VentMedic

If you are considering digital intubation, you should have some access to the cords and therefore it would be very difficult to justify doing a cric. Digital intubation could be considered in dire situations where: 1. for some reason lack the equipment, 2. have equipment that does not work, 3 positioning of provider and patient might be an issue 4. there is a deformity either due to nature or injury that hinders the use of a regular laryngoscope scope or 5. using the BVM is no longer or not an option. Digital intubation has it place but less often now in the adult world since there are LMAs, King tubes and even the OPA that can be used if ETI is not immediately possible. NTI may even be a consideration but only not always the best. Of course the Tomahawk method should still be a technique taught as an option as well. However, for neonates and pediatrics, digital intubation may be a necessary option. Any RRT or RN that does intubation in the hospital or on transport has probably been taught this procedure if they work in the neo/pedi population. That includes the big male nurses and RRTs with large hands and fingers. It does not matter what size your fingers are, you learn to perfect the technique. Your technique may vary slightly from someone who has tiny hands but the goal is the same. Most of the procedures done in that population require a delicate touch which can be acquired through practice and a desire to work with infants as a health care provider. That should also include the Paramedic. Most pediatrics can be effectively maintained with the use of an OPA and BVM which is another technique that should be taught well, but often isn't, since pedi ETI is now removed from the protocols of several EMS agencies. But, they also seem to forget to teach OG/NG placement which then only gives you limited bagging time before the abdomen takes over the tiny chest cavity and the BVM becomes useless where even a tube placed now will be ineffective until the belly can be decompressed. There will also be infants and pediatrics that have deformities either present at birth which have yet to be repaired or may be with them for the rest of their life. This might include some cleft palate malformations or even the Down's Syndrome child whose tongue may require some manipulation. If a neonate is being born with a known congenital defect like a diaphragmatic hernia, the intubator can not dick around looking for another scope if the one he/she is using fails. That baby must be intubated and the BVM is not an option. There was also a discussion here a few months ago where someone said they used or saw/heard someone use an adult MAC 4 in the field in an attempt to intubate a baby. I would rather use my fingers if I had no other appropriately sized equipment and very little experience intubating babies before I would use a large piece of metal and risk damaging the airway to where a cric might then be a necessity or the blood from the traumatic attempt would asphyxiate the baby. Someone with a thousand infant tubes to their credit might be able to pull off just about anything with any type of equipment but then they are intimately familiar with the anatomy of a baby. Thus, learn, practice and perfect as many different intubation techniques as you can for every age group. Know how to score a difficult airway to help you choose the correct device and technique for the patient. Do not become one that says "I always use curved because I like it better" which is something that is too often learned from the classroom by playing with the manikins under poor supervision or listening to instructors who know little about educating for airway emergencies and spout off their own style as "always worked for me" rather than explain the purpose of each blade and/or method. Of course there are a few words of caution no matter what technique you use. Even if you have given a paralytic to a patient, teeth or no teeth, have a bite block in place preferably on both sides of the mouth so you don't get taken by surprise if you plan on putting your fingers into someone's mouth. This can include trying to get a better grip on a FBO. Even those without teeth can leave a nasty bruise on your finger.

Ending life support is very literal and final. My responses were to your statements below and my response was to inform EMT(P)s what they can do in a situation such as this. My posts were not an opinion about whether end of life support is right or wrong. After a very nasty exchange of PMs with you and being told my posts were too technical for this forum as well as a few other choice words, I apologize and promise not to post here again.

