VentMedic

I believe a lot of the team make up should depend on the acuity of the patient and the length of transport. We have several hospitals within our system and transport may be required throughout the system for specialization. Due to the high acuity of our patients we had to go with establishing transport RNs to accompany our patients because we were finding out when the Paramedics arrived they may have little or no knowledge about certain medications, lines or ventilation. An RN would have to go anyway leaving the ED or ICU short staffed. The hospitals have no control over the skills, knowledge, education, competencies or equipment of the paramedic teams that were showing up to transport. The hospital formulary is also constantly changing as new medications are being added. The ALS transport companies have difficulty getting all of their paramedics inserviced properly on all the new meds. There is little doubt that a paramedic is capable of learning additional medications and equipment. But, it is gaining experience with the medications and equipment that becomes difficult. Even when it comes to working with various IV pumps, skills and competencies vary greatly. Factor a ventilator into the equation and it can become a very difficult transport. Many don't realize that the switch from the ICU vent to the transport vent may cause a profound decompensation about 15 minutes into transport. A couple of turns of the knobs and you may have to quickly titrate the vasopressors. Then, that titration leads to another ventilation/oxygenation effect which the inexperienced may get caught up in a cycle without understanding how to get out of it without experience. Also, fixation on one particular system is what can also happen that leads to a very bad transport situation. For inter-facility transport, no RN at our hospitals will be considered with less than 5 years of ICU experience. Even the ED RNs can be at a disadvantage if they have not worked ICU and may not be considered for inter-facility transport of an ICU patient.

Actually, it may be in the ambulance more frequently now and it may involve members of a CC team if they are transporting patients on Nitric Oxide for any length of time. We have done our own studies for our own safety P&Ps. Usually NICU transport may only run approx 20 PPM but adults may run at 50 PPM. A small area with poor ventilation flow can make the difference. Short transports are rarely a problem though. Our nurses also know better, now, than to sit close to the bedside when we are running a pt at more than 20 PPM for any extended of time especially if it is an open port system such as the oscillator vent (HFOV). We also find high MetHb levels appearing in patients that are on the nitrates for extended periods of time. They may seldom get mentioned to an ER Doc unless he/she has put the request in for the co-ox values even though the values may appear to the lab technician or RRT running the blood sample. If it is for shortness of breath, the RT will usually mention it and get an order to release the information. It is a great topic to research especially for those pulse ox dependent assessment people.

Methemoglobin is another one that skews the pulse ox readings and there are many things that can also contribute to it. The level present can be 5% or 50% and the SpO2 may remain in the 80s. I believe 85% is the magical number as stated somewhere here in this thread. A cooximetry measurement will be the most accurate direct measure of MetHb.

Like Carbon Monoxide, some of the "numbing" 'caines have been known to bind with the hemogloblin. I've seen it a few times after endoscopy and bronchoscopy procedures. Usually not as severe but can create some shortness of breath for a while. However, there are a few cases in the literature when intervention must be taken to break the binding.

At the hospital I'd check his methemoglobin but I would expect a higher SpO2 with the additional binding.

The effect of insulin is partially blocked by a variety of hormones made in the placenta. This is called insulin resistance and begins about 20 to 28 weeks into pregnancy. As the placenta grows, more of these hormones are produced and the greater the insulin resistance becomes. The pancreas normally is able to make additional insulin to overcome insulin resistance. When the pancreas makes all the insulin it can and there still is not enough to overcome the effect of these hormones, gestational diabetes results. So, as the body's hormones fluctuate with the developing baby, so does your insulin and glucose levels. The mother will get usually get over the gestational diabetes once the baby is born. However, if the mother doesn't use care during pregnancy, the baby will feel the effects the most. Watch your diet and listen to your doctor.

Is there any question as to why the public doesn't always get the "terminology" correct?

Do you realize how expensive that would be? Do you also realize how thin the doctors in the various specialities as well as nursing and other staff members that work in these specialties would be stretched? These hospitals are too close to be duplicating services. And yes, most trauma centers bleed money. They cater to an expensive group of indigent trauma patients. Nobody gets shot and costs less than a half million dollars these days.

