New Alberta Protocols

[tniuqs]

What that a home wall mounted CO monitor ?

Or what is referred to in the new RAD 57 http://www.masimo.com/rad-57/ as in SPCO refered to in Fire Fighter rehab protocol, have yet to see a box load of those devices on car.

I have question about discontinuation after 15 minutes down time ? is this cost cutting ONLY ?

I have a question as to the "dial a drip" ... with epi ? sheesh not me I would rather count a 60.

I have a question about narcotic max for pain is this down town EDM / Calgary or at marker 45 on the Icefield parkway on in a bottom of a coulee in Drumheller (super cell reception)I have myself this question of OLMC how does that work at 28 thousand feet in an Alberta Air Ambulance? call STARS ? <insert knee slapping noise>

I have a question since the "SS" is heading up this EBM, these are "opinions of meta-studies" no volume expanders? Well the CAF is using them why not EMS in AB Canada ?

No HOB up 30% in Head Injury .. using Ketamine to intubate with suspected increase in ICP ? interesting.

So all STARS for every red patient? Oh btw Mr Stelmach ... so STARS is a supposedly not for profit operation right, ... but they now have control as to who and what responds. When the red blot clot flies do they not get reimbursed so following that fuzzy logic, isn't this kinda like the fox running the hen house ? Is that not "a private health care operation calling the shots now" most very curious that lottery dollars now being used to dispatch Air Ambulances ... just wait till that hits the news !

I wonder where they put the TNK in the cupboards (most likely beside the $15.00 bedside troponin tests ???) ... sure is going to be difficult to administer TNK and even if the 12 lead is transmitted to OLMC if you don't have ANY besides ALL the EBM studies are saying that PCI and TNK are equally as good outcomes.

Well I have many questions the CPAP studies quoted for one are not studies done by a $70.00 device .. nor was this cheesy device ever approved for use in hospital by respiratory therapy evaluators for Alberta Health ... this is just BS and boasting from the manufacturer (accelerating oxygen at the molecular level like a jet engine LMFAO !) and the Israeli studies are not worth the paper they are printed on, there studied states lasix, B2 and ipatromum +++ were also used) as I have posted prior.

Now the latest and greatest folly "attempting to restrict" a L + S response to the speed limit and come to full stop at intersections .. that's going to be difficult to do #!%! WITHOUT WINTER TIRES ! Why doesn't that hit the news ? ... RCMP have the best of the best winter tires ? why not the Ambulances ...its not like we dont have ice or snow in Alberta.

A commenter on CBC news called "paddy boy" and I must concur .. AHS took a system that was one of the best in the free world and broke it.

Throw this Government OUT they are killing people in the Emergency Rooms (documented) and are now trying to do it in the field.

[HellsBells]

I have little knowledge of CPAP devices, I do, however find the "hurricane of air" tagline pretty weak for a device that is supposed to be used by medical professionals. "Hold on a sec miss, just let me prepare this device so I can treat you with a Hurricane of Air (as the scorpians hit Rock you like a Hurricane plays on in the background). I did treat a pulmonary edema pt the other day, but she responded well to Nitro, so I have still yet to give the prehospital CPAP a test drive.

[tniuqs]

I have little knowledge of CPAP devices, I do, however find the "hurricane of air" tagline pretty weak for a device that is supposed to be used by medical professionals. "Hold on a sec miss, just let me prepare this device so I can treat you with a Hurricane of Air (as the scorpians hit Rock you like a Hurricane plays on in the background). I did treat a pulmonary edema pt the other day, but she responded well to Nitro, so I have still yet to give the prehospital CPAP a test drive.

The little knowledge part (and not intended to be personal in the slightest) is very problematic / legalistic, AHS has introduced a completely new treatment / device so has there been any education to go with this ? ps accelerating oxygen molecules like a jet engine works is also used to market this device

I must agree with the EBM AHS protocol on CPAP and that the concept and implementation of CPAP (better and far more effective would be BI Level Support) that said: properly applied to the right patients with enough education by the practitioner to be successful as CPAP therapy and when a patient is in extremus this is practitioner experiance dependant success rate (something one can not very effectively be quantified) by any study.

