VentMedic

COPD patients can be tricky to dive in the chamber especially if they have blebs (bullous) or might be prone to pneumos. Also, the potential for increased mismatching could lead to some respiratory distress issues and an increase in PaCO2. ARDS has many different components and it may be difficult to manage them on a ventilator designed for the chamber. The many meds they are on may also be a challege. As well, the development of ARDS can be a concern as the potential for O2 toxicity exists with HBO therapy. There is some irritation noted at 3-6 hours of exposure of 2 ATA oxygen and at 10 hours it can become intense.

But only if you have the education to back up the skill. Imagine a pt involved in an MVC on a cold Winter night in the north. The EMT decides to undress the patient in the cold with cold hands and palpate. He/She finds the abdomen rigid and tender. Calls this data into the ED where they may actually take that data and activate a Trauma Alert which adds several thousand dollars to the patient's bill. Upon arrival the patient states he/she had his clothes removed by someone in a wrinkled T-Shirt and bed head with cold hands. Also, the patient states the MVC had made him want to move his pee and bowels really bad especially while the EMT was poking his belly. The patient also states he/she had no pain and the EMT replies, "it's in our protocols". No, a skill should not be done just because. There should be education to support why you are doing such skill even if and especially if you are to do it each time. EMT-Bs also use a NRBM for many things just because and often it is due to lack of education to where it is easier to just say do it this way rather then try to justify otherwise with only 110 hours of training.

This should go nicely with some of the other O2 topics. Or, it may confuse a few. We have been using HBO to treat a variety of injuries and disease processes for many years. Hyperbaric Oxygen May Benefit Traumatic Brain Injuries via PRNewswire http://www.emsresponder.com/article/article.jsp?id=11613&siteSection=1 MINNEAPOLIS, Jan. 4 /PRNewswire-USNewswire/ -- A 5-year study of patients with severe traumatic brain injury conducted at Hennepin County Medical Center in Minneapolis shows significant benefit of hyperbaric oxygen therapy to improve brain metabolism and its ability to recover from injury. The results were recently published in the Journal of Neurosurgery. Every year, more than 1.4 million Americans sustain a traumatic brain injury (TBI) - the leading cause of death and disability in children and young adults. Those who survive often face months or even years of therapy, and sometimes the damage to the brain is irreversible. Decreased utilization of oxygenated blood to brain tissue immediately after the injury is often to blame. Cells need oxygen to fuel metabolism for cellular growth and repair. Healthy brains produce their own energy to maintain brain tissue and keep the rest of the body doing what it's supposed to do. That includes automatic processes like breathing and circulation, as well as voluntary actions like walking and talking. After a traumatic brain injury, the brain itself needs care. Barriers to blood flow can be compromised from the impact of the injury itself, and then when the brain swells inside the skull, a secondary injury can occur that causes even more brain damage. "There's a direct correlation between clinical outcome and the degree to which the brain's metabolism is restored," explains one of the study's authors, neurosurgeon Gaylan Rockswold, MD. "In previous research we learned that the brain's energy production is improved and maintained with hyperbaric oxygen treatment, but this study confirms that hyperbaric oxygen treatment has a major impact in terms of increased energy production." Within 24 hours after injury, eligible patients for the study were randomized into three groups: One group received "normobaric" treatment: oxygen delivered at the patient's bedside; another group received hyperbaric treatment in Hennepin County Medical Center's hyperbaric oxygen chamber; and a third (control) group did not receive additional oxygen therapy. All groups received the intensive standard of care for brain injury consistent with good clinical practice. The patients who received higher levels of oxygen (hyperoxia) via the hyperbaric oxygen chamber were found to have a marked increase in positive brain metabolism when compared to the normobaric and control group. "Our goal was to evaluate the brain's metabolism and intracranial pressure, and whether or not too much oxygen posed a concern with hyperbaric oxygen treatment in these patients," said Dr. Rockswold. "The results indicate that hyperbaric oxygen treatment was found to significantly enhance the brain's energy production and reduce intracranial pressure without any toxic effects on the brain or lungs from too much oxygen." This research provides important preliminary data for a National Institutes of Health (NIH) supported multicenter trial. NIH trials directly assess the ability to improve clinical outcomes, which is the final step needed to change standard clinical processes. Currently standard clinical practice does not include hyperbaric oxygen for traumatic brain injury. "TBI is not only devastating for the patient, it's also heart wrenching for his or her family. We couldn't be more pleased about the impact this study will have for patients with traumatic brain injury." The Traumatic Brain Injury Center at Hennepin County Medical Center offers comprehensive, multidisciplinary patient care education and research to serve people who have sustained a traumatic brain injury. Providing a full range of state-of-the-art medical and rehabilitative services, HCMC's expertise spans the entire continuum of care for adult and pediatric TBI patients, from prevention to emergency care, neurosurgery, critical care, rehabilitation and the Mild to Moderate Traumatic Brain Injury Clinic. About Traumatic Brain Injuries Each year, more than 1.5 million Americans sustain a traumatic brain injury (TBI). In Minnesota, nearly 100,000 brain injuries occur annually. A large percentage of those injuries are mild to moderate cases and often go untreated. As a Level 1 Trauma Center, Hennepin County Medical Center admits and treats the most traumatic brain injuries in the state. More information about HCMC's Traumatic Brain Injury Center can be found at www.savethisbrain.org. The state's only permanent, fully accredited hyperbaric chamber is located at Hennepin County Medical Center. HCMC's Hyperbaric Medicine program is one of only 60 programs in the country to achieve accreditation by the Undersea and Hyperbaric Medical Society (UHMS). The multi-chambered unit is fully staffed year round and is used for a variety of critical and chronic medical conditions, including treatment for carbon monoxide poisoning. Hennepin County Medical Center is a Level 1 Trauma Center and public teaching hospital repeatedly recognized as one of America's best hospitals by U.S. News & World Report. http://www.emsresponder.com/article/article.jsp?id=11613&siteSection=1

