VentMedic

And a great income for Dubin. :x

NT suctioning is often the first line of treatment in the hospital to "clean up the breath sounds" to hear what we're dealing with. Sometimes it just takes a tickle to get a good cough response and the patient does the rest. This is also how many sputum specimens are obtained for a nice "no spit" sample. Of course, if the condition is obviously CHF and/or hemodynamically compromised, suctioning may be deferred while other airway stabilization may be considered. NT suctioning is usually well tolerated, although, it is uncomfortable for about 15 seconds. Be sure you have been trained on good technique and care must also be taken not to damage to the soft tissues of the nose and throat. I usually do at least 2 NT suctions in the ER each morning for "CHF vs PNA" brought in by EMS crews. Usually, it's neither, just breakfast. Follow up will then be done for infections from the aspiration. The 100% SpO2 on a non rebreather is deceiving. The PaO2 could be 90 or 400 mmHg. For this the ABG is useful in telling us that the A-a gradient is reasonable for a 95 y/o. Not great, but will suffice for the moment.

The ABGs can be used to treat an immediate need as in oxygen or possibly clearing secretions by NT suctioning for more effective ventilations and watching quality of respirations. As tniuqs explained, much of the ABG is calculated. Getting serum (BMP) values to get also the anion gap, along with BNP, lactate level and of course, blood cultures will be the path to determine further action is taken. The ABG will not tell anything about tissure oxgenation as in the case of sepsis. They will just give some idea of V/Q mismatching. A CXR is also limited in adequately diagnosing all pulmonary and cardiac issues. A CT scan is actually more beneficial in diagnosing some PNAs. If the patient is still an alert 95 y/o and consents to informed therapies and diagnostic tests, then more definitive testing might be done if the lab work is inconclusive. As for as lung sounds in PNA and CHF, I find listening to the heart sounds to be beneficial. Checking urine output or the foley bag contents can also give a good direction to look for sepsis or renal failure. And yes, there will be pulmonary involvement if there is renal failure either acute or chronic. Is the Lasix listed on the PRN/one time medication sheet or scheduled? I see it beside Lorazepam and ambien as well as the Lopressor. If the lasix is scheduled, the I&Os may have been monitored along with periodic weights. Is the lasix for cardiac or urinary output problems? Lopressor - renal insufficiency or CV or both for HTN? There are so many different PNAs and etiologies of CHF that it is possible to have mixed. CHF by itself is not an end all diagnosis but rather a symptom of something else. However, which one to treat while not exacerbating the other is the tricky part. Use of a beta-2 agonist would be questionable and probably of little use here. Administering a nebulizer via BVM, as mentioned earlier, may be difficult on an alert patient. You would take away their ability to breathe at their desired MV where the BVM 10 to 20 lpm flow may not be sufficient for their drive. You would also need perfect timing to trigger the valve in synch with the patient. Expecting a patient to trigger the BVM valve by himself requires an uncomfortably tight face mask seal and -20 cm H2O of pressure to open the valve. This will definitely increase the WOB especially with a nebulizer in line and tire the patient to failure quicker. If the patient is unresponsive, by all means, it is an excellent way to provide a nebulizer as long as you are assisting ventilations. Atrovent, (anticholinergic, parasympatholytic) is not my favorite drug in the elderly especially if renal insufficiency is an issue which many times is in the older population.

The THUMPER, which has been around for almost 3 decades, has some "stories" attached to it when poorly trained people try to use it. http://www.michiganinstruments.com/pdf/1007Manual.pdf The LUCAS appears to be a modernized version of the THUMPER.

