VentMedic

Sometimes when I am delivering a nebulizer treatment with a mask, I use the 6 inch tubing that comes in the package (for use with the mouth piece) to insert in the holes on the side of the mask and make a pseudo high flow(entraining air from the outside), slightly "higher" FiO2 device. This works better in pediatrics because their minute volume is lower so the entrainment will be less and FiO2 higher. Then we try to joke about their "horns" or "tusks". This is also where the Demand Value can be handy if you have the mouth piece adapter. Trivia question: How much FiO2 is your BVM delivering if the reservoir is not attached? (excluding contained flow bags)

Very true. A 2 L NC on some on who has a minute ventilation demand of 22 L/min is not getting the text book 28%. Matching the device that will deliver the FiO2 at the patient's demand requirement is the key element. There are times when a NRBM will not work on someone with that high of an inspiratory flow demand. Key Points: The percentage of O2 delivered by a low flow device is variable because RA is entrained. FiO2 will vary depending on the patients RR, pattern and VT. Increasing flow on a high flow device will not increase FiO2, only total flow High FiO2’s (>.60) may not meet the patient’s inspiratory flow demands To insure adequate flow with stable FiO2’s, a special made high flow device should be used or two flowmeters set up to provide at least 40 L/min total flow Low Oxygen (FiO2) Delivery Devices Nasal cannula Nasal Catheters Transtracheal Catheters Face Tent Face Shield Simple Oxygen Mask Moderate Oxygen (FiO2) Delivery Devices Partial Rebreathing Mask Venturi Mask High Oxygen (FiO2) Delivery Devices Non-Rebreathing Mask Oxygen Hood Low Flow systems: NC Nasal Catheters Transtracheal Catheters Simple Face Masks Partial Rebreathing Masks This can include the NRBM if you are running at a fixed flow and their ability to entrain air is limited. If you remove the side port flaps to entrain RA, you are more to the "high flow" category but approaching a moderate to low FiO2 category. High flow systems : Venturi masks Aerosol masks Face Tent T-Piece (use 50 mL of reservoir tubing to maintain FiO2 with adequate flow) Oxygen Tent High flow aerosol systems (Misty-Ox) The aerosol devices mentioned will be dependent on the venturi setting on the nebulizer. If the setting is to 100%, you will have less total flow thus now may be in the "low flow" category. High Flow Nasal Cannula systems (capable of delivering 32 - 40 L/Min of humidified O2 off a blender system for a lower FiO2 at a higher flow). ex: 28% at 20 L/Min. Used for comfort and meets the MV demand. ex. of a pt: pulmonary fibrosis. Vapotherm Aquinox The oxymizer is popular in the aviatioin industry and now home care. It's expensive at about $25 each. If someone wants to conserve their O2 tank they can go from 4 L/min to 2 L/min depending on the model of cannula. The high flow cannulas by Salter pictured above have not caught on yet due to cost and in the home care environment they would be impractical due to O2 Concentrators rarely capable of putting out more than 6 L/Min. Humidification could be an issue also. The standard NC humidifiers are not meant for more than 6 L/Min. I'm sure Salter would want the agency to buy all the accessories like all of the other companies. If all of the above doesn't work then we go to the next level of high flow: CPAP and BiPAP (BiPAP is a trade name for Respironics - may be called many things depending on the machine) It's all about learning the principles of operation and not memorization.

