croaker260

My agency is seeking to improve the rescitation performance in the field, and we are generally dissasitified with the standard merit badge courses. How many of you provider either: 1- An in house alternative to ACLS or PALS/PEPP or; facilitate higher performance in resuscitation Or; 2- An in house supplement to ACLS or PALS/PEPP to facilitate higher performance in resuscitation If so, could you relate any specifics (on list or off) as far as course length and content? Also , if you are a NREMT state, what do you do about NREMT recertification. For the record, we are NOT looking at ACLS-EP. While this concept showed promise, it is logistically prohibitive to put the course on here or to train a cadre of in house instructors to the ACLS-EP level. its not from lack of trying, but rather logistical hurdles put up by the AHA. -Steve

At my part time job teaching, Nitrous oxide is now in the AEMT scope. I know that in the 70's, 80's through the early 90's it was popular in some rural parts of the country and in the New England area but I honestly havent heard hardly anything about it in the past 20 years. I have heard its hard to even get FDA approved regulators for EMS anymore. I have two questions: 1- Does anyone out there have a NO specific skills sheet for credentialling this? 2- Is anyone planning on doing this? Is anyone currently doing this? 3- What are your lessons learned that might be useful for an educator who is unfamilier with this modality (other than personal use at the dentist). Many Thanks Steve

Unfortunately this is becoming mroe and more common in the so called "civilized world". amd even in uncivilized america too..LOL

Good for ya Bush, though bummed you forgot me. TheN again, Ive been dealing with life too, so Im not on as much anymore. Still... WTF,over?

I signed up. I am pretty well versed in the topics anyway, but I am hopeful I will learn something new.

All good advice and comments, I would add this: Remember that you also are a new medic. even though your cert is higher, and by policy you are in charge, a collaborative approach may be in order. on the street and in the mud you are both peers. Perhaps a "we are both in this same crap-bilt boat. Lets try not to tip it over while we learn our jobs together" is more warrented. Especially if I was older, A younge rookie paramedic trying to tell me, even though I am a rookie too, how things are going to roll...is a bit hard to swallow. Remember: if you have to have a talk on how you are in charge, you probably are not. You get better results wth leadership and collaboration than with managment and dictation.

I have been involved in our own theraputic hypothermia project at my agency, and we currently do it s/p cardiac arrest. I think its safe to say we are out of the "early adopter" phase and into a more mainstream acceptance of the curve for mild hypothermia s/p cardiac arrest. That said I am unaware of hypothermia in multi -system trauma. As mentioned above; hypothermia is typically very bad in trauma, increasing mortality significantly. the only possible exceptions may be isolated closed head injury and isolated spinal cord injury, though this is still in the research and case example phase and far from common. If you have anything different, I would be happy to hear about it.

Oh..well Most of the comments would still apply I guess.

