VentMedic

Here's an EMT class in the Miami area for almost $3000. http://www.barry.edu/emt/whyBarry.htm Barry University is a an excellent but expensive school and I still have not figured out why the started teaching an EMT class even for adult continuing education. Miami is full of expensive EMT and Medic Mills that may be slightly more or slightly less than this program. The only possible reason has to be to attract young people to the other programs.

Vomiting - Aspiration - Ventilator - PNA - ARDS - Trach - Vent Farm *Use caution; a human patient isn't some manikin you've been playing with in EMT class *don't force against the patient's breathing *have suction ready *understand the underlying cause and why the body is responding accordingly (fever, acidosis, V/Q mismatch, air-trapping) Yes, you can BVM a conscious patient. But, use some commonsense and work with the patient by using verbal support for reassurance that you know what you are doing and coordinate with their breathing. If you are still unsure about this, find a good mentor to give you some additional advice for this and other possible scenarios. Control of an airway is too important to put off thoroughly understanding a procedure until it happens.

U.S. trivia In the U.S., Funeral Home directors and workers (grave diggers) ran the ambulance services in small towns until the late 1980s...without doctors on the ambulance.

Very handy devices to keep around.

Magic Johnson confronted these issues in 1991. He was also a member of the Dream Team for U.S. basketball which won the Olympic gold medal in 1992. The same "what if" arguments posted on this thread were used in 1991. The world knew alot less about HIV back then. Yet, the some of the same lack of education and reasoning still exists. You don't hear these discussions by other educated healthcare professionals. Maybe the years of mandatory HIV/AIDS/HCV education in the colleges and work places have paid off. Through that education and the realization of risks in everyday life have made them practice their profession more efficiently and not fearfully. They know their coworkers with HIV and HCV are just as well educated, and probably more, about their diseases and risks. Maybe some here are assuming that because the infected person is an EMT or Paramedic, they are not educated enough to know the risks or precautions about their disease and will infect others due to that lack of education. Some of the "what if" arguments presented in this thread have made EMTs and Paramedics out to be pretty ignorant in the way they would "unknowingly" go about infecting their patients. Even those that are not infected are cautious about not dripping their blood on their patients. There is a very good chance that someone on this forum will contract or have contracted TB to which they test positive for the rest of their life, HCV or possibly HIV through personal or professional contact. Some may already be positive and not even know it, yet. In the year 2008, with our medical advancements and education, should that mean you quit being an EMT or Paramedic and just give up? I would hope not. There are many HCWs out there in this situation. Fortunately the numbers are not shocking and majority of the exposure (except TB) is through personal/intimate contact. Those who become symptomatic or whose T-cells drop will look for work out of direct patient care. That is the real world.

Along with I-85, EMT-S, EMT-B, EMT-P, MICT etc. Does anyone have any questions as to why the public doesn't know what to call us? We don't know for one state to another or from one day to another. And, that doesn't include the list of "skills" each can do. Unfortunately, there is little said about education for each of these levels on the state websites. Just "skills".

That is definitely something to think about. I know we do in Florida every hurricane season. The 2004 season had us flying patients out of state because some of our hospitals were maxed from taking in patients from damaged subacutes, NH and other hospitals. Supplies such as oxygen may not be available for several days to replenish the rapidly depleting main supply tank. Hurricane Andrew taught us alot in Florida. Unfortunately, when Katrina was heading for NOLA, those lessons were never applied there even though they were talked about alot. Citizens get irrate when hospitals do evacute in the face of potential disaster. They too have the opportunity to evacuate but may make the choice to stay and then complain when other exercise good judgement for safety. If the hospital keeps emergency staff available, it may encourage people in the community not to evacuate. If the hospital takes a direct hit, emergency crews will have to take the risks of rescuing the hospital based crews. This takes the resources away from other rescues. I have participated in the evacuation many hospitals over the last 3 decades. It can be a nightmare if there is not plan in place but just random calls for assistance. Returning the patients back to their proper facilities can be even more taxing on resources. Hurricane Georges taught me alot on that situation. One of my more memorable evacuations was Tampa General many years ago. Why someone would build an 800 bed trauma center on an island with one little bridge is a question to ponder. http://standeyo.com/NEWS/06_USA/060710.Tampa.surge.html http://www.sptimes.com/2005/09/24/news_pf/...l_s_plan_.shtml

