iStater

Ruff meister Please accept my apologies for not replying to you. I thought from our previous messages that you were finished with the conversation. I have not replied to you because I am not always on these forums. I don't care to get any notifications about this site. I work fulltime and I do have a life outside of work and forums. At work I do not get much computer time except for charting. I am not Ventmedic nor do I know who that is. Thank you for telling me who Triemal and ER doc are. I only got on this site because of an EMT who posted identifiable information about a patient who was an IFT. I hope I prevented him from losing his job. Hospitals do take their patient confidentiality seriously.

island EMT There was nothing when I signed on with the name iStater that it was already in use by someone else. I will take your comments as an attempt to discredit my concern about profanity being directed at a 14 YEAR OLD on a public website which has EMT in the title. If you do not want children on this website you should have the entrance like a liquor website. It may not prevent them from entering but it might deter a few. I will do my part to get our IT department to filter this site out of the Children's hospital internet which should help for your mission of little children should be seen and not heard from. Your comment should help make this easier to accomplish.

Why do you feel the need to vent against this 14 YEAR OLD triemal04? Why can you not type without cursing or insults? I could have offered advice to the OP but that would have probably just made you more angry and wanting to carry on your venting at this 14 YEAR OLD and probably at me too. If you swear at kids to shock them....

By the post make by island EMT, not much is off limits here when it comes to addressing kids. I am not just sticking up for this 14 YEAR OLD KID. I am sticking up for kids. You adults with professional certs and licenses should know better. The first post gave his age. You should have adjusted your posts accordingly. I will restate, YOU are the adults responding to a 14 YEAR OLD kid regardless of the topic. EMS is not in very good shape if a 14 YEAR OLD kid who is wanting to be an EMT but needs some guidance is reflecting negatively on you.

The only ego at stake here seems to be your ERdoc. As I said, give it a rest. You have beat up this 14 YEAR OLD enough. Even if you use the abbreviations, a 14 YEAR OLD will know what they mean when it comes to cursing. I am still not so concerned about a 14 year old who wants to be an EMT and hasn't learned all the legalities of it as I am about someone who should know better than to go after a 14 year old on an EMT forum in the manner you have. If someone hears a 14 YEAR OLD make a statement about being an EMT, those are in his area might know he left off the "junior" or explorer part. I doubt if it warrants a cursing. But, if others were to over hear the conversation posted here directed at a 14 YEAR OLD, I would hope any responsible adult would intervene regardless of your patch.

We are hearing how he understands this as a 14 YEAR OLD. He may know only what the card issued to him but no one has told him about all the ins and outs of state and the NREMT or if his state uses the NREMT. A quick search on this forum also shows people who say they are EMTs an Paramedics but are also confused about the new levels and the NREMT or their state certs. He will learn more about the legalities of a "title" when he gets into the EMT class. Until then, you could have explained it to him without attacking him and the profanity. I have stated that the NVFC has a program and participants are "registered" with them after completing the training. New York is one of the leaders in these programs. But, unless you participate in youth programs you probably won't know much about them but that does not mean they don't exist for ages 14 - 17. My main issue here is with the bullying and abusiveness by the profanity which is directed at someone who states he is 14 YEARS OLD. Coming from those who claim to be Paramedics and EMTs, this is inexcusable. If you thought the OP was bogus, you could have chosen not to respond and report it the moderator of this forum. You did not have to engage in an attack with profanity with someone claiming to be 14 YEARS OLD. Regardless of the subject, don't use profanity at a 14 YEAR OLD and definitely not when you are an EMT or Paramedic in public or on a public forum. ERdoc, give it a rest. You have shown us you know more than a 14 YEAR OLD.

