VentMedic

Unless you have a bag like a Jackson-Reese circuit, it can be difficult to bag a conscious and alert patient. Jackson-Reese is a free flow bag like you see in some Neonatal units but larger, in the OR, ICUs and ED for intubation. For the standard BVM, you would have to make a tight seal and match breath for breath until you could overcome their ventilatory drive. If they have to fight against the valve of the bag, which on most bags takes a minimum of -20 cm H2O to open, they will become more anxious and increase O2 consumption at both a systemic and ventilatory level. If by some chance the patient allowed this and you were able to match breath by breath, you could gradually increase the VT of each breath until possibly slowing his rate but still giving the same minute volume with the bigger breaths. So the shallow and rapid breathers may present as easier to over ride their effort if matched with gradual increase of VT provided they will allow for the tight mask seal. And then there is that aspiration thing you have to worry about when using the BVM. The NRBM is actually not a "high flow" mask. It is limited by design at 15 liters or whatever you put into it. Many patients have a Minute Ventilation demand of well over 20 liters/minutes when in distress. This is where the old Elder demand valve could actually be very useful provided the EMT(P) knew what they were doing with them. It all depends on the quality of each breath. 36 is nothing for someone with metabolic acidosis such as DKA. For a DKA patient, if they were maintaining their own pH, I encourage them to "keep on breathing"(kussmaul respirations not panting) until the lines are in and the fluid/meds are hanging. They must keep their pH about 7.0 and their body knows that. To do that they must get their PaCO2 down as low as possible. I do not interfere because I doubt if even my ICU ventilators could do a better job. If they wear out then yes that is another story. Pts with PNA, especially PCP(Pneumocystis Carinii Pneumonia), have very high RRs. They may need intubation but again it would be very difficult to ventilate AND oxygenate them by standard BVM. These pts are usually an immediate tube when they are sedated down. People also use the word ARDS loosely. When a pt is going into ARDS, they too are a difficult BVM job. Their lungs are "whiting out" to where ventilation and oxygenation are difficult for even the ICU ventilators. These patients will fight to maintain adequate oxygenation and ventilation for as long as they can. Until you are adequately prepared with effective alternatives, their own bodies may do a better job than most "skilled" providers with a BVM.

Silent chest usually means not air movement. In Emphysema or disease processes where there is a loss of elasticity and hyperinflation, there may be silence even on a good day. When exacerbated, serious silence. This is not a good sign for the asthmatic. If the patient is still very symptomatic with the chest still silent after a couple of high dose albuterol BAN treatments, heliox is started and may continue for many days even if the patient is intubated. Obese patients may also have chronic hypoventilation with little air movement or poor lung inflation and can be CO2 retainers without a history of lung disease. Along with the systemic HTN, there may be Pulmonary HTN which can also cause severe hypoxia. This can get into right heart failure also. For older patients with extensive medical history or the odds of having severe health complications, it could be any one or many things that can exacerbate an already compromised breathing situation. What failed first? HTN and IDDM also sets her up for renal failure which pretty much affects all systems including electrolytes and acid-base.

Patient confidentiality rules for your company and regional statutes apply to those situations. Many confuse these with HIPAA. Most U.S. states have patient's Bill of Rights statutes that includes a patient's expectation and right of privacy. Each medical service also adopts those and expands on them for their own purposes for employees to follow. The Canadian version of the U.S. HIPAA does apply to insurance and electronic records which we do a lot of transactions with Canadian "snowbirds" in Florida. They sign our form with the understanding that the privacy with PHI and insurance should also be observed in Canada through their personal information and electronic data security laws. There are similar electronic security rules and laws in many other countries also. http://aspe.hhs.gov/admnsimp/pl104191.htm PUBLIC LAW 104-191 AUG. 21, 1996 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 Public Law 104-191 104th Congress An Act To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes. If more than one patient is transported, your billing office must be made aware so they can pro-rate the charges. If this doesn't happen, your service can be set up for an investigation for violations of billing practices which can result with an unflattering fraud headline in the news. That pertains to the U.S. companies.

