VentMedic

Flight RN. The Flight Team may also have more protocols if needed to stabilize the patient for flight. Safety for the patient and the flight crew must be considered for the duration of the flight.

You need to start laying the academic foundation for the sciences and math classes required for pre-med now. Some of the survey science classes (survey of chemistry and survey of physics) in an AAS and RN school are not going to cut it. Go through the science and math sequencing to otain the higher courses. They will of course still work for the degrees as Paramedic and RN (if that is your prefered route). Both are considered "entry level" and both may not be necessary if MD is your goal. Your bachelors should be geared toward pre-med even if you are also able to work a BSN in there. If you get to that point and realize MD school isn't for you in the future, you can still easily go on to NP or PA. As far as clinical patient care experience, you will start will that in medical school and then do several years of residency at the bedside. A Fellowship or two will follow that. If you don't push for your dreams early, you can get too comfortable later working as a Paramedic or RN and MD school will continue to be pushed aside for "another year".

OT is a different story. I can make that also with OT. I, myself ,have posted some amazing OT salaries from OT for FF and EMT-P in San Francisco as well as California's Sheriff's and C.O who can get well over $200k/yr. I could definitely pull in that OT salary in MA as an RRT. Of course, my degrees help put me to a higher pay class where ever I go. As just a Florida Paramedic, no, I am not going to make 6 digits unless I live on the helicopter even with 30 years of experience. With my RRT to supplement, yes, I can pull it off. Our 2 year EMS programs offer 5 semesters of clinicals for Paramedic after the EMT-B. We are still exploring the option of an internship post grad.

So, again I ask, if the hospital staff are such screw-ups and work a code as a cluster mess, why do so many paramedics run as fast as they can with L/S to get to the hospital? Especially with a cardiac arrest? Maybe the hospitals here in my area of Florida are a little better than the rest of the rest of the country or so it seems from the posts. No, not every code runs smoothly. Sometimes it just takes 1 thing to throw a knot into the situation. ED staff have many other patients also that demand attention especially in small EDs where there is limited staffing. This may be the 5th code they have had and it's not even 12:00. So yes, maybe they would like someone else to do compressions. I seriously doubt because they are a "nurse" that they can not do compressions. We rotate frequently like the quidelines and everyone gets a turn to keep the compressions adequate. Nurses, RTs and MDs all must maintain ACLS, PALS and NRP every two years if they work in an ED in most hospitals. If the hospitals are messing up this bad on your patients, request a JCAHO review. Don't just sit around on a forum and bash away at a few incidents to make yourself look better. If the ED is really that incompetent, then inform the State and Federal agencies. Although, you had better have some good documentation to back up your claims. And, make sure you are perfect before you cast stones at other professionals. As for as someone working in the ED as an ER Tech, you will have the opportunity to learn alot from many professionals. Most are more than willing to show and teach you anything. Even if your scope is limited, it doesn't mean you can not still acquire knowledge.

Experience as what? An EMT-B? A good two year college program can organize their clinicals more effectively than a 90 day medic mart. They can also include a work internship prior to eligibility to setting for the boards like other professionals. Actually, $41k is not a bad wage for that area. This is at the level of many RNs in the area. And yes, cops can advance with education. Actually this is one of the few times the paramedic is being recognized monetarily for having a degree except for the state of Oregon which requires the equivalent of 60 credit hours for licensure.

