VentMedic

Do you really believe that the public does not know EMS exists? Do people having chest pain do not know that they will get help when they dial 911? Do you think they don't know the importance of the emergency vehicle that is going to the accident scene? Have you never listened to a group of informed senior citizens discuss 911 issues? Have you ever taught CPR at a senior citizen center? Have you ever glanced through an AARP magazine to see what retired people are concerned with? Actually, they might be able to better educate you on the intricacies of different systems. You truly under estimate public awareness. Anyone who pays taxes or lives in a county that has put a trauma tax on the ballot is bombarded with literature and commercials on trauma and EMS. Florida just went through its tax reform amendment on the ballot to which we spent almost a year of BS from various know-it-alls telling us where our tax dollars should go. This election year has many people talking about all aspects of healthcare including what type of service they can expect and how to pay for the ambulance bill. How much medical detail do you think they need or want to know? They don't need gory details and you may hope they don't ask for your educational background. Most people have other professions because they have no interest in medical stuff. People in the medical field have accountants because they have no interest in doing their own taxes. Although, I do want to know the educational background of my accountant who I would never hire if he only had 700 - 1000 hours of training. Yet, these professionals do trust you even if they know you are not the most educated or work for XYZ private company or you are a volunteer whose service they support at the benefits. Of course, one could say they have no choice in the matter either for the most part. Rather than having people know who the individual players are, I would like to see people having chest pain awareness reinforced to those busy professionals that think a heart attack cannot happen to them. Yes, they know what 911 is for but they are in denial about their own health situations. I would like to see people educated on how to use the 911 system or what other options are available. They don't need to have their mind boggled with different "certs' of individuals, just how to use the different services. Maybe I missing your point. I really don't think the general public wants to know each and every little detail of your job. I know I could go into great detail about what I do in HEMS or on a specialty transport team as could others with different professions. When I show up with a NICU team, the parents just know we are there to help their baby. We don't need to impress them with some of our very impressive years of experience or extensive education and credentials. They just know that we're there for them even if they had never heard about us until the unthinkable happened.

It is very difficult if not down right confusing to explain many EMS systems. As with the recent article with the multiple responders in Florida, how do you actually explain something like that without the public wondering why and who? If you start to explain the many "certs" that some states have like Washington which is 6 or more with the difference between some is just 1 "skill", do you think that the public is not going to think WTF? Especially since someone has to maintain the public agencies that are administering all the "certs". And, if John Q Public steps into the next municipality, it all changes with a different system and different providers. If EMS has not been able to show standard definitions that at least have some similarity rather than "prehospital" to the legislators, how do you think we should start to explain this mess to the public? Do you think that if some in the profession view it as a maze of a mess that the lay person can also figure this out if they haven't already when they get their tax bill? With the inconsistent educational requirements which are now public knowledge by some recent news articles that it takes longer to be a nail polisher or hair cutter than a paramedic, I don't believe this profession is actually ready to explain itself to the masses or to offer any good reason in the lack of education part. EMS is now 40 years old and much older than many professions that have achieved recognition if not in the public eye but in the pockets of the legislators and agencies that are responsible for reimbursement. To continue to argue "young" profession is just another excuse. Most of the reporters are also too young to remember or care how "old" something is.

