VentMedic

Do you have the ability to transport to a more appropriate facility if you make the DD as ARDS? What criteria do you use? It is a bitch to move ARDS patients once they get to a local little general with limited resources unless a specialized transport team is available. What do you do differently for ARDS that you wouldn't do for Acute Respiratory Failure? Since as ETT is established, position would be to accomondate BP. Once in the ICU, they will probably be prone once the HFOV is started or whatever protocol short of ECMO.

At $10k per dose, not all hospitals will be on board for that. Also, the patient will have to meet the criteria for it as well. http://www.xigris.com/Pages/organ-dysfunction-assessment-animation.aspx THAM is a buffering agent that does not break down to CO2 which is ideal for permissive hypercapnia. However, it will require close glucose monitoring. Good reading: http://ajrccm.atsjournals.org/cgi/content/full/162/4/1361 http://ajrccm.atsjournals.org/cgi/content/full/161/4/1149 A lactate level may diagnose sepsis and a CXR may either indicate a PNA with or without a pattern for ARDS. Fluids and pressors may be initiated but the ED doctor will be wanting this patient out of his/her ED quickly and into an ICU bed where ScvO2 monitoring, an A-line and the ICU ventilators are. Eydawn Acute Respiratory Distress Syndrome (ARDS) is a syndrome of inflammation and increased permeability associated with a constellation of clinical, radiologic, and physiologic abnormalities unexplained by elevations in left atrial or pulmonary capillary pressure. Criteria: Identifiable associated condition Acute onset Pulmonary artery wedge pressure </=18 mm Hg or absence of clinical evidence of left atrial hypertension Bilateral infiltrates on chest radiography Acute respiratory distress syndrome (ARDS) is present if Pao2/Fio2 ratio </= 200 Acute lung injury (ALI) is present if Pao2/Fio2 ratio is </= 300 We will also do a BAL (bronchoalveolar lavage) to gather fluid for multiple diagnostic tests. For H1N1 Flu Associated ARDS, patients seemed to experience a cytokine storm. Very, very nasty ARDS to deal with which is why the deaths but unknown why the young were so harshly affected. Clinical conditions associated with ARDS Direct lung injury Pneumonia Aspiration of gastric contents Inhalation injury Near drowning Pulmonary contusion Fat embolism Reperfusion pulmonary edema post lung transplantation or pulmonary embolectomy Indirect lung injury Sepsis Severe trauma Acute pancreatitis Cardiopulmonary bypass Massive transfusions Drug overdose Good ARDS ppt. http://www.ohsu.edu/radiology/med/chest/ards.ppt Thus, you can have PNA with localized infiltrates and go home with a script. If you have require a ventilator and an RRT at your bedside 24/7 for severe hypoxia and diffuse infiltrates, you probably have ARDS that may have been precipitated by that PNA infection either bacterial or viral. ARDS also goes down the path of multisystem organ failure and is not just isolated to the lungs. This is the reason I pointed out the caution with being overly aggressive with the ventilator until BP MAP is tanked up with pressors and fluids. Something will shut down and it the additional ventilator settings hurried that along, it may be difficult to recover or resuscitate the patient. Acute Respiratory Failure can be from many causes including the patient too tired to work at breathing to compensate for lungs or better term "cardiopulmonary" system that is failing them. People with pending ARF may have normal blood gases or close to it right up to the point of the tube. One thing I hate to hear is "but the ABG is normal" when the patient is huffing at 40 breaths per minute and diaphoretic with a BP that is about to bottom out. For this patient breathing at a rate of 40, the term should be tachypnea rather than "hyperventilation" unless the ABG confirms a low PaCO2 which could be possible with sepsis (falling pH) or a PE. By definition, respiratory failure is defined as a PaO2 value of less than 60 mm Hg while breathing air or a PaCO2 of more than 50 mm Hg. ARDS patients will do well to have a 60 mmHg on 100% oxygen. The act of respiration engages 3 processes: (1) transfer of oxygen across the alveolus, (2) transport of oxygen to the tissues, and (3) removal of carbon dioxide from blood into the alveolus and then into the environment. Respiratory failure may occur from malfunctioning of any of these processes.

