chbare

Ketamine has a rather large side effects profile. Also, it's a direct myocardial depressant. However, those effects are usually negated by the increased sympathetic tone associated with ketamine administration. That is until you administer it to a catecholamine depleted patient...

I'm not sure a similar analog exists. When comparing epinephrine and albuterol, you are comparing complex molecules. The big difference between them involves molecular changes. With albuterol, you make a change to the hydroxyl group on the number three carbon of the benzene ring of an epinephrine molecule and you end up with albuterol. Magnesium is an element and modifications would either change the element all together or substantially change it's electronic structure. The only realistic change would be to add electrons to the Magnesium ion and revert to elemental Magnesium. Unfortunately, the consequences of administering elemental Magnesium would be disastrous. However, you may be on to something. Perhaps there exists a molecule the acts like Magnesium on smooth muscle but lacks the side effects?

When considering the deposition of aerosol particles in the airways, assuming the correct size for the specified generation you wish to penetrate, three mechanisms should be considered: 1) Brownian motion and subsequent diffusion 2) Gravitational effects 3) Movement bias and inertial impaction Unfortunately, having a patient wear a mask and allow them to talk during nebulised aerosol therapy is counterproductive and makes an already inefficient mechanism of delivery even more difficult. The optimal breathing pattern is a slow, deep inhalation followed by an inspiratory hold and exhalation. This minimises inertial impaction in the upper airways and optomises the role of Brownian motion and gravitational settling in order to ensure penetration of the lower airways occurs. Unfortunately, this is not likely to occur in a sick patient who is already tachypneic. However, having somebody talk with a mask only compounds the issue. While you interview them, they will be taking short breaths with an irregular breathing pattern. Also, when the mouth is closed, particles experience inertial impaction on the mask and the patient's face. Ideally, we would like to coach the sick person in a proper breather pattern using a mouthpiece and optimise the three mechanisms as discussed above.

Bushy, I am not sure how helpful an ICU book would be to a fledgling paramedic student. For example, how helpful will it be reading about early goal directed therapy when you don't even know what CVP is or have any detailed understanding of sepsis and septic shock. Recommending a book to an entry level student with a rudimentary understanding of medicine is exceptionally difficult. Anatomy and physiology, medical terminology and dosage calculations would be at the top of my list. However, it's still not going to be helpful reading material you do not understand. Therein lies the crux of this thread. Is there material that is inherently intuitive to understand that will result in high yield information for the prospective paramedic student?

Just remember, the OP asked about respiratory arrest. In this setting, non-invasive ventilation would not be helpful.

Did you talk about early and late phase inflammatory response in school? If not, basically, you have two broad periods of time associated with asthma triggering and the inflammatory response. You have the early phase where you have mast cell degranulation, release of inflammatory mediators and so on. Next, you have the late phase response that is associated with the metabolism of a substance from ruptured cell membranes known as arachidonic acid. This phase can take several hours to develop and is one of the reasons why you can treat initial signs and symptoms, only to have them return hours later. My point being, steriods are good at preventing the early phase and preventing the late phase issues; however, not as good at dealing with an acutely deteriorating patient. However, the long term benefits of early steriod use cannot be ignored. Unfortunately, treating a severe, refractory asthma attack (status) will be difficult and quite complicated as the patient you have described will likely be moribund. Ketamine, magnesium sulfate and inhaled anaesthetics are potential options with varying degrees of evidence to support their use. Ketamine and magnesium are probably realistic options. I would also be very careful about ventilator management. You will need to allow for a prolonged expiratory phase. You may even do this at the cost of allowing the CO2 to rise and initiate permissive hypercapnea. IM epinephrine and terbutaline are options along with in line inhaled Beta agonists with an anticholinergic agent. Also, a fluid bolus is probably a good idea for many acute asthma patients. In the hospital, you can even look at heliox therapy.

I had a case study published in a short lived EMS magazine and I am a contributing author for the AMLS instructors package. Currently working on an airway study and will hopefully publish next year,

Yes, started a new IV and readministered with desired effect.

I received a PM some time ago asking me to provide evidence regarding statements I made about the "hypoxic" drive scarecrow. I am sorry that I have taken so long to look at my PM box, life has been crazy with my wife taking a job out of country and my new full time teaching job and part time EMS associated moonlighting. No excuses however. If you are willing to put down some money, I highly recommend a respiratory textbook known as Egan's Fundamentals of Respiratory Care ninth edition or above. I will warn you that it does not hold hands and it does not pull punches, therefore it can be a difficult read if you are not at least familiar with physiology and chemistry. The acid-base balance chapter is rather liberal with basic equations. There is actually a dedicated chapter on the regulation of breathing and the physiology of Oxygen associated hypercapnia is discussed. Conventionally, people say that the hypoxic drive causes the PaCO2 to increase in COPD patients; however, newer thoughts paint a different story. While the hypoxic drive theory is not totally dead, many issues must be appreciated such as the alleviation of hypoxic pulmonary vasoconstriction and changes in V/Q matching among other thoughts.

As a 99 you have to transition to paramedic. You will not end up having less ability assuming you transition.

