VentMedic

Medicine recycles itself. Old practices becomes new again. Hypothermia and Cardiopulmonary Bypass were both popular in the ED in the 1980s. Both still stayed around primarily in Neo/Pedi, but re-emerged to the adult mainstream about 5 years ago. We do one or both in the Neo/Pedi inside the hospital. We do initiate hypothermia protocols in the ED for some adult cardiac arrests, case by case. Some doctors want to see it initiated for all, but there are other factors to consider. There have been discussions again about initiating hypothermia protocols on the amubulances, but many do not carry paralytics to control the shivering. I do remember the early 1980s when we were packing ice around the heads of near-drowning victims. No easy task in Florida. Unfortunately in Florida, we have no body of water to chill a person and get the results as they have in Michigan or Minnesota.

als_medic_uk, So, what data are you basing your information on? High mortality rate? Pulmonary Function Testing is done in the hospital setting to determine medication effectiveness. That is how the information is gathered to publish all of the articles you see in the journals about medications that affect the pulmonary system. From the data published, and yes there are more than the 2 articles I mentioned, and from experience, I have not found furosemide to be effective enough by itself to be routinely used. When we did try furosemide a few years ago, it was in conjunction with other medications and therapies. Furosemide may have to be reformulated as did tobramycin(TOBI) for inhalation, for the pulmonary system to accept it more readily. The factors I mentioned in the previous post also skew results in the ER. And, please don't confuse simple ER spirometry with the PFTs done with calibrated data collecting equipment from a Pulmonary Lab by a trained professional, not meaning to be derogatory of course. The 2 articles I linked to are to inform you what we use nebulized furosemide (and other meds) for off label in the US, in case, some pre-hospital workers do see it here. Nebulized furosemide is not used for COPD at this time in the US. We have various P&Ps that must be adhered to for off label medication use. There may be some facilities that are trialing it for research to publish but that will be in a more controlled setting. If the manufacturer offers us a grant to do some controlled Pulmonary Function Testing, maybe our hospital will get an article published also. I have be doing this long enough to "make" the data work for whoever wants results. If you have been in the medical profession for any length of time, you should be familiar with "reading the literature" and how the data is collected for results.

We're a very large, fairly self contained burn center and like to get everythng done in the cleanest areas possible. Our OR and Tub rooms are almost next door to each other so that is why we'll take them in there for line placement or whatever else necessary depending on the type of burn. Positioning the patient for some posterior work is easier there as well. For tubes, we'll take whatever they bring us. Appropriate size would be nice but, some EMS staff are very inexperienced with burns and like IVs we don't want a lot of pokes at the airway. For our tubes, we like to get a subglottic suction tube in as early as possible if possible at least until they are trached. We've seen a big difference in our sputum cultures with those. That's all we stock now on our carts.

Nebulized furosemide as off label use has been tried periodically for at least 30 years. Many of the studies have been critiqued to death. It has never gained any type of recognition or popularity in mainstream USA except in some hospice situations. Feeling of dyspnea alleviates: Is the neb ran off a 7 L/m O2 flow? Mouthpiece? Possibly a little "CPAP" effect. The same effect was found when runnig 7 L/M of compressed air and placebo on COPD with DOE in pulmonary labs. The patient may also need to be pre or post treated with an albuterol tx to tolerate the lasix neb. FEV1 changes? see above. I'd like to see plethysmography results. Nebulizing off label medications in the back of an ambulance can present possible hazards to the crew. Albuterol and Atrovent are bad enough after repeated exposures. We try to use filtered nebulizers or an isolation room as well masks for staff with direct contact if running off label in the ER. Furosemide might be seen nebulized in the neonate more commonly. It can be part of hospice programs for terminally ill cancer patients. I have found nebulized morphine and fentanyl to work well in giving some relief to the end-stage cancer or COPD patient. http://www.medscape.com/viewarticle/545484?rss http://www.factsandcomparisons.com/assets/...nov2004_off.pdf It was mentioned the pt was put on BiPAP. Regular CPAP, especially some of the models carried by EMS today, could actually increase pt's work of breathing and lead to respiratory failure quicker. This would also be dependent on pt's air-trapping and secretions.

Anyone interested in learning about burns a little more indepth should take Advanced Burn Life Support (ABLS) at a major burn center. Some burn centers offer other classes besides ABLS to any medical professional that is interested for CEUs.