How did you come up with the diagnosis of ARDS and what protocols to you have for field management? ARDS is often an overused and misused term like "hyperventilation" or the statement "all COPD patients are CO2 retainers". Just like CO2 retainers, ARDS is a diagnosis that is not made very often. Managing a badass PNA can be difficult but it usually responds fairly quickly to treatment once antibiotics are initiated and doesn't always require much out of the ordinary for ventilation/oxygenation stategy once on a higher level ventilator that is not considered an "ATV". ARDS on the hand wants you to try everything you've got including ECMO at times. It can make the best ICU technology and practitioners work hard for their money with even the priciest ventilators groaning. The best we can do sometimes is supportive care with pressors, maybe corticosteroids, maybe Nitric Oxide, maybe serious diuretics or not and maybe dialysis of various types. An elderly patient with septsis PNA, ARDS patient with a pre-existing "no immune" system will have a very high incidence of death. An elderly septic patient with PNA and even a compromised immune system has a much better chance of survival although not great. We will not initiate an ARDS protocol until we have radiographic evidence and then the ABG and metabolic panel will dictate which direction. Too much damage which is difficult to reverse can be done by just doing a few bits and pieces of a protocol by buzz words such as "recruitment maneuvers" or "PEEP 'em" or "low tidal volumes" if you do not have an adequate way to monitor pressures (hemodynamic and airway such as plateau pressure) and CVP.

Actually it is because the people in the community are taking an active interest in their health care that these issues may arise. Insurances are also putting the fear of medical debt into their clients. For some cases such as a MI, you can asure the patient their emergent needs may be covered by their insurance at another hospital. People who have Kaiser insurance will be hysterical if they land in another facility regardless of how serious their emergency is. Also, as soon as the patient has had a cath or has been intubated and stabilized for whatever reason, Kaiser will insist their patient be transported to them. Thus one has to be aware of the patient concerns and address them to the best of your ability but don't make promises. Granted insurance issues are not your concern except to complain about people who don't have any that ride your ambulance. Just considering the patient to be a moron and ignoring their concerns without at least expressing some interest in them even though you will still have to transport per protocols isn't exactly good patient care either. My own insurance will not cover many emergencies if I go to a hospital out of network. It may be left up to me to prove I was going to die if I didn't go to the closest hospital. So your report had better reflect that since I will be sending out copies to the insurance and probably an attorney if the bill is significant to get copies of your protocol so the issue can be resolved. If I break a leg and cannot get to a network hospital by POV or taxi, I will be paying 50% of the bill. That may be 50% of $20k - $220k depending on the severity. If at all possible I would choose to be transported out of the ED by another ambulance to a network hospital but then that might not be possible without an accepting physician and bed availability. Since the ED also wants their bed back, I may be stuck at that hospital and going into serious medical debt.

Considering the vomit around her and the rhonchi, aggressive sucitoning is probably what she needs. This is something some Paramedics seem to be rather shy about doing and will often bring the patient in with scrambled eggs buried in the airways from using high level of PEEP or CPAP trying to force the O2 through the food and vomit. A 7.5 ET tube would also be nicer if she needs a bronch later to clean out airways, hopefully when more stabilized. Ventilation that is too aggressive that might cause a drop the BP MAP will be detrimental in the front resuscitation phase especially prehospital where you may be very limited to the necessary pressors, management capabilities (see IV gtt thread) and monitoring to know if you are running too lean or over the top. PNA will also not always need PEEP in the rescue phase and may not need it until CXR confirmation of ARDS or oxygenation is a problem. If this patient also has an asthma hx, one would have to be concerned about over distending her FRC to cause further hemodynamic compromise. Clear the airway before and after ETI, 100% O2 if you have enough oxygen in your tank to support it and worry more about increasing your BP MAP rather than your airway MAP. Once you BP MAP improves, the SpO2 should follow. Unless you are concerned about CHF and the need for fluid distribution pressure factors or oxygenation is still a concern after BP MAP is stabilized, then PEEP might be considered as a treatment. A central line would be a "must have" for ScvO2 monitoring as well as CVP to where the BP MAP can be ramped to increase the ScvO2. A foley catheter would be a big factor for monitoring a suspected sepsis during a fluid resuscitation since renal failure from the dehydration would be an issue. You are also not going to be able to do an "ARDS" ventilation protocol in the field and doing just parts of it without full access to all the buffers and medicaton protocols for low volume high PEEP dump the BP and pH. If your volumes are too low when you back off on the PEEP, you will set the patient up for atelectasis which decreases the ability to oxygenate/ventilate and then re-expansion trauma later if the opening pressures are high. An iSTAT would also be nice to know where your pH is before you try to manage a ventilator for "ARDS". You may have to run THAM (preferred) or NaHCO2 but then her Na+ might be high or the metabolic condition may not warrant it as a buffering agent. THAM is more useful for the permissive hypercapnia. Understand the whole consequence and benefit sequence for any ventilation maneuver since every knob turn affects more than just that one setting. This is a sample sepsis protocol if you are in the ED, ICU or on an aggressive/progressive CCT team. http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf

It seems some are viewing this situation as just "one truck" when in reality it is several trucks from several stations. In a small city with 4 stations and an average of 2 - 4 trucks per station (average 24 FFs) each making at average of 2 - 4 trips to the grocery stores each day plus coffee runs, this can add up. In larger cities you may have 20 - 40 stations. The city miles/gallon for an engine is about 3 - 5 mpg while a ladder may average 2 mpg. You don't have to go far in a city to burn up 5 gallons of fuel easily. Granted the bigger cities may have a larger budget but fuel cost is still a considerable amount and FDs, especially those that do EMS, may even exceed that of the PD. This has been the topic of many FDs and some are limiting unnecessary trips and some are rethinking how they respond to each scene by cutting the number vehicles to each alarm, both Fire and EMS. Also, some FDs would rather cut back on the community service activities that do benefit the public rather than tell their FFs they can not make several trips to Starbucks or shop all over town for each meal. Surely some here have noticed their own fuel expenditures in this economy especially when it comes to short city errand trips and that is with your POV averaging 20 mpg. Planning a meal for each shift or even the week of 2 - 3 shifts should be no different than what a family does with both parents working FT jobs and seeing the kids are taken care of. There should be enough down time at a fire station to work up a simple menu to either limit the trips or buy the food the night before or in the morning. This can be done for each individual or for the group. Millions of people in all industries work long hours and probably get a lot less sleep then many FFs. Doing 12 and 16 hour shifts at any job(s) for several consectitive days allows much less time for someone to plan for each meal and shop than a FF who works 2 - 24 hour shifts 2 - 3 days apart. Yet, other workers are able to get their meals and all it takes is a little planning and knowing it is a necessity for them to assume this responsibility on their own dime and time. It is also the stations with very few calls that worry the most about shopping. The busy ones do plan ahead because they may know trips to the grocery would be a luxury. They are rarely in their station long enough to play house. It is also the busy ones that may understand a fuel budget and the importance of keeping a certain amount of vehicles available at all times. Regardless of what company you work for, one should take the time to know what it costs to run a business and especially one that is commonly seen in public begging for tax dollars and public support. Abuse the privileges or bash the concerned taxpayers and it may be harder to convince the public they need to pay more property taxes especially when support is needed at election time for certain amendments.

Do you live in Afghanistan? Is it your community? I am not saying all this just to be a shithead. I live and work in a predominantly Spanish speaking community. Besides, the nonEnglish speaking EMT who can still pass a test in English can do all those BS routine calls that so many American EMTs don't want to do or believe they are too well trained and educated for.

Have you missed all the education threads we have had about the EMT? It is also not included for the accreditation by CoAEMSP. It is a 110 hour cert class that can be taught just about anywhere that can lay claim to a classroom. And how about the standards for the instructors? It can also be taught by bilingual instructors to give those in the class enough exposure to English language for the EMT student to master the few concepts and skills in it. Again, nonEnglish speaking people are not stupid and usually can pick up English medical terminology. But of course if some close their mind and refuse to help them learn what all they may not know, then there might be a problem. Luckily, that doesn't exist in all parts of this country. You seem to miss what I have stated over and over again. It they know enough English to pass a test that many who speak English fail and they are hired by companies that know their clientele, why are you complaining about qualified people getting an entry level job? The EMT cert again is not that difficult and not every EMT runs 911 calls. I over and over explained that proficient English would be needed for a FD. So again, if the person can pass a written test in English (THAT MEANS THE OP'S ORIGINAL QUESTION HAS BEEN SATIFIED) and passes the skills stations in English, why do you say they are not entitled to work? You do not know all the employment situations, dispatch situations, crew configurations and hospital situations in all parts of the country. Yes it would probably be so much easier if we did not allow anyone, including tourists, into this country that don't speak English but how are you going to stop that? How are you going to deny someone who does meet the minimal standards for a cert from seeking gainful employment? Do you think that an EMT who speaks Chinese or Spanish can not find employment in a hospital that caters to these communities? Or at a dialysis center for transport? Open you eyes, there are many opportunities for those who seek them. The EMT is an entry level cert. The communities these facilities and hospitals serve are over 100,000 people speaking a different language in an area. This is not just one or two patients to cater to. These EMTs probably won't be coming anywhere near you. I already stated that in another post that someone speaking Spanish probably will not be seeking employment in Indiana or Kansas. If you have never worked out of your own all English speaking area, you may not know what those who speak enough English to pass an EMT test in English are capable of regardless of where they come from. Open your mind a little.

