VentMedic

Transmission technology now used by some in EMS in the U.S. http://content.onlinejacc.org/cgi/content/full/50/6/509 The ECG is tranmitted and prehospital treatment can be continued without fear of the hospital missing ST segment changes or waiting until you get to the hospital. It is amazing that for an area with the size and wealth of LA that the 12-lead ECG is just now getting started. But again, there are many areas in the U.S. that can not do 12 lead ECG and many areas that are only BLS. Michigan just announced their first 12-lead ECG about 5 years ago. Here's an article from September 2009 about Chicago. Believe it or not Chicago FD EMS does have a decent reputation. http://www.chicagobreakingnews.com/2009/09/chicago-behind-the-times-in-heart-attack-response.html Here's another area in California: San Luis Obispo County http://www.sloemsa.org/ http://www.sloemsa.org/policy/pdf/619.pdf

For your age, that would mean you have not actally spent much time working in the U.S. We do know that other countries have different EMS systems than the U.S. Are you comparing how they do things differently or just trying to impress us? Some on ths forum are also from other countries and some have more experience in EMS than you have been alive. Some also know the EMS systems in the U.S. well enough to know that blanket statements can not work in a country that has over 50 different EMS levels each working under different scopes and their own medical directors. If you knew much about the history of EMS you would realize that Florida has been doing 12 lead ECGs probably for well over 2 decades and was also one of the first states to do thrombolytics. However, we also have the ability to transmit thus the ED doctor or caridiologist can actually be the one to have the final say on if the cath lab gets activated. Does that mean they don't trust the Paramedic? No. It just means they may also have more education or will be going by the hx of the patient for determining if the cath lab is the best option for that patient at that time. Also, when some EDs at hospital with cath labs get over 100 EMS trucks in a few hours, some traffic control is necessary and that ambulance may need to be diverted by someone who has existisg knowledge of all the cath labs. Stats from NH: Numbers of EMS services: Fire department (paid), 46; fire department (volunteer), 123; volunteer squads, 61; commercial, 24; hospital-based, 5; funeral home, 2; police department, 11; other, 18. You state progressive EMS but you must use a 15 L/M NRBM? Below is the OP and I do not see anything mentioned about a 15 L/M NRBM HEMS is a little different. We also don't advise ground EMS to sit at scene for an hour with a chest pain patient waiting a helicopter. We are not dispatched simultaneously with ground EMS for chest pain as we can be for trauma. Is your helicopter service dispatched to every chest pain call with ground EMS? That patient may also be much better in a hospital ED who has a rapid transport IFT agreement for STEMI but can also initiate treatment rather than waiting in some field for a helicopter provided the hospital is closer. Chances are a few eyes have seen that patient's ECG before calling a helicopter. However, if you are flying in with a helicopter for IFT, I bet there were doctor to doctor communications for the referral for them to clear a path to the cath lab for you. We could also get into some of the HEMS issues in AZ as well as some their EMS companies but that can be another thread. Few states are perfect and every hospital and every EMS system performing to the highest possible level without some issues. We could or have already had discussions about Michigan and that state's outspoken reluctance to have its EMS education programs accredited. Again, the states you listed earlier, you can not overlook the fact that many of their services are BLS volunteer only. Thus, it is difficult to toss around a stat like >90% activate the cath lab if there are only a few ALS EMS agencies in the state.

John, You have made many blanket statements about a lot of services in a lot of states and you might be surprised to know that there are services in those states that do not even have ALS in some areas and others may not all have 12-lead capability. While FL may not be perfect, it does provide ALS to all residents and there are some excellent EMS agencies in that state. You might also remember who did some of the first thrombolytic studies for EMS in the 1980s. Post some of the protocols from those services you are familar with so we can see if their recipe states O2 or 12-lead first. Also post whether they transmit the 12-lead to either the ED physician or Cardiologist for viewing prior to arrival. Bypassing the ED can be done but...did one of the other 2 two physicians make the call? We get a lot of CP patients in the EDs everday and even with EKG changes not all will go directly to the cath lab. Some will be directed to bypass the ED and some will come in to the ED for more monitoring and tests. Hell there might even be a patient will NO ECGs changes that gets sent straight to the cath lab. Each patient can be different so blanket statements for one treatment to fit all is not a good way to do medicine...except for some EMS agencies.

