VentMedic

The Respiratory Therapists' organization (AARC) already checked the O2 bars out several years ago. The concentrators aren't medical grade since they are not that efficient at scrubbing the nitrogen out of the air. One would also not be misleading if it is only 21% oxygen. Even some of the medical grade concentrators don't deliver a high concentration if they are poorly maintained. The bigger problem is seen from the flavoring or scenting chemicals that are put in the humidifiers. Those can trigger pulmonary problems.

The differential physical assessment will have to be done very carefully. This is something that just has to be stressed. As I said earlier, there are many disease processes that mimic CHD. PPHN is not limited to diaphragmatic hernia or mec aspiration but can happen to almost anything associated with a cardiorespiratory compromise at birth or before. We may have to use 100% O2 for PPHN and as low as 14% for cyanotic heart disease. We want a high SpO2 in PPHN in hopes to decrease the PVR and low SpO2 of 70 - 80% to keep the PVR from decreasing and keep the PDA from closing. Keeping an adequate HCT will be necessary to maintain O2 carrying capacity. Nitrogen and CO2 may be two of the gases uses instead of O2 to mix on the gas blender. One will also need the ability to buffer the body as you monitor the acid base. However, each of the buffering agents have their own set of problems. And, if you recognize an infant in distress with a possible cardiac disorder, just because a NICU is level 3 certified does not necessarily mean it can handle cardiac babies for emergency interventional procedures as in a pedi cath lab. For some of the cyanotic hearts, an atrial balloon septoplasty may have to be done immediately to increase mixing. If you have a choice of NICUs, choose carefully. The Norwood procedure has been very successful and many of these babies are able to live into adult life before they need their heart transplant. There are many now of adult age, some near 50 y/o so don't be surprised to see them in your ambulance. I always stress to EMTs to read the charts and get a history. Not all hx of CHF is just CHF nor is the sternal scar from a CABG.

chbare, Pardon me for dropping in here, but: How about the differentials between R to L and L to R shunting? How about elaborating on O2 (mentioned in earlier post) as a medication? What it does in cyanotic heart disease and in PPHN? Actually same action but different outcomes. And the differential for PPHN and cyanotic heart disease which have similar presentation but with a couple of distinquishing features. The difference in O2 therapy? Crackles? TTN or CHD? With adults, you can screw them up from the wrong treatment but usually not much more than they already are from their own habits. However, the first few hours of treatment for a newborn will determine if the child will have a somewhat normal life or be part of the trach and peg section in the cabbage patch class. Physical differential assessment of the newborn for CHD, PPHN and RDS is very systematic and it wouldn't hurt for a Paramedic or EMT to review the processs. Probably some already have now that you have brought the subject up. Some will not because they don't believe they will ever see a baby like this. And, then there are those that wonder why they can't do more "skills' on a Neo/Pedi transport team when they have never bothered to look up some of this stuff. It might then be evident to them why it is a specialty transport.

I do not believe in having a chaplain in the ambulance. However, if there are ministers, priests or chaplains that would like to be on call for your service, especially in small communities, that is not a bad idea. For the families, they can be asked if they would like someone else in their family called, their minister or someone that is available called. They can just say know no if that is their wish and would feel as obligated to talk to a chaplain if one is not immediately present. I also believe they can work much better in some situations for EMS providers than CISD. Larger PDs and FDs do have chaplains available for their employees. Chaplains are always available in the hospital for patients, families and the staff. I have talked to them on particularly disturbing calls and patient care issues. We may do end of life on several children and babies in one week which can take its toll as well as all the pedi/neo codes we may work in the ED and ICUs. Even some of the adult codes can be stressful especially if it is a co-worker. Usually after we terminated life support or have a bad code, the chaplain will at least make eye contact in acknowledgement that they are available but the decision is yours.