You wouldn't expect me to drag all my stuff down to the ED, set it up and then haul it back up to the ICU. I'd rather not work that hard.

Is this in the United States? How many hours of actual education for the care of the ICU patient did you get in your Paramedic program and how many hours of hands on care in the ICU did your clinicals provide. There is a considerable difference between a patient that is stabilized for transport from the field and one that is in an ICU. There's a different focus, different protocols, many different meds that are rarely mentioned in most Paramedic classes and technology that one would not use in the field. Even RNs who work in the ED don't consider themselves to be ICU capable unless they have had the training/education due to the dynamic nature of the ICU patient. The same goes for many ED physicians. I don't believe there are too many Paramedic programs that produce ICU capable Paramedics. Yes they may be able to handle some ICU patients for a very short time but that would be only if the medications are familar to them as is the technology. However, it would be wise to have additional training and education beyond the normal Paramedic program. The focus of the Paramedic is emergent care in the prehospital setting which includes stabilization. The patient is not yet "ICU" and all the things that make the patient "ICU" may not always be initiated until they reach the ICU. Not every ED is capable of performing at the level of an ICU. Have you never heard "gotta get them upstairs to ICU as soon as possible"?

Do I need to repeat all of my posts again? How many times have I used "non English speaking"? Again and again, this is for the EMT cert and not even 911. If they enter a college they will take an English proficiency test. How much clearer can I make that for you? If someone knows enough English to pass an EMT cert given in English when several English speaking people can not pass it, leave them alone. If their employer accepts them and is sponsoring their employment, leave them alone. What right to you have to tell someone they are not allowed to work in the U.S. when they have met the same requirements as someone else and their employer knows what language they speak? I do have experience in this and do know about non English speaking people first hand in several occupations. You have refused to even acknowledge that someone who doesn't speak English could be a competent care giver at any level. Not speaking English does not make them an idiot or incompetent. So yes, I think you have presented yourself as I previously stated.

LOL! I have been to hospitals in other countries on various missions where English is not spoken. I have also been to Chinese Hospital in SF. We have also hired "English Only" RTs and we have hired "Spanish Only" RTs before a degree was required and it really isn't as big of an issue as you make it out to be. That is unless the English Only RTs had an attitude such as yours and couldn't accept their Spanish speaking peers. There can be a place for each. I have also worked in the VA system where the Puerto Rican RNs spoke almost no English. Yet, the patients survived and just like another EMT, there was another RN around that could speak to the patient and somehow things got communicated. It may not be the most ideal situation but still not impossible. And again and again and again I will repeat that now in the U.S. if you go to college there is an English proficiency exam. What part of English, again, do you not understand? At this time the EMT is a tech cert similar to the CNA. It requires no college. But in the situation the OP mentioned, one spoke English and one didn't but both saw the same patient. Do you not think two EMTs can't figure out what to do between them? Have you absolutely never been anywhere where another language was spoken with a patient? The assumption that one of the EMTs is English speaking is because one of them started this thread in ENGLISH.

The dispatchers aren't on the ambulance. What are you talking about? I have given you examples of how a system can work when there are non English speaking people in an area. Do you not understand how a bilingual dispatcher is of importance when dispatching trucks for either the community or the providers? You continue to argue that there is absolutely no place in any situation for a person who does not speak English in the U.S. in an entry level medical job that requires no entrance into a college. Even though this has been done you refuse to see how anyone that does not speak English can serve any purpose at all to patient care. The guy is not a doctor. He is NOT applying for a MEDICAL LICENSE. Oh the hell with it. JP you have your own close minded little world and refuse to see how entry level non English people can be of any value here in the U.S. to assist in patient care. So yes, my previous statement still stands or maybe you are tolerant only if they speak English.

