VentMedic

Even in the ICU, we listen to the patient. Especially, when they are at risk for complications from just being in bed. There are reasons TEDS and pneumatics are used for many patients. While some patients may be more sensitive than others to being sick, it is no reason to blow off what the patient is saying just because your SpO2 machine is giving you a great number or you believe the person to just be a whiny BS patient. Research is constantly disputed. More research is done to either duplicate previous efforts or to disprove. I can easily pull up 20 articles for each of Bledsoe's summations that are pro and 20 more that are con. When you read the literature, you must also know the setting (field, ED or ICU) the study is being done, along with all the interventions including medications and O2 delivery devices. You must also know age, health (especially recent surgeries), meds and compliance. Read the authors own admitted statements of the limitations. Find a couple of reviews for that article and read their opinions. I don't believe you will find any arguments that high concentrations of O2 is not harmful in the long term. Some of those studies were done from patients who were at facilities that could not do advanced interventions (even hospitals in the U.S.) just like EMS has limited abilities. My hospital sees patients that should have been transported to us a lot sooner. The effects of bad ventilation and oxygenation techniques along with poor pharmacological interventions make for an extremely challenging patient. But, you are dealing with minimally educated who can only minimally assess. You also have the minimally educated training the minimally educated in the schools. There is something to be said about taking a real college level A&P class from an instructor who not only has 6 years of college studying A&P but also educated to teach. There is new equipment out there that could eliminate some of these arguments. The OxyMask can replace the NC, Simple Mask and NRBM. It can go from 1 - 15+ L to catch all those inbetween numbers. However, more education would be needed for when to use 5 instead of 6 or 9 instead of 10L.

Can a stroke patient not have respiratory issues? ACS- I addressed that. It depends how the body responds, arrhythmias, existing conditions, other system involvement and the oxygen delivery ability within the body. Who is to say sepsis does not have a role in some of these events? Cardiac arrest? This is an interesting one. The studies done for NRP (infants) were conducted and/or collected in countries where O2 was not readily available. Thus, there are nutritional and environmental issues that must be also sorted out. The same for the studies done on baby animals. When a baby codes, there are also considerations as to why the baby coded, since that is not normal. Was the damage present from a disease process in utero? Many NICUs are now compromising, as is the one I work with, and doing 40% initially since we found we were going to 100%, and still are, for many cases. The adult studies without O2 are also being researched from other countries that don't have O2 available but again special considerations to the limitations of the studies must be made for living condtions, overall health of the population and environment. If O2, supplied by research teams, is used on any of these patients, will there already be damage from free radicals from other factors? What about their whole medical system and meds or lack of? Research is not always black and white with definitive anwers. We are constantly picking studies to do more studies to see if we can duplicate the results. How many examples and examples within examples do you want me to give you? Every disease processs in the body can bring about another response or complication. One could argue O2 is not required for trauma but then if pulmonary hypertension or an embolus is present, do you still make the same blanket statement? It would be wonderful if the only complications and diseases processes that a patient can have are just those covered in the EMT(P) book but it doesn't work that way. The human body is just too complex. All I did was point out many situations where high concentrations are still needed and all of them can occur in the situations Bledsoe mentioned. As I mentioned, O2 is just one intervention. If EMS can not do the other interventions in ACS, stroke or cardiac arrest, all you have is O2 and that may not be enough if the other factors and interventions can not be dealt with appropriately and in a timely manner. Until EMS is able to fully recognize what it should be doing, improving education and protocols, we may not see many changes. O2 protocols should NOT be changed until assessment skills, knowledge and interventions are adequate. If you do not know what you are assessing and have few or not interventions to maintain BP or an airway, consider those issues first. You also mentioned hypothermia protocols. Remember that has been around for a long time and this is not the first time it has been tried in EMS. Technology has just advanced to where it can be done more effectively in the field but that are a few issues with that also. Cult? Have you read all the literature out there to dispute all the claims made? O2 is not a cult thing. It is a costly service and is closely monitored in most hospitals. NHs do not like storing H tanks either. Even to qualify for home O2, the patient may have a PaO2 of 55 or less. That is very low for some patients. To qualify on other considerations is a battle with almost any insurance. Start a new thread and we'll discuss this. Different mechanisms and different issues. quote: VentMedic For the O2 studies, I said this was nothing new about high concentrations of O2 and being on the clock. We don't keep patients on an FiO2 of 1.0 because we are too lazy to turn the knobs. We know the hazards of high O2 therapy for extended periods of time. I am not disputing that.