CISM/CISD? That has lost a lot of favor in the past 10+ years. Its effectiveness and potential for harm was even questioned in the later 1980s when CISD was first being implimented in some of the EMS agencies. But, EMS will buy into any quick fix or another "cert". Good article by Dr. Bledsoe http://www.jems.com/news_and_articles/colu...g_Vampires.html http://www.jems.com/news_and_articles/colu...g_Vampires.html

Here's a good link with an overview of O2 devices and the air entrainment formula. http://www.virtual.yosemite.cc.ca.us/lylet...es%20Oxygen.doc My favorite use of the venturi is with my wine aerating device for quicker decanting. :wink:

High flow systems deliver about 40l/min of gas through the mask, which is usually sufficient to meet the total respiratory demand. This ensures that the breathing pattern will not affect the Fio2. The masks contain venturi valves, which use the principle of jet mixing (Bernoulli effect). When oxygen passes through a narrow orifice it produces a high velocity stream that draws a constant proportion of room air through the base of the venturi valve. Air entrainment depends on the velocity of the jet (the size of orifice and oxygen flow rate) and the size of the valve ports. It can be accurately controlled to give inspired oxygen levels of 24-60%. If you have been through the FF academy, Venturi and Bernoulli should be easy for you to understand.

Venturi masks are high flow. People often confuse high flow and high FiO2. However, if flow is inadequate, high FiO2 may not be possible either as with NRBMs in some situations. A transport ventilator may also not provide adequate flow depending on its entrainment system and demand valve. An ATV is almost useless on a hypoxic patient with a high MV requirement. You would need lots of sedation and paralytics to just keep them on that ventilator and then the chance of adequately oxygenating and/or ventilating them is slim at best. Some prehospital vents are just for ventilating post code nearly dead patients without a lot of lung disease processes complicating things. People who are now trying CPAP in the field should also be aware of their device's flow limitations and understand the principles that make the device function with the flow available.

You found the deadspace and alveolar equation relationship for ventilation. That illustrates when I say TACHYPNEA does not always mean HYPERVENTILATION. For those that want a further explanation of this: http://www.ccmtutorials.com/rs/mv/strategy/page16.htm Minute ventilation = RR x tidal volume.

Lots of assessing to do since there are about 32 different things that can also have similar presentation in neonates that come to mind. "Guessing" is not acceptable in neonates unless you have some assessed data to at least make a more "educated guess". Maternal hx? Nourishment? Baby go to bottle okay? Glucose? Output? Wet diaphers? Breath sounds? Heart sounds? Murmur? Gallop? SpO2 pre and post ductal? Pulse quality and BP in extremities? Peripheral perfusion? Vessels on the cord normal?

A simple mask is not the appropriate mask to use for shortness of breath if the patient's MV is more than 6L unless you run it at 10L. Even at that, a patient who is short of breath will probably want more than that easily. A NRBM is also not considered to be a high flow device because only 15 L/m is the cut off flow from that. Simple masks primary are popular in post op recovery because the patient is still sedated and will breathe a MV of 6L or less initially. They usually have the option to set up a High Flow device with cool aerosol also which may be close to each bed space. Very few people look at a patient's minute volume when choosing an O2 device. Some still believe they are delivering 28% with 2 L/M NC on a COPD patient when they are pulling in 15 L/m or more of RA with their MV. The same when they think 6 L/m NC is alot of O2 but again if the patient has a high MV, it is diluted greatly. That is why I always find the arguments about how much O2 to give a patient by recipe so ridiculous on some forums. For some MV is just a formula that was calculated once in the paramedic program but never fully explained how it relates to practical application. It is not too uncommon for an ambulance crew to disconnect their NRMB from the ambulance tank , leave the mask on, get directions from triage or front desk, go to bedside, wait for ED staff, move patient and then hook up to the ED O2. When I "asked" if they though there was enough O2 going to the patient, they usually reply there's still "some" O2 in the bag. They could at least take the mask off the poor patient. I also see a NRBM or Simple mask with no O2 on a patient to minic the paper bag for "hyperventilation". Unfortunately the patient was "tachyneic" due to infection, fever, acidosis, PE or PNA and needed to raise their PaO2 and maintain a decent pH. Even the common BVM is not designed to run much more than 15 L/M. Some even remove the reservoir bag or tail because it gets in the way and report off as bagging with 100% because they are still hooked to O2. They believe the bag just "prevents rebreathing" as on the NRBM but since they are doing the breathing for the patient, it's okay. So, it is not just nursing homes that could use some O2 education. I get to see many ambulances come in during one shift if I'm in the ED and see way too much that indicates the medic mill system is not working that well. And it doesn't just apply to O2. For every incident we can think of for nursing homes, others can also come up with just as many for EMS crews.