You are only speaking from experience from the two ambulance services you have worked for. Do you also realize many dispatchers are bilingual that can relay a call for 911? The ambulances services will have bilingual dispatchers and so will 911. You really seem to think that everything is done in English everywhere and all the time. Tourists and transient visitors to this country may not want citizenship. Do you also want to force Disney to only sell tickets to English speaking people only? And you can not see where I got my statement from? Your other thread addressed Russian speaking EMTs and ambulance services. My posts were to show it is not impossible for this to happen and that is can work out very well for the patient. Is this one non English speaking EMT you are speaking of the only non English person in PA? Is that what you mean by "conservative state"? If he is surrounded by English, it shouldn't be that difficult for him to pick it up. Again, non English speaking people are not stupid or disabled because of their language. The FDs in my area prefer the Paramedic cert at time of hire or within the first year. There may be several tests which will be in English to get hired by a FD and to get through the Fire Academy. The EMT is only one of them and probably the easiest for someone to prep them with enough English to pass. And yes there are places that hire EMTs but not as likely in a state that prides itself in providing all ALS paid EMS to its citizens and is largely Fire Based EMS. The positions for an EMT in 911 will be difficult to come by and when there is an opening there will probably be 500 EMTs applying. Being bilingual in some areas may give you the advantage of the 499 who aren't.

Posted earlier in this thread: Were the chemistry classes required for your Paramedic or were they in preparation for a Physiology degree?

Patient's preferred language? What is that supposed to mean? An EMT who only speaks English is at a disadvantage in a community that consists of people speaking another language. If the company is contracted to do routine transports in that community, what service does it do the patient if no one can talk to them? However, it doesn't matter what language you speak if you know your job and have good communication skills even if it is not by words alone. It just helps if the company knows they are contracting to a group that speaks a different language if they can provide at least one person who speaks the language. Isn't that part of good customer service? Routine transfer trucks depend on that and it helps to keep the EMTs employed if the contracts can be obtained. Again and again and again, this is NOT for 911 EMS. How many times do I have to repeat that? EMTs are not involved in 911 EMS everywhere. How many times do I have to repeat over and over that if the person wants to work for a FD or to attend college for more than just the EMT cert they will have to meet the English proficiency requirements? What part of ENGLISH in my posts are you not able to understand or do you just want to turn this into a pissing match with racial terms? You obviously have not spent much time in communities, clinics and hospitals where English is not the dominant language. There are places in this country where one could go for days without hearing English. You need to get over seeing Americans as all white English speaking upper middle class heterosexual Republicans. Don't get testy since you are only a few years from being a doctor. I also used the term RN and we already had this discussion. But let me change that to medical professionals with a license.

Did you read any of my other posts as to how it has been done in the past? Also, unless they can speak English they will not be getting on with any FD to do 911 EMS. I also used the words "may be allowed". Right now it is very difficult for Haitians to get a permit or to even be allowed entry into this country so you can rest easy that there may not be that many or any Haitians allowed into this country to have a chance at becoming EMTs to drag down EMS. However, I hope some will see past their prejudices to allow those willing to work into this country. BTW, there are also many Haitians who are bilingual because even in a country that is looked down upon by some Americans and the U.S. government. Its school systems did encourage a second language. I did NOT say anything specific about doctors. There are more medical professions than just Doctors and EMTs. I can't and won't cover each and every one of them. I already posted a link about RNs and discussed it. You even replied to that post.