Some are making much more of this than what it is. What has been stated over and over is that if you have the education, you may be able to obtain more skills. However, if your "training" lacks education about A&P to even give you the bare essentials to understand why you are doing a skill, don't expect everyone to just allow you to mess with their patient just for the sake of a "skill". Those laminated cards on nursing carts are required by certain certifying agencies and not because the nurses have never been educated about the basics of giving a medication. If they did not have the education to begin with, they would not be allowed to touch a medication cart and they would not have the "expectancy" that someone should allow them to touch medications until they have be properly educated first. In this situation and as it should be in many that involve patient care, education should come before just allowing someone to attempt to do something that might cause discomfort or even harm to a patient. Maybe the intubation failure rate for some EMS providers would not be as high or the medical directors might actually put more trust in those they have oversight of.

None of the residents or interns in your area are required to take A&P? None of them have done any patient contact clinicals as med students? You seriously are not comparing your education to that of a doctor? What about the differences in oversight? Have you actually seen what happens to a resident when they muck up badly? Let's just say it not a sight for the weak or meant for the ears of those who cry easily when criticized or go off on a "he/she's picking on me" tangent. While there are some skills they may get limited practice with before actually doing the procedure, they do at least have the advantage of the science as well as some of the whys or why nots of the procedure. In the preveious paragraph you just stated we are doctor like. Did you not read my post? Did you not see the word "Paramedic" mentioned many times and I used myself as an example?