Unfortunately the 2 liters per minute by non-rebreather happened too frequently and that is why we changed to the OxyMask in the hospital. It usually originated from a couple of ED doctors that regularly ordered 4 L/M by NRBM for "hyperventilation". The patient would then go to med-surg by transporters with the NRBM and that order in place. After a couple of serious incidents, we switched masks much to the dismay of the two ED doctors. But, nobody has bought a ventilator from a NRBM order since we did that. I think nursing homes would be a little safer if they also went just to NCs and the OxyMasks to get rid of the mistakes made by Simple and NRB Masks.

You should only be stuck with them for 8 hours since that is the length that an OB/Maternity/Peds facility can divert for...unless extreme conditions cause an extension. Initially I thought this thread was a spinoff from some of the political commentaries and blogs that are making headlines today.

It is hard for NHs to rely on concentrators but many are not capable of switching to a bank or liquid tank system. We have noticed the 2 - 3 liters by mask increasing over the past 3 years and some hospitals may be part of the problem. We use a mask that can go from 1 - 15 L and often the transfer orders are not converted to NC. That has been put to task with our risk management and education department in attempt to get a handle of this serious order problem.

They probably did not make up the numbers but took a machine's word for the values especially the HR. A pulse ox will have difficulty analyzing a rapid poor perfusioning rhythm and will give you a value of 1/2 to 1/3 of what the actual HR is. The same with the HR reading on the BP machine. Unfortunately they are not the only "professionals" that rely on a machine to do their assessing these days. It is probably more a matter of very poor assessment skills than lying. As far as the non-urgent call, the nurses may be caught between an EMS system and/or doctors that want them to arrange for transport rather than using the 911 system and what they know they should do. If it is sepsis, it may give some symptoms earlier but can progress very rapidly. We have had patients BLS'd in by crews who thought their patient from the SNF just had some BS fever but was being intubated by the ED staff before they got back out to their trucks. The same with a new onset A-Fib. It depends on what may have triggered it.

There is a difference between removing from life support, which includes blood pressure supporting drips and ventilator, and bringing on death by other chemical means. Sedation and/or pain medication are used to make a patient comfortable but also careful guidelines are observed not to cross that fine line of "over medicating" to where one's actions could be questioned later. This also should be a comfort to the healthcare provider who must care for this patient but is not comfortable with "end of life" decisions. However, part of being a healthcare professional is being able to get your own personal feelings and beliefs under control to do what is legally and medically necessary to respect the wishes of the patients and families.

Here's a few links that may be of interest. I found Texas' outline for end of life procedures which explains the terminology and decision making process in easy to understand terms. Guidelines for Treatment and Life-Support Decision Making for (Minor) Patients http://www3.utsouthwestern.edu/pmh-ethics/...pportminors.pdf This article is about end of life for a baby in the NICU. Understanding, Avoiding, and Resolving End-of-Life Conflicts in the NICU http://www.mssm.edu/msjournal/73/73_3_pages_580_586.pdf Florida's SCHAVIO case http://www.myfloridalegal.com/schiavo.pdf Now, here is another controversial subject. In the past "Brain Death" was the standard criteria for organ procurement. Today we can now use "Cardiac Death". Organ Donation after Cardiac Death http://content.nejm.org/cgi/content/full/357/3/209 Volume 357:209-213 July 19, 2007 Number 3 The Definition of Death and the Ethics of Organ Procurement from the Deceased http://www.bioethics.gov/background/rubenstein.html

