VentMedic

You are taking that very personally! Do you realize how many students or professionals in training at a large teaching hospital? Many are competing for the same skills that a Paramedic student is doing. And yes you are competing with people who have much higher education then you and with very set schedules. If your instructors has not petitioned on your behalf for a piece of the action, then don't blame others. Even MDs and DOs are from different programs and will have different privileges on the hospital property. I can not allow some of the residents to intubate either in our ED if it is not part of their program or if they are not cleared for that skill by their senior. I may have 15 people sign in with me for a chance at intubation or for the physicians, an art stick or A-line. I may only have 5 intubations in the ED or emergently inhouse for that 12 hour shift. The Chief of CC Medicine may also give me a priority list. That being said, I will still try to work with others or ask if there is an OR rotation available for some students. I don't think you quite realize the responsibility someone has who is mentoring you on a live patient for "skills" especially if they do not know your background or anything about what was already expected of you in your program. I have even had students of all types come expecting to intubate and not know which hand to put the laryngoscope. So don't take things so personally or act like you are entitled to special treatment because you are a medic student. If you cop that attitude, no one will have time for you. If your school has made the proper arrangements, get the name of a contact person and don't let them tell you to "just show up". An ED in a large city teaching hospital will be the most chaotic but controlled scene you will ever have to work probably in your entire career in EMS.

If his school has not made the proper arrangements, the residents and anyone else has every right to kick him to the curb. If they have not filed the correct paperwork for invasive procedures, it will be observation only at a distance. I can not imagine the hospitals in Boston being that much different than any other hospital.

That's exactly the crap that the medic mills tried to pull at our hospital and couldn't verify their insurance with our risk managers. That is why their students can not touch any of our patients and will observe from afar if the hospital even decides to allow them inside for the day. If you want to do skills inside a hospital, your school had better make sure they have got you covered and the hospital knows what you can and cannot do or what the hospital sees fit to allow you to do. It should not be a mystery and all arrangements should already be made and your school coordinators should check schedules to get you in when other students are trying to get intubation time.

Does you program not already have some type of arrangements with the hospitals? We won't allow students into our ED unless they have a clinical coordinator to answer to. We also had to stop allowing Paramedics students from doing intubations and rotating through L&D due to some serious problems with some medic programs and their students. The Paramedic students can not "run" codes but can be present and the person leading the code might ask them what next. On the other hand, a teaching hospital is one of the best places to gain knowledge and an insight on patient care. You can also get as many IVs in as you need plus extra. IVs is probably one of skills that some lack when they enter the field. You can participate in rounds and have access to a wide variety of medical professsionals who are use to teaching. You will gain vast knowledge of what happens to a patient once they enter the ED and know what professionals are looking for in way of assessment and information. It will be more about your attitude and expectations. If you have no previous hospital experience, this will be your chance to learn. Most look only at the skills aspect which is why very few of the medical professionals will waste their time on someone who has no interest in the knowledge that goes with the skill. That could be the reason for some students "bad" experiences.

If only CC Medicine was that easy. This scenario can be continued to great length. If 50 mcg/kg/min of propofol was allowing the patient to still breathe more than 2x the vent settings (luckily to correct pH), whatever alternative sedation/pain meds that are liver and gut friendly may have a difficult time holding him for synchronous ventilation by a transport ventilator. Thus, more aggressive BP management may need to be in place to maintain MAP. But, without the advantages of a CVP monitor, the patient my still be need fluids or NOT and that fine line of fluid homeostasis may be crossed. Paralytics may also have to be considered but again that does not negate the need for increased sedation/pain management. Unlike EMS where you usually have only one working dx to run with, CC medicine has multiple issues to be concerned with for present and proactive. Every body system, medication and even the ventilator must work together. Whatever adjustment is made to the ventilator may rock the sedation/pain/hemodynamic aspects of the patient. Likewise, any titration, up or down, of the meds may have a profound effect on ventilation and oxygenation. Even in the controlled environment of the ICU, scrapping one plan to start with another may mean several more hours of fine tuning the patient back to where everybody is satifisfied that the patient is somewhat stable or more stable than before. In some ICUs it may take several hours to round on high acuity patients to make sure MDs, RNs, RRTs, Pharmacists and Dietitians are all in agreement and on the same page in the treatment plan.