Yes, both nurses and RTs can do these "skills" in many different settings depending on the hospital's needs and specialties as well as transport situations. Both professions are a minimum of a 2 year degree. EMS got its start by a group of doctors betting that they could teach a few advanced "skills" to just about anyone at any education level. This "skills" mentality has stuck. Every time someone wants to make a change or advance the profession, they add a "skill". Every certification or license in EMS is based on "skills". We have state certifications called just by the "skill". For example, Washington State has 6 different certifications; EMT-B, IV Technician, Airway Technician, IV/Airway Technician, IV Intermediate Life Support Technician (ILS), and finally Paramedic. As with most states, the education concerns itself primarily with the skill. Shifting around the skills to make a hodge podge fix for what is truly lacking seems to be the only answer EMS can come up with. But yet, EMS personnel have supported this by "they're doing it, why can't we?" "They have a new gadget, we want one too." For healthcare, I prefer the professionals that master the gadgets they have through education and demonstration of clinical expertise. Just because you can doesn't always mean you should. Reading through the threads on anything from oxygen to chest pain, the difference in education levels is fairly obvious. In many areas, the training for paramedic level lacks many fundamental principles of A&P and critical thinking. Many paramedics rely on "because we can, it's in our protocols" when questioned in the ED. The "attitude" is defensive leading the ED staff to believe whatever of these EMS professionals. The doctors and nurses may just be wanting additional input other than the cook book reguritation of data. Yet, for some, discussing the BASICS as mentioned in other threads by senior members here, is difficult. Critical thinking and reasoning are going by the wayside. Now I must go and ponder the question on the PPV thread. If that is truly a test question, then there is work to be done.

Your speed is not going to make a surgeon hurry any faster. There is still alot of prep work at the hospital that will have to be done. This is where if any time at all can be saved. If the hospital knows your coming, they can start the preparations by gathering the team and technology. A good assessment and accurate report to the hospital will be of the most benefit. The 1 - 3 extra minutes traveling by L&S will not make that much difference. If the patient is that critical, there will probably be little inside the hospital that can be done to prevent the inevitable .

I hate cook book norms! Every patient and every medical situation represents a different set of values. Yes, it is good to know what a 25 y/o, 75 kg, normal height male or female breathes, but there are some many physical elements that alter the "norm". DKA: Kussmaul respirations, definitely not normal but the body will do its best in the breathing department until action is taken to correct the metabolic side. Biot's respirations is another that the body will probably do okay until advanced intervention. Obese people and people with pulmonary fibrosis will have a higher normal resting respiratory rate due to a decreased tidal volume. Their body is concerned about maintaining an overall normal minute volume. Air trapping COPD patients may have a lower than norm rate. These are the more obvious patients. Quality and not necessary quantity is key in assessing respirations and the need for aggressive intervention. And yes, for testing purposes you have to memorize but for practical purposes, the patient sets the norms. Understanding disease processes along with experience with enable you to know how much deviation from the norm and fatique or work of breathing can occur before intervention is required. As for PPV, this term is used loosely in all professions. Mouth to mouth and mouth to mask are the simplest forms of PPV. BVM and then some of the mechanical devices attached to masks that the AHA is promoting is the next level. The next step is attaching a Bag Valve to some adjunct airway that is supraglottic: LMA, King and in many instances, the Combitube. I rarely recommend attaching a mechanical device to a supraglottic device. Next, it is ventilation using the subglottic devices; ETT, trach and occasionally the Combitube. I am mentioning the above because with each type of "power" used to perform PPV, the characteristics of ventilation change. Flow, tidal volume, resistance and distribution of gas within the lung fields can change with each different airway adjunct. I am disappointed in the AHA's promotion of mechanical devices without elaborating on some basic principles. The resurgence of the Demand valve brings with it some concerns about "PPV".

Exactly how does PPV relate to the normal physiological process? How much pressure are you delivering? What determines the amount of tidal volume delivered? What determines the amount of pressure? What unit is this pressure measured in? Why is the amount of pressure important? What is a pressure gradient? Negative pleural pressure? How does this relate to atmospheric pressure? What is the difference between passive and active exhalation? Any scuba divers here? For those considering prehospital CPAP, this whole PPV process is good to review.

Good post NickD. California has its act together more in Phlebotomy than EMS in many ways. Phlebotomy has the national certification program which many states are now recognizing while they establish legislation similiar to California. MLT and CLIA are giving the push and they are huge and powerful as a whole. They also demand some sense of unity. I also know this from running a PFT and Blood Gas Lab. I also found out what a mess can happen when our flight team first wanted the iSTAT. As a paramedic I thought this was great. As the Respiratory Therapist who would have to maintain their compliance and competencies through our lab, this was a freaking nightmare. EMS could still take some lessons from other professions in obtaining professionalism just by the way they have set and obtained national standards of recognition through education and professional organizations.

