VentMedic

More studies will have to be done before accepted to the mainstream in the US. There are studies currently being conducted to reduce hyperinflation quickly in the ED before the code situation including ventilators with an active exhalation instead of passive, heliox and vests. This site has some potential studies that has been attempting to gain more interest in the area. http://www.americanheart.org/downloadable/...8Nov04Final.pdf

This guy also most likely had complications from his medical history of asthma, cardiomyopathy and HTN such as pulmonary hypertension. Also, how compliant he was and/or how far behind he had gotten himself before you saw him can be a factor. Rarely do you have a pure asthmatic especially in the middle-aged adult. All the other systems that have be affected by "life" and the maintenance meds for COPD will start to show their break downs. CPAP would not have been a wise choice in this type of patient...profound hypoxia with combativeness and air-trapping. Even with intubation, you would have had an airway but ventilating would have been difficult even with a bag. Bagging in a very high dose of albuterol neb (15 to 30 mg of 0.5%) might have helped via mask or tube if given the chance for a quieter moment. It is doubtful albuterol alone would have made a difference immediately. Even in cardiac arrest, the airways may not relax for ventilaton/oxygenation. In the ER, heliox(70/30) via a Jackson-Reese system with extra O2 bled in if necessary and high dose albuterol (via mask until intubated) might be attempted. Then once on a vent with heliox and a lot of knobology to get the lungs to tolerate the machinery, hopefully with sedation he would settle. Unfortunately, neuromuscular blockers and solumedrol don't get along and can result in permanent paralysis. If pulmonary hypertension is also coming into play, nitric oxide or Flolan may have to be utilized somewhere down the road after the airways are open enough to receive these meds. If this pt made it to the ER, it might have taken days for him to open up and a couple weeks on a ventilator. If there was another disease process that brought about this episode, it would have to be resolved. This would not be an easy patient even with the all the technology and drugs available.

Hospital Based; Pros: Health insurance and retirement plans may be better with the hospital. Education money allowance for taking college classes. Continuing education for licensure requirements and job enrichment. Opportunities to do skills competencies in the hospital's ED, OR and ICU. Opportunity to see a variety of patients, procedures and attend rounds during down time. Opportunity to follow up on the patient easier. Opportunities to learn from the physicians and other health care professionals. CONS: Some may think the mandatory skills competencies and continuing education are a waste of time. Closer supervision and Quality Assurance/Control monitoring may feel invasive to a former street paramedic. May be asked to assist in other areas of the hospital during down time. (can also be a pro)

Disclaimer; I don't advise "alternative" treatments in repiratory problems in place of accepted medical practices. That being said... In the hospital we will switch to heated water humidity systems both on the ventilator and face/trach masks if we are having difficulty bronchodilating or secretion mobilization.

Caffeine is part of the Xanthine family same as theophylline. Patients going for Pulmonary Function Tests are advised to hold all caffeine products 12 hours prior to testing. It does produce some bronchodilation and skew percentage results when testing albuterol. I have seen the bronchodilation effects of expresso in the PFT lab. It was impressive. http://content.nejm.org/cgi/content/abstract/310/12/743 In rural regions, physicians have long advised parents to give their child black coffee or tea when experiencing difficulty breathing while driving to the hospital. However, I would rather have an inhaler or nebulized Albuterol for a more direct application if given a choice.

Actually South Florida's EMS roots have their beginnings in Public Safety departments. The Police Officer and Paramedic were the same. Before County wide EMS systems and AMR, there were local FD and volunteer ambulances. Atlantic Ambulance was the paid service for much of Palm Beach and Broward Counties. This era ended for the most part in the late 1980s with the population growth. We were also paid by the number of calls, cash collections and by the call if as a paramedic you were needed on an ALS inter hospital run. Palm Springs, Coral Springs, Coconut Creek, Green Acres, North Palm Beach, Lake Park...any city that still has Public Safety in their title probably had dual trained P.O./EMT-P in their patrol cars. I have heard of a couple small towns in rural Florida that still have the public safety concept.

See my previous post. You can also find the info under Florida's Physician MQA license (or lack of) board.