Again, someone who speaks a foreign language is not less intelligent, disabled or retarded. I also believe the language the OP is referring to is Russian. We are also talking about the 110 hour EMT cert, less training than the CNA in many places...not Paramedic and not RN. If you don't want this to be an issue, put the EMT into the colleges with required college classes so that the requirements of the U.S. education system can be in effect. It is also possible if we became familar with the "EMT" standards from other countries, U.S. EMS might advance so just maybe their influence could be a good one. If 2 EMTs are not required on the truck, this is probably not for 911 calls. Do you not think that some populations wouldn't be better served for routine transports by someone who spoke their own language? Are you going to teach an 80 y/o Russian or Spanish dialysis patient who has only been in this country a couple of months how to speak English or else on a 15 minute transport? Would you apply at any of our hospitals where Spanish is the dominant language just to exercise how superior your rights? Would you apply at Chinese Hospital in SF just to show you are the more intelligent American and those elderly Chinese people had better learn English no matter how sick they are once you're there? It also doesn't look good if EMS either BLS or ALS can not communicate with their patients. Other countries encourage their citizens to be bilingual. We have many businesses that cater to people who speak a different language in this country. Why should health care be any different. It is also now part of the patient's rights to have their care communicated in their own language during a hospital stay in the U.S. After the Haiti disaster there may be more Haitians allowed to enter this country for employment. However, if they do not speak English, is it safe to assume you would never allow them to be gainfully employed as a CNA or EMT on a transfer truck that also largely caters to their communities in South Florida even if that is what they had done before? Also, as previously pointed out, Puerto Rico (Spanish) is a U.S. territory and some medical licenses from that country are recognized in the U.S. So like it or not Spanish is also very much part of the U.S. in some way.

Can you post a link to your Paramedic program so that it can be used as an example? If this was in MI, why is that state in such of an uproar about just getting accreditation for the Paramedic programs?

Actually in many parts of the country the Paramedic is still taught in the back room of the FD or ambulance service and not in a college. TX still only requires 624 hours to be a Parmedic. And yes there are still 3 month mills to crank out Paramedics. If you listen to some in EMS you would think that is too long. When was the last time you were responsible for 25 - 30 patients at one time with maybe just one CNA? Do you think you could get to know everyone very well in 8 or 12 hours while passing out 300 meds and doing 20 dressing changes? Do you not know how quickly the mental status of a brittle elderly person can change from day to day? Do realize the nursing home has to justify each transport and is subject to a Medicare inspection at any time? Do you realize that if a nurse is found guilty of fraud he/she loses their license and goes to jail? Do you realize that many EMT(P)s flap their jaws about fraud but yet most are afraid to take a legal stance even though there are avenues to do so? Yeah some talk big but cower in a corner when asked to put up the proof. Unless the nurse is from Puerto Rico, they may be required to take the ENGLISH NCLEX exam. What about the EMT(P)s that do supposedly speak English but can not put a sentence together? You are only talking about "skills" again. Finding the CT Scan room? Get real! Do you not think about assessing the neuro patient to determine if the change warrants a CT Scan? Yes, that is the RNs call to make. Dumping urine? What are you going to do with the information? You believe all there is to Physical Therapy is handing someone a cane? Do you honestly think you are now a Physical Therapist as well as an RN? Do you even know how many clinical hours they must complete? I think you just proved my point as to what you do and do NOT know about total patient care. You've got one big chip on your shoulder and not that much experience. You also have failed to mention anything about EMS and what the Paramedic should be focusing on rather then trying to take over nursing, PT, RT and the Dietitan's job with all the expertise you acquired from your one Nutrition class. You also may actually have been one that didn't spend enough time doing routine transports to know what some of the threads on the EMS forums are about or what the attitude is amongst those who don't do 911 calls.

