VentMedic

Again: Per the link I posted earlier from HB 509: (5) a licensed or certified emergency medical technician-intermediate or emergency medical technician-paramedic. Drawing blood for DWI suspects will not be the responsibility of just those in EMS. EMS providers are just a few of the medical professionals that can draw blood as specified by the bill. This might even include Paramedics working in an ED or outpatient clinic that LEOs use. The bill only outlines who can and where for the blood to be drawn. A more detailed P&P is available as to how. EMS will not be burdened by all the calls for drunk drivers. It is highly unlikely that PD will be calling for an ambulance just to draw blood since their agency or the DA may be responsible for the payment. This may be only if you are called to the scene for the MVC and there are not other patients with injuries that need your care more. This may also prevent the suspected DWI person from being taken to a crowded ED and taking time away from other patients. Some in EMS have always wanted more responsibility to expand. Here it is as a little service to the community and PD. Do it well.

It wouldn't take much for (CLIA) Clinical Laboratory Improvement Amendments to get involved in this. CLIA is one of the reasons why lab specimens are not being drawn in the field by Paramedics in many areas now. The training for handling the specimens was not adequate. Many specimens brought in from the field were hemolyzed, improperly labeled and not handled correctly. There is sometimes also the attitude: "well I got blood anyway...give us credit for that". Those that draw 30 specimens a shift will have some idea immediately if the sample is going to be good. CLIA could also have a problem with the word "sanitary" being stricken from the document. A good lawyer could use the argument that due care was not exercised by the Paramedics when starting that line to get the fluids running. They may not have waited for the prep from the LEOs kit. Thus, the specimen gets thrown out of court. Yes, there are LEOs that certify to draw blood and many of them actually get more practice in doing it correctly than Paramedics since documentation of their clinical sticks can be proudly presented in court as can their regular recertification. Their training programs for blood draws do meet CLIA standards. There are areas where some Paramedics may not do that many sticks especially where everybody is a Paramedic or the call volume doesn't warrant it.

By that comment it is easy to see you have not even looked at what classes make up a degree for EMS . http://www.mdc.edu/medical/AHT/EMS/ems_curriculum.asp English Composition I Psychology of Personal Effectiveness Fundamentals of Speech Communication Critical Thinking/Ethics In this prgram, these are the only 4 classes that aren't found in a "cert" program. Do you not believe it is important to know how to read, write, think and speak effectively as part of being a Paramedic? Even a class like medival literature would be entremely beneficial due to the reading comprehension as well as critical thinking that goes with the detailed analyzation of many literary works. If one had actually taken a literature class, they would have known this and not be critical of why it is a great class to build a solid foundation for being more literate. To downplay any education that makes one think, speak and write more clearly just keeps one at the grunt and groan level when talking to patients and other medical professionals. Patient care reports will also continue to be poorly written. Here is a Bachelor's program: UMBC http://ehs.umbc.edu/ParamedicTrack/ParamedicHome Concepts of Biology Contemporary Mathematics Introduction to Statistics Basic Concepts in Sociology Introduction to Psychology Abnormal Psychology Composition Which of the above classes do you believe to be a waste of time for a MEDICAL PROFESSIONAL? Another example from Loma Linda with different tracks to take: http://llu.edu/llu/documents/2007-08univer...og.pdf#page=124 20 hours of humanities? That is not alot especially since you can include foreign language classes. You do get to pick which of the humanities you want to take out of a long liist. If you chose Medival literature in your degree, that was probably your choice. To complain about your choice of a humanity class is another matter and should not be used in an argument for higher education in EMS. Associates in Science degrees for EMS have been around since the 1970s. I got one in 1979.

You do realize Florida is the Winter home for a lot of Canadians? Even though Florida is a "Right to Work" state, EMS is largely Fire Based. It will be difficult to avoid FDs and unions. We already have more attitude, including my own, in Florida than we know what to do with. What is your 2nd option for a state to relocate to?