It is actually just a relatively small extra fee to have an internet search done on an individual when an employment check is done. I had a check run by an employer last year when I traveled as a Respiratory Therapist. The forums and listserves that showed up were the sites that I use my true name . On some, my true name appears because the sign on is my license or professional membership number. Some of these sites are supposed to be closed and protected. Fortunately it actually helped because they were all professional RT forums and looked like I was very involved in the profession. Just have to be very careful now.

www.streetdrugs.org http://www.streetdrugs.org/pdf/street_terms.pdf

Possibly, but if treating this pt at the EMT-B level, I would rather error on the side of caution until I am in the hospital setting. Again when you make a diagnosis without all the diagnostic tools or much higher initials behind your name, it comes to educated guessing.

You do live up to your sign on name

Okay, after re-reading the wording of the instructor, I'm taking a new angle. The question in perspective: "What is his/her condition and what is your treatment?" I would take this to be a chance for the EMT-B to identify different levels of urgency and plan supportive care/treatment and/or need to have ALS if long transport or immediately nearby. A lot of info but do we have our ABCs intact and maintainable? Is there a chance of immediate deterioration based on your assessment? JasonA, I like your concern for oxygenation in all of your treatments. Case 3; Epiglottitis can be caused by Haemophilus influenzae type B. This is also contagious and no picnic for an adult either. Luckily there is the Hib vaccine. Keep this kid "content" during transport by all means. Blowby O2 will be fine if the child shows signs of being annoyed by the looks of a mask.

Case 1; I would put more to GI causes. Noc productive cough along with the tea and choc milk could be GERD. Bibasilar rales; chronic aspiration at night. Abdominal pain; bowel obstruction, bladder infection, renal disease (also leads to HTN), acid-base problem and/or electrolyte problems for confusion, cyanosis; pulmonary hypertension or any assortment of V/Q mismatching. But then, I'm going treat the immediate needs first and see how long it takes the hospital doctors to come up with one or more diagnosis.

It would be so nice if we could categorize all the ailments in the world into the disease processes that are taught in Paramedic school. Without further diagnostic procedures, it can end up being guess work at best. Trying to "name that disease" can distract one from observing signs and symptoms that may be relevant but doesn't fit with your diagnosis.

A little tracheal suctioning preferably NT (with an NPT in place if available for comfort) after hyperoxygenating with the NRBM would determine the quality of secretions as for as pulmonary edema or aspiration in some cases. It would also clear the airway somewhat to hear breath sounds better. All gurgling, rhonchi and crackles sound misleading until you take out the excess noise. It may not be pneumonia at this point in time but will be soon. Pts with difficulty moving or nursing home pts are usually positioned side to side. Thus aspiration tend toward LLL or RML. Supine pts aspirate toward upper lobes. If pt aspirates while chest is vertical (while eating) then RLL. LLL is also more likely to have atelectasis making it very prone to pneumonia. Pts who are losing control of their airway and swallow ability will have some combination of all lobes involved. CPAP in a pt that has lost muscle tone in the oropharynx is not recommended. The continuous positive pressure will lead to further aspiration of oral secretions and possible occlusion of the airway. The pt should still have some control over their own airway for safe usage of CPAP/BIPAP. A little BLS before ALS.