I wouldn't say there are "many" ALS services carrying Retavase. Unfortunately, there are many EMS companies that do not have 12 lead capability and some that do are not able to transmit to the ED. And, not all cath labs will activate unless someone with MD behind their name makes the call. The ED physician or cardiologist on call activates after seeing the 12-lead from the field. These situations are NOT just for BFE. California is full of major cities that do not have 12-lead capability and some 911 agencies must still transport to the nearest facility with a chest pain regardless of clinical findings. There are also cities such as those in Southern CA that probably shouldn't have 12-lead capability as their poor results and cath lab physician frustration with them was made known. Thrombolytics have been trialed in U.S. EMS even in the 1980s but with cath labs springing up everywhere, some of the cities involved initially did not see a need to continue that protocol. There are a few EMS agencies that do have this protocol but much of the literature is from other countries where EMS is slightly more advanced than the U.S. Of course in the U.S. your flight and specialty teams may be the exception which is what you are most familar with.

SpO2? What is the relationship between the SVO2, DO2, and VO2? You have to be thinking about the pathophysiology behind various disease processes and what factors pain influences. SpO2 is just one number. If there is any possibility that cardiac output will be affected, so will the SvO2 and tissue oxygenation. The SpO2 will not always reflect that. Even if you do not have advanced monitoring capabilities you can still get a good idea about what direction your patient's cardiac output might take be it high or low. You also may have the consequences of tissue hypoxia even if the SpO2 remains high. Multitask and do both since you should have a partner around or a dozen fire medics in some areas.

No it wasn't because of Trauma although there were some expensive oversights in the contract. It was mostly political and probably has more to do with the affiliations of this person's husband, actor Peter Coyote. He is actively supporting Jerry Brown for Governor instead of SF's Mayor Newsom who was her boss. It also saves the city of SF about $132k for her salary which isn't very much by Northern CA standards.

This Air Station has been closed since 1997. Most of it is now in ruin and there have only been the rare sighting of a sailor or Marine in that little city. Their budget and the Federal (EPA) regulations probably didn't allow for too many props or extras. Since the Navy is still in control of much of the property and the City of Alameda (Historical regs) leasing the rest, no explosives were used. I also believe some of the Navy property still on that base is off limits to being filmed. Sidenote, the Mayor of SF just fired the head of the city's film commission.

If you already saw this "cutthroat" stuff, why did you even consider nursing school? It sounds like you already have formed an opinion against nursess. If you don't want to be a nurse, dump that program and finish a degree in EMS. Many colleges may allow you to transfer whatever military education money to other courses. Are you attending a college nursing program or the famous mail order program for Paramedic to RN?

When doing the personal approach it should not be too melodramatic to where it crosses the line into whining or give the feeling that pity is being sought. It may give the public the wrong impression that some in EMS are weak, unhappy, not satisfied with career choice or totally in the wrong profession. You could easily make the provider appear more needy than some of the patients or that they have so many personal problems one would have to wonder how they could even concentrate on the patient. The public watching may not be as sympathetic and might just think with so many health care job opportunities, why would one not choose something else rather than putting their family through the emotional turmoil and financial difficulty or the possibility of your baggage interfering with patient care. It could turn out like a soap opera which many in the general public already know how all too well.

The forms generally come from the EMS agency and you or your supervisor should have easy access to them which contain all the information and authorization for treatment and follow up. Hospital EDs see many different providers and it is difficult to keep track of every form and every company contact person. Each company may also have its own policy and will vary from others. However, it is your right to know what that policy is and it should be clearly stated in your employee manual. If the hospital later determines the patient is positive for something like TB or meningitis, they have their own Public Health forms for followup with your EMS agency and hopefully that information is correct. This is why there should be a Designated Infection Control Officer for each agency.

There are a couple of things to be aware of with Physio-Control's model on the LP12. 1. The monitor shows the maximum CO2 value over the last 20 seconds. a. If the EtCO2 values are increasing, the change can be seen with every breath. b. However, if the values are continually decreasing, it will take up to 20 seconds for a lower numerical value to be displayed in the CO2 area. 2.As such, the EtCO2 value may not always match the CO2 waveform. Or, one is understanding the numbers do not always match the waveform. Two is knowing there is a 20 second delay and why or how the numbers are obtained.