Now I cringe to think of the people I could have harmed and may have. Even now the hospitals don't always contact every ambulance agency for every screw up although it may be documented. You may never know how bad you mucked up until you are called before your company's attorneys. How many have gone back to see the result of some of those difficult intubations? Ever go back to see if the patient got a trach? Maybe it is all written off as part of "saving a life" but does that mean messing up the cords because you didn't really know what you were doing is okay? Let's say you are an EMT-B and have very little manikin time or a decent instruction on the Combitube. You are allowed to "practice" on a real patient and do serious damage to the cords to where a trach is necessary or rip the esophagus to where the patient would need urgent surgery. Do you feel the patient's complications were warranted just so you could "try it out" on a real person? Working in the hospital has also given me an opportunity to "attempt to fix" the mistakes made either by myself or by others. Screw up on a ventilator setting and create a pneumo, you get to help decompress but it then really isn't as thrilling as finding a pneumo in the field. Botch an intubation and do many leak tests while corticosteroids are given in hopes the inflammation lessens to where that patient doesn't get a trach and that is on your permanent record. Let an IV infiltrate and do many perfusion checks or maybe Wydase to keep the tissue from becoming necrotic. Screw up an arterial stick and sweat out if the radial nerve or artery will be the same. Screw up doing ETI with suction on a meconium baby and do ECMO for several days until the infant can be weaned off or dies. Of course, some of these are what we see from the field and many times the Paramedic will never know since they may not be immediately obvious. If you cause a pneumo, we might speculate that it was you in the field but may not be able to prove it. Some of the damage might be from the circumstances surrounding the incident. Some might be part of that "what happens in the truck stays in the truck" mentality which has been a factor that prevents tracking medical errors in EMS so that there can be an improvement. Also, FDs do enjoy have some limits on their liability as a agency of some government entity. Essentially if your patient dies, you can say they may have died anyway. However, occasionally something is caught and it may even make headlines so you do get to enjoy the equal status in medicine with the other health care professionals.

Did you notice EMT-I will no longer be one of the levels?

They're everywhere on the internet. Yes I have. When they put forth the effort to learn a little more A&P to actually know what they are palpating.

Once I got to the next level I realized how little I knew and probably shouldn't have been allowed to do half the things I did. Those just starting in the lower levels really haven't gotten even a good sampling about medicine or Paramedicine. You can palpate an abdomen all day long but if you do not know what you are palpating or just know one big disease process, what exactly are you doing? But who makes them stay at the EMT-B level either by certification or by education? Who says they can only have 120 hours of training and can not take any college classes to expand their knowledge? Often it is the provider themselves that sets the limits to what they know regardless of what they are or are not allowed to do. But, some still complain 120 hours of training is way too much for them and what little book learning is in that class should be eliminated. And going to the NREMT and state offices is exactly what has been done and hopefully the changes in 2014 will be a start although not near enough. Have you reviewed the new levels?

In any healthcare profession you are not allowed to do certain assessments until you have mastered a certain level of education and training. A CNA can not do the same assessment a nurse can nor would they ever be expected to. A doctor who is a general practitioner will not do a neuro exam the same as a neurologist. If you are a med student, you will be told when you are ready to do complete physical exams. Before one embarks on exams, for the sake of the patient for both safety and hands on intrusiveness, one should have some base knowledge and confidence of what they will be assessing. Thus, it doesn't matter if you are going to do more harm to the patient or not but if you understand what you are doing and not just coming off like you are poking around. Also, one has to remember all the other health care professions do have strong prerequisites before they do hands on thus they have the background to associate what they are feeling with what could be a disease process. We could also use EKGs as an example. How many look at an EKG and say "that looks like what I saw in the ED a few years ago and I think it was.." rather than actually having an understanding of how to interpret an EKG piece by piece? How many look at a patient and allowed their past experience skew their judgment because it "looked like" rather than doing an assessment to gather actual facts? This comes when some do not have the base education to create a foundation of knowledge to properly assimilate the physical data they might come across. Thus, you end up making the patient uncomfortable and can do little to change their "abdominal pain". You may increase the pain and who knows if you did more damage since there is not a CT Scan immediately prior to you touching and one immediately after. I have seen patients crash during a physical exam and who is to say it was due to the exam or just time for the AAA to become a serious problem. As well, one has to remember, a physical exam can be stressful for the patient especially if it causes pain or the provider is inexperienced and lacks the knowledge to know when, how and why. That in itself can exacerbate some conditions by changing the vitals according to stress levels.

Anyone can poke around on a belly and say "gee that feels weird". Will an EMT-B be able to make the diagnosis of AAA vs Bowel obstruction vs necrotic bowel or vs any of the many other adominal abnormalities? But, anyone can also stick a piece of plastic down someone's throat and call it intubation. When do we stop in EMS with doing a "skill" without proper knowledge and education as to why, when or when it should not be done?

