AZCEP

First off, welcome. Now this business of the intermediate level. From what I can tell, in your area, you are working in a BLS capacity. You may very well be an ALS provider, however, if you are required to have a paramedic partner, you are doing a job that a BLS provider is well suited for. That is assisting the paramedic. Getting some experience as an intermediate is admirable, but if it is in a BLS role, exactly what good have you done? Yes, I realize that occasionally you will get to start an IV, or maybe even push a drug, but you will still be behind the wheel when the time comes. Not taking care of the patient you did those things to. The system that you are working in has fallen for the fallacy that a BLS provider can't succeed in an assisting role to paramedics, or ALS for that matter. I will go so far as to say that it is not your system's fault it is set up this way. That responsibility falls directly on DOT/NHTSA for constructing the curriculum to include intermediates. As an entry level position, it would not be to large a step to educate current EMT's to an I-85 level, and better use them in 911 services. The mid-point of the intermediate between EMT and paramedic is a farce. It was established to allow smaller departments-read: volunteers-to provide advanced levels of care without the cost/commitment of moving to full paramedics. The departments didn't have to pay as much, the fragile volunteer system could sustain the limited growth, everyone was happy. The intermediate level needs to be done away with altogether. Teach entry-level providers the current I-99 level. Raise the programs to associate degree levels. When these folks decide they want to advance to paramedic, they do so to a Bachelor's degree level. Services improve, education improves, there is actually a future in EMS, those that enter the profession spend more time learning how to perform the job, and they don't want to leave as quickly. Soapbox is now open for the next rant.

Ask your service rep to upgrade your LP12. Same capability as the Zoll, and it will be much cheaper. Also, consider the other devices that you will be intermingling with. If you interchange with hospitals and other providers, being able to do so without having to remove the equipment from the patient will make it much easier.

Most providers are so insecure with their own ability that they can't wait for someone else to make a mistake. If only so they can jump on it, and deflect attention from themselves for a while. Get three different levels of providers together, and you can bet that they will report the others mistakes long before their own. We the unknowing, led by the unwilling, etc., etc.

:shock: Wow Ghetto! Hard to believe you would believe what Dateline had to say. :shock: Besides, the removal of all of the bugs reduces your immune system's ability to fight them off. Bring them on!

Where in his back was the pain? Since he was moved prior to your arrival, it would be difficult to assess mechanism of injury. The decision to restrict spinal motion should be based more on your assessment findings than a strict protocol. Depending on information that is/is not readily available, both the medic and you could be right. You could both also be wrong. Take it for what it is worth.

Sounds like a good idea, but I can't help thinking the paperwork will be a nightmare. I work in a small western town, so I guess I don't qualify, but I'd like to give it a go.

In any group of people, there will be at least one that does not have any idea what is happening around them. EMS is no different. Some EMT's-of all levels-couldn't find their own backside with both hands and a mirror. Yes, the educational requirements in the US are god-awful. However, some providers take it upon themselves to become exceptional. Rare, yes, but it does happen. Increasing educational requirements, as has been stated numerous times, will only help the problem. I can't help but wonder how many of the current providers, would be willing to go back to school to be "upgraded" if and when it happens.

The state of AZ does NOT require any job/life/educational experience before enrollment in a paramedic class. The state requires: --current EMT certification --current BLS Healthcare provider, or equivalent --MMR/Hep B immunization record prior to clinical rotations --TB records within 6 months of clinical rotations --24 hours HazMat operational first responder. Scary, yes, but it is what the powers that be require. Now, the individual schools will add a point system for more experience, that can make it difficult for those that don't have any to get in. I know that my program, won't admit students with less than 1 year of EMT experience. Those that have 1 year are at the bottom of the list to admit, but they can be.

http://www.rxlist.com/cgi/generic2/propof_ad.htm There is where I got the information from. It doesn't give a time frame, only that it can happen.

You have been given absolute power for a day. In your new capacity you have decided to eliminate one level of current EMT certification. Budget is no concern, and everyone will support your choice. Which one do you choose? 1. First Responder 2. EMT 3. Intermediate(PCP in Canada) 4. Paramedic (ACP in Canada) I'm guessing a bit as far as the equivalency with Canadian levels, so work with me a bit.

Propofol can cause some tonic activity that mimics a seizure, but it will be short lived. Not really a common problem, but it is possible.