Those studies were done many times and were summitted for medical instrumentation approval before any pulse oximeter is allowed on the market. That is also how we check accuracy of our pulse ox in the ICU. Of course, as far as PaO2 and SpO2 or even SaO2, you can have a PaO2 of 90 or 490 mmHg and still have a sat of 100%. A patient that is bleeding and has a Hb of 5 will be short of breath and still be 100% SpO2 but with a seriously diminished carrying capacity. The pulse ox actually tells very little about the oxygenation of a patient until some other clinical correlation is made .

I would pull over. LEOs should be respected. One minute of courtesy may prevent embarrassment later. It is very rare that they will pull over an ambulance. They may have a good reason. 1. You could have a mechanical problem that the LEO noticed that could affect safety. If it is something simple like lighting, the LEO may escort you safely. 2. The LEO will not detain you for any length of time but will get your destination if there is something more to discuss. 3. If it is your driving that is the problem, the LEO still will probably not detain you but will warn you and may still meet you at your destination. 4. If your driving is an issue, the LEO probably has already contacted your dispatch and supervisor to meet you at the destination. Many times the LEO will find out your destination from your dispatch and just follow you. 5. There have been instances when an ambulance changes lanes quickly or accidentally cuts someone off while running L/S and may have caused an accident which was not noticed by either crew member. This may be to protect you later so concerned citizens aren't going to be able to say it was a hit and run by an ambulance.

That IV will be removed very quickly if possible in the hospital as do most field sticks. However, whatever IV is available to start fluid rescusitation immediately will be used. The IV site will have to be capable of handling a large volume of fluids. If there is potential damage to the vessel itself, then it will be useless very quickly. The patient may be tubed, tubbed, bronched (if airway is an issue) and possibly taken to the OR all within the first two hours. In the OR they can place any type of line necessary for the long haul. Infection of course will be an issue, but they will probably have major antibiotic coverage. Of course 3rd degree burns and obviously blistering sites are not feasible. Sometimes the hand veins are too small to run alot of fluids through, but they are a start. The burn team will be more upset about multiple unsuccessful sticks than a good stick that they can use until a secure line placement is obtained. A good burn team is very aware of the difficulty of starting IVs on burn patients due to a fluid redistribution and loss.

The original post was for long term monitoring. I would take that for more then just a "sat check". Since donedeal also listed his occupation as ER tech, the pt could be in the ER for more than 4 hours easily which may be long enough to cause problems depending on the degree of injury. With swelling and then later casting or OR, any potential for sores and infection should be avoided if possible if it is not necessary especially those induced by the care givers. Granted if it is a 20 - 30 y/o with good skin intergrity and no hx of diabetes, monitoring on the affected extremity may not be a problem. However, for the very young and the very old, it can become a problem quickly which is why we have this long assessment form about every inch of skin on a patient if they are admitted to the hospital. I've also seen disposable probes taped in place not attached to a monitor and then missed for many hours as the patient goes through the system. The same standards for skin integrity care holds true for ER techs, RNs and RTs. ALS or BLS shouldn't be an issue for that. For perfusion checks, I don't believe a pulse ox is listed as a valid assessment tool because it will not tell you about skin color, warmth, sensation, swelling or quality of the pulse. A good pleth may be helpful, but too many other factors may skew accuracy for documentation of perfusion. In other words, this should not replace frequent checks by actually being at the patient's side. Although, I did mention we have used its pleth in the ICU with a nurse and/or physician at the bedside but only only secondary to all of the other technology and manual skills.

Good one! The beeping bar graphs on many portable pulse oximetries may be misleading especially in a moving ambulance. In the hospital we will on rare occasions monitor the pleth on a monitor based pulse ox if we have a good base line established. Of course, we also have dopplers and a variety of other technology along with the old fashioned assessment of putting an X on the pulse point and occasionally checking it by using our fingers. If there is a good pleth with the palpable pulse , SpO2 should not differ from other areas. Of course, all the things Lilacmedic mentioned will affect reliability of the numbers. The SaO2 should be the same thoughout. For accuracy to check pulse rate with the HR rate number on the pulse ox, we were taught to listen at the PMI of the heart's apex and palpate the arterial pulse. At the same time, this is also good for determining the heart sounds as an assessment point if you're involved in CCTs. Depending on the age and/or condition of the patient, some adults haven't had good palpable pulses in the extemities in years even on a good day. Usually if you don't have a palpatable pulse, the pulse ox is useless anyway. If you have a palpatable pulse, good. But I probably wouldn't want to leave a pulse ox attached for any length of time on an effected extremity for the possibility of poor circulation to some of the tissues. Pressure sores can easily form leading the way for other issues such a infection. That is the reason we don't normally monitor the SpO2 on an injured extremity in the ICU. If we must use damaged extremities, we will initiate more frequent site rotations. Or, even in the ICU, the pulse ox will be determined as useless for that patient and we'll just rely on other aspects of physical assessment such as color, RR, HR, BP, mental status and aggitation. So, in answer to the initial question: No, I don't make it a practice of putting a pulse ox on an affected extremity for monitoring for any length of time if I can avoid it.