So much for some not confusing "basic tools" with EMT-Basic. Before you get on your "anti-EMT-B crowd" high horse, did you read the comments in the posts about people being properly trained and educated? I speciffically used examples of medical students and doctors. No med student or resident will touch a patient in anyway that they have not been previously instructed to or given the okay by their seniors. That including intubation, IVs, palpation or any number of exams. EMS providers should also be held to some standard when it comes to performing certain "skills" and that especially pertains to education. A 110 hour EMT course also can not be compared to a 4 year pre-med degree especially when the majority of EMT courses in the U.S. require no prerequisities...not even A&P. Thus, how do you know what you are palpating with such limited knowledge? Basically all you can tell is where it hurts and how hard or soft the abdomen is but again, those are patient specific and can be subjective to the exam itself. I went through a college degree program for Paramedicine which required 2 semesters of A&P before starting EMT-B and then continued on through Paramedic. I believe that is the way several others did their programs. I did not need to stay an EMT-B for 10 years to master a few first aid skills. However, having A&P prior to EMT-B did make that much easier and definitely made palpation skills easier if you knew what organs are in the abdomen. Also, a Paramedic that can not think beyond EMT-B is of no use on an ALS truck. The "Basic" attitude must go away to understand what the true "basics" of EMS are in order to provide critical thinking and advanced PATIENT CARE.

Some might find this interesting: http://www.privacyrights.org/fs/fs8a-hipaa.htm What are HIPAA's shortcomings? Like it or not, you are not the only one with an interest in control of personal health information. The balancing act between your interests and those of other stakeholders is often tipped on the side of government, the medical profession, related businesses, and public interests. Consumer and patient advocates are critical of HIPAA for its numerous weaknesses. Here are some of the ways that patients' rights to privacy come up short: 1. Your consent to the use of your medical information is not required if it is used or disclosed for treatment, payment, or health care operations (TPO). In many situations such as emergencies, this makes perfect sense. You don't expect the ambulance driver to get your permission to call the hospital emergency room when you are having a heart attack. On the other hand, since your consent is not required for payment, your health care provider could submit a claim to your insurance company - even for a procedure you wanted to keep private and intended to pay for yourself. In addition, treatment, payment, and health care operations have broad definitions that encompass many activities that most people are not familiar with. 2. Your past medical information may become available, even if you thought the information was long buried and would remain private. An event, treatment, or procedure from your distant past can be disclosed the same as information about current conditions. Of some comfort, old information is given the same protections under HIPAA as current information. In addition, HIPAA's "minimum necessary" rule applies to old as well as new records. This means that the amount of information disclosed should be limited to what is necessary to accomplish the purpose. 3. Your private health information can be used for marketing and may be disclosed without your authorization to pharmaceutical companies or businesses looking to recall, repair or replace a product or medication. (For more on the marketing of your medical information see Part 5 below.) 4. You have no right to sue under HIPAA for violations of your privacy. In other words, you do not have a "private right of action." Only the HHS or the U.S. Department of Justice has the authority to file an action for violations of the Privacy Rule. All you can do is complain to the one who violates your privacy or to the HHS. However, you may be able to sue under state law using the HIPAA Privacy Rule to establish the appropriate standard of care. 5. Business associates of a covered entity can receive protected health information (PHI) without a patient's knowledge or consent. Before entering into an agreement with a business associate, a covered entity must receive assurance that information will be handled appropriately. After that, handling of sensitive data by business associates is left only to an honor system. Even when the limitations of the Privacy Rule are applied, many people can still see your medical records when carrying out the business of the plan or provider. Business associates may include billing services, lawyers, accountants, data processors, software vendors, and more. Your doctor may, for example, disclose your health information to a business associate that processes medical bills. A written contract for this arrangement is required, but the doctor doesn't have to check to see that your information is being handled correctly. If there is a violation, the business associate is supposed to report it. 1. Law enforcement access to protected health information under HIPAA is a significant concern of privacy and civil liberties advocates. Some disclosures may be made to law enforcement without a warrant or court order.

However, this should not be confused with the terms in EMS as they relate to "Basic".