Well, respectfully, I beg to differ a little bit. The FTEP is both training AND evaluation, often (but not always) together as mentioned below. Like you we have an academy (Phase 1a), also for 2 weeks. Unlike what you describe we follow this with a training only phase. This "training only" phase (Phase 1b) is for (up to) six weeks. Bi weekly evals and updates to sups and FTEP/FTO coordinator. There are no daily evals (yet...we found it counter productive at this stage). During this time the trainee is a third rider until cleared as a second by the FTO. Focus is to continue the training and orientation (i.e. mapping, driving, etc) done in the academy with field exposure. We aded this phase after seeing too many new hires fall flat on their face early on. At first we lengthened the academy, but that didnt work. They neeeded a period of in the field orientation before we closed the lid on the pressure cooker. Then, like your agency, we have a minimum of three FTO's for "Phase 2". During this time training continues, but daily eval's also start. Additionally the bi weekly updates to the FTO/FTEP coordinator continue. During this phase 2 the trainee rides as a second with his FTO, he is not a third rider. IMHO, this is good because it turns up the presure to perform a bit. It takes away any "crutch" he may be using. At any time the traininee can be recycled to either (very short) training phase and a PIP if they demonstrate major issues. EMTs and seasoned medics typically go through 3 six-week FTO rotations before moving on. Brand new medics straight out of school we typically double that automatically. This means a brand new medic will typically be 6 months prior to going on to phase 3. Phase 3 is a 2 week evaluation only, sink or swim, pass or fail , final field test with an FTO they havent had yet. It is followed by a 1-2 hour sim man test with one of our med control docs, oral review, and a final exam . If they fail they can be recycled to phase II with a PIP. For phase 4 they are released into "General population". Phase 4 is simply monitoring of their charts and performance for the remainder of thair first year. So comparing our two programs, it seems part of your programs issues is confusion about the role of evaluation, when to do it, and what to do with trainees who are not meeting standards. I would also say that 10 shifts is probably not much time with an FTO, and perhaps (depending on what schedule you use) that should be pushed out quite a bit. Its worth noting that for EMT's (who are already employeed) in our system who get their medic cert go through the same process except they bypass the "training only phase" and go straight into phase II. it is assumed..unless noted otherwise by an FTO, that they should already be well oriented to our system. My response would be that sounds like a great idea, but from a legal and ethical point of view you should probably involve your training coordinator earlier. In otherwords, get an idea of the plan , put it on paper, talk it over with the TC PRIOR to hitting up the trainee. The reason you do this is to prevent any legal pitfalls you may unwittingly fall into , or even cause, despite your best efforts. The meeting with the TC is not a PIP, and therefore doesnt have to be a big deal, do it over coffee, breakfast, what ever. But if the trainee falls flat on his face or there is a critical failure while this training "plan" is in effect, you dont want left holding the bag in a wrongful termination suite.....or worse..a medical malpractice suite. Keeping the TC in the loop protects everyone. You know we went through the same thing about 5 years ago. It was tough on all of our FTO's because they were also taking paramedic students too. In the end we had to limit the paramedic and EMT students to "mentors" only just to give them a break. It worked out well. Now an FTO can take a medic student on his field internship , but only if he wants to. We still have about 12-15 FTO's... Like your agency, it is a lot of extra work. But its a lot of fun too. My only final bit of advice is this. Just because they are a good/nice/smart person and are smart doesnt mean they are a good EMT, and of course the opposite is true as well. The truth is we want/need people who are BOTH. There is a fine line betwen doing "everything you can" and dragging it out". Being an FTO isnt about personal relationships, though we often build them with our trainees (and that is OK). Being an FTO is about end user performance. No matter how good of a person they are, if they cannot perform in the field at 3am to standards....despite training...then they cannot..must not... pass. I have several friends who have failed the FTO process, they are still my friends. These are two seperate issues. Good luck.

I am both an instructor and an FTO..a formally trained FTO even . Anyway, there are several issues here. First is the FTEP (Field Training and Evaluation Program....though your terminology may differ) has issues. Is it a Training and Evaluation program, or simply a training /orientation program? From both a professional and a legal point of view, if there isnt some sort of evaluation (daily, end of phase, what ever) prior to being "released"... then the program is setting everyone..the trainee, the FTO, and the agency ...up for failure. In this case, either the trainee was evaluated for his /her ability to perform the job...and legititamately passed..and now has a previously unknown issue...or there was no or poor evaluation and the trainee was simply "passed" for simplicity. . I cant speak to how your FTEP is set up, but here, if that trainee is having consistantnt issues...were these issues documented during FTO? If so... then a "performance inprovement plan" (PIP)is held. This is a Formal "Come to Jesus" talk and process that is both legally defensible and practical. Without cutting and pasting the entire process, here is it in a nutshell: 1- The FTO(s) and supervisors identify the problems in clear terms, and make sure that the problems are documented previously. They also make sure that the "problems" are true issues and not personality issues. We have some specific criteria for what warrents this. 2- A "PIP" meeting is held with the trainee. This is a scripted, agenda led meeting. The reason for this is it keeps all parties on task. It also avoids any "Ambiguity" about the seriousness of the situation. This has been a probelm with previous, less formal meetings with problem trainees. The FTO/Training coordinator or designee evaluated progress. Typically up to 90 days may be given by policy, but most problems we are looking for improvement with in 30 days. if improvement is not seen and it is clearly documented, then we look at why, and termination is a real option at that point. Now, from the trainee pont of view, this may seem harsh, but really this is best for everyone. it keeps a trainee from being caught in "limbo" for ever, it clearly spells out the issue without any sugar coating. Some people simply need to know what specifically they are doing wrong, and given step by step plan for improvement. And if the trainee succeeds, then EVERYONE gets to "move on"...including the trainee..into the rest of his/her career.