Were you ready to dive right in without any orientation, precepting or any type of additional training as a new RN? Probably not. The orientation can be very extensive for some hospitals especially if they recognize their nursing program at the local college sucks. However, if you read the posts and talk to some Paramedics, after two shift or at little as 5 supervised calls, they are on their own regardless of whether they graduated with a 2 year degree or from a 3 month wonder mill. I believe on of our local FDs puts the Paramedics on the streets right away if they did their ALS engine sleepovers at their station. Forbes? Both of those articles have been circulated extensively out of fear of what the DNP actually is. They have been bashed and thrashed on every forum. The AANP published their own statement defining the work "doctor" and "doctorate" because of these articles. The DNP has been around for over 15 years. It is just when it was announced that this would become the new entry level that some took notice. http://www.aanp.org/NR/rdonlyres/105556AC-24FC-4FFF-A9EE-08CDC6DB1BE5/0/DNPGROUPLETTER608wcopyrightandattribution61908.pdf If there was really an issue with nurses in the NP role, do you not think that an organiztion as powerful as the AMA would not have put an end to this 5 years ago when the new standard was announced? As stated before, nursing has taken an active role in cleaning up their profession first by changing from diploma to degree. This was actually done well after the Paramedic and their degrees appeared but has definitely advanced faster than the Paramedic which no longer advocates for degrees as it had been done in the 70s. Nursing has taken a stance with the LVN and have stated they need to advance at the very minimum of the ADN to function in acute care settings. Period. No whining or exceptions. Those LVNs at our hospitals who did not want to advance could be moved to a nursing home or if they wanted to stay in the hospital, they could work as PCTs for about the same money. Nursing recognizes the ADN is not enough and will often prefer and encourage the BSN. Since they are lagging in education (along with the RRT), they will be an expectation of promoting the BSN until the majority of RNs have the degree. Then, it will be a smooth transition to make it the entry. This was also done prior to the diploma change as the schools started linking to the colleges. RT promoted the A.S. degree for almost 20 years until almost every RT had the degree when the transition was made. Nursing appreciates the CNA but does not cater to the CNA when it comes to their own professional agendas. They encourage the CNA to take part in a hospital's tuition assistance to advance to RN. EMS still makes excuses for the EMT-B to remain the lowest level and accepts all excuses for not taking a few hundred more hours to be a Paramedic. Nursing does not accept other CNAs being the primary instructor for a CNA class. EMS allows minimally educated to teach even less educated (by 110 hours). The RN classes are taught by a minimum of a BSN with it usually being an MSN with Doctorate oversight. Paramedics with a Paramedic cert teach Paramedics. Nursing has minimal hours of education and on the job experience before they allow testing for many of their certifications. EMS allows weekend certs such as the "CCEMT-P" and then puts these medics on a CCT for the higher reimbursement rate. Nursing does a background check for licensing which is something EMS is still not doing in all states. CA just started and it was amazing what they found. CA also made all the RNs who held licenses for more than 20 years go back through the finger printing process for their renewal. You can bash nursing all you want but for the number of nurses there are and the many specialities they have, I think they have done a very good job at legislating for their future. That also includes the states that now are petitioning for nurse to patient ratios such as CA and I believe NJ has done. Even with the diversity, there are many fundamentals and standards they do agree upon. For EMS to share one common thought even about patient care is a rare occasion. for all of its faults nursing is still a proud profession and is always seeking ways to improve patient care and the total outcomes.

Yes and it is in Spanish. Since Puerto Rico is a U.S. territory, it is recognized without the additional hoops to jump through. However, here is the NCSBN's analysis. https://www.ncsbn.org/PuertoRicoExamComparison.pdf

