FireEMT2009

Kiwi, I like you wandered back into the forums after a few years hiatus myself. Happened to get a random junk email from EMTCity about a post I might be interested in and here I am looking through forums and reminiscing on my old, posts as a paramedic student and new paramedic. The nostalgia is real my friend.

So, I am a paramedic program director (have been for a couple years now) Some of you who remember me from few years back will know I started out in the fire service, got my paramedic, and did rural EMS before landing into EMS education. I just want to make it clear I didn't go directly into education without paying my dues in field time. I think this is a bad move for NREMT. It adds a loss of trust to hold EMS certifications in a higher standing as well as a loss of trust that they are acting in good faith. Let me explain why. If you look at most any other healthcare profession, whether that be nursing, PA, NP, respiratory therapy, radiology technician, etc. They are all accredited programs and you have to be accredited by their one or multiple accreditors before you are even thought about being allowed to test. Accreditation means that you get reviewed every so many years (CoAEMSP which is the EMS accreditor through CAAHEP, does their reviews every 5 years with annual reporting every year). This site visit and comprehensive review makes sure that you are holding to the minimum standard expected by CAAHEP and if you aren't, what you need to do to get yourself straightened out. CoAEMSP luckily is not a hard-ass committee on accreditation that wants to immediately punish you and revoke your stuff because you missed something, but they act in good faith that they will inform you of your missing areas and give you time to get it straightened out and assist you in doing so if you ask. The current NREMT requirement of CAAHEP accreditation makes sure that all paramedic programs are at least meeting those standards. One of the biggest standards is that the programs are held accountable to what they require of students as well as mandating that programs do continuous internal reviews of their programs to improve them every time. This is hugely beneficial for programs in general but also improves our education and end level competency for our paramedics who are entering the field to start filling holes set forth. How can this be seen as acting in bad faith? I see it as an act of bad faith because it makes all the work and stress of programs who had to meet and maintain the CAAHEP accreditation requirements and the money and time spent to do it a waste. Accreditation is expensive, especially initially getting accredited, whether that is going through CAAHEP programmatic accreditation or starting with institutional accreditation and then getting programmatic. It is also a huge time investment for the programs. Especially when you look at program directors. We see about a quarter of program directors leave the position each year in paramedic programs, a lot of the time due to the stress and hell that the job can be from time to time. Also, I don't think we do a great job prepping our program directors to transition well from EMS providers to program directors, but that is a different Ted Talk. NREMT made this requirement with a hard deadline all programs must meet (again some just needing to get programmatic accreditation while some had to get institutional accreditation then programmatic accreditation as you cannot get programmatic accreditation without institutional). This was done with the expectation, belief, and faith that NREMT would not back down from this requirement and it would hold true to that mandate. They started this requirement to mandate full CAAHEP accreditation or letter of review (meaning in process of gaining programmatic accreditation) as of January 1, 2013. We are now less than 10 years or two site visit cycles away from that decision and suddenly they have decided to back away from that mandate. It is hard to demand our profession be respected, paid better, and recognized as the profession we should be when our own certification agency is willing to drop standards and burn all the programs that have been working to obtain, meet, and maintain these standards. I hate the comparison of EMS to nursing as its apples and oranges, but EMS and NREMT need to pull their head out of their asses and keep the accreditation requirements they have adopted just as all other healthcare professions have before us. Once you go back to "state approved", its hard to say what standards those students are being held to cause there may not be a third-party double checking them.

Alright guys two things. Here's the deal. I am considering starting my critical care paramedic education process. They offer a satellite campus of the CCEMT-P class nearby me but I also found the University of Florida Critical Care Paramedic program that can be done online that you come to Florida to do a cadaver lab and have two days of clinicals, and the Creighton University Critical Cara Paramedic program is also online but does require clinicals in your local area. I know many people do like the CCEMT-P course but did anyone have any issues with it? Did it allow you time to practice skills, etc. Does anyone have any experience with the University of Florida CCP or the Creighton University CCP courses. Trying to get a good wealth of reviews and experiences in each program if I can. Also I have the Brady (Bledsoe authored) Critical Care Paramedic textbook, is that a valid critical care book to start my self studies in, or should I just go ahead and pay for the Critical Care Transport book that the AAOS puts out? Thanks

My only issue with using Roc right off the bat is the fact that it has such a long period, which as a continued paralysis med, absolutely but at the same time if we have the issue where she is a difficult airway for some reason you are looking at BVM ventilations through either a king or OPA for about 30 minutes and I don't overly like that idea, which is why I would use the succ for initial induction. For the ICP as I put in earlier since we are looking at a strong indication of ICP with possible herniation we need to increase her vent rate to 20. Also keep her about 45 degrees during transport. If your looking for a medication and your department allows it and you have the right tubing, Mannitol would work great here as an osmotic diuretic. Sounds a lot like a subdural bleed to be honest. If you have the pictures and follow up I would love to see and hear them