I agree if you want to put out accurate information about who and what you are you should have a Public information system in place. News teams don't know all the correct titles of every one on scene. Half the time we can not assume who is on scene with the many different credentials and possibilities of various professionals on an ambulance. Do you want news people to interrupt patient care to find out who you are? Again, in some areas you are recognized by who you work for like the FD and not your specific titles. Using the term ambulance driver might seem to be the most benign if they see you behind the wheel of an ambulance. If they use the term EMT and heaven forbid you are a Paramedic, that could be scandalous. Likewise for using the term Paramedic and you are an EMT. Of course, that doesn't begin to cover the other 46 different titles you could be called. quote by Scaramedic You honestly don't give the public much credit so why should they give you much thought? The public is bombarded with TV shows and Medic Mill commercials that enable them to get a good idea of what EMS is a about. Even the old show EMERGENCY hinted that Paramedics could at least start IVs and that was in the 1970s. We've also got Paramedic characters on shows that are not "in your face" EMS but still get the point across about what they do. What about the shows that recreated a dramatic rescue with EMS providers and then had a happy reunion with their Paramedic life savers? Rarely if ever in those shows were the countless other health professionals ever mentioned including the nurses and surgeons. Which, if it had not been for a whole team effort, the paramedic may not have had that "save" to their credit. Most people in EMS have no idea what many if any of the other healthcare professions actually do along with their correct titles even if you see these professionals every day in the ED. How often do EMS providers bash ALL NURSES in general without taking into consideration the extensive education and professionalism of ICU and the many specialty care RNs? News teams are also more cautious about printing blood and horrific photos from accidents. So are the EMS magazines that used to run endless photos in their magazines from amateur EMS photographers. This however does not stop EMS from getting recognition. If you notice on almost every EMS forum website there is a news feed that is continuously picking up stories from newspapers around the world. Yes, it picks up both the good and the back but there are still some really good articles that are being printed in some papers. If you believe that EMS is picked on by bad stories being printed, you should visit the forum websites of other professionals for their news links. Everyone gets a piece of the limelight at sometime for both the good and the bad. Often the ones that complain about not getting enough attention in the media are also easy to spot in the ED or trauma room. These are the EMTs and Paramedics who sulk when the doctors and nurses don't take time out from working on the patient to chit chat about what a great job they did and give a hand shake or a slap on the back. Maybe doctors and nurses just have patient care as a higher priority. They also may not get recognized in the same news article as FD and PD for what they will do to save that patient's life. Of course when Nurses and other allied health professionals feel the need to inform the public about who and what they are, they have strong national organizations that can run a few promotional ads and articles. The FD doesn't hesitate to promote itself in a wide variety of ways. If you are truly a healthcare professional, somewhere in your education you should have been told you may not always be recognized for the work you do. You will have to find satisfaction in knowing that you gave good patient care. This goes for the thousands of health care professionals who also have important roles in patient care even if they are not always visible on the street in a nice uniform with a big truck.

In Florida we don't worry about that because EMS is all about the Fire Department who also usually owns the helicopter. Occasionally it may even be one of our communities featured in the photos that are still Public Safety so you have LEO, FF and EMT-P all in one person. Also in Florida, you may not be expected to be a Paramedic for a "career" if you are with the FD. You may be rotated to an engine after 2 - 3 years and not have to work a rescue ambulance again. If you are with a private ambulance service that is also responding with the FD, please try not to block the photo op for the expensive fire department equipment so the tax payers know where their money is. So, for some areas, the boundaries are blurred and priorities are different.

Clumping or non-clumping liter? Not that I want to venture North of the Mason-Dixon line or even out of the sunbelt region, but you never know when this information could be useful.

