VentMedic

And for more reading on the subject Nitric Oxide: INOmaxTM (nitric oxide) for inhalation http://www.fda.gov/cder/foi/label/1999/20845lbl.pdf Nitric Oxide in Adult Lung Disease http://www.chestjournal.org/cgi/content/full/115/5/1407 Inhaled Nitric Oxide Therapy in Adults http://www.temple.edu/imreports/ReadingLis...O-NEJM-2005.pdf Inhaled Nitric Oxide for High-Altitude Pulmonary Edema http://content.nejm.org/cgi/content/full/334/10/624

Nitrous Oxide is N2O. This has been available to Paramedics in the field for at least 25 years in some areas for pain control. Nitric Oxide - NO is currently used in the various ICUs on a selective basis and can be done on Specialty interfacility transports. Nitrogen - N2 is also used in NICU for subambient O2 delivery and can be done on Specialty Transport. Nitrogen Dioxide - NO2 causes lung edema. Nothing like a little basic chemistry to help in the medical fields.

Another thing to consider would be finding a medical director who has experience in NO since it is not used in the ED. It usually requires the expertise of a Pulmonologist and/or intensivist to manage the protocol which can get lengthy depending on the patient population. The same in the hospitals. Then, the ED RNs would all have to be familiar with the protocols and the hospital would have to have the equipment. Many RT departments can budget for it but some doctors are still reluctant to dive in.

Nitric Oxide in preHospital? NO. It is definitely not a gas you want to mess with unless you have some differential clinical data and serious education on all components of the disease process and NO. Each medication the patient is on must be noted and regulated prior to administration. The initial investment for the special delivery system and tanks can be in the 6 digits. We rent a lot of our equipment due to the initial cost and that it will probably be out dated next year like computers. Each tank is very expensive and must be recouped through reimbursement which would be difficult in prehospital since the need for it must be make through differential diagnostics including an echocardiogram. NO should be titrated to PAP and SvO2 monitoring which prehospital would not have a PA catheter, RA line or time to do differential blood gases. The cost also makes it difficult to get in the hosptial situations. Very few hospitals have NO capability. Prostacyclins such as Flolan and Iloprost are also used in the hospital but not that wide spread yet. You do not always see instant results with NO. If the patient has profound hypoxemia in the field there may be many etioloigies causing it. Knowing the V/Q mismatch would be important since PNA or almost any insult to the Cardiopulmonary system can exacerbate CHF with or without PH. Even with NO as supportive or treating PPH, it may take days for the PH to resolve if there are other underlying causes. Of course, there are good possibilities that you will run into home care patients on NO, Flolan and Iloprost (Ventavix). The studies for NO and CHF now are looking at the relationship between endogenous NO to the basal vasomotor tone of the peripheral vessels in the CHF patients and if it varied according to the plasma BNP level. For most patients, the body seems to adjust accordingly. NO is being trialed for people with CHF and endothelial dysfunction found in some ethnic groups. Nitric Oxide has been used in NICUs since the 1980s when the majority of the clinical trials started. For adults, the clinical trials started in the late 1980s and early 1990s. Since these studies are usually done through the RT departments: www.rcjournal.com has articles and abtracts of current research projects. Diagnosis and Management of Pulmonary Arterial Hypertension: http://www.rcjournal.com/contents/04.06/04.06.0368.pdf Congestive Heart Failure: Diagnosis, Pathophysiology, Therapy http://www.rcjournal.com/contents/04.06/04.06.0403.pdf Aerosolized Prostacyclins http://www.rcjournal.com/contents/06.04/06.04.0640.pdf Retrospective Studies and Chart Reviews http://www.rcjournal.com/contents/10.04/10.04.1171.pdf Heliox is used because it is less dense and can replace nitrogen to reduce airway resistance.