It is a good tool only if you have the capability of monitoring the waveforms and the knowledge to understand them. Numbers alone will not give you a good diagnostic picture. The patient, of course, and the deadspace ventilation must be considered. It should be used to confirm what you may already suspect. Some get fooled when a COPD patient in respiratory distress appears with a low PetCO2 number but not considered is the PaCO2-PetCO2 gradient of that patient. The PaCO2 may actually be very high. A low PetCO2 can be accompanied with a wide PaCO2-PetCO2 gradient which could be atelectacis, over distention of the alveoli, PNA, pulmonary edema or pulmonary emboli. Also, the cardiac output must be considered as many patients are not just one single disorder especially if they have a chronic lung or a chronic cardiac condition. Long term steroid dependent patients may also present another factor with their glucose that must be examined. For the patient that is spontaneously breathing, these factors may not be a major issue with the chance of correcting something based on a numeric value. Thus, trending of the number and waveforms may be of use in the treatment. However, if you have a patient on a ventilator and since the tricked out demand valves or ATVs are gaining in popularity, it could be very easy to over or under correct if you do not understand the waveforms, numeric valves and clinical correlation of both chronic and acute. There are a couple of things to be aware of with Physio-Control's model on the LP12. The monitor shows the maximum CO2 value over the last 20 seconds. If the EtCO2 values are increasing, the change can be seen with every breath. However, if the values are continually decreasing, it will take up to 20 seconds for a lower numerical value to be displayed in the CO2 area. As such, the EtCO2 value may not always match the CO2 waveform.

Was it nursing or the military with their rules and regulations for end of life care and protocols that he did not fit into? I also get a little frustrated with the way the VAMCs handle end of life issues. I wish there was more information on this part.

I would say I recently got a more thorough physical from my physician when preparing for a scuba diving vacation than many FFs/EMT(P)s get. However, when I went in for a yearly checkup with Paramedic as my job title, I got a quick "any problems question" and a sign off of good health. It is strange that many doctors got the memo about the number of diving deaths related to medical problems but don't get the same message for FFs and EMT(P)s.

That woman was well into her 40s. There are people a lot younger than that dying of cardiac arrest while doing very little. We've got young FFs and EMT(P)s dying at the scene while caring for other patients. It is actually very rare that anyone dies at the Fire Academy. I would have hoped a physical exam by a qualified physician would have been done on volunteers prior to the academy to determine risk factors.

I have yet to watch this show except for the first 10 minutes of the first episode but I've seen the filming everywhere in the Bay area. The "helicopter" used in the city scenes is a prop and not a real helicopter. Someone must have forgotten the sound effects. I believe this is the episode that was filmed at the old navy base in Alameda and cast the local FFs and EMT(P)s in some of the scenes. This is a San Francisco thing primarily in China town. You can buy live poultry to go with or without the neck being wrung first. At the farmers' markets in the city you will often see a large truck full of live chickens or turkeys for people to purchase. The MUNI bus drivers get a little annoyed when people try to bring them on board still alive so it is not unusual to see some little elderly lady pull the live bird out of her shopping bag and break its neck right there so she can get on the bus. Thus, that is not too out of the limits of reality. Rarely used by EMS. If that body part is 4th degree, damage is to the bone and amputation will probably be necessary. There is an excellent regional burn center in SF (St. Francis Memorial Hospital) that may use that term occasionally as they get the worst of the worst.

That video is not near as melodramatic as some of the personal lives of the patients. As an RRT I have seen of these patients in both the acute: ED, ICU and then Rehab as they are usually on a ventilator and trached. A pontine stroke is usually the cause and most of the patients I have seen are between 35 and 45 y/o. When you see the family's reactions and interactions with the patient, you see the uneasiness and uncertainty. You can see what role the patient has played in their lives and now the adjustment is one of loss but the person is still there. They hang photos of the patient throughout the room to remind the patient of their past life and to remind the staff that the patient had a life before their stroke. This youtube video shows one of the devices we can now adapt to these patients for communitcation. Here ALS is being called a locked in syndrome which it can be but from a different etiology. http://www.youtube.com/watch?v=GWe5YVV9dWs&feature=related The TV show House featured an episode about locked in syndrome and it actually was watchable. http://housefanblog.com/house-md-seasons/season-5/house-md-5x19-locked-in/ The difference with ALS and Locked in Syndrome is that ALS is progressive neurological disease that attacks the nerve cells and will cause death not too long after onset. A pontine stroke patient may be able to be rehabilitated to where they can move around in a wheel chair with either head or hand controls. With the computer device some can at least communicate. For either patient we try to give them some potential (as insurance and government resources allow) to have whatever quality possible in their lives. Those with locked in syndrome will sometimes say by some form of communication it is worth it if they can just see their kids grow up, graduate from something and maybe see some grand babies. They become a spectator to life but to some it is worth it. Thus, not always do some want to end it all even when one might say that now. Life changes and so do people when faced with different situations at different times in one's life.

