VentMedic

There are many hospitals were doctors are not always the primary intubator. NPs, PAs, RRTs and RNs can also intubate in a hospital and on transport. And, a doctor specializing in onocology or urology may not tube again after residency.

How long are your hospitals leaving your field IVs in? Our hospital had allowed for 24 hours but now the IVs must be changed either in the ED or upon arrival to the floor or unit. So, no, we have had few if any incidences of infectiion with our IVs now. Due to the number of IVs we see daily, we are not going to assume we are perfect and must constantly monitor every procedure. We also started changing our field tubes in the ED or ICU and have seen a drop in VAP. That study should be published in the near future.

Try this link. Medicare is also keeping their tally very closely and should be publishing their data. http://www.ahrq.gov/

How many people were laughing at you when you were learning to intubate? Regardless of what their title is, any new skill needs some practice. What is unfortunate is some med students never get the opportunity to hold a laryngoscope or practice on an intubation head before going live. They are tossed in cold and expected to sink or swim. The same with new equipment. I don't always agree with this but there is a lot of ground to cover in 3 years of residency. Laughing at anyone in a teaching environment just shows your immaturity and insecurity about your own level of training. Doctors aren't always the ones that are expected to intubate. A Paramedic, however, is expected to be proficient at this skill. It is when those that don't take it seriously or don't get the opportunity to maintain their skills that it comes into question.

We don't have MICNs, PHRNs or ECRNs in Florida. However, that might change in the future. The changes could rewrite the statute that requires a Paramedic cert to do scene response and the RNs would not have to challenge the state exam just to have the letters behind their name. They could actually have a training program established such as those for MICN and PHRN. It depends on the size of your hospital as to what their duties will be in addition to the radio. They may also arrange for all of the CCTs to shuttle patients from one facility to another. Who better than someone who has ICU, ED, CCT and field knowledge to do this? Not seeing the partnerships that must be established with other healthcare professionals just further alienates EMS. In the CA hospitals I am familiar with, the MICNs will also do the transporting to the Cath Lab for the STEMIs that get "taken to the nearest facility". At least when the MICNs transport, there is not discussion about if they are allowed to give this med or work that piece of equipment. Even in Florida, the abilities of the Paramedics working the CCTs trucks vary from very limited to very broad and very good to very bad. More times than not in some areas an RN and/or RRT must be pulled from their duties at a packed facility to accompany the Paramedics. There is definitely a need for RNs trained at this level as hospitals consolidate their resources, sicker patients are being saved and technology advances as does the world of medicine. Some professions do grow. Unfortunately, California EMS hasn't be one of them and Florida with more than half of its Paramedic schools still being unaccredited medic mills hasn't gone very far either.