Wow! Did anyone else hear the mental doors slamming shut? :shock: The study that I referenced was begun in 2000, shortly after the last guideline revision. Dr. Ewy published his findings in 2003, and even presented them at the science gathering for the AHA before the latest guidelines came out. American Heart did not buy into them, because of the huge jump in the change from previous. The ventilation numbers are staggering. You guys are absolutely correct. Now, if we think about what happens, they can be viewed as reasonable. The 37 ventilations/minute comes from a study that was done in several locations. The only one that I can remember is Milwaukee, but I know there were other places involved. Even after retraining, providers were only slowed down to the mid-20's for rate. No, they were not using a ventilator, only a BVM. My view on this information is, if doing things a little differently will successfully resuscitate 2-3 more out of the 100 that I have to work on, then why not try it. If we are going to abuse a corpse, why not try something else. As the article states, if results improve only 10%, then wouldn't it be worth doing. Comparing to current/previous "guidelines", what would the harm be?

Cardiocerebral Resuscitation: A Newsmaker Interview With Gordon A. Ewy, MD Laurie Barclay, MD April 17, 2006 — Editor's Note: Cardiocerebral resuscitation (CCR) — employing chest compressions but no ventilations — improves survival of out-of-hospital cardiac arrest, according to the results of an observational study published by Michael J. Kellum, MD, and colleagues in the April issue of the American Journal of Medicine. Unlike traditional cardiopulmonary resuscitation (CPR), which was designed both for cardiac and respiratory arrest, CCR is designed only for unexpected, witnessed, cardiac arrest, which is by far more common than respiratory arrest as a cause of sudden collapse in adults. Animal experiments showed that the most important factor determining survival after CPR is cardiac perfusion pressure, achieved by continuous chest compressions. Ventilations may actually be harmful because they interrupt chest compressions, decrease venous return to the heart, and increase intrathoracic pressure. When paramedics in Wisconsin employed the new CCR protocol, with chest compressions before and after defibrillation but no intubation or ventilations, they achieved a 300% increase in survival compared with use of traditional CPR. To learn more about the clinical implications of this new protocol, Medscape's Laurie Barclay interviewed study coauthor Gordon A. Ewy, MD, director and pioneer of the CPR Research Group at the University of Arizona Sarver Heart Center in Tucson. Medscape: What was the rationale behind the CCR protocol? Dr. Ewy: The major rationale is that CPR hardly ever works. The survival of out-of-hospital cardiac arrest is dismal, averaging 1% to 3% nationwide. And in spite of periodic updates in guidelines, with the exception of early defibrillation, survival has not improved. Several experimental observations, when correlated, provide the rationale for a new approach to cardiac arrest, which we call CCR. It is well known that in patients with cardiac arrest secondary to ventricular fibrillation (VF), early defibrillation is the most important intervention. This is why the defibrillation shock from an automated external defibrillator (AED), when promptly applied, has been shown to improve survival in selected locations such as casinos, airports, and the like. But it turns out that this early "electrical phase" of VF arrest lasts for only about 5 minutes, and emergency medical personnel hardly ever arrive during this time frame. After this so-called electrical phase of VF cardiac arrest, the patient enters the hemodynamic or circulatory phase of VF arrest. And during this phase, applying an AED hardly ever resuscitates the patient. During the circulatory phase of prolonged cardiac arrest due to VF, the factor critical to survival is the prompt restoration of cardiac and cerebral perfusion pressures by chest compressions. Restoration of blood flow might slowly reverse the adverse effects of cardiac arrest so that the individual will again respond to defibrillation. Our interest in alternative approaches to the international guidelines began with the realization that most people who witness a cardiac arrest will not initiate bystander CPR because they do not want to do mouth-to-mouth resuscitation. Therefore, about 80% just call 911 and do not begin bystander CPR. By the time the paramedics arrive, it's too late. So our original question was whether doing chest compressions alone on people who collapse is better than calling 911 and doing nothing until the paramedics arrive. Our swine studies in 1993 showed that during prolonged VF arrest, chest compressions alone are just as good as ideal, standard CPR when we took 4 seconds for the 2 recommended ventilations before each 15 chest compressions, and much better than no bystander CPR. Since 1993 we've been saying that we should encourage the lay public to do chest compressions–alone CPR on adults with witnessed, unexpected collapse. Between 1993 and 1998, we published 6 different swine studies, including one study with the endotracheal tube clamped, all showing that chest-compression