VentMedic

She was alive when the photos were taken. Would you want your dead loved one's photos available on the internet or hanging in some conference center? Remember this recent news story? http://www.emsdailynews.com/?p=395 Paramedic gets punched out then fired after posting photos of fatal crash onlineAugust 24th, 2007 Paramedic took cell phone pictures of crash that killed teenager, posted one online and drew the wrath of teen’s family and his employer A Kentucky paramedic has been fired after he posted photographs of a car crash online which led to a violent confrontation with the victim�s family. John Snow worked as a paramedic with the Clinton-Hickman County ambulance service for 10 years. He was under investigation by the Kentucky Board of Emergency Management Service for some online postings but continued to work because the service couldn�t afford to suspend him with pay. On May 20, 2007, Snow attended a car accident where a 16-year-old boy was killed. While at the scene, Snow took photos of the crash with his cell phone. He later posted a photo on the website MySpace.com along with a blog about his paramedic work.

What is a patient's expectation of privacy at scene? Do you give respect to a patient's privacy when assessing in public view or even in their home? Should the patient be photographed or videotaped at scene by EMS/FD? I've seen many action shots published in various magazines and used at trade conferences for photo contests. I've often wondered how many of the patients realized they were being filmed or photographed and that they would be viewed by thousands. If a photograph is taken "in plain public view", is it a privacy issue? Florida Crash Photos Could Cost Chief Job http://www.local6.com/news/14986331/detail.html http://www.emsresponder.com/article/articl...n=1&id=6816 Story by local6.com UMATILLA, Fla. -- A suspended Central Florida fire chief could lose his job over e-mailed photos from a crash scene that included at least one image of a female victim's exposed breasts.

I've been reading posts on a few different forums and it seems EMS is now focusing on equipment rather than education to pick up for the slack in education or common sense. The EKG monitors for BLS, pulse oximetry, RAD 57 CO-OX (with MetHb option) monitor, ETCO2, various airways, automated BP monitors (complete with HR), CPAP, ventilators, etc have all been recent topics on different forums. However, what I am not seeing is more education other than a quick inservice on what the equipment's true purpose is. And of course, the entry level educational standard has not raised. People say the ETCO2 is a "gold standard" for intubation. Pulse Ox is the only way to go when assessing oxygenation. Advanced airways are a must. Advanced airways? Many people can not use the BVM adequately or bag correctly when they do have a tube. I asked a paramedic (yes, EMT-P) how he determined the correct tidal volume for a patient. His reply was by hand size and not chest rise or breath sounds. I did inquire futher and got "adults are all about the same". He truly did not know even a ball park figure for the volume of an adult bag. He's not the only one. Sometimes, I ask paramedics these questions for a reason and sometimes just for amusement even though I am disheartened by the answers. I have also watched Paramedics stare at their ETCO2 monitor trying to "see a wave" when they should have physically assessed that their patient was extubated instead of "trouble shooting a monitor" as to why they weren't still getting a wave form. Likewise, I have seen EMTs and Paramedics frantically trying to get a "sat" on people who haven't had good circulation below the shoulders in 10 years just to see if they needed oxygen. Whatever happened to assessing what the patient is saying as well as the physical signs for work of breathing or poor oxygenation? There is even very little education or understanding about BP except "high or low". HR numbers are taken from automated equipment such as the pulse ox or automated BP without manual confirmation of rate or quality. And if you have a CR monitor, guess where the RR number is from. None of those gadgets will make someone a better clinician if they lack the "basics" of a solid education. So the "education" is now as piece mill as the 48 different EMS certifications. Patchwork knowledge with little focus on the "basics" such as better assessment, A&P, mechanisms of injury or medication, better use and understanding of the equipment that is standard such as the manual BP cuff and stethoscope. It is truly amazing how many body systems one can assess with only a stethoscope and BP cuff. We can also add on all the extra medications that different EMS levels are giving with a narrow view of what each one does. This is not just at the Basic level but also at the Paramedic level as they attempt to "extend their scope" in CCT by learning a couple more meds or a couple pieces of ICU equipment but without the benefit of critical care education. An 80 hour cert class is not enough if you have very little "basic" education or CC experience to begin with. All of these tools can be very useful adjuncts in the field, but they do not provide all answers and can actually lead someone down the wrong clinical pathway without proper physical assessment. Yet, many in EMS are pushing for more gadgets "to provide better care" instead of eduation.

