VentMedic

Maintaining an SpO2 (hopefully = to SaO2) of >/ 90% will give you a PaO2 of 60 mmHg which prevents hypoxia. Maintaining an ETCO2 (hopefully correlates with PaCO2 if no shunting or V/Q mismatching) of 32 - 40 mmHg provides some vasoconstiction. A PaCO2 of below 30 mmHg risks hypoperfusion of the brain. The exception being if you have another noted state of acidosis....which you probably won't in the field.

Principles of Algebra come to play in many areas of medicine. Pharmacology is just one of the disciplines that utilizes it. It will also enable you to understand the basic equations for the cardiac and pulmonary systems. Many aspects of critical care medicine require higher math to understand even the most basic principles. Several healthcare professions require at least a survey of Calculus (and Physics) with 2 - 3 semesters preferred to enable the student to become accustomed to higher analysis and to understand the scientific literature in their profession. I doubt if the Paramedic will require that much math anywhere in the near future but Algebra is not something that should be ignored in your studies.

It is amazing how long things can come back to haunt you. I've seen copies of posts I made several years ago on a forum that is closed to the public and open only to licensed medical professionals by membership. Fortunately all the posts were about the profession and actually helped my application for the position I was applying for. If this reporter was truly looking for "dirt", there are several posts on different forums that could have been used as examples. However, since there was no formal reference made and just an easily searchable statement, there is little need to criticize the reporter. I have seen that statment on another forum but I would rather not go there to even get the link.

If that's NY's protocols then they may have some reason behind them. I have yet to have an N95 mask dissolve from sputum or sweat. The double elastic band makes them a more secure fit than the single band O2 mask. Usually a surgical mask of good quality will be sufficient. Healthcare providers wear masks to also protect the patient that is immunosuppressed. In the OR and other situations which require very clean or sterile technique, masks are worn to protect the patient's exposed wounds. So, a mask can work both ways. FDA statement http://www.fda.gov/cdrh/ppe/masksrespirators.html If you opt for the 12 L NRBM, make sure they are not at a high risk for airborne diseases or that they do not have a bloody mouth from the struggle. You don't want to inadvertently expose other professionals or bystanders. There are other ways to check for inadequate breathing without looking at the lips which do not always provide a good indication for some ethnic groups. I am not that paranoid that I do this for every patient. We are exposed to people with active TB regularly and as long as they are not spewing droplets around us, the risk is there but not as great. Patients that come from an at risk environment just require a few precautions if I am going to be in very close contact. It just keeps me out of the workers' comp office or from taking precautionary meds and/or testing that I would prefer not to do. I do work in an area with an International airport and seaport. We have a huge jail and prisoner population being treated at the hospital although most are transported not by EMS but by medical professionals from DOC in special vehicles for safety issues. We also have a significant amount of drug and violent crime in the city. And, we have a high incidence of TB and Hep C in our at risk populations. In the hospital we utilize every type of legal restaint available for the extended care of a violent patient. This includes transport throughout the hosptial for procedures. Not everyone may have these same concerns in their area. I've just been around it for 30 years and have become accustomed to taking precautions when there is a chance for a stuggle while trying to do patient care.

The tone of the article is giving a picture of something the lay person would see in the movies with "professionals" with "the syringe" for chemical sedation. However, the article is attempting to clarify if giving the versed is a police or medical decision even though it is the paramedic giving it. The article did not go into detail about the follow up medical care once the injection was given. I do agree that signing any legal paper while under the influence of versed is not the best idea. I would hope that the police have been informed about versed's amnesic effects in their training or by the Paramedics. I know there have been numerous discussions on this forum and others about what responsibilities and the roles EMS and police each play in restraining combative patients. The author did not site a specific reference because he/she is not using it as a specific point but rather to illustrate how some people may view the drug's potential uses whether it has been misused or not. For research, what the author of that article did was probably no different than what anyone from a Paramedic to the elderly lady wanting to know more about EMS and got some forum from just a random Google search. They can search the forum for a couple of words and see what pops up. I have seen that exact "footprint to chest" statement appear in the forums more than once. These forums can be taken as a "chat site" by some since they are in a different format than some professional listservs with a daily emailing of the new posts. The forums also start to lose their credibility if they allow some to continue to post very "off the wall" remarks and statements that do lack safe medical judgement or practice. Of course, credibilty on these open public forums is based on annominity. The link below was found with a quick search looking specifically for that statement. http://forums.emsresponder.com/showthread....light=footprint The forums have had some discussions that have brought about a less than professional tone toward patient care with derogatory terms used for patients including the mentally ill and the elderly. Of course we do know there are some that present themselves as having tons of experience and knowledge but their posted age and myspace page give a different view of the person. We also know that employers may check that "include the internet" box when they have a background investigating agency checking a potential new hire. If it is in print somewhere with your name on it you may be asked about it. If someone is using your identity, you may still be held accountable until you prove otherwise.

