VentMedic

I, too, would like to read a little more from JPINFV about his job. I'm trying to piece together the details he's given us so far. Not all ventilator patients require "critical care" transport. There are many times when the patient is going to a long term ventilator facility. They can also be a quad or ALS patient going to and from the hospital from home. Basically they are BLS except for the ventilator. However, an RT or RN (trained in trachs) usually has to accompany them for basic airway maintenance and ventilator. Many home care patients take care of their own ventilators and just need transport. The parents usually manage their child's ventilator. Policies vary among ambulance companies when dealing with these patients.

Our standards for our Respiratory Therapists are similar to NC's (see previous post). If the RRT is part of a designated transport team, they are expected to perform all of the duties including medications. The RN is also expected to have competency in the respiratory skills and medications. Of course, while on transport just like in the ICU, it is easier for documentation to keep some duties separate. On neonatal and pedi transports, the RRT takes care of setting up all of the medications (none of the sending hospital's meds are used in case of error) and ventilator while the RN gets consents signed with the parents. Respiratory Therapists are normally a very cautious bunch. They like to have extensive knowledge about the technology and medications they are using. Paramedics and RNs sometimes perform functions that they have not been entirely trained in. This is seen in both the hospital and on transport. Sometimes it is through no fault of their own, just the situation and sometimes it is their "can do it all" attitudes. RNs should have a knowledge about all the medications they give patients. Unfortunately there are more medications than time. As a young paramedic, I also did it all and welcomed any challenge. Then, I went back to school and got educated. That taught me something about "you don't know what you don't know". RTs are often put into transports as part of an uncomfortable situation. They are sometimes requested to go on a transport by the Intensivist for various reasons. Now the RT is in the back of an unfamiliar ambulance with an RN and EMT-P they have never seen before. This happened to me recently when the CCT team thought Flolan was a bronchodilator like albuterol. Before I knew it I was told to hand off my other 5 ventilator patients to another RT and go on transport. We have our own protocols for transporting patients, but when functioning as a "guest" with another transport team, it puts us in a grey area. This also happened when a transport team admitted to not being familiar with their own ventilator and asked one of our RTs to accompany them. Now that RT must accept responsibility for their equipment or take ours which again puts the RT and hospital in a grey area. RT is generic for Respiratory Therapist RRT is Registered Respiratory Therapist - advanced practice and usually required to do conscious sedation, ECMO, intubation, IABP, A-Line insertion, hemodynamics, etc. CRT - Certified Respiratory Therapist - lesser license, 2 year degree still required

Very true. You won't find many experienced Neonatal transport teams running lights and sirens either. Irritating noises and movement can have an adverse effect on a baby's hemodynamic stability. There are specially designed headsets for neonates to mute noises such as helicopters. These were first used in the hospitals with HJV due the the baby's head being close to the flow interupter. However, once in flight, the vibrations can be somewhat soothing. ERs do have a tendency to over compensate. That is one reason the AHA wants people to understand the new ventilation rates in CPR. Unfortunately some misunderstand how this applies to minute ventilation also. Less frequency doesn't always mean you have to compensate with more volume. Some ER doctors get obsessed with the "6 - 8L" minute volume equation and forget the practical applications. As far as the RTs are concerned, sometimes they pull out their protocols with the doctor and sometimes they say "the heck with it, the patient will be another ICU or hospital's worry soon enough". Not always the correct way of thinking, but sometimes keeps you sane when you have to work with a hundred different doctors and a hundred different thought processes. If the RTs are smiling and very anxious to help you out the door, there's probably a reason behind it.