H2O is water. HO2 is a perhydroxyl - free radicals when referring to Nitric Oxide (NO) which we use alot in the ICUs. Methemoglobinemia is a concern with NO. CO-OX measurements which the SpO2 does not differientate: MetHb - methemoglobin or MHb (occassionally) COHb - Carboxyhemoglobin O2Hb - Oxyhemoglobin HHb - Deoxyhemoglobin tHb - total hemoglobin The RAD-57 is a nice piece of equipment but very expensive. You can also get one to read MetHb as well as COHb which is of course more expensive. Some medications can cause a non-invasive COHb monitor to read falsely high also. Of course, high readings should be followed by a blood CO-OX measurement.

Children are the most successful at committing suicide. Rarely will they have a botched suicide attempt. If it is botched, it is probably from some type of mechanical failure and not for a lack of trying. Kids take their troubles to heart and have not mastered the coping or attention seeking skills that adults have. Tylenol OD is probably one of the worst ways to do a suicide attempt. Unfortunately many do not realize that the permanent liver damage may become a very slow painful death. Most of the people were just wanting some attention or crying out for help. Now they find themselves on a long liver transplant list. Surprisingly, the search for a new liver actually brings meaning to the lives of some.

Acupressure and acupuncture are accepted in many hosptials now. Some alternative therapies have their own departments or employees in the hospitals. We also have a couple of acupressure schools that use our patients for training although it is usually in the less acute areas such as the phyical rehab areas. Although, families have gotten permission to bring in alternative therapists into the ICUs on many occasions. When we were at a loss as to what to do for a couple of co-workers diagnosed with cancer, we sent them acupunturists/acupressure thereapists to help them between their radiation and chemo treatments. Massage therapy can not be always used on patients that are "toxic" with various meds or chemicals but these alternatives are usually welcomed. In Florida, the Acupuncture Practitioner and Massage Therapist are both licensed by the same board that licenses all the other health care professions. http://www6.miami.edu/touch-research/about.htm The University of Miami has the Touch Reseach Institute which has done amazing work with infants, HIV/AIDs, cancer and many other patients in the past couple of decades. I'm sure they are also working in some aspect with the trauma patients at the Ryder Trauma center with is a 4 story state of the art free-standing facility dedicated to trauma at Jackson Memorial Hospital.

Lee County EMS has managed to avoid some of the problems that your neighbors to the south are experiencing. brentoli, $158,000 for a house along coastal Florida? Is that with or without wheels? single or double-wide? http://www.bizjournals.com/southflorida/st...ml?ana=from_rss

Niftymedi911, you are an excellent spokesperson for Lee County EMS. But, don't forget to mention our cost of living factors for housing, insurance, utility rates and taxes. And then for the family oriented types, there is the little matter of our schools being poorly rated and over crowded. Private education is expensive and can be poorly regulated. Jeb's voucher program kinda crimped the whole system.

Did you do an email to the big corporate companies offices or to the individual pharmaceutical reps of those companies in your area? A pulmonologist or most GPs, hospital pharmacy or RT department should be able to provide the name of the manufacturer's rep. Each should have reps in your area that can provide assistance with the placebo to demonstrate their product. We teach with 8 different placebo inhalers but our reps drop them off at the hospital. There are several different inhalers manufactured by different companies with different formulations with different instructions for each on the market now. Example: Salbutamol or Albuterol is available by at least 15 different names with and without HFA and CFC propellants, each with different delivery characteristics and patient perceptions. I don't believe Canada has been required to make the HFA switch yet. The asthma educators in your area may also have information where to get placebo inhalers. This can be through the Association of Asthma Educators (AAE), Canadian Network For Asthma Care(CNAC), Asthma Society of Canada or Allergy/Asthma Information Association(AAIA).

Did you contact a GlaxoSmithKline representative for the MDI placebo? Any Asthma educators in your area or RT departments?

Kaiser-Oakland is East Bay and not San Francisco for those not familiar with northern California. Wages drop about $10/hour just crossing the bridge. The Kaiser Hospitals in that area will take EMT, CNA or MA certificates with the Phlebotomy certification for their entry level ER Tech positions which is pretty much the norm in other places. It is an easy transfer for CNAs already in the hospital system. http://www.kaiserpermanentejobs.org/ I am one of those that have done the cross country journey and still do on occasion if I can arrange my days at my regular job in Florida. I see it as a very well paid vacation. The union strikes in that area are always a profitable time for those of us from the South to cash in on. They have the strikes so frequently that even the nurses on the picket lines don't know what they are striking for. Nurses from the South especially love it with the restricted by law nurse : patient ratio.