This has the potential to limit ICU ventilated bed admissions and decrese overall morbidity mortality thereby lowering health care costs but not this piece of CRAP CPAP, the AHS EMB links to CPAP justification and this device do not compute.

Now just imagine if a patient died while on this poor excuse IMHO for a CPAP, and you with little or no formal education on it other than a few boxes and arrows AND the family sued or minimum a fatalities investigation, well your ass would be hanging in the breeze as would AHS. OK full points for trying to implement a concept but -5 for allowing purchasing for AHS to get involved.

Then a few more issues as this $50.00 device requires huge oxygen requirements to work effectively and latest research (yes newest EMB) is indicating that increase in mortality morbidity treating the CHF patient with high oxygen concentration levels vs low oxygen concentration levels, one cannot adjust any FiO2 with this, and in passing a real CPAP device in ER is a bit more expensive. In my opinion without far more education and by a dual registered practitioner (say an RRT / Paramedic ?) This CPAP experiment it will fall flat on its face, and worse for entire EMS, if a study is actually undertaken it will reflect very poorly with "AB EMS" CPAP, if you can see where I am going with this.

Again if we go back to "transition" again introduction concept without a true plan of action its very expensive (in passing)

Question Hells Bells are you Pamedic or EMT level (as this does matter before my next comment's as there seams to be some current controversy as to who can use this device, and I cannot open the PE protocol link.

In AOCP the under the scope of practice this "device" is NOT just oxygen delivery it is positive pressure ventilation, with no alarms if apnea occurs or if flow volume is impeded, most simply put device uses the Venturi effect or an application of Bernoulli's principle and it all goes for a shit when you have no forward flow.

EMT

I-3-1 Demonstrate knowledge and ability to ventilate a patient, including, but not limited

to:

• Pocket mask;

• Bag-Valve-Mask (BVM);

• Non-visualized airways;

• Example: Combi-tubes®

(Wow is this an old device)

REMT-Paramedic:

I-3-2 Demonstrate knowledge and understanding of mechanical ventilators:

• Recognize indications for mechanical ventilation;

• Recognize potential complications and safety issues related to mechanical

ventilation;

• Operate mechanical transport ventilators;

• Differentiate between continous positive airway pressure (CPAP), positive end expiratory pressure (PEEP) (I dare you),and "bilateral inspiratory" ROTFLMFAO ! positive airway pressure (BIPAP);

Now that is really scary stuff included in this scope of practice.

• Utilize a mechanical ventilator based on patient’s clinical condition;

• Discuss and understand laminar and turbulent airflow;

• Recognize adequate ventilations being achieved with devices.

This is pretty generic stuff, does anyone wish to jump in and explain the difference between CPAP and PEEP just for example ? .. I would challenge that 90% of REMT-Paramedics to put a patient on a ventilator that is any more sophisticated than a Volume Ventilator with more than 3 coloured knobs. This is not intended to be a slam its intended to enlighten, as just 2 days ago had a phone call from a new grad asking the interactions of ETCO2 and minute volumes and how ETCO2 correlates to PH ... well that was a 3 hour phone bill.

So a couple of questions fer fun:

Does the application of CPAP increase or decrease WOB ?

What is true threshold PEEP ?

Can CPAP be maintained with a BVM a flow diverter with a spring and ball gauge ?

What is average autopeep on a know COPD patient ?

Should FiO2 of 1.0 be used on a COPD patient ?

What is the statistical incidences of a COPD patient that is also CHF ?

I think AHS really screwed themselves with this restriction !

Why can CPAP / BIPAP not be used on an asthmatic ? hint AHS is wrong.

Can auto peep be clinically measured ?

For that matter what is auto peep ?