alone was equal to ideal standard CPR, and dramatically better than doing nothing. After the 2000 guidelines came out, Dr. Karl Kern, who is part of our University of Arizona Sarver Heart Center CPR research team, participated in a study with Dr. Chamberlain and colleagues from England to determine how to get lay people to remember and correctly perform CPR after they've been trained. As part of this study, they did videos on certified lay people doing rescue CPR, which showed that after they did 15 chest compressions, it took an average of 16 seconds for them to lift the chin, close the nose, take a breath, make a mouth-to-mouth seal, blow and watch the chest expand, repeat rescue breathing for a second breath and return to chest compressions. So they were pressing on the chest for only half the time that they were doing CPR. In a subsequent swine CPR study published in 2003, we showed that when chest compressions are interrupted for 16 seconds between each 15 chest compressions, 24-hour survival after CPR was only 13% compared to an average of 70% in our swine given continuous chest-compression CPR. This is one reason why we have advocated and continue to advocate chest compression–only bystander "CPR" for witnessed sudden collapse in an adult. The next observation was published by our colleague Dr. Valenzuela. When paramedics perform CPR following the 2000 guidelines, they spend only half the time on chest compressions because of the time they spend on other guideline-advocated activities, including intubation and ventilation. We therefore concluded that the recommended alternating chest compressions with breathing should be revised to improve coronary perfusion. The next observation was that in Tucson, the emergency medical personnel arrived at an average of 7 and a half minutes [after collapse] — not in the electrical phase of VF arrest, but in the circulatory phase. Thus, following the guidelines which advocated immediate defibrillation and 3 series of defibrillation was deleterious, as chest compressions were interrupted for inordinate periods of time while the AED analyzed, shocked, and analyzed. Because of these and other observations, we concluded that there is a better way to do resuscitation than the standard CPR advocated for the last 40 years. We called the new method cardiocerebral resuscitation, or CCR, to emphasize the importance of saving the brain. Medscape: What were the findings of your recently published study in humans? Dr. Ewy: We taught Dr. Mike Kellum and associates in Wisconsin the new method of CCR. When they implemented it, the paramedics would comment that they were having "saves" that they would never have had before. When Dr. Kellum and associates looked at the data, they found that neurologically normal survival improved from 15% with standard 2000 guidelines CPR to 48% with CCR. This 300% increase in survival in this study is almost too good to believe, but there is no doubt in our minds that CCR is definitely better than CPR. Medscape: How does this protocol differ from standard CPR? Dr. Ewy: One of the reasons that the CCR protocol is better than the standard CPR protocol is because it recognizes the 3-phase, time-sensitive model of VF articulated by Drs. Weisfeldt and Becker. The most important intervention in the first 5 minutes is defibrillation, which is why implanted cardioverter defibrillators and AEDs are effective. After the first 5 minutes, the fibrillating heart continues to use up its energy stores, becomes weaker, and cannot generate a perfusion pressure even if defibrillated. Studies in humans by Dr. Cobb and associates from Seattle, and Dr. Wik and associates from Norway showed that if one does chest compressions for 90 seconds to 3 minutes before defibrillation, survival is better. Therefore, rather than immediate defibrillation, the CCR protocol incorporates 200 compressions at 100/minute before defibrillation. Equally important, it also incorporates 200 chest compressions immediately after the defibrillation, prior to rhythm analysis and pulse check. The reason for this is that in our experimental laboratory, after prolonged chest compressions for VF arrest, the shock almost always defibrillates, but defibrillates the rhythm to pulseless electrical activity and not to a perfusing rhythm. In our experimental laboratory, we are looking at the pressure waves, so we immediately restart chest compressions to perfuse the heart, and the cardiac-generated blood pressure gradually returns. The most controversial aspect of CCR is the elimination of active positive pressure ventilations. We first delayed or eliminated intubation by the paramedics.This is a hard sell to paramedics. But this eliminated one intervention that resulted in a prolonged interruption of chest compressions. But why not let the paramedics or emergency medical service personnel ventilate with bag-valve-mask ventilation? The rationale for our approach of placing an oropharyngeal airway, a nonrebreather mask, and high-flow oxygen without positive pressure is as follows. With normal breathing, intrathoracic pressure decreases, but positive pressure ventilating increases intrathoracic pressure and thereby decreases venous return. The result is decreased cerebral and myocardial perfusion. Thus, chest compression