Phlebotomy Cert and CNA are usually required and preferred for an ER Tech job. In SF, $25 - $30/hr would probably not be too far off for ER Tech. RN new grads start around $40 - $45/hr at Kaiser and Sutter. Experienced RNs can make about $50 - $65 per hr but that is about $25 - $30/hr in the South. In SF, less then $75,000 yr is considered very low middle class or poverty level.

There hasn't been a nurse in every school in my state since the '80s. Some states also require an RN with a BSN for a School Public Health system which is great but harder to fund when compared to an LVN. And, even with a fairly decent EMS response time, for kids that may not be good enough. Not to be overly dramatic but why put a fence around a swimming pool if there's a Paramedic nearby. Kids want to be part of a team and participate. They may deny symptoms or venture away from their own boundaries of safety just to belong. I spent my elementary school years in the 60s watching kids like that who were not allowed dress for PE and usually were in the nurse's office constantly. I think by having the schools provide some safety measures to allow parents some relief in knowing there is someone looking out for their kids when they can not be there AND that their kids can still be "normal" in activity is a big service. Somebody posted about what to do to support more education all around. That is where I found the most benefit from having an organized state and national organization. I saw and still see kids and parents that need assistance in many areas as a paramedic but it is as an RRT that I can help to make a difference. I have been part of AARC's national and local level push to get inhalers back into the hands of kids that can manage their own. It is also in that profession that we can do the most education both inside and outside of the hospital. We also have a population in the schools that most paramedics are not prepared for. That is another part of my RT department trying to get these professionals up to speed on the type of patients that are out there. Since we've been saving the preemies with BPD, trachs, G-tube, shunts etc., they are now in the school system. And, the teachers are getting more education both in college and with inservices on the medical aspects of these kids than Paramedics. Some Paramedics still shun being taught by anyone but one of their own about medicine. I can pull out whatever credential is convenient but with HEMS as an EMT-P and then RRT, I am not that involved with the ground EMS on a regular basis. I have been involved with the classes for the teachers through the college for the past 20 years. A lot of these issues are not new. It is just some systems are more receptive than others. The additional legislator for funding if schools recognized kids carrying their inhalers and Epipens helped.

DustDevil, With all respect, I know your opinion on Vollies. You've made good points. But, even in areas with excellent paid EMS services, we still have children dying needlessly because of ego trips within the school systems, EMS and legislative B.S. Epipens and AEDs should be accessible. Inhalers, diabetic meds or whatever should also be easily accessible to the child if they can administer it themselves or another qualified person can assist.

Each state has its own set of statistics on the deaths of children originating on school property. There are only about 3 states in the U.S. that are still hold outs on forming adequate policy to allow anyone but a nurse in the school system to carry medications and administer medications. That even includes an asthmatic child that can not carry their inhaler to the ball field. Good information for anaphylaxis: http://www.safe4kids.ca/content/schools/anaphylaxis_eng.pdf Great organization for information and good links: Allergy & Asthma Network Mothers of Asthmatics http://www.aanma.org/ http://www.aanma.org/breatherville.htm Rights of the child to carry or receive medication. http://www.aanma.org/cityhall/ch_childrights.htm

The teachers and coaches usually have access to witnessed or known history and medical information of their students.

Your "tech" better get their butt in gear. The credentialing (NBRC) organization was kind enough to grant them another year to credential. They had a 5 year notice of the change which ended 12/07. After this final grace period, they could find themselves cleaning vents in the equipment room instead of managing them. If your state does not recognize the changes, it may put RT in your state in the same boat as EMS in some states in terms of advancing the profession. The educational degree has spoken for entry to licensure. The OJTs were granted a 20 year stay from being abolished from the profession. It is now time to get with the rest of the herd.