Per the link I posted earlier from HB 509: (5) a licensed or certified emergency medical technician-intermediate or emergency medical technician-paramedic.

You could also be making some court appearances. CHANGES http://www.legis.state.tx.us/tlodocs/81R/b...ml/HB00509I.htm By: Riddle H.B. No. 509 ORIGINAL Sec. 724.017 Sec.A724.017 BLOOD SPECIMEN (a)Only a physician, qualified technician, chemist, registered professional nurse, or licensed vocational nurse may take a blood specimen at the request or order of a peace officer under this chapter. The blood specimen must be taken in a sanitary place. (b)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 as provided by this chapter if the blood specimen was taken according to recognized medical procedures. This subsection does not relieve a person from liability for negligence in the taking of a blood specimen. ©In this section, "qualified technician" does not include emergency medical services personnel.Acts 1995, 74th Leg., ch. 165, Sec. 1, eff. Sept. 1, 1995.

This might get a little confusing since both are L/M. Minute volume is a "volume measurement" as to how much is moved in 1 minute. And, when we talk about L/M for flow, we are talking speed. And when we get into ventilators or your more effective CPAP machines, we are running off of the 50 psi outlet and not the stepped down liter flow. If your mask or ventilator cannot meet the needs of your inspiratory volume and speed, it is not a "high flow" device by technical definition. A NRBM is in true definition not a high flow device since it actually restricts what a patient can intake for demand. A venturi device or hi-flo aerosol are high flow because of air entrainment. So yes your 15 L/M example is correct. Some transport ventilators just don't have the flow and the demand valve responsiveness, thus increase work of breathing because the patient must work to meet their own demand. A high tech finely tuned precision ICU ventilator knows what the patient wants before the patient does. When choosing a transport ventilator, one must look at it like cars. Power, speed, responsiveness, gas economy, handling, price, options and of course sleek design are all factors that must beconsidered. Earlier in this thread I posted a link that compared these factors for 15 transport ventilators. Most vents will offer the same modes but it is how each ventilator can keep up in delivering those modes to meet the patient's needs that is the deciding factor. Per curse's comment on teeing in a neb on a transport vent, yes it is possible but one must be mindful of your total flow as it will increase VT. We prefer using MDIs in many patients as the dosage can be acheived quickly. Many of the transport ventilators are also homecare or LTC ventilators. These patients may require nebs as part of their maintenance. The Pulmonetics LTV is a good example and is a very popular CCT and Flight vent. It was also the vent of choice for Christopher Reeve.

Actually that is exactly why I and all the RRTs in the departments I work with take precautions. Long term exposure has now been documented. The same from the days when we were running large amounts of Pentamidine and Ribavirin. We also do all the inductions AFB specimens. Flolan and nitric are also something that requires precautions. In the Peds side of the ED we can set up 10 continuous nebs in the holding and run 8 more in the front section as singles. Yeah we're pretty large also with a huge children's hospital. We also have the HIV and TB section for the kids. Risk management and workmen's comp insurances have already issued the bulletins. We may not be covered for certain exposures since we have strict P&Ps that have been enforced since the mid 80s when several of our RRTs unfortunately became headlines due to exposure to TB. We can run over 35 different gases and medications on our patients. We treat each one with the same respect whether it is Flolan or Albuterol. Your own health is not something to take chances with and when you have RN, RRT, MD or whatever behind your name, you should know better. Sorry for the lecture but our residents hear something similar to this on their first day in our hospital. We want to set good examples for a long career.

No it isn't compared to the 280 l/m the ICU vents can do. The Respironics Vision BiPAP maxs at 240 L/m. That is why we giggle when EMS wants us to switch to their 15 L models.

