Jwade

Hey, I completely agree with everything, I am NOT quoting PALS as the gospel by any means...Tons of crap I disagree with for sure, HOWEVER, my point was that for the PUBLIC and the use of an AED with PEDI PADS, the joules will be dialed down to 50 in THEORY.........Again, I would rather shock regardless of the age and there is NO time for mother may I BS!!!!! I apologize for not clarifying my point better in my previous post....Can you elaborate on the red text above....Not sure what you are talking about here....The PEDS AED stuff I have always used, literally has a box wired inline with the PADS which tone down the joules from 360 - 50. Better to ask for forgiveness than permission any day! Respectfully, JW

I have to take issue with the RED highlighted portion.....This is the problem with so many field providers...... Lets review some basic pathophys... BLOOD PRESSURE = BRAIN PERFUSION Normal CPP ( Cerebral Perfusion Pressure) Adult = 70 NEO / PED = 40 - 60 CPP CALCULATION CPP = MAP - ICP A reliable estimate of ICP in a NON-Head injured patient is 10% of your MAP MAP = Systolic + 2 * Diastolic / 3 Lets say you have a HR of 76 and a BP of 60/40 after a ROSC ......Do the simple math MAP ( Mean Arterial Pressure ) = 46.6 ICP ( Inter-cranial Pressure ) = 4.6 46.6 - 4.6 = CPP 42 This is NOT perfusing the BRAIN! No brain perfusion = DEAD Remember, the Coronary Arteries fill during DIASTOLE.....So, if your diastolic is 40, you have some issues.... ALL one can do is the proper rate of 100 min with adequate depth and chest recoil...... Respectfully, JW

AS a PALS instructor, The Pediatric AED pads have essentially a " Voltage Regulator" that will dial down the joules from 360 - 50 joules....If they are in VFIB / Pulseless Vtach and the 6H's and 5T's have been ruled out, you NEED to be shocking the patient....End of story, regardless of age.....The bottom line after all the BS and anecdotal crap, is you still have a lethal rhythm that is potentially reversible..... Not quite sure why so many people are afraid of the NEO / PEDI population, Dead is Dead, they will continue to remain DEAD if you do nothing....... Respectfully, JW

Fire, I would NOT worry about being sued! One only has to look to all of the Medical Apps available for the Iphone. What you NEED to do, from my Business Law MBA class, 1. I would form an LLC for your software company. 2. Find a good contract attorney who can write up the " Fine Print" for your software programs. This will include the disclaimers. 3. Make sure your software works BEFORE releasing it to the masses.....This is from a business point of view...If it sucks the first time, people are going to be hesitant to go there twice... 4. Find a good CPA JW

Ok, Let me give you the real deal on traction splints. First, I spent 8 years as a Surgical First Assistant in Trauma Surgery at Detroit Receiving Hospital. Combine that with my 17 years of EMS experience, I can give you an educated and experienced opinion. Here is what happens when a fractured femur comes into the ER and then to Operating Room. If patient is on a traction splint, the splint is removed, xrays taken, and usually a traction pin will be inserted into the tibia or distal femur and 20 pound of traction will be applied until patient goes into surgery. NOW, here is where it gets really interesting and very FEW people know this information. When the patient comes into the OR, all the traction is removed, the patient is put to sleep, and the desired surgical anatomy is prepped and draped for surgery. Now, imagine if you will YOUR broken leg hanging from the end of a weighted IV pole with kerlex wrapped around your ankle to the IV pole. This is how the legs are prepped with Beta dine and then draped. The legs sits and whatever angle it is broken in on the IV pole. Someone had mentioned that if the bone would have moved a little the patient would have bleed out....Well, this is not exactly an accurate statement. IF the bone transects ANY major vessel during the INITIAL injury period, then potential huge blood loss is a probability. The chances of an already broken bone causing an IATROGENIC injury during bone reduction and or placement of a splint, or moving to a backboard are statistically NOT significant. Hence, the broken limbs get hung from IV poles. Once the limb is prepped and draped, we will determine using the C-ARM and xrays, what the best course of action is to fix said bone... Femur fractures will almost 90% of the time receive a femoral nail via the Retrograde or Ante grade approach. If the injury occurs high on the Femur such as the Femoral Neck, then a Hip Screw is needed or a combination of screws, if the Greater Trochanter or Sub-Trochanter is involved, then it gets very complicated, and a combination of a nail, and a blade plate might be required to achieve perfect reduction. The same things goes for the distal femoral condyles, if there is one place you dont want to break on your leg, it is the top or very bottom of your femur........If it is my leg, PLEASE make it a mid-shaft....LOL.... The FEMORAL NECK Fracture is really the only one that must make it to the OR in 6 hours to be fixed emergently or AVN will develop. Any open FX must also go to the OR for at LEAST a washout, and then can return in a couple days to have a definitive fix applied. fx Moving on to my Pre-Hospital usage, I might have used them 3 times during 17 years, I think it definitely helps the conscious patient with pain control once properly reduced. Along with generous amounts of Fentanyl and Versed......Fentanyl is the drug of choice due to it's synthetic properties, and the potential transient BP drops associated with MS and the pathophysiology behind it.. Having flown in a few different helicopters, I have had to remove traction splints to be able to get then in the aircraft....This is always entertaining.....Lots of premedication need to happen before you try this maneuver at home..... Drop me a line if you need any more help, I collaborated with some of my previous surgeons on journal articles, so I am very familiar with the process involved..... Respectfully, JW