You may have more of a chance of getting infected with something from a child. 1. They look cute and innocent. You relax your precautions too much. 2. Not all children have Junes and Ward Cleaver for parents. And, especially with the June and Wards, one can let their guard down too much. 3. They can be infected with Hep and/or HIV. 4. Varicella (also adults) and Pertussis are prevalent in some areas. (How many EMTs and Paramedics keep their vaccines up to date?) 5. CMV positive for some. 6. Wiggle like greased whatever even in the restraining devices. It is very easy to get stuck while sticking them. 7. They can bite and scratch if given the opportunity also. 8. Our policy is to mask and glove, gowns recommended, for a child presenting with a respiratory illness and/or needing a neb in our ED. If caught giving a neb without a mask, you get verbal, written and termination. If you come up with some infection, workmen's comp does not have to cover. The same policy applies to the resuscitation and trauma rooms. As I mentioned before, I have been exposed to more stuff in the ED by EMTs and Paramedics bagging a patient than from acts committed by the patients themselves. That can also include partners on both ground and air ambulances. Luckily, our ED isn't cheap with supplying us what we need for universal precautions.

In any aspect of health care you will have patients with HIV/Hep including newborn and Peds. Many times most HCWs do not know what the patient has because the patient may not have been tested yet, labs aren't readily available or the treatment and precautions will be the same. If you go for an outpatient lab drawn, the phlebotomist is not going to ask for your HIV or Hep status. He/she will just do business as usual with the same precautions for all. The same for the IV nurse, RRT or any other healthcare professional. Patients that are coughing will see me wearing a mask when I assess them regardless of it being the flu, allergies or TB. We also do not allow religious beliefs to alter patient assignments. If your religion disagrees with the gay life style or you claim some white supremist group, too bad. If you are a nurse and your religion is Jehovah's Witness, you will still hang blood on patients if you are working in that area of the hospital. It is not fair to other staff members to keep picking up the slack for what another professional feels is wrong by religious belief when caring directly for patients. The only exception is end of life support. Some RNs have trouble coping with the families and heavily sedating patients for the terminal wean protocol. Some RRTs also have problems when pulling the tube and watching a pt gasp for ventilation. Combine that with the families screaming at you to put the tube back in and you do have a difficult situation. But, this is the only exception I can think of right now.

A compliment from spenac. Now that is impressive Dwayne! Excellent post.

Paramedics and EMTs only compare their jobs to others by "skills". Pulling a tube out or drawing blood are "skills". They can be taught in a few minutes or a couple of hours. It is the knowledge that goes with these "skills" that counts. Most critical care RNs and RRTs work off of protocols and don't have to wait for a doctor to spell it out for them. But then, even the phlebotomists are now required to have 150 hours for a certification now in some states. Many hospital labs now prefer Paramedics not draw labs in the field due to errors in drawing and labeling. If you look at the job description for nurses and RRTs, they want education and knowledge. I can not even begin to list what I can do as individual skills in the hospital. In EMS as a Paramedic it is listed on a couple pieces of paper. You are comparing people with 2 (entry) - 4 - 6 years of college to someone with a few months of "training"? These professions saw long ago that the "knobologist" or "skill monkey" was not the way to professionalism. The insurance companies and legislators saw it that way also. Don't insult the professions that saw the way of their initial errors and got over them to advance their status in the medical world. I started as an OJT in Respiratory over 25 years ago. I had to eventually get first an Associates degree and then a Bachelors in Cardiopulmonary to maintain ICU status. I don't care who draws the ABG as long as they are properly trained in the "skill". But, when it comes to making acid-base corrections either by some buffering med or adjusting a ventilator running Nitric Oxide, there should be someone with some education and specialized knowledge tweaking the knobs. If a certificate paramedic wants to become an RRT, they will need another 60 to 76 hours (2 years) of college. Most RNs and RRTs like their specialties and don't constantly whine about wanting to be "paramedics". When I am working in EMS on a helicopter, I am more limited as a paramedic then I am when working specialty transport as an RRT. My RN partner on HEMS can do everything I can do as a Paramedic and is still happy to be a nurse. His BSN and 12 years of ICU/ED experience definitely comes in handy also. HCWs licensed in Radiology, Radiation and Nuclear are a whole realm of education, licensures and specialization that in no way would I want someone with just a "skills" mentality performing any of these specialized procedures on me or any of my friends and family. Luckily their professionals organizations see it that way also and have educational standards to close the loopholes allowing unqualified wannabes into their practice. So brag about all the skills you want. But if you don't have the book learnin' and knowledge to go with them, what is your real value?