That is why I prefer to pull up the original article to see exactly what was said and not just one sentence that may be surrounded by other pertinent information. JEMS authors have a tendency to over simplify and insert their own opinions. Unfortunately some do take JEMS as "the absolute truth" and look no further. Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study. Original Articles more from the article Journal of Trauma-Injury Infection & Critical Care. 65(3):573-579, September 2008. Hildreth, Amy N. MD; Mejia, Vicente A. MD; Maxwell, Robert A. MD; Smith, Philip W. MD; Dart, Benjamin W. MD; Barker, Donald E. MD DISCUSSION Etomidate has been used for many years as an induction agent for RSI in trauma patients. Advantages of etomidate in this population include easy dosing and administration, minimal cardiovascular effects during induction and a short duration of sedation. There has also been a reported reduction in intracranial pressure which may have obvious advantages in head injury patients.31 Numerous studies have demonstrated that etomidate produces chemical evidence of adrenocortical suppression when given as a single dose.6–20,25–28,30 However, a difference in clinical outcomes related to chemical adrenocortical suppression has not been prospectively evaluated in the trauma patient population. However, the possibility that etomidate causes chemical adrenocortical suppression after a single dose raises concern for its safety in the trauma population who may have minimal physiologic reserve. This study prospectively evaluates the effect of etomidate on total serum cortisol and outcomes in trauma patients. Physiologic data and resuscitation values were recorded for the 24 hours immediately after dosing because previous studies have shown that the effects of etomidate as a single dose usually resolve within 12 to 24 hours after administration.7–10,12–20,22,32 Although patients in both E and FM Groups had equivalent baseline physiologic characteristics, after induction, the two groups developed noteworthy differences. Consistent with the findings of previous studies, the E Group patients had significantly lower postintubation and post-CST serum cortisol levels. E Group patients required more packed cells, FFP, and intravenous fluid than FM Group patients in the first 24 hours after RSI. Urine output was similar between groups indicating similar adequacy of resuscitation. We theorize that the E group patients received more blood products and intravenous fluids because of physiologic alterations. E group patients had significantly longer ICU and hospital lengths of stay and more ventilator days, although these patients had similar lung and brain injuries as analyzed by AIS. The only patients who required vasopressors, decompression for abdominal compartment syndrome, or expired were in the E Group. Together these findings suggest that the suppression of adrenocortical function caused by etomidate leads to subtle hemodynamic instability and greater resuscitation requirements, which ultimately may result in more ventilator days, increased hospital and ICU length of stay, and possibly mortality. In our study, we measured total serum cortisol concentrations. Critical illness has been shown to variably depress concentrations of circulating cortisol-binding proteins. Concurrently, marked elevations in free serum cortisol occur independent of total serum cortisol level.33–35 It is difficult, if not impossible, to analyze free serum cortisol status based on total serum cortisol levels. In fact, different values may be obtained with different total serum cortisol assays. In the present setting, it is likely that the E Group patients had lower free serum cortisol concentrations as well as lower total serum cortisol concentrations, as evidenced by outcome differences between the groups. We were not able to test directly whether depression of total serum cortisol concentration after etomidate also represented depression of free serum cortisol concentration, a measurement better representing adrenocortical function, because an assay of free serum cortisol with validated reference ranges in trauma is not yet available. Our study had other limitations. It was a small trial at a single institution. We were unable to blind the study because of constraints imposed by our facility’s Institutional Review Board. Therefore, this inability to blind the study may have led to bias. In addition, all patients were resuscitated at the discretion of each attending trauma surgeon. There