Dude, I do truly hope your joking? You want to do Pediatric Critical Care Transport having JUST finished Paramedic SCHOOL? Short Answer = ABSOLUTELY NOT! I will tell you what, if you can tell me the pathophysiology of Tetralogy of Fallot without having to use GOOGLE, then I might be willing to listen to your argument. I really hate to sound like an A$$ here, BUT, there is NO way on this earth, any brand new paramedic is ready to do ANY type of CC transport. That included myself back in the day.....In fact, I have tons of CC experience, education, and when I took PNCCT last year ( Pediatric Neonatal Critical Care Transport Course) ( 10 Days, 8 hours day) i only scored an 86 on the final exam........This stuff is NO joke, and will truly be beyond the mental capacity of 99% new paramedics. So, Unless you are the statistical outlier, the answer is NO..... I suggest, go work the streets for 3 years, start taking CC courses, PNCCT, read some ICU nursing books, do ride alongs with a CC crew. Send me a PM, I can point you in the right direction for books and classes to get you started. There is an old saying, You don't know, what you don't know, ( Until it is too late)! Respectfullly, JW

DUDE, Talk about a fallacy of epic proportions!

LMAO...Thanks :-) Seriously though, I would be more than happy to send her an email, keeping your name completely anonymous of course, and providing her with correct FACTUAL documentation to support both your premise, and to show her conclusions are erroneous. Just send me a PM... Respectfully, JW

Ok, I did my part. I gave my vote! jW

Hey man, That is an easy one, Just send me her email, and I will be happy to educate her for you. Sorry, you have to go through this my friend.... Let me know, JW

CH, Great post, Just wondering about your algebraic straight line graphing equation? Simple Linear Regression The objective of simple linear regression is to determine the straight-line relationship between a dependent (y) variable and an independent (x) variable. This includes a single explanatory variable, or how much of the variability in the dependent variable (y) can be explained by the independent variable (x). When several explanatory variables exist, a multiple regression analysis is performed. For this paper, three simple linear regression analyses are performed. Linear relationship hypothesis are as follows: H0 p(rho)=zero HA p (rho) does not = zero The author will want to reject the null hypothesis and accept the alternative, or show that there is a linear relationship. Respectfully, JW

Vent, How do you qualify and quantify a satisfactory level of education in EMS? Who determines this? At what point did I achieve a satisfactory level of EMS education? EMT-Basic EMT- I EMT- P ( All university classes, with A&P, Pathophys, Micro, Organic / Inorganic Chem, Pharm I&II, Nutrition,) Physiology Degree Business Management Degree MBA MHA 17 years experience > 1000 flights CCEMTP, PNCCT, FP-C, ACLS / PALS instructor ..........and the blah blah blah goes on and on....Where is the end point? Am I a statistical Outlier? Again, I fully agree education is the key, and the people who don't have it, literally dont know what they dont know, but would be interesting to see your response.... Respectfully, JW