The thing our attendings have stressed to our teams (neo, peds and adults) is don't risk our lives or the lives of others for a pt that may or may not have even a 50/50 chance of survival. Many times if we have an outside transport driver or pilot, they will never be told how sick the baby or child is that we are transporting. We do not want that to influence their driving since emotions and adrenaline run high with children on board. I have also sat at a gas station with a broken ambulance and a baby so sick that the referring hospital practically threw it at us as we entered the room. You just find an electrical outlet for the isolette and let your education and training do the rest while you try not to attract attention. L/S should not be a substitute for education and training.

Vicki, I've gotta ask this since it has been discussed a hundred times in my home state. Are you saying RNs without EMT-I and/or RNs with EMT-I can start IVs? In other words, is it okay for an RN without prehospital credentials to do scene response and treat in your state?

Camp and school nurses administer medications already prescribed to the students. They assess and call EMS. Physicians' offices and clinics are under direct supervision of physicians. They may not be required to maintain a code cart or keep a large variety of emergency medications so they also assess and call EMS. Is her service licensed by her state to do more than an EMT scope? Would they have to upgrade to a higher classification of service? Would their service have to maintain a higher insurance for liability? And, that doesn't include the questions the nursing board will ask? They don't want RNs doing something against their license just because "a doctor says so". The same is true inside the hospital. That is why it sometimes takes months to get P&Ps written by physicians approved. RSI and conscious sedation are two examples that take serious review before policy is made. The nursing board is there to protect the nurse and the public. When you have dual credentials, you will have these gray areas. If licensed as an RN, one will always be a nurse but must play by the rules that govern the current job description and certification/license.

Are IVs in the scope of practice for EMTs in your state? If not, then you would have to petition the state to change its scope or create another certification by skill only. Washington State is an example of that alphabet soup. Your service may be unique in that ALS will follow shortly. However, many areas have only BLS and starting an IV may be of little use if no medications can be given. So, now you have a BLS service wasting more time at scene. Skills with only minimal education is not good either. As far as your own credentials, are you working on that ambulance as a nurse or an EMT? That is the job description you follow. That ambulance or FD service may not be licensed in your state to provide more than BLS services. Nurses can work in prehospital in some states with MICN or PHRN. Other than that they hold EMT or EMT-P and function under that certification and scope as determined by their state and in the job descripton designated by their employer for the services that ambulance or FD is licensed to provide. So, check what an EMT is legally allowed to do in your state. http://www.emsresponder.com/survey/KS.jsp The other issue, if your medical director wanted to write protocols for you as an RN, you must ensure there are no conflicts with your nursing board and the protocols must designate this would be for an RN. Again, the way your service is licensed would play a factor. It could also open up a can of worms in the EMS world in your area. And of course Texas is different.

"Inspiratory Support" is a whole different "mode". This is a pressure supported breath and is available on ventilators and home sleep apnea machine. The common name for that is BiPAP which is a trade name of respironics. CPAP is Continuous Positive Airway Pressure which utilizes priniciples of flow with an end resistive valve in the simplest of systems. Some prehospital devices make better uses of the flow principles than other. (I described the flow principles earlier in this thread) Even on an ICU ventilator, there is no "inspiratory support" pressure with CPAP. This requires a machine capable of a 2 pressure level mode. Some patients can not tolerate just CPAP and is not appropriate for everyone. I know there is a lot of confusion with different terminology and "trade names". However, if you understand the basic principles and look graphically, it is easy to distinguish the difference between CPAP and BiPAP (trade name) which offers inspiratory support.

They can recruit the people that don't meet Oregon's education minimum to be a paramedic.

Does that system work for Ontario? Did they start out with 48 different certifications?

My ideal EMS program would be 2+ years in length. Just like other profesional healthcare programs, you would have to satisfy the prerequisites prior to applying. This would include at least 1 semester (2 preferably) of A&P, Math and General Chem. After the prerequisites are met, you could then apply for the 2 year program. At the end of the 1st year you would be eligible to sit for the EMT-B. If there must be a lesser level than Paramedic then it should at the very least combine some of the intermediate level. At the end of the 2nd year, you'd be eligible for the EMT-P. If you stop at EMT-B, you would have 5 years to go back for EMT-P or repeat all the sciences. There should only be the two levels; no A, advanced B, C, D, or whatever. Eliminate 46 of the 48 different certifications. Period. Okay, the FireFighters could still have their First Responder cert.