The NHS Paramedics' autonomy doesn't sound that much different from the U.S. http://news.bbc.co.uk/1/hi/health/256382.stm Health Paramedics could solve NHS staff crisis Interesting blog: http://nhsblogdoc.blogspot.com/2005/12/read-this-or-die.html This is an interesting study: http://emj.bmj.com/cgi/content/abstract/20/5/473 Emerg Med J 2003; 20:473-475 Paramedic accuracy in using a decision support algorithm when recognising adult death: a prospective cohort study So the Paramedics don't have to work with a physician but haven't bene fully cleared to declare death without one? I am referring to a quote from scott33's post: This is interesting with potential: http://www.jephc.com/uploads/Woollard990156.pdf Journal of Emergency Primary Health Care (JEPHC), Vol.4, Issue 1, 2006 The Role of the Paramedic Practitioner in the UK

WTF? Thread after thread of complaining that the public doesn't know what a Paramedic is and Paramedics still can not identify other professionals correctly. Respiratory Therapist: Certified (CRT) or Registered (RRT). Didn't everyone get the memo stating that the "tech" term is not used anymore for the RT profession in the U.S? What was the BNP? Did the CXR show pulmonary edema? Which regions of the lung field were the crackles in? Singultus and ineffective breathing can give a presentation of crackles which can be indicative of atelectasis from ineffective breaths. This is usually seen post operatively on some patients recovering from anesthesia or with inadequate pain management. Crackles or Rales can be heard in a variety of lung diseases states. That is why PNA and CHF are very often treated the same in the field because it is difficult to differentiate by breath sounds alone. In the hospital we have the chance to differentiate between the two before overly aggressive treatment which may worsen the underlying disease process. I usually use my stethoscope before making an educated guess. Upper airway and glottic noise can also be deceiving on assessment. That is why there are various assessment techniques to help differentiate or filter out the noise. I distract a person while listening with my stethoscope to see if the quality of the sound suddenly differs. Not everyone can tolerate CPAP or BIPAP. This is especially true in people with some obstructive component or claustrophobic issues. In the hospital we also have strict guidelines as to who BIPAP/CPAP devices are used for since it can create as many problems as it can solve.

I can not believe someone would complain about this. It has taken several deaths of children and many years of fighting with state legislative issues to get easier access for lifesaving medication and devices in the school systems. I can not believe an EMT with a 120 hour certificate and no other education could be that much different than a teacher with a college degree which may include a semester of first responder type training in that degree along with other additional training for the available equipment. The coaches and athletic trainers may definitely have medical education that by far exceeds the EMT's. These same teachers should have some knowledge and access to their students' medical conditions. The epipens are very regulated and are probably only given to those students that are do have a doctor's perscription. Teachers are probably very familiar with their state's statutes and aren't looking to "stick" just anyone with a needle. Having easy access beats running back to a locker or nurse's office or waiting for an EMT to find their way around a school campus. Hopefully there was also an oxygen tank near the other equipment.

Don't use the word ALL. The allied health therapies prefer not to be part of a union because they have strong national organizations that help set the standards and do the research for wage requirements based on value as negotiated for services with reimbursement. There are also many nurses who prefer to let the data from their professional organizations do the talking as opposed to being on strike every few months as we have seen this past year in California. The clinical ladder can be more rewarding when promotions are based on effort and education rather than burnt out years with a service. When I was in the FD, I had to be part of a union and found the negotiated promotional ladder stifling. I am no longer part of a union either as a Paramedic or a Respiratory Therapist. I hope that forward looking professions such as RT would consider letting their education and professional organizations do the talking and keep unions out of the picture. SLT, PT and OT all have a minimum of a Bachelors for entry and it is rare if ever they have been part of a union. Even in closed shops such as California hospitals, a department can choose not to be part of a union. Only a few RT departments are union in California and with the recent education increase for licensing that may change as other opportunities are now being negotiated in the legislature at the national level. Those opportunities are too good to pass up by being locked into a contract that limits growth potential. Too many people confuse a union as being a spokesperson for their profession. A professional organization that lobbies for licensing, better education, reimbursement for services and can document value accordingly are the true representatives of that profession.