You just brought up a good point. Some EMS crews are also quilty of not reading the DNR carefully. The EMS crews usually just ask when entering the Nursing Home if the pt is a DNR and they will just hear DNR. Some also don't realize that hospice does not alway mean DNR. In some States the patients are given the option of signing a DNR or limited DNR. There are also stipulations for Medicare/insurance to pay for other medical care that may or may not be related to the terminal illness thus the Hospice care has to be revoked just for the duration of that hospital trip. Some hospice organizations that specialize in HIV/AIDS have special contracts that allow their patients to remain a Full Code in order to get hospital treatment for other illnesses that should not necessarily be life ending. Revoking a Hospice order does not always mean some family member, caregiver or the patient had second thoughts. There are EMTs/Paramedics that also get very upset when the hospital will put DNR patients on non-invasive ventilation and go all out short of actually coding a patient to treat CHF or PNA which sounds a lot like "death rattles". There are also some medical professionals, including those at nursing homes, that equate DNR to Do Not Treat and provide very little care including O2. The nurses are also put in an uncomfortable situation by EMS crews. Sometimes, no matter what they do they will not be able to please their employer, the patient, the family, the BLS crew and the ALS crew. Initiating different EMS responses, ALS 911 or ALS transport or BLS transport, also require different procedures that must be followed with the doctor, insurance and hospital. If the nurse reacts one way somebody is going to play the arm chair quarterback and second guess his/her decision. There's always someone, including EMS crew members, that yells the remark "I'm reporting you and get your license taken away". Not a good position to be in for stress of constantly defending one's decisions even when you've attempted the best care under bad working conditions and poor continuing education. There may be only one licensed person in the facility. Many times the doctor is also controlling the calls but the nurse is the face you see. That is why even in the hospital settings throughout the country, a special team (Rapid Response Team) had to be initiated when the primary doctor drags his/her feet to prevent a code situation. Yes, some nursing homes and extended care facilities leave a lot to be desired. Many are running on limited funds and are ran by owners who want more profit for their own pockets. Some nursing homes do not have piped O2 and utilize a concentrator provided by a homecare service for each O2 patient. There may only be one O2 tank available. The same with suctioning. There are some long term ventilator facilities ran like this also with LPNs (RRTs or RNs are costly) managing the ventilators and O2 concentrators supplying the ventilator FiO2. California is one state that allows this. Many facilites are not required to have much for emergency equipment/medicaton (thus 911 is called) and all medications must come from an outside pharmacy. Even the medications that you would expect to be available for some emergencies like albuterol are not available unless taken from another patient's supply. So, very little education is focused on emergency situations. This again puts the professionals in a precarious situation. The turnover is high because there is little they can do over ride the system. Sometimes they are scraping the bottom of the barrel when when comes to hiring employees. If the place has a reputation of bad working conditions, quality people do not want to jeopardize their licenses. The agencies that monitor these facilities are overburdened. Some hospitals do track the patients and their condition from facilities especially Medicare admissions that are within 30 days of each other except for scheduled visits. The U.S. healthcare system needs some overhauling when it comes to taking care of the disabled and elderly.

Your post assumes paramedics are male and nurses are female. Extrication skills can be easily taught and used by nurses or just about anyone else in the emergency field. We've seen volunteers (EMS and FD), EMTs and Paramedics do this with minimal education or hands on training. The medic factories proved this point. Nurses in ICUs/EDs/CCT/Specialty Transport Teams practice Advanced Life Support on all ages very well without a paramedic's assistance and at times outside of the hospital on ambulances. Nurses and a variety of other providers work outside of the hospital in ambulances in many roles in the U.S. Nurses have been in various aspects of the emergency field for several decades. HEMS nurses direct ground extrication crews with no problem. You might be surprised to see it is RNs that are the directors of many Paramedic education programs in the U.S. Nurses have also been on ambulances in other countries for several decades. Nurses have been a vital part of developing pre-hospital care in under-developed and developed countries including the U.S. And, let us not forget our "sister nurses" serving in the armed forces in a variety of roles. If EMTs and Paramedics don't want to push for some standards in education and professionalism or even agree on what their profession is, then maybe the nurses are the best to pave the way to push EMS into the future.

Ask the RNs, LVNs and CNAs how many patients they each are overseeing. In many NHs, the RNs or LVNs may be responsible for more than 25 patients. 15 is the usual number. One CNA may have 20+ patients. And yes, in many states this is legal. Even California, the nurse:patient ratio is low for the acute setting as mandated by law, but can be quite high in the extended care areas. There is a big difference from the 1:1 patient to EMT ratio. Or, actually, it is 2 EMTs for 1 patient.