GO UNIONS!! My RNs friends and I are enjoying a 10 day paid vacation in SF during the CNA (nurse) strike. My RN friends are making almost $90/hr with 1.5x after 8 hours and 2x after 12 hours. We are in a beautiful hotel in downtown near the bay. Our flight and meals are paid for. Do I have a problem being a "scab" by some union standards? NO! This strike is the 3rd for these nurses in less than a year and they are going to have another in 3 months. The strike is not about wages or benefits. They can not even say it is about working conditions since their nurse to patient ratio is protected in California statutes. It is about the hospital corp building a larger neuro/CVA center for acute intervention and rehab in a non union hospital. It is being built there because that is one of the few facilities that is retrofitted for earthquakes. It is not just to piss the union off. Luckily 50% of the RN didn't see this as a valid reason to walk out. The other 50% were led like sheep. Bless them because I needed a vacation in another state for awhile to appreciate Florida even more.

As Tniuqs already made reference to, ETCO2 and SpO2 are just simple tools that may help guide you with treatment for your working diagnosis from the whole clinical picture the pt is presenting to you with other signs and symptoms. This is off topic but I just want to demonstrate that the intended use or capabilities of the Pulse Oximeter and ETCO2 monitor may not be fully understood by some. ETCO2 monitors are excellent if it is a respiratory event and waveform analysis is used to narrow down some possibilities. If one does not know the PetCO2 : PaCO2 gradient for a V/Q mismatch or perfusion abnomalities you may be misled. If the ETCO2 respiratory status is in the face of a metabolic abnormality where you do not know the anion gap of the patient, again, you may be guessing in another direction. Remember there are metabolic, respiratory and mixed acidosis. These all come in varying degrees of compensation. The same goes for pulse oximetry. One may have 100% SpO2 but may have an A-a gradient of almost 400 mmHg (sea level). The oxyhemoglobin curve is also not understood by many Paramedics or EMTs. A shift in it, significant V/Q mismatch and various perfusion problems give you a train about to derail and with an SpO2 of 94 - 100%. Hb and HCT values also influence the validity SpO2 and CaO2 especially if the H & H is low. When running a sepsis protocol in the ICU, we will not allow the SpO2 to drop below 97% if possible by the creative use of ventilators and pressors, using the measured SaO2 and PaO2, for the first 12 - 24 hours if the lactate is staying at 4 mmol/L or above. Most of our O2 titration and BP pressure support treatment will come from the SvO2, CVP and MAP. Once the sepsis is stabilized, hopefully the PaO2 will be adequate to where O2 can be weaned enough to get off the O2 clock and still keep a PaO2 of 55 mmHg. That may still give a high A-a gradient if the FiO2 is at 0.60. Even for many cardiac patients, not all MIs are straight forward and have other underlying causes or disease processes which must also be taken into consideration at some point. Some may need to be addressed before cath lab intervention. There is not enough differential diagnostic equipment, time or knowledge available to the Paramedic to adequately rule out or rule in the many disease processes. Flight Paramedics come with various backgrounds and knowledge. Since flight medicine has increased in the number of companies, many trying to stay alive financially, standards have changed. Even by reading some of the posts on the specialty forums, one can tell the education and mentorship is not that great in some of services. There are some areas that I (myself) would prefer an hour ground transport with very knowledgeable and skilled ground paramedics or EMTs to a haphazard 10 minute flight with some of the teams whose company is utilizing the warm body or cowboy mentality.

While it is nice to have the SSN and meds memorized, how many times have you asked how did the dialysis go? Was the BP stable? Were they able to get off the amount they expected? These are questions the ED staff will usually ask if you divert. Many treat dialysis pts and other "routine" calls very lightly and don't actually look at the patient they are transporting but just go about doing their paperwork. That is, until something happens. The various forums have had dozens if not hundreds of threads started by people complaining about doing dialysis transports. Most don't understand dialysis or the disease processes of these patients enough to even construct a worthy argument.

You don't have to move out of California to still be a "traveler" or contract employee. It no longer matters where you live anymore as it had in the past. One just has to hook up with an agency and negotiate a contract. A few health care professionals have eliminated the agency and negotiated they own contract after forming their own agency.

But, once you do get the RN license in California, the perks and mobility are quite nice. And, even though the wages for RNs in Southern CA are 1/2 to 1/3 of Northern CA (SF Bay area), one can still go contract and get the rent paid along with a decent wage.