Often, fatique is mistaken for "knocking out the hypoxic drive". Out of all the COPD pts, which that are many different classifications and levels within each, only a small percentage can actually be classified as CO2 retainers. http://home.pacbell.net/whitnack/The_Death...rive_Theory.htm The Death of the Hypoxic Drive Theory On March 15th I gave a talk at the 22nd Annual Tahoe “Odyssey” Conference, a conference for Respiratory Care Practitioners, Nurses, and Physicians. The topic was “The Death of the Hypoxic Drive Theory. By “Hypoxic Drive Theory” I am referring to either the default assumption that any chronically compensated respiratory acidosis implies reliance on the hypoxic drive to maintain adequate gas exchange….or …..that chronically compensated respiratory acidosis means the central chemoreceptors are defunct or deficient. This is more than just a theory, it’s become a clinical mindset, almost a medical urban legend. “He’s a retainer”, “that’s where he lives”, “he’s in the 50/50 club”, etc., all are like so many clinical buzzwords. There is the existence of a hypoxic drive. It normally accounts for about 10-15% of the total drive to breathe. We all have it, unless perhaps we’ve had bilateral carotid surgery. It becomes obliterated at a PaO2 above about 170, and becomes a greater stimulus as the PaO2 drops below 70, and especially below 50. There is a hyperoxia associated hypercarbia, which can develop in certain patients while they are in crisis. But it has little, if anything, to do with respiratory drive. When COPD patients are in acute respiratory failure they are usually breathing somewhere near their maximum limit. When 100% O2 is applied the CO2 can be driven up by 3 factors… The Haldane Effect. Unsaturated hemoglobin carries CO2. A patient in crisis may arrive in the ER with an SpO2 on room air of 75%, the unmeasured mixed venous saturation may then in turn also be much lower than the 75% norm. All this unsaturated hemoglobin is then carrying an extra CO2 load. This is in the setting whereby the patient has an already elevated PaCO2, perhaps has an elevated Hgb after years of hypoxemia, and is “topped off” on their ability to ventilate. So for every rise in their SpO2 we are driving more CO2 into the plasma. If this were you or I, we would simply then ventilate this extra CO2 out via the lungs. But their lungs can’t and don’t, therefore the CO2 shows up in the “downstream” ABG. The release of hypoxic pulmonary vasoconstriction. Imagine the worst ventilated alveoli. The local CO2 pressure there may be 100 or more. On room air the local O2 pressure will surely be less than 60 torr. At this level of local hypoxemia, the adjacent pulmonary vasculature will constrict. Blood will then be sent to the alveoli which is ventilating more effectively. Ventilation/perfusion matching is enhanced. But if 100% O2 is given the O2 pressure will not drop below 60, the pulmonary vasculature will not constrict, and V/Q matching will not be optimized. Just as giving Nipride may drop the PaO2 as hypoxic pulmonary vasoconstriction is released, so giving 100% O2 may also raise the PaCO2. This also can happen to patients in an asthmatic crisis given 100% O2. It’s not that we knock out a hypoxic drive, so much as we drive in a hypercarbic potential. Then further compromise ventilation through increased V/Q mismatching. A small amount of the CO2 retainers whom are in acute failure, and whom have their PaCO2 increased further from the two mechanisms listed above, will then reduce their minute ventilation further by about 15-20%. Usually the PaO2 will have been about 40 on room air, the PaCO2 70. Given 100% O2 the PaO2 rises well above the 170 range whereby all hypoxic drive is obliterated, and the PaCO2 rises to 90 or more. But is this a result of a central drive deficiency? Or of central wisdom? When the PaO2 is 40 the patient can’t let their PaCO2 go up to 90. If they did the PaO2 would plummet to about 20 and rapid death would ensue (per the alveolar air equation). But when the hypoxic drive “gun to the head” is removed, the patient then titrates their respiratory effort such that the ventilatory effort and work is proportioned out for the long haul. It is not a drive deficiency. We may view this as patient permissive hypercapnea, may apply non-invasive ventilation, may simply realize that hypoxemia kills and hypercapnea does not, or may intubate them. Or hypoxemia may be used as a respiratory stimulant. But if this is the tactic chosen, it should be viewed as akin to giving epinephrine to an already compromised myocardium in order to maintain adequate perfusion pressure. Just as if we were to see this same patient arrive in stable condition for a clinic condition later we wouldn’t insist they needed an epi drip to maintain a sufficient cardiac output, so too should we not insist that a CO2 retainer not in crisis needs hypoxemia in order to stimulate adequate respiratory drive. In the May 98 issue of Clinical Pulmonary Medicine is an article titled Acute Respiratory Failure in Chronic Obstructive Pulmonary Disease” by Schiavi. In it the author concludes that…… “....The traditional idea that oxygen induces hypoventilation by suppressing hypoxic ventilatory drive at the level of peripheral chemoreceptors is no longer tenable.” MUCH MORE INCLUDING REFERENCES: http://home.pacbell.net/whitnack/The_Death...rive_Theory.htm

If you understand the oxygen-hemoglobin dissociation curve, V/Q mismatching, shunting and deadspace you will understand "hypoxic drive" better. If the person has significant V/Q mismatching or acute lung disease going on, they may still require large amounts of oxygen to maintain a decent PaO2. We look at A-a gradients and not "SpO2" in the acutely ill. In other words, for someone with normal lungs, the PaO2 might be 400+ mmHg on 100% O2. The pt who is distressed might still have an SpO2 above 90% on 100% O2 but have a PaO2 barely above 60 mmHg. If the person has low Hb and diminished O2 carrying capacity, you have a very ill and compromised patient that needs oxygen. Also, 2 L by NC is not the same FiO2 for everyone. Neither is a NRBM if the pt's minute volume exceeds 15 L/Min. If a person has a rapid RR, they are entraining mostly room air diluting the O2. I rarely worry about hypoxic drive in acute processes unless they are a chronic hypoventilator. If a person still can tell me they are short of breath, then O2 is still appropriate. If they have some neural muscular disease such as ALS or MD where they chronically retain CO2 due to muscular weakness and not lung pathology, I will be prepared to support respirations with the O2. Some people with severe obstructive sleep apnea are also prone to this. And then you have the central apneas which just require ventilation if they fall asleep such as Odine's curse or Central Hypoventilation Syndrome.

