chbare

If you go through the first couple of pages, you should find the answers to your questions and even a study comparing oral glucose to EMLA cream in the setting of invasive procedures. Take care, chbare.

No, I am going to tie the hypothermia in a little later on because something about this situation sets divers up for hypothermia. No worries, not forgetting about the hypothermia because it is absolutely relevant. Absolutely; failure of the scrubber can be a primary concern and something to rule out. Failure of the electronic monitoring and mixing systems is also another thing to rule out. This is also why the prudent rebreather diver carries an open circuit bailout system. For this scenario, lets say there were no failures of the equipment. The FiO2 is a tricky thing to understand; however, if we look at Dalton's law, it explains the sum of all the individual partial pressures equals the total pressure of the environment. So, at 1 ATM the total pressure is about 760 mm/Hg, and if we have an FiO2 of oxygen of 0.21, this means that about 21% of that 760 mm/Hg will be oxygen. I will leave vapor pressure and other concepts out for the sake of simplicity. So, this gives us a partial pressure of oxygen of about 160 mm/Hg at sea level. However, what does going underwater do? It increases pressure. To breath underwater, the pressure need approximate or be higher than the pressure in the environment. This explains why we cannot breath through a 30 foot snorkel. The gas laws can further explain pressure, temperature, and volume relationships in more depth; however, I will keep the math to a minimum. We know that about every 33 feet of water equals an atmosphere. So, lets say we are 100 feet under water. The pressure equals about 4 ATM or about 3,040 mm/Hg. So, an FiO2 of .21 at sea level will have a much different meaning than an FiO2 .21 at 100 feet under water. Assuming equal pressures to keep things simple, an FiO2 of .21 at 100 feet under water equals about 638 mm/hg. Therefore, we run the real risk of oxygen toxicity when we dive because the partial pressure of oxygen is so high, even if the FiO2 remains 0.21. So, it is common for divers to transition to "hypoxic" gas mixes at deeper depths. (Hypoxic at sea level, but just fine at depth.) Therefore, an FiO2 of 10% may be just fine at depth. In addition, divers will typically replace nitrogen with helium. Helium is a stable gas with a full octet and very low density making it an ideal choice for deep dives where nitrogen narcosis is a problem. However, do you think a simple 90% helium and 10% oxygen mix could have problems at deep depths? Is there a reason deep divers actually begin adding a little nitrogen back in the mix during really deep dives? AKA trimix (Helium, Oxygen, & Nitrogen). What advantages does trimx offer over heliox, and can this explain what occurred? Take care, chbare.

Take care, chbare.

No worries, this is a tough one that will most likely take some mad google skillz. So, you fly him to the multiplace chamber and he is taken back down to depth for a several hour decompression. His signs and symptoms resolve upon "diving" to depth. While the hyperbaric gurus work their magic you track down the dive buddy for the story: The dive began without incident with both divers planning on utilising trimix at deeper depths. However, upon reaching 435 FSW, the patient began acting strange and suddenly developed a brief period of what is described a "seizure like activity." The buddy immediately recognised there was something wrong and terminated the dive. The patient transitioned to a bail out tank of trimix by open circuit and he immediately improved with no further "seizure activity." Then, the patient and his buddy began ascending per dive computer instructions while the support team ensured additional tanks of gas were available. ** Side note: you can google a rebreather; however, it works much differently from a SCUBA apparatus. A SCUBA apparatus is also called an open circuit because you inhale gas from a tank and exhale out into the surrounding ocean. A rebreather works by recycling exhaled gas and utilising chemical reactions to "scrub" carbon dioxide from the breathing circuit and recycle the remaining gas. Clearly, it is critical to monitor the levels of the various gasses in the breathing circuit or disaster can ensue. However, the advantage to a rebreather being very little wasted gas and extended dive times while utilising less gas. In addition, the prudent rebreather diver brings along a SCUBA setup as a backup in the event of rebreather failure. The terminology for transitioning to an open circuit device in the event of rebreather failure is called "bail out" or going to the open circuit bailout. What do you think occurred at depth? You may need to google; however, what occurred is not unique to rebreather diving? In addition, could this problem have been a factor in the development of the bends in spite of ascending per dive computer and dive table recommendations? Take care, chbare.

Got it, you call DAN and they ask the following questions: How deep did the patient actually go? Remember, he planned to go a specific depth, but did something happen during the dive? Bottom time? What type of equipment? What type of gas mix? Remember, he planned to use something. They recommend rapid transport to the multiplace chamber. Take care, chbare. So, upon looking at the equipment you notice that he was in fact not using SCUBA equipment. He was actually using a mk 15.5 closed circuit rebreather. You look at his dive computer and at 435 FSW ( ~132.6 meters) it looks like his mix was heliox 90/10/ (90% helium/10% oxygen). Does this jive with this history that was given earlier in this scenario? You also note that 435 FSW was the maximum depth with a "bottom time" of about a minute. Does this jive with what was said earlier? ((You may or may not actually access this info in real life, but your going to get it to ensure advancement of the scenario.)) Does something seem fishy? Take care, chbare.

What other questions should we ask? Are there things we can look at? Who should we contact during transport for the most reliable information? Any other sources we can call for dive emergencies? Where will we take this patient and how will he go? Take care, chbare.