A plethora? Small towns in the US don't always have a college, a big library or lots of EMTs. Even EMTs or students in the big cities complain about their resources or seek out help on the forums. Why does anybody ask questions on the internet? Maybe he just wants to branch out a little or network to see if all EMS is just like the volunteer and maybe partially paid organization he is familiar with. I doubt if the paid EMTs have that many calls to their name in a very rural situation. Several small communities start junior EMT and FF programs to increase an interest in EMS since there are not that many other ways to gain an insight but still resources are limited. He may also have limited access to the paid EMTs if they conflict with his school hours. He even stated he was asking this to gain information from more experienced people. There are also many websites just dedicated to EMT study questions but some are good and some are really bad. Young people today also like to use the internet for meet and greet. Maybe if the discussion had be directed more towards what part of studying for the EMT he was interested in before starting in with profanity to prove a 14 y/o wrong, it might have been interesting to hear from a young person who takes an interest in EMS including the mechanical aspects of truck maintenance which is somehow overlooked by a few as the headlines have pointed out in recent months. I doubt if many 14 y/os have this much of a grasp of what EMTs or FFs do. This 14 y/o was telling you as he understood it and as he was told. A lot of paid EMTs don't understand their certifications or state and national agencies. So much for all of the teach the public stuff. How many members of the public, after seeing this discussion, would be eager to ask questions about EMS if you tell a 14 y/o to STFU?

This young person asked for advice for studying for the EMT exam. Why not clarify a few things first about his certifications before cussing at a kid out on a public forum? To the OP: Are you part of a junior volunteer program which is part of the National Volunteer Fire Council - NVFC? The word National can be misleading as Federal but this is a National program available to all states with similar recognized standards. This is a program which is available to communities/departments for ages 14 - 17. Each state has a part in regulating what participants can do per labor and child safety laws. The participants are "nationally registered" meaning they are listed as junior FFs and junior EMTs. The card they carry will use that terminology also. There are also explorer programs by departments which may fall under a different category and standards outside of the NVFC. Their training is similar to the regular EMT program just like the Boy Scouts' program although the Boy Scouts' program usually exceeds EMT training by including wilderness first aid as an option among other survival skills. The uniforms are often the same as the regular FFs and EMTs which means you have to look close to see "junior volunteer". They are allowed to participate in public events, at first aid stands and to ride in the ambulances. Some of the things the junior members are allowed to do can be a little disturbing to have a young teenager doing but are often defended by the Medical Director, the Doctor. An example would be a 15 y/o junior EMT removing the bra from a woman or young girl and placing the ECGs electrodes. When the ED staff questioned this the Medical Director told us the juniors had to get used to nudity if they wanted to be an EMT. The US Department of Labor and each state have child labor laws. The OP did state he worked with a mechanic and not as the chief mechanic. A lot of kids get jobs at 14 or 15 especially in rural areas. As long as no child labor laws are violated, I say good for them.

Decreasing the tidal volume prior to transport could lead to problems. The ABG was 7.40. Transport ventilators do not compensate for compressible volume loss. If yoy have a PIP of 36 cmH2O this could mean a loss up to 72 ml. If the patient decompensates mid transport from a significant decrease in tidal volume plus the compressible volume loss you will have a difficult time regaining previous staus and may cause damage with the reopening pressures. Making several changes on the meds just because you can before knowing how and why this hospital got to those settings can lead to a crash. Sometimes attitudes of the transport team towards the sending facility gets their patient into the most problems. Since it is still not clear about the type of flu, practice strict precautions o prevent airborne contamination. Transport ventilators are difficult to isolate. Make sure you have adequate filter at the ventilator outlet and one to prevent or minimalize exhalation spray. Even with that masks for the caregivers would be advised.

Of course there is concern which is why I asked about it earlier as did someone else. You also asked about the CT angio earlier. The OP just told us about the leak stopping when pressed. The post I wrote about ARDSnet ant ventilator settings, that was in response to the OP's question. That also is a very brief explanation.