Well her airway and breathing is an issue.. Suction her airway and start BVM ventilations at a rate of 20 due to possible herniation (see below) since her SpO2 is still bad with BVM. If she continues to show poor airway management then RSI would be my next step in this (I would delay this to see if the BVM ventilations would improve her mental status. I am concerned about a brain bleed or at least ICP so I would stick with Etomidate at 0.5mg/kg and Succ at 1.0mg/kg as initial induction and paralytic as well as an amp of lidocaine for possible ICP. I want to stay away from the ketamine here due to the possible issue with ICP.) I would use standard PPE with N95 respirator. Is there any symbols or letters on the pills that I can see and reference either with poison control or online index? This heart issue is it anything to do with mitral valve or irregular heart beat? Any medical paperwork, Dr notes, file of life, etc. in the residence? Currently I am suspecting either a head bleed or CVA or even a narcotic overdose especially since there isn't as careful FDA requirements in other countries and with her pupils being sluggish and her breathing slow. I would try IV narcan at 0.8mg to see if that effects anything unless we find out something on the pills. At the same time I'm worried about the head bleed due to the two of the three Cushings Triad with the hypertension, irregular respirations. Right now all we are missing is slow heart rate but we are probably gonna get close to it with that or the bradycardia from hypoxia. Did she collapse suddenly and regain consciousness PTA or has she remained semi-conscious since initial syncope?

If she is unconscious I would insert an OPA if she could handle it and start bagging her about 10 to 12 times a minute and probably go ahead and intubate her for confirmed patent airway if she does not arouse after oxygenation for a couple minutes. In either scenario, lung sounds? heart sounds? bilateral pulses (paradoxis?), skin color temp? Bibinski reflex? If she is conscious give her 15 LPM NRB to start with, titrate down to keep her from becoming hyperoxemic. Everything Matt above me stated as well as getting some information on what herb she took if she has the box or bag it came in and also what did she eat over there I.e. Bird meat, beef, etc. This brings St. John's Wart to mind for some reason but I would also consider SARS, bird flu, mad cow, and any other weird disease she may have brought back. How long of a flight? Any hx of blood clots or birth control? Did she get up at all during the flight? And any complaints of CP or SOB? Did she go diving?

I don't think you are dinging me at all, criticism and discussion makes us better as providers. I don't believe I gave enough information on the assessment that was actually performed. There was no fever in this case, nor any resolution in his symptoms. They actually evolved and worsened over the transport. As far as I know it was listed as a CVA although I know there was no head bleed, which was what I was suspecting throughout the transport.. This was an interesting case, but sometimes, as we all find out, it may not overly work well in scenario forums especially since it is all dependent on if I give the correct information in the right places.

Nervous, I am not sure how to answer that question, as I am not a OTR truck driver. It may be better to find a forum that deals with OTR trucking to get the answer you need, or contact the company in general.

I agree, and I apologize for my delayed response. Lactate levels are there to show hypo-perfusion, I was using it in this scenario as a way to detect the hypo-perfusion of the brain in this case since this case deals with a possible head bleed or CVA. Even though we all can tell this is some sort of neurological impact, it may not be exactly clear whether or not this is a CVA, TIA, infection, etc.I understand that I "mis-typed" my response by oversimplifying it to a point that it became muddled and incorrect, and for that I apologize. I don't glamorize lactate as just a cool tool, but as a diagnostic tool to build,and strengthen my differential diagnosis. I know field lactates are very sparse in who has them or doesn't have them, therefore was just giving a way to see if anyone, A. used them, and B. would want the information there if they had access to it. I am all about treating my patient not my machines.

Haha! The bird has a flight time of 25 minutes one way to you, whereas, there is a regional hospital approximately 20 minutes away emergent, and they do have a CT scanner but they are not a stroke center and will either fly or ground transport the patient out to the same facility that is the stroke facility (also a neurosurgery center) that is 45 minutes away form you currently. Would you consider using lactate testing on this patient? His pupils are mismatched, with the left side being about 5mm, and the right being 2mm. The left eye is also sluggish to respond to light. You also note now that after approximately 10 minutes from arriving on scene, he now has weakend grips in the left hand and weakend strength in foot and also has facial droop on the let side. He also tells you that his eyesight in his left eye is getting much worse. Would you rather go by ground or air, and if by ground, which hospital? You are approximately 20 minutes since onset time. If you decided to transport what would your treatment plan be?

Well right now the only one offered near me starts in September that runs for 12 weeks., but I will be in some training that the fire department I work for wants me to take, and I will start precepting our new hires shortly. I could challenge the CCP-C soon, but I want to take the CCEMT-P course first that way I actually have taken a true critical care class. Since UMBC teaches it I am about 4 hours away from there and wouldn't mind taking their two week course but its $1500 for just the class not including hotel fees, food, gas, etc. So I am trying to save up to take it either there or the closer one that is $1,000 dollars.

So when you start to get some demographics he can give you his SSN, but is unable to give you his date of birth or address. No expressive or affective aphaisa. He also complains that his left eye seems slightly blurrier than normal. You are approximately 45 minutes away from your nearest stroke center, and you aren't in one of those fancy ambulances. Once you move him into the ambulance you notice that his speech has started slurring. What other information would you like? Any diagnostic testing you want?

Hello everyone, Has anyone taken the CCEMT-P? I am looking into taking it in the next year and am interested to get anyone that has taken it, their opinion. I have been interested in critical care for a while now and want to work on getting my critical care certification. Once I take the CCEMT-P I want to challenge the CCP-C (Basically its the ground transport critical care certification that matches the FP-C, and is given by the same organization). After I get them I want to try and get hired to do critical care transports, not flight since it would be very hard for me to get around 200 lbs due to my height.

Thanks guys!