For this reason I can never understand why some EMTs and Paramedics consider dialysis pts "BS". Too many things go wrong quickly. These do occasionally get diverted to the ED before or after dialysis. Many times they have to be stabilized including intubation prior to going on the machine. Often the machine may have to come to their bedside in the ED or ICU. Some EDs get a little concerned because their hospital may not have dialysis capability. That can be a nightmare reality for an RN and ER doc to be stuck caring for one of these patients and finding transport for them to an appropriate dialysis center. The patient may have had a recent change or should have had a change in their dialysis "recipe". Electrolytes and fluid balances do many things. Many pts have on or post pump MIs. Some dialysis centers will have a code cart but still rely on the code team from the hospital if attached. Others rely on 911. As far as the dialysis center giving you very little info, you may have been one of the few that ever asked wearing an EMT or Paramedic patch unless it is a code at their facility. When these patients are diverted to our ED, the only info we can get from some ambulance crews is Diagnosis of dialysis or Renal Failure (luck guess). Code status is rarely known. The pt is known as the M-W-F 0700 dialysis run and that is all. Many crews have seen these patients several times as their regulars and know very little at all about who they are transporting. Rarely do we even get baseline vitals because it was just a "routine".

Respiratory Therapists are usually bounced from these "bars" as I was 5 minutes after setting foot in one. Airheads Rentals http://www.oxygenbarrentals.com/index.html http://www.oxygenbars.com/barsfaq.cfm http://www.oxygenbarsanfrancisco.com/

The maintenance and testing is still done under the company name. The company should also define safety for their volunteers carrying the O2 in their POV and how much responsibility they are going to absorb. The differences being with these volunteers, health clubs, schools etc, as opposed to anybody with an EMT cert, there is a paper trail that must be made for each usage of equipment just like any other run report. Unfortunately I have even heard of some "EMTs" running around with non medical or industrial grade (87% - 98% ) which can be obtained through welding shops. This is also what the O2 Bars are known to use.

The guidelines for non-prescription use are meant for public areas such as healthclubs, chiropractor's clinics, schools and dive boats where the AED might also be found. Documentation of training must be kept, maintenance records and a special registration to purchase the O2 must be obtained detailing everything. The tanks must meet the flow and minute requirements and yet be small enough to be safely stored in public. The O2 can not leave the site with some worker who wants to go off to find their own rescues after hours even if they are an EMT. Other than that exception, O2 is still very much a prescribed drug. Even the "O2 Bars" are aware of that. People in the health care profession should be aware of these regulations but most don't know some of the basics of O2 storage, tank maintenance, documentation, purchasing and FDA standards pertaining to their own job on the ambulance. You would also have to purchase the masks and NCs. If you choose to "take just one" from your employer, that could get you into problems down the road since stealing paper clips from your employer can be considered a crime eventually. If you are working for an event such as a bike race, SAR or wilderness outings through your company and still under your medical director's protocols, that might be a different situation. If it is the company's tank that you are using, they are responsible for you and that tank.

In California, if you can get a position even if just for the duration of RN school, the big hospital systems will help get you in to a program, pay for your classes, and may pay for you to attend class instead of working. University of California, Kaiser, SDA and Sutter are all known to have programs like this. Most will also reimburse you up to $40- $50k for approved schools. The SDA also have their own RN degree programs. Kaiser has its own health care schools for various technology oriented degrees in healthcare such as Radiology and Nuclear Medicine with an agreement from local colleges for the prerequisites.

Excelsior is not recognized in California as well as a few other states. For some states they will recognize it if you get two years of work experience in another state. As an entry level degree, it also may not be recognized for advanced RN positions or ICU jobs at some hospitals. There are no Excelsior grads in any of our ICUs nor can they apply for a Flight RN position even with Paramedic cert and experience. They must have the ICU experience. The managers have made an issue of that. Their point is they don't want to spend a lot of time training someone on the very basic patient care nursing duties which should have be taught in the first semester clinicals of RN or LVN school. Some Excelsior grads are viewed as baggage with just a paper degree and no practical hospital experience that must be dragged around with other staff picking up the slack. Granted, there are exceptions to the rule. Just be careful with some shortcuts as they may cause a problem in your career path later. Most college RN programs will give you credit for your Paramedic certificate if you graduated from an accredited school. That can cut some time off your schooling. Be glad you're not going for Respiratory Therapy or it would be a full 76 semester hours for just the Associates.