I wouldn't try this with a few of ATVs found on some EMS trucks in the U.S. What transport ventilator are you using that has a built in nebulizer. Price for this extra accessory as an option? Whenever nebulizing any med, filter your machine to prevent contamination to it and the exhalation port to prevent exposure to you and bystanders. Albuterol rarely causes a reaction but like any med that YOU don't need, avoid inhaling the stuff. Even when giving a regular neb in the ED I practice the 5 foot rule or wear a mask. And yes I will wear a mask when in a closed space like a truck especially with kids. I just draw a funnier face than my own on the mask for them to stare at so not to frighten them. Even without the med inline with a ventilator, whatever bacteria/viruses/fungi are in the patient's lungs with be exiting the exhalation port at up to 60 L/m. When running meds like lasix, mag, morphine and high dose albuterol, we don't use a regular acorn neb. The waste and particle size variation makes for inefficient delivery.

Don't flatter yourself. You and this patient are almost the same age.

You're right. Cancer that requires a wound vac is nothing to complain about. She should just tell her husband to shut up and die already. Geez, imagine an immunosuppressed patient's family worrying about a little fever. It is such a bitch to get sick and be a bother to the EMTs. And heaven forbid you do need a specialist in this country. Like I said before, anyone that gets sick should never be stuck in the boonies if they are sick where there is only one ambulance and probably not even a taxi. This is where helicopters get sent to calls that should have been handled by ground ambulances. Some one blows off a patient to where it becomes an emergency or the ground ambulance doesn't drive very far and then get stuck at a little general. A helicopter must then be dispatched to the tune of $10K - $15K instead of $1500. Like I said before, only if you and your area have a working reasonable alternative to get a patient with special needs to the appropriate facility, you should rethink your argument. Just refusing or taking to the nearest facility and dumping is not the answer. Your system needs to be reworked. The patients shouldn't suffer because there are no reasonable alternatives.

Bag it in. Adapt the neb between the bag and ETT. Some BVMs have an MDI port but with the new HFA (thank you Canadians ) canisters, not all may fit properly. The same if they are on a ventilator.

Trach vs ETT in the nose? The nare can restrict the tube further increasing . An ETT is several cms longer. A trach is 6 - 10 cms in length. An ETT is approx 33 cms. Do you know why is a patient is changed to a trach to facilitate weaning from a ventilator? Basic math on this one. The FFs should also know this although they may not have calculated it since the academy. Airway Resistance = (8 x viscosity x length)/pi x radius to the 4th power The radius should also be considered at the narrowest part through the nare. A reduced airway lumen has a dramatic effect on airway resistance...hence the 4th power part. A trach tube is more rigid and will maintain its radius throughout with the exception of secretions. A naso ETT will also risk bloody secretions which will further reduce the inner lumen. Also if the mask is resting on the tube, the patient now has that resistance to overcome. Increased work of breathing can cause other systemic effects that can lead to failure with more than just the respiratory system. It this patient is too deep in unconsciousness to meet the effort needed to overcome the resistance, failure can result from retained CO2 and the histotoxic hypoxia chbare described. SpO2 tells you nothing about the A-a gradient or the SvO2. An unnecessary nasal intubation may also result in antibiotic coverage and/or nasal packing which may not have been necessary otherwise thus prolonging a hospital stay in an already overcrowded hospital system.

It was discussed in this thread: http://www.emtcity.com/phpBB2/viewtopic.ph...&highlight=

Or, at least find out if this was also the patient's informed decision. A cath lab procedure might have brought death many hours earlier. If patients know this, they at least have a chance to be with their family if they choose the conservative route with being told what their prognosis is with and without the procedure. Did they work him as a code when he died? There are tough decisions in medicine that must be made by both the physician and the patient. It is not unusual to have patients wait for days, weeks or even months for a surgical procedure if there are other labs or medical conditions that make the procedure risky. Also, if the person is faced with the possibility of spending the rest of their lifetime as a vegetable even if correcting the cardiac condition is possible, is it the best option for the patient?