I seriously doubt if they would ask you to turn off the ventilator and all you would have to do is say you know nothing about the ventilator and it is not the reason you were called or not part of your job description. You could also just say you are not comfortable doing that. About the only situation I could think up where this might happen and ONLY if the physician is present would be for a patient that has agonal respirations on the vent, is in hospital and is near death. Even at that it would be the physician that would assume the responsibility of shutting off the ventilator You don't have to do everything a physician tells you if you are uncomfortable or it is harmful to the patient. If the physician who is present told you to push a medication at a dose which you know would be harmful and he/she still insisted, would you? Or would you again ask if he is sure that is the med and then hand the syringe to him? Nobody can make you kill a patient unless you are a willing participant or just have no clue about the situation situation. I also will not just go into an ICU/ED and terminate life support at random just because a doctor ordered it unless it is a known patient with the proper orders and paperwork. As health care professionals we do have the right to do the right action to the right patient and ask for the right procedure to be followed at the right time if it involves our hands on the patient or technology. And remember, the doctor won't take the fall for your ignorance in a situation. That has been learned the hard way many times by many different health care professionals.

Who is telling you to turn off the ventilator? If someone did tell me to turn off a home ventilator, I would. And then they would have to put up with me bagging them to the hospital instead of being on the settings they have grown accustomed to. I have had patients tell me quite often they want to die or "shoot me now" or "put me to sleep". We have also had family members attempt to turn off ventilators in the ICU which is why many of the hospital machines have a coded control panel. If a family member wanted their loved on dead in a home situation, there are plenty of ways to achieve that including turning off the ventilator. However, the ventilator will testify in court with its stored data. Once life support is initiated, unless the patient is dead (yes they can be found dead with the ventilator still doing its job contrary to the belief of some), proper paperwork, signatures and orders must be obtained through a specific process for termination of life support to take place. For some, the process is moved quickly with a valid DNR and one or two doctors in agreement.

Are you against ending life support? We have terminated several ventilators in the ED although not by EMS. Sometimes it is when a patient is alert and their DPOA has shown up with the paperwork for a DNR. If the patient is in agreement and expresses a wish for end of life support, we will honor it. However, more often than not, if a patient is intubated in the field before the patient's wishes are known, they may linger for days until the family, physicians and/or ethics committees can come up with a plan. I have never had a problem pulling the tube and shutting off the ventilator for termination of life support. While some cases are sadder than others especially when it comes to infant and children but there is still a peace in knowing the alternative would be alot worse if the suffering or hope was allowed to continued.

We share alot with the families especially in pediatrics/neonates. If a parent accompanying their child on transport, we will brief them on the basic numbers and alarms they might hear. We will also go over the rules for the parent for safety and to remain calm or at least freak out in place and not move during tranport. How much they see and hear will be dependent on the transport mode we are using such as helicopter with 1 or 2 pilots, fixed wing or ground and where the parent will be sitting. We do not want them to be alarmed by what they hear and see especially if it is a true critical alarm. Above all we don't let them see us sweat and will continue to communicate with the family as much as possible. (Sidenote: The pilot or driver of the ambulance will know very little about the condition of the child or neonate.) In the ICUs, the family members will eventually become as good with the monitors including identifying a dicrotic notch on a waveform as some of the staff. Everything will be explained in detail by members of different specialties such as RT, RN, MD, RRT and EEG technicians. And yes the parents will be told of the alarm parameters as to why they are set and when they become a concern for action. This is especially true in the Neuro ICU where BP, ICP and CPP are being monitored. It doesn't take long for the family to start monitoring the foley catheter and the EVD as well. If the patient codes with the family present we will ask if they want to remain and assign a staff member with them to explain what is happening. In the past we would shove them out and slam the door in their bewildered and frightened faces. Now, the thought behind allowing the family to stay is that seeing everything done for their loved one gives them closure. A good staff member at their side may also be able to distract or prepare the parent (or other family) before the code team opens the chest or does some other shocking procedure. Of course if the family becomes uncontrollable or too distraught, the staff member will shove them out the door and remain with them. Allowing loved ones be with the elderly patient also gives them permission to say stop when the code is starting to look brutal but the "kids" were insistent on saving their 99 y/o mother or grandmother. They too will have a better chance for closure in that they still attempted to save their loved one's life and could also agree to stopping when they realize it may not be the wisest to continue or the staff member monitoring the code with them explains "no hope of being just like the loved one they once knew". When we do an end of life procedure or "terminal wean" as some refer to it, the procedure will be discussed with the family and it will be their choice to be present for the actual discontinuation of life support. If I know there is no spontaneous respirations without the ventilator, I may encourage them to stay with the family member because that patient will probably not last in the time it takes to get from the waiting room. If we suspect the patient will last may even for days, it might be best the family is not present until the medication can be titrated to ease the appearance of respiratory distress. But again, the family will be informed of as many steps as possible including what to expect on the monitors which may be muted but still visible.