Should auto PEEP be matched or exceeded.

Name 3 complication with the application of CPAP.

cheers

ps I know an RRT that is an REMT-Paramedic, flight and yes a fossil but that is a positive Health Care Activist looking to travel and work days ...

sorry for all the edits ... I like making up questions.

Edited December 31, 2010 by tniuqs

[HellsBells]

Wow tniuqs I dont know why all your relpys are so brief, try actually including some detail in your responses.

To answer your question I am a paramedic. As far as I know, and as I read the protocols, EMT's will not be administering CPAP, as it is part of the continum of care for CHF/Pulmonary Edema, including Nitro, which is also of EMT scope in that instance.

I by no means take offense to your characterization of Paramedics knowledge of CPAP and ventilators. I learned a lot about the subject in school. However, the only expierence I have had with vents in practice was during my OR practicum, where I basically hooked it up to the ET tube after intubating and was sent onto the next pt.

ACP seems to want us to be knowledgable about vents, based on the numerous questions asked about them on last summers paramedic exam. The same exam, in fact, that had exactly zero questions regarding 12 lead ECG's or ACS.

Our training on CPAP was quite minimal. It involved a demonstration on its use. We had about 15 mins to set it up. Went over indications/contraindications. About a half hour on total I guess.

As for your CPAP questions... Well lets just say I have some reviewing to do.

[tniuqs]

Wow tniuqs I dont know why all your relpys are so brief, try actually including some detail in your responses.

Sorry I will try to be more concise and detailed in the future as you know this topic this topic is rather dear to myself firstly because well its the "B" part and not as simplistic as air goes in, air goes out, traditionally with Paramedic / EMT education that about as far in depth as it gets.

The lack of recognition of Dynamic Hyperinflation has now been overly compensated by the new and improved (CPR standards and ACLS guideline's) DHI leading to PEA/EMD was a very serious concern unrecognised for years in EMS, or even addressed.

If the throw this "carte blanche" CPAP device ON out of the plastic wrapper on to a real patient (reading the directions first on the insert of course and a 3 page follow the arrows and refer to coles notes ) Then to implementation a new therapy on a global / provincial level is huge folly, as I have stated before, this will be a huge fail for EMS EBM as I have stated. The 5 minute trial, and the do not use on COPD or Asthmatic ??? perhaps if it was proven that it works with EBM on PE alone then CPAP would be expanded ? I dunno but the logical thought process is flawed firstly, so only attempt 5 minute trial of NIPPV then go to directly Invasive Pressure Ventilation ? another Epic Fail in methodology alone and contra indication "PneumoThorax" being the justification, in NIPPV but not in Invasive Ventilation ?

So do you see a pressure release blow off valve on YOUR BVM or on this B CPAP device ? Because if the patient coughs well big time interthorasic pressure again just saying, its not all good air goes in bad air comes out.

I attended a "Futurist Lecturer " whateve the heck that is in an ACART convention, YES a very forward thinking College and ASSOCIATION (oddly just like the RN equivalent) Well this at a Respiratory AGMs (not just a one day don't answer questions and make motions, that will be overthrown by council day) but a true advocacy don't get me going about that group, I get hypertensive myself.

Back on topic: Now with the demographics alone and with soon to be massive retiring baby boomers, yup the CHF/COPD crowd, hell even Ralph Klien is a self admitted COPDer, well someone ain't doing the math or lacks some serious Vulcan logic to decrease admission overall lower health care costs in the millions (if effective) BTW a extremely effective device with 2.5 of PEEP, to get an immediate bed O/A to ER and not wait in the hallway

IF CPAP or BI Level support is to be effective and the bottom line with this "present govenment" is to lower health care costs (still shaking my head over that prostitution of the term in the scope of practice document) as bi means 2 levels not 2 lungs and only on inspiration, well just I had to laugh. I guess DON'T ASK DON'T TELL was adopted from the USA military "protocol" And don't get me going on whom is making these changes.