You'll find working in the ER an excellent experience and a chance to get a broader picture of patient care. The philosophy and direction of each ER will vary with the Medical Director of the ER. Also, every different healthcare professional(Lab, Radiology, Respiratory, ICU staff, etc) have their own Medical Director to establish their protocols. Medical Directors have meetings to keep the protocols and job duties of each professional in check so the SYSTEM flows. Learning the SYSTEM offers you the knowledge to make a decision about your future goals or education plans. The hospital setting will give you the opportunity to ask questions and explore your future options. You as an EMT and as many EMT-Ps do, are working under another job title with another set of rules and regulations that are recognized by the hospital and State that you are in. Since education and experience varies so much for EMTs and Paramedics, this is a way for the hospital to establish a minimum of skills that they want their employees to have and train accordingly with some flexibility within State guidelines. This may give you the opportunity to do some things that you can not do as an EMT-B such a phlebotomy. You will also find many ER techs that do not have EMT certifications or Paramedic licenses but have been trained internally by the hospital. However, YOU may also gain additional certifications to compliment your EMT making you more employable in many different healthcare settings (OR or Ortho tech). The hospital will also assist you in your education. Many systems are now set up where you can go to school during your scheduled days and get paid. Some hospitals have their own affiliation/schools for training as nurses, Radiology, Nuclear med techs, etc. Many EMTs just starting out just see two career options, nursing and paramedic. There are many great careers out there in the medical profession. As an ER Tech, you will learn a wide range of skills. Going back to school for additional college courses will give you the knowledge to compliment these skills. This is where Paramedics and RNs appear similiar but are different. The RNs, whether it is in the class room or on the job, have learned different protocols and "prep work" to get the pt moving along into the next level of care in the hospital. They are constantly checking labs prior to different tests. Ex. BUN is necessary before CT with contrast. The Rad. Technologist will be quite upset if an opening is made in a busy CT scan room and the pt has not been cleared. The pt and doc will not be happy either if the test is delayed because of a nursing "oversight". All will be upset and pt possibly harmed if contrast is given to a pt with a very high BUN or history of lupus. This is just one of many examples that nurses are checking and "responsible" for although the doctor is ultimately responsible but depends on everyone to keep him/her informed. When the system doesn't flow due to a medical error or lack of training; big traffic jam and lots of unhappy people. Respiratory Therapists start thinking about VAP (vent associated PNA) and ARDSnet before the pt is intubated. If the pt was intubated in the field, they have another set of concerns and protocols. Many RT departments are involved in a nationwide data gathering for research for both VAP and ARDS. All healthcare professionals' (including yours) skills are closely monitored in the hospital settings. Different accrediting agencies require proficiency data to be constantly updated. Various re-embursement agencies will be monitoring that procedures are done within their guidelines. Many underlying factors are occurring behind the scenes constantly that are not always obvious to a causal observer. Paramedics have extensive skills but many lack the knowledge for long term maintenance and care of the pt. This comes through more education and learning the things that some paramedics perceive as "BS" or "who cares about that" extra knowledge. ERs are also many times acting med-surg wards or extended ICUs when placement is in a holding pattern waiting for a bed. If "service" has been transferred to another physician like the Intensivist, the ER RN must assume the responsibilites now of the ICU protocols as well as the ER protocols. Lots of orders come with the ICU protocols and even the med-surg pt. New orders and new set of responsibilities to be followed. The ER physician will no longer be involved in the care of that patient unless they code. On the ambulance, it's you, your partner and the pt. In the hospital, you will learn to coordinate your knowledge and skills with many, many healthcare professionals. Teamwork is tops. Flow with the system to get all the training and knowledge possible. Take advantage of every opportunity offered if you enjoy the medical profession.

Nicely said Ridryder and you are right this is cheap. My neighbors' 9 y/o son fell skate boarding. A Pedi trauma alert was issued not by the medics but by the hospital(level II) staff. Reason for the alert; the child realized he might be in trouble and changed his story a little..."memory loss". By the end of the day the kid had a $23,000 band-aid. Of course better safe than sorry later, but... The hospitals themselves are now calling the trauma alerts more not necessarily EMS. Are they seeing every MVC as a potential insured customer? Trauma alert charge...entry fee into the ER. This gives you an ER doc, anesthesiologist, surgeon, at least 2 RNs, RT, Rad. Tech etc. They disappear usually within 5 minutes of pt arrival if they see there is no need for their services. The trauma charge remains. I agree a more careful use of assessment, old habits and resources could be in order prior to activation. These players will still be inhouse with their beepers on if this is an accredited trauma center. Unfortunately our medical insurance policies aren't that great in covering everything. A lot of policies are now 80/20. 20% of $100,000 is still a lot. The care of a preemie will hit $1,000,000 in just a few months. Many insurance policies have that as their cap. The parents are forced into taking state and federal assistance for the baby. Plus, they too may not be covered by insurance themselves once the cap is reached. This isn't just about the uninsured junkie, but also anyone who might be changing jobs especially in healthcare and think they can get by 30 - 90 days without coverage. The junkie as well as the knife and gun clubs are results of deeper society and political issues that have evolved over a long period of time. It was thought that if we don't mention them in the political arena they would go away just like the healthcare issues. A little "band-aid" here and there with a little talk and we're good to go until another election year. I'm not picking on any one political person, but many. I also know an RN who was a traveler. He was between assignments and was going with another company. While flying to his next assignment, he developed a pulm emboli. Eleven days in the hospital and well over $100,000 in med bills. He negotiated the hospital to $95,000 which is a bargain. Also, if you vacation in remote areas like the Florida Keys, there are hospitals but if you want transferred back to the mainland, keep an extra $7000 available on your credit card. Most insurances will not cover an inter-hospital transport(ground or helicopter) if the medical services aren't out of the scope of that hospital. If it is not trauma criteria, EMTALA guidelines will be strict. If it is your request, you'll be footing the bill. And yes, people do use the ER instead of a clinic or doctor's ofc. But, the ERs keep advertising PDQ service...30 minutes or less. But, if you know you need a CT scan and if you say the right words in the ER, persistent head pain, blurred vision, etc...you'll get the CT that you might otherwise not get without insurance. Even women with lumps in their breasts may have to wait months for an appointment to get a mammogram through a clinic. They too may have to resort to getting into the hospital system by way of the ER to get treatment earlier. Don't have any answers, just opinions....