If the Paramedic is black, does that mean she no longer cares about black people because she is working in this agency? I think there are other deeper issues other than just race here starting with their EMS training and oversight for the medical side as well as failing to instill a sense of professionalism for EMS as health care professionals.

The actual article from Dave Statter's page referenced by JEMS has this title: DC Police conducting review of Paramedic who provided care to dying two year old girl, homicide detectives will try determine if EMS worker was criminally negligent. http://statter911.com/2010/03/11/dc-police-conducting-review-of-paramedic-who-provided-care-to-dying-two-year-old-girl-homicide-detectives-will-try-determine-if-the-ems-worker-was-criminally-negligent/ It states nothing about being a homicide as the JEMS newsfeed implies.

You still don't give any consideration for the girl he sexually battered and what additional troubles he added to her life. Taking advantage of a troubled youth is probably one of the lowest actions someone could do. I am very surprised he made the FD unless he has some help from a relative within the FD. If his co-workers knew of his problems with drugs, they should also be disciplined since there is that "protect and serve" thing with the FD and that shouldn't mean just protecting their own.

If these crews actually did the paperwork to support their decision not to transport and they presented a valid assessment, then yes, maybe one might be able support them...but... D.C. EMS Crew Disciplined Over Failure to Transport Woman to Hospital WASHINGTON, D.C. -- DC Fire & EMS Department officials confirm an EMS crew has been disciplined for failing to take a woman with trouble breathing to the hospital after she called 911 on December 22. Kimberly Kelsey of the 900 block of Rhode Island Avenue, NW was transported to a hospital only after she called 911 a second time, about 56 minutes after her first call. According to Kelsey, crews from a paramedic engine company and an ambulance refused to take her to the hospital because they determined she was not symptomatic. On the second response, a paramedic supervisor treated Kelsey for her chronic asthma and accompanied the woman to Georgetown University Hospital. Kelsey says she was put into the intensive care unit and spent a week at the hospital. Department spokesman Pete Piringer confirms that supervisor immediately followed up on Kimberly Kelsey's complaint. According to Piringer, the supervisor counseled the crew and disciplinary action was taken. Piringer also confirms there was no patient care report filled out on the initial response. This incident has parallels to the case of 2-year-old Stephanie Stephens who died on February 11, at Children's National Medical Center. An investigation is still underway into why a medic crew did not transport Stephens to a hospital after her mother's first call to 911 a day earlier. It was about nine hours later that a second call to 911 resulted in the little girl being taken to the hospital by paramedics. The call to the little girl's apartment occurred in the middle of the second of back-to-back blizzards in Washington. Stephens' family said the girl died of pneumonia. A paramedic and EMT have been removed from field operations while the probe continues. Numerous sources confirm, like the December case, the EMS crew failed to fill out a patient care report or get a signed release from the girl's mother. Statter911.com has been provided internal department emails showing regular notifications to supervisors about missing electronic patient care reports. The emails from January and November each show at least 30 missing reports. The department has not been able to tell us the percentage of reports that are missing because of technical issues versus those that first responders failed to submit. http://www.emsresponder.com/article/article.jsp?id=12402&siteSection=1

For ventilator management, it is best you get the training video directly from the manufacturer along with a rep. This is a decent one for the LTV 1200 since it is the national disaster vent of choice. http://www.aarc.org/education/webcast_central/archives/2009/09_22_2009_ltv_1200.asp While "numbers" may look the same in the generic literature, they do no always translate well to the many different pieces of technology out there. Too often CCT and Flight teams get the patient into trouble by just matching the numbers while not understanding the vast differences in the equipment. This also goes for the many different chest tube devices. Each device might have a different application such as those preferred for HBO, Flight or ICU. And, each of those specialties will use many different types of devices. For HBO, hands on is definitely the best especially if you have a chamber to where you can set up the equipment. The portable vent you use with HBO may not be used in other places as we may have different pressure adjusting vents. We will use cadaver labs and practice on ICU patients for many of the invasive procedures such as chest tube insertion before working with HBO patients.