Mike, I think you answered your own question. Your EMT class simply did not have a robust enough curriculum to provide enough of a foundation for you to even understand what pacing actually is, let alone how and why we use it. This is not an insult against your intelligence, rather I am simply pointing out that certain procedures cannot be performed by people who do not have a certain level of education. For example, I could not go around administering general anaesthesia or performing hip ORIF's because my level of educational preparation has not prepared me to adequately understand those concepts in any detail beyond a rudimentary appreciation

Actually, we are very conservative about continued paralysis in the hospital. A paralysed patient cannot interact with the ventilator, cannot interact with us and may have issues with thermoregulation. Paralysis beyond the initial intubation is not something I commonly see. Paralysis for procedures such as bronchoscopy is not something I see as well. Paralysis may be a consideration for transport if you can document valid safety concerns, but judicious should still be the word of the day.

Dwayne. What you are asking would be a different study. This was a retrospective study of over 60,000 patients in over 400 hospitals. I have not seen the entire study but multilevel regression models and risk adjustments were included. The exact methods they used are not known to me. This is how the scientific process works. Interesting literature is presented and people like you ask questions, design their own studies and over time, with enough studies that look at enough angles of an issue, a clearer picture develops.

Hyperoxygenate is administering significantly greater amounts of Oxygen and increasing the blood Oxygen levels higher than normal. Hyperventilate is to move air in and out of the lungs at a greater than normal rate. For example, you can hyperventilate your self on room air but not hyperoxygenate. You can also hyperoxygenate a patient but not hyperventilate. *Ventilation is the movement of gas in and out of the lungs. (Minute ventilation is the product of respiratory rate and tidal volume and generally measured by looking at the PaCO2) *Oxygenation is the amount of Oxygen in the blood. (Measured by the content of arterial Oxygen equation but generally the PaO2 is a reasonable reflection of Oxygenation) Many people, including health care providers, confuse these two concepts.

It varies pretty significantly, even within a company and with people working the same job description. Unfortunately, I cannot discuss specifics about what I was paid due to non-disclosure agreements. It's highly variable, but experience and education can make a significant difference.

Unfortunately, you do not understand the material nor the framework to put the material in the context of a registry question. Are you able to access the score reports? What areas are you consistently failing? In addition, do you understand what the questions are asking? Are you well versed in taking tests and quickly dissecting test questions? Be brutally honest and really ask yourself if you understand what the questions are asking. One of the best exercises is sitting down and taking timed mock registry exams then grading yourself with brutal honesty and close attention to understanding the questions.

Supraglottic airways, particularly the second generation devices have really shaped contemporary EMS practice IMHO. Now that we have reliable alternatives to intubation that can effectively be used by people with less education, critics of pre-hospital intubation have even more ammunition. While the visceral response to criticism is anger and denial, I believe that continued research and criticism of high risk procedures will only help us identify the efficacy, safety and educational requirements for implementing said procedures. On a side note: I am one of three people currently performing a study comparing three of the contemporary supraglottic devices that are being used by EMS services around the United States. My hope is to have it completed by the end of this year and possibly published next year.

Sly, I think we have already established that not using may lead to loosing. My question is not about refusing to work clinically, but rather how much clinical experience is needed.

Sounds somewhat similar to the intermediate-AEMT transition I recently completed. I paid the money, did the transition course, took national registry and completed the transition to the new level. Sometimes it sucks and it's not fair, but it is what it is. Good luck.

You can find all the specific data on the nremt website. However, the cardiac arrest management station that the AEMT must take is not the same as the paramedic dynamic cardiology station. I am not sure what you mean by AEMT-2011 however. That is not a national registry provider level or are you referring to the year that the registry officially rolled out the AEMT?

The course I taught last semester was about 216 hours and I slipped in a few more didactic and clinical vignettes for a total of about 250 hours. As I have stated on other threads, I have a plan in motion. My institution is starting to take steps to change. The most recent is using changes in financial aide and certificate credit requirements. My programme director is adding anatomy and physiology as a requirement for an EMT college certificate and a math class and an English composition class for intermediate/AEMT college certification. Of course, people can still become credentialed with just a course completion certificate, but the hope is that this first step will galvanise people into generalised changes. Baby steps...

I appreciate the replies. I agree that much of what I am asking is probably rather subjective. However, I do not want to become clinically irrelevant. Not only simple skills such as IV placement scare me, but higher risk modalities such as managing, transducing and zeroing invasive lines and managing balloon pumps are modalities that concern me. I am just trying to get a feel for what others in my situation have done to ensure they remain clinically competent.

Check the NREMT website. My state has already mandated all new intermediates must test the AEMT psychomotor and written exams. I graduated one of the first classes of AEMT candidates back in May. In fact, as of next year the psychomotor exam will mandate a cardiac arrest management station. Also, I had to take the AEMT exam to transition from my prior credential as an I/85. Your state may not yet require registry, but the testing process is already in motion at the national level.

The NREMT is already testing both AEMT psychomotor and written exams. While the written exam is a flat 135 questions, I imagine it too will eventually become an adaptive exam. Testing at the I/85 level will end in 2013 however.

Awesome, thanks for the clarification. Clearly, a clerk position will not offer as much in regards to clinical experience, but I would not fault you for doing it if it will allow you to ultimately achieve your goals. Additionally, it will put your foot in the door at a hospital and making good impressions and networking will be nothing but helpful when you start looking for a job as a new grad nurse. Good luck.