Then as a nurse you probably know many times the nurses may have a valid point. Example; Why did you bring them to that facility? This is true especially in the city where there are many hospitals of many different specialties. In many areas, it was decided to allow paramedics to make their own decisions on appropriate facilities. Cardiac to cardiac centers, CVA to stroke centers and trauma to trauma centers. Yet, in many cases we have ambulances bringing everything but the above to the appropriate centers and an AMI gets dumped at little General less than a half mile from a cath lab. Then a NURSE from that ER has to get into another ambulance, leaving that ER short staffed, to transport the patient to the cath lab. Diversion is another topic that gets Paramedics upset. If the ER is full, its full and the staff is maxed. Why make the patient suffer in an overcrowded ER when again in the city there is another ER just a few blocks away. Yelling and complaining to nurses is not going to make the system work any better. In rural areas, the little hospitals have no choice. The nurses will be stuck more patients than they can safely watch for all 8 or 12 hours and the EMS crew leaves. And, the "short of breath thing" when the patient is talking and on room air gets old as a reason to take to the closest facility. I have even pulled this one a couple of times as a Paramedic for a quick unload, although, I did make sure the patient was wearing oxygen when I entered the ER. Of course, maybe hospital workers might pick on the next crew that comes along because the other crew members were total wastes as far as paitent care. Too often the standards and expectations get set at the lowest level and those who do excel at patient care get the brunt of the criticisms. Now, as far as comparing U.S. Paramedics to the Paramedics in other countries; apples and oranges. The U.S. does not have set minimums in place to adequately form a comparison. The 46 certifications that make up different State EMS programs are a good example of that. To the dually credentialed RN/EMT-Ps, if you have it so rough in the field, why not work for more money and what you believe to be better conditions in the hospital? I crossed over for the money and better hours after 20 years in EMS. I also enjoy keeping most of my "Paramedic" skills in the hospital while acquiring more knowledge and other advanced skills. I did spend a few years working both jobs just to get a comfort level established for a career change.

Reasons for Nurses to make more money: 1. In the U.S., no set minimum educational standard or consistent licensure for Paramedics. 2. Many more patients for 1 nurse to be responsible for continously for 8 or 12 hours. The number can range from 2 in ICU to 15 on a med-surg floor. In nursing homes, one RN may be responsible for 25 patients at one time. There are some paramedics that will not see that many patients in one month. EMS: for the majority of the time it is still 1:1. 3. Continous work for 8 or 12 hours with an occasional chance for a break and definitely no sleep on the night shift (unless you are a California nurse). There are some very busy EMS stations and then there are some that may only run 1 or 2 calls and you will hear people still complain that is too many. 4. A Nurse must deal with the same obnoxious and/or violent patient (or 2 or 3) the entire shift. EMS unloads those patients quickly and disappears. The nurses will also get the family and all of their problems for the enitire shift. This will be in addition to the families of his/her other patients all demanding time NOW. 5. Nurses must endure constant scrutiny of their behavior and skills in the hospital by administration, peers, patients and their family members. QA/QC of everything they write, say and do. No matter how perfectly they have performed, there will always be some criticism. 6. Nurses learned long ago they were mighty in numbers and unity was the best way to get things accomplished. More important then unions are the professional organizations that represent them at local, State and National levels. 7. Myth: There's always a doctor around. Many nurses and other health care professionals work under protocols. There are times when a doctor is not able to be reached by telephone. ER doctors may or may not help out. ER doctors rarely set foot in the ICU areas if they can avoid it. The ER is their responsibility and they must stay available there if at all possible. The hospitals now have Rapid Response Teams (RN/RT) to act quickly under protocols to get a patient through a crisis before something worst happens. ICU and ER nurses can be very impressive in an emergency situation. Those that don't know what RNs can be capable of have not been around many critical care settings. Critical Care RNs and RTs don't wait for a doctor to get the life-saving started. 8. For anybody that doesn't think nursing and total patient/family care for 8 or 12 hours, I can try to get some input from the 3 of the 5 paramedics who just quit nursing school. The remaining 2 EMT-Ps are looking pretty discouraged also. They are in a bridge program with LVNs who all 10 for 10 are still around.

There should have been enough female Paramedics around 20 years ago to help the male nurses with the lifting and that aggressive time thing.