I am all for a thorough physical exam of the abdomen provided you have adequate education and supervised training to understand what you are palpating. If you are palpating just to palpate and the few things you might assess may not be relevant to the situation or more to do with cold hands and patient comfort, then NO, you should not be palpating the abdomen. If you do it should be gentle and not digging around for a pulsating mass which is only detectable 38% of the time. Sorry but 120 hours of first aid training just doesn't address all the possible medical conditions to where one is qualified to many any type of differential diagnosis. How much does this physician know about prehospital providers to have him be the authority for EMS. Look at that prehospital section. Again, how many diffent disease processes is the EMT-B trained or educated to identify? There are also many Paramedic programs that don't address how to properly palpate and some have preconceived notions about what a AAA will feel like but have never actually felt on or have it described by someone who has.

Maybe there needs to be a differentiation between asystole in trauma and nontrauma situations. We don't know if there were obvious signs of death. I've seen some pretty nasty TBIs that we had to doppler for a pulse who later walked out of the hospital without assistance. Did they just say "Wow! That has to be dead." while they were palpating which may have skewed their assessment.

Did you read the section pertaining to prehospital? http://emedicine.medscape.com/article/756735-treatment That article also states: The physician authoring the article still believes MAST is on the trucks. But then, maybe they are in some areas. How many EMT books give much information about the different hernias, bowel obstructions, necrotic bowel or AAA? Here's another articles as the search engines are full of them and it depends on the audience they are directed at as to whether palpation is emphasized but precautions are mentioned. Does that mean it is ruled out if it is not felt? Does that change your destination? Where does "experience of examiner" place the EMT-B? These articles are primarily directed at MDs and advanced practitioners. Does 120 hours really prepare an EMT-B to tell the difference between a AAA and a bowel obstruction or the many presentations of both? http://emedicine.medscape.com/article/463354-overview

But how many EMT-Bs in the U.S. are taught all the things that can go wrong in the abdomen or the complications? How many are given step by step instruction on how to or how not to palpate an abdomen? How many have felt a AAA in some of the ways it can present? How many know the many differeentials? Other than, tender or not and rigid or soft, there is not much instruction and these can be dependent on the patient and one's cold hands or comfort. I have seen med students and residents get their hands smacked by attendings when they just started poking around in a situation that warrants caution. Of course, that rarely happens because they generally have the education base to know they should wait for proper instruction and training to approach various situations. I have seen various aneurysms start leaking for a variety of reasons and there is nothing more frightening for a physician than to have a patient scream in pain or just die on the stretcher during a physical exam. Perforations, foreign bodies, aneurysms and a few others that are suspected may need caution and if a physician suspects something serious, he/she may send the patient to CT Scan or do an ultrasound rather than aggressive palpation.

This depends on whether you are giving the information out over the radio, which is definitely not acceptable, or by a secured line. Of course one could argue that a cell phone is not secure either. Some hospitals have telephones set up for ambulance personnel to do such calls. It also depends on what role and software your dispatch is using and if they are also multitasking billing information. If that is also in their job description, then yes, they may need to know some of the information. If the patient has consented for treatment and signed the necessary paperwork, your company can continue with the processing of insurance data provided it is in a secure manner and not over the radio.

But then in some areas, every FF is a Paramedic. As well, imagine the surprise some Canadians and Europeans get when they realize what the U.S. EMT-B actually is or is not. Also, some are very surprised at what the American Paramedic is or is not. However, is just feeling for a pulse adequate for all situations? Look at the number of incidents we have had in EMS involving mispronounced deaths over the past couple of years.

There are situations where the electrical activity on the monitor and the actual perfusion pulse are very different. You may have a HR of 200 - 300 on the monitor but only have 60 effective perfusing pulses. You may also have a lot of ectopic or abnormally conducted beats that also many not perfuse but may get counted as electrical activity. And then there is PEA: Pulseless Electrical Activity which used to be know as EMD; Electro-Mechanical Dissociation. This is where the heart is still sending out electrical activity but the heart is at a standstill with no mechanical activity.

If you read my post you will see I pointed out many reasons why even experienced fingers may not always be able to palpate a pulse even at the carotid. The patient may have been a "neonate" and has extensive scarring from many A-lines in their childhood. They may be a COPDer who has had multiple radial and brachial art sticks. They may have been on ECMO as either a neonate or adult from some illness that involved ARDS. They may have had vascular surgery or may be in need of vascular surgery. They may have abnormal anatomy. Even before doing a radial art stick we must determine they have a decent radial and ulnar artery. Necks? I have seen some seriously displaced anatomy either by nature or by surgery. Radical neck surgery can do a number on where you think things should be or when a fibula becomes a mandible. This is now seen in some of the reconstructive surgeries done on the soldiers.