Did you even read the beginning or middle of this thread? I posted educational information and links to additional sites. And, I posted all this on a prehospital forum with EMTs and Paramedics as the intended audience. You even posted on another forum where I started the Texas RSI thread and where I was pro proper protocol and procedure. rogue medic If not properly secured, as you stated earlier to being guilty of, the tube can migrate during transport or transfer. Conclusion? ... Once again, did you actually read my posts? Or, is this just a snip at those who do not have ETCO2 monitors? When you intubate, the first thing you look at is the vocal cords. You do not close your eyes but rather you watch the tube to pass through the cords. You can also use the vocal cord marks on some of the smaller uncuffed tubes to determine placement. If you have any neo/peds experience, you should be aware of that already. You can also do a quick check for the tube before you yank out the tube especially if it is just a cuff above the cords which can be fairly easily remedied. Direct visualization with a laryngoscope is only of my many favorite methods in the ED, ICU or on transport. I can give you many examples of things that can skew just about any assessment scenario and that is why it is not good to rely on something electronic but also to have several alternatives that require physical assessment. But then, I have already stated this earlier in the thread. I also posted an extensive list of things that can present similar waveforms which may require a physical assessment to determine the cause. It is going to be a long time before all of EMS is on the same page in this country. Protocols and equipment differ from state to state, county to county and city to city. I do not criticize those that do not have all the latest and greatest gadgets. That includes ETCO2 monitors. The exception, of course, is if they are doing advanced procedures such as RSI or IFT - CCT with ventilators. But, I am just repeating what I have already said. BTW: This thread was not even about pro or con Capnography in the field. There was not a question as to its usefulness. It was started by the OP asking for some information to learn more about Capnography in the field.

I think Florida and its firefighters are having a bad news month. Fla. EMT sues 911 caller over injury claims http://www.ems1.com/ems-products/personal-...r-injury-claims By Helen Eckinger Orlando Sentinel Copyright MOUNT DORA — When firefighters rushed Steuart Baker's mother to the hospital in May 2005, he never expected anyone to sue her. Elizabeth Baker, now 84, has moved into an assisted-living facility. But her son continues trying to fend off the lawsuit filed against his mother by a firefighter-emergency medical technician with Lake County Fire Rescue. Jennifer Roland claims she suffered back and neck injuries when the front left wheel of a fire engine broke through the lid of an old septic tank in front of Elizabeth Baker's house in Mount Dora. The lawsuit, filed a year ago in Circuit Court, seeks unspecified damages of more than $15,000. From the start, Steuart Baker said, he's been upset that a paramedic would sue a patient. "Police officers, firemen, paramedics are public servants," he said. "If I call a paramedic and they hurt themselves they'll sue me? That wasn't how public service was intended." Roland would not comment on the case. But her attorney, Kim Cullen of Orlando, said that he thought that the paramedic was within her rights to sue. Baker, a gun-shop owner in Mount Dora, grew up on the property with his parents and brothers, including state Sen. Carey Baker, R-Eustis. He said no one knew about the septic tank until a fire engine arriving to take his mother to the hospital broke through the lid during an emergency call in March 2005. The engine had to be pulled out with a tow truck. After that, Baker said, he filled the tank in with sand himself, and thought the problem was solved. But in her lawsuit, Roland says she was hurt while riding on a fire vehicle that broke through the septic-tank lid on another emergency call two months later. Steuart Baker is coordinating the family's defense of the suit because his mother is too ill to handle it herself. Roland's personnel file indicates she has received above-average performance reviews since joining Lake County Fire Rescue in 2001. The file also contains documents pertaining to Roland's multiple periods of medical leave and light duty since the accident. Christopher Patton, a spokesman for Lake County government, said that Roland had received worker's compensation benefits, but would not specify how much, citing privacy laws. Patton said that Roland notified her superiors when she filed the lawsuit, but that they now are looking at the case with more scrutiny. "They didn't actually view the lawsuit. They didn't understand all of the ramifications that were involved," Patton said. "Perhaps we're at fault for not investigating what the intentions were in the suit." Last October, Casselberry police Sgt. Andrea Eichhorn sued the family of then 2-year-old Joey Cosmillo, who fell into a swimming pool, suffering severe brain damage, in January 2007. Eichhorn responded to the scene, slipped in a puddle, fell, and broke a kneecap. Eichhorn dropped the lawsuit less than two weeks after she filed it, in response to numerous complaints and criticism from the public. The Casselberry Police Department fired her in December after an internal investigation concluded that she had violated several department policies, including damaging the department's image and filing suit without giving the police chief advance written notice. Patton would not say whether Lake County Fire Rescue would take action against Roland. But he said that the public shouldn't fear calling 911 because of potential legal ramifications. "Any time you call 911, there is an expectation that you should be safe and not in harm's way," he said.