Bargaining power for better reimbursement rates from the private, State and Federal insuring agencies. The paramedic carries very little weight because of ther lack of licensing standards across the board when it comes to asking for reimbursement for individual professional services. When I have to do a transport on the ambulance as an RRT, the hospital bills the insurance or medicare separately for my services. The same for an accompanying nurse. This may seem unfair to have the patient billed twice for the same transport, but there are some ALS/CCT teams that are only that in name and not ability. The nurses on our HEMS program make a good "nursing" wage since the helicopter is hospital based. Another HEMS that is county based through the Sheriff's office is offering the nurses the same pay they make in the hospital also which is 2x the paramedic wage. This service is a money loser across the board but necessary. They need the interfacility transports along with EMS to stay afloat. The hospital based CCT nurse makes her/his hospital nurse wage. These teams do have a different reimbursement/billing code for professional services.

I know a couple of regular patients, young women in their 20s, that now have multiple problems including cardiac arrhymias and esophogeal errosion. Unless they can get their psychological problems of image under control soon, their physical problems probably won't let them live past 28. We also see cardiac problems from patients taking many diet aides along with their binging. The Karen Carpenter Story is an excellent movie and true story. I am in that generation that watched her weight yo-yo over the years and literally die slowly in plain public view for all to see. Yet, in the 1970s and beginning of 1980s, bulimia and anorexia were not talked about.

It is always a pleasure to read your opinions Dustdevil, especially on education. I would like to see more history especially as it has pertained to taking care of the people and where the U.S. system has gone to heck. We could start with the Revolution and taxation especially after reading the volunteer/paid threads. Then we could exam Hoover's Bonus Plan and his betrayal of veterans right into FDR and the Depression era. The legislation passed during the early decades set precedence to the fiasco we now have called healthcare. Maybe we could start learning from all the mistakes made through history when setting policies or electing idiots to make decisions. Political Science should be a must also. The easiest way to get funds for a paid EMS service is to elect a politician sympathetic to EMS who is well connected and corrupt enough to divert funds from another infrastructure budget or another corrupt politician's pork project. Those that have been successful in doing this usually can afford 3 ALS trucks to every sprained ankle. However, the school system that trusted the honest politician will have cutbacks. The Icelandic literature requirement sounds like the 5 Spanish language and culture classes I had to take in Miami (small country just south of the U.S. and north of Cuba). Excuse my attitude today. I was just on a different forum reading another thread bashing education again.

Good information provided the HIV status of the patient is know. If not... Here NY's 2005 guidelines for obtaining a specimen. http://www.hivguidelines.org/GuideLine.asp...p;guideLineID=3 Also http://www.guideline.gov/summary/summary.aspx?doc_id=5906 http://www.hivandhepatitis.com/hiv_and_aid..._test.html#S13X[align=center] Florida: http://www.doh.state.fl.us/Disease_ctrl/aids/ http://www.mecop.org/HIV3hr/chapter7.htm

Even in the case of sex offenses, testing can be a legal problem. In some cases the victim may have to pay for the testing. The same with a court ordered test. In the case of an LEO assaulted, their employer will usually pick up the cost if necessary. http://www.nycagainstrape.org/survivors_factsheet_76.html The informed consent for HIV testing due to occupational exposure is a protection for everyone even though one may not see it as such. Many times the occupational exposure is due to "accidental" carelessness on the healthcare providers' part. The testing expense will be put on the patient's bill and many times insurance may not pay for it or 60/40 if not part of the original treatment. Also the patient has the right to counseling prior to testing. The ACLU has outlined the discriminatory practices that are associated with testing whether in actuality or not. It will be on the patient's medical record permanently and raise questions later possibly in your insurance coverage. The patient's medical information will now be disclosed to a stranger. The patient could be you just in for a routine physical and now you may be spending extra on a test that you did not want. This expense may be out of pocket for you. Granted, everyone should be tested for all the Hs occasionally if there is any chance of occupational or social exposure. However, getting tested at the state sponsored clinic is much cheaper than a hospital. Again, each state has guidelines specifically outlined on their state's website. That is a Federal requirement. Your EMS licensing website may have the link. If you want to prove a point, make a copy of that statute or policy and not rely on heresay. If informed consent is required in your area, then you need to move quickly to your other options or alternative means of obtaining a specimen from that person. The non-invasive testing now makes court orders much easier. Anyone in healthcare that has the potential of occupational exposure should be aware of the laws in their state and employer. That is also why mandatory education and EMT refreshers are important.

