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chbare

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Everything posted by chbare

  1. You should find a copious amount of information about the complications of aspiration via a quick Google search. Aspiration pneumonia, septic shock, and ARDS among other problems are well documented and studied complications of aspiration. The obvious literal answer to your question is death. Take care, chbare.
  2. Not really IMHO. Much of the team medics job will include "non tactical" tasks if you will. Gathering medical intelligence, creating medical SOP's and IAD's, keeping up with team mate medical problems and an active medical dossier, performing an area survey, coordinating care with local, state, and federal resources, providing a medical intelligence report and threat assessment for the team leader, and many other tasks. Therefore, I believe a team medic should train with the team and have a comprehensive understanding of the equipment, tactics, and methodology of the tactical environment regardless of the level of "tactical operational" involvement. This level of involvement goes beyond an ambulance stationed a block away. Take care, chbare.
  3. I am not really in a position to make definitive, intelligent comments. However, are these medics entering the hot zone? I did not read anything about the medics stacking up and making entry with the team. Are we reading more into this than we need? Having a medical provider close is not a bad idea. Take care, chbare.
  4. If somebody aspirates, it can quickly becomes a systemic problem regardless of the side. I have yet to find definitive evidence that one side is the best. A study that some pregnant anesthesia techniques are better in one position, GERD may be better on one side, Left side may worsen CHF patients, ILMA works both sides among other types of research. However, no smoking gun. Again, the best position may vary and a degree of flexibility is most likely the best choice. Take care, chbare.
  5. A mallampati by it's self may not change my practice; however, my plan may change after a complete airway assessment. If enough red flags are raised, I may not even intubate. Perhaps I will call for anesthesia or use basic manuvers until I reach the hospital, or I may look at an awake technique such as NTI. Yep, flight nurse chbare would actually defer advanced airway techniques based on assessment findings. Just did it the other night. The assessment effects my choice of airway pathway utilization. One of the biggest sins in airway management is doing something like a RSI when everything is screaming " don't do it."
  6. In addition, a proper airway assessment may keep you from choosing to go down a path where doom is inevitable. The Mallampati assessment is only a small part of the airway assessment. I say airway assessment and not difficult airway assessment simply because every patient should receive an assessment to identify the potential for a difficult airway. A general assessment includes the LEMONS assessment. L: Look for gross external anomalies and the presence of a beard E: Evaluate the 3-3-2 rule M: Mallampati assessment O: Obesity/Obstruction assessment N: Neck mobility assessment S: Saturations Difficult BVM assessment: B: Beard O: Obesity N: No teeth E: Elder S: Snores frequently Difficult Cric assessment: S: Neck Surgery H: Neck Hematoma O: Obesity R: Neck Radiation therapy T: Neck Trauma Clearly, a complete assessment may not be possible for every patient; however, making as thorough an assessment as possible is paramount. This comes as no surprise as I had absolutely NO airway assessment education when I went through an EMT-I program a few years ago. Take care, chbare.
  7. In addition, cricoid pressure DOES NOT improve the POGO score/glottic view/Cormack & Lehane score. If you dramatically improve the glottic view by applying cricoid pressure, you are most likely performing ELM. Cricoid pressure involves locating the cricoid cartilage and applying pressure in an attempt to seal the esophagus and theoretically prevent passive regurgitation. This involves proper identification of anatomic landmarks. The most prominent structure is the laryngeal prominence, AKA Adam's apple. This is part of a large cartilaginous structure known as the thyroid cartilage. This is NOT where you apply cricoid pressure. However, many people in fact use this land mark and apply pressure. What we are looking for is the cricoid cartilage. Just inferior to the thyroid cartilage is a little valley known as cricothyroid ligament and membrane. (The area we use to perform a surgical/needle cric.) Just inferior to the valley is a smaller bump. This smaller bump is the cricoid cartilage. This is in fact where we go to properly perform cricoid pressure. With that, in many documented cases, cricoid pressure actually worsens the glottic view. In some cases, you may need to release cricoid pressure and manipulate the thyroid cartilage in order to obtain a better glottic view. This procedure is known as ELM/BURP. Take care, chabre.
  8. Except, aspiration pneumonia, ARDS, septic shock and the such develop into systemic problems regardless of the location of the initial insult. The reality of patient positioning is a bit more pragmatic. Position to best protect and manage the airway. Take care, chbare.
  9. If somebody has vascular disease significant enough to cause a stroke, it should come as no surprise that the cardiac vascular circulation would also be involved. So, a cardiac evaluation may be warranted for two reasons. Cardiac embolic cause as you stated and concomitant cardiovascular disease. Therefore, I cannot argue against having such a protocol. While a XII lead may not reveal "high yield" information in many of your patients, it is quick, easy, and may in fact help identify underlying or concomitant problems. Take care, chbare.