Of course we can train non-RTs to transport short term on non complex ventilators. That is part of my job descriiption now. Of course, it is much easier to train people if the have a solid education in the sciences. RNs usually understand the usually physiological reasons while the paramedic grasps the technological quicker on the learning curve. If a paramedic has all the prerequisites of A&P, Physics, math, patho and micro, grasping some basic concepts and skills will be relatively easy for them. If they don't have the education, then I have to resort to teaching "basic knobology" since time does not allow to also teach a lot of science. I've seen some of the ventilator "competencies" given by some Flight and CCT organizations. Luckily most transport times are short. There are a couple of popular flight forums on the web that make me cringe when they try to explain ventilators amongst themselves. Without the BASICS of ventilator theory, it's pretty much guessing. Sometimes it's guessing in the hospital, but RTs have more data to help them make an educated guess. On transport and in the ICU, RTs will have the experience of managing 6 ventilator patients every working day for a few years to rely on if no other equipment is available. When ventilators are utilized in 911 EMS, they are usually ventilating the dead as in a code situation. Of course, incorrect ventilation and oxygenation can make them deader. When preparing a patient for inter-facility transport, RTs will sometimes take their ICU vents out of their specialized modes and attempt to mimic a transport vent. Many will know how a patient will react to conventional ventilation by having used transport vents on the patient for inhospital transports such as CT, MRI or IR (interventional radiology). This may be one reason the settings on the ICU patient may appear out of the norm. There are probably about 10 different lung recruitment strategies used routinely by RT and Pulmonologists. It all depends on the patient, their technology and whatever adjunct therapies being utilized with mechanical ventilation such as proning, Flolan, Nitric Oxide or heliox. For transport, adjustments may have been made such as a higher tidal volume to compensate for the discontinuation of a therapy until they reach the next facility. RTs and Pulmonologists argue/discuss lung recruitment strategy constantly at educational seminars, in the ICUs, and on forums constantly. Big volume vs small volume, high PEEP or no PEEP, high flows or min. flows or auto flow. However, once committed to a plan of action, caution will have to be exercised to change aggressive ventilation strategies. The days of "knob turning" are expected to be in the past. Of course, I also have done my share of "knob turning" as an RT. But, in the hospital setting, I usually have plans A, B or C as backup. Lung decruitment effects will happen several hours post ventilator change. It many then take hours to recruit again and trauma to the lung tissue may occur due to reopening pressures. Capnography is just one tool utililized in fine tuning a ventilator. The vents in ICU now have sophisticated graphics packages that allow us to graphically visualize when we are meeting the patients flow demands, monitor opening pressure when using PEEP and avoid (or allow) over or under inflation. In RT school, there is now a class 1 semester long on just reading ventilator waveforms. The same with other Pulmonary Function analysis. For QA studies, we've downloaded some of the data from transport ventilators on one local Flight program RN/EMT-P. During one transport, the crew made 22 ventilator changes. Just like the hospital machines, transport machines store the data. If anythng happens, the ventilator will take the stand as a witness. One's charting will have to reflect these changes with some rationale for them. Several RTs have been EMT-Ps in their early life and that may be how they worked their way through RT school. The two professions are very complimentary to each other skill wise. However, I know what I can make as a FT flight Paramedic and what I can make as a FT flight RT that is hospital based. Big difference. Economics is one reason why Paramedics are utilized instead of RN/RN and RN/RT configurations. For HEMS, Florida still requires a paramedic on board, but no problem there since RNs and PAs can challenge the EMT-P(FL State test) and there are still many PDQ medic factories in FL. Of course, challenging a test doesn't substitute for some of the onscene specialized knowledge that a paramedic has. The skills can be fairly easily taught. RTs also would have a difficult time doing just transport and maintaining their specialized competencies. Even many CCT RNs still work actively in a Critical Care setting to stay current. RTs are also afforded extensive protocols and skills when they do function as transport RTs. North Carolina outlines this best in their State statutes. http://www.ncrcb.org/Declaratory%20Ruling%...d%2010-6-05.pdf And, in RT, we also have different abilities and different practices (like nursing) that vary from one geographic area to another and from hospital to hospital. However, RT has stepped up its national licensing minimum standards and there are plans for another step up in 5 years. Hopefully within 5 - 10 years, the RTs that don't want to keep up their education and raise the profession to the next level will be gone. Not everybody does critical care as an RT either. However, RT will still require the same minimumal educational standards for the floor therapists. An RN now would need 2 more years of college to cross train to be an RT. For RT to RN, about 1 year if sciences are current. Much of RTs' education is specialized in the ICU. RT, like nursing and other professions, you can make the most of the profession or you can coast for a paycheck. Which tranport team configuration works best? Sometimes it's not about the credentials but about the extra steps each individual on the team takes to excel at their profession. Specialty teams such as Neonatal and Pediatric are a whole different skill and knowledge area. That is where the Respiratory Therapist is most utilized in transport. Keeping the RT in the ICUs to run the various technology with different modalities that are not easily transportable (though not impossible) is the probably the most cost efficient and effective for the care of the adult patient. In summary, yes, professionals can be interchangeable in SKILLS and some knowledge in the transport setting. The knowledge makes the professionals unique. When establishing an ARDSnet ventilation protocol, PEEP may also have to be increased as per protocol to maintain oxygenation and adequate lung recruitment. In transport, this may not be hemodynamically feasible. For more reading on controversies in ventilation, specifically ARDSnet protocols as "One size does not fit all": http://www.ahrp.org/infomail/05/05/20.php http://www.thoracic.org/sections/career-de...-list/ards.html http://scalpel.stanford.edu/articles/protective%20vent.pdf