Sounds like an interesting company. Just a quick Google got quite a few hits. It is a partnership and the EMT driving should know his paramedic doesn't belong up front when there is a patient in the back. My question in this article that popped up is if you know someone is impaired, why do you still allow them to be on an ambulance? Sherwood Cuts Ties With Ambulance Provider Wednesday, Oct 4, 2006 @07:42pm CST http://arkansasmatters.com/content/fulltext/?cid=49800 - The City of Sherwood is cutting ties with ambulance provider Arkansas Emergency Transport (AET). Next Tuesday morning at 8 a.m., MEMS will take over as the interim service provider for the city of Sherwood. This comes on the heels of several recent incidents involving on-the-job performance for AET. On Monday morning, September 25th, Sherwood paramedic Amy Smith was arrested for public intoxication. According to a police report, she showed up to a home on a medical call, where her speech was slurred and she stumbled around the living room. In that report, co-workers say she had been up for 72 hours and was taking seizure medications. In another incident, according to Lt. Cheryl Williams of the Sherwood Police Department, AET did not properly respond to an emergency call made by a man with a heart problem. MEMS Executive Director Jon Swanson says two ambulances will be sent over on Tuesday, and they will be prepared to operate 24 hours a day, seven days a week. He says this added coverage will not short-change the regular fleet. Swanson added that most of the AET workers are good paramedics, and he has encouraged them to apply for jobs with MEMS.

Finding an ideal site for intraosseous infusion of the tibia: an anatomical study. Clin Anat. 2003; 16(1):15-8 (ISSN: 0897-3806) Boon JM; Gorry DL; Meiring JH Department of Anatomy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa. jmboon@medic.up.ac.za Intraosseous infusion is a technique used for the administration of fluids to a hemodynamically shocked child in whom attempts to access the vascular system have been unsuccessful. Although few complications are seen, injury to the epiphyseal growth plate during the performance of this technique remains a serious problem. This study investigates the relationship between the site of insertion of the intraosseous needle and the epiphyseal growth plate, and the ease of needle insertion into various locations of the tibia in newborn infants. Fourteen newborn infant cadavers (28 tibias in total) were dissected after placement of four needles: 1). through the tibial tuberosity (Site A); 2). 10 mm distal to the tibial tuberosity (Site ; 3). 20 mm distal to the tibial tuberosity (Site C) and; 4). 10 mm proximal to the tibial tuberosity (Site D). Distances from the distal end of the epiphyseal growth plate were measured. A high number of needle placements at Site A were inserted into the epiphyseal growth plate. Most placements at Site B were between 10 and 16 mm from the epiphyseal growth plate on the right side and between 10 and 15 mm on the left side, and all were inserted without difficulty. Although far from the epiphyseal growth plate, most placements at Site C were very difficult to insert because of the thick cortical bone. All placements at Site D entered the epiphysis or the epiphysis and joint space of the knee. An insertion site of at least 10 mm distal to the tibial tuberosity is therefore recommended to avoid epiphyseal growth plate injury and ensure ease of insertion. Food and Drug Administration Update: Pediatric Highlights Posted 04/27/2007 Marcia L. Buck, Pharm.D., FCCP; Kristi N. Hofer, Pharm.D. The above paragraph is in almost every set of instructions including those by the manufacturer. You can follow the references cited in the manufacturer's instruction manual or in the PALS book for more information.