Saw this article in San Francisco Chronicle. If the poor guy had just crashed a couple more miles down the road. http://sfgate.com/cgi-bin/article.cgi?f=/c...UG1LOTC6T75.DTL Uninsured patient billed more than $12,000 for broken rib David Lazarus Friday, March 30, 2007 There are 47 million people in this country without health insurance. Richmond resident Joey Palmer is one of them. He learned how costly this can be after fracturing a rib in a relatively minor motorcycle accident and subsequently being hit with a bill for more than $12,000 from San Francisco General Hospital. "There's no way I could pay something like that," Palmer, 32, told me. "I'm not a bum, but I'm not making a lot of money right now. How is anyone supposed to pay a bill like that?" Iman Nazeeri-Simmons, director of administrative operations at San Francisco General, said she sympathizes with Palmer's situation. "It's not us," she said. "It's the whole system, and the system is broken. We need to look closely at making changes and at how we can deliver care in a rational way." Palmer's story illustrates the broader problem of runaway health care costs in the United States and a system that leaves millions of Americans to fend for themselves. It also underlines the importance of universal coverage that guarantees affordable health care to anyone, anywhere -- a goal that's become a central issue in California and in the current presidential campaign. "We are the only developed country that doesn't cover all its people," said Stan Dorn, a senior research associate at the nonpartisan Urban Institute. "We also spend a lot more than the rest of the developed world." The United States spent an average of $6,102 per person on health care in 2004 (the latest year for which figures are available), according to the Organization for Economic Cooperation and Development. Canada spent $3,165 per person, France $3,159, Australia $3,120 and Britain a mere $2,508. At the same time, life expectancy in the United States was lower than in each of these other countries and infant mortality was higher. But those are just statistics. When you talk about America's health care crisis, you're really talking about people. And Palmer's experience speaks volumes. He was riding his motorcycle through San Francisco's Presidio on Sept. 19. It was late afternoon. Palmer was heading toward the Golden Gate Bridge and then home to Richmond. Suddenly his brakes locked, sending the motorcycle into a slide. Palmer slammed into a guardrail. He was pretty shaken up, but he could tell he wasn't badly hurt. A passer-by saw the accident and called for help. An ambulance arrived within minutes. Palmer said he told the paramedics that his ribs felt banged up, possibly broken, but that he was basically OK. He said he preferred to be treated in Contra Costa County, where he lives and would probably qualify for reduced hospital rates because of his income level. Palmer is a woodworker who specializes in the decorative touches on wealthy people's yachts. He said he made only about $7,500 last year, getting by primarily with the assistance of relatives. Palmer said the paramedics were concerned that he may have sustained internal injuries and insisted that he be treated immediately at a hospital. So he was driven by ambulance to San Francisco General, the only trauma center in the city. Palmer got lucky here. The ambulance was from the Presidio Fire Department, which is run by the federal government and doesn't charge for ambulance service. Had the trip been made by a private ambulance company, it likely would have cost Palmer between $700 and $1,000. On the other hand, what Palmer didn't know is that as soon as the paramedics radioed ahead to say they were bringing in an accident victim, San Francisco General, as per the hospital's procedures, issued a trauma alert to its staff. Basically, that means a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital. The actual hospital experience was, to put it mildly, a nightmare. After blood was drawn for a variety of tests (the cheapest of which