VentMedic

No, but that's nice. Surf him up...Tampa, FL 1986

And how many of you own Dale Dubin's EKG book?

This is a follow up to my earlier post about Medicare caring about your education. Besides being a paramedic, I am also a Respiratory Therapist. The happenings on Capitol Hill with RT are getting good. Respiratory Therapists are relatively new...Nationally certified for more than 30 years but in most States, licensed less than 20 years. Their educational standards have been growing...trying to keep up with OT, PT, ST etc to get Medicare funds. Every profession acts like a separate business to keep money coming in to stay alive. Medicare affords a number of advanced-level allied health care providers the privilege of working without direct physician supervision, such as physician assistants, nurse practitioners, and clinical nurse specialists. The AARC Medicare Respiratory Therapy Initiative will give respiratory therapists with an RRT and bachelor’s degree similar recognition that they do not now have. A respiratory therapist would need to have an RRT and bachelor’s degree to be eligible to participate under the AARC Initiative. Because other allied health professionals recognized by Medicare have a minimum of a bachelor’s degree, or in a number of cases, advanced professional credentials, the AARC feels strongly that it is important to make a niche for the advanced practice respiratory therapist so that the initiative is more likely to be supported on Capital Hill. This applies mostly for reimbursement purposes outside of the hospital. They will be able to contract their services to physicians for disease management programs and testing. A profession's education level can make a big impact on the opportunities available when you look at it from a business point of view.

A.S. Emergency Medical Services B.S. Cardiopulmonary Science M.S. Exercise Physiology

Prerequisites? Steven has the U.S. flag by his name... See other discussions.... Is the paramedic program at a technical school, community college or private trade school? Step back and access your priorities. It just may not be the right time. If it is your calling to be a paramedic...the time will come...continue to prepare at you own pace. Ease into the educational process if you can by taking a "prerequisite" that might be of some future use. Slide into some short continuing education classes for healthcare professionals...like the ACLS ECG and Medication prep classes just to hear the names and uses. See what jobs your local hospital has to offer...ER Tech, PCT, Phelbotomy tech, Monitor tech or even transporter. It will get you free continuing education and may get the rest of your education paid for. Monitor tech is a great way to get paid, talk to all the doctors, and study(usually). It may sound boring...but if you are serious about a stable environment and income to prepare for future things... Doing just about any type of work in a hospital will get you patient exposure. Experienced Phelbotomists do great IVs as a Paramedic. Monitor techs can analyze rhythms at a glance. Transporter will give you a chance to help/see and move a lot of difficult patients. It will also give you the run of the hospital to meet other professionals. Transporter in the OR is pretty educational also.

The same for people of all professions, healthcare or not, who live/work in rural areas. People who have a dream/desire to become something must make choices. With more online courses being offered, that would cover the basic gen. ed and some of the science requirements. Next, rural areas can always petition their tax based educational colleges to offer extension classes in the rural areas. This is how many nursing classes are conducted. Or, a larger college may place an instructor at a local small college to offer the needed core courses. Many private colleges will also do this with hopes of having more enrollments for future programs. This gives opportunity to someone who may be qualified to teach but also wants to live in the rural setting. It can give a chance for all to go forward with their ambitions.