Some of the readers' comments are interesting as well. Doctor stands behind requirements for fifth Medic One unit http://www.bellinghamherald.com/2010/03/05/1324731/doctor-stands-behind-requirements.html#ixzz0hhSC8sON Facing public criticism and political pressure, the doctor in charge of approving paramedics to work in Whatcom County is maintaining his requirement that the staff of a fifth Medic One unit complete field evaluations before operating. Dr. Marvin Wayne says to do otherwise would undermine his standards for medical excellence for Medic One, and go against decades-long requirements he's had. Fire District No. 7, which covers Ferndale and surrounding areas, will staff the fifth unit. The five paramedics completed training at Harborview Medical Center in Seattle last summer, as well as a protocol exam and skills tests that Wayne requires for paramedics trained outside the county. The final hurdle to operating is Wayne's approval on field evaluations, and delays in getting those are costing taxpayers, said District 7 Fire Chief Gary Russell. Due to a long-running union dispute, the paramedics could not get the field evaluations locally and are doing them with a private ambulance company in Wenatchee. The union local representing Bellingham Fire, which is different from the union representing District 7 employees, argued its staff should man the fifth unit, and have refused to assist in the evaluations. The calls District 7 firefighters need to be evaluated on have been infrequent - as of last month, they had only three out of the 25 calls they need - but they continue to go to Wenatchee at a mounting cost to taxpayers in District 7. Russell estimates it costs $2,600 per week each week they're in Wenatchee. He said approving the paramedics to work would not compromise Medic One's standards of excellence. "He doesn't need to lower his standards," Russell said of Wayne. "He just has to be flexible." Bellingham Fire Department staffs the other four Medic One units. The fifth unit's creation was called for in the 2005 emergency medical services plan that voters approved to fund through a sales-tax initiative. The plan calls for the fifth unit to operate on a part-time basis in 2010. Paramedics handle the most life-threatening 911 calls. Bellingham Fire Chief Bill Boyd said he supports Wayne's position. "Marv's getting a tremendous amount of pressure to change his standards on how these guys get certified, and I just think that's wrong," Boyd said. "It's pretty rare to hear someone say they need to lower their medical standards." Whatcom County Council President Sam Crawford has conditionally proposed pursuing a split system - one that serves Bellingham and one that serves the rest of the county - in July 2011 if the unit isn't operating by then. But the contract between the city and the county that sets up how Medic One is funded and governed requires three years to elapse before one entity can pull out of the system, Boyd said. WAYNE'S STANDARDS Paramedics work under Wayne's license, issued by the state Department of Health, so he's liable for their performance. He has long required additional training for paramedics who are trained outside of the county, to ensure they know medical protocols used here. Wayne said he requires this because the county's paramedic service is largely protocol-driven. With one hospital and a limited number of doctors to consult, paramedics frequently have to make decisions on how to treat patients, based on those protocols and their experience, he said. "My job is to validate that the services are quality," Wayne said. "I don't feel that we have to defend giving good care." The paramedics for the fifth unit have completed two of three requirements - a written exam to ensure they know the county's protocols, and a skills test - but each still has to complete field evaluations on five calls with a patient suffering a life-threatening injury or illness. "The easy way out would be to put a stamp on these people," Wayne said. "I have one vested interest, and that's that we continue to care for patients." SEATTLE EVALUATIONS Russell, the fire chief, contends Wayne should give the paramedics credit for some of the 60 calls on which they were field-evaluated while training in King County. But Wayne said Seattle