One I remember was the thread: What constitutes a save http://www.emtcity.com/phpBB2/viewtopic.ph...onstitutes+save

larocca465 Take Dustdevil's advice before moving on to ventilator theory. (See thread Vent questions/concerns). A solid foundation will make everything come together a little easier.

What is your background for education and certifications? Which ventilator are you using? Here's a starter for some basics. http://www.ccmtutorials.com/rs/index.htm There are many different transport ventilators (at least 12 popular ones come to my mind now) in the field from the very simple to the complex. Knowing your equipment VERY WELL with the help of the ventilator rep and/or a Respiratory Therapist would be a good start. Just getting the "just turn this knob and that knob" lesson from someone else who only has a tiny bit of knowledge doesn't always work if you don't understand why you're turning those knobs and the possible consequences. Integrating patient and machine can be difficult at times. That is why there are many different ICU machines and each have many different modes. Knowledge and hands on practice will ease your fears somewhat. Volunteer at a sub-acute facility for a couple shifts. (Sub-acute as in a ventilator nursing home) You'll learn airway maintenance and clearance as well as moving patients from point A to B like into the showers with their ventilators. Not the same as critical care but it will get you comfortable with several different portable ventilators and airways. In each facility, you'll find about 40 - 60 ventilator patients to check out. Each patient will have a different reason for being on the ventilator and can be high maintenance for the RT staff. There's a good possibility that these sub-acute patients will be your patients somewhere down the line also depending on the type of service you are with. Critical care experience will teach you more about the pharmacological and hemodynamic aspects of the ventilator patient. And don't forget the filters to protect the ventilator and yourself from exposure to the microbes of the pulmonary system.

