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Apply for the AEMT exam. The I-99 level is being phased out and in three recert cycles you will either need to become a paramedic or you will loose your 99 credential and transition to AEMT. The scope of practice is set by your state. The national level has a minimum level that everybody must meet, but states have flexibility in any event.

You know, maybe someday we will consider our foreign brothers and sisters in countries such as Canada and Australia. Make everybody fundamentally a paramedic, then have different levels of paramedic based on education such as Primary care medic, Advanced care medic and Intensive care medic. How easy is that, everybody is a paramedic and we understand there are different levels of education much like nurses and successful systems in other countries. An interesting video where they discuss this and even say we never even looked outside of the United States when the levels for the "new" national SOP was developed:

There is actually evidence that does not support this theory. A decrease in core temperature can occur, but the mechanism may not be as clear as some think. We traditionally believe that peripheral vasidilation leads to the phenomena, but there is literature from the mid to late 80's if I remember that looked at rewarming people who were placed in states of mild hypothermia and rewarmed. The physiology of thermoregulation may be even more complex than we think. I'll see if I can pull the article or at least an abstract.

I would like to emphasise the fact that the FP-C/CFRN question has been asked more times than I can count on flightweb. If you do a quick search, you should find all the information the you need. The ACE SAT book is somewhat of an industry standard for preparing for these exams. If you are looking for something to teach you critical care transport, I highly suggest you get some critical care experience. Spend time working with critical care nurses and respiratory therapists in a good ICU and perhaps do some fly along time. Often, I find medics fly for at least a year or so to obtain experience prior to taking the exam. I flew for just over two years before I tackled the CFRN. (Nursing analog for the FP-C.) Good luck.

A DNP is a so called "clinical doctorate" and not to be confused with a PhD.

The literature is not particularly conclusive on HFOV, PCV and others. However, they are still considerations. Pressure controlled ventilation can have nearly any inspiratory time you want to select. Remember, modalities such as APRV and HFOV are basically forms of PCV. Also, is there something somewhat unique about the way flow is delivered in PCV? (Many modern ventilators can do this in VCV as well.) I'm not sure about keeping this patient dry however. We are running fairly high PEEP and we may want him well hydrated to ensure his haemodynamics are not as sensitive. Let's say we try PCV, what settings would you go with?

Wendy, I'm surprised this debate has not come up in school. There exists a highly militant fraction of nurses who continue to push for independent practice without any physician involvement. This, IMHO has isolated nursing from the very people we interact with the most, physicians. Additionally, I see the DNP as an analogy for what often occurrs in EMS. We mandate a little training, then add on a bunch of skills. A similar situation with the DNP. Do some online classes and perhaps less than a thousand clinical hours and bam, you've got a "clinical doctoral" degree after your name and the ability to practice medicine independently. (Already starting to happen in places like Arizona). Of course, I must freely admit my bias against the militant nursing movement. However, this DNP issue has become a big enough concern that it was recently discussed at a respiratory therapy conference that I attended. There are concerns among some therapists about DNP's and direct entry programmes where providers with limited experience may be giving orders to respiratory therapists regarding highly complex respiratory modalities.

Why would you decrease the PEEP? What is your PEEP threshold? Can we actually do testing to determine optimal PEEP?

Decreasing the I:E can be a consideration; however, this does decrease the time for exhalation, so you need to consider the pitfalls. In addition, continuing to increase the rate will eventually take us past the point of diminishing return. A small volume and high rate doesn't to always equal improved minute ventilation in spite of what we learn. (Ve= f*Vt). Ultimately, we must consider the alveolar ventilation. So, we are at the end of the line for lung protective ventilation? Being aware of the literature and mortality, can we still consider other modalities?

That's cool, the additional context makes sense. I can be a little dense on occasion.

I guess I missed the punchline?

Good: we have one ideal body weight calculation. An imperial based on we use in the United States for a male is: 106 + (6 times number of inches above 60). Then divide that number by 2.2. The duck bill pattern is not necessarily ARDS, but it does represent over distention. Also the PV loop is good at identifying increased WOB. Remember looking at quasi static PV diagrammes in chemistry under adiabatic conditions? The area within the loop was the work that the system did. This is also true of a human being. The PV loop indicates that significant work is being applied as well. Blood administration is a murky decision here. The patient is anaemic, so it would be good to look at what happened during surgery. What do you guys think about the patient's temperature? Let's say we do a lung protective strategy and administer a bolus of warmed fluids? We have the following: Vt 420 ml f- 18 with f total at 30 in VCV PEEP 13 cmH2O I:E is 1:3.1 PIP 40 Pplateau: 38 PV loop is unchanged Patient is saturating 84% What are we going to do?

