VentMedic

You maintain your professionalism at all times. We deal with this in the Peds ICU unfortunately too often. Until the "parents" are charged, convicted and put behind bars, you will have to exercise your own restraint by focusing on the child and maintaining your composure around the "grown-ups" even if you know in your heart they are guilty. If you allow yourself to be sucked down to their level, you may give grounds for a lesser charge or even a dismissal on some technicality as well as putting yourself into the spotlight and subject to an investigation. Thus, put the child first and allow the justice system a chance to do its job. Or, give the inmates at the jail or prison an opportunity to show their "love" for child abusers.

The money comes from some budget the same as the state and Federal funds to the healthcare providers to support the write offs from those without insurance. Some tax money is shifted around to cover the costs of these programs and support funds. Education or other clinics may lose as money is shifted around. Thus, the store's owner may hit by taxes or another cut in services that does affect him.

This is all relative. What exactly is "Paramedic" training? Intubation is not exclusive to Paramedics and other professions have been intubating long before Paramedics got started. The same with IVs. Spinal immobilization is also nothing new and many professions have to be familiar with it in the hospital for the numerous SCIs and surgical patients we do. The medications are also nothing new. The major difference is the environment but then RNs and many other professionals are accustomed to following the protocols for whatever unit they are working in. The onocolgy unit is very different than ED and ED is different from ICU. This is also why we must have ICU trained/educated RNs in the ED for hold overs to do the ICU protocols since the ED doctor will no longer be covering the patient and the ICU doctor does not hover but expects certain things to be initiated. If the RN to be trained for another environment, it should also be at their professional level. They should not have to go through 10th grade A&P or read about Sidney Sinus node. They also shouldn't have to cast aside their nursing knowledge about infection control for IV starts and "do it like a medic" either. Weekend certs like PHTLS are also available to many different health care professionals. RNs can get just as much out of it as an EMT(P). RNs should also be able to function at their level of education and expertise. RNs are often paired with Paramedics on CCTs and Flight because the Paramedic's scope of practice is very limited. Some RNs get the "exciting Paramedic cert" only to find they can no longer titrate meds or access certain vasuclar devices because it is not within their scope. Thus, a person should be trained/educated to a level that places them at a higher level of expertise and not a cert that might take away from what they already have. But again, for many professions, the Paramedic cert in the U.S. is just that...an additional cert much like some of the other certs they must obtain and maintain. It is not considered a profession and should not trump their existing license that allows them an extended scope of practice. And for the U.S. Paramedics that believe they are autonomous, you do have a medical director. You do have protocols which are signed by your medical director. Like it or not, those are your written orders. Also, for some services, if you lined up all of your protocols side by side, you will find most of them are very similar just like the doctor stated in the 2000 vs 200 hours of training article. Some paramedic services do not have a choice of multiple pathways or guidelines as other professionals have which includes RNs work in and out of the hospital. There are also reasons why RNs do call for certain orders. There are more variables known to the RN and if a med that is nephrotoxic is about to be given, the RN will defer that choice to the higher license. If that situation arises with a Paramedic, they may not know the kidneys are failing either by training or lack of information. Their medical director has already weighed the odds when writing their protocols and has taken the responsibility. It is not uncommon for an ALS/CCT with Paramedics to transport a patient for a CT Scan procedure with contrast who has a high BUN/Creatine number. Even if they have the lab work in their hands, they may not know enough to put the info together. Thus, it will fall on the Radiology Technologist's license to double check what should have be caught by the RN and MD. The RN can also not claim ignorance if he/she acknowledged those lab values before sending the patient.

That depends on which country you compare the Paramedic/Ambulance officer. The Dutch system: A major difference between a Dutch ambulance crew and those in other countries is the strict separation in the scope of duties. Every ambulance includes a crew of two. One is the nurse, skilled and trained in medical issues, procedures and performances. The other crew member is the driver, trained in vehicle operations for all circumstances. The driver also assists the nurse but does not interfere with any medical issues. If the Paramedic is also little more than someone from tech programs which do only a minimum of 600 hours while an RN is expected to have a year of additional training along with their RN, then that could be another argument. Of course, if it is only money then the "ambulance driver" system with just providing a speedy taxi ride to the hospital might be the cheapest. But it would also burden the ED with patients someone similar to an NP or Ambulance RN could have triaged to another facility or offer some form of on scene treatment. They could also follow the U.S. and train all of their FFs to be "Paramedics" and just merge the systems.