For the 2 states I am most familiar with, Florida and California, the white all American born male has the most problem with passing the EMT-B. In Florida we have a large European and Cuban population where the elementary schools out perform most American high schools so getting an EMT-P is not a problem especially with the 10th grade text book. Thus, it is difficult to find all white American born applicants to make the score when the competition at 8th grade is academically higher than some of our college freshmen. Also those from other countries speak at least two and usually three different languages fluently which makes them an asset to any employer. Of course, Oakland, CA FD did drop their EMT-B requirement and got well over 10,000 applications for 20 openings and actually had a difficult time picking out qualified individuals to fill those positions.

Could it be they are also continuing their investigation to determine if additional charges will be filed? The muck up by the Paramedics could change whether it is vehicular manslaughter or whatever if the autopsy's proves her injuries were not survivable regardless of the Paramedics' failure to determine death. As far as declaring death, there are reasons why the AHA has de-emphasized checking for a carotid pulse. Even for health care practitioners, it might be difficult to palpate and especially when one has become dependent on technology. How many times to do Paramedics palpate pulses? They have the pulse oximeter, automated BP monitor and the cardiac monitor to tell them HR. Why would one need to actually touch a patient beyond placing one of these devices? How many times a month would they even work a code? Or, how many times have they physically checked pulses when CPR is being performed? Many times they may just attach the pads and let it do the work for them. I also learned recently while teaching NRP to a group of Paramedics that they are not taught listening to heart sounds of any type including the apical heart beat even on an infant or child. Some should also spend more time in an ICU assessing critically ill patients. They will find that we keep a doppler around because sick patients just don't have obvious pulses. We also have a whole know generation of post ECMO "kids" that are now adults. Finding a carotid on them might prove difficult at best. Then we have the adults who have been on ECMO for H1N1 which may present a challenge depending on where the cannulation was. Even after many years of palpating pulses I still have to remove a glove, provided there are no messy sustances and then I might just clean off, to find the pulse. I also had to unlearn all that 70, 80, 90 stuff for BP that I learned in Paramedic school or part of the "street smarts" when I noticed that I occasionally got a radial pulse at a BP of 70 confirmed by A-line and cuff as well as having no pulse with a BP of 140 systolic. This is just another incident that happened to make headlines because the patient was left in the field. EDs across the country have their own horror stories about Paramedics who fail to recognize life threatening situations or notice their patients are dead. Not knowing what agonal breathing is one of my personal favorites. Not recognizing it because the patient's RR is "text book normal" of 12 is almost laughable if it was not so tragic for the patient. The other is when a CCT with a couple of "CCEMT-Ps" don't believe the asystole on their cardiac monitor because the ventilator hadn't alarmed "apnea" while set on a rate of 12. Yeah the LTV 1200 is a little too much machine for them like giving a Porsche to someone who still has training wheels on their bicycle and telling them it is idiot proof and practically drives by itself. Many of our FDs want a Paramedic cert at time of hire or within one year of hire. Thus, no time for a proper education and a PDQ medic mill will have to do. For some, once you have served on the ambulance or lead on an ALS engine/ladder you might move to a position that requires little to no patient contact but may still maintain you Paramedic cert for extra pay. After a few years that requirement may be dropped if your position is on that requires no patient contact. Florida also has the option for the Paramedic to drop to EMT-B status for FFs to still maintain minimal standards or if they screw up bad enough to have their Paramedic license removed they can still be an EMT-B.

In a slight defense of the Florida FireMedics, they probably thought the patient wasn't "too attached" to the leg. As for as the Fire cheif and the boob implants, a few women can get a little carried away with pride of new ownership just as some men also want to show off their implants, be it pecs or penile, in the ambulance or ED/hospital. However, if you remember you are a professional, any urge to touch for something other than medical necessity is greatly diminished. While an implant can rupture in an MVA, rarely is it immediately life threatening and very little can be done in the field except maybe an ice pack especially for the men with penile implants.