We were taught to do this in a pinch... http://en.wikipedia.org/wiki/Abdominojugular_test

Uhm..background checks are already mandatory for internet and all commercial sales outside of gun shows. If you purchase one over the internet, you must have it shipped to a dealer locally..you cannot receive it directly..and that dealer does the check. The problem is that the average democrate doesnt even understand "guns", much less the legal issues.... which is why the lies about so-called assault weapons and background checks caused even more mistrust on this issue. Pro-gun advocates simply (and correctly...IMHO) believed that Democrats were deliberately misleading the public on this issue. Honestly..and this is my opinion only, of Obama had "just" gone after more comprehensive background checks on commerercial sales only..i.e. not between private citizens/family...and not tried to "take a mile" with the "assault weapons" issue, the "Magazine Issue", or the "registration" issue... If he had been moderate from the beggining instead of trying to use Newtown to get his entire christmas list..then he probably would have been successful. He is a good orator, and can appear quite reasonable. But the truth is the Democratic party, rolling high on Obama's re-election, took the Newtown tragedy as a chance to strike back at the people they have been fighting for decades...middle class conservative republicans...and it backfired onthem. Even when they "tried" to be more moderate...the damage was done.

Searching the bas of certain people has long been practice here. The detailand depth may vary, but I agree with the previous poster that the the best "search" is asking, and seeing their response. If they get himky about it, there isusually a reason why.

As a gun owner and somewhat a student of history it is simple. The fear is that registration leads to confiscation. There have been plenty of statements from the anti-gun groups that todays proposed gun laws are "just the beginning". Conficscation has occured in other countries. and if allowed to will happen here. Hell, even Hitler got several contries to agree with voluntary gun confiscation " for the children". . Sound familier? Therefore many gun owners take a no-compromise stance becasue they dont trust the other side to be reasonable, despite all their "fluff" and statements. The pro-gun and the anti-gn crowd comes from two different ends of the spectrum on a lot of beliefs. but the differences in opinions on guns is just too much to ever compromise on I think. Add to the fact that the anti-gun lobby lost any credibility with their thin definition of assault weapons (a made up catagory by the way) and their own demonization of gun owners themselves...these two sides will never agree. Its as personal as pro-life and pro-choice. On a personal note, for a party that built its reutation in the 60's on civil rights...which included gun rights for black people (*little known fact)....they need to remember that GUN RIGHTS are CIVIL RIGHTS. If they protected them as much as they protected the right to vote, the right against search, the right of free speech..then they would have a lot of respect by gun owners like me. Instead they are in my view very hypocritical. Gun rights are a consitutional right, and that is what sets it seperate from every other example...such as car registration, the right to smoke, etc.... To answer the "well regulated militia" question.... This was defined as a well equped soldier by a SCOTUS descision in the 1930's, and again in the 1990's. Therefore any individual weapon is offered protection by the second ammendment, where crew served weapons (i.e. true machine guns like the M2 .50) are not. Going further back, a collection of writings called the federalist papers further discuss that the term "well regulated militia" applied to every person of majority who could bare arms. There are some who are pro-gun to preserve the right to fight against tyranny , including by our own government. There are others who are pro-gun because they understand...like most of us I would imagine, that the world is a harsh and unforgiving place with a lot of bad people in it. They want guns for self defence. History has it that any government that would deprive its citiziens from self defence The reality is that they are the same argument. Guns in law abiding hands protect gun owners and their family against tyranny, whether it is tyranny from govenrment, or tyranny from the meth head down the street. And the same reality is that any goverment that would deny its citizens the same basic protections it grants its enforcers of the law...i.e. semi automatic firearms with magazines in excess of 10 rounds...is by defintition tyrannical. A great scholarly discussion is here: http://www.guncite.com/gc2ndpur.html And a not quite as scholarly but equally moving discussion here: http://jpfo.org/filegen-n-z/six-about-2nd.htm In short, if you value any of the other rights you enjoy, how would you feel if they were taken away from you? Even under good intentions? Thats how I feel about the second ammendment as well.