How about this question: How many healthy EMTs and Paramedics expose their partners, many, many HCWs, bystanders and other patients to TB, Hepititis, Pertussis, Varicella and Meningitits (along with many other bacterial/viral diseases) with the exhaust from the BVM, portible ventilator or CPAP on a daily basis? Since we can determine which patient someone is infected from, should we prosecute those who have no regard for others when bagging a pt? It is rare that some EMS workers are mindful of what or who they are spraying when they enter the ED. This can include bloody droplets sprayed on HCWs and any equipment in the area. THIS IS A COMMON OCCURENCE and not one of those "what if" scenarios that have been tossed around on this thread. Getting sprayed by BVM or Ventilator spray is probably one of the leading causes for occupational exposure in the ED and is responsible for many HCWs testing positive for TB. Hopefully their body's immune system keeps it as latent. If EMS was more diligent about testing for TB and Heptitis, they would find many people working that are positive for something and not symptomatic. Many systems only test the employees involved if a hospital notifies them of an exposure. In EDs, the employees know that strict universal precautions are required for resuscitation of any type. The hospital can also choose not to cover the employee for workmen's comp claims if they violate precautions. As far as the original question, I think I made my answer pretty clear. TB should not have been even included in the question and just shows how little education about very important issues is in the EMS field for some.

The IAFF already has done the research and posted their references which I referred to in a previous post. Your employer, if you are employed in a company with more than 15 employees, also will have a copy of the CDC and OSHA quidelines that they follow. You're not doing any new research that hasn't already be thoroughly studied, tried and trialed. Read your company's P&P manual as they should also site their references especially when it comes to certain regulated state statutes and Federal law. Of course if you choose to do selective reading you can find agruments of all types to support your own opinion although the source may not always be the most reliable. You can also select one sentence from an article published by the CDC to use at your own choosing and form your own interpretation. I think this has been done with the Bible for other purposes and specific agendas. At far as a patient being informed of an employee's HIV or Hep C status? NO! How many people would want to even consider healthcare if they privacy was not respected and yet must respect the patient's privacy. My life is an open book for no one unless I myself make that information available to them. Most of the time even the HCWs don't always know what a patient has until we work them up for something. And even then, not every employee in the medical environment is entitled to all the information. A patient is NOT bound by any privacy agreement if given that information and could annouce it at the next town hall meeting if they so desired. Now for those in EMS that are getting hurt and bleeding everywhere at scene. If this is acutally happening on a regular basis maybe some additional training on scene safety and extrication is needed for your EMTs and Paramedics. The FFs don't get themselves all cut up and dripping blood when they extricate a wrecked mess prior to me and my helicopter arriving. If there are FFs around, let them do the stuff they are better trained for so you don't get hurt. How do you treat your patients? Most of them as I mentioned, as well as others, before will not tell you if they have an infectious or contagious disease and many may not know they have something. I think education is the key here. Florida had (past tense) required HIV education with every license and recert for all professions. With the EMT being only 110 hours and the Paramedic at 1000 hours, there is very little time to cover much of anything thoroughly. It is possible that some EMTs and Paramedics do not have enough information and education to form a scientific conclusion on some things in the medical profession. College A&P x 2 semesters, Microbiology and Pathophysiology should be required before either level is attempted.