This does not sound like a C5 -C7 injury as described by Rid. His friend also sounds young. I have seen several in our Rehab facility that were not only able to come off the ventilator but also be decannulated. However, even with that they run the risk of an infection or even a systemic reaction to pain or a missed BM that could become life threatening. Take into consideration this lady was 65 y/o. The fact that they were not able to allow this patient to vocalize her requests, even with the ventilator, indicates a very high injury. Even a brief ventilator disconnect can create serious problems leading to an anoxic event. At this level she will not have much of a cough which will make her very prone to infections and plugging. She will also be very prone to decubitus ulcers. Care givers will have to do strict skin care, BM programs and catheterizatons. These are all very heavy responsibilites to place on the family especially if blinking will be her only way of communicating her anxiety. Being institutionalized in this shape will be the luck of the draw. While there are very good facilites, it doesn't take much for a bad event to happen. While that could solve the question about "brain function", one would not know what anxiety she would endure if her ventilator did not give her a breath from either a disconnect or plugged airway. She would try to struggle for breath but due to her paralysis, she could not actually achieve this. Life would slowly slip away. She might not die but just go through this anxiety each time her ventilator alarmed, not knowing when someone would come to her assistance. She would be constantly reminded not only of her paralysis but also of her inability to communicate. Or, she could get PNA or sepsis. The V/Q mismatching and the feeling of shortness of breath without again being able to fully communicate her anxiety of not "getting enough air" would just be torture. Her loved ones even in their best efforts might see a decubitus form that eventually goes to the bone. She may have to undergo multiple surgeries in attempts to debride and cover it with grafts. Her family may feel the pain of failing her even though this might have happened even under the best of circumstances at her age and with the paralysis. All hospitals have an Ethics committee to assist with the decisions for ending life support. This committee will be asked to step in to confirm the patient's decisions or to assist the family who may not want to be responsible for such a decision. If the decision is made, life support will be withdrawn and sometimes, if we feel the patient will die slowly we will have a Comfort Care suite for the family to stay with the patient. The patient will be kept comfortable until nature takes its course. Others, like those with "near" end stage diseases, like AIDS, COPD, Cardiac disorders or CF, may have to be placed on a ventilator for something that "shouldn't" be life ending like PNA or CHF. However, these patients will stipulate that if there is any chance of them becoming ventilator dependent, they want life support withdrawn. Their wishes will usually be respected. There are many more situations in which a patient's or family's request will be honored to end life support and not put the patient through more painful procedures if the quality of life will forever be compromised. As a Respiratory Therapist, I have participated in ending life support for all age groups many, many times over the past couple of decades. It isn't always easy but there is usually a feeling that the patient's wishes were honored. The family is there. They will have been prepared by the physician, the nurse and myself on what to expect when life support is terminated. A Minister, Chaplain, Priest or representative from whatever type of worship may be present. The nurse hangs one or two drips for sedation and/or including pain and gives a little bolus when everyone is ready. I unsecure the ETT holding devices while the nurse is getting the sedation ready. The CR monitor alarms are turned off. I then silence the ventilator, pull the ETT, shut the vent off and push the equipment out of the way. The patient may or may not be placed on O2. Rarely will anything more than a NC be used. The nurse and I will make sure we have made the patient and family as comfortable as possible and step aside for a few minutes. We will have tried to prepare the family for gasps and changes in the body's color. We will still be there to help the family as their loved one dies. As Rid mentioned, there are cases that should be encouraged to fight for life. Yet, there are many cases in which it would not be a sound medical decision if the patient's wishes were not respected. However, our subacutes and nursing homes show that the U.S. medical professionals still can not always bring about these decisions either for their own personal opinions or trying to respect family members' choice more than the patient's.