You are in their ED. They have every right to remove your stuff and apply whatever equipment they want or not. Your stuff may not be compatible with their stuff. They may not want more lines to get tangled when moving the patient and prepping them for procedures. They may not want extra deadspace in the circuit if it is no longer performing a function. Maybe they want to use only the equipment that belongs to them that is properly calibrated by them if they are putting their licensed signature on it. If you have any ICU experience, you should already know some of these things. I don't know what your argument here is, but there are still some acceptable standards in the field that are also dictated by well known authors, researchers and medical directors. Name dropping can be impressive but not an end all for all research. I already said it was a valuable tool but care does not have to stop if you don't have one. Even hospital ICUs don't fall apart without one. Believe it or not but I do remember when I was first introduced to ETCO2. I also remember how it was integrated into my life at work both in and outside of the hospital. Is the machine also holding those tubes in place for you? The transport environment is not always a smooth ride. That is not at all what I stated anywhere. Just because a service does not have ETCO2 does not make the paramedics working for it any less competent than those that do. After seeing your other posts on another forum and your blogspot, are a rep for an ETCO2 company selling to EMS?

People have also been intubating successfully for almost 4 decades now in prehospital without the use of an ETCO2 monitor. Not everyone is trained equally or has a good medical oversight in place. Not every service has the same tax base. Not everyone is doing RSI yet or even a lot of sedation. Not everyone is working in comfortable environments with lots of extra help to carry lots of equipment. If your intubation skills suck, capnography is not going to improve that. It may not mean you are an incompetent provider but if the company thinks buying more tools is going to improve that instead of getting your skills up to par.... As I mentioned before, capnography does have its place. I am definitely not against it. However, before you make blanket statements, you must take into consideration all the different levels of training and skills abilities as well as the frequency of intubation per month or even per year for different services. Sometimes one tends to get very self absorbed in their own perfect world that they can not see all the issues surrounding something as what you perceive to be as simple as capnography. In both the ED and the ICU, it is used as a diagnostic tool and not an expensive tube sitter. It will definitely be removed in many ICUs across the country if that patient did not warrant ETCO2 monitoring. Experienced ICU personnel do not need another piece of equipment to add to all the other bells and whistles just to tell them a tube is here or there. Since they have ventilators, CR monitors and educated professionals at bedside, they know where their tubes are. They also have diagnostic tests to tell them what is going on with the patient. If there is an ETCO2 on the pt, the pt may be a difficult wean or they are expecting the lungs to worsen or maybe improve or predicting mortality by the deadspace ratio. It also does not have to be used for simple ventilator weans. So no, these people in the ICUs or EDs may be not ignorant, just better educated and more confident in their training and skills as well as their adjuncts which you may not be aware of. As high tech as many ICUs are, they also know they may have to triage out their less needed electrical appliances in a disaster. Quess where the ETCO2 monitor ranks as must have equipment by experienced ED and ICU personnel? The problem starts at the "training" institution and continues throughout the medical oversight. I have used capnography in various situations many times over the past 25 years. I have learned its limitations as with any technology. It sounds like you are putting alot of faith into a piece of equipment that can fail you. The wave may not change at the slightest movement. I listed other variables that also mimic similar wave patterns. What are you going to do the day your piece of equipment doesn't light up? Are you going to pull what could be a perfectly good tube if your monitor still says flat line because you don't trust your own self with watching it "pass through the cords". Or, will you ignore the patient and "work the machine" instead? Are you not using another assessment skill and sense of "feel" for this procedure and relying a little on your human qualities to do this? Just curious, who sold you on capnography and who trained you? How long ago?