Over 30 years ago when I first started in EMS, pericardiocentesis, central lines, chest tubes and intra cardiac epi were taught as part of the Paramedic curriculum and were in the protocols throughout the country. Research and urban growth has changed alot of protocols in many areas of medicine, not just EMS. Look at how many times ACLS and CPR have changed the guidelines. While I prefer ETI, I also understand the need for solid initial education, continued competency and alternative airway. I also know Paramedic schools are having a difficult time getting intubation time for their students in the hospital. Some schools just use the mannequin if the student can not get live intubations. I heard one school substitutes 5 successful mannequin intubations for 1 "live" intubation until they get the equivalent of 5 live intubations. Others may not practice again on a mannekin after school even if they are not getting may live intubations. I do 5 mannekin intubations each morning while I'm making my coffee in the office as a warm up for intubating during my shift. This is even with many years of experience and the chance to do a lot of intubations. I do get to see a lot of new equipment and one should be very familiar with it before using on a live patient Now, because I am a very good at one skill of intubation, it is the whole basis of my worth in either EMS or as an RRT. I can use a BVM or alternative airway device just as well. But, I also have the knowledge to know the functions and limitations for each device along with the ability to be flexible as the situation or patient anatomy dictates. Some fail when it comes to seeing the need for Plans B and C.

The minimum education requirements should be standard but different regions of the country may still require advanced techniques while other EMS agencies run into a hospital every couple of blocks. Some very rural EMS agencies still can do pericardiocentesis, central lines and chest tubes. They know these procedures may be necessary and do keep up their skills. The same goes for some HEMS, Flight and Specialty teams.

But unfortunately EMS is just looking at a very few broad statements from a few evidenced based articles and not seeing the whole picture. Oxygen is just one part of the equation. The other parts that are needed before the oxygen can be reduced must be in place. The majority of the other parts of the equation, EMS does not have to ability to detect or correct. First, broad general statements about not using O2 is what got people started with the other myth "Do not give more than 2 L NC to any COPD patient". Now for the literature: most of the articles are done with O2 exposure over 24 hours. This is nothing new as it is known a patient goes on the O2 clock with an FiO2 great > 0.5 or 0.6, depending on the facilities interpretation. Other research is also proving O2 is necessary even at an FiO2 of 1.0. Sepsis protocols generally run at an FiO2 of 1.0 until the lactate level starting a continuous trend down or is below 4 mmol/L. SpO2 is not the primary measurement nor is an ABG. SjvO2 and measured Venous SvO2 are monitored. Ventilator and pharmacological adjustment may be made to increase the BP MAP if the ventilator is still on an FiO2 of 1.0. PPHN of the neonate still requires an FiO2 of 1.0. Nitric Oxide and nebulized prostaglandins can help vasodilate to help wean the FiO2. The same goes for pulmonary hypertension in the adult that has intrapulmonary shunting, increased PVR and decreased P/F (PaO2/FiO2 ratio). Other research has shown it can be beneficial to use as close to an FiO2 of 1.0 on Decompression Sickness until the HBO treatment and is now included in the recommended guidelines. For ARDS, the A-a gradient for severity will not be known. EMS will not have access to the technology to get the patient's PaO2 to an acceptable range or reduce lung injury with an ICU ventilator. Oxygen and a BVM will have to suffice until in the hospital. Once the PVR starts increasing as a response to hypoxia the patient is going to be a challenge. When an ARDS protocol is running, pressors and buffering will need to be ready when the ventilator strategy is implemented. There are also many other V/Q mismatches that must be understood and treatment initiated. The patient with a failing heart and dropping cardiac output needs some serious pharmacologically and maybe PCI to get oxygenation back to an acceptable level. In the hospital, high concentrations of O2 are weaned as quickly as the other conditions are met to correct the problem(s). The last thing some patients need is further hypoxic insult from early removal without the pressors, ventilator or cath lab ready. However, if the patient has no signs or symptoms of respiratory distress or dropping cardiac output, minimal oxygen may be adequate. The other issue is EMS is not teaching the limitations of O2 delivery devices and how FiO2 is maintained. A NRBM is a low flow device by definition regardless of how EMS perceives it because "it uses a whole lot of oxygen". Only under ideal situations will it deliver anywhere close to an FiO2 of 0.8 - 0.9. If it is, the patient is probably resting quietly and is not experiencing must dyspnea. When a patient is hypoxic their inspiratory flow demand and over all MV will increase to where a flow limiting device such as a NRBM will be ineffective. The NRBM is not even the mask of choice anymore in some hospitals due to its limitations for flow and consistent FiO2 delivery of at least an FiO2 of 0.6 in respiratory distress. A NC at 4 L/M will deliver totally different FiO2 levels to almost every patient it is on depending on their inspiratory flow demand or rate (L/M) and VT and MV. It might only be delivering 24% to a pt with high inspiratory flow rate. So blanket statements and recipes are not appropriate. It would be better to educate about different disease processes and perfecting advanced assessment skills with appropriate interventions. And, learn how the O2 devices actually work so they can be used appropriately and effectively. Without a lot of aggressive meds and ventilation techniques as alternatives to higher FiO2s, what do you suggest for your patient that says they can' breathe? Your patient will know when their heart or lungs is failing before your technology. A pulmonary embolus is a great example which is difficult to detect and your SpO2 monitor might even say 100% but they will have an increased MV. Do you know how many times one of these patients have been diagnosed in the field as having anxiety or the misused term "hyperventilation" and their face stuck in a paper bag or on a NRBM with no or very low flow? This is a good statement.