If bradypnoea occurs before arrival at hospital, this is far more likely to be due to exhaustion than hypercapnia. The overall minute volume of the patient may drop, (respirations slow), as the patient's oxygenation needs are met. Ventilation is still a problem for them and thus the bronchodilators are now needed. Also in the home environment now you may start to see patients with O2/Helium mixtures, usually 30/70% which they use for exercise or walking longer distances. This is usually the same mixture used in the ER. If a respiratory arrest occurs suddenly, then it was probably likely to happen with or without oxygen. CO2 "narcosis" is what can knock out the ventilatory drive at high levels in combination with the underlying accute illness such as sepsis or PNA. The V/Q mismatch will have to be appreciated and dealt with. If these patients do end up on ventilators, they may be on much higher then 28% O2 and need a creative ventilator strategy to get them to a good baseline for weaning. Hypoxic and ventilatory drives exist. That is how WE exist. The ventilatory response of "normal" humans to isocapnic hypoxia is triphasic. First, there is a rapid increase in expired minute ventilation known as the acute hypoxic ventilatory response (AHVR), which occurs with a time constant in the order of seconds. Second, there is a fall in expired minute ventilation known variously as hypoxic ventilatory depression (HVD), hypoxic ventilatory decline, or ventilatory "roll-off" with a time constant in the order of minutes. Third, there is a progressive rise in expired minute ventilation with a time constant in the order of hours that appears to be related to ventilatory acclimatization to altitude. Any disease process can change a person's overall physiologic responses to hypoxia. Obesity, lung disease, pulmonary hypertension, lung and heart transplants, etc all may change the way a person "breathes" as their body changes to tolerate the disease. There are many other disease processes besides COPD that also retain CO2 either for metabolic or ventilatory reasons. Jeff Whitnack's summation of current studies on the hypoxic drive theory is an excellent read as well as the references he used. You can find this in an earlier post in this thread. Athletes train in altitudes to develop increased O2 carrying capacity. Hypoxia-induced secondary polycythemia is a major contributor to increased work capacity at altitude. COPD patients that live in a chronic "hypoxic" state may also develop polycythemia. This is the body's way of acclimating to chronic hypoxia. If the patient is polycythemic, then they may tolerate lower SpO2s easier. Not every one can live comfortably at 88% SpO2. Polycythemia creates many other medical problems though that are related to the increased chances of clotting. These patients are usually on supplemental O2 and blood thinners. If the person is still smoking then you will not be able to determine their "actual" oxygen saturation by SpO2. Carbon Monoxide may contribute 2 - 10% of the SpO2. However, NOT all COPD patients live at a hypoxic level. Many athmatics are classified as COPD but have normal PaO2. COPD is a broad term. There have been hundreds of studies done and are being done on all the the different diseases and their reponses to O2 and CO2. Everybody arrives at a slightly different conclusion then someone else. Everyone uses a different group of human specimens and different methodologies. Humans are hard to study because they usually don't have just one pure disease process. It would be hard to make a general "text book" statement for treatment that fits each and every one even with the same "similar" disorders or disease processes. Understanding the diseases processes and human physiology allows the practitioner the opportunity to use clinical judgement and sometimes common sense in treating the patient. And, there are always protocols to guide the medical professionals until a definitive diagnosis or treatment plan is made. ( Or just follow tniuqs suggestions).

We are judging other professionals now based on the scenario given to us by a patient who experienced a traumatic event. This is not an objective scenario. No disrespect to broken, but we probably do not have all of the facts. broken's anger is pretty evident in his posts. If anybody has ever worked in a hospital, patients, especially those that have been through some traumatic event, may remember events differently every time they talk to somebody. This can be for a multitude of reasons ranging from the trauma itself to medications given later or to some emotional issues. They may hear something said at scene and hang on to it. The more they think about it while trying to justify what is happening to them, the more skewed objective thinking can become. And, you will get the "professionals" feeding them their opinions. At least for the majority of this thread, the bashing or firemonkey language was kept at a minimum. After reading through some of the bashing posts lately, this would be the perfect place to come if you wanted people to critique poor EMT and Paramedic service. Why are we so quick to find fault within our own profession before we actually know all the facts? broken mentioned he wanted these guys fired. I do hope employers, judges and juries are more objective then some of the opinionated views expressed here on this forum out of deep seated issues of our own. I hope some of you don't make it a practice to engage in bashing other healthcare workers or hospitals when you are with your patients on the ambulances or in the ER. It is enough that they can read our bashing comments on a public forum about each other. broken has now identified himself as a patient who was serviced by EMS in some capacity. We should treat him respectfully and keep any medical advice or opinion at a professional level.

I use large Kentucky Fried Chicken buckets to catch the puke, then lid and bag it (or the homeless get "curious" outside the ER). Vicks to dull the smell. Put the head sets on so I don't hear the retching. The retching noise gets me more then the actual vomit. Hate GI bleeds.