http://www.thebostonchannel.com/health/21702241/detail.html Mass. Responders Given Wrong Flu Vaccine NEEDHAM, Mass. -- Fifteen Needham firefighters and several Needham residents were caught in a medical mix-up when the H1N1 vaccine they thought they were getting turned out to be a vaccine for another strain of flu. NewsCenter 5's Randy Price reported Monday that the Centers for Disease Control and Prevention is now warning health departments about the possible vaccination label confusion. The label of the seasonal flu vaccination had H1N1 on the label as one of the strains targeted -- but not the current H1N1 strain. Paul Buckley, the Needham Fire Department chief, was among those coming in Monday to get the H1N1 vaccine. Buckley had been notified by the department that the vaccination he originally got, along with a number of his colleagues, was the seasonal flu vaccination by mistake. In all, 47 people were affected. The mistake left people confused and concerned. "Hopefully, we haven't had any issues in the past week where some of the people came in contact with the H1N1 virus or possibly got sick from it believing they were vaccinated when they actually weren't," Buckley said. The town's health department has been calling everyone to tell them about the mistake. Officials said it was harmless and amounted to getting a booster for the seasonal flu. Dr. Janice Berns said it is the first mistake like this that she has seen in her 40-year career in public health. "I think the label doesn't appear to be clear," she said. Health departments are now being alerted to the possibility of making this mistake. http://www.emsresponder.com/article/article.jsp?id=11181&siteSection=1

Steven Laureys, the neurologist, has published a few very interesting articles. http://www.coma.ulg.ac.be/home/steven.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&term=%22Laureys%20S%22%5BAuthor%5D Further research is always continuing to distinguish conditioned and learned patterns or responses in the brain as they are to be interpreted for the potential to higher function. http://www.coma.ulg.ac.be/papers/vs/MCS_emotion_Neurology04.pdf There are also several different levels of a coma that must be assessed for each patient and should also be included in research articles. http://calder.med.miami.edu/pointis/tbifam/coma1.html We get several patients with Locked In Syndrome (aka coma vigilante and pseudocoma) sent to our rehab unit if they can manage to open their eyes. We can then sometimes get them back to a higher level of functioning and even some type of communication. However, if they don't open their eyes they may be warehoused in a LTC facility and labeled as comatose.

EMTs and Paramedics have no powers of detainment. The LEO has that power to detain for whatever reasons within his/her guidelines. The person detained for the emergency hold is then seen by a qualified health care professional/doctor to determine if the hold is legitimate. Quite often the 72 hour hold can be overturned by that doctor and the patient is admitted voluntarily or released. Florida's Baker Act was scrutinized and revised a few years ago also when many patients,especially the elderly, were being detained for questionable reasons.

You can also take the NR for Paramedic. But, first find out what the requirements are for that state. Some like CA want you to have at least 1000 hours of training for the Paramedic.

John, the OP is an EMT-BASIC. If you look around at some of the other forum members, many are still students in EMT-B class. For some this is their first introduction to a few basic and advanced concepts about O2. In EMT-B, oxygen therapy is really not covered very well nor are the disease processes and the oxyhemoglobin dissociation curve. Many of your posts were very technical as were mine so sometimes some things must be repeated and reinforced for those new to the profession and with only the training that the EMT-B provides so that they may have a solid understanding of the concepts at hand especially if they are reading them for the first time. So no the subject of oxygen should not be closed since there is so much more for them to learn.

However, for the benefit of the new EMT(P)s, if you read or hear "history" of anemia, that does not necessarily mean it is still true in present day. Many medical conditions can cause anemia and then improve as that condition has been treated. As well, they may be receiving regular treatment or even blood transfusions to deal with this problem. Don't let that word "anemia" distract you from still attempting to treat the shortness of breath and for doing a thorough assessment to look for acute causes.

The NR is now the state exam for the EMT-B. Once certified, FL will issue you their certification to function as an EMT in the state. Transferring with the NR, you may not have a problem in many of the states. You will of course have to apply for certification in the state of your choosing to work there and pay the fees. For Paramedic, FL has its own state exam and that may be an issue in some states.

The issue for end of life are not always clear cut and somewhat ridiculous when one considers them. Comfort care is with the intent that the patient will die but there is always the concern of over dosing a dying patient as the body starts to shut down and thus, some RNs do or even must back off on the meds with it being either the physician's or the family's request. In the ICU I, as an RRT, also see a lot of this where the physicians are afraid to give a decent dose of pain and sedation medications in fear of the fine line of euthanasia but yet, I'm pulling the life support ventilator and removing the ETT in the process to leave the patient on room air or 2 liters NC with the intent for the medications to be the comfort part. If the patient dies quickly after the ETT is removed, we all breathe a sigh of relief. However, if the patient continues to live for several hours or even days, keeping that patient comfortable and not having them begging us to put the tube back in becomes a stessor for all especially if they are a "noisy" breather in their final days which puts a strain on the family members who remain at the bedside as well as the health care providers.