Why DNR patients? DNR does not mean do not treat. Even CHF or PNA will be treated with CPAP or BiPAP. I am not totally opposed to not transporting but unless you also have a reasonable alternative for transportation, you just can't leave a cancer patient to drag their wound vac into a taxi or a finger laceration that needs suturing without some follow up. If the finger becomes infected they could always say you bandaged it and said it was fine. Even EDs have a followup call or visit from a case manager for some of the patients they don't admit into the hospital. As for improving a service: I do believe monthly training rather than relying on the required recert CEUs is more effective. There are so many topics that are not covered in some of the recert refresher courses. The changes in laws, regulations, P&P, infectious disease standards, etc should be updated.

SFFD has had troubled waters for many years and when it appears it might get better, they get another set back. This is a description of how they are operating now with a few minor changes here and there. http://www.sfgate.com/cgi-bin/article.cgi?...;type=printable SAN FRANCISCO Fire Dept. to be restructured Firefighters and paramedics will cease to be merged Jaxon Van Derbeken, Chronicle Staff Writer Wednesday, September 22, 2004 San Francisco's troubled Fire Department will soon be restructured under a plan hailed by the mayor as both improving service and saving the city $3 million a year. The new approach marks the end of a seven-year merger between the firefighter and paramedic ranks. The merger has been described as difficult by the department. In June, the San Francisco grand jury, which reviews city operations, found that the department was dogged by on-duty drinking and unchecked harassment of paramedics by firefighters in the wake of the 1997 merger. Union officials dispute the claims of harassment. Under the merger, paramedics said they endured a heavy workload and hostility from their firefighter colleagues at the firehouses where they both worked 24-hour shifts. Firefighters, among other things, claimed they could not sleep because of the sound of sirens from the responding ambulances housed at stations. Rather than continue with the merger, Mayor Gavin Newsom said Tuesday, he will create a three-tier system of paramedics, firefighters and firefighter paramedics. Once the system is in place in 18 months, he said, the city could save $3 million in salaries. "This will bring better service, better, more consistent responses,'' Newsom said. "From the taxpayer perspective, we're going to same money.'' At the entry level will be 200 lower-paid civilian paramedics and emergency medical technicians to staff the city's ambulances. They will be hired at $65,000 or more a year, $20,000 less than fully trained firefighter paramedics. The ambulance crews will be housed away from fire stations, and the crews will work 10- to 12- hour shifts, without the same benefits as their higher- paid colleagues. The next rung will be firefighters, followed by the highest paid group, the firefighter paramedics created in the merger, who earn a starting wage of $85,000. The firefighter paramedics will no longer staff ambulances on a regular basis. Instead, they will be stationed at the city's 42 firehouses, riding with fire crews to provide emergency life support until ambulance crews arrive. Fire Chief Joanne Hayes-White said the plan was "the best use of our resources'' with a goal of a 4 1/2-minute response time within 18 months. Critics say the plan simply abandons the costly merger of the department at the behest of the powerful firefighters' union, Local 798. "The merger could have worked, but it didn't because of a lack of leadership,'' said Michael Creedon, a firefighter paramedic who is an outspoken critic of the current administration. Creedon and others worry that the paramedics assigned to stations will not have the variety of experience needed to keep up their skills, a contention dismissed by Hayes-White, who said the department would compensate for the change by increased training. The mayor's office and Fire Department tout the new plan as solving some long-running problems with the department, including fatigue. They point out that new ambulance crews will work only 10-12-hour shifts -- instead of 24- hour shifts -- to reduce fatigue. "Because of the high call volume, the workload became essentially unbearable,'' Hayes-White said. They say the new ambulance-crew spots will also provide an entry-level good avenue for minorities. But Kevin Smith, head of the San Francisco Black Firefighters Association, said the new plan wouldn't necessarily help minorities, who have to finance their own training before applying. "They say you have to get the training on your own, where the department provided it before,'' Smith said.