This whole scientific study business is what drives medicine. Unfortunately, the scientific method is often neglected or not even covered in many EMS educational programmes. Just because something has been around for a while does not make said concept a "golden standard." Part of any theoretical framework for scientifically based concepts is a concept known as falsifiability. That means the concept can always potentially be dis-proven. Even the most important and well tested theories are still being examined with new tests to see if they hold up. Many concepts such as aggressive fluid resuscitation have changed due to the availability of new evidence. We need to be dynamic in medicine and be aware that the latest and greatest idea can potentially be falsified by well obtained and reproducible evidence. I do not think the underlying argument from many of us is that endo-tracheal intubation is useless. However, there exists a large body of evidence that suggests the role of intubation in many situations is not necessarily that of a golden standard. Also, there is little doubt that intubation among many other modalities is inherently dangerous. Intubation gone wrong is a sure fire way at getting a clean kill so to speak. The bigger debate IMHO is in some situations, do the risks of intubation outweigh the possible benefits? Regarding your question about CPR, medications and so on, I strongly encourage you to read the link that I posted to the American Heart Association's science based journal called Circulation. In this journal, the AHA makes consensus statements based on the current literature. In addition, the AHA uses a multinational team of providers to re-examine the evidence over the course of several years, culminating in a new consensus every 5 years. You can then look at the literature the AHA used to come to their consensus. After reading through those studies, you can make up your own mind about what is helpful. However, the literature is often technical in nature and requires a good understanding of statistical and data collection/interpretation methods. In other words, quantitative literacy. Does the process contain possible pitfalls and flaws? Yes; however, going away from the scientific method means we regress back to relying on anecdotal stories and faith. Neither of which can be reliably tested and falsified under most circumstances. Please do not take the tone of my post as an attack or aggression. I simply want to present decision making in a new light. My objective is to clarify and perhaps educate and not attack personally. I just want to be clear about my motivation here.

Used it back in 2006-2007 and anecdotally, we had many issues with it. Currently use the EZ-IO and the old school Jamshidi derivatives.

What is the patient's ideal body weight? Why is the patient acidotic? Why crystalloids over blood, is blood indicated at this point? The X-ray shows bilateral ground glass infiltrates. The PV ventilator loop shows something called a duck bill pattern. What is the significance of that? Lung sounds indicate crackles in all lobes. So, it seems most are putting ARDS at the top of their differentials? I want to see if we can get some type of concensus of vent settings and an overall management plan for this patient. Thanks for participating and keep em coming! Edit: Urine output has been about 30 ml over the past 12 hours.

PV loop on the ventilator looks like this:

The patient weighs 108 kg and is 5 feet 9 inches tall. ABG: pH 7.04 PaCO2 53 mmHg PaO2 58 mmHg HCO3- 17 mEq/L Haemoglobin 10 g/dl Serum Lactate 10 mmol/L SaO2 84%, SPO2 is currently reading 86% Chest X-ray:

To start what exactly? Home health paramedics, or something else?

This is actually a great point. Firefighters are very well organised in certain areas and in fire/ems dominated areas, implementing significant change would be very difficult without getting through the department/s.

I thought we were talking about intubation and cardiac arrest? Once we change the boundary conditions of the context within this thread, we can inject many other arguments. However, in the context of a person in cardiac arrest without ROSC, I cannot appreciate consistent levels of evidence that say intubation should be considered a "gold standard.

Who is seriously calling it a "gold standard?" The paradigm has shifted significantly recently. Many lawsuits that I've seen have been due to endotracheal intubation related issues.

No rash. Crackles in all the lobes. You can calculate WOB but he's currently in a controlled mode and he appears to be triggering the ventilator with little effort. 8.0 ETT at 23 cm. Yes to both Cxr & ABG. PIP is 48, Pplat is 42. Vt is 700 ml. FiO2 is 0.8. PEEP is 8. Nothing else upon report that wasn't already mentioned. You want to give crystalloids or blood products?

P-122, B/P-80/62, SpO2-88%, RR- ventilator in AC with mandatory rate of 12 & total rate of 24, Temp-97.9 F, patient responds to tactile stimuli with eye opening.

You are called to perform an interfacility transport of a 38 year old male who was involved in an up an over motorcycle accident. He sustained bilateral femur fractures and a hepatic laceration. Haemostasis was accomplished following the injury and the femur fractures were stabilised about 24 hours later. The patient developed poor lung compliance following the second surgery and abdominal compartment syndrome was identified after a foley transducer was placed. The patient has just returned from a decompressive laparotomy. The facility is a level two trauma centre and the patient is being transferred to a level one about 25 minutes by ground. Take it away...

It has not proliferated and progressive people can only take things so far in a fragmented environment where a common, significant impasse in certain areas is an argument about the colour of a first out bag. A united and well organised machine is required to negotiate the logistical, political and fiscal complexities of a nationwide movement. No such machine yet exists. It's a great pipe dream and one that has been the topic of more than one thread on this site. We need to overcome several obsticals at the grass roots level. Progressive people are badly needed here.