How many Paramedics have been to ICU other than for a brief look during clinicals? How many have followed a TBI patient to and from many CT Scans? OR? Bedside drains? Step-down unit? Med-surg? Acute Rehab or SNF? How many who do "routine trucks" or BLS even know or care to know that their patient may have been a "cool trauma" at one time. How many take the time to understand the communication deficits of a TBI or just ignor the patient for the entire transport. I have been in the EDs, the ICUs, the med-surg floors, the Acute Rehabs and subacutes to know the interaction between EMT(P)s and patients. I have also listened to patients talk about their transport experience. I have listened to EMT(P)s bitch about transporting such a BS patient from a subacute at 0300. I have also tried to get EMT(P)s to see their patient as a human being rather than a vegetable wasting their time when they could be doing a cool EMS call. This is over 30 years and in many locations. I get an ear full when we fly into a place that requires us to be transported by ambulance. The EMT(P)s compliment us on what a cool job we must have and then procede with a rant about BS calls from nursing homes not realizing the patient we will be picking up will eventually end up as a "BS" nursing home patient even though today he is a cool flight team patient. So no, don't tell me that all EMT(P)s know all the painful procedures and even more painful recovery that a patient experiences after the ED. Sitting in a room is not the same as actually working in a patient care situation everyday. You have not taken the same nursing classes. If you want to use your own reasoning there is not reason an RN can not do exactly what a Paramedic does. They also have the same classes. It shouldn't be too difficult to pick up a couple of skills and believe it or not there are RNs that do just that and become successful MICNs, PHRN, Flight and CCT RNs. However, most are not so arrogant to believe they are "just like a Paramedic" as soon as they leave school be it with an ADN or BSN. Not knowing what you don't know is what will get you in trouble and that seems to be your situation. You seem to be only for advanced education for yourself and use only yourself as an example. You fail to recognize that this is not true for all of EMS and nor is it true that all of your clinical hours are spent at a patient's bedside in various situation in the hospital for any length of time. There was a program in Georgia that was attempting to incorporate more critical care experience but as of right now there hasn't been any word of their success. Did it ever occur to you that the ED RN sees more of the Paramedic's acutal skills and patient interaction with the patient so they are better to form an opinion than the ICU RN who may see you and your RN partner only for a CCT or Flight transport but will more than likely be giving the report primarily to the RN? Or, they might see you for a little clinical visit where they are told to play nice with the students. However, consider yourself fortunate as a Paraemedic student because the RN students don't get the kid gloves treatment on med-surg or the ICUs as they are expected to have reviewed much of the material before class and actually participate, not just there for the view. Symbolic because they knew you were not to actually learn about these devices but rather to see them. You had an overview of ECMO and not an orientation since a Paramedic will not be doing ECMO in the U.S. anytime in the near future. If you do participate in transport, there will be an RN, RRT or Perfusionist doing the ECMO. For IABP you also may have been given just enought info to babysit the pump from point A to B and not actually manage one. There is a difference. The same for the LVAD. I also love to hear when a Paramedic says they "learned" ventilators and procede to pull out an ATV for a critically ill patient. You also wouldn't want to get into a peeing match with all an RN has seen as an "overview" or has actually participated in. As I said before their list of "skills" is very impressive and what they have seen for procedures and equipment is even more impressive. So nurses are not worth anything? I think that is rather insulting considering you have not worked as a nurse. What do you suggest? We replace all RNs with Paramedics? There was a reason nursing did away with the LVN in the acute care setting as did the RT do away with the "tech". How many Paramedics want to do total patient care which includes many of the things Paramedics avoid and give up doing EMS? We have had a lot of Paramedics get their RN patch through Excelsior just so they could avoid doing "nursing stuff" during clinicals. Many were found to be useless in the hospital and now just have an RN patch to add to their Paramedic. Thus, many states have refused to accept the Excelsior or they require over 700 hours of clinicals doing nursing care. Now, you don't hear about Paramedics scrambling to take that course. As far as fraud, right now with the monitors in place, Medicare is seeing that we don't waste alot by extending hospital stays with causing more injury from improper care. They do hit the hospital in the payment. You have criticized higher education for nurses from the BSN to the DNP. You argue that the Paramedic is a good as any RN. I don't know exactly what your angle is. So you think advanced education for RNs and other allied health professions promotes fraud? Have you even looked at how the petitioning is done for reimbursement based on education and expertise or the studies that higher education does promote savings in the hospital? I DID give you example of that from different profession. Are you also calling educated RRTs guilty of fraud because we promote shorter ventilator stays? How about the doctorate PTs? Are they guilty of fraud by promoting a higher level of rehab to have a patient become a productive citiizen again? You seem to want to tear down all other professions because you are still held to the standard of the weakest link in EMS. Get your own yard in order before telling other professions their education is worthless or they are quilty of being frauds or committing fraud.

I forgot to mention that nurses from Puerto Rico who have taken their exams in Spanish are recognized in the U.S and do not have to take the NCLEX in English regardless of what language they speak when entering the U.S. And, there are services that assist Spanish speaking RNs in finding employment. The Federal government is of course one of the best places to look.

It's easier to explain the patterns on paper. The different patterns are very important symptoms for different etiologies or diseases processes. Examples would be DKA and TBI or other neuro events. Found you some new links to pretty pics and information tniuqs. http://images.google.com/imgres?imgurl=http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi%3Fbook%3Dcm%26part%3DA1308%26blobname%3Dch43f2.jpg&imgrefurl=http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi%3Fbook%3Dcm%26part%3DA1308&usg=__rnLU8QxHfxZ46ER_BwS0QFYSPkE=&h=346&w=467&sz=67&hl=en&start=4&sig2=S_AfTUdFxfI4txFsddSr7A&um=1&tbnid=4izgMQ8RoDusNM:&tbnh=95&tbnw=128&prev=/images%3Fq%3DRespiration%2Bpatterns%26hl%3Den%26sa%3DX%26um%3D1&ei=TlJWS9e0BoO6tgOOopjKAQ http://images.google.com/images?hl=en&source=hp&q=Respiration+patterns&um=1&ie=UTF-8&ei=SFJWS_CKMZDusQO1zvXpAQ&sa=X&oi=image_result_group&ct=title&resnum=4&ved=0CCoQsAQwAw