Actually Medicare does care about education levels and minimum requirements for health care professionals. When it comes to reimbursement to stay in business and keep your profession alive...education. Physical Therapy; Masters - min, Ph.D preferred...big gains in their reimbursement, leading to more opportunities in the past 10 years Occupational Therapy; Bachelors - min. ; another cash cow for health care programs Respiratory Therapy; A.S. min, Bachelors preferred; big battles for reimbursement in the home care and hospital settings. More leverage now that they have established minimum educational standards. The clock is ticking for RTs who need to advance to Registered. Exercise Physiologist; M.S., Ph.D petitioning for licensure (have national certifications) and then they may own Cardiopulmonary rehab reimbursements...big pocket of funds waiting to be tapped. Medics want credibility to work in hospital settings; where's the education and minimum standards for hospitals to bargain with for payment of services provided...not everything should go as "nursing charge". Ambulance companines struggling to stay independent... ALS units want a 2 medic crew... Again, reimbursement from government and insurance for funding... The lobbyists for EMS have to have something to show government agencies that EMS is a profession of professionals that have professional standards worthy of attention. You have to look at a broad picture...the employers need something to work with to keep the money flowing. If they can get more reimbursements from insurance and government funded agencies; wages may go up also. All of the professionals mentioned above made very little 20 yrs ago. Suddenly as they became recognized as money makers by their employers, wages have been steadily increasing. The requirements were set by their national boards...the education had to follow. But, it has to be unity at a national level. There are a lot of community and city colleges with relatively inexpensive tuition costs. R/r 911 is right...no excuses.

Paramedic certificate (1978) A.S. in Emergency Medical Services (class of 1979 - we were told the degree would be a "must have" in the future) B.S. in Cardiopulmonary Science, M.S. Exercise Physiology

I too believe a degree is important but I also think the quality of the clinical training should be tops. I have known Paramedics who have chosen one training program over another by the ease of completing the clinicals. The competency sign-offs are seriously deficient in many schools. The basic college level sciences should be completed prior to applying to a program. Once in the program, the majority of training should focus on skills and relating the skills to the situation. As for as nursing degrees, I thought the 3 year diploma programs produced nurses that were ready for patient care and discouraged any slackers from remaining in the program. These programs were at least 70% hands on and probably would be considered cheap slave labor today. The nursing students lived in dorms adjacent to the hospital and could be put to work at any time of the day or night. By the end of those 3 years, these new grads were pretty seasoned to the profession. Today, some of the 2 and 4 year degree nursing programs are not producing nurses that are ready for patient care at any level. Extensive training must still be done by the hospitals just to get them on the floors. Nursing in the US is still the last clinical health profession to have a "mail-order" program at entry level. This "degree" is still recognized by several states. I, too, like to do classes online. But, when it comes to a profession that deals with human lives, I prefer hands-on education.

Nebulized MS; usually end of life to knock down the dyspnea centers directly. Nebulized Lasix; usually given on a ventilator; ARDS, TTN If given while not on a ventilator; special nebulizers to conserve aerosolized particles for more effectiveness and reduce staff and family from unnecessary med exposure.

The idea of nebulized lasix has been around for about 20 years. We tried it a few times in the early 90s in PICU and NICU. Mixed results, mostly not favorable in our units. Nebulized Morphine has been around for a long time and is used quite frequently in endstage COPD and lung CA. Nebulized steroids did prove very effective during the trial and error times of the 80s and 90s. Effectiveness of nebulized furosemide added to nebulized salbutamol in children with acute asthma. BACKGROUND: Nebulized furosemide has been shown to be protective against bronchoconstricting stimuli. METHODS: To investigate whether inhaled furosemide ... Allergol Immunopathol (Madr), March 2006 http://www.medscape.com/medline/abstract/16606546 Efficacy of nebulized furosemide in children with moderate attack of asthma. effects from bronchodilators. OBJECTIVE: To investigate the efficacy of nebulized furosemide in children with moderate asthma exacerbations. METHOD AND ... West Afr J Med, July 2005 http://www.medscape.com/medline/abstract/16276705 Effect of nebulized furosemide in terminally ill cancer patients with dyspnea. We evaluated the effect of ultrasonically nebulized furosemide (20 mg) on dyspnea uncontrollable by standard therapy in patients with terminal cancer. ... J Pain Symptom Manage, October 2003 Dose-dependent evaluation of the effects of nebulized furosemide on pulmonary function in ventilated preterm infants. OBJECTIVE: We have previously shown that a single dose of nebulized furosemide improves tidal volume and pulmonary compliance for up to a 2-hour study ... J Perinatol, September 1998 http://www.medscape.com/medline/abstract/9766411 Nebulized furosemide as a novel treatment for dyspnea in terminal cancer patients. Three terminal cancer patients with severe dyspnea were treated with nebulized furosemide. The underlying causes of dyspnea varied. Twenty milligrams of ... J Pain Symptom Manage, January 2002 Nebulized furosemide for dyspnea in terminal cancer patients. J Pain Symptom Manage, September 2002 Effect of inhaled furosemide in acute asthma. We assessed the acute bronchodilator effect of nebulized furosemide when added to conventional therapy of acute emergency department (ED) asthma. Using a ... J Asthma, January 1998 http://www.medscape.com/medline/abstract/9513587 Furosemide for transient tachypnea of the newborn. picture of transient tachypnea of the newborn. Intravenous, oral or nebulized furosemide compared to placebo or no diuretic in the first 7 days. DATA ... Cochrane Database Syst Rev, January 2002 http://www.medscape.com/medline/abstract/11869651 Effects of inhaled furosemide on platelet-activating factor challenge in mild asthma. Furosemide (Fur) may have an anti-inflammatory effect on airways in patients with...asthmatics. The aim of this study was to assess whether pretreatment ... Eur Respir J, September 1999 http://www.medscape.com/medline/abstract/10543284