http://www.ems1.com/products/consultingand...rticles/318000/ Tenn. area attracts more paramedics with higher pay scale by Lauren Gregory Chattanooga Times and Free Press Copyright 2007 Chattanooga Times and Free Press HAMILTON COUNTY, Tenn. — Though ambulance services in surrounding counties have complained of an acute shortage in paramedics, Hamilton County officials say local recruitment problems stem from the quality of applicants — not quantity. "I think the numbers are there," said Ken Wilkerson, Hamilton County Emergency Medical Services chief. "We're blessed with the luxury here of a top-of-the-line pay scale, so we're able to attract employees from lesser-paying organizations." Chief Wilkerson said there are only three openings in his staff of 105. After a training program that generally takes six to 10 months, emergency medical technicians can begin work in Hamilton County with an annual salary of about $30,000. Paramedics who complete a more advanced, two-year training program begin at about $41,000 a year, Chief Wilkerson said. Both job tracks feature benefit packages through the county, he said, and a total compensation package that is in line with other major cities in the region such as Atlanta, Nashville and Memphis. But that means applicants may be attracted to work here for the paycheck rather than for the public service aspect of the job, Chief Wilkerson said. "I think the basis for the career has changed," he said. "Nowadays, you become a paramedic because you get out after just two years of college and you start out at $41,000 ... I think this generation is just more me-minded." Capt. Darlene Poole, EMS training supervisor, agreed. "Since (the terrorist attacks of Sept. 11, 2001), it seems like we've had even more folks wanting to come out and be paramedics and EMTs," Capt. Poole said. "But they're not willing to work for it. It used to be that there was a real desire to help people. Now, it's just another job." Capt. Poole says her agency receives large numbers of applicants from local programs at Chattanooga State Technical Community College and Cleveland State Community College, but that most of those people do not make it through pre-employment screenings involving practical skill and physical agility testing. Those applicants tend to arrive straight out of school, without the real-world ambulance experience that generations past seemed to have, Capt. Poole said. Monique High, a 35-year-old Chattanooga State student studying to be an EMT, said her program does not require any such experience. Ms. High, who has worked as a bus driver and corrections officer, said she views the classes as "just a transition" to a career in nursing. Though she said she truly is interested in helping people through medicine, she sees classmates with more cynical views and agrees that younger people tend to look out for themselves above others. "Any career that you go into, very few people do it because they have genuine care and concern," Ms. High said. http://www.ems1.com/products/consultingand...rticles/318000/

That actually has been a recent argument even in the hospital setting when we were revamping our Code and Rapid Response Team protocols. There is no reason why the licensed people should be the only ones doing CPR. CNAs are very capable of doing CPR. When I posed that question to Nursing Administration "They have other duties". (???!!) Despite what many EMS workers believe, unless it is a teaching hospital, you don't have a lot of people to respond to Codes in the hospital. Usually 1 RT, 1 CCU RN, RN supervisor (paperwork and administrative) and hopefully the RN who has the patient can break away from her other 10 patients to join us. Rarely can other RNs participate due to their patients' acuities. Hopefully there is another RT is available. But, the ventilators in the ICUs have to be monitored by RT although RTs can usually bend the rules easier then nurses when it comes to emergencies. The Radiology Technologist who shows up for the CODE usually ends up helping with the CPR. We also can not depend on an ER doctor to be available. Since the hospital has an established Code Team with established protocols just like and beyond a Paramedic on the street, there is not a need for the doctor to respond immediately if at all. The medical control for the RN and RT will be directed by the ICU Intensivist. It has just been part of the nursing culture to exclude CNAs from our training scenarios which for the longest time I have thought to be a mistake. At one hospital they trained the transporters in CPR and utilized them everywhere including the ER. That worked great! They were also the lifting and moving masters especially for the bariatric patients and the Hoya lifts. We also have hospitals that own free standing nursing homes who have enough ACLS and BLS trained personnel to get the CODE initiated. The hospital then sends their own CODE TEAM/CCT usually consisting of RN/RT and maybe a doctor (teaching hospital - usually senior resident) by way of the Security department's van. An ambulance service is called if transport is needed to the hospital once the patient is stabilized. And then, we have SNFs inside of or attached to hospitals that must call EMS for a code who then works the code and wheels them to the hospital's ER. I have read the regs a 100 times on that one and am still puzzled. And, heaven for forbid if I am passing by at the time of the code, get things started and intubate while waiting for EMS to catch a slow elevator after arrival. My function as a Hospital Code Team member is to go to the ER and wait for EMS to bring the patient. But, if they don't get an ETT placed in SNF, I can then tube the patient in the ER. So, healthcare makes little sense in so many areas. Regulations and out of touch administrators have done everything possible to make systems that weren't broken or should run smoothly and turn them into an internal disaster. I have come to realize that I may never become a top level manager because I hate wasting time on the obvious. SNFs and long term care facilities are usually privately owned (even if State or City owned) and operate on a ridiculously tight budget as mandated from the various reimbursement agencies. It is rare to have ongoing education or much of any additional education except for the initial orientation of who to call for an emergency.