Vent, Just to play devils advocate with you for a minute, I am confused as to your statement above, Why is is so IRONIC that Cosgrojo chose to get a BS in a non-ems related field....? I have been in EMS since 1992, moved up through the ranks from EMT-Basic, EMT-I, EMT-P, FP-C blah blah blah, I am 36 now, and just finishing a Double Masters Degree in NON-EMS related fields. MBA / MHA . I have always loved saving lives just as much as the next person, but honestly, we have to truly look at the statistics I think to understand we are rarely saving lives anymore, and have become for the most part expensive taxi rides, and primary care providers. I always teach and preach having to understand the " WHY" your doing something as opposed to knowing you have to do something, just yesterday in my ACLS class, I had to sit down and explain Cerebral Perfusion Pressure and why a CPP of 42 is bad in an adult. I am PRO education for paramedics, and I agree with 99% of what you say, I just don't see why it is so IRONIC for people such as Cosgrojo and Myself to pursue advanced degrees regardless if they are EMS related or not...... One last thing, CAREER versus JOB debate, these lines are becoming more and more blurred today, society has changed dramatically over the past 50 years and people are no longer willing to be subject to society dictating they MUST pick a career and work it for 30 years, retire, and move to Florida....:-) I read a recent study that showed, todays teenagers will likely have 3 different substantial " Careers" during their adult working life.....I personally regress against the thought that someone must stay in a chosen career field just because they like to do something.....I have multiple passions in life, HEMS, Aviation, Fishing, Cars, and I would be happy to be working in any of them..... Respectfully, JW Just in case anyone was wondering about Fallacies.......... Logical Fallacies An Encyclopedia of Errors of Reasoning The ability to identify logical fallacies in the arguments of others, and to avoid them in one’s own arguments, is both valuable and increasingly rare. Fallacious reasoning keeps us from knowing the truth, and the inability to think critically makes us vulnerable to manipulation by those skilled in the art of rhetoric. What is a Logical Fallacy? A logical fallacy is, roughly speaking, an error of reasoning. When someone adopts a position, or tries to persuade someone else to adopt a position, based on a bad piece of reasoning, they commit a fallacy. I say “roughly speaking” because this definition has a few problems, the most important of which are outlined below. Some logical fallacies are more common than others, and so have been named and defined. When people speak of logical fallacies they often mean to refer to this collection of well-known errors of reasoning, rather than to fallacies in the broader, more technical sense given above. Formal and Informal Fallacies There are several different ways in which fallacies may be categorised. It’s possible, for instance, to distinguish between formal fallacies and informal fallacies. Formal Fallacies (Deductive Fallacies) Philosophers distinguish between two types of argument: deductive and inductive. For each type of argument, there is a different understanding of what counts as a fallacy. Deductive arguments are supposed to be water-tight. For a deductive argument to be a good one (to be “valid”) it must be absolutely impossible for both its premises to be true and its conclusion to be false. With a good deductive argument, that simply cannot happen; the truth of the premises entails the truth of the conclusion. The classic example of a deductively valid argument is: (1) All men are mortal. (2) Socrates is a man. Therefore: (3) Socrates is mortal. It is simply not possible that both (1) and (2) are true and (3) is false, so this argument is deductively valid. Any deductive argument that fails to meet this (very high) standard commits a logical error, and so, technically, is fallacious. This includes many arguments that we would usually accept as good arguments, arguments that make their conclusions highly probable, but not certain. Arguments of this kind, arguments that aren’t deductively valid, are said to commit a “formal fallacy”. Informal Fallacies Inductive arguments needn’t be as rigorous as deductive arguments in order to be good arguments. Good inductive arguments lend support to their conclusions, but even if their premises are true then that doesn’t establish with 100% certainty that their conclusions are true. Even a good inductive argument with true premises might have a false conclusion; that the argument is a good one and that its premises are true only establishes that its conclusion is probably true. All inductive arguments, even good ones, are therefore deductively invalid, and so “fallacious” in the strictest sense. The premises of an inductive argument do not, and are not intended to, entail the truth of the argument’s conclusion, and so even the best inductive argument falls short of deductive validity. Because all inductive arguments are technically invalid, different terminology is needed to distinguish good and bad inductive arguments than is used to distinguish good and bad deductive arguments (else every inductive argument would be given the bad label: “invalid”). The terms most often used to distinguish good and bad inductive arguments are “strong” and “weak”. An example of a strong inductive argument would be: (1) Every day to date the law of gravity has held. Therefore: (2) The law of gravity will hold tomorrow. Arguments that fail to meet the standards required of inductive arguments commit fallacies in addition to formal fallacies. It is these “informal fallacies” that are most often described by guides to good thinking, and that are the primary concern of most critical thinking courses and of this site. Logical and Factual Errors Arguments consist of premises, inferences, and conclusions. Arguments containing bad inferences, i.e. inferences where the premises don’t give adequate support for the conclusion drawn, can certainly be called fallacious. What is less clear is whether arguments containing false premises but which are otherwise fine should be called fallacious. If a fallacy is an error of reasoning, then strictly speaking such arguments are not fallacious; their reasoning, their logic, is sound. However, many of the traditional fallacies are of just this kind. It’s therefore best to define fallacy in a way that includes them; this site will therefore use the word fallacy in a broad sense, including both formal and informal fallacies, and both logical and factual errors. Taxonomy of Fallacies Once it has been decided what is to count as a logical fallacy, the question remains as to how the various fallacies are to be categorised. The most common classification of fallacies groups fallacies of relevance, of ambiguity, and of presumption. Arguments that commit fallacies of relevance rely on premises that aren’t relevant to the truth of the conclusion. The various irrelevant appeals are all fallacies of relevance, as are ad hominems. Arguments that commit fallacies of ambiguity, such as equivocation or the straw man fallacy, manipulate language in misleading ways. Arguments that commit fallacies of presumption contain false premises, and so fail to establish their conclusion. For example, arguments based on a false dilemma or circular arguments both commit fallacies of presumption. These categories have to be treated quite loosely. Some fallacies are difficult to place in any category; others belong in two or three. The ‘No True Scotsman’ fallacy, for example, could be classified either as a fallacy of ambiguity (an attempt to switch definitions of “Scotsman”) or as a fallacy of presumption (it begs the question, reinterpreting the evidence to fit its conclusion rather than forming its conclusion on the basis of the evidence).