Denver Health (formally Denver General) was one of the original "run and gun" places to work in the 70's , 80's, and 90's. The photo-jounalistic book "the knife and gun club" was on their system. Fairly well respected in EMS circles. Protocols are decent, but not what I would call leading edge. The paramedics there justify it based on transport times....it is what it is. The call volume, operational tempo, and demands of the service are pretty high. Its an urban inner city system... Denver Helath was in the news a few years ago for some not-so-ethical practices involving patient assaults by paramedics, and at least one case I heard of involving walking in an opioid OD to the ER with a nasal ETT still in place. This is on par with what i have heard through the grape vine on the "dark side" of the system. Take that with a grain of salt too. In the end, if you can get on, Denver (right or wrong..or both) does things the "Denver General" way...and damm the rest. You can give it a sdhot and if you dont like it, it still looks outstanding on your emplyment history as they are still very well respected.....

Unfortuanetly, those resorces and programs cost money, and unless you are well ensured, frequently you are out of luck. I grew up around a lot of drug use and abuse as a child. Also as some of the older people on here may recall, I had a friend of mine who was a medic end up addicted. As a result of her addiction, she had a rather horrible and unsual death, and due to the circumstances her issues became quite public. I also had my best friend overdose on cocaine and dilaudid in 2002 as well. What these things have taught me that we ALL ...each and every one of us..are suceptal to addiction. In fact my best friend told me a week before he died..."We all have our addictions. All of us. Each and Every one. For some its drugs, or alcohol. Others, its work, or women. But we all are addicteed to something. Some just manage it better than others. Some are in recovery. Some arnt. " I have thought about that many times over the years. The issue is far froom black and white. And while a "one strike and your out" seems reasonable, until you yourself have been touched or seen others touched by addiction on a personal level. Until you have seen the struggles. I agree with Artikcat that there has to be some way "back" from addiction, some goal, or why bother with recovery? Too many good people are lost to addiction as it is. If they can get the help they need, and are independantly determined to be safe to return to work..then perhaps we should consider it on a case by case basis. There are some who can come back , and some who should not be given the chance. Where do you draw the line? I think its safe to say you draw the line when their actions directly adversely impacted the safety of a patient or co-worker. Swapping narcotics with saline. A medical error. Wrecking an EMS vehicle. Up to that point....perhaps some careful consideration can be made. Not an easy answer...

We do the same, hyperK is presumptive based on a combination of Hx of renal fauilure or other etiology, and EKG changes.

At my agency, typically we look for about 10 years post DUI. We are a third servic, county run, respected EMS agency in the NW. We also look at the remainder of your record. It could be 15 years, but if you have 1-2 tickets a year since, you ar'nt getting in. Patterns of behavior are equally important as a single event. Also, if it was a felony/aggrivated DUI , then you are simply out of luck.