People always want instant gratification. One dose of albuterol delivered with the standard issue nebulizer probably will not give a response immediately everytime on severe exacerbation, beta blocker or no beta blocker. The average oral beta blockers that COPD pts, including asthmatics, are on will still leave enough receptors sites available for albuterol. This is proven time and time again in pulmonary labs on COPD pts who have all the "ol" meds on board. Usually it will take just a standard dose nebulized or by MDI for maintenance. That is one purpose of the Pulmoary test to determine an effective rescue inhaler for them. If a pt is already on albuterol and he is still wheezing when you see him, doesn't always mean that med is not working for him. That dose and delivery may not work effectively now. People using MDIs without spacers usually have poor delivery anyway. When a person is SOB, their technique worsens. AND, the cause of their wheezing needs treatment. The albuterol will help some but effective delivery will have to be accomplished. Maybe once the cost of the BANs (breath activated nebs) come down alittle, that should be your neb of choice on the rescue vehicles. You'll have then 80% better chance of binding with the receptors. The days of the standard 2.5 mg x 3 are hopefully moving behind us. With the newer nebulizers, the continuous nebulizer is also taking a back seat. To have a person sit with a "face mask" for 1- 4 hours getting the same medication dose that a BAN can deliver in 7 minutes is wasted time. We used to have people on continuous nebs for hours and in some instances, days. Most of the medication is wasted by the face mask and the delivery is ineffective. The airways may also be so tight that Heliox will have to be used. Whatever is causing him to wheeze may need serious treatment without further delay. Hydration, steroids, antibiotics, diabetic meds and is there a cardiac component involved? COPD pts are not always straight forward. They come with several medical issues and breathing is just one of them. Forcusing on one system may distract you from other things that can create respiratory distress and wheezing. In the hospital, it may take us hours or days to turn a pt around. A definitive diagnosis, if possible, needs to be made by the various diagnostic tools to determine what has spurred the battle before defeat is imminent. Trying other things enroute is fine as long as it doesn't cause delay transport or complicate other medical issues the pt may have.

You will still get some bronchodilation. I see this often in the Pulmonary Lab since the majority of the older pts are on a beta blocker and 3 puffs of albuterol can produce nice results. IV Beta blockers may give albuterol a harder time competing for the receptors. Inderal used to be the Godmother of all beta blockers and put up the biggest fight. However, high dose nebulized albuterol (10 - 20 mg) given very quickly in an aerosol sparing/Breath activated neb such as the Aeroeclipse can be used for beta blocker OD. On our inhouse ER/ICU protocol we can go up to 40 mg of 0.5% albuterol for beta blocker OD or hyperkalemia. Of course, for our Canadian and European friends who can use IV albuterol...0.5 mg IV albuterol can trump all.