This is why some in EMS have gotten to the point where ETI is in question. Too many agencies have failed to monitor their providers' competencies. If problems and deficiencies were recognized earlier and ongoing, this might not be an issue. For the agencies that have carefully monitored their employees, ETI is not an issue.

EMS2712 My comments were not directed at you. They are being brought in by EMS to be resuscitated. ED doctors know that Hospice patients have a lot of pain meds on board so they may need to get those off if they want to attempt to get the patient conscious and increase BP. Before the ED doctors can give anywhere close to what the patient was receiving for meds in hospice there will have to be some clarificaton of the patient's and family's wishes. There will also have to be serious discussion with their primary doctor. This could take awhile. In the meantime, attempts may be made to make the patient comfortable but it may mean putting them on a ventilator and pressors to which they may not come off alive. Thus, an ICU bed will be taken by a terminally ill patient indefinitely. Hospice patients are rarely happy campers in the ED or ICU and usually they are there because of their family members' issues...not theirs.

I am going to suggest you review Venturi, Bernoulli and work of breathing a little. These will give you an understanding of the relationship of flow and FiO2. If you decrease flow you can greatly increase work of breathing. If your neb is running at more flow than the patient has the ability to exhale agaiinst, you increase the work of breathing. Or, perhaps the neb inline with the extra flow is the only thing that is keeping them from crashing if you are more concerned about your tanks, which you should carry enough to run a CPAP machine at it fullest from the most distant point of your area. If you can't do something to all the way, don't bother doing it half-arsed. I also hope you only use the CPAP on spontaneously breathing patients. Here's the link to Respironics' learning center so you can review the WhisperFlow. It is free and the sign on easy. http://elearning.respironics.com/index_f.asp