There are actually over 300 A.S. Paramedic programs in the U.S. Many were started in the 1970s. Unfortunately, they got lax and offered the core as a certificate. Thus, most missed the English, Math and Science classes. The skills "extended" to us in the 1960s by physicians actually were built on the theory that a few physicians could teach a few lifesaving skills to anyone. At this time the models were in the inner cities starting with unskilled and uneducated labor. Miami used the FD in 1966 to show that firefighters could jump start a heart with electricity. The 1970s were actually pretty good. We had our degree programs which even nursing was still trying to establish as a standard. We were actually ahead of many allied health careers in education. The phrase "physician extender" was given to us but now doesn't hold any legal bearing and is misused or over unused in our profession. Physician's Assistants and NPs are true legal physician extenders having earned this privilege through many education and clinic hours. Both PA and NP are now making the Masters degree their minimum. When I hear people say there is not a need for a higher level math class, it is easy to say they have not been educated in hemodynamics or respiratory dynamics. I sat through a Flight medicine class with about 25 paramedics. Most of the paramedics were certificate trained so we had to spend a day reviewing simple gas and liquid principles, A & P and math before we could even get in to the flight med "basics". A few microbiology lectures and one might also understand how to clean their own hands and equipment better.

It has be an event that warrants litigation. My area has several government ALS services so they fall into whole other set of processes for fact finding before the courts are petitioned for the actual lawsuit to be allowed into the system. This is not to say the patient is SOL nor the paramedic is off the hook. It doesn't have as much to do with "proper minimum standard" as following the minimum standard. If the device is in the protocols, then that's the device to use if there are no other options. For my area, it is the backup device for Paramedics. If the ETT was not ATTEMPTED, we want to know why. How was the paramedic trained on the device? If there is not record of competency maintained by the employer on this employee's use of this device, why? What role did the Medical Director have in training the paramedic on the use and protocols? How many times had the paramedic used this device in the field? If competency and records are maintained and the paramedic has a valid reason for not bringing out the laryngoscope and ETT, then the paramedic may have no problem in court. Complications happen. However, since the paramedic has options, he/she may be held to a higher standard. It is unfortunate in some services, when a paramedic screws up with the CombiTube, the EMT-B loses access to the skill and not the EMT-P.

I like the LMA personally but I also use it frequently in the hospital for conscious sedation. I think it is a viable option for ALS though it may be more difficult to maintain placement while moving. Due to cost, not all ALS providers are aware of the many versions of the LMA and the potential benefits. The King is like a remake of the old EOA. I do like some of the options on it and the fact that you are aiming for the esophagus. Probably for BLS, this would be my choice.

I don't particularly like the CombiTube. However, if properly trained and competency is maintained, it's another skill. However, I do have a problem with EMT-Ps using it due to laziness or not keeping their intubation skills at a competent level. This device makes me a little extra money when the attorneys need an "expert". It also drags me and the ER doctor into the deposition room to give a statement when "CombiTube goes very wrong" in the field and is brought into the hospital I'm working at. Misplaced ETTs are one thing. This thing can tear up the esophagus and totally relocate the vocal cords to another zip code if used by idiots.

George Washington University http://www.gwumc.edu/healthsci/programs/ems_bs/ All distance programs at GWU http://www.gwumc.edu/smhs/students/prospect.htm You can also read Mike Ward's comments on education. http://forums.firehouse.com/showthread.php?t=91303 His titles include: Michael J. Ward Assistant Professor of Emergency Medicine The George Washington University http://home.gwu.edu/~mikeward/ Chairperson National EMS Management Curriculum committee http://home.gwu.edu/~mikeward/FESHE_EMS.html

I honestly don't know what you are looking for then. I provided links to almost a hundred pieces of MEDICAL research on positive pressure including the Demand Valve and you call them "anecdotes"? Either you are not familiar with reading medical research or like Dust said "you've made up your mind already". All you had to do is go to any medical search engine like Medscape or PubMed for the info. The educational links I gave you should give you some basics with even more links. Medical research is not going to tell you to buy this or buy that. It will enable you to be a more informed consumer. I think you expected everyone to agree with you. And yes, maybe you should listen to some of the elders who have "been there, done that".

At least the money is going for a good thing. There doesn't seem to be any restriction for only EMS personnel using it. My gray hair condo dwelling neighbors would love this. It's just another plate to raise money like "Save the Whale, Manatee or whatever" or Florida's Challenger plate.

I remember those. It was like a BVM with power assist. It delivered a seriously big tidal volume effortlessly. Too effortlessly. One could get carried away and hyperventilate a patient down to a PaCO2 of 1 and a pH of 8.0.