For those of you who use the terminology PPV or Positive Pressure Ventilation, can you explain why it is called that from the physiological definition?

The phlebotomist cert will open several doors outside of EMS before an EMT cert. Certified Phlebotomist and EMT is a great combination for either the ER and other any other area where blood is drawn. This can include research/outpatient clinics at a medical university which many are always looking for cert phlebotomists. Occasionally these are used as a training ground for medical students to do phlebotomy. But there are always opportunities somewhere. UCLA probably has such clinics which could also get you a paid education for paramedic school. For the ER, you may improve your hire on chances since they will not have to send you for phlebotomy training which may put you one step closer than the other applicants. Inside the hospital you will get a new job description, not EMT, which the hospital will help you get the training and provide you with a scope of practice. Too often, paramedics and EMTs come to the hospital looking for jobs and actually limit themselves from many opportunities with those titles by their own perception of their scope or "entitlement". The Phlebotomist is another healthcare worker that a need for national and state standards was in order to better protect the patients and be compliant with CLIA. State and National organizations moved quickly and California put through their cert legislation about 4 years ago. California phlebotomists can also do arterial blood puncture which nurses are not allowed to perform in a few states. It is pretty impressive that Phlebotomists now have programs providing almost 160 hours of training. A couple years ago our ED and Lab got a CLIA note of violation from accepting Paramedic field blood draws. It didn't help matters when the nurses, knowing the regulations, were taking the credit for the draws in attempt to bypass the standards. The EMS agencies had to show some proof of the paramedics knowledge of good sampling technique. Which it is true, some of the samples have been hemolyzed giving skewed results. The date, time and labeling were other problems. In busy ERs, it is easy to mix things up and many lab samples are on a time limit. If you draw it you should label it yourself and not hand it off to the nearest person that looks like a nurse or lay it on a counter somewhere. Bag and tag it yourself. Apologies for the soapbox. We also no longer hire paramedics as phlebotomists for the morning lab draw rush unless they have a phlebotomy certificate. This is a very nice well paying job for 4 hours of work. Extra money without taking up the whole day. Once you get inside information about CLIA and various lab certifying agencies, you'll understand the controversies and regulations concerning prehospital blood testing such as glucometers and iSTATs. This knowledge may be of value in the future. Good luck!

They are too excited about their new toy. They are excellent paramedics but sometimes mechanical devices need a little more training about principles instead of the just "use it" mentality. This was also part of the failure behind the Demand (Elder) Valve. The just push here "skill" without the understanding of what exactly happened after that brought the problems, not the device. Sometimes when you make things too easy, the thinking part goes out the window. We have 4 main EMS systems coming to us, 2 using WhisperFlow, 1 PortO2Vent and 1 with some cheap face mask device with a 15L max flow. They can't understand why we don't switch to what they're using. For CCT ground and Flight we use the LTV vent for all purpose ventilation. Right now is the time to be a sales rep for CPAP to fire departments.