were no standardized resuscitation guidelines, and we depended on the clinical judgment of the attending trauma surgeon to analyze adequacy of resuscitation. We did not designate a transfusion threshold hematocrit, and this could have led to bias concerning amount of packed red blood cells transfused. We had some difficulty with patient recruitment, in large part because of protocol violations that occurred as hospital and prehospital air medical personnel were becoming acquainted with the study protocol. In addition, the clinical data in this study were only accumulated over a 24-hour time period after RSI. Clinical data accrual over a longer time period may have led to a better understanding of the differences between the two groups in outcome variables. In conclusion, we assert that single-dose etomidate for RSI suppresses serum total cortisol in trauma patients. Our patient outcomes suggest that this suppression is indicative of decreased adrenocortical function in these patients. In light of the results of our study, we recommend that other drugs should be used as first-line agents for RSI in trauma patients. Any report suggesting suppression of adrenal function in critical illness should include data pertaining to the use of etomidate. Further study should be undertaken to evaluate the safety of etomidate use for RSI in trauma patients. ERdoc Look at the long list of references I posted from this trauma article. They appear to have the thought, "it this occurs in sepsis patients, what about trauma". It was the sepsis articles that changed our thinking somewhat where I work. I just happened on this article from "reading JEMS". But, if the article interest me, I pull up the orgiinal or the abstract if I am not on the University or hospital computer to see how they derived at their conclusions. The article is 7 pages but I will try to post more excerts that may be relevant.

They can Timmy. At least 90% or more of the time no extra orders or permission is needed. Having an RN with specialty training to take messages and provide some assistance if needed frees up the other RNs who have patients and the doctors who are over burdened. These MICNs also do CCT without Paramedics and can perform all the skills and interventions of a Paramedic as well as the advanced therapies/technologies of the ICU patients. And, it is rude to just rock up to the ED without some announcement for a patient that will need a bed and not just a chair in the front triage.

What or who do you propose as an alternative? Who is trying to eliminate them? Obviously not the FD since their EMS Education Manager employment notice was pretty specific in wanting an RN/MICN.

Hopefully that is the case. It is for a salary of only $71,208 for an RN. Although TX wages might be a lot less.

Mobile Intensive Care Nurse This is interesting from San Diego. I don't mean to sidetrack the thread but it appears there is some credibility to MICNs in California. The areas I am familiar with use them instead of Paramedics for CCT. http://apps.sandiego.gov/pjaol8/bulletins/3630.pdf It is a job announcement for EMERGENCY MEDICAL SERVICES MEDICAL EDUCATION MANAGER. The Position:The EMS Medical Education Manager reports directly to the Emergency Medical Services Battalion Chief. The position works with other managers and staff within the EMS Division, Training Division and San Diego Medical Services Enterprise partnership, a joint venture which provides medical transportation services to the City of San Diego. The position is responsible for managing and developing the content of pre-hospital continuing education. Duties comprise oversight of programs including field training, job-related orientations, paramedic internship and other specialized pre-hospital training programs. This position will also be responsible for the maintenance and administration of paper based records and electronic learning systems used to facilitate educational experiences. Qualifications: The ideal candidate will possess the following qualifications: • Demonstrated teaching experience in the pre-hospital setting; ************************* Any combination of education and experience that demonstrates these qualifications may be qualifying. A typical way to qualify would be possession of a Bachelor’s Degree in nursing (BSN), a minimum of five years experience as a Registered Nurse (RN) and five years of progressively responsible experience in pre-hospital education. Practical experience as a Mobile Intensive Care Nurse (MICN) is desirable.