Luckily, you are in Florida. The mean age of many parts of Florida is 85. They make up the majority the the tax payers and voters. Public Services such as EMS and Fire will be okay. One Sheriff's service in Florida is cutting out the Police Officers at schools to pay for the trauma helicopter staff. So, just make sure you've settled in a part of Florida that is considered a retirement area and you'll be set for job security. Many departments have phantom positions on the books that can give the illusion of positions being cut when they actually weren't there. These can also come as positions that have not been filled or posted even though the money has been available. Some companies view this as sort of a "saving for hard times" plan. As for as insurance and cost of living, that's another story. I've actually found the San Francisco Bay area to be reasonable for cost of living when compared to some areas of Florida. Earthquake insurance is cheap compared to all of the insurance policies needed in Florida. The wages are also almost triple. Granted you'll get more square footage for a home in Florida than SF for the same price. Insurance of any type is expensive in Florida, that is if you can even get insurance. Florida has relied on the Sunshine Tax on tourist industies to keep our income from being taxed. The hurricanes have put a strain on this revenue. Florida does offer some tax breaks though. They repealed the intangible tax effective this year. http://www.bankrate.com/yho/itax/edit/stat...ate_tax_Fla.asp To live in Florida, there'll be a price to pay with your low income, rising costs of housing, expensive and difficult to get insurance, possibility of losing everything in a hurricane and now tornados (a rarity until 10 years ago). So, welcome to Paradise!

There are mountains of research on this already. More mountains being generated every day in research hospitals on the subject. PAP - Positive Airway Pressure is part of the CPAP - Continuous PAP. You have to grasp an understanding of the specific physics of gas properties or basic flow principles. Taking a small phrase out of context can skew the whole purpose of these concepts. The demand valve has only specific uses in EMS. The BVM can be the superior tool depending on the skill of the practitioner. But, you definitely don't want the unskilled or poorly trained using a Demand Valve. BVM is the better choice. Not saying that you can't still have a couple of Demand Valves around.

The first article was an edited version on JEMS of the original article in the SacBee. EmsResponder also ran the full article. I like to link to JEMS because they keep their links active for a long time. Newspapers tend to archive their news and the links don't work after a couple days. I may have to be more careful that I get the full story in the future from the original source. Not condemning everyone that commits a crime. I do think we are too easy on some violent criminals and child molesters. These are not white collar paper crimes. Let some first time offenders of petty theft walk. Keep perverts who prey on children locked up regardless of their profession. I already read the "oh poor guy they're picking on him because he's an EMT and the SacBee is out to get him" on another forum. Please! This is not about political/media bashing. This is a guy that the EMS system has allowed to work because one county doesn't know what the other county is doing. This is about a guy with a conviction and several arrests involving moral turpitude . Yeah cut him some slack if he only had one brush with the law, but.... He'll be okay at the desk job.

Actually the history is not "allegation". He does have a conviction on his record. In 2001, there is conviction for contributing to the delinquency of a minor. I'm all for the "innocent until proven guilty". But, when you have very close public contact and numerous arrests involving violence or acts of child abuse on your record, I think somebody in EMS should notice before the MEDIA has to dig it up. This guy would have continued to work with the public if a newspaper hadn't asked why. He's union, he could still be suspended with pay pending outcome of the charges. One can also plea bargain on some arrests such as spouse or even child beating and get off with an anger management class in this country. The San Francisco Fire Department says it cannot take action because Gutierrez's certification came from another agency and because the charges against him involve off-duty activities. http://www.sacbee.com/797/story/195436.html http://www.emsresponder.com/online/article...p;siteSection=1