cost $44 and the priciest $107), some X-rays were taken ($423). Then, Palmer said, he was left in a room ($2,070) with a junkie "who was having a real bad trip." He asked to be moved elsewhere but was told no other rooms were available. So Palmer ended up on a gurney in the hallway. And he waited there for five hours. Palmer's bill indicates that he was twice given Vicodin ($22) to ease his pain during this interval, but he insists he took no medication. "I finally saw someone and asked if I could check myself out," he said. "The guy said they were still waiting for the results of my CT scans. I said that I hadn't had any CT scans. It turns out they forgot to put me on the list." So Palmer was put on the list for CT scans. And he waited another hour. At last the CT scans were taken ($3,334) and then another round of X-rays because, Palmer said, the first batch apparently hadn't been done correctly. "Finally a doctor came to me -- it's now almost 2 in the morning -- and said, yes, I had a fractured rib and some bruised muscles," Palmer recalled. "That was that. End of conversation." Shortly afterward, he said, a clerical staffer approached with discharge papers for Palmer to sign. "She asked how I intended to pay for everything," Palmer said. "I told her I didn't have any insurance. She looked at me and then asked if there was anyone I could sue." Several weeks later, he received a bill for $11,082 in hospital charges and a separate bill for $922 in doctors' fees. Palmer's hospital visit was expensive and time consuming, but it wasn't unique. Many people could cite similar (and similarly costly) experiences in receiving "emergency" medical care at U.S. facilities. "We view health care as a chance to make as much money as you can," said Dorn at the Urban Institute. "The goal of health care should be improving people's health." San Francisco General's Nazeeri-Simmons was unable to comment on Palmer's lengthy hospital stay because she didn't have access to his medical records. But with Palmer's permission, she was able to examine his billing file. "These charges are comparable to the entire health care market," Nazeeri-Simmons said. "They aren't out of line with what other hospitals are charging. They're actually lower." Not always. Trauma activation charges, for example, typically range from about $2,000 at some Bay Area hospitals to $7,000. At Marin General Hospital, the charge can run as high as $12,636. Nazeeri-Simmons said a sliding scale is offered for low-income San Francisco residents. But Palmer, as a resident of Contra Costa County, wasn't eligible for the program. "If you were uninsured and making less than $10,000, you would pay nothing," Nazeeri-Simmons said. "But that's only if you live in the City and County of San Francisco." After receiving his bill, Palmer complained to the hospital about how much he was being charged. Nazeeri-Simmons acknowledged that a second look was given to the bill at Palmer's request "and we decided to eliminate the trauma activation charge." That reduced the amount due by $4,659. But Palmer still owes more than $7,000 for an eight-hour hospital visit that involved, by his estimate, only about 15 minutes of actual care. "It's unfortunate that he's in the situation he's in," Nazeeri-Simmons said. "But what is an individual hospital to do? Are we supposed to eat the costs?" She said a government-run program similar to systems in place in all other developed democracies would almost certainly keep costs in check while ensuring that everyone has access to treatment (without being impoverished in the process). "Universal coverage would mean that a Joey Palmer doesn't get left out in the cold just because he was in the wrong county," Nazeeri-Simmons said. For his part, Palmer said he'll try to pay off his hospital bill as best he can. And then, if he can swing it, he'll leave the country. He's thinking seriously about moving to France. "If you get sick over there," Palmer mused, "you can go to any hospital and it won't cost a fortune." He said that with a tone of quiet disbelief.