operates a different system that allows paramedics more access to doctors to consult, and has shorter ride times with patients. "Seattle was radically different than Bellingham," Wayne said. "It's a physician-dependant program. Ours is 90 percent protocol-driven. We have 45-minute medics that have patients a lot longer than other medics." Jerry Martin, District 7's division chief of medical services and a former Bellingham paramedic, said Wayne's contentions are off base. "We're asking him to look at these books (of the Seattle calls)," Martin said. "He hasn't even acknowledged this data." Martin said paramedics trained in King County work in Mason, Kitsap and other large counties in Washington that have longer ride times without problems. In Whatcom County, paramedics have the option to consult a doctor at St. Joseph Hospital, he said. District 7's paramedics know the protocols - they passed the tests. The field evaluations in Wenatchee, which Wayne approved and which show a paramedic's ability to lead and apply skills, are on protocols used in Chelan and Douglas counties, Martin said. Wayne approved the Wenatchee evaluations because the protocols are similar to this county's, and the area is similar geographically, which would equate to similar ride times. "These should be screaming that these people know how to do it," Martin said. WENATCHEE The District 7 paramedics have been working with Ballard Ambulance in Wenatchee since last November, said Shawn Ballard, a co-owner of the company. Ballard said he's one of several people evaluating the paramedics and estimates he has ridden with them on 30 to 40 calls. In a letter to Martin, he gave his impression of their abilities and performance. "From the beginning each of them has operated above that of an entry level medic," Ballard wrote. "The consensus of the other medics I talked with is they are street ready." Ballard said each paramedic comes over and works three 24-hour shifts, answering all calls while awaiting one of the calls that fits Wayne's criteria before returning to Whatcom County. "I think we are in some ways wasting their time waiting for them to see all the patients necessary to meet the criteria," Ballard wrote. "Actually, if you want my humble opinion, we are probably hurting them in the long term by delaying them getting out on the street and ... doing what they already know." At a County Council finance committee hearing, Russell could not offer a timetable for how long it will take for the paramedics to get the calls they need to meet Wayne's approval. He said he hopes Wayne will show flexibility in approving the paramedics to work here. "We're just up against this one final hurdle," Russell said. "Give us credit for the calls in Seattle, give us credit for the calls over there (in Wenatchee) and let us operate." Wayne said Russell agreed at the beginning to continue the Wenatchee evaluations until they met his criteria. "The fact that they're not getting enough calls - why am I the bad guy?" Wayne asked. "I'm being singled out as the obstructive force here, and I'm not." Bellingham Assistant Chief Roger Christensen credits Wayne for standing by his requirements. "He's shown incredible fortitude and courage in sticking to his guns," Christensen said. THE FUTURE Christensen called for the labor groups at the heart of the union problems - the International Association of Fire Fighters local representing Bellingham Fire Department employees, and the union representing District 7 employees - to end their dispute. "The labor groups have to resolve this," Christensen said. Boyd cautioned that a fractured Medic One system would violate the voter-approved initiative, and perhaps invalidate the city and county governments' abilities to collect the sales tax revenue to pay for services. "We're the envy of a lot of counties because we're not fractured," he said. Russell agreed. "We're not trying to compete with Whatcom Medic One," Russell said. "We're trying to support Whatcom Medic One." Wayne said he will maintain his standards. "Let's get this resolved," he said. "I'm not going to be the one to resolve it, but I am going to be the one who follows the rules." Read more: http://www.bellinghamherald.com/2010/03/05/1324731/doctor-stands-behind-requirements.html#ixzz0hhSzPDLw