There have been some really excellent posts. Since Florida decided smoking was not a protected right in 1995, I'm surprised this is a headline in the newspaper 12 years laters. Anyway, I going to post my own summary of my feelings about smoking, especially where the kids are concerned. Be fore warned, along with some facts and figures pulled from national organizations such as the Academy of Pediatrics, I express strong opinions for the rights of children and the elderly. Against: Smoking related illnesses costs insurances, Medicare and Medicaid, billions of dollars. Lung disease patients don't always just die. They linger for years racking up impressive medical costs. This doesn't compare though to the suffering the patients and their families must endure. More long term facilities needed to "warehouse" the ventilator dependent patients associated with smoking related illnesses. They are now being housed in the acute care hospitals occupying much needed bed space in the ICUs and at a serious cost. Employees who smoke take an average of 5 more sick days per year. Employees that smoke carry an offensive odor to some (both patients and co-workers). The same with perfumes which are already banned in patient care ares. Tired of covering co-workers for cigarette breaks and then supposed to cover them again for their regular breaks since the cigarette breaks aren't true breaks. Cigarette smoking parents contribute to the lung disease of their children. Parents who smoke are placing their children at a 40 per cent greater risk of developing asthma than children living with non-smoking parents. The measured COHb (carboxyhemoglobin - carbon monoxide) level in a child's blood can range from 3 - 8% just from being inside a car with the parents smoking, essentially the same as the COHb level of the adults smoking. This is besides contributing to the other factors associated with reactive airway diseases. There's also that little issue of women smoking and being around smokers during pregnancy. Thus, now the children are a major cost factor in the insurances and government subsidized health programs. A child diagnosed with asthma at an early age can easily need more than $1 million dollars in care by age 30. If this child also chooses to smoke as many do if the parents smoke, even with asthma, this may be a very conservative figure. Asthmatic children of smoking parents are more likely to experience being on a ventilator during their childhood. They are also more likely to develop complications post operatively. Now if you want to talk about the elderly non-smokers on very limited income who are forced to live with their adult children who smoke, I put that at a new form of elder abuse. Pro: The future looks good for Respiratory Therapists. Con: Rising costs of uninsured (and insured) smokers force cut backs in health care in other areas. Employers will be forced to raise the out of pocket portion for medical insurances for all employees. In summary: To keep cigarette smokers smoking, it is at a considerable cost to others. The very young and the very old who don't always have a voice need to be heard. Obviously Americans aren't doing too good when it comes to taking care of our health or the health of others especialy the previous and future generations. I don't like government regulating activities either but I also don't like seeing children with trachs in pre-school either.

While it does seem like good fun, I have seen links to this website on nursing and community forums. Since this is a public forum, anybody with a computer can view anything with just a sign on. That includes potential patients. Some of the remarks have made me cringe by a few nsensitive remarks concerning patients. The internet is a power tool and can be used for promotion and demotion of image. It seems a little contradictory to talk about wanting to enhance professional image and then bash the people that you want respect from, ie nurses, doctors and patients. Overall, there is a good exchange of information. However, I do agree that when almost 10 of the threads on scroll is about "bashing", I would say the causal surfer might form an opinion about this forum without seeing the truly good posts by people that are dedicated to the profession.

I hear your concerns which are all valid. Did you ever work for a hospital owned by the Seven Day Adventists? I smuggled my coffee and colas, not to mention real meat for the two years I worked there. I hear they have lightened up now and are allowing their patients to at least have meat. These restrictions are actually nothing new for hospitals. Unfortunately, there ARE more perks for those that smoke and are overweight than those who aren't. The smokers get a choice of many programs including massage and Tai Chi classes to relax. For the overweight, there are health club memberships with monetary bonuses for amounts of weight lost. Yes the non-smokers and norm weight can take part but usually will have to pay some fee and no bonuses, except for health. Fair?