There are many, many formulas for various methods and protocols for the ventilation of children. If you see an RRT or RN bagging "outside of BLS or standard PALS" guidelines, it may be because they already know something about the type of ventilation the child needs. Here is an article that is very indepth for different ventilation methods in the pedi population. http://www.rcjournal.com/contents/04.03/04.03.0442.pdf Chest rise with adequate time for exhalation is still a good guideline. The 4 - 6 ml/kg is a good average. In the hospital we have formulas for correct ventilator settings from the ABGs along with disease/disorder driven protocols. Different BVMs have been analyzed in multiple studies and all vary to some degree for delivery which is also operator dependent. Unless you have the capability to monitor each breath for volume, visual assessment of vital signs, color, breath sounds and chest rise will be your best "formula". ETCO2 monitoring is good to stay consistent. The ETCO2 and the PaCO2 may not match due to some type of disease process or V/Q mismatching. You may also see a Neo/Pedi team using a BVM to 21% or on O2 but without the reservoir for FiO2 less than 0.40. The possibilities are endless in the world of peds with their many anomalies both repaired and not repaired along with the many causes of RDS. When you are starting with the unknown, follow your BLS or PALS guidelines and adjust from there according to your visual and physical assessment.

They usually prefer RNs with several years of ICU/ED experience who have an EMT-P cert (by challenge).

Regardless, there were processes at various ports of entry including Ellis Island and Angel Island that had to be followed. Even in present day, people who choose to enter this country legally experience long waits and discrimination. The quota system is not always fair. Look at the paperwork and stipulations for healthcare workers (RNs, RRTs) that enter the U.S for even short work contracts. I'm probably wasting my typing skills. I didn't check to see if this was placed in the "funny stuff" section. My apologies for thinking this was a serious discussion and spoiling the joke.

My family came through Ellis Island after the Indians had already sold NY.

Those 12 million illegal immigrants consist of several different nationalities from several countries. The fact that the U.S. government treats some very different than others makes this a highly charged issue. Just the issues concerning illegal immigrants in Chicago, NYC, Miami and Los Angeles are vastly different. You then have the differences between the students from elite universities that remained after their visas expired to the farm workers in the southwest. There's also the difference in treatment for those seeking political asylum and the refugee status. Quota mandates are placed on some and not others. Cubans, Haitians and other residents of politically embattled countries are all treated differently in the hands of the U.S. government regardless of the laws on the books. One can not just speak of a certain population of illegal immigrants and not deal with the other groups fairly also. I don't believe in amnesty across the board. I believe in due process if they are willing to do the paperwork and be finger printed.

The pillow case is not a good idea. You can not observe the patient if there is a sudden change in the status. If can also cause them to become more combative. A NRBM can become a dripping mess which can be flung all over you and the ambulance. The O2 would have to be running for safety which can also expose anything or anyone to droplets. The O2 can also become disconnected during the struggle which can bring about a hypoxic effect and make the patient more combative. The claustrophobic feeling of these masks can also exacerabate the situation. The surgical masks are somewhat safer. The patient that tries to "eat the mask off" becomes too preoccupied with his/her mouth full, thus creating a nice distraction for you to get the upper hand on the situation. You can double mask the mouth with the light weight surgical masks and expose the nose for an airway. We have to do this just to transport the patients in the hospital from the ED to procedures and to whatever unit or room they are going to just to protect anyone that might happen to venture into their spit path. Some of these patients from the street have active TB or other resistant bacteria in their sputum so the N-95s are used on the patient and caregivers. Security will usually help to clear a pathway to prevent exposure to other visitors in the hospital. My least favorite job in the hospital is transporting a combative TB positive psych patient to the lock down unit. Some may need to go on ventilators and may require both physical (5 points) and chemical restraints to keep them from hurting the staff. Some of the meth ODs and withdrawals from other drugs require intubation for the acute detox period so they can be adequately controlled without hurting themselves or the staff. Getting the IV for sedation and intubation can be risky depending on how quickly the IM meds take to slow them down. It makes for a long 12 hours. Thus, I prefer working the Neonatal unit in the hospital - two little velcro cuffs and they are "tied down".

The patient is in a nursing home. How old are they and/or why are they there? What meds have they been taking? Do they have PO intake or G-tube? Chronic O2 use?