I've been reading more about the Dutch Ambulance nurses and it seems they are indeed very similiar to the Nurse Practitioner here in the U.S. which definitely gives them an advantage. The NP (and PA) in the U.S. has been going into the community, outside of clinics for several years to help people in shelters. Several major cities have them in roaming vans so they can go to the people who need them and arrange for the patient to be taken to the appropriate facility. Sometimes EMS personnel don't realize how many patients they could actually be called far if it wasn't for these professionals getting to them first. We also have numerous other healthcare professionals that see patients in their homes who also can get the patient by nonemergent transportation to the appropriate facility before EMS is required. However, the NP has the advantage of an autonomous scope of practic to where it would take years if not a couple of decades at least in the U.S. for the Paramedic to come close to that in education and being able to obtain a DEA number which requires a Masters degree in many states. If the Dutch Ambulance RN is even close to being like the NP, then their system is truly very advanced and it would be a shame if it went backward to something like the U.S. system even for a short while. Few entry level professional degrees specialize. Nursing generaly realizes their entry level education is just that and they can choose the path they want through more education. Even RT, PT, OT and SLP realize their degrees are entry level at Bachelors and Masters. If they want to work with neonates, emergency med, TBI or SCI patients they will need additional education and maybe a higher degree as well as specialized training in that unit. Unfortunately, too often it is the Paramedic that fails to see the limitations of their trainning. Some are fed this line about "critical thinking" which is magically supposed to appear with their cert and very little education or experience. They also believe their few "skills" entitle them to the title of critical care or that an 80 hour course makes them a "CCEMT-P". Thus, most get in over their heads and what is the most frightening part is that they don't realize it because they don't know what they don't know. At least other countries recognize this for their Paramedics and do ensure more education and experience is obtained. From reading about the Dutch Ambulance nurse, they have education, experience and then more education. In an ideal world, this is world this is how EMS should be. Unfortunately some believe it is by considering the EMT-B to be the "experience" part which has little to no education in the U.S. There is a difference betweening treating and dispensing medications. Our Flight and Specialty RNs (and RRTs) do this quite often outside of the hospital even without having NP behind their name. In the U.S. RNs (and RRTs) have a large scope of practice which makes them ideal for CCT, Flight and Specialty. Just because you don't see someone with that title intubate every day may not mean it is not within their scope of practice. Not every facility will have a need for all the skills one professional may legally be allowed to do. If you have 1000 RNs working in a hospital, is it really feasible to teach everyone to intubate? It is no more practical than having 2000 FFs in on FD be Paramedics and do few to no tubes each year on an ALS engine. Fortunately the states settled for somewhere between 500 and 1200 hours of training instead of just 200. However, this doctor was a consultant for many FDs in the U.S. so this crap will be around for a long time.

What part of nursing do you think is unnecessary? Community health is expanding and with the patient care experience a nurse has for the physical, psycho and social needs of the patient, their education is spot on. Also, remember that only a small percentage of EMS calls are codes and traumas. Most are medical, either chronic or acute, and not all require the EMS specific services of a Paramedic trained only in prehospital emergencies.

This is where the Paramedic really doesn't understand "critical care nursing" since most have never been around the ICUs in the hospitals. I also found from reading a couple of posts on the other forum that some EMT(P)s can only relate to nurses in nursing homes. The nurses I work with have no problem using paralytics. Infact, most ICU RNs will have assisted in probably well over 100 RSIs before they make the decision to do CCT. They are also in control by protocols of paralytics and sedation for the long haul. RNs in ICUs also have protocols to follow when there is a code or any emergent situation. Hospital Rapid Response Teams (different from code teams) have a very long list of protocols to initiate and way more than any Paramedic since they do have lab values available. If I need to intubate a patient in the hospital with RSI, the RN will have a protocol to get the job done without waiting, while bagging a patient, for an hour until a doctor calls back. Working a critical infant, pedi or adult has also not been a problem for Flight, CCT and Specialty RNs who may be a thousand miles away from their base hospital. An experienced ICU RN may work a couple hundred codes to where it is second nature. RNs are also very capable of intubating and doing central lines as well as chest tubes if given the training. If you had read the article I posted, you will see that thrombolytics are not an issue with the Dutch Ambulance nurses. How many Paramedics (at least in the U.S.) can actually determine if a patient is sick enough for ICU unless they are coding? There are studies that state most will under estimate how sick a patient is because they don't fit the text book "emergency". And, due to the lack of a strong background in the sciences such as A&P, pharmacology and pathophysiology, the U.S. Paramedic is very weak in many medical issues. On the other hand, the RN is responsible for determining which patient is sick enough to be moved to a higher level of care or tossed out of the unit to make room for another patient. Even though a doctor's order may be needed to make the actual move, the RNs are constantly triaging and retriaging their patients. The RN would also be a better judge about chronic patients. How many Paramedics would even consider taking a patient's temperature or turning over a quad to check for a decubitus ulcer? How many remove the shoes and socks off of diabetics or street people? How many would ask about their nutrition, urine or bowel moverments? How many Paramedics are well versed with insulin or even some of the common asthma medications? How many Paramedics in the U.S. know about the various venous access devices or could check their patency? How many Paramedics are familiar with the various forms of dialysis and the issues with each? Yet, some transport these patients everyday and only know "renal failure" as the reason for the dialysis and have no clue about what caused the renal failure. Very few EMS calls are "trauma" or "codes" and the other 98% of the patients are brought into the hospital by Paramedics who have done very little for the patient except for a taxi ride. Some even miss very important issues with the patients because it "doesn't appear to be an emergency" because it was not in the one Paramedic text book. Considering this Dutch system has an experienced ICU RN who then gets another years training/education in EMS appears to a good situation. Our Flight, CCT and Specialty RNs go that route. Our NICU RNs get a couple years of experience outside of the NICU and then get 2 more years in the NICU before they can apply or be invited to the transport team. They then spend another year getting intubations, central lines and chest tube skills along with more intense transport education before they are actually put into that situation. I don't know many Paramedics that are that well prepared for transport except perhaps those in Canada. We could also use the Paramedic (U.S.) who might be lucky to get 1 ETI or IV chance per year and misses either because he/she is one of 7 Paramedics at each scene or because of laziness. There are also those who work ALS/CCT and only move a patient from one facility to another with the RNs at the facilities doing the packaging, pump and whatever other equipment setup. If the patient is really sick or "critical care" the RN will probably have to accompany the patient. How many tubes and IVs do these Paramedics get? These are nice jobs for Paramedics who like a "CCEMT-P" patch and very little to do. Of course there are exceptions but harder to find them in the U.S. Melclin, I do know some very good RNs from your country and I can say they are not incompetent and can definitely manage themselves in an emergent situation. They have also made great transport nurses. Maybe they were the last good RNs from your country. It would be truly sad to know nursing now sucks where you are that nurses are incapable of learning more than what their basic program taught them. At least here in the U.S. RNs can learn new things and work in many different units while continuing their education. From the Dutch article, it seems those nurses can as well. RNs must also adapt to many different situations since hospitals love to float their nurses throughout every floor and unit when given the chance. Maybe if you had the opportunity to work with critical care nurses in a progressive hospital, you might have a different opinion. However, it is good to see your EMS education is advanced. As hard as it is trying to explain what RNs are capable of, it is equally difficult for those in EMS in the U.S. to understand a Paramedic that comes from a system that requires a solid education. We have EMT-Bs arguing that book learning is of little use and trying to hold the standard for EMS. Let me leave you with this little article which some seem to go by in the U.S. 2,000 Hours to train a Paramedic? http://www.fd-doc.com/2000Hours.htm