I've seen the green pee only a couple of times and it did not seem to accompanied by any adverse affects. We are also strict about our tubing changes. Propofol infusion syndrome has the been the required reading lately for us in the ICUs since the article ran in a couple of different CC journals. Personally I believe since Propofol has become almost "routine" in some ICUs, we will start to see more adverse effects. Before it was very controlled and limited to the OR and a few advanced practice ICUs. Now it is in almost every local general's ICU if cost is not a concern. However, many of our EDs will not set up a drip even on ventilator patients which usually for the COPD or CVA pt it is not needed. Even with an ED holding area for 6 - 8 ventilators, we can manage with other sedation and pain management. Those that need propofol usually go to the OR directly from the OR or to the trauma ICU. We use propofol in high doses for many days if we have must just to get a patient through a difficult stretch especially if we are doing an aggressive ARDSnet or HFOV. If the patient is also a complex surgical patient, it takes creative pain management to accomondate whatever intense ventilation strategy imposed on them as well. We try to avoid paralytics except when the O2 consumption and/or synchrony are of serious concern. Are Paramedics allowed to monitor and/or titrate propofol on ground CCTs? They still require an RN to accompany in my area and the areas I am familiar with in California. For Flight, it is not used for HEMS and those that are able to do interfacility have RNs on board.

LTV 1000 - The ventilator of choice for Superman. The LTV 1200 is even better with internal PEEP. PEEP wasn't mentioned here, maybe due to BP or not. 3 - 5 cmH2O usually won't affect too bad and will prevent some collapse. Somebody on a Flight forum was talking about buying Uni Vent 73x for their interfacility transports. I cringe when I hear stuff like that from supposedly sophisticated teams. It is as bad as a Paramedic CCT showing up to the ICU with an ATV. Apologies chbare, we drifted.

Anion gag was 22. Anything else beside lactate from MUDPILES? Propofol related infusion syndrome is not unheard of especially with liver injury. Although bradycardia is typically found, tachycardia can also be present. That is a standard volume mode settting. Hopefully it is Assist capable. PCV would not give a preset volume. I would hope no one uses SIMV (very old weaning mode but still found on some transport ventilators) on a sick patient. Even the most sophisticated transport ventilators are still very limited in options. Thus, the person managing them must be knowledgable of the disease process and not treat the ventilator as a separate entity just to correct ABG numbers. Different suspected disease process require very different ventilator management. This patient is still doing most of the work on the ventilator to which his flow requirements have probably exceeded the ventilator's capabilities. The I:E ratio of !:2.2 as stated is probably the calculated for the rate or 10 since few if any transport vents can achieve adequate flow for that ratio with a RR total of 22 without deficit. Thus high WOB which will increase V/Q mismatching and deadspace with inadequate flow distribution.

Did I miss your Diprivan dose? It is also metabolized heavily through the liver. He is on very minimal ventilator support. I also don't see a mention of anything for pain? Fine tune pain and sedation management with the pressors and/or fluids for BP and you still have lots of room for ventilatory support. What's you BP MAP? Visual perfusion signs? HCT available? No way to monitor CVP or SvO2.... Vasopressors will be ineffective or only partially effective in the setting of hypovolemia. Are they still managing the ventilator "separately" while you're in flight? Was an Early Goal-Directed Therapy (EGDT) established by the hosptial post op?

The vent settings now have a rate of 10 and FiO2 of 0.6? With a serum lactate of 6 and a pH of 7.3, why decrease the Rate and FiO2 settings on the ventilator? With this being a common scenario for CCT regardless of location, do you have an established sepsis protocol or guidelines to at least initiate and maintain since you are Flight with CC capabilities?

