VentMedic

I am writing this under nursing supervision at the nurses' station. Nurse attending to motorcyclist: Must make patient comfortable; pillow under head, warm blanket Nurse bagging intubated patient: darn RTs wouldn't let them use the ventilator again. Seriously though, one of our RNs from our smaller ICU/ERs makes at least one trip per shift with a patient to one of the bigger hospitals. We have a wide variety of CCT crews. It is hard to get one with an ICU/ED trained nurse. Many are paramedic teams who are restricted to what meds they can haul attached to the patient yet they are supposed to be critical care transport. Ventilator or even trached patients are other examples. If the patient is on anything but a conventional volume ventilation mode (which is so yester-year), an RT or RN has to go. Also, if I am placed on an ambulance from my hospital position to accompany the patient, I follow my RT medical director's protocols which gives me more protocols than as a paramedic. I am working as an extension of my ICU. So yes, you do see alot of non-EMS people in the back of an ambulance. However, it not by the choice of the non-EMS personnel. We get drafted and our work load suffers. Better training and education of the paramedic would keep us off the trucks. I will say that Flight and Mobile ICU nurses are highly trained mobile professionals. Also the specialty teams with air and ground transport nurses have excellent education, knowledge and many, many skills. Let us not forget some of the the military nurses. Many of the Flight and CCT nurses may also have a big trauma specialty since many of their transports may be recent trauma from the little ERs. The helicopter RNs also do scene response. Many of the states do not require them to have a paramedic license. Also a flight nurse and a flight paramedic usually must have 3 - 5 years experience in their respective fields. If a flight paramedic gets his RN license, he/she may not apply for a flight RN position (in most employment situations) until they have completed the requirements of a flight RN - 3 -5 years ICU/ED experience. An RN may get a paramedic certificate as just that, another certificate. Many companies, unless it is a mandatory requirement, may not pay for a nurse to get a paramedic certificate because it is a lesser or equal (if A.S.) degree.

Too bad. With the data that is collected in a lab, you have a medical baseline for other purposes such as chemical or other occupational exposure. It will remain as part of your medical file. HIPAA will guard it except for certain research data bases. But, it can also work against one for deconditioning reasons. We also do altitude simulation for flight personnel as well as for patients wanting to fly or vacation in a different altitude. If you have an unknown cardiac abnormality or O2 carrying capacity defect, we may find it with our technology. We can mimic a wide variety and types of stress loads to the body and capture the body's response. We have two EMS companies that we do MVO2 max every 5 years and spirometry in a PF Lab. Simple spirometry as done for field tests is not acceptable. We have actually found that there are people that pass the field tests that shouldn't be even walking around although they appear very healthy. High school and college athletic programs also send us some of their athletes. We have "failed" a handful of star athletes due to a medical problem being detected.

Assessment of functional capacity is typically performed on a motorized treadmill or a stationary cycle ergometer. Functional capacity can be measured directly by determining O2max or estimated from the highest treadmill or cycle work rate achieved. O2max is measured in liters per minute, although, it is usually expressed per kilogram of body weight to facilitate intersubject comparisons. Functional capacity, particularly when estimated rather than measured directly, is often expressed in metabolic equivalents (METs). So essentially, you could be running on a treadmill, hooked to an ECG, breathing through a mouth piece with nose clips on. Or, if the equipment is not that sophisticated, it'll be "trot till you drop" with a steadily increasing incline on the treadmill.

Isn't medic class "prep" for ACLS and PALS? The certification class should be just a formality to get your "card".

There is another private EMT/EMT-P school that has be driving me crazy with their ads. It is actually their internet site that I have been trying to get them to correct for two months. That is unless "endotracheal incubation" is a new skill. It probably is a new certification that now makes the total 47. :roll: http://www.floridacareerinstitute.edu/emergency_medical.htm I have emailed and telephoned them. My introduction and credentials mean little to the person that usually takes my call. My emails haven't been answered probably because I didn't fill out the questions expressing my desire to be something "new and exciting". I have gotten nowhere except an invitation to come up and check out a "new and exciting" career. When I inquire about the price I just get the same "exciting in demand career yaddy yahda". I have heard it is a hefty price tag for just EMT-B. This school might be the greatest thing since buttered bread, but if only they would correct that one little typo on their website. Then, I might be able to tolerate the commercials. Of course one of their competitiors has even more annoying commercials. But, that is what a mute button is for on the remote. Almost forgot to mention my opinion on the ACLS card. Granted it is required to have for many professions. It is little more then a certification that really no longer even demonstrates or tests your skills or knowledge. The practical no longer has a stress factor or even the urge to vomit by students anymore. The written test is also a joke. And yes, I know this "everyone can pass" attitude is supposed to promote learning. But, let's be real.

I haven't seen the new thread yet. But, it is unfortunate that students get hooked in to signing a $20,000 loan for a job that will pay $7/hr. Of course the school can promise a job to any unsuspecting person who is not aware of the turnover due to low pay and burnout. There's a gung-ho youngster just waiting for the opportunity to "bypass all that college stuff" and get on with the exciting career of EMS. And so as the "you too can do all this in just a few short weeks" advertisement goes, just sign here. The words accreditation are used loosely by many "medic factory" programs. Yes the school should be accredited by the state or region of either a college board or a vocational board. Many people forget to check with their state professional EMS licensing board to see if the program itself is approved. If the EMT/EMT-P is approved by the Commission on the Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP) tjen they are usually good with the state. Some states still do not recognize the NR as their exam. With the long list of hodge podge education and individual state certifications (46 last count), how could we possibly agree to have a nationally recognized exam by all 50 states? Florida just within the past few years started accepting and using the NREMT exam. They still have their own paramedic test which nurses can also challenge. Maybe somebody will start another thread, but this is old hash on the burner getting more burnt in the U.S. EMS educational system until the new standards and new attitudes come about.

Your PCR and your refusal form and/or instructions for the care giver should in actuality be 2 different forms. This is the area that leaves EMS wide open for scrutiny and this is not necessarily meant to be a HIPAA issue. Even in the strict hospital environment, the "transporter" or a volunteer who takes the patient from point A to point B has access to certain necessary information with the ability to give it quickly to a response team if something happens to the patient while in his/her care. This information is provided anytime the patient leaves the primary care giver's sight (usually nurse but can be any ancillary staff ie special tests). The transporter will not move the patient until they are sure that information is available. No, they do not need to know their SS# or insurance, but some vital information is always available for ready access. So, no, HIPAA is not a valid argument for side stepping other responsibilities that directly involves patient care. Giving a care giver instructions about what to look for in the patient's condition that might require EMS to be called back is not a HIPAA violation. Please keep us updated after your meeting.

I'm sorry for your bad experience. Dealing with a loved one and the healthcare system takes a whole new understanding of the word "quality". But please don't be so hasty to judge. Again it all depends on the State and its contractual agreement. Some states take their responsibility very seriously and actively monitor these homes. Some of my patients prefer them because they still feel like they have some independence and are in a more residential type setting. Although I myself have seen a few that resembled army barracks style living rather than the home bedroom. So, it is hard to put a blanket statement on these homes. I personally cringe at the mention of nursing homes. Yet, when it came time to place my 91 y/o mother in one, I had to try to "shop" objectively according to her long term insurance allowance. Many are established with good intentions and many are established out of money. That is why the oversight of these facilities have gotten tougher over the past few years.

This type of home would also have a contractual agreement with the state that licenses it and must also abide by certain agreement of care for adequate supervision of care and appointed agents. The person calling you on behalf of the home and the patient then may become an agent of that facility as defined by your state's guidelines. In order for them to maintain their license to operate they must show that they have extended the offer of adequate medical assistance to a patient in a timely manner. This has been a huge legal issue and has resulted in the pulling of licenses from these facilities for failure to act or to provide adequate documentation when brought before their licensing board. I would not blame anyone for wanting to cover themselves if they were acting on behalf of the home and the patient. This again depends on the contractual agreement this home has with the state and various reimbursement agencies. An agent does not have to be a licensed medical person under most guidelines for these facilities. HIPAA also covers authorized agents in its regulations. Transfer of care does not necessarily mean leaving the facility. Your minimal contact with that patient may legally bind you for that moment of care. You will then, in good faith, leave that patient in care of themselves or another person. Was there adequate communication between all parties involved? The best way to assure this is by something in writing. Since you are the evaluating party and have accepted refusal by the patient it would then fall on you to ensure adequate communication has been provided.

EMS Refusal of Care forms greatly need to be examined for their adequacy. I am not attacking anyone's care here, especially if they are just following protocol. With that being stated... In most situations when a patient refuses treatment and/or transport, EMS fails to meet the standard of care of most other medical professions. Normally, a crew member retrieves the clipboard and obtains a quick signature from the patient, telling him, "Sign here. This says you do not wish to be transported to the hospital." After a signature is obtained, the crew leaves and returns to service. If a patient signs a refusal, can your system prove that your responders provided the patient adequate information and advice? More important, what specific advice did they provide? There are systems that either provide a specific information sheet or write specific instructions on the Refusal Form. The patient is then signing not only a "Refusal form" but that they have been given a form with some specific instructions. Nursing Home personnel also would like show that you did more then walk in, take a refusal and leave. I did just see this issue discussed in a recent journal. This issue actually has very little to do with HIPAA, but rather it is more of a "transfer of care" issue between two healthcare providers. This is similar as to when you hand off a copy of your PCR to the ED. For the patient, new forms with specific information now show you have transferred the responsibility to patient that he/she was informed and he or S.O. can read about it again if he forgets what you said. You may also see an improvement in "transfer of care" for the patients (BLS routine) that are picked up at hospital to be transported to other facilities, ie nursing homes, dialysis, HBO etc. HIPAA is pretty specific for certain data. However, for direct patient care, hospitals and nursing home have other accrediting agencies that are directly related to patient care information that they must abide by. General Privacy rules still apply.

In the US, you'll find nurses on: Helicopter EMS crews Mobile Intensive Care Units Critical Care Transport Teams (inter-facility), ground and air Specialty Transport Teams (NICU/PICU/Heart) air and/or ground Air Ambulances, domestic and international International Medical Accompany/Assistance Services

50% is actually a good reimbursement by many medical standards. There are other issues concerning that which are also related to legislative issues, licensing and educational standards in the EMS that also keeps reimbursement lower. But, that should be another topic. EMT is a great start in the medical profession. You have limited supervision. You are mobile. You do (contrary to some beliefs) get some respect. Although, the uniform and the ambulance with lights and sirens does help in that area. Then, you get comfortable and enjoy the job or get involved in your life. Continuing your education takes the back burner. Your significant other may make enough money for you to still continue working for minimum wage. You like the people you work for or with. You've got a nice station and decent working conditions. There are definitely worst jobs that also pay minimum wage. As long as your family is comfortable, well cared for and you enjoy your job, money may not be the biggest motivator. I'm at a stage in my life now where good benefits including insurance and retirement are my concerns (and can be a hindrance when a good job opportunity does comes along). You may not be academically inclined but have found a job that you could still feel like you are helping people. Maybe you haven't been exposed to or researched all of the great professions that are out there that would be a compliment to your EMT or Paramedic training and pay better. However, today, there shouldn't be any excuses especially about money problems if you do want to enter another healthcare profession that pays better. Hospitals are willing to repay/pay almost all of your tuition for many professions. There is now daycare offered by the colleges and some hospitals. Hospitals and other employers may allow you class time on the clock for some professions.