Yes, but unfortunately due to cutbacks in funding, not all the services are available at all the clinics. And, some of the health care professionals that worked in these clinics are now part of the unemployed and uninsured. But then since you live in California, that should be well known to you since that state has been hit hard by the state's financial situation. I'm sure you can get just about any doctor to tell you about the problems they are having and how some have had to layoff their office staff which includes the licensed medical professionals. I know several doctors that have given up their office entirely and sought work with agencies doing home visits or becoming staff at hospitals as Hospitalists. EMTALA does have requirements as to who does the examine and determines it is not an emergency. Once that medical professional does an examine to satisfy EMTALA they may as well treat or otherwise another medical professional will have to do another examine. However, some larger medical centers have their clinic areas close to the ED to where the patient can easily be referred and still be within the guidelines of EMTALA. Not entirely true. The U.S. has food stamp and WIC programs as well as food banks which I noticed are becoming very popular even by those who once thought they were just for "certain types" of people and not for them.

What Paramedic program are you going to? Community college education in California is still very reasonable and a whole Associates degree won't cost that much. A Paramedic cert will be even less. Also, the counselors at the college are generally good at offering suggestions for financial assistance.

Three years to master a few EMT skills? Then go on to learn a couple more skills as EMT-I? About the only one benefiting from your dues would be the union and that would probably be Fire. Longer does not always equal better if you do not have the education to know the "whys" of the skills you are doing. I would be more nervous with someone who took two - three years to master the 110 hours of EMT training. At least other countries do emphasize education before specialty education/training and skills. Even in the U.S. other professions require a base education of anywhere from 2 - 6 years before specialty training. RNs must have a minimum of a two year college degree. If they want to get the CCRN cert, they must work for 18 months in the ICU of their preferred specialty to take the test. If they want to get another specialty cert, they must again work another 18 months in that area. For a Paramedic in the U.S. to be called a "Critical Care Parmedic", their employer usually just gives them the title. Their training might be as little as 1 hour in the backroom of the FD/ambulance service or a whole 80 hour course with no ICU experience required. Only about 5 states have the official level of Critical Care Paramedic. There is also a test for CCP which just requires you to pass the test with no other requirements other than a Paramedic cert. I wouldn't say you have stepped on anyone's toes but rather you have highlighted how the U.S. has fostered the lower levels of training and placed no emphasis on education. Thus, it didn't matter if you knew why you were taking a BP for 3 years as an EMT. I really do apologize for sidetracking a good thread about EMS in a country that emphasizes education. I would like to know why the OP believes the Dutch system is not working to make him ask about changing it. If they go with the Paramedic what would be the education and training requirements? How long would this take to implement?

Let me highlight the Dutch System Ambulance nurse education and training again: In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment. Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses. In the U.S., some of those same requirements are expected of RNs who do HEMS, CCT and Specialty transport. Imagine if the U.S. had the same requirements for education and experience for Paramedics before they were allowed to work on an ambulance. Imagine the scandal if some U.S. states increased the Paramedic cert to a minimum of 1 year fulltime college.