Yes, FireGuard69, we all know your pet names for people, especially your patients as you mentioned in the Ambulance Driver thread.

That is truly the exception to the practice for Neo Transport teams. The good Neonatal teams are trained to travel long distances with the sickest of the sick. We do not allow our team to run Code 3 to or from any hospital. Since the Neo doctors at our facility are in communication with the doctor at the other facility, things can be done prior to the team's arrival by the staff there. It's not like the baby is waiting on the curb with no healthcare workers by its side. Yes they need specialized care, but if the ambulance gets in an accident, the baby's chances are greatly reduced to nothing. Time is best saved on paper work and having priority to different transport modes that the hospital does not own such as a fixed wing aircraft. If the helicopter we own is out, we have plan B. If we have to go to the airport to make a connection, no code 3. The neonatal team consists of RN and RRT. If we take our ambulance, the driver is an EMT who is also a staff member of the hospital. All the equipment we need goes everywhere with us. If we have an ambulance meeting our helicopter on a Specialty Transport in another town, we do not want a L/S response. We may notifiy the ambulance service at least 1 hour in advance. Yet, on approach, we'll look down and see the fools "running" for the airport. We will shut down completely to unload. It is rare for a specialty transport that we will load or unload with anything still moving on the helicopter. There is time to get to us calmly. We just hate to see people "rushing" up to us. Bad mistakes can be made quickly. If the weather does not permit flight, some transports may be 6 hours one way. Some flights may be to South America or the islands. There is little we can do by saving a few minutes. We do not stress the truck, crew, other people on the road and especially not the baby with Code 3. Also, if there is any chance of the parents following, we will try our best to discourage that or drive unbelievably carefull. Around 10 years ago, many of you may have heard about the mother and father being killed at an intersection while attempting to follow the ambulance that was traveling at a normal pace and then "lit up" to go through a busy intersection. The baby lived but was parentless. That set an example for the industry. I would say that team needs to re-evaluate their skills and expertise. Neo/Peds teams have huge conferences at a national and international level with same for all modes of transportation being a big issue. The only time we take an M.D. on board anywhere is for training purposes only for a resident. Then, they look, don't touch and sit quietly. The other rare occasion might be for an ECMO candidate and the attending goes. His/Her presence may be more for family information and various consents that will be needed. It is really disgusting to hear about teams like this. It sounds like this may not be a dedicated team but something that gets thrown together at the last minute. So no, you may not have 3 "highly trained Neo professionals" on board but some "I'll go! Pick me please!" volunteers. The other reason and possibly one of the very few situations to consider L/S is when you have medical incompetence in back with the patient.

How many male nurses do you call "sweet heart"?

Anybody look at their own state's legislation and proposals concerning AEDs lately? State Laws on Heart Attacks, Cardiac Arrest & Defibrillators http://www.ncsl.org/programs/health/aed.htm You can also find new EMS legislation on that web site. http://www.ncsl.org/programs/health/ems.htm

The altitude would affect the SpO2 but it would also depend on the patient's acclimation and Hb available. His respiratory symptoms would be dependent on his total carrying capacity. Even small amounts of CO can produce the other symptoms. The other thing to consider would be a touch of altitude sickness if he was from sea level and not a native to the area. Since CPAP and Hyperbaric are two very different therapies, the CPAP would be beneficial for CO poisioning only if it visibly reduced his work of breathing and 100% O2 could be delivered. Of course if there are other lung processes involved such as the pt having COPD or Fibrosis, then yes, it would probably be beneficial. If the guy was 48 y/o with a pack of cigarettes in his pocket, he probably has 30 - 60 pack years of damage already to his lungs. CPAP might help him out provided he was not vomiting. The half-life of carboxyhemoglobin is approximately 5 hours. For example: If the patient has a level of 30% COHb, it will take five hours for the level of carboxyhemoglobin in the blood to reduce to 15% COHb, once the exposure is terminated. Did the hospital or clinic mention what his COHb measured at on the CO-Oximeter? or if they have a CO-Oximeter with their ABG lab?

But, you are measuring two totally different aspects of Respiration: Ventilation and Oxygenation with each device.