For those of you in the San Francisco Bay area, the SF Paramedic Association offers some decent classes. This is their link with a description and a sample AMLS pretest. http://www.sfpaonline.org/detail.lasso?classid=59e20on0iipz http://www.sfparamedics.org/pages/pdfs/cou...AMLSPretest.pdf Sidenote: They also offer a good airway class occasionally.

Nurses don't brag about how dirty they get or how much they have to lift. Those hefty 300 - 800 pound patients that some EMS crews transport in will have to be turned, transported and cared for many times a day by a nurse. Very few hospitals have the luxury of a lift team and those teams are usually only on day shift. Yes, there is lift equipment but the patient is still going to need placed on the lift pad. It is also impractical to get the lift equipment out for all bowel movements. If the patients are on special beds such as air mattresses, moving any patient can be difficult. And then, you have equipment of all types on all sides of the bed attached. Patients also have a way of falling when they weigh more then 350 pounds in hospital bathrooms. Nurses also do not brag about the messes they see on a daily basis that would make many EMTs and Paramedics run away. Even the blood from an HIV patient can still make a Paramedic run in fear and yet they don't realize the number of times they have started an IV on an innocent looking Hep C patient. Nurses constantly clean up blood from pulled IV and art lines along with other body excrements. Who do you think cleans up all the street people that EMS teams bring in? And then, they have to retrain them to use a toilet. Of course, hospital staff does not brag about anything they get into because it is part of their job and they have total patient care to worry about as well as their own physical well being. After working in both worlds, the muddy ditch doesn't seem too bad. I do however draw the line when it comes to Florida canals. Fire Fighters with their protective dive gear can brag all they want about their jobs and I will definitely respect them.

After reading the thread about Muslim Women Medics in the U.K., I see at least one country has taken an aggressive effort to control infection with a few common sense measures. In the U.K., the white lab coats worn by doctors and other professionals have been ruled unfavorable in the healthcare setting. In the U.S., only in the higher level NICUs and surgical ICUs have the "no sleeves or jewelry below the elbow" been enforced adequately. The U.S. has put a strict enforcement on handwashing but not equally across the board. EMS is still lagging there. Most believe gloves will protect them from everything and buy the super heavy duty gloves only to use them as a notepad with a pen and the possibility of poking holes in them. They also use one pair to load, drive, deliver and chart at a nurses station while continuing to wear them until they are back in their truck after walking through the entire hospital. Hospital staff that have been diligently working to control infections at both the sending and receiving hospitals are now seeing other possibilities as to where these infections are coming from. The CCT ventilator that infected several patients a couple of years ago was an easy one to figure out. There are now hospitals that are conducting their own surveys on transport teams. Some "spotters" will tell the EMS teams to remove their gloves and wash their hands especially when they are as the coffee pot wanting to get a cup for the road. Even without being one of the "spotters", that is my pet peeve and I will slam the lounge door in an EMS crew's face until they remove the gloves they just transported with and wash their hands. I especially don't like to hear "but they don't look dirty". Unfortunately, EMS education has put little emphasis on infection control due to time constraints and/or it was always considered "not their problem". "That is something for the hospitals to worry about". We were told that even clean (not sterile) technique didn't matter in prehospital because the patient would be covered by antibiotics. Guess where all that antibiotic coverage has gotten us? So, my questions to the audience here: How often do you wash your hands? How often do you change gloves? Do you walk outside the patient room still wearing gloves? Do you go to the nurses' station still wearing the gloves you touched the patient with? Do you make notes with a pen on your gloves? Do you wipe your pen and stethoscope with a disinfectant before putting it back in your pocket or around your neck? Do you reach in your jacket or pants pocket with gloved hands during patient care? Do you consider your gloves dirty only if visibly soiled? Do you clean the steering wheel frequently? Do you wear long sleeved shirts? Do you wear a jacket? How often do you launder your jacket? If you have long hair, do you keep it pulled back? Or, do you have to push it back while working on a patient with your gloved hand? Do you treat all patients with the same infection potential either for their safety or others? Do you wear a mask if you have a cold around an immunosuppressed or elderly patient? These questions are asked of all heathcare professionals inside the hospital on a regular basis.