I think this guy is another reason why California needs to get control over their oversight of disciplinary actions. There are alot of counties to hide and work in California. He just has to find another county with lax standards and apply for his county issued EMT certification there. If he was in any other profession (RN, RT), his license would have been at minimum suspended throughout the whole state. http://www.jems.com/news/288995/ Bay Area EMT accused of crimes is sidelined By Andrew McIntosh The Sacramento Bee Copyright 2007 McClatchy Newspapers, Inc. All Rights Reserved FAIRFIELD, Calif. — Solano County and San Francisco fire department officials on Thursday took separate steps to sideline a Northern California emergency medical technician who had remained on the job as an EMT-firefighter, despite his history of stalking women and a string of arrests for child sexual abuse, indecent exposure, spousal battery and vandalism. San Francisco Fire Department Chief Joanne Hayes-White reassigned Timothy Lee Gutierrez, 39, of Fairfield, to a desk job so he will have no contact with the public. Solano County officials have asked Gutierrez to voluntarily surrender his county-issued EMT certification card by noon Friday or they will suspend it themselves, citing a pattern of allegations of disturbing off-duty sexual and other behavior that are incompatible with his status as an emergency first responder. More at http://www.jems.com/news/288995/

Actually those numbers do pose a lot of work of breathing. Modern ventilators have gone to flow triggering instead of pressure triggering. For your continued reading; http://www.umdnj.edu/idsweb/idst7100/annot...ib_example1.pdf I have used the Oxyalator and found it relatively effective in a primitive sense. Would I want to put a patient with a severe pulmonary problem on it for any length of time? Probably not unless they were sedated and I knew what I could get away with in terms of oxygenation and ventilation. This would include ABGs, CXR and waveform analysis of pressure, flow and volume. As a back up for a non-pulmonary patient, yes this is a decent "ventilator". This device is included in a generation of "safer" demand valves in that they can be regulated for pressure and volume. http://www.lifesavingsystemsinc.com/em100.htm Ventilation and Oxygenation being key principles when choosing the right device for the job. The straight demand valve is not CPAP. Review the gas flow principles of using resistances and retards that make use of flow. Now for an article on some history of the Demand Valve, IPPB and modern CPAP. http://ajrccm.atsjournals.org/cgi/reprint/163/2/540.pdf

On another thread, OXY-PEEP for CPAP?, you'll find an explanation of CPAP and PEEP. There are also some links for more reference material. Now, let us remember the Elder Valve briefly ( a history lesson for the youngsters) and then put it back to rest since we now have safer forms of ventilation on the market. The Elder Valve via mask; high flows at high pressures = gastric distention, turbulent flow, ineffective ventilation. Via tube; overinflation, pneumothorax. For Pulmonary Edema: BVM or a portable ventilator for ventilation with PEEP or a CPAP/BIPAP system (can also be some ventilators for effective NIV). On the Demand Valve, if the patient can trigger the demand valve, great for ventilatory assist. But by mask that requires a tight seal so the patient can effectively generate greater than -20 cm H20 pressure without a seal leak. Not as easy as it sounds even at -20 cm H2O. However, if you're the one pushing the button and your counting is bad..... Dr. Norman McSwain probably got the idea for the McSwain Dart after the Elder Valve gained popularity in the 70s. Evaluation of the Elder Demand Valve Resuscitator for use by First Aid Personnel. Pearson JW, Redding JS Anesthesiology 1967 Vol 28 Pages 623-624 OF HISTORICAL INTEREST The authors begin by noting that mechanical resuscitators have often been too complicated to be consistently reliable in the hands of first aid personnel. A tight mask fit is difficult to achieve and a diversity of control knobs gives rise to confusion and ineffective resuscitation. The Elder Demand Valve appears to overcome most of these objections. A maximum flow rate of 150 lpm can be delivered. This is claimed to be enough flow to ventilate in spite of major mask leaks. Flow ceases when a pressure of about 54 centimeters of water is attained, even if the button is still depressed. 10 full-time personnel of the ambulance service at Baltimore County Fire Bureau were evaluated, comparing values for mouth-to-mouth, bag-valve-mask and Elder Valve ventilation. The values using mouth-to-mouth did not differ significantly from those obtained with the Elder Valve. The same values with the bag-valve-mask were significantly less (P<0.05) than those obtained by the other two methods. The authors conclude that the advantages of the Elder Valve over previously available equipment include simplicity, delivery of 100% oxygen, ability to use two hands to maintain a mask fit, high flow rate allowing adequate ventilation in spite of mask leaks, and avoidance of personal contact with the victim. Disadvantages are the lack of ready availability and dependence on compressed oxygen as a power source.