Ruff, Today at the hospital, I count 5 RNs (Hospital), 1 RRT and 1 Paramedic (EMS) with HIV that are actively on shift now. One RN has been dx'd since '91 and has remained working in patient care areas. I know there are at least 2 RNs with Hep C and probably more but their infection status has never been an issue. I also don't know and don't make it an issue to know what other clinical people are infected. I have also lost more co-workers who were RRTs, EMTs, Paramedics and RNs to AIDS than I care to think about. Many struggled to remain working in some aspect of healthcare for as long as they could for the insurance. Of course, when their CD4 count dropped they went to a low risk area. I can not tell what stress some narrow minded attitudes can place on people who are already dealing with a difficult situation. We do occasionally hear about someone getting treated for MRSA. They disappear from the schedule for a few days during treatment. And yes, if several patients become infected we can identify the source and will do that with a MRSA outbreak by culturing the nares of employees. If someone is utilizing good hygiene and universal precautions there should not be an issue. I would let any of the staff I mentioned start an IV (and one has) on me. You don't need to know the HCW's HIV status unless you have sex with them or there is an incident involving blood. Chances are it while probably be your blood and not theirs that causes the incident during an invasive procedure that would be of concern. How often do you routinely get checked for Hep () or HIV? Varacella titer? Pneumonia Vaccine?

TB is not an issue here because if you insist on working with positive AFB in the sputum then a court order will be issued and you will be in isolation either in a regular hospital or a special hosptial like A.G. Holley in lockup. This a directive of public health orders from the Federal level. Once your sputum is clear, you are okay to be in public. If you are not compliant with your meds during the next few weeks or months, you may be placed under a house arrest type monitoring system or put into a secure facility in a hospital throughout the course of your therapy. People with Hep B, Hep C and HIV are not isolated from general population. The sad and bad aspect when attitudes are involved that discriminate, your partner may keep many secrets from you including their HIV status. I also see the brotherhood of FF/EMS disappear when someone who is openly dx'd with HIV. People, who should be better informed, run especially if it develops into AIDS when the person could most use the support It seems that there is a stigma about the disease itself more than the actual virus.

Wow! I feel like I'm back in 1986 as FFs and Paramedics made the same comments as they watched the family home of the Ray brothers (hemophiliacs with HIV) burn due to arson. The FFs were not about to fight the fire because "you know that HIV stuff could be in the smoke". The house was also burned for the good of the community. One could get away with those comments and the fear in 1986 since HIV was still relatively new. But, this is 2008.

That would depend on the person's CD4 and viral load count. I have just one more comment about getting cut while on scene. Commonsense should prevail here regardless of one's infectious status. Hopefully one would feel themselves getting cut. Take a minute to utilize your basic first-aid training to clean yourself up, bandage and glove. This is again important for a couple of reasons: 1. It is just not polite or in bad form to bleed on everything or everyone regardless of your health status. 2. You need to take care of yourself and cover the wound before you do pick up something either from the patient or a dirty environment. I do agree with ccmedoc on passing the flu and other common ailments to immunosuppressed patients. In the hospital, if the pt is neutropenic, WE mask even when we are healthy. If we feel like we are getting a cold, WE mask regardless of pt dx. Right now several employees have had the flu. We would rather they stay home. PERIOD. Elderly people do die from the flu. Pts with TB are isolated until their sputum is clear which is 3 - 7 days usually. They will continue to be treated for several weeks or possibly months after that. If the patient is seriously non-compliant, we still have a TB hospital (A.G. Holley) in South Florida. It has some good links on its web page if you want more info. http://www.doh.state.fl.us/AGHolley/index.html

Lonestar, Are you referring to the Kimberly Bergalis case and her dentist in Florida 20 years ago? That dentist was truly the exception and not the norm. As far as dentists losing their license because they have HIV: http://www.ada.org/prof/resources/topics/hiv/legal.asp Is HIV/AIDS education not done anymore in EMT or Paramedic school? Are updates not done at any of the recert classes? This is the IAFF position on FF and EMS personnel with infectious diseases including HIV. http://www.iaff.org/et/JobAid/InfDis/What_...t_screening.htm Manual on infectious diseases which should be required reading regardless of the source. http://www.iafflocal21.org/docs/IAFF%20Inf...se%20Manual.pdf You can also search the CDC for their position. As I mentioned before, it all depends on the job description. Making a blanket statement for all EMTs and Paramedics is not appropriate and only shows a "knee jerk" attitude of your own. As far as the nurse and doctor safe environment thing: When you consider the number of patients and open wound care that nurses and doctors see on a daily basis, it is not even a close comparision in most cases. Yes, JPINFV, the CDC has the stats.