How big is this patient? The ventilator is set in a volume mode at 500 x 10 which only gives a 5 L MV. CO2 of 28? What's the pt's total RR? Anion gap? SvO2? CVP? BP MAP? What's the goal for the MAP?

fmti student Are you from Florida? FMTI? Would you suggest someone going into debt for what Paramedic training costs there if they can not get a license to get hired?

Yes. We just request PD to stay until the ME or funeral home comes for the patient. For certain parts of the city and with some calls where this is likely to be a problem, they will be dispatched with Rescue.

In Florida it depends on what the felony was at to whether you will even get a license before you can apply for a job. Each case is reviewed individually. If you have commited a crime of physical violence or sexually assaulted a child, don't get your hopes up to high.]

Yes. The Collier consolidation mess is now being compared to that. Collier EMS was also a good EMS only system. EMS49393, The news articles said the foot was severed. Often an extremity may already be almost totally detached so there is no need for the saw but rather just a little skin to cut through. That is done occasionally to remove the patient safely and then the extremity. There is now a decent success rate for reattachment depending on damage and preservation of the body part. Farmers and machinists may cut their own fingers or hand off prior to our arrival if they have a sharp object nearby. We will then take the patient to the hospital, leave a container to put the extremity in and the FFs can retrieve it after they dismantle the machinery. A LEO will then bring it to the hospital. Even if the patient is airlifted, there will still be enough time for LEOs to get the part to the hospital while the patient is being prepped. If it is a fairly long distance, the police will set up a relay team of intercepts through their dispatch to keep the body part moving quickly across county lines. It is rather impressive to track such coordinated efforts. Okay, that what professional EMS/FD/PD systems do. I don't know what happened to the county in this article except they figured the patient wasn't going to use that foot again and the dogs could put it to a better use. Good idea but the wrong way of doing things. Always check with the patient to see if they are really finished using that extremity or have no other plans for it. :roll: Maybe I shouldn't say that. Someone might ask a patient if they are finished with their foot because they want to take a doggie bag home.

Oh please let me show off a couple of our larger FDs! Miami-Dade http://www.miamidade.gov/mdfr/emergency_stations.asp I bet the majority of the applicants already had their medic mill cert in hand. Palm Beach County Please check out the station/apparatus "showcase". http://www.pbcfr.org/stations.asp?view=text And then we have Broward County (Ft. Lauderdale) which has created another breed of FR under the SO. http://www.sheriff.org/about_bso/dfres/ Bigger is better?

The limb should be sent to the hospital to see if it is salvagable or if a tendon, muscle or ligament may be needed for repair of other body parts. Then it becomes ME property until the patient or family signs acknowledgement of the extremity and its disposal or burial. Cadaver parts can be obtained but only through limited sources that are approved by the state with a declared purpose. This was in the paper today: "An FHP investigator took the foot to the hospital Wednesday afternoon, Frith said. He did not know who gave the foot to the investigator or where it had been kept until Wednesday." http://www.sun-sentinel.com/news/local/tre...0,6586185.story +++++++++ What about all the other FFs that knew about this? Shouldn't they be reprimanded for this also?

The news station article is better. She was the recipient but it was a group effort. http://www.wpbf.com/index.html

However, on the same news page just below the amputated leg story is this: Firefighters Find 5 Kittens On Fire Truck http://www.wpbf.com/index.html http://www.wpbf.com/slideshow/slideshows/1...574/detail.html Lucky for them the FF/Medic was looking for human body parts and not feline. The cadaver dogs were probably owned by or trained for the FD so her actions will be declared they were in the best interest of the FD.