Anyone familiar with Nadine Levick MD, MPH and her work for ambulance safety? The website has some good safety proposals and seminar information. http://www.objectivesafety.net/ The other big article on safety released earlier this year was on sleep deprivation and safety. http://www.jems.com/Images/March_2007_Arou...075891061D243AE

EMTALA/COBRA . THOU SHALL NOT: Delay the MSE in order to obtain financial information nor induce the patient to leave without MSE by drawing payor issues or financial demands to the attention of patient or family prior to the completion of the MSE and initiation of stabilizing care. Care may not be denied based on denial of pre-authorization. Financial questions, documents, and pre-authorization is at your own peril.

Florida and Alabama (the 2 States I was familiar with at the time) also had many time management studies back in the 1980s. We had standard norms for everything from IVs, intubating to assessments. For codes we stayed a little longer depending on what we started with and the response during the 1st round. For CVAs and other medical emergencies we streamlined the on scene time down to where it seemed like we could take the scenic route by the beach to the ER and still be way ahead of the average dispatch to ED times. A calm transport, paper work in order, thoughts collected for a good report and you're back in service. There are times now when I hear a ground crew get dispatched, I have time to read my email, clean the office, make another pot of coffee, call a few friends and the crew is still on scene. Finally they call it in as a Code 3 enroute. On arrival to the ED they pat themselves on the back for getting a CP or CVA patient to the hospital just under the critical time. However, they forget that the hospital, that had been awaiting their report, must scramble to get things started. The ED staff could have gambled on the dispatcher's information when the call was initially dispatched, but, calling a team together to find that is not the actual situation is not always a good idea either. For inter-facility transports, if we are the team picking up, we try to make sure the referring hospital knows what we prefer as far as paperwork and pre-transport instructions.

One of the reasons we started our own Adult (already had the Neo and Pedi) inter-facility ground transport team was the L/S issue. We would call for ALS transport maybe just because of a medicated drip. The patient is either being transferred for specialized services at one of our affiliate hospitals or for insurance reasons. The patient is stable on release from the our hosptial, but we notice the ambulance leaving our driveway Code 3. We weren't sure who authorizes the L/S, why and where the liability might fall if something happened. When we inquired to the ALS ambulances services; "Paramedic's judgement to call for L/S if he/she thinks the patient is unstable". That left us with more questions about the competency of these crews and how they determined our patients were unstable. So, my question is why? With all of the improved technology, skills, protocols and "trust"granted to the paramedic, why are L/S still used so much going to the hospital (or another hospital)? What is the rational for turning on L/S if you are ALS? I will comment on some of the busy Florida BLS teams and L/S because I am not shy about asking a crew about this that is coming in to pick up a routine transfer like the devil is chasing them. They are told to "expedite". This is perceived by some as permission to run Code 3.

Why, even with all the protocols in place, new technology to monitor with and the availablity of hospital Stoke Teams and Chest Pain Centers, are lights and sirens (Code 3) still used for almost every "priority patient" going to the hosptal? This is true especially for Cardiac Arrest patients. Paramedics have agrued and are correct that in many situations in the field they are doing everything that can be done initially for the patient. So why are they still in such a hurry to get to the ER? The crew should have ACLS and protocols. For Chest Pain or Stroke, the appropriate hospital people and teams still have to be notified and respond to keep the interventions going that should already have started with the Paramedic. Even with immediate notification of the hospital, there will still be a short delay going to the cath lab or CT scanner regardless of those 2 - 3 minutes saved by the ambulance. So why all the noise? I won't even mention speeding.