This is the probably the easiest thing to look up in your state statutes. Many states now require health care professionals (including EMTs) to take at least 1 hour of HIV training to stay up to date on the new laws. Many states may still require informed consent from the patient. If that is not obtained voluntarily then a court order may need to be issued. Some states are working on different legislative acts to bypass the consent. I believe NY is one of them. Human rights is still a big factor regardless of the events that occur. examples: http://www.hiv.va.gov/vahiv?page=prtyp-qa-testc http://www.cdc.gov/hiv/resources/guideline...tm#occupational http://www.oregon.gov/DHS/ph/hiv/data/oars333.shtml

They have been licensed in most states for more than 20 years. PT now has a Masters minimum with a Ph.D preferred in their professional standards. Most allied health professionals are licensed in the U.S. Massage Therapists are licensed in most states while certified in others awaiting licensure. They, too, are in the process of establishing college degrees for entry level. The college programs are up and running while the legislative process is churning. Massage Therapists are now recognized in healthcare and are very employable in the hospital setting due to their reimbursement potential. They have very strong state and national organizations to keep their presence known in the political arena. Phlebotomists and Patient Care Technicians have increased their requirements for certification. The Medical Assistant is still certified but are struggling to establish some minimums and get recognition by their states. They too have been affected by the numerous PDQ Marts in their profession and are going to have a long struggle to gain professional status. The establishment of licensing has little to do with control of one profession over another. EMS actually had more going for it in the 1970s than nursing. EMS was establishing degree programs in colleges. RNs were still diploma based. RNs then spurred themselves on to being degreed and recognized the LVN as a much less skilled professional inside the hospital. EMS lost it by not establishing the degree for licensure. Too many ambulance services, FDs and private tech schools started turning out EMTs and Paramedics at a rapid fire rate. The "I can do anything you can do" attitude without the extra education helped bring whatever push for minimum education standards in EMS to crawl by 1990 if not before. The sheer number of nurses that had to unify to achieve a higher professional standard should be recognized as a great accomplishment. The diversity in their profession is incredible with the thousands of different nursing specialties and places of employment. Yet, nurses were able to come together and agree on education for minimum licensure requirements. They are now struggling for the Bachelors as a minimum. I'm sure there will be an agreement soon. They know the need and the colleges are graduating more BSNs every semester to bring fresh progressive attitudes. Why is it that pre-hospital people who work primarily in the pre-hospital setting doing pre-hospital job descriptions, whether private, public or FD, can not come together for one common goal?

Almost 30 years ago I started in EMS and got the A.S. in EMS because "that was the future" as told to me when I was 18 y/o. This was impressive since the roots of the paramedic started by some doctors wagering that they could teach a few advanced life-saving skills to any education level in the 1960s. Yes, RT has come a long way. I am watching a handful of co-workers sweat as the December 2007 deadline approaches. If they don't upgrade to RRT, they may lose their unit (ICU) status as well as the ability to do their advanced skills (ECMO, transport, intubations, IABP, A-line and central line cannulations etc) in many hospitals. The A.S. is the minimum now with another increase to B.S. in the next 5 - 10 years. With it, we now have more billing power and are lobbying for independence outside of the hospital. This piece of legislature I personally am following for the prospect of a cush job with a small medical group when I tired of hospital work and vested at the university. And yet, RT is modeling after OT and PT. PT is especially impressive in the way they have been able to obtain professional status and reimbursement recognition. Their command of the political and business machines have generated them an impressive salary and recruitment as well as retention bonuses. Nurses must now closely re-evaluate their minimums because it is more difficult for them to maintain their same status, even with history, alongside allied health professions with a minimum of Bachelors, Masters preferred professionals. These professions do not make not claim to anything in the nursing field even though they have similar (and often more advanced) sciences and skills. They do not want to be nurses. Their focus is integrating into the healthcare profession with their own unique knowledge and skills for the benefit of the patient. Thus, they use this uniqueness to reap the benefits of the politically charged reimbursement challenges. These allied health professions all channel their lobbying power for the patients' benefit and stress that which gives them as edge in not looking like they are purely in it for greed and personal gain. For example, Medicare is always readjusting it coverages for home O2 and pulmonary rehab. Strong AARC RT lobbyists are present fighting for the people who need these services. Great PR and reimbursement possibilities for RT. Again it is about knowing how your profession is viewed by the people that make the legislation. Then, each profession must think of itself as a business. The profession must surround itself with enough business savvy to acquire the right lobbyists to get a part of the money that's being handed out or budgeted for each year in government. They have to keep their state legislation active enough to have a voice. Paramedics waste more time comparing themselves to other professionals like nurses instead of defining who they really are and attempting to profect that. They have actually provided the nurses with more valid arguments to justify the nurses' strong hold than they realize with their vocal comparisons. Do the paramedics realize they were a profession specially designed for pre-hospital with an unique set of skills and knowledge? Just like their predecessor the Mobile ICU Nurse, who is still very much around in the U.S. and many other countries, they have a special place in the world of healthcare.