Apologies to all, this should go under a professionalism thread...except for the last paragraph. Ridryder 911, Fortunately Respiratory Therapy in the US has finally gotten together to raise the bar starting last year 2006. 2 year min in education. Also anybody lagging behind as Certified, waiting too long to get their Registry will be left out in the cold. The days of diploma mills are long gone for the RT profession. We haven't "grandfathered" in over 20 years in most States. There were still a couple States lagging about 5 years ago. The 4 year programs are grueling but rewarding if you can make it through. Employers look for cheap ways until they pay for a couple lawsuits. With the heightened JCAHO requirements, no room to cut the standards now. www.nbrc.org Now EMS needs to get its standards together and raise the bar a little. There are still way to many diploma/PDQ mills mass producing "stretcher techs". I am against other professions being able to challenge the EMT-P. I do believe in training. Another thread...another time... The point I was attempting to make with ZippyRN, in this high tech society, the days of "jack of all trades...expertise at none are gone". I would prefer someone with much expertise overseeing my lung tissue. Who would I want pulling my loved one out of a wrecked car or rescuing from a hiking accident or being present at a cardiac arrest at the dock? I want a person with expertise in that area. Nurses are very vital to healthcare. However, like other professions, their training, education and scope varies region to region and hospital to hospital. They still have a mail order program in the States for entry level. Enough said...I have too much respect for the nurses that do excel in their education, training and skills to let someone who needs to feel above it all warp my view of their professionalism as a respected team member in the healthcare system...where ever that may be. Our nurses generally welcome the team approach. Sharing educational/training ideas can show us that we still have a lot to learn. Embrace the changing times. If we keep shooting each other in the foot as professionals.... Just like the O2 protocol, every different professional with a different level of education, with a different level of training, with different experiences and with a different professional journal subscription will have a different take on the subject. That is what makes medicine so challenging and stimulating that we can agree to disagree and still do what is best for the patient.

zippyRN, I'm crushed! You didn't use anything from my post. Give peace a chance. There are many types of health care professionals now that have improved pt care tremendulously over the past few years. We offer offer a multidisciplinary approach to pt care so that something is not overlooked. And actually, healthcare costs are decreased with the shortened vent and ICU days. Relatively new professions such as EMT/Paramedic and Respiratory Therapy have made their impressive mark in the health care realm. They are still evolving and will continue to grow. I too can start IVs, hang meds, and manage just about any technology in the ICU. But, I prefer a team approach and am willing to work with anyone who can help improve the outcome of the pt. That is what healthcare is supposed to be about. Egos need to be checked outside of the health care environment. Too much wasted energy on how to get one up on the other. I have not worked with many nurses from UK in the ICU. I do not know your skills. By your comments, I would say you have not researched our education or skills. I only know the doctors from the UK who have visited and attended our seminars. They are very receptive to innovative ideas and technology. Let's not put the healthcare profession back into the dark ages. There is still so much work to be done.

scratrat, Thanks for the info. One more question if you don't mind... How long on average do you or your co-workers usually take to set-up CPAP on a pt? Is the head gear usually with the mask as a complete set?

Respiratory Therapists from Canada and U.S. are present in the UK but as educators and consultants to the physicians for getting new technology/therapy started. There have been a few hospitals in the U.S that have hosted groups of physicians from the UK that wanted to see observe Respiratory Therapy in action. Seems they are fans of the many articles published by RRTs in internationally recognized medical journals and the technological advancements in our ICUs. Improving pt care, decreasing ventilator days, preventing vent assoc. PNA and providing optimal breathing comfort both on and off the ventilators have provided RTs with a wide open universe of opportunity to show their worth. Entry education has now equaled or passed the RN. Other professions that have gotten a heightened professionalism through education include Physical Therapy; M.S. and now Ph.D., Occupational Therapist; B.S., M.S. at entry level. Our physicians throw new articles at us almost on a daily basis wanting us to keep up with the evolving theories and technology in critical care medicine. Sometimes our budget does not keep up with all of the new technology. So, the RRTs write for research grants or petition a company for a trial to get resources for new equipment. Sometimes it is necessary to delegate some of our duties on the floors to nurses to free us up for more duties in the ICUs. However, we are still there for training other professionals and can be called for consultation on any patient. Endnote for the thread; If Paramedics could kick up their educational standards, more credible opportunities for in research would open up. Debating something such as prehospital oxygen therapy would be in their court at the advantage.