This is complete Bullsh&T, as a current ACLS & PALS AHA instructor, and a paramedic, completely erroneous info! In fact, I just taught ACLS this morning, and I had Docs, Nurses, and RT in my class! Hmmmmm The only one that is tight anymore to get is NRP, very FEW are allowed to get NRP instructor status anymore... back in the day when it was NALS it was pretty easy.... Respectfully JW

Yes, One of our helicopters crashed and killed a friend of mine. We went through the entire CISD stuff. Let me know what I can answer for you. JW

I fully agree let people do their jobs, the inherent problem is, how many non-pilots can tell the difference between an 800ft & 500 ft ceiling? 3 or 5 mile visibility? Temp / dew point spread? How many of you can look at Nexrad weather and decipher the radar picture in depth? How many people know how to tune in the ILS or Localizer, or read an approach plate properly? I am all about keeping my a$$ on the ground if weather is closing in, or could deteriorate in route, but too many times people jump the gun and start quoting something they know minimal about, and this includes flying, medicine, sports whatever..... This is what really irritates me to no end..... VentMedic, Nice to see you are still ruffling feathers on Flightweb! LOL......Same old crap over there i see! Hope you are well... Respectfully, JW

In regards to the highlighted portion of the text......In the most basic terms....NO, Advanced education is the key, and I will probably offend a lot of people on this board in a second when i say, YOU REALLY DONT KNOW, WHAT YOU DONT KNOW!!!!! There is NOTHING worse with someone who has a little bit of knowledge on a subject to start imparting opinions to the masses as if fact...... Unfortunately, I can easily give an example is the world of HEMS.....You take type A medical people, put them on a helicopter or airplane for 1 year, and all of a sudden they are experts on METAR's, Cloud Ceilings, Prognostic charts, Approach plates, and last but not least, think they can fly the aircraft if ever needed in an emergency.....I see it all the time.....This is why you have the inherent in fighting between pilots and medical crew.....It makes for a bunch of second guessing....However, you never see a pilot lean over and say, " Did you really need to Intubate that patient?" I can speak on both sides because i have the education as BOTH a pilot and flight paramedic! So, the bottom line IMO, Make the EMT-I the new EMT-B, and force all Paramedic programs to a minimum of a 2 year degree, and then give us the option of pursuing the Critical Care Paramedic or Certified Flight Paramedic.....Both latter certs are way beyond the general paramedic and require much more extensive knowledge....I cannot imagine not having taken Pathophysiology, Organic / Inorganic Chem, Pharm I & II, etc.....and be where I am at today....Again, a little bit of knowledge is the scariest thing alive! I apologize in advance if I offend anyone..Not my intention.... Respectfully, JW