Can we add a "PATHETIC" category on the forum to put some of the Fire Medic stories coming out of my home state? We're starting to make California look normal. http://www.emsresponder.com/article/articl...p;siteSection=1 Florida Medic Accused of Taking Amputated Leg Posted: Thursday, September 25, 2008 Updated: September 25th, 2008 06:34 PM GMT-05:00 Story by wpbf.com Video: WPBF.com PORT ST. LUCIE, Fla. -- Fire officials are investigating after a St. Lucie County firefighter allegedly took an amputated leg from a crash scene last week and used it to train her cadaver dogs. The attorney for Karl Lambert, 46, of Melbourne, told WPBF News 25 on Thursday his client's leg had to be amputated after he was involved in a traffic crash Friday on Interstate 95. "Mr. Lambert's lower left leg had to be severed at the scene because of the amount of the wreckage and in order to get him out of the wreckage," attorney Raymond Christian told WPBF News 25 in a telephone interview. "It's our understanding at this time that one of the paramedics, one of the fire-rescue people at the scene, took the leg. ... The purpose of her taking the leg, as it was our understanding, (was that) she was some kind of training person for cadaver dogs, and she basically took the leg." Christian said Lambert was notified by a Florida Highway Patrol investigator Wednesday. WPBF News 25 first learned of the alleged incident after receiving an anonymous call from a firefighter at St. Lucie County Fire Station No. 10 in Port St. Lucie. The caller alleges that while the man was airlifted to an area hospital, firefighters took the amputated leg, wrapped it a towel and took it to the station instead of bringing it to the hospital for reattachment. One of the firefighters allegedly had a family member bring the leg home to use for training her cadaver dogs. St. Lucie County Fire District Chief Ron Parrish said in a statement that his department is conducting an internal investigation, saying the allegations are "personally disturbing." http://www.emsresponder.com/article/articl...p;siteSection=1

One must also remember that there are many reasons a heart stops. Majority of the patients you see are the multi-system - broken. They may have had a massive CVA, emboli, aneurysm, chronic illness with pulmonary HTN, renal failure, DM, liver failure, cardiomyopathy and just plain ole old age where you may not bring back every 90+ y/o. However, the importance of CPR for the younger person can not be emphasized enough. Granted I have had many more saves inside the hospital than out but every once in a while you will get someone that had good citizen CPR and they do have a chance. By a save, I mean return to a life with quality life with near or full function. Surprisingly I have the best luck with dialysis patients. Last week out of the 4 dialysis patients that coded, 2 lived and were extubated within two days. I'm sure if the other 2 had not been over 90 they might also have had a better chance. I also find the same attitude that is conveyed by the OP in other providers. Thus you get a patient brought to the ED with half arsed CPR. On a NH patient it is difficult to put much into it but they may still be a full code. But when it is done half-arsed on the 20 or 40 y/o because the stats say it is useless and you apply the numbers to mean everyone, then you don't need to be in EMS. If you are going to do CPR with only half the effort put into it, stay at scene and just call it there. Another reason for ineffective field CPR is too many codes are worked in the back of a truck running L/S and the person supposed to be doing compressions is hanging on for his/her own life. Even in the hospital, we work the patient where we find them no matter if it is in the breezeway to dialysis or on the floor of their room. If we can not get a pulse back, we don't take up an ICU bed. We put our best effort into it and see what happens. Not all will have a good outcome and now physicians are becoming more at ease with getting an end of life statement from the families to terminate life support 24 - 72 hours after the hypothermia protocol is finished. An inhospital hypothermia portocol lasts for 24 hours and then there is a rewarming period that can take several more hours. Only after that will is completed will testing start to determine brain function.