IF the patient has a pulse, a 12-lead EKG is necessry because they are prone to ischemia and the good ole MI. Lee County Healthcare has already streamlined their system except for a few details with the two recent additions to their family of hospitals. And even though, Lee county is large, it would be difficult to correct electrolyte imbalances in the field as well as carry all the necessary meds and fluids to do so. Also, and especially in the dialysis patient, whatever you attempt to correct will have an effect on other systems. With the iSTAT poc you will still have just about 7 values out of a minimum of 24 needed to even begin to adequately correct. And, with renal failure on even a non dialysis patient would you know what to do or what you could do to those patients. Yes, the POC testing is very important on specialty transports and is used regularly. But, a baseline as already been established and whatever might be needed to correct something has already been anticipated. Your JEMS reference pretty much makes every point I would want to make about POC testing in the field. It is strange that you chose that article if you are pro POC in the field. As far as decreasing times in the ED, not if CLIA standards are not complied with. This is the biggest thing that EMS workers have trouble understanding. Work will have to be duplicated again if the CLIA guidelines are not followed to the letter. Why do you think phlebotomists must now have 150 hrs of training to draw blood? It is easier to draw another lab than to untreat a patient who had been treated by a mishandled or mislabeled specimen. And, god bless that lab that wants to undertake the task of CLIA testing, certifying, compliance checking employees as well as QC recording each machine at least once a day all those machines on a large EMS company. How much are you going to raise the county taxes to pay for the machines and the cartridges? Any EMS system that is good, needs to perfect some of the things they have been implementing before jumping ahead to something else. Their good reputation could easily be damaged.

HIPAA has its purposes for the protection from release of PHI to the unintended . Even some PHI can still be used for research. I work at a large teaching hospital. Many of the ED codes are video taped for teaching purposes. That is their intended use. Surgeries in our ORs have also been video taped for many years. Legislation is now being passed throughout the country to mandate video taping of all surgeries. Throughout the hospital we do have little signs that inform people they are on camera. It is also in the fine print on their information packet. We have them sign HIPAA papers but it clearly states we will not release any PHI collected for any purposes other than who they designate or the intended person or purpose. It also states that their medical information will be part of our data base that can be used for demographics and research. I'm sure you have HIPAA info release forms on your ambulance also. They should state "release of PHI only for intended purposes". This primarily has to do with billing, secure means of transferring data and data storage. Other privacy issues are dictated by state, local and company policies.

Don't forget all the recent articles about video conferencing ambulances, their medical control and/or ED.

Every patient in our ICUs are watched 24/7. The people monitoring the cameras are also required to chart periodically on the CR monitors, med pumps and ventilator settings. If I turn the ventilator away from the camera for even a few minutes, I get screeching from someone attached to that damn thing in the ceiling. They also have electronic access to all orders for comparison. And no, it is not a HIPAA violation because they are serving a purpose for patient safety.

He could probably still get a job in California until they figure out how to do background checks on their EMS applicants. This has been a problem in the past before we did do background checks. And, yes there have been many disturbing news headlines even in Florida. Unfortunately, the psych and police detainees also heard about this and used it as a "get out of jail free" card. So, for the longest time we were careful to run male/female crews for these transports. And yes, we have had patients in our ED for a rape exam that were accusing their transporting EMT or Paramedic. We've also had patients from another hospital who were assaulted in their patient rooms. We've had RNs, RTs and MDs accused and convicted of sexual assault. Extreme cases but not unheard of and yet, can be more common than one would expect in the healthcare profession. Sexual assault can have different definitions to many people. The privacy of the victim is protected as much as possible. Rarely do the majority of assaults ever make it to the news. I will occasionally see a suspicious loss of license in the state EMS bulletin. The paramedic's attorney could also have leaked this to the press in hopes to discredit the victim by getting support for his/her client. And, this could have back fired. We have also seen on TV how anxious other members of EMS are to get their 15 minutes with a news teams. The police will keep as much of it private as possible but too much must be made as public record. I don't know what to make of the patient privacy issue anymore. We have video cameras everywhere in the hospital and on the specialty transport ambulances we own. In the ICUs we have a live video camera in each patient room as a second set of eyes. The people monitoring these cameras are hospital staff and physicians who identify themselves but may not be personally known to us. The patients may be too sick to be informed and may not ever get informed about the cameras although it is in fine print on the information handed to them at sometime during their stay. When we want to undress or bathe the patient, we just stare at the camera until it swivels around. Sometimes we have to tell "it" to remember its manners. It is a little unnerving but we get used to it until we hear a voice from above speaking to us. The violation of HIPAA would be if the information was transmitted by unsecure means or used for other than its intended purposes of patient and personnel safety. HIPAA would not be the issue as much as your own company's privacy policies. Even in the hospital, employees and physicians are not immune to sexual assault charges. Even with EKGs we are very careful and if there is a choice a female will do the EKG on a female. Even as a female, I will be careful to expose and touch what is necessary unless it it is emergently impossible. It is rare for an EKG dept to have male EKG techs for the routines. In the ED and ICUs it is not that much of a problem due to the lack of privacy in those areas. We even have male foley techs for men of various cultures that don't want any female not married or possessed by them to touch their penis. I also can not imagine healthcare providers murdering patients but we have enough Court TV cases about nurses. Every California RT will also be forced to remember Efren Saldivar, the Angel of Death, every time they recertify their mandated Ethics course. You can not imagine the scutiny California's RT profession went through on that one. And then, along came the child molester and Respiratory Therapist, Wayne Albert Bleyle, at Rady Children's Hospital. These were just two cases but they made not just national headlines on CNN but also international headlines. This paramedic assault will probably run in the local paper and get picked up by the EMS wires for EMS professionals to make a deal about being in the news and think the press is picking on them. I don't expect Anderson Cooper to fly in for coverage. However, Nancy Grace might like this case.

