VentMedic

If the patient is truly "hyperventilating" I would probably not bag them. They are blowing down their PaCO2. Of course, one may not know that unless they can do an ABG. Rapid respiratory rates may also skew ETCO2 by sidesteam capnography. If the patient is tachypneic, understanding the reason for the rapid respiratory rate will determine the best method to assist either by supplemental O2, BVM or pharmacology. If the cause is fever, pain or severe V/Q mismatching, you may make little head way with a BVM and actually increase work of breathing. With the standard BVM, the patient is only getting the oxygen if the timing is good between the opening of the valve and the pt's inspiratory effort or clear airway if unconscious. If you are assisting a patient that is breathing rapid and shallow, they may be ineffective in opening the valve between the breaths you are giving them. If their mentation is off, they may think you are actually trying to suffocate them when they have their face pressed into a piece of plastic with little or no air moving when they want it.

A brief follow up identifies her as an EMT. Rockland emergency medical technician still unconscious after losing arm in crash http://www.lohud.com/apps/pbcs.dll/article...EWS03/804150410 WEST NYACK - An emergency medical technician whose right arm was amputated after the ambulance she was in crashed on Route 59 yesterday, remains sedated this morning and does not know the extent of her injuries, officials said. Bonnie Ames, 20, is recovering at Westchester Medical Center in Valhalla. "She's still intubated and she's fighting," Ray Florida, executive director of Rockland Paramedic Services, said this morning. "That's a good sign." Ames, a resident of the Orange County village of Florida, has been unconscious since the ambulance she was riding in crashed into a parked truck on the side of Route 59 in West Nyack yesterday morning. "She doesn't know that she lost her arm," he said. Colleagues have started a fund to help her family pay for her recovery. Contributions can be made in her name to the Regional EMS Benevolent Fund, P.O. Box 614, Nanuet, NY, 10954. "She has a long recovery ahead of her," Florida said. EMS workers are holding a vigil for her at the hospital. The driver of the ambulance was also injured. Scott Millar, 19, of Haverstraw is being treated at Westchester Medical Center for a head injury and may be released today, Florida said.

Not always. But, there isn't much information being released from the hospital, police or families at this time to the media except the obvious. Those "reliable sources" are probably wearing their uniforms into the hospital in an attempt to get a look at their injured co-workers. They are then running to their computers to post all the details of what they saw and heard.

I was reading through some of the comments of the locals from that article who were also speculating about the trucks parked alongside of the road as well as a few other factors. If you can weed through the usual disgruntled ex-employees grapping the opportunity to bash their former employer, there are some good posts.

There doesn't seem to be an official report as to what actually caused the accident or where the blame will fall. Right now we the the word of someone who "knows the driver" and is quick to cast the blame toward him.