No trauma. Core temp: 91F (~32.7 C). No past medical or surgical history. Take care, chbare.

Are there any other things we need to assess and find out, or are you guys satisfied enough with the current amount of information to make a diagnosis and pursue a treatment pathway? Take care, chbare.

Take care, chbare.

Take care, chbare.

Not a shark attack. Non commercial diver. Take care, chbare.

Take care, chbare.

Interesting article, and the prices quoted are rather low compared to what patients are changed in some areas of the country. Take care, chbare.

Your LZ is a large, secure, open parking lot without any nearby wires. Even with a large patient, the pilot says you should have as much out of ground effect power as needed to take off and get through transitional lift. No weather concerns are noted, and it is early afternoon with lots of light and no visability or local air traffic hazards. No flight restrictions temporary or otherwise, or NOTAMs are noted. You have a single, male patient. Take care, chbare.

You have limited information at this point. Current information being, you will be intercepting an ALS ground crew who have a sick SCUBA diver. Take care, chbare.

You are working for a rotor wing based medical evacuation service in the beautiful costal state of Arkorgania. Unfortunately, you are called to intercept an ambulance near the beach. Take it from here. Take care, chbare.

Read the sheet very carefully. This is from somebody who took the 85 exam and psychomotor tests: You can immediately begin bag mask ventilations on room air after BSI, opening the airway, and properly placing an adjunct. However, you must verbalize that you will attach the bag valve mask to a high concentration of oxygen. Failure to ultimately ensure high concentration (FiO2 greater than 0.85 by NREMT standards), will result in failure of the entire station. However, you can elect to begin bag mask ventilation with the device initially attached to high concentration of oxygen. The choice is up to you. As mentioned, stick to your method as long as it meets the criteria. You can download the psychomotor skill sheets from nremt.org. Edit: Yes, there is a difference between hyperventilation and pre-oxygenation. Hyperventilation is ventilation that exceeds metabolic requirements and is often associated with lower than normal CO2 levels. Pre-oxygenation is a process commonly defined by replacing nitrogen with oxygen in the functional residual capacity (FRC) of the lungs, in essence creating a reserve of oxygen that will continue to diffuse with its gradient out of the alveoli. Take care, chbare.

It's not even theoretical. This is the basis of a concept known as histotoxic hypoxia and explains conditions such as cyanide toxicity. This is typically because of the inhibition of the membrane bound protein cytochrome c oxidase. Take care, chbare.

Hmmm, looks like it works in a similar way to the ILMA without the handle and the ability to ventilate prior to a blind intubation attemp. Both are serious pitfalls IMHO. Any evidence supporting the 98% success claim? The ILMA was nowhere near 98% when it first came out and it still does not have a 98% first attemp success ( varies with the study, but I accept about 90% ) with the addition of Chandy maneuver. Take care, chbare.

No worries mate. Take care, chbare.

How did you get that I am burnt out? I asked valid questions and no where did I indicate that I am burned out. If you do not like what I said or I somehow offended you, perhaps you should let me know. In addition, you did not say nursing is "not for me." You stated nursing was cut throat medicine and hinted at your displeasure of "drama queen" and "burned out" nurses. Take care, chbare. "Why would you want to go to New Zealand and attempt to obtain work as a Basic Life Support provider when you will have a degree in nursing? No offense to New Zealand providers; however, things do not add up in my mind. True, I worked over seas as an Intermediate Life Support Paramedic; however, the pay was just a bit better. Take care, chbare. " This was my original post. Please point out where I offended you or put you down. In addition, please identify where I failed to express my opinion, put anybody down, or made "gutless" comments. Take care, chbare.

Four thousand hours? Up until the last year or so, the DOT NSC called for a Basic EMT curriculum of about 110 hours, and a paramedic curriculum of just over 1,000 hours. A fact check may be in order. Take care, chbare.

I was simply quoting numbers from one of our NZ members. Take care, chbare.

No error, a simple question of money and opportunity. All the trouble of attempting to move around the world and attempting to land employment at $36,000 - $45,000 a year when you have a degree that can take you many places in the United Stated is rather interesting IMHO. With the global economy not doing all that well, I suspect an American with a level of education in EMS that is much different than New Zealand would most likely face some difficulty obtaining employment. Additionally, the OP has not even visited New Zealand. Therefore, giving up on a potentially good career path based on bad experiences in one ER to move across the world in order to attempt to seek employment in a country you have yet to visit where your wages will be much lower is an interesting concept, IMHO. Take care, chbare.

This may sound like nit picking; however, it is important we use proper terminology because different concepts apply in this situation. EtCO2 is a form of capnometry. Capnometry is simply a number. This number is obtained at the peak/end of the expiratory plateau. Hence, the term "end tidal." When we monitor and appreciate a waveform, this is known as waveform capnography or simply capnography. Many devices combine these concepts; however, some are stand alone. Therefore, capnometry is simply looking at a number. While trending this number and applying it to our overall assessment of the patient can be helpful, I assume people are also talking about monitoring for waveform changes. For the sake of people who do not know, perhaps we could discuss the normal waveform plateau and abnormal findings such as shark fin patterns, then associate these patterns with conditions? Take care, chbare.