Nice post. But, too many spend more time troubleshooting the machine before the patient. It also still gives you a false sense of security as the tube's cuff migrates or stays above the cords if you didn't see it pass. The problem with accidental extubations is not assessing for proper placement of the tube in the airway . Is the cm mark appropriate for the height and neckline of the patient? You can still get a waveform with the cuff laying on the cords being used as an "LMA". After that, the tube is haphazardly secured. If I nickel for every tube that was placed by recipe and not by commonsense, assessment or cord marks, I would have been in retirement long ago. No piece of equipment is going to magically correct imperfections in how one places or secures the tube. Nor, is it going to make someone who already lacks assessment and intubation skills any better. That has already been "discovered" with the pulse oximeter. I think those that have understood intubation and assessment have not had those experiences mentioned above when they get to the ED. I'm not arguing against capnography but rather for a better educational system that fosters intubation skills before capnography is used as a crutch rather than a diagnostic adjunct.

While I do agree capnography is important for IFTs, it should never replace physical assessment. I also argree with firedoc5 that a visual of the tube going through the cords should ensure the cuff is also below the cords. Breath sounds are still a good standard for placement below the cords and above the carina. Skin color and quality of pulses or BP are still important. Unless you have a thorough understanding of capnography and all of its many components, you could chase the wrong numbers or read too much into it especially if you have too little info to correlate with the numbers. If you are not accustomed to reading the wave forms, you again may read the wrong things into a situation if you are not watching the patient more than the monitor. Just like the pulse ox, too much or too little can be read into the results especially with all the factors that can also affect ETCO2. Some of those listed below concern us more in the hospital, but if you do interfacility transport you must be aware of factors that can give less than optimal waves and normal numbers. This is especially true with some of the portable transport ventilators with single limb circuits and external PEEP/exhalation valves. Sudden drop in etCO2 reading to close to zero : Complete deconnection Totally obstructed tube Esophageal intubation Complete malfunction of the respirator Sudden drop in etCO2 reading to low value : Partial obstruction Leak in respirator system Emboli (Air, Fat, Thrombus) Exponential drop in etCO2 reading : Pulmonary embolism Sudden hypotension (blood loss, caval compression) Cardiac arrest Esophageal intubation (respiration of the stomach!) Persistently low etCO2 without a good plateau : Bronchospasm Partial obstruction (kink in tube, cuff hernia) Secretion in tube, respiratory tract Discharge rate from capnograph too high Breathing frequency too high (Children, tidal volume too small) Persistently low etCO2 with a good plateau : Large dead space (in respiratory tract) (Chronic Obstructive Pulmonary Disease, COPD) Non-calibrated equipment Pulmonal hypoperfusion with hypovolaemia and high positive pressure respiration Gradual decline in etCO2 : Hyperventilation Hypothermia Reduced systemic or pulmonal arterial perfusion Gradual increase in etCO2 : Hypoventilation (Leak) Rising body temperature (malignant hyperthermia) Absorption from external CO2 source (Laparoscopy) Sudden increase in etCO2 : Beginning of partial deprivation of blood supply Injection of "Nabic" *(sodium bicarbonate) Gradual increase in both base line and also etCO2 : Rebreathing (valves, bypass, breath calcium, fresh gas flow) Flattening out of the decreasing side (inspiration) and increase in the base line : Defect inspiration valve with large counter/contrary flow Increase in the base line and artifact between the single capnograms : Defect expiration valve with rebreathing Short dip in plateau Patient fights against the ventilator Leak at the cuff of the tube Gradually increasing expiration side : Bronchospasmus caused, for example, by COPD Secretion in respiratory tract Kink in tube 'Shoulder' in the plateau phase : Uneven emptying of lungs (lateral positioning or surgery, lungs leaning on the thorax) Source: http://www.medana.unibas.ch/eng/amnesix1/lungmain.htm

I am always amused when this question comes up. If EMTs and Paramedics pay attention to the WHOLE medical environment they are in especially for all those "BS" transports, they may see alot more of the medical field. They might also be able network with other professionals including physicians who have who knows what opportunity for them. EMTs and Paramedics really do limit themselves by staying to themselves and not venuring into a mixed audiences for CEUs or inservices. I also think taking the EMT-P degree at a college offers the opportunity to meet other future professionals of various professions to see what motivated them to choose that particular career. The isolation because "we're different" gives them little experience to see the vast opportunities there are in the medical world. Paying attention as a Paramedic ambulance driver on IFTs is how I found RT. I then found Exercise Physiology as a way to serve several options including more Cardiopulmonary education, physical fitness training, research opportunites and a Masters degree to teach with. ACLS was even taken to a new level in excercise challenge tests. High altitude testing knowledge also benefited my career in HEMS. Of course, the ultimate in my career was being able to do both excercise challenge tests and altitude testing on pediatric cardiacs and pediatric heart or lung transplant pts. As an RT, I too could travel anywhere in the U.S. and make a good wage with all expenses paid. With my teaching credentials, I could do educational seminars or moonlight at the colleges during the slow times to pick up extra cash. Everything still comes together to even create new opportunities if you use your education and not just rely on skills. Too much competition in the hospital where all the skills overlap. The education makes them unique. That is why there should be not quick jump by skipping important material and experience in some bridge programs. A mail order RN program gets you nowhere in many places especially if you want to do critical care medicine. Thirty years ago, if I had known the frustrations of EMS being self-limiting as a profession due to attitudes and lack of edcational standards, I probably would not have entered it for a career. I probably would have been a hobbyist at it instead. Of course, I probably would not have found and followed the other rewarding paths without it. I see several other professions that are in as much demand as RNs. Physical Therapists can command as much if not more in many areas of the country for pay and travel benefits. They can work in almost any type of environment. But, their education level is Masters minimum with Doctorate preferred. A Bachelors minimum is preferred for almost any profession now in a hospital. Nursing educators need a Masters in most larger hospitals. Many Paramedics don't even consider HBO especially at large burn centers because most have never been in large burn centers. HBO in coastal areas can also be a good "retirement" job. I know a couple of Paramedics who are managing their own multi-place chamber. Public Health degrees? Look up the on at UC Berkely. This is a popular degree now for disaster management at all levels. It is also very popular for some areas of research.

That 35 - 45 is only a NORMAL value. Different patients may have some variance from that depending on what their normal PaCO2 is, lung pathology and acute disease process. Secretions, pulmonary edema, poor perfusion and a whole list of things that skew that number. We give that just for a decent reference point and an easy number for paramedics who do not have a starting reference or some idea about what is going on with the patient's overall clinical picture. Biggest pet peeve is when "well meaning" CCT Paramedics 'make' IFT ventilator patients NORMAL by screwing with the ventilator settings thinking they are doing us a favor "because the number wasn't between 35 - 45". Watch the links and learn more about V/Q mismatch and shunting. The other problems is unfamiliarity with the equipment. Poor calibration, maintenance, cracks in lines, cracks in the sensor, malfunctioning sensor, poor connections etc. Just like the pulse ox, there's always the human factor of both the provider and the patient to be aware of.

Lots of information to cover if one wants to have thorough knowledge. Capnography with waveform is preferable over Capnometry (color change) which can be subject to false positive by the presence of CO2 in the esophagus. A good waveform is helpful in determining the tube is in the trachea with each breath. Changes in the waveform can indicate changes in placement, cardiac output or pulmonary status. Different waveforms can help with a field diagnosis as well as trouble shooting problems during ventilation. Watching the numbers (and waveforms) can prevent over ventilation. Observing the trend in numbers can be most beneficial to check for sudden changes or change in patient's status. Observing the waveform can give you a clue what the change might be. The numbers: 35 - 45 mmHg is the norm PaCO2 range for normal lungs to maintain a good pH provided there is not a metabolic acidosis present. PaCO2 is measured by an arterial blood gas. There is an error of +/-5 as well as a chance the numbers do not correlate to the actual PaCO2 due to deadspace ventilation or V/Q mismatch. V/Q mismatch can be caused by blood shunting such as what occurs during atelectasis (perfusing unventilated lung area) or by dead space in the lungs (ventilating unperfused lung area) such as what occurs with a pulmonary embolisim or hypovolemia. If there is an arterial blood gas available we look at the difference (gradient) between the Pet and PaO2. As far as using ETCO2 during a code, the ETCO2 will increase with effective CPR and ROSC. If you lose circulation or the person doing compressions tires, ETCO2 will fall. Quick and easy overview: http://www.capnography.com/outside/911.htm Another good website which contains alot of other useful info on BiPAP, CPAP, WhisperFlow as well as capnography. http://elearning.respironics.com/index_f.asp

Or, you can just move to Florida where we run 4 different trucks to each scene to offer a good variety. You can choose from an ALS engine, BLS engine, ALS Rescue with or without transport capability, ALS ambulance, BLS ambulance, private or public, and a few mixed crew trucks for good measure. At the scene you can pick a partner(s) and climb into the back of the truck of your choosing. Then all can form a Conga line to the hospital so that no one feels left out.

Even better is when you have an ALS engine and an ALS Rescue with transport capability responding to a patient with a true emergency. For a few cities in Florida, that ALS Rescue ambulance is just for show even though it is perfectly capable of hauling a patient. The ALS crews will still wait the 15 minutes (or have them run L/S) for the contracted BLS ambulance, load up the patient, all their ALS gear and 1 or 2 paramedics into that BLS ambulance. They will then proceed to the hospital with the ALS engine and ALS Rescue ambulance parading behind to pick up their paramedics at the hospital.

Another thing to consider besides personal safety, will your vehicle and the many other vehicles of well meaning citizens delay/hamper the EMS and Rescue vehicles by taking the good parking spots? If EMS/Rescue have to park a half mile away, that is not productive. The more vehicles that park at scene the more attention and rubber neckers it attracks even tempting more to stop to see what all the excitement is about. Thus, the traffic slows even more delaying EMS.

Dead In Bed? It may mean Difficulty in Breathing which got its start a few years ago when "SOB" was considered offensive because it got "giggles" in the EMT/Paramedic classes. And they wonder why the ED staff doesn't bother to read their reports. Each agency has their own set of terms and abbreviations. Of course, since most skipped any standard medical prerequisite classes that covered basic medical terminology/abbreviations, what can you expect?

This was all mentioned in the Amendment 1 Tax Reform election last year. The taxpayers cast their ballots and spoke out against the big spending when the budgets with problem areas of spending were made public. The commercials used by those in favor of the amendment were designed to scare the senior population into thinking there would be no FD or ambulance ever again coming to save them. They didn't expect an educated voter turnout. Luckily, most of those seniors were retired business people who could read a balance sheet and saw through the bs. I also remember some heated discussions on the forums about this topic. The unions were hitting for the emotional response. Of course, the only county in South Florida that is really counting its nickels is Monroe. But they've got their disproportionate pork that is making parts of the county EMS struggle while money is diverted to "special projects" within the Sheriff's department and EMS. Some of the other rural counties that do not have the tax base as St. Pete or Boca Raton are struggling but some of it is perception because they are the have nots being compared with the haves which are counties with services like the one in the article. Finding quality ambulance services to take an area's contract is also an issue in some counties. Of course, when the ambulance service is doing just fine, the FD wants it.

It can be nice to support all the toys of the FD. That is, until you get your property tax bill. Of course if your house catches fire, the ALS engine will probably be on an EMS call.

What part impresses you? For over 2 decades parts of Florida have not be able to function with less than 3 vehicles responding to a sprained ankle and that is with ALS on each truck including the ALS engine. Running only two crews from different agencies is a big stressor for some. And, let us not forget the helicopter that also responds to some of the trauma calls. Florida must ensure there are enough jobs for all of the medic mill graduates. That is one of several reasons why I was not upset with the tax reform amendment that passed.

Congratulations! That goes double for getting your degree!

Actually many professionals work directly under a medical director's license including Radiology and Respiratory as well as anyone who is involved in specialty transport. My medical director has the ability to bust me to tank jockey even before the state takes my license if he so desires by taking away my ICU job description. A Paramedic can be busted to a BLS or transport van if they want to stay with the company. That has been done a few times in South Florida. If you are with fire rescue, you just go on an engine. That is probably the biggest advantage of working for a FD as well as the blessing of the union to protect whatever you may do. Anybody remember some of the articles I post occasionally about the San Francisco Fire and EMS department? The 1980s had the worst times for departments and companies in South Florida. They learned some hard lessons during that time concerning illegal activities of their employees. Florida, as do many states, publishes the names of people disciplined. It makes for very interesting and embarrassing reading. http://www.doh.state.fl.us/mqa/enforcement..._reports06.html If you know the person whose license you want to look up for specifics: http://www.doh.state.fl.us/mqa/enforcement...ne_reports.html Side note: Dale Dubin's name is still in the files. Florida also pubishes a newsletter with general news and a list of violations but no names. http://www.fl-ems.com/ Site outlining disciplinary steps: http://www.fl-ems.com/Investigations/Inves...ons.html#idiscp There are also employee assistance and "rehab" programs provided by the state of Florida DOH for people to participate in to save their license.