RSI has been utilized outside of the hospital for around 20 years by specialty teams that include Paramedics and many other health professionals. It actually was easier, and still is, to have Paramedics included in the protocols especially for Flight since some States have more regulations for nurses. Perhaps if EMS had continued with the push for standardization of education and licensing which was attempted in the 1970s, this would not even be a controversial topic. Training and skills competencies will be difficult for many services. It was mentioned at the very beginning of this thread all the things that have no measurable standards within the industry that hinder the progress. There is still a lack of adequate and appropiate education for the devices used now that still needs to be addressed. CPAP, Pulse Oximeters and ETCO2 monitors all have their place if they are understood. Some EMT-Bs and EMT-Is do ETI but may not have access to the other devices mentioned above. There are very few standards one can use across the board of EMS when comparing systems in the U.S. Physical assessment should still be the "gold standard" whether it is visualizing the cords, assessing breath sounds or just looking at and listening to the patient. The pulse oximetry: excellent device but am I going to withhold oxygen when the patient c/o shortness of breath just because the patient has a "good sat"? The ETCO2: excellent device for "getting a wave" for tube confirmation. Great to have in a noisy environment such as the back of a truck or helicopter. But, the numbers may not be a true representation of "ventilation" as one is taught in a brief inservice. In the hospital, it is used for shunt and deadspace determinations. For many patients, that is not always needed. I use it to determine how FUBAR a trauma or ARDS patient is by the deadspace ratio. The sophistication of the ventilators will let us know if there are any compliance or resistance changes as well as increases or decreases in respiratory status. And, heaven forbid one does a "vent check" and not a patient check also. So there are appropriate times and places for everything. Common sense should not be replaced by technology. Also, just because you can, doesn't always mean you should. Standardization of the Paramedic basic standards (education, training, licensing, competency maintenance, medical oversight, leadership) may have to come before "standard of care" will really be adequately defined.

1. Budget meetings 2. Florida's "snow bird season" starts officially

Have your RT department PM me. I would love to have ETCO2 monitors everywhere. For 100 ventilators to be dressed out with ETCO2 that would cost an additional $1.2 million. Each vent averages $35 - 45,000 "naked". A few cost $60,000+. You also have to figure in the software upgrade, maintenance contracts, supplies, etc. I would rather have a dozen more FTE hired if I have to choose between them and more machinery. If there is anything left, I would prefer it goes to more education time. We have monitoring capabilities for everything else from bowel movements to expensive CR and hemodynamic monitors. I would have more humans around. Speaking of a hospital environment of course. Substandard care is relying on technology and forgetting how to assess. Technology will not make a better clinician. I don't know when you last calibrated your machine. I don't know your drift factor. Those numbers also do not tell me how fast you were ventilating or the VT you used or the IBW. Depends on your P&P. At many teaching hospitals, 3 confirmations are taught, one has to be phyical assessment. Clinical skills and education improves patient safety. At any deposition, you will hear, "didn't hear the alarm because of all of the other alarms". And I am definitely one for change which is why I got more degrees to work in other areas with more gadgets and technology than one can ever imagine. However, when it comes to a sick or injured patients, the technology may be an adjunct but my skills and knowledge are what I will use the most. During a code, I like to spend more time utilizing my other skills to quickly get the job at hand done. This can be in a nice ICU, ER, med-surg room or on the street. My physical assessments skills are mobile and I won't leave them in the truck. ETCO2 definitely has it place in prehospital. I just hate seeing it used as a crutch like the pulse oximeter has become. Are referring to ETCO2 monitoring or RSI? Although yes to either wouldn't be good. Again education and clinical skills are essential. I can also ask several professionals to tell me what they see by the waveforms. It is sad but many only use that expensive piece of technology to "get a wave". I enjoyed your post but I have to balance reality with budget and technology. My rant is someone who can not tell me if a patient is breathing effectively without first looking at a pulse oximeter or ETCO2. And yes, a patient can become intubated with an SpO2 of 100% and ETCO2 of 40. Of course you'll always hear "but the numbers look good". I apologize for my rant but that's a very sore subject for me especially with November approaching. I mean no offense to anyone, but hospital workers also have to manage with what our healthcare system deals us. Just because we don't have all the latest and greatest that technology has to offer doesn't mean we don't care or that patient safety is taking a back seat. Our priorities are different because we do have other technology to assist us.