Tolerated and allowed are two very different areas. It has taken many years of court battles to actually adopt Zero Tolerance policies in many EMS and Fire companies. Tolerance has also come in the form of co-workers looking the other way when off duty personnel show up with alcohol at a station. It also comes in the form of knowing you partner is not quite "right" due to off duty drinking and/or on duty drinking. But, you keep your mouth shut because he/she is going through some rough times and you don't want to jeopardize their jobs. Years ago before we had zero tolerance policies where some EMS companies would fire both partners. Then, the court systems got involved. The NAEMT just this year came out with their position on Zero Tolerance. Most companies adopted their policies officially after 2003 when a couple of court decisions were finally decided. Much of this has to due with the possibility of random drug and alcohol testing that might come with a Zero Tolerance policy. People don't want their rights violated. The other argument is "tradition". Much of this also comes unfortunately from some fire departments. Although, the large private ambulance companies bought out many "traditional" ambulance services that were more laxed. Some isolated and low call volume stations are harder to supervise. I, myself, remember a couple good parties at one of our nicer residental stations. "I cannot recall if the crew members on duty were drinking". Of course, if there actually was a policy in effect, all of us should have been fired. It would be naive to think that alcohol is not being ingested in some of the many EMS stations across the country. Tolerated, yes. Granted, many of the news making examples are concerning the fire departments, EMS is part of many of those fire departments. I agree that what should be commonsense isn't always what the argument is about. Example: http://firefighting.com/articles/namFullView.asp?namID=8676 http://www.sfgate.com/cgi-bin/article.cgi?...BAGB15K1SK1.DTL http://sfgate.com/cgi-bin/article.cgi?f=/c...BAGR6BR9LU1.DTL

Of course I'm not defending it. I just had the displeasure of reading about it for several months in the SF Chronicle with my morning coffee. I actually found it absurd that there were defenses made for the behavior. But then, we can find reason to justify almost any type of human behavior as defense against a violation of our perceived rights. And then, there are the "functional" alcoholics who are may or may not be known by fellow co-workers. If anyone has been around for more than 5 years in the business, they probably know someone who has an alcohol or substance abuse problem and is still on duty.

Not every department has a zero tolerance policy and if they do, it may be interpreted differently. As long as there are lawyers and union reps, there will be excuses made and the behavior may or may not be punished. The alcohol scandal in the SFFD department 2 years ago showed the nation the meaning of "case by case" partiality.