This the outline of the study and how it was set up with inclusions and exclusions. http://www.clinicaltrials.gov/ct2/show/NCT...ate"&rank=6 The original article came with a long list of references cited. The article in JEMS by Dr. Wesley was a review of just one study. But, you would have read the original article for all of the references cited and the reasoning of the researcher for conducting the study. One must be aware that the opinions for just one article may not be a blanket statement for Etomindate applications or studies. REFERENCES 1. Bergen JM, Smith DC. A review of etomidate for rapid sequence intubation in the emergency department. J Emerg Med. 1997; 15:221–230. 2. de Jong FH, Mallios C, Jansen C, Scheck PA, Lamberts SW. Etomidate suppresses adrenocortical function by inhibition of 11 beta-hydroxylation. J Clin Endocrinol Metab. 1984;59:1143–1147. 3. Ledingham IM, Watt I. Influence of sedation on mortality in critically ill multiple trauma patients. Lancet. 1983;1:1270. 4. Watt I, Ledingham IM. Mortality amongst multiple trauma patients admitted to an intensive therapy unit. Anaesthesia. 1984;39:973–981. 5. Fellows IW, Bastow MD, Byrne AJ, Allison SP. Adrenocortical suppression in multiply injured patients: a complication of etomidate treatment. Br Med J (Clin Res Ed). 1983;287:1835–1837. 6. Wagner RL, White PF, Kan PB, Rosenthal MH, Feldman D. Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med. 1984;310:1415–1421. 7. Allolio B, Dorr H, Stuttmann R, Knorr D, Engelhardt D, Winkelmann W. Effect of a single bolus of etomidate upon eight major corticosteroid hormones and plasma ACTH. Clin Endocrinol (Oxf). 1985;22:281–286. 8. Allolio B, Stuttmann R, Leonhard U, Fischer H, Winkelmann W. Adrenocortical suppression by a single induction dose of etomidate. Klin Wochenschr. 1984;62:1014 –1017. 9. Wagner RL, White PF. Etomidate inhibits adrenocortical function in surgical patients. Anesthesiology. 1984;61:647– 651. 10. Fragen RJ, Shanks CA, Molteni A, Avram MJ. Effects of etomidate on hormonal responses to surgical stress. Anesthesiology. 1984; 61:652– 656. 11. Duthie DJ, Fraser R, Nimmo WS. Effect of induction of anaesthesia with etomidate on corticosteroid synthesis in man. Br J Anaesth. 1985;57:156 –159. 12. Fellows IW, Yeoman PM, Selby C, Byrne AJ. The effect of anaesthetic induction with etomidate on the endocrine response to surgical trauma. Eur J Anaesthesiol. 1985;2:285–290. 13. De Coster R, Helmers JH, Noorduin H. Effect of etomidate on cortisol biosynthesis: site of action after induction of anaesthesia. Acta Endocrinol (Copenh). 1985;110:526 –531. 14. Borner U, Gips H, Boldt J, Hoge R, von Bormann B, Hempelmann G. [Effect of an introductory dose of etomidate, methohexital and midazolam on adrenal cortex function before and after ACTHstimulation.] Dtsch Med Wochenschr. 1985;110:750 –752. 15. Fragen RJ, Weiss HW, Molteni A. The effect of propofol on adrenocortical steroidogenesis: a comparative study with etomidate and thiopental. Anesthesiology. 1987;66:839–842. 16. Mallios C, Scheck PA, de Jong FH, Lamberts SW. [Transient inhibition of adrenal cortex function following induction of anesthesia with etomidate.] Ned Tijdschr Geneeskd. 1987;131:918–920. 17. Diago MC, Amado JA, Otero M, Lopez-Cordovilla JJ. Anti-adrenal action of a subanaesthetic dose of etomidate. Anaesthesia. 1988; 43:644–645. 18. Sear JW, Edwards CR, Atherden SM. Dual effect of etomidate on mineralocorticoid biosynthesis. Acta Anaesthesiol Belg. 1988; 39:87–94. 19. Jameson P, Desborough JP, Bryant AE, Hall GM. The effect of cortisol suppression on interleukin-6 and white blood cell responses to surgery. Acta Anaesthesiol Scand. 1997;41:304 –308. 20. Zhang Y, Luo A, An G, Huang Y. [Effect of propofol and etomidate for anesthesia induction on plasma total cortisol concentration.] Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2000; 22:284 –286. 21. Montalban C, Del Moral I, Garcia-Unzueta MT, Villanueva MA, Amado JA. Perioperative response of leptin and the tumor necrosis factor alpha system in morbidly obese patients. Influence of cortisol inhibition by etomidate. Acta Anaesthesiol Scand. 2001;45:207–212. 22. Fillinger MP, Rassias AJ, Guyre PM, et al. Glucocorticoid effects on the inflammatory and clinical responses to cardiac surgery. J Cardiothorac Vasc Anesth. 2002;16:163–169. 23. Oglesby AJ. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department? Emerg Med J. 2004;21:655– 659. 24. Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med. 2001;8:1–7. 25. Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia. 1999; 54:861– 867. 26. Malerba G, Romano-Girard F, Cravoisy A, et al. Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Intensive Care Med. 2005;31:388 –392. 27. Mohammad Z, Afessa B, Finkielman JD. The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate. Crit Care. 2006;10:R105. 28. Cohan P, Wang C, McArthur DL, et al. Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med. 2005;33:2358 –2366. 29. Schulz-Stubner S. Sedation in traumatic brain injury: avoid etomidate. Crit Care Med. 2005;33:2723; author reply 2723. 30. Cotton BA, Guillamondegui OD, Carpenter RO, Morris JA, Patel SH, Fleming S. Etomidate use in the critically injured patient is associated with an increased risk of adrenal insufficiency. Crit Care Med. 2005;33:A46. 31. Cunitz G, Soerensen N. Control of intracranial pressure during pediatric neurosurgery anesthesia. Childs Brain. 1978;4:205–215. 32. Nicholson G, Bryant AE, Macdonald IA, Hall GM. Osteocalcin and the hormonal, inflammatory and metabolic response to major orthopaedic surgery. Anaesthesia. 2002;57:319 –325. 33. Ho JT, Al-Musalhi H, Chapman MJ, et al. Septic shock and sepsis: a comparison of total and free plasma cortisol levels. J Clin Endocrinol Metab. 2006;91:105–114. 34. Arafah BM. Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods. J Clin Endocrinol Metab. 2006;91:3725–3745. 35. Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004; 350:1629 –1638.

The research thread by fiznat gives me an opportunity to present this topic in hopefully a scientific perspective. The review on JEMS.com Etomidate and Adrenocortical Insufficiency in the Trauma Patient Keith Wesley, MD, FACEP Street Science 2009 Jan 5 Review of: Hildreth AN, Mejia VA, Maxwell RA, et al: "Adrenal suppression following a single dose of etomidate for rapid sequence induction: A prospective randomized study." Journal of Trauma. 65(3):573–579, 2008. The Science The administration of etomidate has been linked to subsequent adrenocortical insufficiency in non-trauma patients but has not been well studied in the trauma population. These researches enrolled 30 multiple-trauma patients and randomized them to either receive etomidate (18 E patients) and succinylcholine, or a combination of fentanyl and midazolam (12 FM patients) with succinylcholine for RSI. They then measured their serum cortisol levels four to six hours afterward and performed a cortisol stimulation test by administering ACTH. The patients reportedly had similar degrees of trauma and were aggressively resuscitated. They followed their clinical course and found the following. The serum cortisol levels of the 18 E patients was significantly lower than the FM patients and failed to respond to ACTH as well as the FM patients. This would consistent with suppression of the adrenal cortex. Clinically, the patients in the E group required longer ICU stays (6.3 days versus 1.5 days, p < 0.05), more ventilator days (28 versus 17, p < 0.01), and longer hospital stays (11.6 days versus 6.4, p < 0.01) compared to the FM group. The authors conclude that the use of etomidate for RSI in trauma patients let to chemical evidence of adrenocortical insufficiency and may have contributed to the clinical findings listed above. In the text of the article, the authors make this statement: "In light of our study, we recommend that other drugs should be used as first-line agents for RSI in trauma patients." The Street Just when you thought you had a handle on the RSI issue, someone comes along and throws another wrench in the works. The concern for adrenal insufficiency is why we abandoned high-dose steroids for suspected spinal injuries. Although I don't contest the cortisol levels the authors obtained in this study, I do question their conclusions. First, the treating physicians were not blinded to which patients were in which group. They knew who was adrenosuppressed. Did this affect their treatment? The E group received significantly more intravenous fluids, blood and blood products. The authors state the patients had similar brain and lung injury severity scores, but we should take notice that the overall injury severity scores were higher (26 versus 19). Although not statistically significant, this may be due to the relatively low overall sample size of only 30 patients and the fact that 60% of the patients were in the E group. The authors attempt to theorize that the adrenocortical insufficiency may have somehow altered the physiology of the E group in some way as to require their need for a greater need for volume replacement, but they do not provide us any supporting evidence for this theory. I would feel more confident if I knew more about the specific injuries of both groups. The injury severity score is simply not specific enough for such a small study group to make such generalizations. Although this article sparks my interest, I'm not prepared to eliminate etomidate from my protocols just yet. More study is warranted, and I would ask future authors to be prepared to provide more details about the patient injuries so that we can attempt to determine what if any impact adrenocortical insufficiency, as it relates to etomidate administration, plays in the trauma victim. ******************************************************************************** Abstract of the orginal article: Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study. Original Articles Journal of Trauma-Injury Infection & Critical Care. 65(3):573-579, September 2008. Hildreth, Amy N. MD; Mejia, Vicente A. MD; Maxwell, Robert A. MD; Smith, Philip W. MD; Dart, Benjamin W. MD; Barker, Donald E. MD Abstract: Background: The administration of etomidate for rapid sequence induction (RSI) has been linked to subsequent adrenocortical insufficiency in nontrauma patients. However, etomidate-related adrenocortical insufficiency has not been well studied in the trauma population. Purpose: We performed a prospective, randomized, controlled study to assess the effect of one dose of etomidate for RSI on adrenal function and its clinical significance during and after resuscitation in trauma patients. Methods: Adult trauma patients admitted to our Level I trauma center requiring RSI were randomized to receive etomidate 0.3 mg/kg and succinylcholine 1 mg/kg (E group) or fentanyl 100 [mu]g, midazolam 5 mg, and succinylcholine 1 mg/kg (FM group) for induction. A baseline serum cortisol level was drawn before RSI. Four to six hours after RSI, a postintubation serum cortisol level was drawn. An ACTH stimulation test was performed. Results: Thirty patients were enrolled: 18 E group patients and 12 FM group patients. No statistical difference was detected between the two groups with respect to age, injury severity score, and baseline serum cortisol. Mean serum cortisol levels were significantly lower in E group patients than in FM group patients 4 to 6 hours after intubation (18.2 vs. 27.8 [mu]g/dL, p < 0.05). Change in serum cortisol between baseline and postintubation levels was different (-12.8 [mu]g/dL +/- 9.6 [mu]g/dL vs. 1.1 [mu]g/dL +/- 7.6 [mu]g/dL, p < 0.01). Patients in the E group had an average increase in cortisol after ACTH administration of 4.2 [mu]g/dL +/- 4.9 [mu]g/dL vs. 11.2 [mu]g/dL +/- 6.1 [mu]g/dL in the FM group, p < 0.001. Patients in the E group required longer ICU lengths of stay (mean, 6.3 days vs. 1.5 days, p < 0.05), more ventilator days (mean, 28 days vs. 17 days, p < 0.01), and longer hospital lengths of stay (mean, 11.6 days vs. 6.4 days, p < 0.01). Conclusions: The use of etomidate for RSI in trauma patients led to chemical evidence of adrenocortical insufficiency and may have contributed to increased hospital and ICU lengths of stay and increased ventilator days. Further studies should be considered to evaluate the safety profile of this drug in trauma patients.