The patient may also have had a bronchospastic or hypoventilatory component. The Hb not attached by CO may have desaturated. CPAP is good if it helps with their work of breathing. However, it they must "work at breathing" with the CPAP on, then it is defeating the effort. I would also not advise placing CPAP on someone who is vomiting. Also, for CO poisioning, with the different CPAP machines on the market, use care to keep the FiO2 at 1.0. Adding more PEEP or cmH2O may not make a difference if there is not an existing lung pathology that warrants it. It can also add to the work of breathing. Not all CPAP systems are created equal. However, the Porto2Vent is definitely better than some. Even with the RAD 57, your prehospital treatment probably would not have varied since you suspected CO and was using as close to an FiO2 of 1.0 as possible. If it affected your choice of facilities to take the patient, then yes, the RAD 57 would have made a difference.

I asked about the cuff to see if there was a clue as to what type of airway device it was. There are about 300 different artificial airway devices on the market. Not all nursing homes are certified for certain airways. Some Montgomery stoma devices may be acceptable while others require at least a SNF rating. You stated that it was a NH and the pt was wearing a NC leads me to believe it may have be more of a Montgomery tube rather then an extended cannula device. You also did not mention an available humidification system with a trach collar which one might also believe the patient was able use his upper airway majority of the time. Thus, there could be more than a plugged trach causing the desaturation. Was the patient able to speak? Did he have a speaking valve? A cuff is NOT used to stabilize a trach. It is used to make a slight seal for ventilation purposes. Unless the person was on a ventilator at night, cuffed trachs are rarely used for long term. It is also a myth about the cuff preventing aspiration since the cuff is located below the cords. The diameter of the yankeur can create problems if inserted into a trach. It can create atelectasis and suction trauma on the tracheal wall if the trach is angulated in an awkward direction or just a different anatomical structure is present such as in some of the post radical neck resections. If the yankeur suction device was just laying around, it is loaded contaminants. They lay on the floor, in the bed,in the butt crack of the patients and are used to suction up just about any mess. Even for NHs and homecare, there are easy sleaved suction devices where you don't even have to know a thing about sterile techique. I always suggest those for transports since they are cost effective with their reuse capabilities. If the patient did have a Shiley, Portex or Bivona trach with an inflated cuff and was wearing a NC, I would take the patient in for some serious humidification and mucolytic therapy along with a CXR to check for more complications. This would also alert the hospital staff to contact the NH and send some educational material before this happens again. You mentioned this happened before. Anytime you have patients either at home or in a facility with special devices and equipment if is good to get all the information you can about it. You can have your supervisor request an inservice. Then, you'll be better prepared to quickly assess. You might also be able to make valid points to the physicians so that a followup is done at that facility to improve their system for caring for long term artificial airways. There are many things to assess with a patient who has an artificial airway. These patients are rarely just a "respiratory" patient but a multi-system time bomb. SpO2 will only give you a small view of the whole picture. Many times healthcare providers do get distracted by a "trach" and forget about all the other systems that are needing a little attention. Edit note: Damn, I just realized this post was listed under FUNNY STUFF. Although, I rarely pass up the opportunity to get people thinking about airways no matter what their level of certification or what category the post is in.

I would definitely now send him to the hospital for evaluation and possibly some antibiotic coverage. Just curious, was the trach cuff inflated or deflated?

Welcome davidkinback. Atavane? or Ativan? Zanex? or Xanax? 10 30 AM? or 2230 PM? Spelling and timing are two big causes of medication errors.

[web:64841b7149]http://classes.kumc.edu/son/nurs420/unit7/respiratory_patterns.htm[/web:64841b7149]

I guess you have never seen the inside of a pediatric lock-up psyche unit? Those 8 y/o and under scare me the most. You see them as children. They see you as someone to hurt.

The closest thing we had in Florida was a couple of county agencies attempted to do community service clinics which included immunizations. That was not widely welcomed by the Paramedics. There may also be protocols for disaster type situations where the paramedics can become part of a public health effort and help immunize against infections. I know we revised ours after Hurricane Andrew.

Words of advice: Don't work at Disney or any large tourist attraction. Or, do not have an emergency of your own at Disney or any large tourist attraction. For any "emergency" from a scraped knee to a cardiac arrest, you will have at least 100 tourists thinking it is part of some event that isn't listed on their brochure. There will be at least 100 cameras snapping pictures, people commenting inappropriately about the "show" and cheering even if the patient is pronounced dead at scene or in the back of an ambulance (not on the golf cart EMSmobile - death with dignity at least). The one thing working in Florida has taught me through the years is to look professional in public view even if you don't have a clue as to what you are doing.