I haven't seen these items yet but I did come across some of the literature when I was researching alternatives to the Vapotherm which is still in FDA limbo. They look promising. I hate venturi masks unless they're one unit and then I always find them on something different each time I do a pt check. With the "component piece together sets", I can never see the numbers and every manufacturer has their own set of colors.

Sorry to hear you had to experience this first hand. At least you now can give a first hand account of CPAP vs BIPAP. Impressive settings... For Peds ER we have strict policy when giving nebs to kids...5 ft rule/mask. Pertussis got a couple of our staff one year. They too couldn't collect benefits. I remember being so concerned while working in PICU about mycoplasma that the nurses and RTs were drawing each others blood to check for it. We had two kids on vents with it. r/o TB; guilty until proven innocent. I worked in NICU with 10 - 20 morning xrays...scatter. I hated to see our rad badge readings each month. Now I occasionally do bronchoscopies...4 - 5 / day with flouro. I really look forward to the pulmonologist having a resident with him/her to learn the forceps. As I get older, MRI transports don't appeal to me either if the vent isn't in service. Thank goodness for students and nurses Back to CPAP and different pulmonary diseases; Sometimes we have to re-educate the ER physicians what CPAP/BIPAP is used for and its limitations. Like Albuterol, it is sometimes thought of as the universal cure-all. I have not examined too many prehospital CPAP machines so maybe you could help me out on this one. With the hospitals' Respironics Vision (love this machine), the higher you go on FiO2 the lower the flow curve. Are the prehospital machines essentially flow generators with a manual PEEP valve?

FormerEMSLT297, For all practical purposes in prehospital, stick with that definition you just studied. The world of a "neonate" inside the hospital NICU is a whole different "life". If you want to explore the world of "neonates"; http://neonatal.peds.washington.edu/ http://www.neonatology.org/ Breaks down the gestational/BW categories. http://www.emedicine.com/ped/topic2982.htm I got my first experience with "neonates" as a young medic over 25 years ago. Essentially I was the muscle for the neonatal transport team; lifting the isolete and carrying the equipment. Later when I became a Respiratory Therapist, I worked FT in the NICU and did NICU/PICU Transports for many years. Fantastic experience!!! Great way to get literally hundreds if not thousands of neonatal/infant intubations to your credit.

I don't know about the long term effects of DLCO. For the patients, they may only get checked once or twice/yr. The RTs in PFT lab have to keep their machines in cal and do frequent staff normals. My COHb will go up to 3.0+ after 4 checks on myself to do a staff normal. Other worries for RTs and PF/other; long term exposure to pentamidine, ribavirin, various antibiotics, nitric oxide (esp at 50+ ppm), flolan, other nebulized Prostacyclins, morphine and of course the old standards; albuterol, mucomyst etc. We take precautions to keep nurses and family from being exposed. We are always telling the nurse to sit further away from the pt or keep the isolation door closed for his/her own safety when we're running these drugs in the ICU. For the EMS teams, I will always voice my concerns for them when they do interfacility transports with some of the above drugs running on the pt. Precautions must be observed especially in close quarters. In the 80s, when doing 24 pentamidines 3x/wk, I was checked by spirometry weekly. I was younger then.....