Until the OP gets back to us, the Dutch system is rather interesting. My comments are in red. EMS in The Netherlands: A Dutch Treat? http://www.jems.com/news_and_articles/articles/EMS_in_The_Netherlands.html Dennie Wulterkens, RN, EMT-P, RMA-P JEMS.com 2005 Dec 6 In the 17th century, the place we now know as New York City was called New Amsterdam. Founded by Dutch merchants to start trade, the place was named after the Dutch capital. This Dutch influence in the Big Apple is still present. Old Dutch city names remain, including Flushing, Harlem and Brooklyn. New York has become a world capital. And what about the Dutch? This article will provide a renewed acquaintance with the people who many assume to live between tulips. And how do you drive an ambulance wearing wooden shoes? Brief history Europe has a rich history with the “transport of the sick and injured.” In the 18th century, Vienna, Austria, had an organized service comparable to a true EMS system. Holland has the same tradition. Before the invention of the automobile, patients were collected by organized horse-and-carriage services, mostly municipal services. From the moment the automobile was available, the services transferred from horse-drawn carriages to ambulances. This development continued but was disrupted by the second World War. After the war, ambulance services resumed, then using abandoned Allied vehicles. In the cities, municipal health care organizations managed EMS as a third service. Outside the cities and in the villages, ambulances were operated from private corporations, such as local taxi or automobile dealers and garages. A difference in the quality of care was noted. Ambulances from the municipal services were staffed by nurses. Local village ambulances were staffed with merely first aid personnel. In the 1960s, ALS equipment became available for ambulances, including monitor/defibrillators. In the '70s and '80s, developments increased. Self-respecting private ambulances changed from first aid personnel to nurses. By the mid 1980s, 99% of all Dutch ambulances were staffed by nurses. In 1988 the National Ambulance Education Foundation was founded. In 1992, a law stated that all ambulances in The Netherlands must be staffed by a nurse. The Foundation later became the Dutch Ambulance Institution, which provided rules and regulations concerning labour conditions, protocols, education, equipment and even the appearance (uniforms and vehicle striping) of EMS and its personnel. Organization A major train crash in 1962 revealed that EMS lacked organization, cooperation, negotiation and dispatch. From that moment on, EMS enforced by law was introduced. What started as a reorganization of EMS in 1962 has now become a dedicated and truly professional system in which EMS flourishes. Holland has a high standard of health care. Every Dutch citizen has the obligation to be insured for health care. Low income citizens and unemployed people are provided with health-care insurance by the National Health Trust. Part of the health-care system is that everybody who needs medical attention will visit their personal general physician (GP), the house doctor or family doctor. The GP is, therefore, the gateway to clinical health care provided by hospitals. In case of a medical emergency, the patient can call for an ambulance by dialling the (European) emergency number 1-1-2. Emergency dispatch can decide if the emergency is of a nature that does not require EMS or hospital interference. If so, the patient’s GP will be informed or the patient is asked to contact their GP. In any case of doubt, an ambulance will be sent. All over The Netherlands, 195 ambulance stations operate a total of 650 ambulances. Due to the EMS reorganization as mentioned, The Netherlands are divided into regions. In a region, one or more ambulance services can operate. At the time of writing, Holland has 15 regional ambulance providences in which 45 ambulance services operate. By law, a dispersion of ambulances must guarantee that an ambulance will be on scene within 15 minutes after an emergency call anywhere in the country. Dispatch is also organized per region, meaning that one dispatch center handles all calls for emergency and non-emergency transport in the whole region. Regions differ in size, depending on the number of people living in each area. The Dutch health-care system includes three types of ambulance response. The first one is the emergency response, coded A1, in which the ambulance immediately responds using lights and siren. In cases without serious life threat and the patient is relatively stable with a GP present, an ambulance can be requested as an A2 emergency. For an A2 call, the ambulance will commence immediately but without lights and siren, which is much safer for the crew and causes less disturbance in the community. The ambulance must arrive within 30 minutes after an A2 call. If a patient needs to be admitted to a hospital or needs medical attention during inter-clinical transport, an ambulance is requested with a so-called B emergency (non-emergency). In 2004, EMS responded to 341,000 A1 emergencies, 153,000 A2 emergencies and 313,000 B emergencies. The macro budget for EMS in 2004 was € 293 million (approximately 346 million U.S. dollars). Personnel Dutch health-care personnel are also divided into levels. In the case of an emergency, first responders are available; depending on the situation, these responders are trained in first aid and are mostly police officers and occasionally firefighters. Other emergency personnel include GPs, EMS and hospital care providers. Each group of caregivers has its level of skills and knowledge and know when to hand over care to another entity. A major difference between a Dutch ambulance crew and those in other countries is the strict separation in the scope of duties. Every ambulance includes a crew of two. One is the nurse, skilled and trained in medical issues, procedures and performances. The other crew member is the driver, trained in vehicle operations for all circumstances. The driver also assists the nurse but does not interfere with any medical issues. Dutch EMS consists of 1,400 ambulance nurses, 1,240 ambulance drivers, 330 dispatchers and 330 other personnel/staff. A special service is provided by 10 level-1 trauma centers, mostly university hospitals. They send out a mobile medical team (MMT). An MMT consists of a resident surgeon or anaesthesiologist and a nurse. The team is available around the clock and can be requested to perform medical actions that exceed the possibilities of the on-scene ambulance nurse. Inserting chest tubes, performing anaesthesia, including muscle relaxation (narcosis), administering advanced analgesia and performing amputations are a few examples of the MMT capabilities. The request of an MMT can be criteria-based dispatched, depending on the call. Education As identified earlier, the main medical care provider on an ambulance is a nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment. Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses. Higher level of education AND patient experience before even entering an additional 1 year educational program...U.S. EMS providers should be taking notes. After becoming a registered ambulance nurse, post initial training and educational programs are also mandatory. One of the required programs is the NAEMT Prehospital Trauma Life Support Course. Nurses are trained in the PHTLS program on an advanced level, and drivers are trained on a basic level. Continuing education is organized on two levels: national and regional. The mentioned PHTLS courses are in the national program, as well as special paediatric courses. For regional education, a wide scale of topics are available and held in smaller groups, mostly at ambulance stations. A number of appointed and licensed training institutes carry out the educational programs. Doctors in an MMT have also had additional training to prepare them for the prehospital setting. For example, extra courses in extrication techniques are required. A nurse participating in an MMT is a senior ambulance nurse and has taken the same additional training as the MMT doctors. This level of training and education allows ambulance nurses to work on a rather independent and self-supporting basis. If an ambulance crew encounters a situation that aren’t within their protocols, procedures or standing orders, providers can contact the medical manager of the ambulance service. If medical procedures must be applied that are beyond the possibilities of the ambulance nurse, providers can request for an MMT. All procedures are brought together in the National EMS protocols. These protocols are revised or adjusted every four years. Within these protocols, ambulance nurses are allowed to administer 31 different types of medication. (See Table 1.) Ambulance nurses are also allowed to carry out many medical procedures, including thrombolysis, which is practiced on a common basis. The drug in use depends on the region of the ambulance service. In the case of thrombolysis, providers select the medication after deliberation with the admitting hospital staff. Equipment All ambulances in The Netherlands are equally equipped. Aluminium cases are stocked with medical appliances, such as syringes and medication. Other materials, such as scoop stretchers, backboards, splints and collars, are also stocked. All vehicles are equipped to perform both BLS and ALS, with enough supplies on board to treat three patients on scene in case of an MCI (depending the extend of care they need). All ambulances carry 12-lead ECG equipment, a monitor/defibrillator, a ventilator, infusion pumps and pulse oximeter. Only 50% of the U.S. ALS ambulances have 12-lead ECG. Fewer have infusion pumps as even ALS CCTs must use the sending hospital's pumps. A few ALS trucks now have ATVs which is a very simple ventilator. For communication, mobile radios are mounted inside. Every ambulance carries a cell phone as well. Especially in major cities with a medieval inner city, speed-lowering obstacles are commonly built in the road. Old inner cities are accessible for only pedestrians and cyclists, with the exception of emergency vehicles. To enter such an area, emergency providers carry several remote controls and special keys to bypass the mechanical obstacles, such as rising steps. All ambulances are equipped with a tracking system so dispatch can locate them and control their status. A digital routing system is also present in all ambulances, which is handy when in small villages and narrow inner city streets. For recognition, all ambulance personnel are dressed in blue and yellow uniforms. Helmets are present on the ambulance. In case more ambulances need to respond to a scene, the first arriving ambulance starts the incident management and identifies themselves by wearing green vests and by flashing or rotating a green light on their ambulance. All arriving crews can easily identify and respond to the first arrived crew. MMT personnel can be recognized by their red and yellow uniforms. Patient data in the ambulance are gathered and digitally processed by handheld computers. Vehicles In the 1950s, emergency vehicles acquired lights and sirens. In those days, the Dutch police and fire departments received more respect from the public than EMS did. To make that distinction clear, ambulances were given a different siren. Police and fire departments use a two-tone horn, and ambulances use a three-tone horn. This difference remains today. Emergency vehicles in The Netherlands carry blue rotating or flashing lights. The one exception is the green light for the first arriving crew in a multiple-unit response, as described. In The Netherlands, the same development in vehicle building was seen as in the United States. Because of the increase in equipment carried on board, ambulance expanded from the limousine-like ambulances in the 1960s to the van types of later date. Many cities still maintain a medieval city center (the old town). Cosy but narrow streets are usual, which makes it impossible to use large vehicles or trucks. Even in current days, ambulance are built on limousine chassis, mostly Mercedes Benz. One Dutch builder, the Visser-company, has its own distinctive design. Every ambulance service is allowed to choose its own type of ambulance from one of three ambulance builders. Manufacturers build ambulances on Mercedes Benz (for vans and limousines) and Ford Ecovan or Chevrolet on a regular basis. If requested, ambulances can also be built on cars, such as Volvo, Fiat and Volkswagen. Other ambulances are imported from manufacturers in various countries, mostly Germany and the United States. In the past 10 years, emergency services have been cooperating, founded on laws regarding disaster relief. To become more distinctive and yet more recognizable, the emergency services all carry the same striping. One major difference is the background color. Police vehicles are white with blue and red striping, fire trucks are red with white and blue striping, and ambulances are yellow with blue and red striping. The striping is found on all emergency vehicles, from motorbikes to helicopters. In response to the large amount of traffic congestion, a rather new development is EMS motorcycles. They are stocked like first responder units, carrying enough equipment to start ALS while waiting for an ambulance to arrive. The MMTs are all equipped with a van that contains additional medical equipment. Four MMTs also have the disposal of a helicopter, called Lifeliners. They’re based in the cities of Amsterdam, Rotterdam, Nijmegen and Groningen. For the past 10 years, the helicopters flew only during daylight, but they are expected to start night flights very soon. Also, in poor weather conditions that prohibit air transport, MMT vans are used. The helicopters, each with a flight radius of only 45 miles, cover approximately 80% of Dutch soil. The remaining 20% is covered by helicopters from Germany and Belgium. With the arrival of an MMT, additional medical specialists and medical treatment are available on scene. The helicopter is basically for the transport of the team; transport of the patient is done in most cases by the ambulance, with the MMT doctor present to treat the patient during transport. Disaster Relief Due to several large scale incidents and the increasing population, disaster relief has been a major point of interest since 1992. That year, the Department of Home Affairs released the Law on Disaster Medicine. It was contemplating the organization of a Medical Disaster Control System, aiming for the creation of a functional organization for emergency medical care that guarantees upstaging from routine to effective disaster medical care. With this plan came the assignment of 10 major hospitals to provide an MMT. It also implemented so-called medical combinations. And within 25 regions, regional medical commanders were made responsible for disaster relief. Carrying out the plans meant that not only should the disaster be organized, but it should be controlled. This plan involves all emergency services. We now recognize four different levels of mass casualty incidents, all being Coordinated Regional Incident Control Procedures. For each level, a higher authority is in charge. When a procedure starts, daily routine is upscaled. Officers in charge are added, and a medical combination is added from the second or third level, depending of the nature of the incident. A medical combination is the cooperation of a double ambulance crew arriving in a special vehicle equipped for medical treatment of up to 30 casualties, a team of The Red Cross to carry casualties, and an MMT. In The Netherlands, most of the Regional Medical Disaster Control Systems are operational. The government has stated a budget that allows training, exercise and knowledge development. Conclusion Like most other Western countries, The Netherlands are well developed in health care and EMS. On Dutch ambulances you find a well trained and educated team, with separated tasks for each member of the crew. By having prehospital providers working in conjunction with house doctors on one side and MMT doctors on the other side, the patient can receive optimal care. In the chain of emergency care, Dutch EMS is certainly not the weakest link