I rarely if ever see pre-hospital people following their state ambulance and EMS organizations' activities in legislation to see how more recognition and reimbursement would be allowed for paramedics. True, it makes for boring discussion but important. The key is getting Medicare and the various medical reimbursement agencies to recognize you. There are so many variables to consider besides "I deserve it just because...". There's legislation called The Medicare Paramedic Intercept Services Coverage Act of 2003. Currently under Medicare, some paramedics, called "intercepts" are not reimbursed under Medicare. Has anyone made themselves familiar with this because it may set precedent for other legislature? Especially in the areas where volunteers and ALS may respond together? This is only one example. When bargaining for improvement benefits and reimbursement, what does the lobbyists have to "sell"? On a national level as well as state, you have a mish mash of education levels, skills and various certifications. There is no consistency in any identifible form for an educated legislative body to decipher any value or worth of the profession regardless of the life-saving issues. Even discussions on this forum raise issues that question how EMS defines a professional. What is a "paramedic"? Other professions can say they have a minimum degree (not certification), standardized credential testing for minimal proficiency and similar licensing requirements throughout all states. Now medicare has a minimum professional standard to consider in that industry. Other professional forums and newsletters are full of pending legislation and its effect on each healthcare industry. Their national organizations are going full steam and have had excellent successes. Many hospitals expect their employees to belong to a professional organizaton (not union) that respresents them. And, most professionals proudly list these organizations on their resumes. All I hear from some pre-hospital providers is "waste of time and money" to belong to state and nation organizations. And these same individuals wiil continue to complain that life is so unfair to them. They are also the ones who will probably not advance past their PDQ Medic Mart certification either. The educated will have to take the lead. But what to do with the rest? Other professions did get strong enough to put a little pressure on the lesser credentialed individuals and raise the bar. That has made a big difference now in their present and future bargaining power for their dollar value in the healthcare industry. Other professions also teach in their college curriculum the "business model" and how it pertains to their worth. So, they are more politically aware of the factors going on around them and how each one will affect them. This gives them the opportunity to strengthen and plan accordingly.

I'm giving you a couple of links on another forum that has some info on different models and experiences. http://www.flightweb.com/forum/viewtopic.p...showtopic=11492 http://www.flightweb.com/search.php?query=...amp;mode=search

With the low O2 percentage (7-8%) at each drilled hole...hope is fading. A look at mine accidents and the how long trapped miners survived until they were rescued, listed from the longest to the shortest span of time: - January 1983: Two coal miners rescued after 23 days in northeast China. - September 1982: Four South Korean coal miners rescued after 14 days. - May 2006: Two miners rescued after being trapped for 14 days following a collapse at the Beaconsfield Gold Mine in Tasmania, Australia. - November 2005: A coal miner in northern China rescued after 11 days. - May 1968: Six miners rescued after ten days, in Hominy Falls, WVa.; days earlier, 15 miners had been rescued after five days. - October 1958: 12 coal miners survive six days at Springhill, Nova Scotia. - July 2002: Nine coal miners rescued after surviving eight days in a mine in northwestern China. - July 1996: Three miners survived eight days trapped in a flooded mine in southern China, living off water that came up to their necks. - May 1972: Two miners rescued after eight days in northern Idaho. source: http://kutv.com/local/local_story_225180829.html

What may seem as "advanced scope" of practice may actually be their every day life in the hospital. IABPs, A-line insertion, RSI, conscious sedation, central lines, IVs, intubation and all the meds, especially if the RRT is an ECMO team member, are just part of the job description in RRTs for progressive ICUs. And just like EMS, RT job descriptions vary from area to area. The scope of practice is usually written into each state's statutes for a wide variety of advanced practices. However, just like EMS, advanced scope of practice in the statutes doesn't mean every department takes advantage of it. In some areas, both RT and EMS have very advanced scopes of practice defined in their statutes but still practice in the dark ages. Also, while there are many CCTs that utilize the RRT as a team member, many times the RRT is just "drafted" to go on the transport because the ICU attending has sized up what has been sent to us as a "CCT" team and doesn't feel comfortable with their skills or knowledge. An ICU nurse and/or RRT employed by the hospital may be elected to accompany the patient with the CCT team. Not all CCT teams are created equal. For some, it is just a name on the truck to impress the local town folk.