A positive (now called "significant") reaction indicates infection with TB. Someone who is infected with TB has the TB bacteria (Mycobacterium tuberculosis) in their body. The body's defenses are protecting them from the bacteria and they are asymptomatic . This is referred to as latent TB. It is also something many RTs and RNs have to look forward to in their careers. Once you test positive you will get periodic (usually yearly) CXRs to check for signs of active disease. If someone has active TB, it can be confirmed by AFB cultures by sputum. They are sick and may be able to spread the disease to other people. This is a no-brainer since it is airborne. This is pulmonary tuberculosis as there are other areas of the body that can be affected. As far as the other infectious diseases, I agree with Dwayne. The CDC has spelled this out in guidelines for hospitals and other agencies to follow. The healthcare works (HCWs) that are infected are probably the most informed of all about protection. Many people with HIV have been positive for 20 years with few symtoms and many work in healthcare. While it is possible for the HCW to infect the patient, it is usually the reverse. Depending on your job description, it is the discretion of the employer as to what position you may hold clinically. It has been determined that nurses, RTs and even paramedics may not present much risk for direct exposure to their patients in many areas of health care settings. When you are given your employee phyical, you can ask for an employee rights statement concerning this if you do happen to test positive. Employers should routinely monitor their employees to ensure their vaccinations are up to date. Hep B titers should be ran periodically since that may have to be renewed. When I turned 40 my varicella titer came back negative (rechecked for false negative) even though I had be positive for 32 years. I then had to take the varicella vaccine. I would bet that an immunosuppressed patient has more chance of catching something deadly from an inadequately cleaned ambulance or equipment and poor hand/glove practices than from an infected HCW.

Found this web site that shows the INOvent that we use in the hospital to deliver NO. http://www.dhmc.org/webpage.cfm?site_id=2&...mp;item_id=8129 The other links offer some good respiratory information also like on the jet ventilator.

AMESEMT, apologies if I offended you. I also lumped in other comments made in earlier posts. I realized my limitations when I was "just a Paramedic" and fell in love with respiratory gadgets many years ago. If one can easily pass a suction catheter and the inner cannula is clear, the ventilation problem does not lie with the trach but rather the patient. Often, the "resistance" inexperience people feel is the carina. For an adult, if the suction catheter is in the length of an adult's middle finger plus the knuckle (length of 15 mm adapter) then you are probably through the end of the tube. For kids, use the length of their middle finger and knuckle. Do an air flow assessment which will tell you if the trach is false trached which can happen if the trach ties are too loose. If there is NO air movement, resistance is met at the end of the trach, inner cannula is clear and the patient can speak with out a speaking valve, the trach is probably false tracked. They can be a b**** to get back in track. If the person can still up their upper airway, take advantage of that. This person would probably do okay with out the trach in their throat since it is in the wrong track. If they are still ventilating and oxygenating adequately I would not try to re-track the trach so not to make the false trach larger. Even the ED and Pulmonary doctors will call the ENT doc for these. I do get annoyed when EMTs and Paramedics pick up "trach" patients from NHs and home for many reasons and never examine the "trach". They assume it is a "trach" like the one in the Paramedic/EMT textbooks. They assume they can just ventilate through that if the patient gets into trouble. Things I have seen and some tips: Shiley trachs have a removable inner cannula which is also the 15 mm adapter. Many patients don't like it because it unclips easily and can be coughed out. So, they don't always use the inner cannula if they are not on a ventilator. Some home care companies may send them the wrong inner cannula if any at all also. Jackson Silver and Stainless steel trachs don't always come with a 15 mm adapter. To remedy this in an emergency, just put the 15 mm adaptor from an ETT into the trach. Many in home care may be smaller (#4 Shiley or Jackson and #6 Portex) which can take a 4.0 or 4.5 ETT 15 mm adaptor. The Montgomery devices can be more difficult like the 9 mm in one of my patients. I can use 4.0 ETT inside the device or a 10.0 ETT on the outside. We also save our 15 mm adapters from expired and opened but not used ETTs for these patients. A trach can also have a cuff and be fenestrated. If air is coming up through the throat with the cuff inflated, look for an inner cannula to block the fenestrations. It shouldn't take much air to fill a cuff. Some patients can still be adequately bagged with a cuffless trach. Not all home care adult ventilator patients have cuffed trachs. Don't be surprised to see a trach patient wearing a NC especially if they want to be mobile or the trach is capped. Always ask for the spare model or box and the emergency equipment that should be customized for that patient and at bedside if in a NH. Make sure the cuff is deflated before placing a speaking valve. Here's some different models: http://www.trachs.com/cart/xcart/customer/home.php?cat=253 Montgomery http://www.bosmed.com/about.html Blom Singer tubes http://www.inhealth.com/featuredproductlaryngectomytubes.htm Shiley tubes http://www.dhmc.org/webpage.cfm?site_id=2&...mp;item_id=8169 http://www.nellcor.com/prod/list.aspx?S1=AIR&S2=TTA Portex® Trach-Talk™ Blue Line® Tracheostomy Tubes http://www.smiths-medical.com/catalog/port...-talk-blue.html Bivona Tubes http://www.smiths-medical.com/catalog/bivo...heostomy-tubes/ The Bivona Foam cuff tube always gives providers problems because the cuff inflates with ambient air so the pilot balloon is uncapped. To deflate fully for removal, you need a stopcock and 20 cc syringe (12 cc will do) and quickness. http://www.smiths-medical.com/catalog/bivo...t-fome-cuf.html