Where's the actual study link? I want to see how, who, what, when, why and not a warm and fuzzy press release. I also get suspicious of studies that are probably financed by some drug or equipment manufacturer. That is why I want to read their methology and sampling profile to test validity for myself. Part of the fun is seeing if you can duplicate the results. From the article:

Good JEMS version of the research but where is the original that explains the methodology and statistical analysis as to how the numbers were derived.

http://www.researchagenda.org/Agenda/Index.htm Advice: Learn how to read medical literature and understand statistical data from a scientific approach. Understand how researchers and critics of medical literature test validity. Many articles are summited to professional journals but very few get published because of flaws in their data collection, methodologies, presentation or computations. Read medical journals. If you read JEMS, look at the reference section following the article for the medical journal links and read those. If there are no references within or at the end of an article that quotes data, I rarely put much credit to what is written. www.naemsp.org has the Prehospital Emergency Care Journal. If you don't have full access through your school or employer, the abstracts will still give you a lot of the information. http://www.informaworld.com/smpp/title~con...8281~link=cover There is also a list of presentations in current and ongoing research that will be presented at the NAEMSP conference. This can give one some ideas. http://www.naemsp.org/documents/2009Accept...tsFinalFile.pdf

Another article of interest from Texas on this subject: http://www.ems1.com/ems-products/medical-p...hurdle-in-Texas Blood draws for evidence hit new hurdle in Texas By Tony Plohetski Austin American-Statesman AUSTIN, Texas — Leaders of the city's two major hospital networks and Travis County Jail officials have told Austin police that they no longer wish to collect blood evidence of suspects in criminal investigations. Officials for the county's central jail booking facility, where such samples have traditionally been taken, informed police last year that they no longer wanted nurses involved in the practice. Jail nurses stopped taking the samples, which are mostly used in drunken driving cases, on Jan. 1. Hospital representatives have since asked Austin police not to bring suspects to emergency rooms for blood draws, a procedure that has grown in popularity among law enforcement agencies and prompted controversy locally. Jail and hospital officials cite a variety of reasons for their decisions. A Seton Family of Hospitals official said workers are worried about lawsuits, among other concerns. However, an expert in such blood draws for drunken driving cases said state laws are clear that nurses and hospitals are protected from such suits. Dr. Steve Berkowitz, chief medical director for St. David's HealthCare, said, "We don't really feel that the emergency room is really the most appropriate place to be doing those types of procedures, because they really aren't being seen for a medical reason." Berkowitz said hospital officials still support police efforts to curb drunken driving. Staff with the Travis County sheriff's office, which runs the jail, have decided that nurses should spend their time tending to inmates, not collecting evidence. Police say they must now find a new way to get samples in cases in which they think the evidence is necessary. "We have a moral and legal obligation to obtain evidence of a crime, and our ability to do so is being hampered by the decisions of entities we have no control over," Police Chief Art Acevedo said. "It presents a tremendous challenge for us." The decisions come as the use of blood tests in drunken driving cases has grown among Austin police officers and others across the state. During the New Year's Eve and Halloween holidays, Austin police conducted so-called "no refusal" operations in which they obtained the blood of drunken driving suspects who refused to give a breath test. The department hired a phlebotomist for those operations but has still sought blood samples for suspects when the "no refusal" efforts were not in place. Police estimate they have averaged about 30 such blood draws per month in recent months. The effort to obtain blood evidence, which courts have upheld as a practice, has created controversy, with civil libertarians saying that blood draws are an unnecessary invasion. They say that officers should be able to build cases without such procedures. Among other major Texas cities that also have begun collecting such samples, most, including San Antonio and Houston, continue having jail nurses draw suspects' blood, said Clay Abbott, a DWI resource prosecutor for the Texas District and County Attorneys Association. Fort Worth police take suspects to a local hospital for the procedure, he said. Local paramedics collect blood samples in some small towns. State laws allow police to use search warrants to obtain suspects' blood, which Abbott said gives nurses and hospitals lawsuit protection because they are acting under court order. The law also permits police to draw the blood of suspects in drunken driving crashes involving serious injury or death without a search warrant. Abbott said nurses and medical facilities still have legal protection in those instances, as long as they are acting in the scope of their normal duties. According to the law, "The person who takes the blood specimen under this chapter, or the hospital where the blood specimen is taken, is not liable for damages arising from the request or order of the peace officer to take the blood specimen." Abbott and Jim Harrington, director of the Texas Civil Rights Project, said they are both unaware of any lawsuits in Texas against medical officials who have drawn blood of drunken driving suspects. Greg Hartman, senior vice president for Seton, said hospital officials want more time to understand legal issues and other matters before collecting such samples. For instance, he said, emergency room nurses do not perform medical procedures without a doctor's order. When drawing blood for a criminal case, doctors seldom evaluate suspects, creating concerns among the nurses, he said. Hartman said hospital officials also want to further discuss with police who will pay the salaries of nurses if they are called to testify in court for such cases. He said he is not aware of any nurses who have been summoned to court so far for such cases. And Hartman said the legality of nurses collecting blood evidence hasn't been tested in court and that officials are concerned about lawsuits against employees or hospitals. "This is a very complicated issue," Hartman said. "We aren't making decisions as to whether (law enforcement) should be doing this." Travis County sheriff's office Maj. Mark Sawa, whose agency was the first to prohibit nurses from drawing suspects' blood for evidence, said officials decided that they also did not want jail nurses called to testify in court cases and missing work. He said that providing inmate care is their "essential function" and that the department is seeking a national certification in which jail nurses are not involved in evidence gathering. Acevedo said police officials are now trying to find other options for collecting blood, including possible contracts with private clinics. He said it also is possible that the department might train a team of officers to collect blood. Acevedo said he has no estimates on the cost of a possible contract or training of officers. In the meantime, he said, officials will try to work out a temporary plan with either the jail or a hospital. "We are going to do what we need to do to secure the evidence we need while minimizing the cost to taxpayers," he said.