Washington and N.C. have a few scene HEMS teams with RT/RN configuration. They also do inter-facility transport. Florida has a little stipulation in the EMS statutes that a scene responder must be an EMT-P. So, Florida allows almost everyone to challenge the test. Several ground, fixed and helicopter teams have RN/RT configurations for interfacility transport especially cardiac, neonatal and pediatric. These teams all have an impressive scope of practice, knowledge and skills that exceeds the paramedic training. Many times you will fine people like myself who started very young in EMS with the paramedic credential and then went on to RRT. If their interest is still "rescue and scene", they may keep their EMT-P. If they go on to the specialty inter-facility, it is not necessary. The pay difference is pretty great also. Even with many years in EMS, I would barely come close to what I make as an RRT in the hospital. In most hospitals, transport therapists usually have achieved the highest levels of training and are at the top pay step. N.C. also has the best defined pre-hospital rules outlined in their statutes. http://www.ncrcb.org/Final-Declaratory%20R...d%207-12-07.pdf However, the same skills and scope of practice are utilized in many states and teams.

Many hospitals made it their policy to allow families to stay during a code, especially in pediatrics, about 15 years ago. The first few times it bothered me because we did do more invasive procedures, including open chest in the cardiac PICU, than in the prehospital situations. It also unnerved me to be video taped during L&D codes both maternal and infant. The family members were "allowed" or just not asked to turned the cameras off during an unexpected resuscitation. Sometimes the video recorder was allowed on during an expected L&D resuscitation but the family member was "only" supposed to record the birth. However, the recording usually continued afterwards. I've actually had a video camera rest unexpectedly on my shoulder while intubating a baby until a nurse politely asked the family member to give me some room. Luckily most NICU teams are experienced enough to resuscitate quickly and quietly. I'm sure the hospital attorneys dealt with the legal issues with the family in a gentle way later. I do believe it is important for the families to see that everything has been done. Many families also don't want to let go of their elders. These families need to have a role in letting their elderly loved on go in order to finalize that they took care of them until the end. This is especially true in some cultures where the children actually vow their lifelong service to care for their elders.

You won't have an easy time if you come to Florida with all that baggage and burnout. At the age of 20, you sound like a wreck. The cost of living in Florida is not cheap anymore. Utility bills, alone especially in Orlando, will be expensive. Do you plan on using that volunteer FD that you aren't going to the calls as a reference for another FD job? Don't screw it up or take a "sincere" break from them. Will your credit history bring you problems on a pre-employment credit check? Orlando is the city of the Mouse. Everything is scrutinized there also. Traffic and tourists will be just as rough if not rougher for an attitude with little patience. Excellent for working on your prereq. for Paramedic. If you make a move now to Florida, you'll have out-of-state tuition to possibly hamper your educational goals. And, DON'T even consider doing a PDQ Medic School in FL for $20,000 "easy to pay" lifetime loan. The FD departments are going to want everything mentioned in akflightmedic's post. They also want a solid educational foundation. An A.S. or A.A. would be nice. Choose your classes that can apply for both a Paramedic and Fire Science degree if you are serious about the FD. Are you fairly fluent in another language besides English? Spanish? That will help also. There are hundreds of applicants to the FD each time they anounce they are hiring. Your application and background check are going to have to look good. Being a paramedic will also put you ahead of the game. That would also give you more hiring possibilities in Florida at better pay until you do get hired by a FD. Florida has many, many EMT-Bs. But, jobs are not that difficult to find due to job-hoppers/turnover. The pay will be very low and you'll be working the same number of hours or more than you are now for possibly less money. Get yourself in a better position. Everything you do now will be scrutinized by your future employers both good and bad. Florida is a great place but if you are still buried in your personal/financial baggage, it will be very easy to get buried deeper here. Running to find greener pastures may sound like a way out but may not always be the best route. Good luck!