After seeing our research budget for monkeys in our labs, EMT(P)s would be much cheaper and the animal activists would be happier. It would also give them something to do until they are hired by the FD.

If you look at the systems in other countries that utilize RNs in prehospital, their education AND patient care experience is extensive and advanced by the ED/ICU before they can apply for an ambulance job. That is similar to what some U.S. flight and specialty teams expect of their nurses. It would not be a stretch for them do a post grad ( 1- 2 years) and become proficient in pre hospital. Also, if the RN is working in EMS, aren't they exposed to the everyday experiences the same as the newly minted U.S. Paramedic? Many U.S. Paramedics may only have a year working as an EMT-B on a BLS truck or an ALS truck as a driver. Others may have their time in with the FD on an engine while getting their patch. Many U.S. Paramedic programs only teach the bare minimun with a couple of shifts as orientation once they are hired. Even for intubation, in some areas it may be only recommended that 5 intubations be done and a manikin can be substituted for human patients. The RN is also less likely to be limited for scope of practice when it comes to skills and medications with states allowing extended practice to those who are in out of hospital situations. The truck can also easily double for CCT transport. Hospitals are also more accepting of allowing RNs to enter the hospitals to maintain their critical care knowledge (IABP, ventilator, hemodynamics and medications/drips) and "skills" (intubation, IVs, central lines and chest tubes). The U.S. Paramedic may be limited only to what they get a chance to see and do in the field. Thus, we have Paramedics who haven't intubated or even started an IV in months with the way some systems are set up and few opportunities to get additional experience in a hospital setting. The U.S. Paramedic is just not a good model to argue against systems in other countries where both the Paramedic and the RN are well educated and have higher expectations to enter and function in the prehospital environment. The U.S. system in many places also promotes Paramedic/EMT rather than Paramedic/Paramedic. U.S. Flight, CCTs and Specialty teams generally will utilize an RN(s). The U.S. Paramedic has not kept up and has become limited to a few skills and a small section of emergency medicine. Times are changing and those who have a broader education and more patient care experience may be the better choice to provide the role some have been dreaming about as the Advanced Practice Paramedic. Right now the way that title is loosely used in the U.S. is for Paramedics in fly cars to assist other Paramedics in "advanced skills" like intubation or the complicated RSI meds and telling them what facility to take the patient to. In other words, a patch to fill in the missing gaps in the present Paramedic education and training or oversight. I apologize for the rant but the OP posed the same question on another forum right under a thread with a 10 week Paramedic program listed. I now have to change from saying 3 month wonders to 10 week..."blank"...haven't found the right word yet.

Spain and other countries require the nurse to have post grad work similar to the U.S. NPs which puts them more inline with a public or community health model that gives them more field opportunities for providing the best care. Thus the nurse would be the more appropriate provider. If the Paramedic has training/education as the equivalent of a 4 year degree with expanded education for community health needs, then that could be argued as well. But, the RN who has no less than 3 years (5 preferred) experience in med-surg, ED and the ICU, I would say they would be extremely valuable in the community on an ambulance. I included med-surg because those are the nurses that do much of the teaching for diabetics, asthmatics, wound care and other chronic conditions. This is where the Paramedic may be lacking.

Over the past two years we have seen a drastic shift in who is using the ED. If you look a t the umemployment rates for this country you will find several states with double digit numbers. Michigan is almost 15%. California, Nevada, South Carolina and Rhode Island are close to 13%. This does not include the deadbeats and homeless who fell off the map long ago for unemployment statistics. California just has a car manufacturing plant close which is expected to affect over 20,000 jobs in an area that is already hard hit. Florida has thousands of school teachers out of work as does many other states. Tourism is not what it used to be which has affected health care and many other industries. And yes even health care workers are out of work due to cut backs. Nurses, despite all the talk of shortages are having a difficult time finding a job. There are alot of unemployed EMTs who thought the patch would get them an immediate job. They also use the ED for minor sprains and when they feel like they are dying from the flu even at a young age. While there may be some EMT patch holders who are drug seeking for their habits, that may not be a fair statement for all. Also, the typical ED bill for even a minor problem is over $2000. Many of the newly unemployed are embarrassed by their situation. This also prevents them from seeking immediate help when they do need. They may also be one of those members of society that doesn't believe in being a burden to EMS and will try to tough it out at home which leads to sicker patients and longer hospital stays. Of course, if they do call and as soon as the EMTs learn the person is unemployed, the patient may get the "stereotypical" attitude. Health care in the U.S. is not always fair but some in EMS must understand that there are times when the patient can not control what happens to their health. Even those who you call noncompliant may have a good reason for not taking their meds. The side effects may be an issue and trying to get in to see a doctor again is difficult. Also those who do use the ED for their primary physicians risk being managed differently each time and this can further compound the problem. If you get a chance to know some of the patients using the ED and even EMS, you might find that not everyone is out to screw the system. Many would prefer to be working, have insurance and not worry about when their house will be foreclosed on. However, even those with insurance, the hospital and ambulance will be paid at a predetermined rate and not necessarily what is billed. The ED will be lucky to get $500 or $600 on a $2000 bill from many of the private (especially HMOs) or government insurances. Even for those with insurance on this forum, there is a good chance only a portion of the amount billed by the ambulance and hospital will be paid even with the deductible and co-pay you provide. Now to be fair, there is also a group of people who usually have insurance that regularly use the ED. They are young urban professionals who like the convenience of the ED and prefer not to mess with appointments next month. They have minor illnesses and want instant gratification. This will also include those from the medical professions, including EMTs and Paramedics, who have self-diagnosed themselves and just want a script as well as expecting "professional courtesy". They know which EDs to go to and when it is the best time to be seen quickly. They know the right answers to the questions to get whatever they want and thus, even if they don't want to believe it themselves, they probably play the system more than any seasoned drug seeking street person.