D.C. Paramedics Finally Get Access to Narcotics http://www.emsresponder.com/article/articl...n=1&id=7138 By David C. Lipscomb Courtesy of The Washington Times D.C. paramedics by summer expect to get what their counterparts in area jurisdictions have had for decades: access to life-saving medications. The decision to equip ambulances with narcotics comes after the department announced plans last year to run comprehensive background checks on every employee. Battalion Chief Kenneth Crosswhite said the stocking of drugs could not have gone forward without the background checks. "It could not have; it should not have," Chief Crosswhite said. The department has considered putting the drugs on ambulances for more than five years but held off because of administrative roadblocks or fears of theft. Dr. Michael Williams, the department's medical director, said the benefits of stocking ambulances with narcotics such as morphine and Valium far outweigh the risk of theft or abuse of those drugs. "I'm much more concerned about not providing pain relief or not being able to break a seizure," he said. "The nation's capital can't be the last big jurisdiction to have pain relief." Dr. Williams said the background checks would help fire officials who were "trying to make sure we don't put temptation in front of individuals" who may have had drug problems in the past. He said the background checks were a way of "identifying them and saying, 'You probably shouldn't be handling narcotics if you were convicted for X, Y and Z, 10 years ago.' " National Association of Emergency Medical Technicians President Jerry Johnston said morphine can minimize heart failure and Valium can break potentially brain-damaging seizures. "If you don't have it, you can't treat a seizure," Mr. Johnston said. "You basically are helpless to watch them seize." Mr. Johnston said the use of narcotics on ambulances is "very common" and he was not aware of a jurisdiction that does not use them. Fairfax County paramedics have been carrying narcotics for at least 24 years, and workers in Montgomery and Prince George's counties have had them for about 30 years. Maj. Chauncey Bowers, a paramedic with the Prince George's fire department, said the drugs have improved patient treatment since the county started using them in 1977. He also said security systems for the drugs are relatively easy to maintain and he mostly dismissed fears of thefts. "In the course of a year, you're more likely to replace medicine because someone damaged it when they dropped it than because it was stolen," Maj. Bowers said. "I think part of the fear of drugs getting stolen is urban legend." Dr. Williams said the District's fire department is waiting for the D.C. Council to approve funds to purchase an electronic security system for drug boxes in ambulances. The system requires each paramedic to have a unique key and logs who uses the drug boxes. A spokeswoman for Mayor Adrian M. Fenty said the mayor will set aside $65,000 for the boxes as part of a $3.7 million request from the council that he plans to send to the council. D.C. paramedics have been trained since 2003 to use medications that include drugs to sedate patients, break epileptic seizures, treat asthma attacks and emphysema, and to slow rapid heart rates. In 2002, the D.C. Council approved the administration of the drugs, but then-Medical Director Dr. Fernando Daniels III said the process of stocking ambulances was delayed because paramedics needed more training on how to store and account for the drugs.