Michael, I have yet to work for an EMS company or hospital that didn't provide me with CPR, ACLS, PALS, NRP, state mandated CEUs and any additional training that is required for the job. I would also hope the union didn't tell you that 24 hours is anywhere close to a Cardiac Tech which takes an Associates degree to test for the CVT. I would also hope your medical director is overseeing any additional skills he/she is wanting you to be competent at. The unions were not established to educate. They were established to represent laborers who had almost no education and were essentially illiterate. The unions made the decisions for them since the laborers were not able to read contracts or any form of documents pertaining to their work. They HAD to trust the unions. Yes, the companies were taking advantage of the uneducated several decades ago. They still have a strong hold on factory and coal mining occupations because many of these laborers have no college and enter the job right out of high school. The unions have little say concerning the professionalism of EMS when it comes to legislation for standards and reimbursements. Yes, they can lobby for standards on hours and safety but can do nothing to change the 50+ EMS certs or establish an identity for the providers. Nor can they do much for evidence based medicine. Those are the issues that prevent better reimbursement. With the exception of nursing which has its own agenda, there are very few healthcare profession with advanced education that want to be a part of a union unless forced to in a closed shop. PT, RT, OT and SLT have done much better through their professional associations which have emphasized their educational levels and not a "I can scream louder" union technique. The "I've got connections" for the union stance in Washington DC died with Jimmy. RT now has a Bill pending that recognizes Bachelors and Masters degreed practitioners in out of the hospital environments for enhanced reimbursement and autonomy. It opens up many opportunities. Just the passing of the Associates degree for entry level almost doubled our wages in some areas. And, those of us who do Specialty Transport are chosen by skills, knowledge, dedication and not just senority. The same for lead or research positions. Those that are "over it" and have put not effort into their career for 20 years can not just expect to get the job because they have the years in as they would in a union shop. I guess I am speaking more as someone who has education and who has advanced through the ranks by education. I do realize that many EMS providers have only a few months of training and without national standards for education with unified certification levels, it is a tech or laborer job. That is unfortunate because unions will feed on that just like they did on those with only a 3rd grade education 100 years ago. Ask your union officials when they are going to push for the Associates degree to be the entry level for EMS providers and watch their reaction.

Dr. Bledsoe is not calling for an end to ALS protocols but to make us think why and where is the evidence for many of our procedures in the field. Again, too many do things because they can and not because they should. I already stated my position on education in an earlier post. As far as intubation of trauma, I sometimes prefer intubation in the ED or OR because of the ETTs that are used do prevent aspiration and VAP. They have subglottic suction ports. A regular ETT does not prevent aspiration but rather slows the inevitable. To prevent VAP, the removal of secretions that are trapped beteen the glottis and cuff must be continuous. Review: anything that gets past the glottis is aspirated. Often we will reintubate a patient either in the ED or OR for that purpose. This, of course, makes some Paramedics cry foul because they don't understand why we are doing it. Facial trauma patients will also get intubated with another type of ETT that allows manipulation or immediately trached which can be done quickly and under ideal circumstances...in trauma centers. However, ALS providers are secure in their future and this can lead to enhanced arguments for more education including increasing the EMT-Bs' hours. As far as consent, many of the procedures that are being trialed in EMS have already been proven in the hospital situation so it is not like you will be doing a new drug with unknown side effects. However, what is not followed very well is how well those procedures work in prehospital. Ex. RSI, CPAP, thrombolytics, pain management, hypothermia protocol, etc. Good Research article: http://www.pcrf.mednet.ucla.edu/pcrf/pdf4.pdf And one more research article: http://www.nedarc.org/nedarc/media/pdf/Res...MS_Research.pdf Lastly: National EMS Research Agenda http://www.researchagenda.org/

I see a greater need for advanced EMS education from this article. It actually takes more education to understand why you are not doing something rather than "you are not doing it because you can't" if it is not within your level of training. I also see it as a call for more education to better understand why things work and why not instead of "it's in the protocol". It's time to understand the difference between guidelines and recipes. That might mean taking classes such as college level pharmacology and A&P. Too many people are blindly led by articles in JEMS, or some other non-scientific magazine, without being able to differentiate fluff from science. It also means we can not justify 4 Paramedics on an ALS engine or ladder truck if there is another ALS transport capable truck running with it.

The people are Naples are now getting a eye and earful of everything their tax payer dollars were being used for to support the bickering. These articles were also published around the same time of the OP's article. Fire department consolidation could come up at Collier commission meeting By I.M. STACKEL (Contact) 9:08 p.m., Monday, September 22, 2008 http://www.naplesnews.com/news/2008/sep/22...come-collier-c/ Collier EMS medical director will answer to commissioners By I.M. STACKEL (Contact) 6:44 p.m., Tuesday, September 23, 2008 http://www.naplesnews.com/news/2008/sep/23...swer-commissio/ Right now the word is getting around that the FD is looking for a new Medical Director who will do as they say and just sign the paperwork handed to him without question.