If this is the episode with the bank robbery, it was filmed before the hiatus. There were public announcements in Oakland, CA for the locals not to think the fake gunfire was an opportunity to join in for some real action.

SpO2 will show oxygenation but not ventilation. I've seen some patients with an SpO2 of 100% and a pH of 6.9 with triple digit PaCO2. I've also seen some high SpO2 on patients with a very wide A-a gradient that qualified for ARDS with their PaO2 FiO2 ratio. Now for ETCO2, here is a couple of decent articles about trauma and ETCO2 that emphasizes what I have stated in previous posts. (The EMS review) Prove it: Using capnography to guide ventilation rates Review: The Utility of End-Tidal Capnography in Monitoring Ventilation Status after Severe Injury http://www.ems1.com/airway-management/articles/764519-Prove-it-Using-capnography-to-guide-ventilation-rates/ (The Original-abstact) The Utility of Early End-Tidal Capnography in Monitoring Ventilation Status After Severe Injury Warner, Keir J.; Cuschieri, Joseph; Garland, Brandon; Carlbom, David; Baker, David; Copass, Michael K.; Jurkovich, Gregory J.; Bulger, Eileen M. The Journal of Trauma. 66(1):26-31, January 2009. doi: 10.1097/TA.0b013e3181957a25 http://journals.lww.com/jtrauma/Abstract/2009/01000/The_Utility_of_Early_End_Tidal_Capnography_in.3.aspx Background: An arterial CO2 (Paco2) of 30 mm Hg to 39 mm Hg has been shown to be the ideal target range for early ventilation in trauma patients; however, this requires serial arterial blood gases. The use of end-tidal capnography (EtCO2) has been recommended as a surrogate measure of ventilation in the prehospital arena. This is based on the observation of close EtCO2 Paco2 correlation in healthy patients, yet trauma patients frequently suffer from impaired pulmonary ventilation/perfusion. Thus, we hypothesize that EtCO2 will demonstrate a poor reflection of actual ventilation status after severe injury. Methods: Prospective observational study on consecutive intubated trauma patients treated in our emergency department (ED) during 9 months. Arterial blood gas values and concomitant EtCO2 levels were recorded. Regression was used to determine the strength of correlation among all trauma patients and subgroups based on injury severity (Abbreviated Injury Score and Injury Severity Score) and physiologic markers of perfusion status (lactate, shock index, and arterial base deficit). Results: During 9 months, 180 patients were evaluated. The EtCO2 Paco2 correlation was poor at R2 = 0.277. Patients ventilated in the recommended EtCO2 (range, 35 to 40) were likely to be under ventilated (Paco2 > 40 mm Hg) 80% of the time, and severely under ventilated (Paco2 > 50 mm Hg) 30% of the time. Correlation was best for patients with isolated traumatic brain injury and worst for those with evidence of poor tissue perfusion. Conclusion: EtCO2 has low correlation with Paco2, and therefore should not be used to guide ventilation in intubated trauma patients in the ED. Better strategies for guiding prehospital and ED ventilation are needed. Other articles: http://journals.lww.com/jtrauma/pages/results.aspx?k=ETCO2%202009&Scope=AllIssues&txtKeywords=ETCO2%202009

Are you going to give up your career as a FF if you do complete the Masters degree plus a specialty residency to be a PA? In over 40 years EMS has be the only health care profession to not change anything for its education requirements and it has largely been due to the resistance of the FDs. As long as Paramedic education is measured by a few hours of training, it is easy for the FDs to churn out Paramedics from a back room mill to put these new medics on a truck when they decide they want to get into the EMS business. Thus, to some fire department administrations, the Paramedic is not much more than a little more first aid training above EMT. The protocols will reflect that. Even entire states such as California have modeled their scope of practice around FDs which is not flattering by the Fire-EMS examples they used. Also, when some FDs actually get a medical director who wants to hold them accountable as medical professionals, they find ways to get rid of him/her. While there are exceptional Fire based EMS departments out there, even the ones which had an excellent reputation at one time now have had their abilities scrutinized by making every FF become a Paramedic. Forcing someone to do something they have no interest in weakens the system. There are no similarities with medicine and fire fighting. Many years ago (1970s and early 80s)before greed took over, the FDs did recognize this and actually were supportive of Paramedics getting the 2 year degree and only those who had an interest in medicine rode the FD ambulances. As paramedicmike already stated, the FDs in my area may get over 1000 applications for 5 FF positions and to be competitive, most will already have their Paramedic cert even if they have never worked at one or have no interest in medicine.

