Brainstorming EMS Paper Topics

[AnthonyM83]

Vent,

I'll have to find that information source. We were told in class that the county had done that study, so haven't read results. Have the feeling not all the info is readily available since *I believe* it was an internal study from the EMS Agency to see how county resources are being used and figure out needs, etc. Information that would make sense for administrators to have.

And yes, the lack of preparation field personnel have is astonishing, which is partially explains the hesitancy to do any but the most routine procedures around here (along with many just not caring).

The paper could be informative, but I believe a political stance paper would definitely be acceptable, as long as it involves literature review.

Edited April 22, 2009 by AnthonyM83

[VentMedic]

This is a good example by what I mean as confusion for O2 terminology. This can also apply for differences in CPAP therapy or portable ventilator applications. One can not adequately compare all the data collected from ICU machines to most of the portable models. Thus, results may be different and misleading if one does not pay attention to the methodology and devices used in the studies. The below article, link at the bottom of post, is also a good example of that. After reading how this study was done, I can only say "WTF" and "why?" There are easier and more accurate ways to achieve flow and FiO2. It reads like someone just needed a paper to keep status.

http://stroke.ahajournals.org/cgi/content/full/36/10/2066-a

What Are High-Flow and Low-Flow Oxygen Delivery Systems?

Ritesh Agarwal, MD, DM Dheeraj Gupta, MD, DM, FCCP

Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

To the Editor:

We read with interest the article, "A Pilot Study of Normobaric Oxygen Therapy in Acute Ischemic Stroke."1 However, we have certain reservations with the terminology and the method of oxygen delivery used by the authors.

First, regarding the terminology of "high-flow" oxygen used by the authors, the authors mention the flow rates but not the oxygen delivery system used. An oxygen delivery system is a device used to administer, regulate, and supplement oxygen to a subject to increase the arterial oxygenation. In general, the system entrains oxygen and air to prepare a fixed concentration required for administration. Oxygen delivery systems are generally classified as low-flow or variable-performance devices and high-flow or fixed-performance devices.2 Low-flow systems provide oxygen at flow rates that are lower than patients’ inspiratory demands; thus, when the total ventilation exceeds the capacity of the oxygen reservoir, room air is entrained. The final concentration of oxygen delivered depends on the ventilatory demands of the patient, the size of the oxygen reservoir, and the rate at which the reservoir is filled. At a constant flow, the larger the tidal volume, the lower the FiO2 and vice versa. In contrast, the high-flow systems provide a constant FiO2 by delivering the gas at flow rates that exceed the patient’s peak inspiratory flow rate and by using devices that entrain a fixed proportion of room air.3

Second, the authors have also not mentioned how they gave oxygen at flow rates of 45 L/min. The standard flow meters are calibrated to flow rates of oxygen at 15 L/min, although if one turns the thumbscrew of the valve wide open, a much greater flow is delivered.4

Also, there is a tendency to confuse flow systems with oxygen concentrations. However, both are mutually exclusive in that a high-flow system, viz. Venturi mask, can deliver FiO2 as low as 0.24, whereas a low-flow system like a nonrebreather mask can deliver FiO2 as high as 0.8. Thus, if the ventilatory demand of the patient is met completely by the system, then it is a high-flow system. In contrast, if the system fails to meet the ventilatory demand of the patient, then it is classified as a low-flow system.

Response:

Aneesh B. Singhal, MD

Stroke Service, Massachusetts General Hospital, Boston, Mass

We thank Drs Agarwal and Gupta for giving us the opportunity to elaborate on our method of oxygen delivery. As stated in our article,1 we delivered humidified oxygen at flow rates of 45 L/min through a simple facemask. "High-flow" refers to the high flow rates of oxygen used in the trial. Because the peak inspiratory flow rate of a resting individual is typically below 30 L/min,2 delivering oxygen at higher flow rates (eg, 45 L/min) precludes contamination of oxygen within the facemask with room air, so that the effective FiO2 is close to 1.0. The high flow rates were achieved by substituting the standard flowmeter (calibrated to 15 L/min) with a commercially available flowmeter that can deliver flow rates as high as 75 L/min (Timeter Classic Series Flowmeter model O-75; Allied Healthcare Products, Inc). This flow meter can only be attached to an oxygen wall outlet; therefore, during the short period of patient transport to the magnetic resonance imaging suite, we used the standard 0 to 15 L/min flow meter attached to oxygen cylinders and maximized oxygen delivery by fully opening the outflow valve and using a nonrebreather facemask (with this method, the effective FiO2 is 0.8 to 0.9). Although we were able to achieve encouraging results using this simple methodology, we emphasize that further studies, in unselected stroke populations, are needed to establish the safety and efficacy of high-flow oxygen before it can be used as an acute stroke therapy.

The article being referred to:

A Pilot Study of Normobaric Oxygen Therapy in Acute Ischemic Stroke

http://stroke.ahajournals.org/cgi/content/...pe2=tf_ipsecsha

Edited April 22, 2009 by VentMedic

[2wheelinemt]

That idea on GHB is an good idea, we have a large amount of use around where I live and the kids in the high school were buying the ingredients on line. Not that I am suggesting what paper to write but I just thought that as a medic that is something that would be dealt with and be very informative.

Another idea would be the greater use of air ambulances whether they are warranted or not for the increased use. I know the crashes have been discussed but the increase use, valid or not?

good luck with your paper!

2wheelie

[firedoc5]

Sorry, didn't read them all, but....

Balance of medical treatment vs. trauma care pt.

Severed limb care for possible reattachment

OB/ GYN with limited supplies

Treatment of peds. pt's. with "adult" illnesses (I know, kinda specializing)

I ain't woke up yet and coffee has only made to about mid-chest, and I want a cigarette. I'll keep on thinking.