How many trachs have you changed? Where did you get your training for the many different trachs in patients? Are you familiar with all the disease processes and anatomical malformations that require a trach? People shouldn't be pulling out devices needlessly when some have not even had the training to correctly identify or assess the device in someone's throat. Some of these devices require an OR visit to change. If there is a narrowing above or below the stoma or the stoma closes when the trach is removed, you had better have an immediate way to dilate it or even a neonatal tube may not pass. If you make a false track on the first pass, any repeated attempts will follow that false trach even on cannulation attempts with an ETT. If the patient has a disease like Wegener's, the bleeding will be difficult to control. Making a general statement to imply that it is no big deal is not appropriate in all circumstances. To also imply that an RN change the trach with only a BLS crew there knowing that there may not be an EMT-P or RRT around to do another advanced airway procedure such as ETI is not acceptable either. Ignorance is not bliss when you may be screwing around with someone's only airway option.

Are you referring to your RT days? I just had a guy admitted with a Montgomery trach that can not remember the model number of his trach. His device has a 9 mm connector instead of 15 mm. Did you know the Montgomery brand has over 150 devices? Those are always fun to find in the field just like the Jackson Silver or Stainless. The text books made an over generalization when they stated every airway device is 15 mm. I don't like scenarios on the forums because they are mostly guessing games or trying to fit the patient into a diagnosis with one or two general symptoms and a set of vitals. It would be nice if all patients only had one or two well known disease processes that were so obvious.

If you remove the inner cannula and it is clean, I would not advise pulling a trach. If you hear breath sounds and good air movement, don't pull the trach. If you feel air movement through the trach and a suction catheter can be passed I would advise not removing the trach. Put the inner cannular in or briefly insert the obturator to dislodge plugs if necessary. This ensures trach patency. If it is a fenestrated trach and you want to bag the patient, put the inner cannula back in. Make sure the trach is not a custom and if it is, WHY? Ask to see the standby trach to help identify it. If the patient is not moving air through the trach but a suction catheter passes the length of the trach before meeting resistance AND the patient can still speak without a speaking valve (PMV), the trach is false tracked. If you remove it you still may not be able to pass it through the correct path. Support with oxygen from the upper airway and occlude the stoma if the patient is still moving good air through the upper airways. Ask nurse when and WHO replaced the last trach. Even in places with RTs and qualified RNs, an ENT may replace some trach due to special problems such as tumors or coag problems. Some hospitals do not change the trach at 7 days post op but may elect to do it at 30 days at the ALF, SNF or whatever. That first trach change can be very difficult even at and especially at 30 days. Reposition the patient. Unless the patient has a "tie off" as in a laryngectomy or some upper strictures, he/she can still be intubated orally if the unable to put the trach in correctly OR if you have NEVER put a trach in. DO ONLY what you know and use the equipment that YOU are familiar with. If you create a fistula the patient will require extensive surgery and will probably be FUBAR. Ask for an inservice on trachs that are in your area. Different hospitals and subacutes usually use their favorite brand unless it is a special case. Learn to identify and assess a trach before just pulling. Some "trach looking" devices must be inserted under fluoro and have "dry wall" type flanges that anchor it. Those make a big mess if you pull them out. There are 300 different airway devices that can be found in NH, Subacutes and ALFs. Not every piece of plastic in the throat is really a run of the mill "trach". We have offered dozens of these inservices at the ALS stations. Unfortunately, attendance is low because it is a "nursing home" associated thing. Also, because they believe since it is in their scope, there's nothing to it. And, when people tell them there's nothing to it, they never seek any further training or education. They assume any tube in the throat is a "trach". This is my soapbox today because I now have a 35 y/o man on ventilator running ARDSnet protocol following a Paramedic pulling and reinserting the trach ripping trachea at a SNF. The guy probably won't make it. The guy was still talking with his PMV valve when the trach was pulled. The patency of the trach was never checked. Reason for SOB? Spiked a temp with the onset of PNA. I've been working as a Paramedic and RRT for 30 years and there are still some trachs I will not touch without all of my hospital gadgets and the number of my favorite ENT doc nearby. It helps to know the anatomy, disease process and have a plans B, C and D. LMAs are also nice to have around as well as a baby BVM mask.