Long term oral doses. Pulmonary Toxicity "Pulmonary toxicity is perhaps the most feared adverse effect of amiodarone. Initial estimates of its frequency ranged from 2% to 17%, with fatalities occurring in 10% of affected patients10- 18; however, more recent estimates in patients receiving daily doses of 400 mg or less indicate an incidence of no more than 2%.19,20 Pulmonary toxicity presents as either interstitial pneumonitis or hypersensitivity pneumonitis. Interstitial pneumonitis is the most common presentation, accounting for two thirds of amiodarone's pulmonary toxicity,11 and hypersensitivity pneumonitis accounts for the rest.16" Full article at; http://www.continuingeducation.com/pharmac...ne/adverse.html http://www.continuingeducation.com/pharmacy/amiodarone/ More on PF on eMedicine http://www.emedicine.com/MED/topic1960.htm

The ER doctor is not the final word on the O2 delivered to the pt for the long haul. Once the admitting doctor and/or specialist is called and orders are given by that doctor, the rules change. If you have 3 doctors on the case, you'll have 3 different opinions many times. Much of the literature out there is for extended time on O2 rather than a 15 - 30 minute ambulance ride. As prehospital, you are concerned about meeting the pt's immediate needs for safe transport. That is your call to do what is best for your pt during the time he/she is in your care while staying within your guidelines given to you by your medical director and your license.

You are correct about that. Trendelenberg is rarely used in many hospitals except for cannulation of the jugulars. Trendelenberg can lead to aspiration, increased ICP, diaphragmatic restriction and increased anxiety. "Supine is Fine". The Trendelenburg Position: Another EMS Myth By Bryan E. Bledsoe, DO, FACEP December 2004, MERGINET—One of my most-requested conference talks is entitled Myths of Modern EMS. It also corresponds to a series that I wrote for EMS Magazine in 2003. In that lecture, I review numerous EMS practices and the science, or lack thereof, behind them. It stimulates discussion and, as I had hoped, has stimulated some research. Now, I have another EMS myth I can add to my repertoire: the Trendelenburg position improves circulation in cases of shock. Researchers at the University of Southern California Keck School of Medicine performed a retrospective review of the literature pertaining to use of the Trendelenburg position in shock. They found several studies on the maneuver. One compared six hypotensive patients in clinical shock to five normotensive patients. In nine of the 11 patients, the Trendelenburg position was ineffective, causing reductions in systolic, diastolic and mean arterial pressure. They also found that the abdominal viscera moved up onto the diaphragm, restricting respiratory volumes when patients were placed in the Trendelenburg position. Another study looked at oxygen transport in eight hypovolemic postoperative patients placed into the Trendelenburg position. While the position seemed to increase blood pressure, it did not increase cardiac output. Another researcher studied the effect of the Trendelenburg position on blood distribution and found that only 1.8 percent of the total blood volume was displaced centrally. In a relatively large study of 76 critically ill patients (61 normotensive and 15 hypotensive), they found no change in pre-load or mean arterial pressure for normotensive patients. In normotensive patients, they found a slight increase in cardiac output. However, for hypotensive patients, there was no increase in pre-load or mean arterial pressure. In these patients they found that cardiac output actually diminished—a detrimental effect. In summary, the Trendelenburg offers no benefit to hypotensive patients. Like the MAST/PASG, another long-held belief can be abandoned as EMS becomes more evidence based. Reference Johnson S, Henderson SO. “Myth: The Trendelenburg position improves circulation in cases of shock.” Canadian Journal of Emergency Medicine. 2004;6(1):48-49. And for the conclusive last word Use of the Trendelenburg position as the resuscitation position: to T or not to T? Am J Crit Care. 2005; 14(5):364-8 (ISSN: 1062-3264) Bridges N ; Jarquin-Valdivia AA The Neurointensive Care Unit, Vanderbilt University Medical Center, Nashville, TN, USA. OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation. PreMedline Identifier: 16120887

Try this site for Fick's Principle/Law/Equation. http://physiology.umc.edu/themodelingworks...20Concepts.HTML