IMHO the EMT level would gave no problems implementing this therapy as without the option to RSI/RSS they just get to wait till the patient crashes that said: provided the education like "gap" training was implimented as many provinces HAVE adopted CPAP for the EMT or PCP as NOCP/AOCP/SOCP/BCOCP as that will be interesting to watch, if you get the drift.

The history of these terms and "modes" are subject to registered trademark ie BIPAP cannot be used because it is trademarked unless your using that machine, whatever anyway off topic, in real life the terms are interchangeable. Thing is I was researching the HDA for the OLD term's of reference for EMT or Paramedic which I guess has since changed ? In the old scope of practice was "the use of positive pressure airway devices" both EMT/ACP they should have left things as WAS ... just saying. FAIL.

In regard to your comment about Paramedic education in institutes or clinical's it should be mandatory that the Paramedic student be in a "busy" ICU for minimum one week and not sit with one patient / RN but be running your ass off just like the RRTs! I have not only severe critique but also a resolution to the problem get experienced bedside RRT to develop a "special needs" course (for lack of a better term) teach the "B" part and dude no shock and awe about the exam banks I field questions every time there is a write but "good thing" their not asking about STEMI diagnosing or treating

Well in comment 15 minute instruction on CPAP if AHS does not educate there may be very serious medical legal ramifications because everyone loves to sue government, or if one does uses this device especially the "bean counter selection of devices" your own ass may be hanging in the breeze perhaps ask your HSAA rep about that ?

I am happy that I may have possibly affected the 3 or 4 actually reading this tread, and to bone up on this before your asked why you did not use this therapy, or did not.

ps ASK for an explanation in any question and most happy to provide a short answer ... Bhwaaa Haaa Haa were did that evil smiley go ?

cheers

edit a bunch of times for spelling and lack of proof reading.

Edited January 4, 2011 by tniuqs

[HellsBells]

I was going to mention the fact that paramedics needed to have an ICU rotation as part of the program. This would be particularly important for those who wish to go onto the air medical side and even for those who work rural and need to transport pts on vents. Its quite the shame that this part of our program is glossed over somewhat.

[a_shane2_go]

dumb question before i contact ACP. New protocols state EMT/EMT-P for transport less then 30 minutes use nitro PATCH.... (For AMI or ACS not sure which one)

is this in the scope of practice of an EMT-A in alberta? I never learned about patch dosing etc in my BLS class 5 years ago.

[tniuqs]

dumb question before i contact ACP. New protocols state EMT/EMT-P for transport less then 30 minutes use nitro PATCH.... (For AMI or ACS not sure which one)

is this in the scope of practice of an EMT-A in alberta? I never learned about patch dosing etc in my BLS class 5 years ago.

Most correct:

MOST interesting question as in REMT "GAP" there is no mention of transdermal delivery of medications. That said I have added an excerpt from those public domain on ACoP website, point being local/physician order under HDA one can deliver said medication,1- with documentation of course addressing this medication

2- tested and approved "local" MD (how this applies with AHS Medical Direction umbrella I dont know.

Its curious how AHS is getting around these regulations and expanding scope of practice in the intermediate level but restricting at the Advanced level ... perhaps some "forshadowing" of things to come ? But that would be just conjecture on my part as I hide way out in the bush where the police can't locate me .

G-1 Medication Administration

G-1-1 Demonstrate the ability to prepare medication for administration:

• Verify local protocol/physician order

• Assess appropriateness of medication for the condition

• Contraindications, age, weight, allergies, clinical condition, concurrent medication

G-1-2 Demonstrate the ability to apply guidelines for medication administration:

• Right medication

• Right dosage

• Right route

• Right time

• Right patient

• Right documentation

• Expiry date

• Packaging integrity

• Absence of precipitate

• Clarity

G-1-3 Demonstrate knowledge to follow specific legislation and local protocol.

Edited February 8, 2011 by tniuqs