  10. Congrats! Good luck on the name change. My wife had a hell of a time with the name change. We still receive mail with her maiden name. Take care, chbare.
  11. Have had it occur twice in my career. Both times were in the hospital. First, was a patient in his 50's who was having a MI. Developed pulseless ventricular tachycardia and we successfully defibrillated him on the first attempt. He regained ROSC and consciousness immediately and eventually went home after a trip to the cath lab. The other was a female in her 80's having an MI. She was otherwise healthy and in her 80's. She was well within the fibrinolytic window and I had given the first dose of Retavase. During the wait for the second dose, she said that she wanted to go through with filling out DNR. We had the paperwork ready and she wanted to sign; however, our doctor convinced her to take a little time to think about it and ask any questions. She went into Ventricular Fibrillation and we successfully converted her with one defibrillation attempt. She regained immediate consciousness and ROSC as well. Ended up flying her out; however, she did well from what I remember. Neither patient had any memories of the event. Take care, chbare.
  12. I am a bit confused by this statement? Take care, chbare.
  13. Florida strikes again. Unfortunately, I assume these nurses are able to work in other states. It is pretty sad to see my profession becoming a three ring circus. I can only imagine if left unchecked, this stuff may proliferate. We all know that even community college and university level nursing education is not as demanding or structured as years past. Take care, chbare.
  14. "Their ads promise a fast path to a high-paying future. Come to our school — Everest, Keiser, or ITT Technical — and we'll train you for America's hottest jobs, whether your interests are air-conditioning repair, accounting or medical assistant. The recession has been good for proprietary schools, for-profit postsecondary institutions that are seeing their enrollments spike as people look for second chances in a lifeless job market. While public universities are in a holding pattern with tighter budgets and bigger classes, the for-profit sector is spending lavishly on new branches and sophisticated marketing. Log onto Everest University's Web site and you don't get a catalog. You get a live chat with a sales rep. In just minutes, you too can become a student. These schools say they provide critical job training without taxpayer subsidies, but there's a catch. They survive on a firehose of billions in federal and state student grants and loans, funneled through enrollees who need only be willing to sign now, pay later. Nimble at adjusting to the job market, schools that once scheduled classes in massage therapy and pastry arts are moving up the academic food chain to high-demand fields like nursing. Florida, anxious to encourage such startups, last week relaxed the state board of nursing's oversight of new programs. Now if benchmarks are met, a program is automatically approved, no site visit required. Meanwhile, the state agency that licenses all private postsecondary schools is coping with a 55 percent increase in new programs this year. Whether an institution is training truck drivers, bartenders or trauma nurses, the state's paperwork is the same. Everest, formerly known as Florida Metropolitan University, is one of a number of for-profit schools getting into the nursing education business. On Everest's Brandon campus, students are put on the fast-track from novice to registered nurse in an intense, 21-month curriculum. Similar associates programs at community colleges take two years. But speed and access to an RN degree do not come cheap. Everest's program costs about four times as much as programs at public institutions. Some Everest nursing students wonder if they are getting their money's worth. They say instruction is poor and hands-on time with patients in clinical settings is limited. They've found it impossible to transfer credits earned at Everest to other nursing schools. And the first class of Everest graduates stumbled when it came to passing the nationwide licensing exam, the key to qualifying for an RN job. Of 14 graduates in the first class to take the test, 57 percent passed on the first try. The next group of four graduates all failed. Statewide, about 87 percent of all nursing graduates pass the board on the first try. Everest officials say it's common for first classes at any school to do poorly on the test. The school said it has improved its curriculum and better results should follow. Though five of the 18 students who graduated in October have yet to pass the boards, Everest says all have jobs. Landing work is important because students at for-profit schools graduate with heftier debts than students at other schools. Meanwhile, default rates by students at these schools have been twice the rate by students at public colleges and universities. • • • Here's why you can sell a $40,000 associates in nursing program when there's a $10,000 program in the same market: The less expensive programs, at public schools such as St. Petersburg College and Hillsborough Community College, have four applicants for every seat. For Sedina Pilav of Tampa, Everest's nursing course — $41,580 not including books and fees — was a last resort. "I thought I wouldn't get into USF's program," said the 23-year-old, who had flunked organic chemistry at the University of South Florida. "And there were waiting periods everywhere else. At Everest, they called me back in about five minutes." Scheduled to graduate in the fall, Pilav will start her nursing career with about $45,000 in educational loans. "I feel like we're being prepared very well," she said. Gareth Nesbeth, a native of Jamaica, may be the biggest debtor in his class of 23 at Everest. By the time he graduates, including basic courses at a community college, he'll owe more than $100,000. "Everest was the only school I could get into," said Nesbeth, a 32-year-old who needed student status to retain his visa. "But the classes have been excellent." Everest isn't the only for-profit school to recognize fertile expansion territory. Keiser University has rolled out nine associates nursing programs in Florida since 2002; a program will open in Tampa next year. ITT Technical Institute, better known for classes in criminal justice and information technology, also has planned a nursing program in Tampa. This surge of interest in training the next generation of nurses is bumping up against constraints. One is the limited number of clinical sites where students can get hands-on experience. One class of Everest students earned clinical hours by teaching kindergarten students to wash their hands. "It was a teaching exercise," said instructor Darlene Mention. "That's what nursing is about." Nesbeth, the Jamaican who was one of four students the school selected to talk to a reporter, said, "The administration has had a problem securing clinical sites. I've always gotten good sites, but being a new program, we're limited." Frank Weiri, a former student, said he got short shrift on his clinical experience. Weiri, who worked three years at Tampa General Hospital lifting patients, expected to get plenty of practice time in health care facilities. But he said assignments frequently were changed or delayed. Even when he got into a hospital, Weiri said it wasn't that helpful. During four days at All Children's Hospital, Weiri said there were so many students and so few staffers that half his "hands- on'' time was spent observing the operating room. Everest officials said records show Weiri received the required 120 hours of clinical training. That included 40 hours at the school, everything from worksheets to watching a baby being born to a mannequin. "I think you could get more from watching a birth on YouTube," Weiri said. Ruth Abbott, national director of nursing at Everest, said the school provides all required clinical hours and is no different from any other program, at the whim of hospitals that change plans. "We have had institutions cancel on us," she said. "Those things happen." As for Weiri's complaint that observing pediatric surgery shouldn't count, she said, "As crowded as it is at All Children's Hospital, at least you can see kids who are acutely ill." • • • The growing number of nursing schools compete for the limited pool of experienced instructors. Abbott said 67 percent of Everest's teachers have master's degrees in nursing or related fields. At local community colleges, that number is closer to 100 percent. Nicki James is a 42-year-old real estate agent who wants to become a nurse. Though she has earned a 3.8 GPA at Everest, she wonders how much she has learned. "We had teachers for whom English was not their primary language, which is not wonderful when you're trying to learn new concepts,'' James said. "Then we had an instructor who was deaf and mispronounced medicines, some of which sound extremely similar." The school says it never received complaints about either teacher. James knows what it's like to accommodate picky home buyers, and she expected to be treated like a customer at Everest. "If I'm paying $385 a credit hour and there's something I'm not getting, I want one-on-one help till I get it," she said. Although one-third of James' class washed out, Everest's director said every effort is made to retain students through tutoring. "We want to make sure the student is successful," said Abbott, who said most attrition was not due to academics. Patricia Evans, 62, has a master's in teaching nursing and has experience teaching at public and for-profit schools. She taught for 18 months at Everest before quitting in frustration. A nurse for 41 years, she works now at Brandon Regional Hospital. "I didn't agree with Everest's teaching philosophy and how the students were treated," said Evans, who praised both James and Weiri as top-notch students. "I was expected to be a drill instructor and students were supposed to sit there, be quiet and suck it in like a sponge. But you've got to teach students to think, to prioritize, to ask questions. "When I left Everest, I told the director, 'When you care more about what the students are wearing than what they're thinking, you've taken a wrong turn.' " Abbott said Evans was "very nurturing to students, but she was not able to give them the information they needed in a complex, technical world.'' • • • Students unhappy with Everest's programsay they have not been able to transfer credits to other schools. Most of Everest's courses are part of a statewide course numbering system that makes transferring possible. Everest officials said that if schools reject their credits, those schools are breaking the law. But, as state regulators require, Everest must tell students that no institution can guarantee its credits will be accepted. Receiving schools have the final say. Several Everest students have discovered that the answer is no. James, the outspoken real estate agent from Ruskin, said she explored transferring Everest credits but got turned down by community colleges. Weiri was dropped from Everest's program in January after he missed a test due to illness. Everest officials said he failed to retake the exam; Weiri, who had a GPA of 3.4, said he was never given the chance. Now 46, Weiri has been unable to find another school willing to take Everest's credits. His other option is to rejoin Everest's next class in October. Instead Weiri has talked to a lawyer about filing a breach of contract lawsuit against the school. The school says it has tried to resolve the issues with Weiri and his lawyer. "These private schools are short-changing students," Weiri said. "No one is really checking up on them." Everest was licensed by Florida's Commission for Independent Education and accredited by the national