Another Florida hospital stops smoking but slightly less harsh about the employment rules. http://www.keysnews.com/317942768697686.bsp.htm Hospital bans health-care workers from lighting upBY ANNE-MARGARET SOBOTA Citizen Staff A nurse takes a quick last puff off her cigarette outside Lower Keys Medical Center before hurrying back inside to take the medical history of her next patient — a lifelong smoker who's starting to show early signs of lung disease. The irony of the situation is not lost on hospital administrators, who realize the double standard that is set when patients heading into the building see health-care professionals outside smoking — the same doctors and nurses who are encouraging them to quit smoking. That's why they're taking the Stock Island facility and the dePoo Building on Kennedy Drive smoke-free. "We need to set the example for health care in the community," said Randy Detrick, marketing manger for Lower Keys Medical Center. "You can't have nurses and doctors outside smoking and then telling [patients] not to." As of Nov. 15, which coincides with the American Cancer Society's annual Great American Smokeout, all hospital employees and patients will be prohibited from using tobacco products, including cigars, pipes and smokeless tobacco, while on the property of any Lower Keys Medical Center facility. "No matter how many signs we put up, people still puff away right outside the front door," Detrick said. "Everybody's getting more vocal about secondhand smoke." For the hospital's roughly 500 employees, that means no designated smoking areas, and no sneaking out to their cars or the sidewalk for a cigarette, Detrick said. Employees must clock out and leave the property if they want to smoke. The policy also states that smokers are required to minimize the odor that lingers in their clothes and hair from using tobacco off-campus. Igniting a trend Lower Keys Medical Center is one of hundreds of hospitals nationwide that have gone smoke-free, with more facilities jumping on the bandwagon each day. Detrick said there's been a large push in the industry, with agencies such as the Centers for Disease Control and the Florida Hospital Association weighing in as well. "It started in some of the large hospitals in California, and worked its way across the country," Detrick said. One of the most notable recent hospital smoking bans was imposed July 20 at Duke University Health System, which includes more than a dozen hospitals and clinics in the Raleigh-Durham area of North Carolina. The area, called the Research Triangle, is widely known as a leading area of the country for medical centers and technology. The hospitals combined have about 40,000 employees and 3 million annual patient visits, according to published reports. Lower Keys Medical Center also is taking a cue from the newly opened Homestead Hospital in South Florida. The $135 million facility opened in May with a tobacco-free policy. Detrick said the transition there was easier for staff and patients because it was a brand-new building. Hospitals aren't the only workplaces that have yielded to health concerns in recent years. States including Florida, Arizona, Delaware, Hawaii, Louisiana, Massachusetts, Montana, Nevada, New Jersey, New York, North Dakota, Ohio, Rhode Island, South Dakota, Utah and Washington all have laws that designate smoke-free indoor workplaces, according to the American Nonsmokers' Rights Foundation. The American Lung Association Web site says all 50 states and the District of Columbia have smoke-free air provisions restricting smoking in certain places, such as restaurants and/or bars. These laws range from simple, limited restrictions, such as designated areas in government buildings, to laws that prohibit smoking in virtually all public places and workplaces. Detrick said some hospitals, such as the Cleveland Clinic, are going so far as to limit their hiring to nonsmokers. "They are no longer hiring employees that smoke or have nicotine in their system," Detrick said, adding that's not something Lower Keys Medical Center is considering. Snuffing out addiction Detrick said so far feedback about the new policy has been overwhelmingly positive, with only a handful of employees complaining or vowing to find new jobs. "A lot of them are choosing to stop smoking already before we even begin the cessation program," Detrick said, explaining that all hospital employees will be able to participate in smoking cessation programs that include counseling, motivational meetings, education and access to smoking cessation products such as the patch and Nicorette gum. The program will be sponsored by the Florida Keys Area Health Education Center, a local nonprofit whose mission is to promote health and wellness through community education, service-learning programs, health screenings and professional development of health-care providers. "The tobacco-free policy is giving them a motivation and a reason to quit," said Michael Cunningham, CEO of the center. "This is the push. This is what they kind of needed." The center also is bringing in $600,000 to create smoking cessation programs and training for health professionals throughout Monroe County. It's part of the $10 million the state Legislature awarded the center's network. The money comes from the 1998 multistate tobacco settlement that divvied up $250 billion over 25 years to repay states for health-program costs allegedly attributable to smoking. The first phase of the center's initiative will involve smoking cessation programs and cessation training for health professionals, Cunningham said. Certified tobacco treatment specialists will take courses that range from the history of tobacco and the biology of the brain, addiction and tobacco dependency to medical complications caused by tobacco and nicotine replacement therapy. Once the staff is trained, the center can roll out its countywide smoking cessation and education programs, starting with two clinics at the annual Health and Wellness Event in October. As with hospital employees, the countywide smoking programs would involve one-on-one counseling, group sessions, pharmacy assistance for people without insurance, and information on nicotine replacement products, new medications and alternative therapies such as hypnosis and laser therapy. The center also would deploy smoking prevention programs in schools. Cunningham said these programs are guaranteed for at least two years. At that time, the success of the programs will be evaluated to see if the funding will continue. http://www.keysnews.com/317942768697686.bsp.htm

So...as an EMT you are not part of the healthcare profession?