Ruffems, you speak the truth. RTs as Dustdevil joked about earlier have been as guilty as anyone else of being smokers themselves. It is LESS cost effective in terms of worker's comp claims and potential damages by medication errors when the employee is involved with drugs or alcohol. A sentinel event is not the time to find out about drug and alcohol testing. Drugs and alcohol are major offenses. First offense, the physicians and hospital workers are offered treatment but also must summit to drug and alcohol testing routinely and randomly. Surf up the professional boards for nursing, MDs and RTs in almost any state and you will find an extensive list of disciplinary actions taken not just by the hospital but by the licensing board. For any employee, any on the job injury and in some cases needle sticks, the employee will be drug tested. Alcohol will not stay in the system if a 1 or 2 beer/wine drinker that long. However, we have had employees test out at .25 and still appear to be functioning. There was no denying their chronic dependency on alcohol. We have also had professionals addicted to pain medication. This too was be treated as any addiction and they are given the chance to receive help per the guidelines by the hospital and their licensing boards. katbemeEMT-B You may be the exception to the smokers that can not go 13 hours without a cigarette. So, why not just try for the other 11 hours?

For employees with direct patient care in my hospital this is also a reality. The RT and nursing departments do smoking cessation teaching. Part of the job requirement is to be a non-smoker. If you did not meet your job qualifications (after several assistance programs), you could be terminated even and especially if you are a nurse or RT. Some abandoned ship when finding out what the new rules were only to find themselves again in the same situation at a new employer. The employers are going out of their way to offer every possible service to help the employee. This is not a cold turkey firing. If you want to be a healthcare worker, you may have to make a personal sacrifice for the patients. If not, there are probably other jobs that don't require contact with humans that you might be better suited for. Patients have the right to be free of nausea and bronchospasms induced by an employee who smells like an ash tray. If you have ever had chemotherapy or some form of reactive airway disease, you may be able identify with what these patients go through. We also have firefighters and industrial workers who have been exposed to chemicals and are now very odor sensitive and disabled. Co-workers of smokers get tired of switching assignments because of odor sensitive patients and employees who go for a cigarette every couple of hours with a new smell of smoke on them. Of course, the breaks smokers take for a cigarette are not realbreaks, as they will still want coverage for those too.

South Florida Hospital Will No Longer Hire Smokers http://www.nbc6.net/health/13609384/detail...022007&ts=H POSTED: 5:33 pm EDT July 2, 2007 UPDATED: 4:34 am EDT July 3, 2007 WESTON, Fla. -- The Cleveland Clinic is going cold turkey. The clinic announced Monday that it will no longer hire tobacco users, saying the hospital is setting an example for its patients. "To set the example for the health care industry and to really live by their words of -- that we're trying to advise our patients to quit smoking," said Dr. Bernardo Fernandez Jr. "It really gives us the opportunity to set the example." Smoking is already banned on the grounds of the Cleveland Clinic in Weston. Two summers ago, smoking areas were abolished and employees were offered help to quit. Now hospital officials are taking it further by instituting a "no tobacco" hiring policy. Starting this month, all job candidates must take a urine test for nicotine. Starting Sept. 1, the hospital will not hire applicants who test positive. http://www.nbc6.net/health/13609384/detail...022007&ts=H

Ruffems, My apologies. Didn't say you were knocking him. Just wanted to know what you were doing at 16. Although, I think you too were a busy guy with a lot of responsibilities at that age. You make me feel like a slacker. Although I was also working FT, I still had alot of social priorities also. Heavy metal and disco was popular back then. 8) This young person sounds by far more mature than most 16 y/o. As far as driving 90 mph in an ambulance, don't get me started on that speech of mine. Speed is not the answer. Being well trained and confident in your skills will be more effective than the 2 minutes you might save getting to the hospital. My apologies again Ruffems if I hit a nerve.

There is a journal dedicated to resuscitation and it is called Resuscitation. http://www.sciencedirect.com/science/journal/03009572 Some of the articles are free. The abstracts are all readable online. You can probably obtain these articles at the medical library of a teaching hospital or med school. This is an international publication that offers survival and quality views from many different countries.

Quit? You haven't started yet. In another two years you may even find you like driving as you gain more experience in your personal vehicle. Keep school as your priority. If EMS is in your future, start preparing in the life sciences. Build a solid educational foundation and then make your career choice. You're probably doing more at 16 than most young people your age. 16 is a fun age. You don't have to jump just yet into a life altering decision. Hey Ruffems, what were you doing at 16?

You're right on target there. Unfortunately that also applies to the current educational system in EMS.