No you didn't misunderstand me. There were just so many points I would like to make even after my long post earlier. In the city we do have more options for transport. I don't think EMTs and Paramedics actually realize how many people are transported in and out of a hospital per day by all types of vehicles and personnel. Ambulances truly do not bring in the bulk of our patients or take them away either. If the physician signs for ambulance transport let him/her worry about it. Chances are there is something in the medical history that definitely warrants it. Many times the admitting diagnosis or reason for transfer will only say the immediate such as fever or HA. It will not say heart transplant last year on a current diagnosis. Granted in smaller communities, the ambulance may be the only game in town. Of course there probably aren't taxis in the small towns either. Even after I had a small outpatient procedure, I knew I couldn't drive afterwards, but the would not allow me to leave by bus or taxi either. I had to have someone see that I got to my house.

And you're judging who, when and why gets transported?

At least they will hopefully have enough training to recognize something is not right and drop the pt off at the door closest to the ED or make contact with a medical person inside the building to anounce the pt's arrival. We usually find dialysis patients dead by the back door to the dialysis center along side the hospital that had be dropped off by tranport vans. But, depending on the service, the drivers do not always have an obligation to escort the pts inside the building. They would also be leaving a lot of other pts alone in the van. The number of dialysis patients that ambulances transport is relatively small compared to the number of the dialysis patients a center might see per day. Our center is not that big but we can do 25 patients at a time and is open from 0600 - 2300 six days a week fully staffed. There is a crew on Sundays that can still do 10 patients at a time. The patients that do come by ambulance have been determined to need that service because it is not always easy to get qualified for that service. However, you as an EMT or Paramedic may not have access to all of the medical records and the patient may not be a good historian due to their illness. Now, from a previous post, NH patients are "institutionalized" for all practical and legal purposes. The State has taken control of their lives, possessions and freedom. If there is not a family member around to oversee their legal stuff, the courts appoint a guardian who may have no personal relationship with them. They do not have a choice in how they are transported. They do not have a choice in who gets their dog or cat or many times any of their personal belongings. If they could they too would be happy to have the freedom to take a taxi instead of being carted around in the back of an ambulance like a piece of meat. It is humiliating for someone who has been independent all their life.

You did RSI without protocols? And, where's your Medical Director? Doesn't he/she know how to get a protocol that he/she will be responsible for not to mention the medical oversight of your training and continued competency?

This article was released just prior to the Bush Administration announcing the budget cuts for Homeland Security. They're riding on the recent good deeds and news worthy stories of the observant EMTs that did notice some things that weren't quite right which did prevent potential disaster. Keeping current with the news and the environment you are working in should prevail as commonsense without more mandates other than an occassional inservice on things that one should be aware of.

Will these rules and laws be the responsibility of the state or each individual county for the "oversight" again? In other words will it be left up to Bubba county to decide if any of these new rules and regs will actually get carried out as it has been in the past? Just curious since the state of CA gave each county the authority to carry out whatever to whoever whenever if ever. If so, isn't that what got them into the mess that now requires all of this "new and revised" stuff?

Even the every day care aspects that can be involved in transporting the patients can be a challenge. Unlike CNA training, EMTs are not always exposed to various aspects of care where bodily functions are involved but can be a real part of getting the pt from point A to point B. 80 y/o parts of the anatomy can bring about a "giggle" if the person is not mature enough to suppress it and can cause great embarrassment for all involved. Also, anyone that has done enough hospital to NH and NH to hospital transports eventually must deal with a scrotal sling. I still grimace when working with these patients and I get to see a lot of them on my ventilators that have scrotal edema. I don't know if I would want a 16 y/o exposed to that or a machete attack victim.