Does your uncle have DPOA? Does your grandmother want your uncle knowing her medical information? A HIPAA Notice signature is not a wavier for the right or privacy or the right to disclose information to unauthorized persons. This may include other family members (husbands and wives included) unless specified by the patient. All of the general good sense privacy rights are still intact. http://www.hhs.gov/ocr/hipaa/ http://www.mylegalnews.com/ilsdocs/Archives/03_2004.htm

Furosemide, Lasix; loop diuretic Neonates and furosemide: Inhaled furosemide 1 and 2 mg/kg has improved pulmonary function in preterm neonates with BPD as shown by some studies. It is also used for TTN by either oral or nebulized administration. We use it periodically via nebulizer on specific cases in the NICU. Infants have similar indications for oral, IV and nebulized furosemide as the adult population, CHF, liver and renal diseases where a loop diuretic might be indicated. However, I doubt if paramedics in the US would be able to do off-label administration such as nebulized lasix to anyone, adult or neonate. They might be able to do this if they worked on a specialty transport team for a children's hospital.

I can't believe I just read what I read in this case scenario.

FL_Medic Why don't you go to the local hospitals that already have established hypothermia protocols. Observe a few patients on the protocol. Talk to the ICU nurses. See if they have seen a lot of success stories. Like I mentioned before, we do this in our ICUs occasionally. It can be a long 24 hours for the bedside staff. But, get some up close information for yourself. We had our best success with peds. So what is the age range again for your potential protocols?

Have you stayed around to see what the core temp is on arrival with just the cooled NaCl? At least that is easier and can be discontinued discretely once inside the ER if the discision is made not to continue the protocol. But, how would you feel if you knew the hospital wasn't carrying on with something you thought worth while to start? That's most of our population.

I'm going to hit you with some of the questions and statements that those of us who work in the "Condo to Heaven" (aka Florida) have got to ask. How many codes are brought to each hospital ER daily? I know I have averaged 2 - 5 per 12 hour shift easily during season in the ED. Sometimes at least half of those would make it to the ICU with a heart beat. Are you going to activate the protocol on every body? The obese and the very old? When the mean age for some of the retirement communities is 87 (and most are still on the golf course), what a too old? Nursing home patients that are still full codes? Yes, there is a younger population there, but the wealth and power is still older. Are you going to be ready when it hits the news that somebody's loved one didn't get the new and fabulous remedy to death? People love to read stuff like that. What is your on scene and travel time to the nearest hospital in code? I know Lee County is a large geographical area but also has many hospitals. One of the reasons we hesitate initiating the protocol is poor prognosis. If the person is in very poor health, well known to the hospital and/or very elderly, the physician will talk to the family before we continue with more heroics.

Are you talking about Lee County, Florida? Do you know how many hospitals and systems you have in that large county? That's a lot of medical directors (ED and ICU), P&P review boards, nurse managers, budget planners for extra equipment and staff (several hundred to over 1000 nurses) to get on the same page. The P&P for nursing is quite extensive. They also may have to allow for additional staff since hypothermia protocol patients may be 1:1 during the 1st 24 hours depending on the policy. Regular post code patients rarely are 1:1 staffed. A single hospital could probably get the P&P approved and implimented quickly. A few hospitals are probably doing hypothermic protocols but also on a case to case basis. Even with our ready-to-go protocols, not all of our ED or ICU physicians want to implement the protocol. Our doctors also like to do a little neuro assessment while we're implementing the protocol. Those hospitals that don't want to play, are you going to bypass them? How long will it take to get LC EMS paramedics adequately trained? That's quite a project you've got ahead of you.

The simple Newsweek link is http://www.msnbc.msn.com/id/18368186/site/newsweek/ I see you've done some serious research on the topic. Duke University was a leader in some of the data collection and articles published. I heard one of their physicians speak at an ATS meeting. Intratracheal cooling will probably be the most practical for EMS if we can perfect a method. Liquid perfluorocarbons might not be the best for pre-hospital right now. I haven't read through all of your protocols yet. What are you using to chill the patient?