You just summed it up in that statement. Their arguments have been that a skill or a brief class does not equate to the broader education for the whole picture. Inside the hospital: There are some paramedics that will hang blood because it's ordered and never check what the Hb is or when another Hb check is necessary. There are paramedics that want to rush a pt to CT Scan/contrast and not know to check a BUN. Before CPAP joined the pre-hospital therapies, paramedics wanted to intubate right away. They didn't realize RTs have been saving people from intubation for 30 years with CPAP. Paramedics are not always savvy to the options, methodologies and procedures available in the hospital setting. They may still function as Emergency Care providers and may not see the long haul ahead for the patient besides the obvious. Education is key. Nursing has a strong argument that an inservice in one or two skills doesn't amount to much if there are no BASICS to back it up.

I have not heard of nursing being against the educated paramedic as evidenced by the many paramedics working alongside RNs on CCT (although not all is created equal in education there either). Their argument is because the paramedic's education doesn't measure up with the norm in the hospital setting that they should be limited in scope. Nursing has their own problems with minimal education standards now. In order for them to keep up, the BSN may soon have to be their minimum. This is not a popular idea because of the shortage, but their education is low now compared with the other professionals. That is the talk on their forums now. Their ability to supervise allied health professionals is cut shorter when a Bachelors, Masters or Ph.D. is the minimum standard now for most of these professionals. Now as far as the nursing staff model, if paramedics increased their education at the State and National level, that would level the playing field also. If their skills could get out from under the blanket, that would also prove worthy.

There were probably over 100 degreed (2 year) EMS programs in the US when nursing decided to go from diploma to the degree as their standard for licensing and professional standards. EMS did not. EMS could have had the head start on the education market for minimum licensing standards even though the nursing profession was older. Since then, EVERY health care profession has passed EMS up in education. Even the entry level Nursing Assistant or Patient Care Tech now which used to be 100 hours of training is now almost 600 hours or 7 - 9 months. There was a demand increase for EMTs and EMT-Ps in the 1980s. The medic factories started cranking them out either at the ambulance companies, FDs or private techs. The community colleges that offered the 2 year programs then established the "certificate" track to keep up with production. Now when there is a chance for some one to obtain a degree just like all of the other professions, they take the quick way out. Why? Because some currently employed paramedics tell them all that B.S. education is not necessary. It's not nursing or RTs telling the new EMTs that. You can read some of the comments posted on the education threads on this forum and see that for yourself. Now if you want to talk financial value, the EMT and Paramedic, since they are primarily recognized as certificates for licensing, they are not recognized for re-imbursible services in the hospital by the State and Federal agencies. In the hospital, every profession is looked at like a separate business according to their re-imbursible worth. Every department manages their area like a business in terms of revenue that their services generate. EMTs and Paramedics are hired usually in the nursing department. Nursing is a blanket service but the number of services they pick up from say Respiratory depends on whether RT is losing money providing those services. Nebulizers and EKGs are not always money makers, so nursing lumps them into nursing services provided. RT then picks up HBO, intubation and A-line placement which are all re-imbursible for them. If the extra tasks strain the nursing personnel, RT is asked to take them back, maybe at a loss. Departments in the hospital restructure and adjust everytime there are new re-imbursement guidelines handed out by the government and insurances.

Sub-acutes are quite popular these days. As I mentioned earlier, I would advise anyone who sees working with ventilator patients in their future to spend some time in a large sub-acute. This includes new grad RNs, future RTs and CCEMT-Ps. Not only will one see many different types of ventilator patients and different modes of ventilation/airways, but also different ways of communicating with the patients. The patients that are able to speak, as Christopher Reeve did, will be able to answer alot of questions about what it feels like to be initially on a ventilator and the prospects of never coming off of a ventilator. That will put a human voice to a technology centered world. It will also give someone a view of what happens to some of those "saves". That part might be disheartening to some.

No, they are employed by a well known private ambulance company that provides interfacility transport under a new contract with a neighboring facility. I am not sure about their training/education. I just know they are RN and EMT-P. The RN should have at least ICU experience. Of course, not all ICUs are created equal. Not all CCTs are equal in additional training/education. Not everyone is familiar with the nebulized prostacyclins. Some hospitals just use nitric oxide. However, when that is emphasized in report when making arrangements for transport, they could at least read a little on the way over to pick up the patient. We'd be happy to fill in the blanks if they demonstrate some knowledge of what they're doing. I could tell of more stories from a service that has been attempting to be an established HEMS and also trying their hand at interfacility transport. Right now they are in negotiations with their county. After the dust settles I may post some of the articles from their local newspaper and website. It is a good example of someone not doing their homework prior to the starting this type of service in this particular location.