I only stated paramedics who delight in refusing transport as one reason not to live in these areas. Hence, people should be warned if they come down with a chronic or catastrophic illness in your area that there will be no way for them to get to a hospital if they can not tolerate a car. They definitely won't be able to get to the hospital where their specialists are. Hopefully their distraught loved one can drive them safely to the hospital if that is their choice. There probably aren't any taxis available in these areas either. I am not being sarcatistic and I often advise people who have medical needs children or adults to consider relocating for better healthcare. Pregnant women who know they may have a difficult birth, complications or anything abnormal with the fetus should also get closer to a hospital that can provide the care they need and NOT trust their local ambulances to get them to the appropriate facility directly or by transfer . To be a high risk delivery at the little general hospital may jeopardize both the life of the baby and the mother. spenac, You are taking this very personally. Look at a couple of posts before you. Would you call the cops on a cancer patient with a wound vac? Look at the many threads we have had on this subject. If you read position statements made by NPs and PAs by their professional organizations, they are attempting to find solutions for the patients that don't need this but could use that. So far all some have stated in EMS is about their own agenda as to what the patients should do for EMS. If you are feeling I am intentionally picking on you so be it. I just considered your statements an opportunity to make more points about patient care. I also want some to see the patient as an individual and not just as BLS or ALS but in medical terms. Blanket labels don't always apply for every situation.

So that one cancer patient who requires a different level of care than what her local hospital provides means nothing to you. They are essentially a detriment to the greater good. Whatever pain and suffering she is experiencing is her own tough luck and she should have known better than to call for an ambulance. That goes for the stupid husband who cares about her. Honestly, if she could have tolerated a POV or taxi, it probably would have been less trouble and cheaper. She also wouldn't have to listen to an EMT(P) complain about her abusing the system. Are you really sure you know how sick some of the patients are that you pick up? Many on these forums complain about "BS" nursing home calls or dialysis runs and yet many do not know why the patient is actually on dialysis or what sepsis truly is. Many also don't fully understand pain, as we have seen by some threads, or chronic illnesses or cancer. Yet, those in EMS believe they know exactly if a patient is not worthy of their ambulance. Medical illnesses are not as simple as the scraped knee or broken finger.

So you are punishing the patient because of the actions of the nurses? Medical professionals also help patients in their time of need to find solutions for their medical problems regardless of whether it is ALS or BLS. It is just part of being in the field of medicine. Hospitals don't like being thought of as hotels either but each patient's case is taken into consideration and not a blanket approach to deny those that might fall through the cracks of care otherwise. Have you not taken into consideration about a patient's treatment that is specialized and not just any local little general hospital will do? Not all hospitals are created equal and it is this patient's unfortunate luck that she had the misfortune of getting cancer while living in the boondocks with only some rinky dink hospital that can not provide the doctors or the care needed. It is also unfortunate that there may be limited ambulance services for that area and the family has not had time to research all the options. So again you are there only to dish out the punishment for their stupidity of bothering you instead of taking a taxi for 1 hour while risking more pain and suffering for the patient if not able to position properly. The husband in all of his stupidity may only have wanted what is best for his wife. What a stupid fool he is for calling 911 when he thought something could happen to lose what time he has left with her! It is a shame people can not move from these areas such as sirduke's that have no options for the patients who suffer a major illness in their lives. How horrible to suffer through an illness and then have to worry about finding transportation after being refused by argumentative EMT(P)s. It would be nice if one could know about their future illnesses so they could live closer to a major hosptial and not rely on the inadequacies of rural life when it comes to healthcare. We also used to dump all traumas and AMIs at the nearest hospital. The local little general in this case could just start a medicated IV on the woman and request an ALS truck anyway. All you have done is just prolong her from getting the appropriate care she needs. Gee, so glad to see such caring about the patients but only if it fits with your own needs. There are exceptions to the rules and not everyone is a drunk wanting a free ride across town. Maybe instead of bitching about things, you should get a list of agencies that can provide the services to patients in your area. Many are here today and gone tomorrow, as if we haven't seen that through the AMR era, so it is difficult to stay up with the most current agencies. You could even talk about changing the way trucks are dispatched. What about setting up information lines of communication for people? How about attending meetings in your area to improve where the tax dollars are spent? No, it is much easier and probably more fun to piss of patients by telling them they don't need transport.