I think online education is great but NOT at the entry level. Nursing has realized this and the state boards are making more specific requirements for those that attend a program like Excelsior. Once one has their license as Paramedic or RN, I believe online education is an excellent way to get a higher degree. That is not to say some of the humanities or even a couple of the science classes can not be taken online for the degree.

Are you assuming it is a computer repair class because it may have used the word trouble shoot in the description? We are in the computer age and at some point in your career you may stop using the paper patient reports and go with a computer reporting system. Some of the medical classes might even require you to do online research. Some of the medical equipment you may use in the future will be running off various operating systems. Do you think making sure everyone is on the same page in their computer knowledge just might be handy? However, I will say that many healthcare degree programs are now requiring that you have prior working knowledge of a computer before starting their curriculum and are no longer including that extra 3 credit hour class in the degree. If you are computer illiterate, you may be required to take an intro to computer class prior to being accepted for that particular degree program. Congrats on your decision not to go to a medic mill!

Texas is the exception and it appears the state is just encouraging education regardless of what it is. Law enforcement also use this template for their entry level. I believe Oregon may have started out like that but now are requiring the degree to be in EMS. There are plenty of Associates degrees in EMS available to whoever wants one. Florida has a community college in every town there is a medic mill. Unfortunately, Florida is still stuck on a quick quantity attitude for putting as many Paramedics on an engine or ladder as possible. The way to make a change is for more people to get degrees. When the people with the "certs" start to become the minority, change will happen. It would be nice to be in a department were you can ALL look down your noses that the 3 month wonder who wants to run with the big dogs who have an education. Sounds rude but some peer pressure is needed to get things moving. Other healthcare professions much younger than EMS may have advanced more rapidly because there was always someone in the hospital to remind you how little education you have and it was usually in rounds for all to hear. That is a good incentive to keep learning. EMS has been kept too isolated from the world of medicine for too long. I also believe in a community college or university education to expose one to many other medical and nonmedical disciplines just for a better understanding of who is out there. Medic mills in the isolated back rooms of FDs and ambulance stations have to be eliminated.

Yes, so I don't see what the remarks about getting an EMS degree and having to take Mayan history or medival whatever have to do with each other. A Paramedic degree is usually listed as an Associate of Science and there is little time for many extra classes. Also, for humanities, you are usually allowed to select the classes that you feel might benefit you. So, if you did take Mayan history, that was because YOU SELECTED IT. You could have taken another writing class, a foreign lauguage. another psych or sciology class. Humanities are YOUR choice from a long list. I tell some to take a class about their own state government so they can become more aware of how the legislative process funtions. Some may even take a class that interests them for a hobby as a stress relief. Again, the humanities selection is YOUR CHOICE. You got a degree in Geology so I don't see why you are even trying to use that as an example for an EMS degree. The extra knowledge in geology may be helpful but that is not the route most future Paramedics are going to take. You are comparing apples and rocks. Regardless of what your degree was in, you probably still had some control over the classes that satisfy the humanities requirement. Trying to use the argument of having to take classes that are of no relevance to EMS has been used before by people who don't understand college degrees or have not bothered to even look at the degrees. Thus, EMS has remained a "cert" because of these ignorant statements that mislead people into believing they would waste their time with a degree. Those with the "a cert is the same stuff without the BS classes" mentality need to be educated as to what an education actually is. Trying to discourage people with ridiculous examples of Mayan history or Medival lit is just that, ridiculous.

Here's the page with some of each state's requirements before they accept or don't accept Excelsior: http://www.istudysmart.com/content.asp?cid=70 I would say it is a decent program for an LVN/LPN who is disciplined enough for home study. Paramedics that have never worked in a hospital before will miss out on a lot of little details that few nurses will have patience to precept them on basic nursing care if they try to seek employment later. It would be like having an Paramedic who never learned to take a BP or start an IV. Thus, the hospital system I work for does not hire online grads for the ED or the units. That is even after they have worked in another state for two years since work environments can vary greatly and some will try to take the easy way out.