One of the reasons students have a difficult time in Paramedic class is that they have no prerequisites to prepare them for medical education or even basic writing/math/reading comprehension. One is expected to memorize instead of actually understanding or to critically think about how to anticipate and proceed with patient care. It doesn't matter if you have been an EMT for 1 month onr 10 years. You will still be no more prepared for the study of medicine at a higher level even if you think you've "seen" more. What counts is what you understand when you see it. You may "work" with a serious trauma patient but do you really understand enough to know what is happening to the patient to assess if the situation is going well. Cool looking skills are just one part of patient care. The number of times you will perform many of your Basic skills do not warrant delaying the start your education for Paramedic. However, I would suggest you start with some college level A&P, Pharmacology and pathophysiology classes first for a better understanding of the body's functions and what medicines actually do. Then, you will have less memorizing to do in Paramedic class. By then you will also have achieved some study discipline make the Paramedic program's 10th grade text book easier to get through. Too many people also don't take full advantage of the wealth of information those routine transfers can provide. Reading patients' histories, lab values and then looking up these things later to see what they are can be helpful. Noticing different venous access devices, pacemaker locations, insulin and pain management pumps can also be useful further down the road. Assessing the patient thoroughly and not just doing (if it is even done) that one "mandatory" routine BP can fine tune your skills. You can also perfect your communication and interviewing skills. Many of these patients like a little extra attention and are willing to cooperate with you. You can become very accomplished with these skill sets in a short time if you take it seriously and not blow these transports off as BS. To be a successful clinician, you have to put a little effort in both the patient care aspects as well as the academics. Just because your state only requires a minimum of 700 hours of training does not mean that is all you should do. Being better prepared for the Paramedic Program, even if the program doesn't require prerequisites, will definitely be more helpful than the number of years you are an EMT-B.

There were at least 1.4 million people that didn't shoot at the helicopters and evacuated before Katrina. Most had little to come back to. I would suspect many of them are hard working honest people. Some were probably families of those in EMS, FDs and PDs. The volunteers and rescue personnel are moving into place to help evacuate people like those in nursing homes and hospitals. Do you realize the resources it takes to move sick people safely? The facilities and hospitals will be seriously strained with the large number of just patients that require continuous medical care. Even those of us in Florida are assessing our hospitals and see what we can do if people need to come our way or if we can take on more from another hurricane on the East Coast.

Let's not forget these are citizens of the United States and are going to be in the path of a natural disaster. They do not ask for their homes to be destroyed and many would prefer not to be a burden. I, myself, have been in several hurricanes, including Andrew, and although I am well insured, it doesn't take into effect immediately. Nor, can your house and personal belongings be replaced quickly if at all. And heaven forbid, someone loses a loved one during the storm. I hope my family and I will not burdern you with more taxes or affect your beer time this weekend if Florida takes a hit also.

The drug reps for the MDIs will be more than happy to direct you on getting MDI placebos. Keep in mind that with the new HFA propellants, the MDIs have changed in delivery as have the directions for use. There are also about 15 new inhalers on the market in the US. I'm also having a difficult time keeping track of all of the European and Canadian inhalers that are now available, some of which appear in the US by either tourists or other means. You can also get in touch with the Association for Asthma Educators which I mentioned in a post earlier this year for the updates and training devices.

This could get bad. Hanna is shaping up and coming in close behind while another tropical wave with a low pressure system is also forming.

http://www.childrensdayton.org/Health/NICU...tml/NICU005.htm At least they didn't call them "ambulance drivers". The American Academy of Pediatrics (AAP) sets the guidelines for interfacility transport. It doesn't matter what your "state says" you can or can not do as a Paramedic. You still must meet certain requirements to be a working part of the team with direct patient care. One really should be familiar with the guidelines, regulations and direction they are working under before attempting radical changes without a lot of experience. It's not a matter of they're doing it why can't we as in EMS. It all depends on how the team is designed, availability of experience and the acuity of the babies. We don't let our residents touch the babies either on transport unless they have had specific knowledge and skills checked off by the neonatologists. We rarely let someone "practice" on a baby outside of our own NICU. If one wants to get more information or has an issue with this, they can contact the AAP. They also have a database of all the transport agencies for children. http://www.aap.org/sections/transmed/default.cfm

Not lifeguards. Ft. Lauderdale Fire Rescue has an Ocean Rescue station where this occurred. These are Fire Paramedics that are with a special division that cover the beach and waterways. Several County EMS and Fire Rescue departments in Florida will have either a water rescue or beach patrol units if near waterways. Many of the city lifeguards are EMT-Bs to assist in the rescue.