to look at a pretty wave to see if the patient is intubated but don't understand much about the wave or the correlation of the numbers to different clinical conditions. Or, they may be serious clinicians that want to explore all options when it comes to patient care if it can be of some benefit.

ETCO2 detection has been pretty much the standard for Emergency Response teams and ICUs during intubation for many years. This question has been asked many times in the RT and/or ICU worlds and is incorporated into their national guidelines. Very few hospitals totally lack the ability to detect ETCO2. A quick check can be done with a calorimetric device or handheld capnometer immediately after intubation. However, not all will continuously monitor the patient and will rely on other diagnostics for disease determine determination. Since ventilators are now more complex and offer much more ventilation data than in years past, ABGs are not even used that often. For the time a patient spends in the ED and the fact that the indepth diagnostics may start with the intensivitsts in the ICU with the ED physicians stabilizing the patient, a fancy ETCO2 monitor is not always required in the ED. CXRs will be done immmediately and the tube will be secured in place. ICU ETCO2 machines can cost from $10K to $20K. When you have 20 - 150 ICU beds, that is a huge chunk of money that must fit into the budget. It must be weighed with hypothermia equipment or other types of monitoring devices. Often these devices are not necessary since the ventilators also give a graph as well as many measurements with sensitive alarms for everything. Even the ventilators used in the ED such as the LTVs can sound at alarm if the parameters are set appropriately and they can come with a monitor for graphing each breath.

2015 http://www.aanp.org/NR/rdonlyres/59523729-...PCurriculum.pdf Everything you want to know about NPs: http://www.aanp.org The other professions are also advancing or have advanced their entry. PAs are gaining momentum with the Masters. (NP and PA associations have teamed for some impressive ideas.) PT is also at the Doctorate. OT, SLP, RD and a few others are no less than a Bachelors with Masters for some at entry or preferred. RT has a Bill for expanded reimbursible services with Medicare for those with a Bachelors or higher. And that leaves EMS.........

Masters for NP is now pretty much the standard. There have been PhD (Doctor of Philosophy) programs for RNs for several decades as have the DSN or DNS (Doctor of Nursing Science). The PhD is more beneficial for teaching and some research. The Doctorate of Nursing Practice (DNP) has been around for about 15 years. Yes, NPs are looking toward that to advance their professions. The entry level MSN program I am talking about is for those who already have a Bachelors in another profession. If you ever have the desire to teach for a nursing program, you would need no less than a Masters. Unfortunately EMS still allows those without even an Associates to teach which is why there are few educated mentors in the programs for the students to have as role models. This is not an attack on your education. You did use the word "I" several times during your original post. It is also refreshing to read about a Paramedic who is enthusiatic about education.

Darn, we actually have a certificate program 8 months long? Yes, a few of the community colleges that haven't gone "academy" do have programs that are 2 - 3 semesters long. Since Florida only requires 700 hours for the Paramedic, many medic mills are less than 6 months. They had been much shorter but the State cracked down on clinicals done on ALS engines as "sleepovers" for 24 hours. If a 2 year degree was required for the Paramedic, the time you are in school getting your degree would be more than enough working experience. There is little an EMT will learn in Florida except the bad habits of their partner and how to drive for the Fire Medic. Few will take advantage of learning histories and medical conditions of their routine transfers or will not have the education to know what they should look for. At least if they are still in school learning A&P, that knowledge will enable them to seek out more information. You are taking the long way around in education. With an A.S. and the A.A. classes you can get your BSN. With just a few extra core classes in your second major, you get another Bachelors. Or, if you have your sciences with the Public Safety degree you can get an entry level nursing MSN degree. Right now I can not remember which of the west coast schools offer it. If you are talking about Edison, every health care degree EXCEPT EMS has most of the prerequisites I mentioned.

You are taking or took your Paramedic at a State college (4 year) in Florida? In Florida, there is not a degree requirement nor do many of the schools even require science classes in addition to the core. Unfortunately, the community colleges have arranged their curriculum to be "medic mill like" to stay competitive and have dropped the college level sciences form the cert program. That is a very sad, sad situation for EMS in Florida.

The advantage to having classes such as Pharmacology, Chemistry, A&P, Microbiology and Pathophysiology as pre or co-requisites to an EMT or Paramedic class is that looking up a term is just a refresher. There is a clearer understanding to the whole picture than trying to figure out how one word at a time fits in when learning applications for a health care profession. Medic mills often rely on snowballing since there are few or no prerequisites to program. Unfortunately, few even bother to look up the terms and just move on by memorizing a word instead of learning what it means. But, whatever works to get (or got) you through Paramedic school....

Pasco County is not South Florida. We have our own issues in South Florida without adding THAT other coast to the mix.

At least the article didn't mention a person could get the same training in less than 3 weeks instead of 4 months.

At least the bracelets would signal you to look at the chart. We have tried little stars on the charts and the patient boards to signal DNR orders but still code someone that shouldn't have been especially in the SNF part where the RN has 32 patients on his/her wing. But, even on the other hospital floors this is an issue. Computers do help if the docs update the record. We even tried the wrist bands but we have a different band for everything from allergies to fall precautions which usually gets noticed after the patient falls. Consistency of some type would be nice. Guess what I'm getting you for Christmas? A pretty bracelet.