You are right tniuqs about the Paramedic's "save" that may have initiated this circle of life. Yes, some pts may advance to just a trach unit, then to a SNF and then to a nursing home. If the pt is mentally intact and has good family support they may go home with their ventilator. I would say that the way the pt responds to his new accessories would determine the quality of the save. If it gives the pt more time to say good bye or get his affairs in order, even better. That in itself can be worth it. Of course, there are still all the patients back on the "farm". No disrepect intended to these individuals who now totally dependent on life support. It is also interesting as to how differently some Paramedics/EMTs respond when they are called to transport a trach pt to a SNF. They're not always thinking this was someone's "save" but rather "nursing home call". Just flipping the coin back at ya tniuqs Thanks for the good post for more thought

I remember my first "save" many years ago. Through the years and countless bodies later, I have begun to look at "save" from a different angle. This also comes after working at an RT in "vent farms" which can range in size from 20 pt to 200 beds. Chronic ventilator pts literally fill hospitals that were once acute care but closed and sold to large Vent rehab companies. Unfortunately most pts are not to be rehabilitated. These places can make the old movie "COMA" look like a Disney G-rated flick. And then we have the ones that are now all pediatric...includes some of those "NEAR-drownings". I only call something NEAR when the child spits out the water and jumps back into the pool. And of course after countless codes where we went against the patient's wishes to appease the family. Heaven forbid on those terminally ill pts we would be successful enough to keep them alive on the ventilator for another day. I had one young medic tell me if it was more than 24 hours post code, it was a "save" according to the rules. I spared his life at that moment and that too should be considered a "save". I now think of a save when I get a young couple to quit smoking for the sake of their new born preemie. Or, turning around an old COPDer by pulm rehab before they literally buy a vent. Or, get the pt to the cath lab before more myocardium is damaged. Or, the CVA pt treatment quick enough to have little or no permanent damage. Or, see someone come back from a traumatic brain injury. Or see someone who has lost some body part and still achieves their dream. Or, see a person whose severed hand is reattached successfully with >90% function return. No matter how good our medicine is both outside and inside of the hospital, the outcome is still unpredictable and probably not always ours to question why....

Twelve saves may sound impressive on the EMS chats. But, those calls may happen 2 out of a 100 if that in some areas. As an employer, I would want to know how you can handle yourself on the the other 98 calls. The majority of EMS work will not be all blood and glory. Your presentation to your future employer will be what he/she will expect you to be as you represent the company to the public. Somebody mentioned Florida "God's waiting room". (My mother is in that group at 91 - Boynton Beach) Truly lots of codes, but also a lot of hand holding and/or comforting words for the grandmother with the hip fx. Can you talk to people in complete sentences and make eye contact? Are you able to communicate effectively enough to talk anybody through a procedure (splinting, extrication) effectively and assuringly? Can I see your confidence by your body posture? Or, will you give the impression of the grunt, slouch and frown group that hates running any call that isn't filled with the excitement of a "save"?

Good points EmergencyMedicalTigger. I've also had students act like they were shooting a gun for the first time. Just as they are getting ready to intubate, they blink, close their eyes and hurry the process too quickly.

RESUME one page: Name address Statement of purpose; one sentence: EMT-B with 2 years of experience seeking employment with professioal EMS service. Professional Certifications/licenses with cert # Education (professional, college) Additional Training; PHTLS, BTLS, ACLS for Basics etc, professional seminars Work Experience Including Volunteer Briefly describe as "Active volunteer in a service that runs X calls/month consisting of trauma, medical, interfacility transport. If you don't go over the one page limit or crowd the data, list some of the equipment you have worked with. Professional and community affiliations; Prof. State EMS societies, Red Cross, community development, volunteer search and rescue groups etc END Keep everything brief and to the point in the resume and interview. Know all the equipment you have worked with by trade and manufacturer name. Be familiar with a couple of different types of equipment that perform similar functions. Again, answer comparison questions briefly to the point and objectively without elaborating by "that piece of equipment is *&*%". Running "transfer" calls will give you a chance to get more familiar with medical terminology and assessment skills without the stress of time of an on scene trauma call. It may also make the day of that nursing home pt to get a little extra attention and they may enjoy participating in your assessment. Repetition will give you some automatic skills that will start to come naturally with every call and then give you a chance to focus on other critical skills. It will also give you a chance to enhance your communication and interpersonal skills with the patients and other healthcare providers. Nothing worse than handing off a patient at a hospital to an EMT that can do little more than grunt and frown. It leaves the hospital worker feeling like it might actually have been better to have called a taxi for the pt. (a suggestion made by many disgruntled EMTs) Don't know where all of the Medicare fraud stuff is coming from. Occasionally a company will do something and they get caught. There are a lot of monitors out there and whistle blower incentives. Nursing Homes and hospitals have liability issues. If a nursing home is transferring a pt that "looks" good to you, you may not have looked closely. Did you notice the labs, trending BPs or pts overall ability? Your attitude toward routine transfers may cloud your judgement and may make you a very unreliable health care provider in providing quality care to all. Even in Rescue EMS, you will run alot of calls that look routine, but may be far from it.

I put myself in a different state of mind by imagining the adult handle as the handle on a beer stein or the baby handle as a fine wine stem. I look the person at the foot of the bed square in the eyes before I start to intubate. Then when in position I take a deep breath and mentally say SALUT! to the person at the foot of the bed. This works for me when the is room full of commotion. Relax...don't let anyone shake your confidence.

They're private.... http://www.montereyherald.com/mld/monterey...on/16780919.htm http://www.co.monterey.ca.us/health/EMS/ Now San Francisco...yes, they start at about $65- $75,000/yr The cops; impressive http://www.sfgate.com/cgi-bin/article.cgi?.../04/11/RYAN.TMP