Calculating tidal volume is like calculating medication. You don't just pick random numbers or say "ARDSnet" unless your data backs it up. Some hospitals and transport teams may use a different protocol depending on their research or review of the literaure. Transport teams may need to use a protocol which adusts for the compressible volume loss of their ventilator circuit. This can be anywhere from 0.5 ml/cmH20 - 2 ml/cmH20. Studies have shown a 10% variation from set tidal volumes. Check the compressible volume factor on the circuit you are using. You also do not just start with 6ml/kg. The recommendation is to start with 8 ml/kg, get your data including ABG waveforms, PIP and pPlat. For this woman here extra 30 kg of obesity must be considered since that may affect numbers. Your waveform is analyzed by the mode, wave delivery pattern selected and variations of that wave for delivery by adjusting flow and/or rise and termination. You have an ICU vent in front of you. There is alot of data to be obtained which can help you set up a transport vent. The changes in tidal volume from 8 ml/kg to 6 ml/kg are done slowly over 4 hours. You must take into concideration of the MV and may need to adjust the rate up to 35 bpm. This is where waveforms are vital and also where some transport vents fail. Their flow delivery is inadequte to meet demand especially at high FiO2. But, before making any changes to meds or the vent, you do need to ask questions. The nurses flow sheet is a wealth of info for you and the nurse to review. Experienced transport RNs can scan a flowsheet in 30 seconds and formulate a plan for meds and ventilator. The questions include What happens when they triec to wean the sedation? How they got to the vent setting is important even if it is just to chase numbers. Did they try to run a high PEEP ARDSnet protocol and had to abandon it? Did the sending hospital increase everything in anticipation of this transport. This hospital may have had a previous experience from another transport.

Nurses usually measure ventilator patients for a more accurate height. If not, it only takes a few seconds to do. You still need to know what the PIP is and the pPlat if it is possible to obtain with the air leak. Graphics are again impotant. This will guide you in dropping the tidal volume. But, make to many vent changes and taking off sedatives and/or paralytics is a recipe for something happening which you won't be able to correct. Going into a low tidal volume vent setting is no fun for the patient and their body will respond to this setting in not a good way.

I would rather know what the nurse's flowsheet says. The RT sheet seems to be questionable for the info given about this patient. The settings looks random like they were only chasing numbers. I suppose there is no point in asking about the graphics either but waveforms are a very impotant part to consider and very useful to monitor if your transport vent has this ability. What is the fluid amount in via IV? Output? Can the fuids be reduced? Acid base can make or break oxyegenation. I take it the base and HCO3 levels are normal on the abg since the pH is 7.40. Knowing acid base will guide you wiggle room when transferring to a transport vent. Obviously no ARDS protocol is being done for vent management. However that does not mean you shouldn't prepare for acid base issues which might arise from a transport vent. In a patient like this we would not strive for a 7.40/40/3 digit PaO2 if it means crashing the BP and blowing another pneumo. This is why the ARDS protocol expands extensively in acid base. I would still be very careful with weaning too much on the sedation or even the paralytic for transport.

There is nothing simple about this patient. Wean too much too fast and you won't get back the lost ground especially with a transport ventilar. Patient dies. A paralytic would be the easiest to re-establish but deep sedation should be maintained if BP permits. You don't want to risk dys or asynchrony. Still awaiting blood gas verification to see if something creative can be done with the PEEP and other settings. But the transport vent may have vaiations for PEEP and tidal volume if single limb. How tall is this woman?

Still awaiting verification of labs. I would be very cautious about blood products now given the positive fluid balance. If labs were drawn after lots of fliud the number could be misleadingly low. Given the status of the kidneys and positive fluid balance, the paralytic should be the first to go if BP and ventilator holds steady. You also do not want this patient to wake up and buck the vent at any time during transport. You might ask the sending physician if this is his or her thoughts in preparation for transport. No need to repeat past mistakes. Also, considering the fluid balance, is the lactate trending down and was the high lactate attributed to the cardiac arrest or sepsis? Is the sending facility thinking dialysis to happen upon arrival at receiving facility? ECMO? Still dependent on clarification of ABG.