Check the catalogs of colleges that have a variety of nursing and allied health programs if you want a more accurate description. If is usually call Applied Physics or Survey of Physics for Health professions. PHY1001 Applied Physics (AA) Credits/Clock Hours 3 credits (3 lecture hours) Prerequisites/Corequisites Prerequisite: MAC 1105~ Course Description A concentrated, one-semester, applied-physics course; includes essential physical principles for engineering, medical and other technician personnel. An overview of basic physics concepts is presented with minimum emphasis on mathematics. Includes physical mechanics, electricity and magnetism and optics. A grade of C or higher is required for this course to be used as a General Education course. If you need just a little more than the overview, you can take General Physics 1 and General Physics 2. For those that require much more, Physics with Calculus 1 and 2. Then you get into the advanced Physics classes. A "math for meds" class is great but limited. It does little for understanding hemodynamics or the basics of the respiratory system. Yes, there is a little more than blood goes round and round or air goes in and out. We do have computers that do most of the math for us but every once in awhile you have to understand how the numbers were derived. Don't EMT and Paramedic classes teach any thing about mechanism of injury anymore (velocity, force, angle) even in the simplest form? That should get one to think there is a little more to the job than elementary math. Has anyone ever noticed how the people lecturing at seminars or authors in journals present their data to support their statements? Do you just look at the pretty pictures or do you have enough background education to actually process the information adequately? The fact that some Paramedic programs still use Sidney Sinus node to teach the cardiac section speaks volumes about the lacking prerequisites. I still have the greatest respect for Nancy Caroline M.D. and her work. Her text was one of the first and served a great purpose back in the early days. My class did use Dubin to supplement so Sidney was a little easier to take and I was only 19 back then. If you have very few goals for much past the minimum of EMT or Paramedic, than no, don't prep for the future. If you think somewhere in your 30 year career you might want to expand to another area of healthcare than yes prepare with some solid classes. If there is even a remote possibility that EMS might achieve professional ranking with the other professions, prepare for it. It almost happened 30 years ago when modern EMS was still new and motivated. But, it may take another 30 years if the attitudes about "minimal" education continues. EMS can no long claim being a young profession as an excuse. And, you know what they say as someone or something ages, it becomes more difficult to change. RTs started to get their Associates degree long before it became mandatory because that was the plan laid out for the profession by their accreditation standards, national testing and professional organizations. The curtain is closing for the RTs that didn't pay attention to the standards that were going to be enforced. Of course, those that get booted from their hospital positions can probably pick up a PDQ Paramedic course since they may have some of the "skills" mastered already and will have something in common with their new co-workers by not having the college degree. There may also be quite a few people that became Paramedics because they didn't pass or had no desire to the prerequisites for nursing and other allied health programs. Hope was not lost when they heard the commercial for "do all this in just a few months'. When these programs are presented as "you'll be just like a doctor and better than a nurse", the attitude is fostered.

A lengthy front page story in the SF Chronicle today. The public comments are probably the most interesting. S.F.'s emergency responses fail to meet goal http://www.sfgate.com/cgi-bin/article.cgi?...3/MNR0VTB9I.DTL http://www.sfgate.com/ "Where in the hell are They?" Jim Doyle, Chronicle Staff Writer Sunday, April 13, 2008 More at http://www.sfgate.com/cgi-bin/article.cgi?...3/MNR0VTB9I.DTL

Some choose to answer questions with knee jerk responses to incite fear. Others choose to use education. You honestly can not say these questions have not been answered. It implies that you have not read your own P&P or have taken any type of education to inform yourself about what has been done to protect the patient and the provider. These questions have been answered by state and Federal laws that have been passed on as guidelines for policies and procedures in individual agencies. As I mentioned earlier, your HR and employee rights form can provide a lot of answers for you as well as additional resources. Everyday there are meetings concerning the next pandemic or the next AIDS or SARS at all levels of government and individual departments. So no, the "tough stuff" is not being avoided. Have you been involved in healthcare at all since 1984? Have you read your P&P manual? Have you taken any infectious disease continuing education? Have you participated in any infection control planning committees at any level? What have you done to either educate yourself or to formally express your opinion to those that make the laws and policies? There are alot of things in EMS that truly can be be harmful if not deadly to patients that need an ambulance. There is little education in EMS concerning those things either. I would say there is more chance of dying from a botched intubation by a poorly trained provider or in an ambulance accident caused by an impaired or reckless EMS driver than that very slim chance of an EMT dripping his blood directly into your open wound. It also amazes me that some EMT(P)s would even want to do any advanced skills like IVs, Intubation or CPAP with the chances of being exposed to more pathogens from the patients. If you are in health care, there are risks. There are risks for the patients in every procedure performed on them regardless of the situation. Education and improved training reduces the risks. Not scare tactics based on "what if" scenarios. Many of these "what if" cases have similar situations that are addressed in many eduation programs. If you are still asking the same question over and over, talk to your training officer, medical director or chaplan. There may be other issues simmering in the background that continues to muddy any reasonable answers or logic for you. It seems you have an overbearing need to have people agree with your view regardless if it is right or wrong. Not everybody works in your situation and your views may not apply. People that work in more modern BLS and ALS systems may have access to better education and equipment thus reducing the risks. If you can not keep current with safer techniques, the latest laws, statutes and policies that pertain to your job to keep the public and provider safe, find another profession because healthcare is constantly changing. There will be always be new risks as different disease processes are discovered or develop into resistant strains.

Ambulance services may have a different motive; they need warm bodies to fill minimum wage jobs. A college usually strives to produce academically sound classes with standards set by accrediting agencies.

Coming from a small country called Miami which is located just north of Cuba, I've heard all this before. The 1980s were turbulent times in Florida to a point where we finally had to vote on what language was to be the "official language" of the state in 1988. An interesting but very opionated website: http://www.proenglish.org/issues/offeng/states.html

A simple college physics class has little to do with the advanced quantum physics that you are suggesting. It just makes it easier when teaching people who do not have college sciences to use examples of what they know to teach some medical applications. Yes, FF/EMT-Ps may have the advantage over non-FFs and may grasp the basic workng principles but still do not have enough science background for much more than following a recipe when it comes to some procedures and technology. Unfortunately, EMS has based its education on just excerpts and not understanding the concept of what is involved. It is when you have enough classes to apply the learned concepts that you can better understand how the human body functions and how to apply the knowledge to the equipment or skills you utilize. .

Physics is definitely an important class to understand the law of force, flow and pressure which can be applied to almost any system or piece of equipment used in medicine. I have an easier time teaching the basics of respiratory theory to FFs than to EMT(P)s who have no FF background just because the FFs have more recent and practical knowledge of some of the laws of physics. Calculus, or at least a survey course, is also good if you want a higher understanding of the scientific literature especially in the cardiac and pulmonary systems. Of course, calculus and physics do go hand in hand in designing many of equations. Many people in the EMS profession complain that there are very few involved in research for prehospital medicine. There is considerable research going on but by practitioners of other professions that do have a more solid eduational base. The literature is then published in scientific journals which is where it remains until somebody simplifies if for JEMS. A Statistics class is also very valuable to allow you to weed through the masses of medical literature. Unfortunately many in EMS do wait for JEMS or some similar publication to put a scientific article from a medical journal into easy speak language. Some things do get lost in the interpretation depending on the education and understanding of the person attempting to over simplify the article. That person's own personal opinion may also come through in writing the article thus missing the actual value of the original. Both Physics and Statistics enables one to sort out the theory and the facts a little easier. Many often confuse the two.

Yeah, you might be a little rusty. But, that doesn't mean you don't have a lot of good information and knowledge to pass on in your posts. If somebody corrects or criticizes your posts, it may give you a reference as to what you need to review OR defend your views. Not everyone that corrects someone is always correct. Also, others may have had the same questions or presumed something to be true through "heresay". Example: When you used hyperventilate to mean hyperoxygenate, you are not alone. Many people do that without actually thinking through the meanings of the words. It's just "what everybody else says" in the field. It may not have even been noticed if you didn't happen to be discussing this on a forum with an RRT. I've been corrected by some of the best on this forum and have corrected some of the perceived best. For some, I just agree to disagree on a few things.

1 : 5 seconds = 12 breaths 1 : 6 - 8 seconds = 8 - 10 breaths The rates being quoted are for the initial phase as promoted by the AHA as quidelines. The new quidelines for slower rates with an ETT (Endotracheal Tube) are 1 in 6 - 8 seconds which is 8 - 10 breaths. These quidelines are meant to get people to think about what they are doing and not just squeeze away at the bag. Or, in the case of the layperson, not to think, but rather just do something as in the Compressions Only CPR. Once in the hospital, through lab values, a more appropriate rate is determined. THAT is what the RTs have as guides for establishing oxygenation and ventilation. The rules change with the known values, disease process, CXR and patient's own respiratory effort or how much that patient will be allowed to breathe over the ventilator through sedation or paralytics. The parameters may change several times while on the ventilator as the body adjusts, or not, to treatment. The RT may tell the ventilator to give bigger or smaller volumes and may need to adjust the breath rate accordingly if the same minute volume is to be kept. (Minute volume = number of breaths per minute X the volume of the breath) The RT also knows how the BVM must work to compensate for the lack of the features that a ventilator can offer. It is very difficult to mimic a ventilator exactly just because a BVM is a $10 piece of plastic being controlled by a human verus a $50,000 ventilator that has a pretty sophisticated internal computer running it. One of the lab tests that RTs do is an ABG or Arterial Blood Gas. This is blood drawn from the artery to determine oxygenation, ventilation and acid-base. It will give the amount of oxygen (PaO2) and carbon dioxide (PaCO2) in the blood which tells the RT what has to be done to get those values into a normal range. The pH of the blood is also affected by the carbon dioxide present as well as the buffering sytems of the body. The pH may need to be regulated by a change in the rate, either the Bag or vent, or through buffering medications and fluids. You already said it in an earlier post: "every patient is different". Every disease process affects the body differently. In the hospital, the RTs are working under the scope of their license and utilizing the protocols set by their Medical Director(s). They are responsible for that patient and ventilator when it comes to maintaining oxygenation and ventilation. They may also be trying to satisfy the orders or requests of several physicians for a variety of reasons. The guidelines of the AHA no longer apply once known values, protocols or orders are in motion. Once you finish EMT class, continue your education with some college Anatomy and Physiology classes. EMT is barely an introduction into the world of medicine. It seems that you are one that will go further because you are asking questions. Many take the EMT or even the Paramedic class as being all there is to know about medicine.

Hyperventilate - lower PaCO2 Hyperoxygenate - raise PaO2 EMS is Hyperventilating Resuscitation Patients http://www.merginet.com/index.cfm?pg=cardi...yperventilating The goal is to hyperoxygenate. If you hyperventilate, you raise intrathoracic pressure and drop the BP as well as the cardiac output defeating the hyperoxygenation goal. You also can vasoconstrict cerebral perfusion and shift the pH to extreme alkalosis which is just as bad if not worst than acidosis. Again, this is the reason for the new rate for ETT ventilations as I mentioned earlier.

Don't make me write about the OxyHemoglobin Dissociation Curve! Work of breathing and oxygen consumption can also be influenced if the patient has to fight the ventilator or the person doing the ventilations. It can also depend on the patient's pain and sedation medication since not all sedation meds soothes pain. Then you have that little thing with the disease process(es). Cardiac output and perfusion play a big role and we may start monitoring SvO2 as soon as a sepsis protocol is initiated which could be from multiple things like a lactate level or bilateral infiltrates. In the hospital, we may watch the size of our tidal volumes and give a higher rate to keep a good minute volume. Many, many factors go into Critical Care medicine. One statement can not sum it up for any specific rule for any one patient. We also have to be versatile enough to give and take on the ventilator and drips when RTs and RNs are running through a protocol. I may have to back off the vent as much as possible without losing too much ventilaton/oxygenation if the patient becomes hemodynamically unstable until the RNs catch up with one or several pressors and/or fluids he/she is hanging. Once the right stuff is hanging, the ventilator can go for its goal again. If I need a more stable BP or MAP to get into the oxygenation zone, the RN will have to work his/her magic with the pressors and fluids again. It may go on like that for several hours or even days. It is really a fascinating symphony of actions/reactions to do a full press resuscitation for sepsis, burns or cardiogenic shock in the ICU.

I was also wondering earlier in this thread why the student EMT was bagging a pt to CT Scan and a transport vent was not used. I would hope there was a vent waiting for them in radiology and she didn't have to bag through the CT Scan. If not, the RT should look for better working conditions or be nicer to the EMT students that are bagging in CT Scan for her. :wink:

Hyperventilation in prehospital is one of the reasons the rate was changed with an ETT to 8 - 10 or 1 every 6 - 8 seconds. I can see where your doctor may want that prehospital with the assumption of a 5 mmHg error. Hopefully the error is not on the low side of 30. For TBI in the ICU , we try not to go much below 35 mmHg for PaCO2 with 33 being acceptable as minimum to avoid too many changes and that is only with an SjvO2 monitor in place to watch tissue oxygenation.

No problem. The AHA in an attempt to simplify things may have complicated the breath rate picture somewhat with the rate being anywhere from 12 - 0 for adults depending on your level of training. Compression Only CPR is an interesting concept. I am looking forward to seeing lab results on these patients in the ED. I have seen a couple but they were dialysis patients which should be in their own category of Cardiac Arrests.

It is amazing that EMS is so fragmented that it can not even agree on abbreviations and terminology. Imagine the frustration of the hospital that have many EMS and transport services bringing and taking patients. If there are 15 differents companies, chances are there may be 15 different abbreviations for the same thing like SOB, DOE, DIB, etc. And then, you will always hear from some EMT or Paramedic, "they never read our charting anyway". No, we don't if we have to call someone from your service or keep 15 different reference charts to to understand whatever made up terminology is being used. Ever wonder why lawyers enjoy EMS lawsuits especially if they are representing the other party? What's really fun to watch is some Paramedics who have job hopped alot and can not understand what they themselves wrote the year before due to the lack of uniformity in documentation.

Again, if the patient is on a ventilator in the hospital with known lab values taken with a known minute volume, regardless of the back up rate since there are no other settings given here or the patient's own respiratory effort, one may have to bag accordingly to maintain appropriate ventilation/oxygenation for that patient. If the patient was breathing spontaneously, those breaths must also be taken into consideration. A recipe from the EMT protocol book does not fit all patients once known diagnostic values become available and the longer the body is "sick" by either poor perfusion and/or sepsis. The acid/base balance may have to be "chased" until some homeostasis is achieved and the problem(s) of the body are corrected. The guidelines usually taken from the AHA for rescue breathing can be work very well in the initial phase. However, the body may get a lot sicker quickly before it gets better, thus needing more Ventilation/Oxygenation support. The hospital is going to also take into consideration time down and anticipate the acid-base consequences for the disease process. If all the patients could be on the same ventilator settings, there would be little need for high tech ventilators costing $40,000 - $100,000 each and trained specialists such as Pulmonologists and Respiratory Therapists to manage them. In other words, you can bag the patient according to your guidelines and protocols in your ambulance. In the hospital, you may have to bag according to their guidelines and protocols as determined by actual lab values and the patient's own respiratory effort to maintain homeostasis.

Physicians usually call for hyperventilation initially because of down time and acidosis (both metabolic and respiratory) that is suspected. With a BVT to a 100% O2 source, I would expect a PaO2 to be higher. However if it is only 110 mmHg, that will give an idea to the cardiac output and V/Q mismatching or whatever the case might be. 110 mmHg gives you a considerable A-a gradient. ( Look up Alveolar Gas equation. ) Once fluids are infused, pressors started and adequate circulation returns, the body can try to adjust, thus, the ventilations can return to a more appropriate range. Dwayne, Thank you for coming in on this also. For this patient, there is not enough information to determine if this is a ventilation or oxygenation or both type of problem. We don't know the sedation used or the Mode, VT and Rate the pt was doing on the ventilator. It may also have been a Sepsis issue which again affects the lactate, anion gap and SvO2. That also requires special consideration for maintaining oxygenation and ventilation. However, few here including myself that should not be second guessing what is appropriate for a ventilator patient inside a hospital without knowing more of the diagnostics or diagnosis. I also know that I may change my ventilator strategy several times during the course of the shift as the patient's conditon warrants. That is why we have many different protocols along a college degree and many, many hours of inservices/training by our Medical Director(s) as RTs. Again, so many factors to consider once the hospital diagnostics are done. Textbook quidelines are great in the initial phase. Once more information is obtained inside the hospital, the rules that existed for the initial can change quickly. I've had pts deteriote quickly as the PNA or V/Q mismatching progresses rapidly to where I think I am going to have permantently cramped hands from "leaning into" the BVT to keep a patient ventilated/oxygenated until a special vent and/or gas was set up. I've also had PNA patients that were breath 40+/minute to maintain a barely acceptable level of ventilator/oxygenation until intubation is setup for. For those patients, it is a very quick RSI and without ego involvement, the best intubator goes for it. A BVM may be useless on these patients. These patients will usually go straight to an ARDS protocol on a ventilator with high PEEPs, lower VT and a high Rate. Yeah, I'm throwing some nickel terms out there, but the basic level is very basic with lots more to learn. It is too bad the RT didn't take more time to explain herself because now we are only guessing what that particular situation and the ventilator protocol followed by the RT. It is also very likely that she would have sounded alot like my posts. It may be hard to explain it without referring to lab values or specific disease processes that you have not and probably will not cover in EMT-B. If you want more help for what to do in the field or initially, then I know several people on this forum who will be willing to give you advice either on or off line. Don't stop learning. You have just been introduced to one tiny snowflake in the blizzard world of medicine.

You just explained why the RT was not a very friendly type of person. She is covering at least two potentially heavy areas (ED, ICU), setting up equipment for both areas and no sign of backup. She's probably also had pts on a couple of med surg floors as well as the Rapid Response and Code pagers. Nursing probably didn't want to tie up one of their nurses and were of little use to the RT. She had to trust an unlicensed, uncertified EMT-B student with a patient that needs a ventilator in ICU. I normally enjoy the help of students but I also don't let them or my intubated patients out of my sight if at all possible. That includes students from the schools of RT, Nursing, EMT-P as well as MDs in training. Once the patient is is on a ventilator I relax. My ventilator will usually do what it is told. Although some of the newer ventilators like to agrue that they are the "smart ones" until the over ride button is engaged. The ventilator will also tell me what buttons have been messed with and what alarms have been answered or ignored. It will also be a witness for the committees and courts in cases of adverse medical events resulting in permanent damage or death while on a ventilator. BTW, did the RT have you bag the patient DURING the CT Scan? Bookmark this thread and come back to it as you advance your education beyond EMT-B. When you are in the field without the use of most differential diagnostic equipment, your protocols are general guidelines to get you through unknown situations while hopefully doing the least amount of harm. There are many factors in the hospital that determines the protocol for ventilator and patient management. RTs may have no less than 50 different protocols for ventilator management strategies. Each protocol may have several variations or pathways to take for different factors presented by patients that don't quite meet the text book definitions.

You titled the Thread "Bag-Valve-Mask" but you said the patient was on a ventilator? Or was it Non-Invasive Ventilation via a ventilator? I'm going to go with you meaning Bag to tube. Most of the principles with be the same for either ventilator/ETT or NIV. However if NIV, hopefully there was an NGT in place. What was the pt's dx? What was the full ventilator settings including MODE? How many ventilator days? What was the chest X-Ray looking like? What was the last ABG on the ventilator? What was the patient's minute volume on the ventilator? A back up rate means little if they are doing Spontaneous breathing trials or on an APRV mode which may have a set rate of 8 or 10 with an inverse I:E utilizing a demand valve that allows supported breaths at the upper level of pressure. It is not wise to drop the MV far below what the patient requied for homeostasis. If the patient required 22 L/M, that may be what you will have to match. Also, what was the pt's level of PEEP? PEEP valves on BVTs are very different than the flow PEEP on an ICU vent. The RT may have been wanting to maintain a little intrinsic PEEP to compensate for the inadequacy of a flow retard PEEP valve. What type of V/Q mismatching did the patient have? Patients with different lung disorders may require very high RRs and still never be able to blow off their CO2. ARDSnet we may go up to a RR of 35 with low VT and buffer with THAM while allowing for permissive hypercapnia. We also use High Frequency ventilators that have an oscillating cruising rate of 600 cycles/minute. Welcome to your introduction to Critical Care medicine where the challenges for the long haul can be very different. You stated you asked several students about the rate. Did you ask the Respiratory Therapist who had been taking care of the patient on the ventilator to explain anything to you? Many RTs love to teach. If you are an EMT student, I apolize that my post is a little advanced probably even for some Paramedics. ASK QUESTIONS OF THOSE WHO MAY KNOW the answers when they are within reach! Use the licensed professionals as resources. That is the quickest way to learn when in clinicals.

I hope that doesn't include war stories of all their terriffic saves. That can be exciting and fun but also distracting from the material at hand. While it is good to know there are heroic ways of doing things, there are also basic concepts, no matter how boring, that must be taught. EMS is unfortunately lacking in professional educators. Often it is the instructor with the most war stories to fill up the class hours that is voted most popular. Thus, we see people on the street that can believe they will see everything their instructor has seen and be rather surpised when they may not see some of those things their entire career no matter how long or short it is. The smarter ones may also find that they were not taught the basics to deal with the day to day calls and move on. The others may keep waiting for that one war story, not even realizing what they haven't been taught about patient care.