Shane, thank you for coming back to us. I'm happy to see the BVM was finally utilized. CPAP can cause airway obstruction with the tongue in a patient that is unable to maintain their airway. The "contrary to manufacturers recommendations" is actually not from the manufacuturer but from the science of ventilation/oxygenation and utilizing CPAP as a mode. This principle of operation would hold true regardless of the setting or equipment. CPAP has been around for at least 50 years. I have used it for over 25 years in the hospital and on transport. Bird and Emerson started their modern ventilator era in the 1950s which included continuous positive airway pressure. Emerson actually started much earlier with negative pressure ventilation (polio) and then developed primitive positive pressure. The old Marks (Manley-Bird) revoluntionized the ability of cycling the pressure into ventilation. Scott, for further clarification, Bird and Emerson (Neil McIntyre MD later) are to the RRT as Florence is to the RN but with a better science foundation.

I see both sides and I really like the fact that no matter how much of a mess or hassle the patient is prehospital for 30 minutes, it sometimes doesn't compare to the mess and hassle they can create inside of a hospital. If I'm working as a Paramedic, I know I just have to get them through the doors of the ED. Even the ER staff is all to happy to get some of these patients to their assigned beds on the floors or units. Some unlucky RN and CNA (as well as others) will be putting up with the violent behavior, lack of potty training and withdrawals from substance abuse for 12 hours each shift. They may have not one but possibly 5 more patients with that behavior on their assignment. The next shift will probably bring more of the same if not worst since the previous shift's new patients are "detoxing" while becoming more anxious and "outspoken". The medical floors in a hospital is not all "soap opera" stuff. The other side of the coin, I have also seen patients come into the hospital on routine transports totally exposed or laying in feces from the nursing home because the EMT(P)s didn't take a couple minutes to get some assistance getting fresh sheets and sheeted the pt over as is. There are a lot of ride along programs throughout the country for Doctors and RNs to get prehospital exposure. Sometimes there are conflicts as to what their role in the field will be. When physicians (residents) ride with the Specialty teams, especially Neo/Peds, they are told they will be observing and participating only when asked. The protocols being followed come straight from the Medical Director of that transport team or the Neonatologist on duty.

The Division Chief Mark Rhame is also over Quality Assurance. Florida has trauma protocols which outline the criteria for a "trauma". Of course, there might be some extreme circumstance that warrants the call to be handled differently. If the time waiting for a helicopter exceeds ground transport time, then poor on scene judgement was utilized. Part of the "skills" for EMS providers, along with knowing trauma criteria, should be knowing where you are, where you can go and how quickly along with alternate routes and resources to accomplish this.

CPAP on a patient completely unresponsive to any stimuli? And shallow respirations?

Elderly trauma patients. Just knowing that whatever years they have left will be shortened and full of painful procedures breaks my heart.

The asthmatic that codes is a difficult patient. Even in the hospital with the ability to bag a high dose albuterol neb in with heliox, it is sometimes difficult to bronchodilate enough to relieve the trapping. I know of a couple of university hospitals that are researching methods to alleviate the air-trapping. As the below article mentions chest compression, the AHA has been kicking this around for several years. External Chest Compression in the Management of Acute Severe Asthma— A Technique in Search of Evidence http://pdm.medicine.wisc.edu/Fischer.pdf

The other articles are pdf files.

Just intubating a patient does not make the problems associated with COPD and asthma go away. Pouring albuterol down the ETT rarely works due to particle size, med adhering to ETT and cough response which prevents the medicine from getting to the smaller airways that need bronchodilating. We (in hospital and interfacility specialty or CCT) utilize MDIs and nebs both inline and with the BVM while waiting for the appropriate ventilator to be set up. 15 and 22 mm adapters can assist with connecting the BVM to the neb and tube. Many nebulizer T-pieces are designed with these connections for easy use in the field. Many expect immediate results from one bronchodilator neb. Often it is necessary to run high dose nebulized Albuterol either concentrated with the 0.5% solution with a special nebulizer on either intubated or non-intubated patient. This can also be diluted with Normal Saline to run continuous at doses of 5 - 30 mg per hour with or without a ventilator/ETT. Again a specially designed nebulizer is utilized. Putting several unit doses of Albuterol into a standard "acorn" neb may reduce its ability to nebulize the appropriately sized aerosol particles for maximum depostion. For your situations, you will still need to follow your protocols for dosage. There are times when the patient is so tight that heli-ox (helium and oxygen mixture) may be used to facilitate ventilation either by mask or ventilator. This may be required for several days until the inflammatory response subsides. The articles listed below are probably more information than you will need to know in most cases but aerosol delivery is a well studied science and an art. For the field you just need to adapt your nebulizer to the tube and the BVM. Be aware that the extra flow from the nebulizer with increase your delivered tidal volumes and can also hinder exhalation somewhat when "bagging in" a treatment. http://www.rcjournal.com/contents/09.05/09.05.1151.pdf http://www.aarc.org/marketplace/reference_.../01.99.0053.pdf http://www.chestjournal.org/cgi/content/full/115/1/184