Why do you say the fire service is rewarding but being to a higher standard isn't? Even if a service is not known for providing care to a higher standard, you should hold yourself to the higher standard to provide quality care which the public you serve deserves. Too many FFs have thought as your statement about not getting rewarded and then fail at providing quality patient care if they feel it is a waste of time when no "rewards" are given to them. Those are the ones who have no desire to do patient care and give FF/Paramedics a bad reputation. Providing quality patient care to a higher standard should be a reward in itself. If his goal is only to get on with a FD then there is no reason to quit Frito-Lay while getting his EMT as well as the Paramedic cert. Most FDs don't care about previous experience as long as you have the desired certs on the application. In this economy,especially in CA with the unemployment rate at almost 13%, I would not give up a job right now. Considering some city FDs like Oakland in Northern CA had over 10,000 applicants applying for 20 FF openings, his chances of getting hired might be slim to none. Even a Paramedic cert might not give him an advantage since medic mills are pushing out many new grads whose only desire is to become a FF. He may have to keep reapplying at many departments for the next 20 years or relocate to where they are desperate. That may mean working for a really bad department or living in an area that is not desirable. Now if he really wanted to be a Paramedic, he could get his EMT while at his current job and work parttime on an ambulance until he found a good location to relocate to. He could also pick up some college classes while doing this. Taking the EMT and a few extra courses at a community college in CA can be a bargain with the reasonable tuition. Then, when he finds a job in another area that also has a good Paramedic program, he can make his move.

Steam would be bronchitis, the cool night air would be for croup and strong hot black tea for asthma if you followed the home remedies. However, for a child with lung congestion whose grandparent called 911, I would not recommend these treatments without further evaluation. This would be like telling someone who is having chest pain to take a TUMS and suggesting it is GERD without even doing as much as a 12-lead ECG.

I'll give them the benefit of the doubt only if they documented a rectal temp and the I&Os for the last 12 hours. EMS curriculum in the U.S. barely touches on pediatrics and then you have Washington DC which might as well be a country all to itself with lower standards in many things and not just EMS. Who knows what their reason for not transporting was. The toddler may have said "NO!" which many do at that age even if they actually want something. It is their declaration of independence. EMS may have thought the grandmother had no authority to sign for consent to treat the child. They may have thought crying or being quiet was normal. They may have been going on some textbook norms for RR. Children can be difficulty to assess which is why we look at other signs such as dehydration or change in behaviour. Even if the grandmother signed a refusal form it may be because some do put faith EMS since they are just like doctors or appear with the same authority to tell the frightened parent what to do. When it comes down to it, without proper documentation of a thorough assessment the refusal form may be meaningless.

If your statement is true then the ambulance crew that transported her would also be on leave and blamed. So far only the ambulance crew that did not transport has been in question.

Toddler Dies After Ambulance Did Not Transport Her http://www.wusa9.com/news/local/story.aspx?storyid=97975&catid=187 WASHINGTON, DC (WUSA) -- The family of little Stephanie Stephens is wondering why paramedics and first responders did not take the two-year-old girl to the hospital when the initial emergency call was placed. Stephanie would end up dying hours later. Her paternal grandmother, Tondalia Richardson, tells 9NEWS NOW, "I just don't understand it. I just don't understand it. If they were called then why didn't they take her? That's the part I don't understand, this is an infant, why wouldn't you take her?" Investigators say it was February 10th in the middle of two blizzards when the child's mother called 9-1-1 because little Stephanie, whom many called Tu-Tu, had trouble breathing. DC Fire and EMS released this statement, "Within minutes a Medic Unit arrived on the scene. Emergency first responders performed a patient evaluation. There was no transport." Hours later they received another call from the child's home. This time paramedics transported the little girl to the hospital, but the next morning Stephanie Stephens was pronounced dead. Richardson looked after her granddaughter every week and says, "She was the bubbliest thing. She was loving and happy and outgoing." Stephanie was laid to rest this past Tuesday. Her grandmother is wondering why this little girl's life had to be cut short just shy of the girl's third birthday. She says Stephanie died of pneumonia. The paramedics and EMS personnel involved in this case are on administrative duty and are not to have contact with patients. DC Fire says generally, EMS and first responders do not refuse transport. Investigators are now looking into whether protocol was followed.