Here are a few of the states that don't like Excelsior which is the one of the only accredited NLN online programs. Alabama State Board presently evaluates Excelsior College graduates on an individual basis. Georgia State Board presently accepts Excelsior College graduates through reciprocity but will not allow them to sit for boards. Illinois State Board does not recognize Excelsior College degrees. Louisiana, Washington, and Florida State Boards accept all who were LPN's. California also had strict requirements for their grads. Once could end up doing up to 1000 hours of clinicals after the program or working for 2 years in another state before applying for a nursing license in their state. Check with you state nursing board first AND make sure they do not have any pending legislation that will pass before you finish the program. There is a stricter update for GA which I believe they may not accept the online program at all. Careful with some of what you read on Flightweb. Some that rave about the Excelsior program are still sitting in the Flight Medic seat making medic pay. They may be an RN by letters behind the name only. Nursing is the only degreed and Licensed profession to still have an online program for entry level but that could be quickly changing.

All they did was modify the orginal law already in effect for many years. They did not exclude EMT-Ps. EMT-I and EMT-Ps are the only EMS providers listed along with clinical technicians, nurses and doctors. All the bill does is state who CAN draw blood and a limited liability clause. If this hadn't been a news story with the word "EMT" in it, it probably wouldn't have been given another thought. In a previous post I linked both the original and the proposed revision. Yes it would be better if they just trained LEOs (and they do) since they require well over 100 sticks. Compared to the 5 which some Paramedic schools require, they would be the better trained professional to draw blood. And, if you do not receive the additional training for blood alcohol drawing, you won't be doing it anyway. Your company may not want you to do it. EMT-Is and EMT-Ps have just been added to the list of providers that can draw. It doesn't mean you will be drawing.

BATmobiles are great since they also are heavily involved in community education. Examples: http://www.nhtsa.dot.gov/people/outreach/s...TSD%20final.pdf http://www.albany.ga.us/apd2/apd_batmobile_facts.htm http://www.krdotv.com/Global/story.asp?S=8023367 Here's another article from Texas. http://www.dui.com/dui-library/texas/news/...xas-dwi-arrests Blood Tests Increasing During Texas DWI Arrests Posted Tuesday, January 06, 2009 Search warrants to take a blood sample used in fight against drunk driving in Texas. Law enforcement agencies are increasingly using a controversial tactic in their fight against drunk driving. Arresting officers are relying on search warrants to demand blood samples from motorists suspected of driving while intoxicated in Texas. The effort is in reaction to motorists who refuse to submit to a breath test to check blood alcohol content. Such refusal is permissible under state law, though it hinders prosecution of Texas DWI cases because of a lack of evidence. The Texas DWI law states that a blood draw is appropriate for testing motorists who have a prior DWI conviction who have caused an accident with injury. However, both county sheriff’s departments and municipal police departments have implemented ‘no refusal’ programs in their crackdown on drunk driving in Texas. Judges are available for the issuance of search warrants that forces motorists to comply with the request for a blood sample. Central Texas Police Chief Art Acevedo has used such a tactic to check for driving while intoxicated in Austin. In 2005, the Fort Worth suburb of Dalworthington Gardens was the first to train officers in blood draw procedures. Harris County has used evidentiary warrants about 300 times during the past 16 months. The American Civil Liberties Union has questioned the programs from a number of perspectives. Besides being an expansion of what the law outlines, the group has found that warrants are often rubber stamped without probable cause and they are a violation of privacy as protected by the constitution. The actual person and facility in which a blood draw can be taken is also clearly outlined by Texas law because it is considered evidence in a criminal case. In apparent contrast to the law, in some cases police officers are being trained to perform blood draws in jail facilities rather than using a phlebotomists or trained nurses in hospitals. Police say that the blood draw policy is part of an on-going campaign against Texas DWI, and that it is gaining acceptance from law enforcement agencies and prosecutors across the state.

I will be honest with you and say there is not much job security in the private ambulance services in Florida due to all the mergers and consolidations. Sunstar is a decent service but they hold their breath each time contract negotations come around. Lee County EMS (Fort Myers) is a good service and may still be a good option. But they are represented by Local 1826 of the Southwest Florida Professional Firefighters and Paramedics Collier EMS was also an option but that too is undergoing changes. Polk County EMS may also go Fire in the near future. Marion County already has gone to Fire. AMR covers much of South Florida. It may be difficult to avoid the unions even in a Right to Work state. http://www.iaeplocal621.com/ This union site has more info about nonfire EMS jobs. The unions are weighing in that they can protect the jobs from Fire. They haven't been of much help so far.