They can screen for nicotine like any other drug if it is banned in the policy. This can be done during the hiring process. They can refuse to grant new candidates employment. Current employees may have to sign a contract and will be given every opportunity to quit.

I would try everything possible to lose weight or change your eating habits before considering the surgery. Besides complications from just the surgery itself, you will have to consider adhesions and other complications if you decide to have children later. We've had several babies in our NICU who were born prematurely due to the mothers (who had gastric bypass) developing Small Bowel Obstruction during pregnancy and required surgery. In a couple of cases, the baby was too premature to save and did not survive the effects of surgery on the mother. Your nutritional intake may also be difficult to maintain for pregnancy. The surgery itself is not a total guarantee that you won't gain some weight back later. You have to change your eating lifestyle totally to avoid the complications mentioned in previous posts. Many people also adjust to eating smaller portions but eat food dense in calories. I had a co-worker who lost almost 100 pounds after gastric bypass but then gained 50 back eating ice cream and buttery anything.

That has already been challenged in the court system and it didn't fly for the smokers. It did however open the door for many employers in all industries including healthcare to ban smokers from employment. In healthcare, patients also have rights not to have a person stinking of cigarette smoke doing their smoking cessation counseling. That odor is hard to hide even if one doesn't smoke at work. South Florida Hospital Will No Longer Hire Smokers http://www.nbc6.net/health/13609384/detail...022007&ts=H

All D.C. medics to be tested on competency skills http://www.ems1.com/ems-products/education...mpetency-skills By David C. Lipscomb Washington Times Copyright 2008 Washington Times WASHINGTON — The D.C. fire department next month will test all of its 250 paramedics for competency in administering advanced life support, the agency's medical director said. The testing, which will be performed independently by the Maryland Fire and Rescue Institute, is expected to lead to retraining of some paramedics while some others could be reassigned to positions with fewer responsibilities, said Dr. Michael D. Williams, chief medical officer for the fire department. "I expect there will be people that fail this process," Dr. Williams said yesterday. "And I think I will be saying, 'You're really not functioning as a paramedic, so we're going to pull you out.' " Dr. Williams said the policy could create difficulties for the department official who assigns crews to ambulances, but "my obligation sort of trumps his on this one." "I've really got to make sure that we don't let somebody out there that isn't functioning at that level." Details of the testing plan come days after the family of journalist David E. Rosenbaum dropped a lawsuit against the city, saying they were satisfied with the District's progress in reforming its emergency medical services. Mr. Rosenbaum was beaten and robbed in his neighborhood in January 2006 and died two days later. An investigation found that a neglectful, botched emergency response contributed to Mr. Rosenbaum's death. A task force set up to examine ways to improve the city's Fire and Emergency Medical Services department as part of the lawsuit recommended, among other things, improving training and oversight. Testing all of the agency's paramedics, however, was not among the recommendations. "To our knowledge, no one's done this kind of a scope before," Dr. Williams said. He said he and Fire Chief Dennis L. Rubin came up with the plan. He also said he thought it was important to contract the testing to an outside agency, so that the results would be "above reproach." "They're just giving me data. And it's got nothing to do with past loyalties, past practices. It's a contract," he said. Dr. Williams, who has served as the department's medical director since August 2006, said the results of the tests will show whether the department needs to make broad changes to its curriculum or take individual workers out of the system to correct specific deficiencies. The testing will comprise a written exam and a practical skills test performed on a computerized mannequin. The mannequin will monitor each interaction the test subject has with it, and the test will be videotaped by four cameras to be reviewed later by Dr. Williams. "Any really deficient folks who should be pulled, we'd like to find them on a mannequin as opposed to from a quality assurance investigation," Dr. Williams said. Paramedics with minor deficiencies will receive remedial training until they are able to demonstrate proficiency, Dr. Williams said. Those who do not improve with training will be reassigned as an emergency medical technician, which is less complex than paramedic work. http://www.ems1.com/ems-products/education...mpetency-skills