The success of CPAP in prehospital is still all dependent on the training of the provider. It is rare now that even I rush to the ER to set up our machine. When prehospital CPAP first went countywide in my area, we had 22 CPAP calls for the ER in 48 hours. Everybody with the complaint of shortness of breath got a field CPAP mask. Only three of those patients actually warranted setting up the ER machine. Two were actually CHF patients. The calls consisted of a man involved in an MVC with rib fractures and a pneumo and several nursing home patients "gurgling". Three of the nursing home patients ended up intubated due to aspiration. This might have been prevented if someone had suctioned the upper airways prior to placing a mask with high flow gas pushing everything down further in the airways. One patient vomited enroute which of course led to aspiration and required intubation in the ED. There was also the pulmonary fibrosis patient with chronic crackles that came in restrained to keep the mask on. Problem was, the mask was a 15 liter flow with a "PEEP" resistive valve on a patient that required a MV of 25 liters at an inspiratory flow rate of 120 - 160 liters. Tying a patient down and telling them to breathe "slowly" doesn't always work out. This patient got a very high flow aerosol mask, steroids and a lot of ativan to get him over the anxiety of the experience of being restrainted with a tight mask. Later he was able to try one of our Respironics BiPAP machines. I probably run faster to the ED when I hear the patient is coming from a nursing home. The skills and assessment have gotten better but the above mentioned calls were from ALS trucks. Of course, with the exception of WhisperFlow and the Emergent- PortO2Vent or CPAP through the LTV vent, many of the CPAP devices are merely cheap masks with a resistive valve. If the patient is tolerating those things, we don't even take the plastic cover off of the ED machine. CPAP has been around for almost 40 years and is a great tool. But, it's not for everyone and care still must be taken to clear the airway before applying. Not everyone will tolerate the mask especially if they have a high flow demand or moderate to severe air trapping. The better machines do deliver a higher flow rate and provide a more consistent pressure to splint the airways. The real beauty of CPAP in CHF is it decreases venous return and afterload as well as unloading the respiratory muscles. If LV contractility normal any increase in cardiac output due to decreased afterload will be small due to decreased preload. If LV contractility markedly impaired reduction in afterload will tend to overcome concomitant decrease in venous return and cardiac output will rise. One should be aware of these shifts in the hemodynamics especially in the cardiac patient. These changes may not always be favorable in the face of an MI. CPAP is applied with a great deal of discretion in the hospital setting.

I saw this article and remembered this thread. Again, it is very important to be familiar with you state and local laws. Updating EMS professionals on new laws should also be included in recertification classes. http://www.emsresponder.com/article/articl...n=1&id=6255 Updated: September 28th, 2007 01:54 AM EDT Paramedic Supports Massachusetts HIV Testing Bill By Hillary Chabot Sentinel & Enterprise (Fitchburg, Massachusetts) BOSTON -- Lunenburg resident Darrell Demers had no idea what the gash to his hand would mean as he worked on a bloody car accident victim in Fitchburg nearly two years ago. It meant a drug regimen that left the paramedic in constant pain to prevent possible HIV infection. It meant keeping his toothbrush away from his three young daughters and scrubbing the house with bleach if he cut himself. "This whole insult to my body, my emotional well-being and my family could have been avoided with simple blood tests," Demers said at a hearing at the Statehouse Wednesday. The car accident victim was in a coma, and unable to give consent required by state law to test for HIV infection. A bill filed by state Rep. Stephen DiNatale, D-Fitchburg, would allow blood testing of the patient if others could have been infected by them. "This is a bill which will hopefully help others who help us," DiNatale said. Demers, 39, said he still worries about getting infected or having to go through the month-long treatment and year-long waiting period that accompanies a possible exposure to HIV. "I have been a public servant my whole life. I am a loving husband and devoted family man," Demers said, his voice breaking. "I do not want to see any other public servants or health care workers go through what I went through." Seventeen other states have similar laws, DiNatale said. State Rep. Jennifer Flanagan, D-Leominster, was also on hand to testify on behalf the bill, which was before the Committee on Public Health. "It's important to understand we're not discriminating against any particular disease," Flanagan said. "What we're trying to do is make this right. We're trying to protect those who protect us." But due to the six-month incubation period of HIV, those placed at risk could be infected even if the results are negative, argued Denise McWilliams, public policy director at AIDS Action Committee of Massachusetts. "This is one of those unfortunate situations where technology has not caught up with people's needs," McWilliams said. "At this point, the test doesn't really give you all the information you need to make a decision." Demers had to make a decision within 72 hours of possible exposure, and was strongly encouraged to take the anti-HIV medication. He believes the test results would have at least given him more guidance. "I do not feel that it is right that I have no rights in this situation," Demers said. http://www.emsresponder.com/article/articl...n=1&id=6255 Earlier article: http://www.emsresponder.com/article/articl...p;siteSection=1 Updated: April 6th, 2006 01:25 AM EDT Massachusetts Paramedic Seeks Recourse After Exposure REBECCA FATER, Sentinel & Enterprise Statehouse Bureau