Seventh Victim Of Copter Crash Dies Collision Claims Registered Nurse From Salt Lake City http://www.kpho.com/news/16793546/detail.html POSTED: 6:18 pm MST July 4, 2008 UPDATED: 7:11 pm MST July 4, 2008

I guess you haven't met many RNs during your time as an EMT. Of course, you may not have ventured much past the ED doorsteps either. To make a comment like that undermines any credibility you could have brought to the argument. Do you know how many clinical hours RNs and other healthcare students pursuing a degree spend at the patient's bedside besides all of the "book learning" stuff? Probably not since you make comments based only from your own limited learning. If you want to compare clinic hours 1:1 for EMS providers as the educational standard stands now with any other profession (including Nursing) you will find that EMS is lacking by about 1200 - 2000 hours behind the other professions. Even accountants must spend more hours with "hands-on internships" than many Paramedic programs. BTW, do you know why an EMT or Paramedic's protocol book is also referred to as a "recipe book"? Unfortunately......

You are comparing your EMT class with the "American Education System"? A "C" grade in an EMT class may also represent someone who is not motivated enough to get a "B" regardless of commonsense. Many people are attracted to EMS because out of all of the healthcare professions, there are few requirements for entry. Next to phlebotomist and CNA, it is also has the shortest time in training. At 700 hours, the Paramedic program at a Medic Mill follows closely to their minimum time in training for number of "hours". As the flashy ads say "in just a few weeks you too can work on an ambulance". If you sign up for classes at an EMT or Medic Mill, they will even fill out the paperwork for you. All you have to be able to do is sign your name on the loan. Your "independent thinking" also comes from protocols and state statutes writtened by college educated physicians , lawyers, advisors and board members including RNs.

Unfortunately if you read the causes of many collisions, impaired drivers (including sleep deprivation) and mechanical failure have been mentioned frequently. Some people may be trying to take care of their own and not wanting to get someone or themselves in trouble by not reporting a saftey issue. They may also fail to report reckless and/or distracted driving. Wanting to fit in can play a big part in letting some behavior slide. Here's a good news story. http://www.emsresponder.com/article/articl...n=1&id=7821 Partner Describes Kentucky EMT as 'Loopy' Prior to Crash The partner of a Louisville Metro EMS worker involved in a deadly wreck this past April described her as "loopy" and said she should not have been driving the ambulance. Target 32 has learned a Jefferson County grand jury is investigating whether Tammy Brewer should face criminal charges. "It's been like a nightmare," said Maggie Whobrey, the victim's daughter. "My mom's all I had. It's been rough." Whobrey's mother, Vickie, was killed in April after the ambulance driven by Brewer crashed while taking her to the hospital. "I want someone to be held accountable for their actions on my mom passing away," Whobrey said. "She shouldn't have died like that." Records show that Brewer's partner, Greg Gavin, sent several text messages to another ambulance crew telling them to alert supervisors about Brewer's behavior prior to the crash. In a statement, Gavin told investigators, "When we're on scene, I realized Tammy should have called in sick..." Other documents showed that 19 hours before the crash, Gavin noticed Brewer "was not able to drive straight" and that he "made her stop to switch places." Documents show Brewer told investigators a family friend had given her two headache pills prior to work and that she noted she didn't think they were narcotics because they "didn't give her a buzz like narcotics normally do to her." Brewer told police she swerved to avoid hitting a child. Last April, witness Tammy Pablo told Target 32 there was never a child and that Brewer was all over the road seconds before the crash. "It swerved from our lane to the other lane, back to our lane and it wasn't just a little bit of a swerve to the line, they were swerving all the way over to the other lane," Pablo said. "That hurts right there, knowing it could have been prevented that night," said Whobrey. "I think someone else should have been driving then instead of letting her get back behind the wheel I'm out for justice for my mother. She was someone very special." Shively police haven't released results of toxicology tests taken on Brewer after the crash. A Metro government representative told us Brewer is on desk duty and not allowed to drive an ambulance during the investigation. Brewer declined to comment when we called her at home.

Is this during hurricanes? When the storm is coming in and the winds start approaching 40 mph, it's time to start getting to shelter and secure your safety. I have worked on land still picking up patients up to 85 mph and swore that was the last time I do that. So far, I have held to that. The Air National Guard also likes to get their planes, each loaded with about 70 patients, out of the area by the time the winds start kicking at 40 mph. Our medical helicopters are also well out of the area by that time. That was a costly little oversight during Andrew. Florida has the same cautionary signs for slower speeds during wind gusts provided a hurricane is not approaching.