Minimal level of comfort? No, hospice provides comfort to the fullest extent legally possible. This is about the patient. The family needs to respect their loved one's decision if they want hospice. As I have already stated, insurances do cover hospice. But, if your loved one wants an ocean view for their last days, that can be arranged at an extra charge. Comfort care measures can be done in a nursing home or sub-acute. Hospice nurses just have more expertise. Either way, the patient has to decide whether they want end of life comfort and the family must respect that. EMS will not be able to give the patient anywhere near the meds that hospice can. If the patient's code status is reversed, the patient arrives at the ED unconscious, the first thing the ED will do is give narcan to reverse every comfort med the patient has gotten. They will then minimally sedate if at all while re-establishing BP. That is what happens when a hospice patient is taken to the ED. Calling hospice first will prevent that from happening even if the patient is transported to the hospital. There are a few conditions that transport is allowed. Exactly. There is not reason to call EMS except in this situation was a public assist to get the person off the floor. The family was then probably wanting an assessment to see how much longer...not "are they okay" but more "is death coming soon?" The family should still call hospice even if they are going POV. Hospice may allow for some things to be treated like a fever or broken arm. But, if it is for resuscitation, no...why should hospice pay since that is not what they are about? Maybe Medicare or their other insurances will pick up that cost as they had been for Hospice. However, it will be very difficult to get accepted into a hospice program and no regular home health nurse is going to be responsible for that level of comfort. There is no need to bash hospice here. Hospice is a choice. I believe Hospice is an excellent way to provide comfort for your loved ones. But, again, it is not about you or even the families when it comes down to it. It is a personal decision for the patient and they should be able to exercise their right to decide how they will live their remaining days and die. Hospice is the patient's best advocate to see their wishes are carried out.

It is not going to give you the plague. I just don't see how some could not have gotten the basics of OSHA regulations either in school or from their employers.

Here is the history of hospice. http://www.nhpco.org/i4a/pages/index.cfm?pageid=3285 Hospice was around in the 80s. Hospice is still done in the home frequently especially if that is the patient's wish. However, some patients may not have the living situation that allows this. Some may prefer a facility which Medicare will pay to some extent but the better facilities will be out of pocket. We supplemented an additional $40K for one of my family members to be in a very nice facility with 24/7 nursing care for just a few days. From what others have told me that is a bargain. Hospice is covered by most insurances but they may not pay for all the luxuries of a resort style hospice. Extensive initial and continuing family education is why families don't call 911. But, occasionally emotions will cause a family member to crumble when death is near.

No problem. It is a confusing process. It is best when the patient can make the decisions. We have had patients who had been set on being a DNR/DNI until they couldn't breathe. They will then rescend their DNI to be intubated to get through a period of PNA or CHF. But, they may remain a DNR. Confusing? Yes. Luckily BIPAP(tradename) can be done instead for many situations but will only be done if it is agreed that the disease process is reversible. If the patient deteriorates when removed from BIPAP for basic care, the patient may have to go back on BIPAP and a family or ethics committee decision may have to be made to discontinue life support just as if it was a ventilator(which it is but not invasive). If it was not specified, in my area, about intubation (DNI), that may be the next step.

There are specific situations that can be outlined in any hospice contract. If the patient decides he wants to live, there is no longer a need for hospice care. If the patient is running a fever or breaks an arm, hospice can and will allow treatment for these things since they cause discomfort. The key is what causes the patient discomfort and hospice cannot alleviate. Thus, the patient calls hospice for advice. A hospice patient may also be transported to the hospital for PICC lines for better access to the comfort meds. Again, hospice will advise and provide the necessary care without being a dictator of care. However, they are also there to protect the patient's rights if he can no longer speak for himself. The family are also part of that decision. There are also various hospice organizations that specialize in AIDS patients. These patients still come and go from the hospital and may actually not even be a full DNR. They can get dialysis regularly and have infections treated. But, they also have access to a predetermined plan of care which ensures them comfort when it is needed. This is why it is wise to be aware of the many possible legal choices a patient can make.