Hey, Thanks for the compliment.. Just a quick note, I agree that with regards to scene flights, HEMS rarely offers more than your average ALS truck aside from potentially giving blood, chest tubes, and a few others....The big difference for HEMS comes into play with Critical Care IFT. Managing a critically ill septic patient straight out of the SICU, who is on a balloon pump, Vented, swan, a-line, and 6 drips and put all that crap into a Helicopter is very difficult and challenging even for the most experienced providers...That stuff is definitely beyond the ability of most standard ALS rigs in the USA... I agree without reservation, HEMS is utilized for scene flights way too much, most ALS providers do a great job on the ground, and during my Rotor years, I would say the chances of me having to redo something the ground guys did was <20% of the time. When I did have to fix something it was usually airway related, a couple crichs that went bad, intubating very small kids, etc....... So, I would hope most ground guys and gals would seriously take a look at the time commitment needed for calling HEMS, and just get their rig moving in the direction of the hospital.....We can always meet you on the side of the road if necessary..... Great discussion.. Respectfully, JW

In response to the OP question.... ABSOLUTELY HEMS is way over utilized! Having just finishing up an MBA, I can tell you, I have extensively studied the statistics of everything HEMS.....( 3 Graduate Stats classes will force this). I have to disagree with the above poster, HEMS can easily be a money-maker dependent upon aircraft type, location, time and distance, etc..... For example, Take an A-Star B3 , Single Engine, staffed with 4 pilots, 5 nurses, 5 Paramedics for the base. Average number of flights to cover fixed costs for the month is 16-20 with average reimbursement in the 10 - 15k range. Lets take my previous rotor base, Airevac 9, We would average 60 flights month. 60 * 15k = 900,000 dollars gross subtract your 20 flights to cover fixed costs, ( Salaries, DOC,etc...) leaves you with avg of 40 flights @ 10-15k. this will leave you with a net income of 400,000 - 600,000 dollars a month.....NOW, you throw up 10 more bases on every street corner like there is in Arizona, and do the simple math......You tell me if it loses money or not..... ( NOT) Why do you think the amount of helicopters has quintupled in the last 7 years? This would not happen if there were not money to be made..... Again, each company will be different based on aircraft, reimbursement rates etc...... Arizona is by FAR the worst offender of flying patients who have no business being flown.....Many of the ground crews do not want to make the drive into Phoenix, especially during rush hour, so they just say fly them out, regardless of appropriate........This is one of the main reasons I left Rotor wing and went to Graduate School..... having moved to AZ from Michigan, where there is such strict criteria for using a helicopter was a huge shock to me.....In all my time working the ground in Southeastern Michigan, I called for a helicopter twice......Once for a 95% burn patient who was 45 min from ANY hospital, and the other was a very prolonged ICE rescue from Lake huron. We were expected to take care of our patients, and not punt them off to the quickest taxi ride available......It is just absolutely asanine out here in AZ.....There are over 25 helicopters in the METRO phoenix area.......Do you really think there are that many patients who need Air Transport? The studies prove >75% of the patients who are flown DO NOT need HEMS......75% you tell me what is wrong with this picture!!!!!! From this proliferation has come a detriment to the HEMS provider, the talent pool has been watered down to nothing more than a BP and a pair of boots, and a license.......Back in the day, one would have to have a minimum of 10 years experience, instructor status in everything known to man, someone would have to die in the flight program or retire for a spot to open up......and then you would pray you had an inside friend to make a recommendation for you..... Respectfully, JW

Hey, I started initially working in the O.R. at Hutzel Hospital, and then transfered to the legendary Level 1 Detroit Receiving Hospital. I was there from 1996 -2004. I also worked contingent at a few other hospitals in the area as well, Henry Ford, Bon Secours, and St.Joes West. JW

Excellent articles for people to keep with them in the rig or helicopter for sure.....No pain management for these patients was very prevalent in the 70's - 90's, however with the advancement of technology and 64 slice CT scanners, there is absolutely NO reason to withhold pain meds.....I have no doubt some attorney could make a strong case for negligence or malpractice. Having spent 8 years as a First Assistant in Trauma Surgery in Detroit, I can categorically say, none of the Trauma Surgeons would ever hold pain meds so they could " Examine" the patient properly..... Respectfully, JW

Norepinephrine has been studied in only a limited fashion for treatment of cardiac arrest. Human data is limited, but it suggests that norepinephrine produces effects equivalent to epinephrine in the initial resuscitation of cardiac arrest.53,103 In the only prospective human trial comparing standard-dose epinephrine, high-dose epinephrine, and high-dose norepinephrine, the norepinephrine was associated with no benefit and a trend toward worse neurologic outcome (LOE 1).53