The complications will be dependent upon what stage you are at during the dive or if this is before or after. One must recognize that different treatment such as an indwelling catheter or tube must be inserted because the needle will not be enough no matter how many holes you poke in the chest. One may also have to decide whether recompression might be necessary to safely do the procedure. The outlines and material recommendations from the NBDHMT give the specific guides and procedures for HBO. There are more considerations and concerns for those working in dive medicine or HBO which is why even Doctors and Paramedics must take the courses to fully understand the differences. If you are designing this program for those about to take the certification exams or who plan on working with HBO chambers, it would be best to follow the material since this is a specialty.

I can see their point especially if they are contracted for IFTs with that hospital. Make fun of the bread and butter of most ambulance transport services that might cause the contract to be lost and you will suffer the consequences if not by the firing now but by the layoffs that could occur later. Even in Specialty and Flight we are told if we do something stupid to/at the facilities we serve, the other teams in the area are more than willing to take over the contract.

The Buretrol is meant to be used with the IV pump. If you screw up with your calculations, the patient, particularly a child, hopefully with then not be bolused with a large amount of fluid or meds.

I take that to be on a CCT or ALS IFT. All drips should be reviewed during report and a confirmation of doses and settings done before departure. If something is not right it should be pointed out so you are not responsible for any miscalculations because the rec'g facility will look at the last hands to touch the patient. Also, if that dosage which the pump was set at was working for the patient, changing it to the "correct" setting might bring about undesired consequences. Of course on Specialty and Flight, we generally replace the sending hospital's drips with those from our own med bags unless it is a fluid with nothing added. This is especially true for pediatrics and neonates as we will trust no one but our own.

PEEP too early and you may not gain any ground with a sepsis patient. Sometimes you have to be patient and address the sepsis first since the ScvO2 will be extremely low. Oxygen will help get that back up but the BP MAP will have to be climbing as well. Anything to compromise shutting down more organs will definitely lead to death. Thus, patience and careful monitoring before jumping in with a full respiratory press that could dump the BP MAP to never, never land and never to return. Depending on the oxygenation level, we may even start at a PEEP of 0 until the BP MAP is increasing. However, if you don't have the circulatory support, it doesn't matter how much O2 or PEEP you use. The fact that this person is an asthmatic also might make one consider her lung volumes and compliance. Too often some become focused on the SpO2 or just the respiratory part and will crank down the PEEP valve while forgetting all about the circulatory part or lack the protocols for an aggressive sepsis resuscitation. If I did raise the PEEP on this person when the BP MAP is stable it would be because of her obesity more than just the lung sounds. Otherwise, a PEEP of 10 is not commonly used in the ICUs, EDs or on specialty CCTs. Most transport ventilators have a difficult time delivering higher PEEPs to any degree of accuracy or effectiveness and most have insufficient monitoring systems. Aggressive recruitment maneuvers are also not indicated for all patients. Dust and Tnuiqs will probably remember the days when every patient on a ventilator got "Sigh" breaths and we know where that got us. I mastered chest tubes during those days. BTW, HFOV is not just for kids anymore. HFV has been used for over 25 years in adults and HFOV has been used for at least 10 years. Also, one of my favorite amusements is taking a newly patched CCEMT-P into the ICU and letting them have a peak at a septic ARDS patient with HFOV, Nitric Oxide and proned along with all the med drips. Or, I introduce them to ECLS or ECMO. Hopefully then they will understand "critical care" is not just a weekend cert.