That is an external PEEP valve which is found on even the more sophisticated transport ventilators like the LTV 1000. The newer models are now coming with internal PEEP. It can still provide adequate PEEP if the flow by the machine is adequate. Since ventilators are generally capable of providing more flow it is much more efficient and effective than most prehospital devices which use the same or similar valve . It is not as effective on a BVM since the flow available is just 15 l/m max but will still offer some PEEP. This can also be seen by some who crank down these valves on the BVM during a code or hemodynamically unstable patient to "get better oxygenation". They may also be cranking down their chances of ROSC due to decreasing venous return capability by increasing the intrathoracic pressure. ATV: Automatic Transport Ventilator See the Carevent as an example on spenac's links. http://www.emtcity.com/index.php?showtopic=14405

Look at this from the patient's point of view. He is not giving up his rights by entering Hospice. He is exercising his rights to die as he has chosen. He knew he was 86 y/o with cardiac failure, no quality of life and will die eventually. By having the decisions made earlier and putting his doctors and Hospice in control, it relieves the family's stress and prevents more suffering for him. Hospice is not taking his rights away but seeing his rights are followed through and ensuring his comfort in his home as he wanted it. If the patient is taken to the hospital, the family may have even less control and the patient will definitely lose his rights to make any further decisions since he can no longer vocalize or will be intubated on a ventilator. This is going against the decisions he had already made but may now have his rights to his decisions taken away by someone(s) who has issues with how he has chosen to die. The issue should be about the patient. It shouldn't be about what the EMS providers' own personal beliefs are. Choosing Hospice is not done on some whim like choosing an HMO or a new car. Before a patient enters hospice, there will be many participants in this decision making process to assist the patient and the family.

Now if you are talking about something like trying to provide PEEP with an ATV, then it would be a far stretch to consider that a "vent" capable of anything other than pushing air into the lungs like an automated BVM. Mechanical PEEP and CPAP have similiar valving and utilize the same principles. PEEP by ventilator can be by far more effective especially if the ventilator has a greater flow capability than most prehospital CPAP machines. PEEP is the bases for all lung injury and ARDS protocols. What do you think we used both in transport and in the hospital before the CPAP devices got very portable? We used ventilators. We still use ventiators to provide CPAP as well as BIPAP (tradename for Respironics). And, it is the same knob that provides PEEP.

We haven't done quarantine for MRSA in a long time. Even trach patients aren't isolated anymore. We will do selective isolation precautions depending on where the MRSA is located. If it is isolated to a wound, contact precautions will usually suffice. Many of the patients you come across will be colonized with MRSA or some bacteria. Since EMS transports these patients, it is difficult for even the NH to know of every bacteria or virus that the patient has and usually if general precautions are taken, it is not an issue. The exception would be airborne bacteria and viruses. Unfortunately, if the RN at the LTC or hospital doesn't spell it out clearly to the EMS providers, it may be assumed the patient is free of all harmful bacteria. Then, some get upset if they read the patient has been colonized with something or the decubitus ulcer has MRSA. Some will also shortcut their cleaning process if they believe the patients will come with big flags for infections. It would also be interesting to do nare swabs on EMS providers as is occasionally done on hospital employees.

No. I have a Living Will for myself which is very specific and expresses my wishes. I do not have DNR orders yet. A Living Will, as spenac is stating, provides for decisions of continuing care by specific means such as dialysis or feeding tube And, it addresses discontinuing care and can be very specific for when that determination is to be made. A DNR can then take in affect. If a patient was placed on life support and the family presents the patient's requests by Living Will the patient can then be made a DNR while on life support in the event the patient's BP drops or the heart stops. It can then be determined if the patient will be a withdrawal of life support for end of life or comfort care measures which could be the next step. Before insulting someone, you should also understand the many variations there are and how YOU will be challenged legally if you do not. Ignorance is not a good defense to claim in a court of law.

DNR stands for DO NOT RESUSCITATE. DNR orders can also have an accompanying DNI order but that may not mean you withhold oxygen. More than 10 L? Did they specify the device? For some devices, 10 L might only be 28% or even 24% Oxygen. And, some cheap prehospital CPAP devices can function at 10 L. That order would be vague and very open to medical/legal interpretation. Yes, a DNR order can get specific as to whether it is meds only with or without compressions when the patient goes into a life threatening condition where a code will be the very likely. But, again, it is meant for resuscitation. IF the condition can be treated and is seen as reversible, the DNR does not apply. Thus, it is not meant to be a DO NOT TREAT. We do set up high flow cannulas up to 40 L/m on even comfort care patients if that is part of their specific agreement especially on patients with some form of fibrosis. However, it is just part of comfort and no vitals, including SpO2 are monitored. It they still have a strong feeling of dyspnea, they will get IV meds and a morphine or fentanyl nebulizer. The point is, YOU should be familiar with the types of orders and documentation specific to your state and local area. YOU should understand the differences in the various orders and be careful when reading the orders. What YOU don't understand you should immediately contact the sources involved with the orders, hospice or the MD, and your med control. Do not assume.