There are now more opportunities than ever for nurses outside of the hospital. Like Dustdevil stated, CCU/ICU is a great way to go. For many hospitals now, they have their own transport nurses that will accompany the patient regardless of who shows up in ambulance. Many of these nurses are trained by the Intensivists to perform skills that the paramedic does but with the protocols and knowledge of ICU. Intubation, IOs and central lines are skills that can be taught to just about anyone. The knowledge of when, how and why is the key element. For some HEMS agencies, a Flight Paramedic needs 2 - 3 years experience with a busy EMS before applying. The Flight Nurse needs 3 - 5 years in the ICU/CCU and no paramedic experience. If the paramedic becomes a nurse during employment with the company, they must still obtain the 3 - 5 years in an ICU/CCU to be a Flight Nurse. If a nurse becomes a paramedic, it's more letters for the name tag. As a nurse, there are many specialty transport teams to become part of. There are few things more challenging then transporting a 23 week baby, ECMO candidate or a severely injured child. Interfacility transports can be grueling because you may have already lost the first hour on trauma cases. You are now into a whole other realm of resuscitation. A septic ARDS patient that has been mismanaged in a lower level of care ICU can be one of the most difficult patients you may ever have the opportunity to transport. This applies to patients of all age ranges. Of course, this type of patient acuity is not for everyone. If you hook up with a hospital based service, either ground and/or air - EMS and/or interfacility, you can prove yourself to the medical directors in the ICUs. The opportunities to learn and train as a nurse can be limitless. You may also not have to worry about where to go to keep the skills sharp. The ED/ICUs will be your lab with access to professional advice. With the various states now having PHRN and MICN training programs and certifications, nurses are finally seeing how far their scope of practice can go in many different areas. If you're motivated, there are opportunities that can give you the best of both worlds and enhance your medical career. And, did I mention the opportunity to travel as a nurse to almost anywhere in the US and beyond at someone else's expense while making an incredible wage?

Endotrachel Intubation with an ETT is still the optimal way to establish an airway at least after ROSC. However, it is now shown that skills are not maintained to be proficient at establishing this airway in the prehospital setting. The guidelines set by the AHA concern CPR. In the hospital, the BVM and/or LMA might be used for a short period of time only during CPR. If ROSC is restored, the ETT goes in. There are many other instances where the LMA or Combitube will not be appropriate as in anyone who may still have a gag reflex. The CHF and COPD patients near failure may fall into that category. For those patients, the BVM may be your only choice until someone who is skilled (or more skilled with more tools and protocols) in ETI is available. Inside the hospital we do have more ways of facilitating ETI because Combitubes, Kings, LMAs or whatever "rescue" device can not go on a ventilator. Our skills have to be maintained. Period. http://circ.ahajournals.org/cgi/content/fu.../24_suppl/IV-51 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 7.1: Adjuncts for Airway Control and Ventilation

If a patient is tolerating an OPA, they need a definitive airway such as an ETT. An OPA is not to be left in the patient for any length of time due to aspiration risks. It is used primarily when using the BVM until ETI is performed. It is also not to be left in after ETI unless absolutely necessary or you have no other tube guard to protect against clenching teeth.

For a recent article: http://www.medscape.com/medline/abstract/17272251 Esophageal tears vocal cord damage fracture of the larynx damage to soft tissues One case that sticks in my mind, probably because I had to give a deposition on it, was a 20 y/o guy who had a little too much to drink. Because he had "snoring respirations" he got a combitube which somehow did go through the vocal cords. But, the cords were severely damaged to where he would not be using them again. And, then there was the vomit issue which bought him several days on the ventilator for PNA after the tracheostomy was done while his cords were being evaluated. The Combitube was removed in the OR when the trach was placed that night. Too bad, as long as he was moving air with his snoring, he could have just gotten a cot in the ER and maybe a banana bag instead of a stoma and an electronic talkie. If you must use the Combitube, have a thorough knowledge of the anatomy in the throat. Have a good instructor. Don't force the device if resistance is met. Retrain often. If you take a patient to the hospital with a Combitube in place, take the syringe with you if possible and give a brief explanation of the tube to the RT and Doctor. Even if they act like they know what it is, refresh them again on its unique characteristics.

IBW or fat? If it's fat, the glottic region may still be the size of the age. Combitubes are not used in hospitals. Our difficult airway cart has a large variety of devices, but no Combitube. We have gotten a few cases to our hospital as referrals for repair of damage from Combitubes. Some of which were caused by the insertion and some at the hospital by people who didn't know how much air is in those cuffs. It would help if the EMTs would bring the syringe in with the patient. That might provide a clue. The length of time alone it takes someone to deflate the cuff allows for all the apirated matter to drain into the lungs. It's a bad week to save a patient from a cardiac event and then have them die from complications from a tube. We reintubate even if the Combitube is in the trachea as soon as we get a stable opportunity or before the patient goes to ICU. If it is an esophagus placement, then we tube immediately upon arrival to the ER. My Medical Director would bust me down to O2 tank tech if I put a patient with a Combitube on a ventilator in our ICU.

True, we agree on most points with the DNR. However, if there is a DNH form also present, that means there was extended discussion with the patient and/or their DPOA. There could also be an Ethics Committee involvement possibly by the same hospital to which you will be transporting. A call either by you or the nurse to the PCP is courtesy since he/she had to do careful documentation on this DNH order. The physician may meet the patient at the hospital to discuss the patient's needs and to ensure the patient fully understands what will happen next. Although, sometimes all it takes is a trip to the hospital to remind the patient why they signed their DNR and/or DNH especially if they are placed near the resuscitation room with a ventilator patient.

These are the only words heard in many nursing homes, hospitals or psych wards after the sun goes down. And, if patients get their hands on a telephone, they will call 911. That is why the doctors and judges make the big bucks to give guidelines on mental capacity and competency to make decisions. If a patient is competent or with mental capacity they can revoke the DNR/DNH as can their DPOA. If a patient has drug induced confusion from all the comfort care medications, it is nice to have a doctor, either the PCP or your medical director covering your back. A telephone call placed to your medical director and the PCP while you're doing your assessment could save all a lot of grief later. Patients in comfort care are supposed to die peacefully but sometimes it doesn't work as well as planned due to their built up tolerance to the pain medications from months or years of suffering. The healthcare providers may have under medicated and allowed the patient to experience too much pain. Death is also frightening to some near the end. That is why specific orders need to be written and carried out by well trained/informed individuals. DNR orders are revoked all the time. If a patient is in Hospice, often times they have to revoke their DNR to have transport to the hospital for various procedures or treatment for a non-terminal illness related event. Alot of this has to due with insurance and not necessarily the patients wishes. Some Hospices do not require DNR/DNHs. This is expecially true of the Hospices that cater to AIDS patients that do not require DNRs. So yes, a patient can revoke their DNR. But, it's nice to have the facts before you make a blanket statement on every situation.

The reason prehospital people don't see DNHs is because the patient doesn't get transported to the hospital. They die at the facility, hopefully in comfort or pallative care. Inside the hospital we have an order similiar in context "Do Not Send to ICU". DNH orders are not that common depending on the state you are in. Often the DNR contains the specifics and a separate DNH form is not necessary. Some states frown on DNH orders if worded too loosely and specifics must be included. They are usually meant for long term facilites. Again there are exceptions that may be made for DNH orders such as going to the hospital for suctures or x-rays post fall. If the person is having a problem that is not related to their terminal illness, then they can still be hospitalized. For this particular call concerning chest pain made by the patient, I would probably ask if the physician had been called or call him/her myself for a name to add to my documentation. The patient may have a terminal cardiac disorder, dementia or may even have an acute cause for confusion that needs to be corrected. If the patient's normal state is confusion or dementia, I would ask about access to the telephone since 911 is the easiest number to remember and called frequently by residents of nursing homes. Dispatchers usually try to verify these calls with the facility's nursing station if possible.

One of the reasons you see so many 90+ y/o ill patients who are full codes is the families and physicians are afraid a DNR order will be interpreted by some healthcare providers as "Do Not Treat". The DNR order also needs to read carefully especially at extended care facilities or nursing homes. It will contain specific instructions as to what parts of the resuscitation can or cannot be done. For some, no intubation but everythng else or intubation and nothing else. Others, they want drugs and intubation but no chest compressions. And some may just want the code drugs which if an arrhythmia occurs while on a monitor, that may be effective or NOT.