Posted: Saturday, April 3, 2010 Updated: April 3rd, 2010 08:25 PM GMT-05:00 Drunk Man Steals Ambulance in San Diego http://www.emsresponder.com/article/article.jsp?id=12729&siteSection=1 San Diego police said a man just out of the hospital for intoxication stole an ambulance and fled from police before they stopped him with spike strips. Police said 52-year-old Paul John Sos was arrested Saturday on suspicion of auto theft, failure to yield to police and felony drunk driving. Police Sgt. Ray Battrick said Sos had been found drunk and taken to Sharp Hospital in a private ambulance. Battrick said Sos checked himself out Saturday morning then found an unattended fire department ambulance with keys in the ignition. The ambulance had GPS installed and police quickly found it, but Sos refused to stop, leading a slow pursuit through residential streets before he was stopped with spike strips and arrested. Police did not know if he had hired an attorney.

I have nothing against the program in Illinois as it was ran very well from what I have read about it. Several states also train inmates as FFs especially in areas prone to large fires such as California. I just hope these programs are very upfront with the prisoners that obtaining a paid professional job in health care or fire fighting after their release might be very unrealistic in some states.

If he is applying for the NR, that probably means the offshore company may be registered in another state. Thus, he may have to deal with that state as well for licensure. The NR will scrutinize any application which has the "felony" box checked. However, depending on how long ago the friend was 17 and any other circumstances of the felony conviction, the NR probably won't deny if a full disclosure is made. http://www.nremt.org/nremt/About/policy_felony.asp

And that is exactly why your friend needs to find out what is showing up on his record to see if expungement is an option. Not all states or employers will be as lenient as Illinois for having convicted felons working with valuable equipment, drugs and vulnerable patients. You can also look at California for examples of a state that failed miserably with who it or rather its counties allowed into the profession and the resulting blackeyes for the state's reputation. I suppose Florida also falls into that category as well. Also, knowing one really good convicted murderer does not mean all murderers will have exceptionally good character. That does not justify allowing felons into EMS without some safeguards and scrutiny.

In some states felonies such as Grand Theft Auto will be placed in the adult court which means it will be visible on your record. I don't know how thorough IL is with their background checks for licensure, since this is still a weakness in EMS, so that may not be a good indication of what is showing up on a check. The NR is just one hurdle since potential employers will also do background checks. Your friend might consult with an attorney about expungement.

For the H&H, blood products would be in order to improve O2 carrying capacity and help with the MAP. As for the ABGs, you have given info on a CXR and a PaO2 that warrants an immediate plan of action. Just using the SpO2 would be inadequate for this patient even though that might be a accurate number given the low Hb and possible shift on the oxyhemoglobin dissociation curve. The LTV 1000 is a good vent of choice and bilevel ventilation would be needed for a patient with increasing CO2. CPAP alone would tire the patient quicker. However, the esophagus, vomiting and gagging is still a great concern and NIV probably would not be the way to go. At well, with the PF ratio being less than 100, it would be very difficult to justify transporting out a definitive airway. Actually, it would be career suicide. Even the tiniest of hospitals will have an Anesthesiologist and/or Pulmonologist on call. The airway should be secured at the hospital in a controlled environment. The anesthesiologist will more than likely have access to a fiberoptic scope or the RT can provide one which is commonly used for routine bronchoscopies (even in tiny hospitals) and intubations. Some tiny hospitals also have ENTs doctors who can be called to assist. Without the extra resources and you make the decision to do RSI on this patient, the situation may be really bad. Due to the esophageal problems and other anatomical structure issues, you probably will not get the tube and the patient will die. Even placing the larygnoscope blade can be difficult. Bagging may end present some other issues with the esophagus and abdomen. Watch the belly. And,good luck with doing a cric without the consult of a really good ENT at bedside. I see many of these patients in the ED, on Specialty transports and in the ICUs. Each day I get a list of which doctors are on call and their direct cellphone numbers. We don't screw around with beepers for these cases. If on transport, I find out the sending hospital's resources and have our physician (or I) make suggestions during the phone report as to who to call or what equipment to have available prior to our arrival. For some patients I may have the ability to speak with the surgeon who did the cutting and rearranging of the patient's anatomy. He/she may say something like the patient can be intubated by fiberoptic through the right nare only. Sometimes the larynx is relocated and modified. Not many ALS or even CCT teams have that luxury of speaking with the patient's physican or knowing the history. If I don't get much information, I prepare for the worst case and hope for the best. Luckily these patients usually know when they are getting into trouble and will contact their physician who will refer them quickly to the best facility or at least one that can be accessed quickly by a Specialty Team from another facility. Thus, EMS and ALS CCTs teams will not see these patients but they definitely do exist along with many bizarre airways. A truck that is expected to do CCT calls should have a 50 psi regulator on their tank. All of our E tanks now have the 50 PSI port on them and the D tanks have a 50 psi port on the regulator which we use for transport ventilators. Also, if the patient is seriously sick, a Specialty team may have access to an ICU vent that can be adapted to transport. And, since a flu of some type might be suspected, respiratory precautions should be taken in the presence of any high flow O2 device. This also includes devices that EMS calls "high flow" such as the nonrebreather mask.