For once I am in agreement with crotchity. This may not seem like an emergency to those in EMS because it is usually assumed an "emergency" is someone dying right now or at least has some bleeding. The husband may know that whatever time he has left with his wife will be very much shortened by an infection or any complications that can occur when a person is immunocompromised from chemo. While you may not see this as an emergency, whatever is going on with the patient may cause death even if it is not right now. To the patient and her family this is an emergency. I can truly see a family member becoming frustrated when presented with an ambulance crew that doesn't want to transport "because it is not an emergency". The sooner she can get treatment, the more days, weeks or months she may have with her family. This is not only the over reaction of the lay person. I have seen experienced EMS providers call their own ambulance services wanting immediate transport for their loved ones who had a chronic or terminal illness regardless of what trucks must taken out of service. Why must all patients feel like they are being judged by some EMS providers? If the patient waits to see if they feel better and get worse instead, they get "the lecture". If they call before they are actually dying the get "the lecture". Heaven forbid the patient that calls with chest pain that might have any indication of it being reflux. They may wish they had the MI and died before the ambulance arrives so they don't get "the lecture". It is usually the well meaning citizens that want to do good and not be a bother that get "the lecture" from EMS providers about abusing them. Or at least those are the ones that care. Who really expects a catastrophic illness in their life? I would bet that the couple in the original post had never used an ambulance before the wife's illness. While yes you can try to get into a pissing match with the family and tell them their loved one is not worthy of all the available care that an ALS truck has. The husband has also requested to go to a hospital that can provide more care for their loved than the basic local little general. Why do they want a Basic truck? In times like this, you will truly offend and come across as uncaring.

I would say just take her. She probably won't live much longer to be a bother to the ambulance again anyway. Skin cancer can be very aggressive and like many cancer patients, they may put on a great front of denial. I've seen end stage breast CA patients try to do everything for themselves right up until the end. Or you could call the police. I'm sure what they will put her through wouldn't be any worse than what the cancer has put her through and will still put her through until the end. In the time spent contemplating calling the cops, one could see if there was another truck in the area that could transport if you didn't want to go out of service for that length of time.

Missing a few things that could be important: 54 y/o with an ulcer requiring a wound vac? And home health RNs? What is her medical history? Meds? What stage is the wound? Did she have a flap done that required microsurgeons at the other hospital? What was different about the pain that prompted the call? If that fever is an indication of sepsis, she is a ticking time bomb who could go bad quickly depending on the rest of her medical history. How soon would the other scheduled transport ambulance have reached her? Does you ambulance also do non-emergency calls and if so how does your service advertise itself in the phone book? I can see the husband's reason for being irritated if you have not assessed the patient or did not have much more than what you have provided here for information. That could be taken as a "just don't wanna do the call". I do however disagree with the nurses making you wait and they should have gotten things organized prior to calling.

Correct AnthonyM83. A ventilator can only move air in and out of the lungs. ECMO and cardiac bypass perfusion machines are oxygenators and true respirators. Oxygenation can be trended by SpO2 but a PaO2 is needed to determine oygenation and an SpO2 tells nothing about the A-a gradient. ETCO2 can give some idea about ventilation but shunt perfusion and deadspace ventilation may have some influence on the numbers. The shunt perfusion may not affect the number for ETCO2 as much but may have an affect on the A-a gradient for oxygenation. Deadspace ventilation may widen the PaCO2 - ETCO2 gradient. I prefer to look at Minute Volume or ventilation. Did the RR increase while VT decreased or did VT increase and RR increase or did both decrease or whatever combination. That is how I determine compensation or fatique. It may also tell me alot about the work of breathing of a patient. Patients who are nasally intubated may work harder in attempt to achieve the same minute ventilation required to maintain homeostasis. The small diameter of the tube through the nare increases resistance, decreases ability to pull in a normal VT and will decrease VT thus increases the RR to maintain minute volume. Eventually you may get fatique if no assistance is provided.