Hey Chris, My AEMT Students will be taking their tests over the next few weeks at different locations. I have made your youtube visdeos available for all of them in addition to our study time and they all have expressed that they enjoyed the videos and that they were very helpful. So far the only student to take both the written and the psychomotor was a first time pass on both, so I think I am on the right track with them. As an instructor I felt a bit of trepidation teaching a new class/scope to a test that was still an unknown at the time. Looking back, we may have over-taught it, but all in all I feel pretty good and will be repeating the experiance this summer as well. For what its worth, it came out to just over 210 hours didactic and an average of 40 hours clinical (mostly in hospital, though that will change this next time) though some students did close to a 100 hours clinical through special arrangements. We started with 12 and ended with 10. Anyway, I just wanted to give props for the videos. -Steve

1546.... He also stroked too.. which probably counted for his inability to manage his already brittle diabetes, and was septic as well. Ended up RSI/MAI'ing him, but wisely stayed away from the succs due to multiple suspicions...his K was 6.8 on arrival at the hospital.

I think that it may be worth you to repeat the observations over several classes to see if what you first saw, holds true repeatedly.

I looked back, and I see where you mentioned a physiology course, I wouldnt call it "clear", but its not a point worth arguing. I think the point I and others have raised is a valid one. If you are judging the success of the students by passing an exam, any exam..while easy to measure, it may be a fundementally flawed assumption. I guess the first question ou must ask yorself is "What is the goal you are looking for,". Preperation for passing a test, passing a liscensing exam, or success in the field? Obviously one is harder to measure than the other, I will give you that. And one you may have control over, the others you may not. But if you are only measuring success by a single exam, you may be missing the impact of a stand alone course on the "big picture" of the students overall success. So some "food for thought" type of self reflection questions: So what is the " goal" of the class? What are you trying to achieve/instill in the students by requiring the class in the big picture? And it the success (or lack of difference between one group or the other) consitant and reproducable over multiple groups in similar circumstances using the same curricula but differnet instructors?

Uhm, by "exam" are we talking about the NREMT? If so, then perhaps your underlying question is flawed in and of itself. My underlying question is "is the NREMT a fair assessment of a paramedics competence or course success?" I think any experienced paramedic would say "no" ( and to be fair even the NREMT doesn't think so, they intend it to establish the minimum for an entry level brand new paramedic...nothing more). The one advantage of a separate course is that they are very standardized, and I think the variation of quality would be less. Where in the so called integrated approaches your quality would be largely dependent on the instructors, who may or may not be qualified to discuss detailed patho-physiology outside of the paramedic course. Besides, why not do both? Repetition is a key point of learning. And having students with a good foundation makes them better prepared to discuss pertinent physiology on a higher level, hitting the ground running so to speak. So I like the best of both worlds...

In the old days we had a "coctail" on standing order for 5 mg of Haldol, 25 mg of Benadryl, and 10 mg of valium IM for the extreemely comabtive patients. It was used quite often to good effect...sometimes too much effect...but this was pre-versed days. This is our current protocol: http://www.adaweb.net/LinkClick.aspx?fileticket=j79mqGaMLDc%3d&tabid=798

Respectfully KIWI, this is not completely accurate, though it isnt inaccurate either. There is a (slow) process the NREMT goes through, but the good news is that the ground work for Canadian to US transition has been done many times over (moreso that the AUssie/NZ transition) , so it is quicker than most. I only say this because we have at least one Canadian paramedic who works for us now. That said, it is extremely slow and frustrating. I know you will need lesson plans, syllabi and similar documentation to prove equivalency If you are fortunate, someone from your province has already done this so it will be easier. Either way, you pretty much have to start at the NREMT for most cases, then apply for state after that. Someone here may know of a state that will accept you straight across but I dont know of any. If you can get your state cert first you can back door the NREMT that way, but there arent too many of those states left. I agree that if I had my choice I wouldn't work in California, especially in SoCal, its very restrictive for paramedic practice, not to mention the local FDs love to treat private service medics like crap. That said I would definitely do it if it kept me with my family, so best of luck there man. You should keep us posted on the details of your progress. This question comes up about every 6 months or so, so having an ongoing thread with details would really help a lot of people.