T'is the season and I have been busy as an RRT. Did you by chance get a sputum culture done to make sure there is not a bacterial component that could also be easily treated? Recent or current sinus infection? Are you monitoring your peak flows? Is your pulmonary doctor aware of any changes in your peak flows? Are you friends with your Respiratory Therapists? We've had to adjust the maintenance meds on quite a few asthma patients to get them through the rough times and prepare them for the season. I have a few pts that I am following who are post op and cannot use the steriods yet. I am happy to say that with a lot of vigilence, we'll get them through the rough times. There are now several alternatives available to most RTs to keep a pt off the tube. Stay on top of monitoring your breathing, PF and any sign of sputum (sorry about getting personal) changes. And, think positively but not to the point of denial. Keep the faith and good luck!

(Sorry spenac, your posts are the easiest to quote) NH pts are sometimes caught in a revolving door of healthcare. The physicians are being forced to move pts out of the acute areas faster, sometimes too fast. Broken hip pts are barely off the OR table when they are moved to a convalescent. NHs are expected to take care of higher acuity pts without additional help. So, if one RN is responsible for 30 pts they are still responsible for 30 pts but 10 of those might now have the same acuity as what 2 - 3 RNs might be covering in a hospital. We set the patients up for failure in a failing healthcare system. No one has a crystal ball to accurately predict how soon the patient will be back or die from complications. But, those that are involved in the discharge of these patients do quietly place their bets on how soon they'll see the patient or read their obituary in the newspaper. And yes, sometimes we bet they won't survive the ambulance ride back to the NH. EMS people rarely are aware of the frustrations Doctors, nurses and other healthcare providers have with the system. Nor, do they see the end results of that pt's early discharge when another ambulance will bring the patient back a few hours later. I could go on to tell you how many dialysis patients that have come in by either transport van or ambulance with EMTs or Paramedics that have coded (some dead before they are unloaded but not noticed because "they're just routine nobodys") when they enter the door. I have intubated many of these "routine transports" that were presumed BS taxi rides a few minutes after their hospital arrival with the EMTs somewhere in the background doing their paperwork. Many of these EMTs have the skills but their attitudes now prevent them from doing a good job even at the basic level. Once they hear "routine" any assessment skills that have been taught to them are now replaced by "taxi run" mentality. Thus, important information is missed and appropriate questions are not asked. Burnt out, or L/S jockeys or wannabe nothings have no business touching any patient. The elderly and handicapped have very little or no choice in how they are moved. Bekins Moving and Storage could probably do just as well as what we have in our healthcare system currently in some areas. And believe me, after meeting the 2 jackarses of EMTs that transported my mother to Hospice with the iPOD earpieces stuck in their ears, if there was any way on this earth that I could have safely transported her in my car or by cab without causing her more pain, I would have! I have offered to teach the next EMT recert class for that company. My plan is to have it in the day room of a nursing home and let the NH residents do the grading. I'm sure it really makes the elderly and handicapped patients feel good to know they are inconveniencing such important EMTs because they are old and must depend on others for transportation because their body refuses to move like it used to. They should be ashamed of themselves for being such a burden. Sick, handicapped and elderly patients deserve alot better than what the U.S. healthcare system has to offer them. Then we must further burden them with the identity crisis that EMS professionals are having and I'm amazed the elderly, handicapped, sick or injured manage to survive as long as they do. Generalizations and hasty summations are part of the healthcare system's failure. People in State and Federal agencies who are thinking, just like a few people posting here, that it is okay to cut corners and quality. Those that placed the "length of stay" guidelines also assumed everyone was the same in their response to illness and injury. And, there are ways to report fraud for any service involved. But you better be sure of your accusations and not just making an out of your arse statement because you hate routine calls. The training an EMT gets really does not prepare them to make that judgement or even understand what is on the physician's report. "They don't look sick" is only one part of the assessment. Hospitals and physicians also have a legal responsibility to see that their patients get to whatever destination safely. If it is my loved one they are making that call for, I would rather them error on the higher side of care for transport. So, when you can accurately predict which pt is going to go bad, when, where and how or doesn't deserve someone in that truck that can as the very least take a set of vitals, you'll have your alternative system.

Since this is in the Funny Stuff category, I will not go into great detail about my mother's 5 ambulance rides (1 ALS and 4 BLS) that she had to endure in 1 month prior to her death. I do have enough respect for EMTs to not stereotype the whole profession. I will say however that not all are created equal. And yes, my mother and I both asked the EMTs on a couple occasions "Do you take vitals?" Since my mother had a AAA, before repair and after, vitals were important. But since she was "a routine transfer" vitals were not taken on two transports. The routine transfer in her case meant her OR time was already scheduled and she was stable for BLS. Also, the physician may not have wanted a paramedic pushing fluids to get her BP much higher. I could also bore you with the details of what I did to the EMTs that showed up with iPOD ear pieces in their ears while moving my mother from the bed to stretcher on the day we decided to admit her a hospice program. But, since this is in the Funny Stuff category, I'll let it be at that.