without ventilation results in better myocardial and cerebral perfusion pressures and increases survival. Another important factor is that we and others have shown that physicians and paramedics are so excited during a cardiac arrest that they overventilate — an average of 37 ventilations/minute. It is very difficult to get these individuals to ventilate less, unless you do not have them ventilate at all. Another observation that taught us the importance of cerebral perfusion was listening to a recording of a lay rescuer in Seattle doing dispatch-directed CPR. After a while, the woman returned to the phone and asked, "Why is it that every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Out of the mouths of babes! That woman learned in 10 minutes what it took us 10 years to find out. Whenever you stop chest compression to do anything, including breathing, it is bad for the brain as it reduces blood flow to the brain. The question that I am most often asked is what happens to the blood oxygenation? My answer is that if one does adequate continuous chest compressions, the individual often gasps and this agonal type breating provides reasonable oxygenation. In the absence of gasping, the blood gases are very bad — but guess what, the individual survives. Thus, the medical and paramedical obsession with blood gases and thus ventilation, and not looking at neurologically normal survival as the most important end point, has been one of the major impediments to progress in resuscitation science. Medscape: Why doesn't CPR work well? Dr. Ewy: The fallacy of CPR is that it was designed for 2 totally different pathophysiological situations: respiratory arrest and cardiovascular arrest. What is beneficial for one may not be for the other. The reason for a single approach is that it was, and to many still is, thought that the lay public cannot tell the difference between a respiratory arrest and a cardiac arrest. I think they can. If you pull someone out of a swimming pool, or if they stop breathing after a drug overdose, that's a respiratory arrest. But an unexpected, witnessed collapse in an adult is almost always cardiac arrest. The most important intervention for cardiac arrest is continuous chest compressions to perfuse the brain, to keep the brain and heart alive until you can shock it. If one can use the AED in the first 5 minutes, that's fine, but there are 2 major problems: the first is that the paramedics usually do not arrive in the electrical phase of VF, and the second is that the lay public does not use the AED. In Arizona, over 2,500 AEDs are registered, and we have knowledge of only 10 being used by the lay public. Medscape: Are there situations in which the CCR protocol should not be used? Dr. Ewy: For respiratory arrest, you need to breathe for the person. The new CPR guidelines should be followed: 2 breaths alternating with 30 compressions. But the major problem is that most lay people won't do mouth-to-mouth, so they just call 911, and by the time the paramedics get there, the person is dead. Medscape: Are there any negative effects of CCR? Dr. Ewy: Not that I know of, if it is used on adult subjects with witnessed, unexpected collapse. Medscape: What additional research, education, and training needs to be done before this protocol is widely adopted? Dr. Ewy: I think CCR should be widely adopted right now for unexpected, witnessed collapse in adults. In fact, I think it should have been adopted in 2003, when we did. As for teaching, we should emphasize that CPR should be reserved for respiratory arrest. But for witnessed, unexpected collapse in an adult, we teach laypeople a 3-step protocol: first, call 911; second, start chest compression–only CCR. If another person is available, each do 100 compressions and trade off, as continuous chest compressions is hard work. Third, if there is an AED around, put it on and follow the directions. I think this approach should markedly increase the prevalence of bystander CPR, and bystander CPR significantly improves the chance of survival. For paramedics, I think we need to do more research to determine when assisted ventilation is absolutely necessary. We are doing such studies now. Medscape: If the protocol is widely implemented, what effect do you believe it will have on public health? Dr. Ewy: The most common cause of death in the United States, Canada, and Europe is sudden cardiac arrest. CCR is significantly better than CPR, and if it's widely adopted, it will have a significant positive effect on public health. We now have data in humans to support what we've found in our animal experiments. Our recently published observations in humans showed a 300% improvement in neurologically normal survival in patients with witnessed out-of-hospital cardiac arrest and a shockable rhythm when the paramedics arrived. This study is almost too good to believe, but if we can improve survival even by 10%, there will be a huge benefit worldwide. I know if we follow these CCR guidelines, survival is going to be a lot better than it has been for the last 40 years. Am J Med. 2006;119:335-340 Reviewed by Gary D. Vogin, MD -------------------------------------------------------------------------------- Laurie Barclay, MD is a freelance writer for Medscape. Medscape Medical News 2006. © 2006 Medscape