Not many hospitals have dialysis available in house. Even fewer have CVVH available even at some of the higher level ICUs. Except for the part about the Paramedic sitting up front, this is not that uncommon. Many Paramedic services can tranport just about anything if all the meds and equipment including balloon pumps are set up for them at the hosptial. Some accept a LVAD without knowing what it is or because they don't know what it is. They "monitor" the drips and technology attached to the patient. I know of no hospital RT department that would allow a ventilator to be trusted to anyone but their own staff. It is bad enough when hospitals must allow their IV pumps accompany the patient without a nurse and not knowing the knowledge or competency of the paramedic. Again, the paramedic will probably just "monitor" the pump and not do any intervention with it. Surely you've read some of my posts ragging on CCT or some ALS trucks that consider themselves capable of handling anythng because their company bought them some very simplistic vent like the ParaPac or lower level. There's virtually no alarms on these things and very little monitoring capability by the technology itself. The HCW must watch the patient and monitor vital signs. I could give you pages of examples of mishaps that don't make the news because someone is already writing a settlement to the family and/or the state is writing a cert revocation notice. However, it does get a little sticky when the service is part of a government entity. Hospitals are getting wiser and establishing their own CCTs. They then don't have to rely on the inconsistencies in education, skills and training of whoever happens to show up on the ambulance. I've had a few Paramedics tell me they can do ARDSnet protocols because their little Eagle Univent 754 has a plateau pressure button on it. That only tells me they got no education or training about ARDS, plateau pressure or how their machine works. We've even had Paramedics who think their little "face mask with the resistive valve" is the equivalent of a hospital CPAP machine. The saddest part is these transport companies can actually get some hospitals to believe they are capable of things that they actually shouldn't be due to inadequacy of education/training. The Paramedics working for these companies need to also understand the difference between Critical Care Medicine and ALS.

For that reason many patients are still afraid to be honest about their medical history in the year 2008. I guess you haven't been in EMS that long. This has already be tried and trialed. When HIV first appeared, that is exactly what happened all over the country. In some areas, if the patient was transported at all, the EMT(P) would ride up front with the driver leaving the patient alone in the back. Then, a big deal was made out of it like it was a case of Ebola being brought to the hospital. Although, in all fairness, we actually knew more about Ebola than HIV at that time. There was also the infamous case with the Ray brothers whose home was destroyed by an arson fire. The FFs of the community watched saying the "HIV" could be in the smoke and it was for the good of the town that it burned. It also got rid of "them" meaning the young boys who were hemophiliacs. Thank goodness they weren't gay. Who knows what might have happened to them if that had been the situation with the GRID association. If you want to read more about these events and EMS reaction to HIV from the mid 1980s thru the early 90s, visit the archives of the EMS magazines. Hopefully healthcare providers are better educated about HIV now. Although, I still see some reactions from a few providers that makes me wonder about that. Hepatitis is very prevalent and many people don't know they have it until they become symptomatic.

In the original post the pt was alert. Since CPAP was being considered by a couple other members of the forum, it was not taken that the GCS was 5 or I would hope one would not have considered CPAP on a GCS of 5. The patient has gone from the orginal post to knocking on heaven's door during the course of this thread.

bullfrog09, At what point did your pt go from being alert to a GCS of 5?

Bagging is NOT CPAP (Continuous Positive Airway Pressure) unless you have a continuous flow bag like a mod. Jackson Reese. The biggest mistake on UNconscious patients providers make is holding a standard BVM over a patient's face for "continuous CPAP". That is not how that works and it is called suffication. Even with a resistive PEEP valve in place on the BVM, it is not CPAP. Know your equipment and how/why it works. Let's also not confuse the terminology beteen CPAP and IPPV. Those are two totally different things with different affects for effectiveness. If you do not have a tight seal on the face mask, which that is what bothers the patient most usually, you are just giving them a "puff of oxygen". I've seen that enough also. For that you might as well just give them the NRBM instead of teasing them. Now for positioning so a patient can bag themselves. It is much easier if they do this with an ETT or trach. Most adults lack good muscle tone to keep their arms raised for very long. If they bring the bag to the chest they have a tendency to tilt the head forward, thus the risk of ventilating their stomach. Guess what that leads to? The pt will have decreased ventilatory space in the lungs as the belly inflates and later aspiration with or without intubation. Of course they can get an uncomfortable NG placed (or OG if they are on a ventilator later). If the patient is anxious, talking to them for reassurance may help their breathing more than the BVM. However, if the patient is acidotic from some metabolic reason their body is not going to let them slow down. More effective breathing to enhance minute ventilation can improve some situations. If you bag, you must match the minute ventilation or you will get them into more difficulty by dropping their pH quite rapidly. Biggest pet peeve is watching a paramedic "coaching" a DKA to take sloooow breaths. What do you want a pH of 6.0 which they aren't that far from? Deep and more effective breaths to keep their CO2 low and their pH up for just a little while longer would be nice also. As ERDoc said, it is a judgement call. Just don't panick if not every patient responds to bagging like you would expect them to. Always have plans B and C ready to go.