Accrediting Council for Independent Colleges and Schools. The school said its nursing program meets all requirements. "Personally, I wouldn't want to be part of an institution that would put someone out there who would be a risk to patients," Abbott said. Despite graduates' poor showing on the licensing exam, Abbott emphasized that she has not received a single call from the Florida Board of Nursing. "If we'd had a score like this when I was in Michigan, you'd better believe a consultant from the state would have been at my door. They'd be asking, 'What are you doing about it?' " Times researchers Caryn Baird, Will Short Gorham and Shirl Kennedy contributed to this report. Kris Hundley can be reached at khundley@ sptimes.com or (727)892-2996. FAST FACTS About Everest University Formerly Florida Metropolitan University, Everest is part of Corinthian Colleges, based in Santa Ana, Calif. The publicly traded company reported more than $1 billion in revenues last year, 81 percent of which came through federal student grant and loan programs. Everest has about 76,000 students on about 100 campuses nationwide; in Florida it has 14 schools with about 14,000 students. Corinthian expects enrollments nationwide to rise 15 percent this year. In 2007, Corinthian paid $6.5 million to settle false advertising claims in California.The same year, the school paid about $100,000 in Florida to settle accusations that it had misrepresented the transfer value of its classes. Who watches postsecondary schools? Commission for Independent Education: A division of the Florida Department of Education, CIE licenses more than 800 private, postsecondary schools in Florida. It fields complaints against licensed institutions and issues cease-and-desist orders against unlicensed ones. Ninety new schools or branches were licensed in the past year, up 55 percent from the year before. Accrediting Council for Independent Colleges and Schools: A national accrediting body recognized by the U.S. Department of Education, meaning its students are eligible for federal grants and loans. Southern Association of Colleges and Schools: A regional group that accredits all state schools in Florida and most of its private, nonprofit schools. Also recognized by the U.S. Department of Education. National League for Nursing Accrediting Commission: A national group that accredits nursing programs, including more than 600 associates programs nationwide." Link: http://www.tampabay.com/news/business/article1015632.ece Take care, chbare.
  15. You are right on the money. When you have prolonged paralysis following sux, you need to consider a couple of things: 1) Phase two type block. Typically, sux when given properly will cause what is called a phase one I block of the neuro-muscular junction. AKA depolarization block. However, a phase II block can occur if sux is given improperly, repeated doses for example. 2) Decreased plasma cholinesterase activity. Take care, chbare.
  16. Depends, animals are used for a multitude of research studies, techniques, and medical trials. Take care, chbare.
  17. Initial XII lead: Sinus Tachycardia without any other significant findings. While fentanyl is associated with rigid chest wall syndrome (typically, high doses given quickly), it is not typically associated with keeping somebody in a state that mimics neuro-muscular blockade for 24+ hours. Take care, chbare.
  18. Not on metformin. No potassium imbalance noted. No underlying renal problems. This is not an interaction between two drugs. You guys are on the right track. You should essentially think about two concepts occurring in this case. These two concepts relate to one of the medications given during the RSI. Take care, chbare.
  19. It is not related to his injury. While he may appear unresponsive, he may in fact be awake, but unable to move or communicate. Take care, chbare.
  20. Nailed it, classic posterior dislocation. So, patient has a closed reduction in the ER and a CT of the head. He is admitted to the ICU for a cerebral contusion. Unfortunately, I cannot let you off that easy. You return the next day and the patient's doctor asks in an aggressive tone, "What the *@%& did you give the patient?" The patient was admitted in an unresponsive state and remained unresponsive throughout the next 24 hours. His blood sugar was maintained and repeat CT scans did not indicate any worsening of the patients head injury. He remains unresponsive and the patient's doctor states no paralytic medications have been given. Take it from here. Take care, chbare.
  21. Very close, what kind of dislocation? Anterior or posterior? Take care, chbare.
  22. Let's say you go ahead and do the RSI with etomidate and sux. You pass the tube with style and deliver the patient to the receiving ER without incident. What do you think is going on with this guys lower extremities? Take care, chbare.
  23. PACU is not a protocol, it is an area of the hospital where patients are monitored following general anesthesia. You may be familiar with the term "recovery room." A recovery room and a PACU are typically one and the same. Take care, chbare.
  24. Not wearing a helmet. Roc is a consideration; however, you only have access to sux at this point. Many people still prefer sux because of the short duration of action. Roc is popular and perhaps even more so when sugammadex hits the market. Fentanyl is a good premedication consideration. I would also want a dedicated sedation agent. In many cases, people prefer etomidate for it's short onset, short duration, and hemodynamic stability. Take care, chbare.
  25. Midazolam may be problematic with a suspected head injury related to blood pressure depression. This can be especially problematic at induction doses. What makes you think about vecuronium for initial paralysis? The slow onset and long action makes it a less desirable agent for the initial RSI. Take care, chbare.
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