EMS doesn't have to be FF. FF can be EMS. From the gossip mill there's still some issues between the two. The change to EMT/Parmedic truck will be an interesting event since most companies strive for a budget for Paramedic/Paramedic. SFFD has the city for EMS. AMR does 911 for the East Bay (Oakland) areas. I sitting in an ER in SF now typing this with a few SFFD members. There's a mixture of those that claim to be only FF but have EMT and occasionally drive for EMS. There is a mixture of opinions about the department also, like any company. I come to SF as a traveler periodically for short assignments between shifts in Florida. The wages are great if all of your other expenses are paid. $75K is upper poverty level in SF. A single person could probably make it with no expenses other than rent. State tax and union dues will get the rest.

They're still FD in name. AMR and King-American are 2 of the bigger private companies in SF. Any chance of getting your NR Paramedic before moving? An EMT-B in SF will be at the low end of the poverty level for wages on the cost of living scale. As a parmedic you will at least be making middle to upper end of poverty by SF standards. You will also have a better chance of getting hired with the City FD as a paramedic. They have a long list of candidates for EMT positions with several schools putting out a fresh crop each month.

If you already have a degree in Biology from SIU, put it to good use and transfer into a nice 4 year program. If you haven't fallen out of the transfer time limit, you will probably only need the core classes which will give you an EMS degree instead of a "certificate" as a paramedic with just a little extra "quality" education time. This will set you up nicely for your next career endeavor in medicine or the FD since they like degrees for promotion, fire service degree or otherwise. Loma Linda has an excellent EMS program with several different tracks for your degree. It will also put you in a teaching hospital environment with dozens of other specialties in medicine to observe for other possibilites. Don't waste the foundation you have already started. A strong educational foundation is key for security in the future. Listing skills may sound impressive, but without the knowledge, they are just skills which can be taught to anyone at any education level. The knowledge sets the stage for professionalism. http://www.llu.edu/llu/sahp/emc/programinfo.html

I also don't buy art work from prison inmates even if it is a pretty picture. I did own the 2nd edition of Dubin's book. His book was welcomed as an easy read for Paramedic students in the late 70s and early 80s. Nancy Caroline M.D. had a good paramedic text but the Sidney Sinus Tales were a little too simplified. Dubin published his notes and quizzes from a basic med school EKG class for a Cliff note quick learn. Paramedic textbooks still do not cover EKGs that well so Dubin is still a relatively inexpensive supplement. Other professions in the allied health fields do have good indepth text (expensive) sections on EKGs. At the time of the Dubin arrest and conviction, I was working EMS and living in the Tampa Bay area. I know one family that his actions affected. If we had the predator laws in effect then that we have now, his sentence might have been different and they would not have had to rely on the Federal drug (cocaine) charges. Consenual sex shouldn't involve drugs and alcohol with the minor(s). Also, if a person wants to have sex with a 15 or 16 y/o, they don't have to videotape it. When it involves more then one minor in the sex acts, I don't buy the "love" stuff especially if the adult is much more than twice their ages. And yes, there are a lot of pregnant 12 y/o kids having babies. But, more often then not the daddy(s) are less than 20 y/o and equally educated. If he had been Joe Whoever author that wrote this book and still commited the 22 counts of drugs and child pornography, nobody would have noticed or cared. But, he was a physician and respected member of the community. We will never know how many of his patients were in the videos or photos. Their identities were kept out of media. We quickly forget victims when we cannot put a face and name to the incident. Even when we can, we still remember just the predator and not the victim. My friend and his daughter have not forgotten. When a child is told to "trust the doctor" and that trust is broken, there will be scarring. But, anytime somebody in uniform or a trusted member of society crosses the line, it will be news. I have strong beliefs on predators that prey on children. No matter how good this book is, I would feel like a hypocrite if I owned it. This is just my personal opinion and something I have a choice to do or not do.