If you "knocked out" someone's respiratory drive with a NRBM in just a few minutes, they needed a tube. For their CO2 to have risen that high indicates they may have a significant disease process. I'm going to refer to Jeff Whitnack for more details and literature references. http://home.pacbell.net/whitnack/Why_the_Hypoxic_Drive_Theory_Sucks_Wind.htm.6306 I do find this quote from him quite amusing. Where are the episodes on "Murder She Wrote", as then home oxygen would be the perfect murder weapon (the evidence would disappear after the heinous crime) for any greedy relatives of a CO2 retainer? Several of my home O2 patients play with their O2. Although a concentrator is generally limited to 6 l/m which might be the equivalent of 3 depending on the maintenance of the machine. But, in the hospital I catch them cranking their own O2 up all the time and usually it doesn't cause must damage except for screwing up my charting and causing a nurse to freak out who was trained strictly by the "hypoxic drive theory". I have also told a story a few times on the forums about a COPD patient who wanted to end it all and thought he found the perfect way when he over heard a doctor, RN and Paramedic talking about the "horrors of a NRBM" with a COPD patient. He managed to find on before he left the hospital. After getting his affairs in order, he sat up a couple of H tanks which were still used in homecare at that time. He settled down in his easy chair with the NRB running at 12 liters and fell asleep. In the morning he work up refreshed and better than ever. He decided this was a sign and that he should rethink his suicide plans. So, with the NRBM still blowing out O2 around his neck on his O2 saturated PJs, he lit a cigarette to give his life more thought... The End. However, for any patient who does not need more O2 than necessary, I do not recommend high FiO2s to be used. This especially includes post op patients who come out of PACU on 2 - 4 L NC as a standing order. For any patient displaying signs of respiratory distress, they will get what it takes both by O2 and other meds to make them comfortable. Often the respiratory issues are directly related to another system such as circulatory and not necessary a pulmonary problem.

Christopher "Superman" Reeve is a good example. He was on the LTV ventilator delivering a flow to meet his repiratory needs and most of the time it was on an FiO2 of 0.21. I also find recipes of "give 2 L NC for this" and "give 4 L NC" for that to be laughable. It just demonstrates how lacking EMS education is when it comes to understanding minute volume (MV) even though I believe EMT-Bs have it in their text books. Could it be the "instructors" don't understand it well enough to explain the application of MV and some may think it is just some academic BS tossed in for the hell of it? A person could be getting more FiO2 on 2 L NC than someone on 4 or 6 L NC depending on their respiratory rate and minute volume. For more high flow information, I just typed this on the "Threw up and can't breathe" thread. http://www.emtcity.com/index.php/topic/18108-threw-up-and-cant-breathe/page__gopid__239490& That is a good thread since several here probably want to be "CCEMT-Ps" and believe the 80 hours class is more than enough to do CCT. Few get past the skills to understand the whys and hows of the patient. Sometimes the words "critical thinking" are not fully understood.

This is a good thread since some here probably want to be "CCEMT-Ps" and believe the 80 hour class along with their 600 - 1000 hour Paramedic cert is more than enough to do CCT. Few get past the skills to understand the whys and hows of the patient. Sometimes the words "critical thinking" are not fully understood. Fluids to get the CVP over 8 mm Hg and hopefully that will improve the SvO2 and urine output. This is not a good time to be in renal failure. What is the BP now? There might be a pain issue that can be addressed without interfering with the respiratory drive. The BP MAP should be maintained over 65 mm Hg. If the ABG was drawn on a NRBM, we would use 0.85 or 0.90 as the FiO2 for the PaO2/FiO2 calculation. That gives a PF ratio of 67 which is very, very serious. Some should take not that the SpO2 was mentioned at 88% which is possible but in this situation, the SpO2 does not reflect the seriousness of this patient. If this patient is on a humidified high flow system delivering an FiO2 of 1.0, that may be difficult to transfer. BTW, if you see a standard humidifier running of a standard flow meter (not one capable of 70+ L/M) that device will not be delivering an FiO2 of 1.0 to an adult breathing at a RR of 34. It would take at least two ("Dual") humidifiers to get a little closer to an FiO2 of 1.0. The standard humidifier with an aerosol mask, even though it may say 100% on the adjustment, will probably be delivering an FiO2 of around 0.60 for an adult with a high respiratory rate and MV. Now, how to deliver high flow O2 during transport without using a mechanical ventilator for CPAP/BiLevel.... The O2 supply system would have to be addressed since many of the devices require a flow meter capable of delivering at least 70 L/m. Some of the easier and more comfortable high flow devices such as the high flow NC can deliver 30 - 40 L/m but at this time I don't believe any of them are battery powered and the heating element must have keep the humidifier delivering at 37 degrees and a relative humidity of 44 mg/L. The MistyOx or TheraMist can deliver high flows but require a high flow meter to power them at 30 - 40 L/min. The Oxymask can be considered high flow must the standard flow meter may need to be ran at flush. In the hospital I have used a high flow nasal cannula at 30 L/m along with the Oxymask at well over 15 L/M to oxygenate a patient with a good respiratory drive preintubation. The RSI is done very quickly since bagging a patient who has progressing ARDS is very difficult with the standard self inflating BVM. I would probaby suggest taking something like a Jackson Rees bag along with the self inflating BVM. What do those of you from other countries have available on your CCTs for high flow O2? I know Canada and Europe will generally have the better meds and technology available to them long before the U.S. Even our ICU equipment and especially the ventilators are usually at least 5 years behind your latest and greatest.