Were you dispatched just as a lift assist? If so, who asked for further medical intervention? What were the famiy's expectation the care to be provided by you? If it was for a lift assist and the patient is in hospice, that should be honored. A DNR is applied when the patient codes. It doesn't mean "do not treat" prior to that. Hospice and Comfort care orders go beyond a DNR. Vitals are rarely if ever done on comfort care or hospice patients even in the hospital since many of their meds are maintenance and the others are titrated purely by comfort level...not BP or HR. Any form of treatment to prolong life has been discussed and decided against. We have had ambulances transporting to LTC facilities or home fail to understand these orders. Thus, they turn around and run L&S back to the hospital ED because they found the SpO2 to be 80% on 2 L NC and have placed the patient on a NRBM or will be bagging them. Orders usually consist of 2 - 4 L only with no SpO2 monitoring. The respiratory comfort is done by medications, not SpO2 checks since there is little way to adequately oxygenate the body with a failing heart without a lot of technology and drips. If they revoked his hospice status, he could become a full code which would mean intubation and what remains of his life will be full of technology,little privacy and pain since the comfort meds will take a back seat to stabilizing blood pressure. Once the initial resuscitation is done, the doctors and family will then have to go through the withdrawal of life support, probably for the second time, and attempt to make hospice arrangements again or just have the patient die on med-surg in a room with 1 to 3 other patients. If you are unsure what to do, contact hospice and your med control before aggressively resuscitating espeically if they have hospice papers or the equipment of hospice attached to the patient.

Yes, their food or nutrition was by peg, NG or IV from a closed bottle. If the patient must have food PO in a situation such as a long transport, that may be a necessity. Caregivers electively dining in the patient compartment is not.

I'm missing the point? Read the OSHA regulations. Violate any one of those and the penalty will happen. You can also look up the violations in you own state just as well as I can. I've presented a few examples. You can pull up each company and may find out the exact nature of the violations including the food found. It could even be something like a crew member's Chapstick left in the patient compartment. You can google for at least 50 more companies that have OSHA violations. Check your own state first. Call OSHA yourself and find out the FACTS. It really isn't that difficult.

They absolutely do address that. Why do you think food is an issue in the patient compartment? Why do you think no one working in a hospital can eat in the patient care area? It's not because the patients won't like the smell of the food. OSHA could find a dirty needle or a hamburger in the patient compartment. With either one or both, the violation and fine will be given. Honestly, has so few in EMS not taken an OSHA class to understand the hazards that can affect both the provider and the patient? I already know from other posts that there are a few who are clueless about MRSA, VRE, C-Diff and TB. Do the schools and the employers not cover anything about such a crucial subject? Why don't you just contact your state's OSHA department and ask them if you can dine in the patient compartment of an ambulance? I'm sure they would be happy to send you and your ambulance service the information. They might even make a personal visit.

Have you even been present for an inspection by various agencies? If not, your company will be wise to educate you on the Federal and State regulations. This is all spelled out very clearly in any state statute for certification of an ambulance. Also, many states now do publish the list of ambulance violations on their websites just as when an EMT(P) has a violation of some type. This information is also made available to any facility when contract negotiations are being considered. Here are a few citations which the food products can also come under the blood borne pathogen safety violation. You can also find out more information by taking one of mandatory OSHA courses offered for other healthcare professionals. The issue is food in a patient compartment exposes the employee to infectious contaminants as well as the patient. http://osha.gov/pls/oshaweb/owadisp.show_d...&p_id=10725 http://enviro.blr.com/news.aspx?id=15040 http://www.apsta.org/laws-fines.html http://www.isips.org/reports/Articles/MIC0106p14.pdf

No but here it is again. Other professions as a whole do not blame their problems on the patients. They also do not as openly judge those who can not care for themselves.