Maybe they do trust your equipment and that is why they're not using their technology. I would love to have an ETCO2 monitor for every ventilator patient but we run over 100 ventilators per day in the hospital. 6 of those can be in the ED at any given time waiting for an ICU bed. If your equipment looks good, I go with it (at least a waveform check but not the numbers) and do a 2nd (EZCAP) quick check to compliment the rest of my assessment for documentation. We do keep a couple ETCO2 monitors near the resuscitation beds. Depending on the patient, not every patient is going to need all the bells and whistles. Ensuring that all the monitors are current on the cals as well as all of the QA/QI paperwork on each machine can get time consuming. There are probably better ETCO2 uses for a hospital with a limited monitor supply. How did the paramedic ever do the job before RSI, pulse oximetry and ETCO2 monitoring?

Why does one choose an expensive trade school in the State of Florida where almost every community college and state tech school offer EMT-B and EMT-P certificates and/or degrees? The average community college tuition in Florida is $67/credit. The state techs are a little cheaper. At approx 10 credits for EMT-B and 34 for EMT-P for the certificate, the cost is still way less than the privates. http://www.doh.state.fl.us/demo/ems/TrainT...ningcenters.pdf What is the advantage to attend an expensive private trade school?

If a person is on a 3 L NC using the standard length 7 foot tubing, how much extra O2 will be needed if we add 3 additional 7 foot extension tubings?

See if Dustdevil will part with his copy of Egan's 1st printing of the 1st Edition.

This book will more than cover what is used in the field. The most important part is the BASICS. It will be a good reference book for any future healthcare classes. It is the Bible of Respiratory and required reading for all 1st year RT students. If they don't understand everything in that book, there's no need to go on for another 2 years of training. There are basic oxygen principles, theories of flow and entrainment that are applied to all Oxygen equipment. If you've had some fire fighting priinciples, you'll see similarities in the basic theories. Egans Fundamentals of Respiratory Care http://www.amazon.com/Egans-Fundamentals-R...d/dp/0815127987 This is the latest addition. You can pick up older editions cheap at HalfPrice.com or Amazon. Your local college library may also have a copy.

Decreased perfusion, less blood flow, inaccurate count of Hb The Pulse Ox will only give you a percentage of the saturated vs unsaturated Hb it sees. This may not be an accurate representation of the total. It just calls it as it sees it. If the body temperature is low, hypothermia causes a leftward shift in the Oxyhemoglobin curve. A leftward shift increases the affinity, making the oxygen easier for the hemoglobin to pick up but harder to release.

No. Too many things that are not standard: Education Training Competencies Certifications Licensing Leadership Medical Oversight It may work well in some areas that have excelled in the above listed factors.

2,3-DPG Oxyhemoglobin Dissociation Curve http://www.ventworld.com/resources/oxydisso/dissoc.html

Hope this is helpful. http://www.oximetry.org/pulseox/principles.htm Pulse Oximetry Revisited: "But His O2 Sat Was Normal!" http://www.medscape.com/viewarticle/550665_print Factors affecting: Skin color Perfusion Anemia Finger thickness Nail polish - especially the metalic flecks External lights Movement Skin pigmentation Carboxyhemoglobin (CO both extrinsic and intrinsic) Methemoglobin (can be caused by the 'caines - topical analgesics for endoscopy and bronoscopy, nitrates, nitric oxide) Intravascular or intradermal dyes Movement Irregular heart rate Sickle Cell For respiratory distress the value SpO2 100% will be not mean much because if you are delivering O2 at 100%, the ABG value will be of most use to see how much O2 is actually in the arteries vs what is delivered. We call this an A-a gradient - Alveolar to arterial gradient. The hemoglobin may be well saturated but the lungs (Alveoli) were only able to pass X amount to the blood which is measured in mmHg (pressure tension) in the blood. Good site PaO2, SaO2 and Oxygen Content http://www.lakesidepress.com/pulmonary/ABG/PO2.htm

Ambulance services are getting reimbursed at that? Billing at that? I do know that is also the charge in the hospital. As a Respiratory Therapist, I can run up your hospital bill to well over a $1000 with just a neb, EKG and ABG in about 20 minutes of time. Add another $75 for the SpO2 check if I did that also. Sometimes, I throw that in as a freebie as just part of my routine assessment. I can also tack on an MDI instruct, smoking cessation teach and a peak flow for about another $500. Let's not forget the O2 device and set up charge. Of course, Medicare is going to pay pennies on the dollar for what is actually billed.