Look into this before talking about reverting to previous standards. http://www.medscape.com/viewarticle/530114 2 minutes of uninterrupted compressions only. Performed at 100 compressions per minute, then the defib is applied. It is in place as a statewide alternative to standard CPR in AZ.

In the words of Dirty Harry Callahan, "Opinions are like a%%holes, everybody's got one." Anytime you are dealing with other people, especially those you can't see, you need to put the thick skin on. I don't think that the intention to bash or b#$ch is there. The occurrence is more a result of not being able to hear the tone or body language of an individual. Now, some of the threads are started to spark debate. When this happens, you can't expect 6900 people to all agree on every point. If we can read the posts, and learn a little, and at the same time teach a little, then it has been a successful sharing of information. I've been in the chat rooms only a handful of times. I just don't appreciate the utility of the format, so I don't spend much time using it.

I will go ahead and agree with most of what Dust wrote. I will also disagree with eliminating EMT-B's entirely. I want my EMT partners to feel that they can ask any question, and get a reasonable answer. My issue is their timing of the question. Don't argue with me. If you ask, I will be glad to explain the why's and how's of what I am doing. If you present your question so it sounds argumentative, we are done. How do we fix the problem? Yes, education would help immensely, but where do we put it? More before people are allowed into a program, ala "pre-med" style, or do we simply make the current standard longer? Until there is a standard that everyone must be held to, it will be a tough sell convincing the bean counters to pay for more. I would welcome an entrance requirement of, at minimum, an Associate's degree prior to moving into an ALS level course. This way the BLS provider would have a broader view of education than is currently in place, and be able to ask better questions when they get into the field. Also, eliminate the "grandfathering" that is so common now. When the standards are raised, everyone needs to be held to the same one. Allowing some to continue with the "old" ways only cheapens the efforts of those that try to increase what is needed.

Does it count if you dream of blowing up the station? Dust and cosgro have obviously forgotten about the REDHEADS.

Pulse oximetry is only as good as the provider that is reading it. If you truly understand the device's limitations, it will help you. If you add this information to what you have gathered with other tools, it can help you. If you use it as a stand alone measurement, you have made a huge error. Give a monkey a hammer, and they can't build a house.

You can do a similar gyration with the Combi-tube, but again, this is a different situation. Now, if you can find a provider that will grab the Combi-tube first, before any attempts at tracheal intubation, I would ask that you introduce him/her to me. That way I can mark it on the calendar, that I have met someone that will do it.

Ditto Rid, Bag mask ventilation becomes dicey with the end of a tube hanging out the mouth. I will say that I have used this idea on the airway that is destroyed with blood and puke, where visualization was near impossible. If you are considering using it, consider the fact that before you shove a tube into the oropharynx, you really need to be able to see the glottic opening. Otherwise, you are increasing your chances of damaging the soft tissue dramatically. If you feel the need to place a landmark, which is all you really accomplish, use an NG/OG tube for it. It's smaller, designed to go into the esophagus anyway, and you can achieve some degree of airway clearance at the same time. In the off chance it ends up in the trachea, you can place your ETT over it.

They told you this so that they had something to fill the space. Clamp the cord in two places that are far enough apart so you can get the umbilical scissors or scalpel in between them. The distance from either end is really a matter of convenience. Too short, the clamp won't hold as well. Too long, you get the cord caught on things. Preferrably, the cord should be cut sometime before the child reaches puberty, but you don't see this too often.

Anyone that wants to reduce the amount of work that I have to do is welcome. That said, if you want to start IV's, place advanced airways, push medications, or use a manual defibrillator/monitor, I only ask that you receive enough education to justify your being allowed to do so. Four to eight hours in a classroom just does not translate to the field to well. If you have a question, ask us. We may not be able to answer immediately, but we will when we can. If you don't like the answer you get, ask someone else as well. Taking the responsibility to increase your education on your own speaks volumes about your mindset.

So I'm guessing they didn't find much besides the nails in this specimen's skull. Give a man wheels, and he will race. Give a man a power tool, and he will find a way to hurt himself with it.

Time to pull out the reference material again. I like rxlist.com for drug information. It can be tedious to keep track of all the new meds, but the ones that are listed are well described. I also do a daily update through ePocrates to my PDA. This gives all the newest FDA warnings about medications.

Just what EMS needed. Another shortcut for agencies to use to provide pseudo-ALS without paying for it. :roll: