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saboats

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Everything posted by saboats

  1. The theory about this is simple; we inhale approx 21% (20.89) O2, when we exhale we expel a mix gas containing approx 16% O2. Now remember that this is in a normal living, breathing, digesting, full metabolism churning ALIVE person. So it would make sense to think that in a non-breathing, not digesting, no alive person that the 02 uptake at the cellular level may decrease, so say the "dead" exhale 17-18% 02. This means that we use approx. 5% of the 02 inhaled Alive, the theory is if we are only using 5% per breath cycle, then there is plenty of 02 still in the bloodstream if you are not breathing for sometime. I'm not saying that I either agree / disagree with this theory or method of CPR since I have not read any studies on it (they are out there, I just haven't ventured there yet). However, since there are plenty of studies proving that we over ventilate patients, and not allow for full chest recoil decrease return of blood to the heart (negative pressure) I'm curious to what studys of 100 /2 ect may show...
  2. Is it right: I think still open to interpretation. Is it legal: I don't see anything illegal about it as long as you can back it up with some sort of formal training or evaluation eg. testing. I can not think of anything illegal; unless you jurisdiction specifically does not allow it.
  3. saboats

    officers

    Just to throw this out there, as it appears timely... This months JEMS has an article in it about EMS Chiefs, and (in the writer words) why they are valuable in many areas vs titles of Director, Operations Manager, President, ect. Interesting read..... JPINFV: If you location is correct, you work somewhere in the Boston Area, and unless that's for Boston EMS, means you work for on the many private forprofit services in the area...Doesn't matter which one, and I'm not disparaging anyone there, used to be there myself, but in those companies it seems that people are promoted via the buddy system, through attrition, or simple time in service - not through education, mentoring programs, testing ect... So if that's your experience I can totally see where you are coming from. But in the municipal industry, rank structure is important - expecially when divvying up tax payer money at budget time and competing with Fire and PD for the ever shrinking public safety funds....
  4. minimum ANSI2 for Vests, and ANSI3 for outerwear if not wearing a vest....
  5. I see what you were getting at, and I agree it's not the same in a scenario as you state it. And it's soon to be a dead issue anyway with the Final Draft 1.0 of the National Standards being out today. In NH EMT-I(85) is a minimum 80 hour program, - (that's how low you can go!) A lot depends on your states rules and laws regarding initial training programs. Many follow the standards, e.g. if the NHTSA DOT Standards state a minimum of 120hours to complete, then the state requires 120 minimum. I don't think I want to open up the issue that an person in <200hours of training can become an EMT-I here, start IV's, initiate advanced airways, give medications ect ect, but the Wal-Mart training for new hires is 3 weeks to work a register (120 hours); but I digress....
  6. Not that I really want to disagree.... But..... The I/99 curriculum IS word for word the old paramedic curriculum. The fact that many institutions had 700 hours (many back then including clinical hours) for a course that was listed at 400-500 and using that as the basis for saying that they weren't the same is non sequitur . When the 1998 (Current) Paramedic Curriculum was published and placed into practice, the DOT standard EMT-I was the EMT-I (85). After the change to the medic program, a decision was made to use the old paramedic curriculum, and in 1999 was released as the revised Intermediate Curriculum. After many states bucked this change the old I(85) was kept and states used whichever program they choice. However - due to this change in 1999, many states wrote there own Intermediate Curriculums and don't follow either the I85 or the I99. If you still have the DOT National Standards from back then lying around somewhere, and the current I99 standard, take a look. They are practically identical.
  7. saboats

    officers

    I agree you need some kind of structure in any agency, this can vary depending on size, organization, or affiliation. I don't know if paramilitary style structure is the best way or not. Lead me to the question; is EMS public health, public safety, a hybrid of both? This is why I am in this conundrum: #1: Public Safety; means PUBLIC or municipal. Good Pay, Benefits, Retirement on par with you FD/ PD types. #2: Public Health: Safety and Wellness. Promoting the public good, welfare checks, vaccination clinics, BP clinics, ect. #3: Hybrid: All of the Above. Good Pay and Advancement, Retirement as well as all those things in #2... Now, all " Public Safety" is in some sort of paramilitary system. It works, Police Officers in most places patrol alone, yet there is still a Sgt. or Lt around and a Chief in the station. (to ask about the 2 people on-scene, no need for rank comments). We, as EMS are always looking for better pay, better training, more respect, etc. FD/PD types have got this down. EMS is fragmented with Public, Private, Hospital Based systems, low pay and an overall lack of respect in general. Maybe public safety is the way to go. Municipal agency on-par with our cohorts in Fire and Police. Same pay structure, same benefits. Just a thought..... Any opinions?? DISCLAIMER: I currently hold rank in a Municipal EMS Agency, so my opinions my be influenced. But I worked in the private and hospital based world for many years, so I see both sides....
  8. The Interstates are fine, the town roads are pretty well maintained. I ride my bike through the mountains during "leaf peeper season" every fall without much trouble!
  9. LOL: except in New Hampshire, Still have no Seat Belt Law, only state in the Union, and therefore no Federal Highway Funds coming under that law already!!! Live Free [s:e20f6d2732]or[/s:e20f6d2732] And Die!
  10. Didn't know that... but here's a question, how many paramedics out there have been practicing since 1999 or earlier? The reason for the question; if you were registered prior to 2000 as a paramedic, who have the same training, same curriculum, same level of initial education as all the EMT-I/99's out there. The EMT-I/99 is the "old" Paramedic Curriculum. There was nothing changed in that NSC when it was "demoted" the the I level. Now I'm not saying that you/we haven't increased our knowledge and training in the years since the curriculum change, but all those EMT-I/99's coming out of training now are being taught the same things you/we all were taught back in the day..... Interesting huh???
  11. I 100% agree. I wasn't even broaching the subject of a need to increase education. I was actually having that debate with a former employee while I was writing my last post! It is not about skills, when I mentioned thing like permissive hypothermia in post arrest it was all about education. RSI isn't a "skill" IMHO ; it's a tool, that NEEDS to have A LOT of initial and ONGOING education/ QA/QI. 100% agree, education 1st, "skills" second... But isn't even an 80hour intro class (eg CCEMTP) more "education" and therefore a good thing?? PS; to the last post who stated you can bill CC / SCT if a CCEMTP was onboard, not really, unless you enjoy a CMS aduit. There needs to be interventions performed / continued that are above the scope of practice for a "street" paramedic. Simply having you there to give say a Lido IVI doesn't cut it....
  12. Yes.. you are right about the ALS2 vs SCT Billing at most companies, and the lack of training most in charge of these services actually receive on this. As far as FP-C, VS CCEMTP: Both have CME requirnments after initial testing to remained "certified" by them. If you don't complete the required critical care con-ed for either, then you need to take the test again to retain the certification. As far as which test is harder, that's a matter of opinion. Some people found the FP-C test easier then the CCEMTP test and vice versa. I personally didn't find the CCEMTP test all that difficult, but I studied my arse off for it. FP-C, flight phyisiology kicked my arse - the critical care stuff is pretty much the same. I personally have no vested interest in either exam, and I won't advicate for 1 vs the other. The CICP also I've heard is a butt buster (out of the Cleavland Clinic) but I haven't had the pleasure. As far as "being challanged for state credientals if you use NREMTP" ; i had never been asked, excepted when OEMS was at the base doing inspections, and that state required you to carry your card at all times while on-duty. That state didn't even recognize the NREMT at any level and most of us wore our "gold patch" every day, in the state capital.... Again, I think that we as EMS practicioners have bigger fish to fry then this, and maybe we should be discussion permissive hypothermia in post arrest, or hypertonic saline in head injury, RSI, or thrombolytics for STEMI ect ect ect.....
  13. If you look at the current CMS Fee Schedule Rules Specialty care transport (SCT) means; interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT–Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training. The SCT rate is intended for Transport, not 911 care. Those who have stated that the CCEMTP/ CICP does nothing to increase how you treat patients, in actuality this is true if you are providing 911 services only. The field of CCT is an arm of EMS, but knowing about ECMO or balloon pumps or VADS probably will not change your treatment of a 911 patient. These again, or specialty care transports, and a standard 911 ambulance is not staffed or equipped to make these runs. Now, as far as people using NREMTP vs CCEMTP after there names; really what's the big deal. The NREMT is not a LICENSING BOARD, or ACCREDITING AGENCY nor does it grant you permission to do anything anywhere. It is a TESTING AGENCY that certifies a CANDIDATE has met MINIMUM COMPETENCY in their field. It is up to individual states to Certify / License providers to render care. True many states have direct licensure with the NREMT; (eg. all you need is the gold patch and the state gives you a license to practice), some have their own test, whatever. But if you look at the basics of the argument here about using CCEMTP, then that argument would hold about NREMTP. I hold an NREMTP card, and 3 different State EMT-P Licenses / Certifications. If I would hold to this argument, then I should use NH EMT-P, or MA-EMT-P, or simply EMT-P, and withhold the NREMTP because it means nothing! Obviously I don't agree with this interpretation; and truly don't we have bigger fish to fry?!? But I digress, the real point of this post was SCT Rates; they are for transport, you should not bundle ALS2 with SCT as they are different rates, you can still use mileage, your GAF or RAF if applicable.
  14. Who restricts you? Your employer? Ethical Concerns? State Boards? IS Dr. Bledsoe wrong when he has D.O., NREMT-P after his name if he is appearing as a physician? I'm playing kind of devils advocate here I know, but I know plently of Flight RN's who badges say: RN/EMT or RN/EMTP, (FP-C/ RRT also). So is this a standard in your area, or are you stating that this is a national standard? Again, devils advocate here, but if I'm typing it, many are wondering......IMHO
  15. The Parkland Formula mentioned earlier is ( fluids volume)= total body surface area of burn (%) x weight (kg) x 4 1/2 of dose admin. in 1st 8 hours, the rest in the following 16. However I believe FireDoc (I think it was him) was right, start the fluid ressecutation, and that number of CCs will be subtracted from the total vml at the burn unit. Some things to remember, we (EMS/ED) almost always under estimate the BSA, and burn centers re-estimate after 24 hours to get a true messurment of true BSA. The inital fluid administration is over 24 hours (what the parkland formula was for), and we shouldn't be fluid over loading our patient pre-hospitally. We can cause airway problems from too much fluid, eg. non-cardiogenic pulmonary edema, from baseline fluid overload, and these patients are sick enough, we don't need to stress their systems more. IMHO I would say analgesia is more important in the immediate short term.
  16. ?Question, not picking a fight, simple question: There a plenty of RN's out there wearing CCRN, CEN, CFRN, ect ect ect on there name tags. The states do not quantify these "titles" either, although they may be required by an employer. Are these "titles" allowed, and should these providers wear these even though a state agency may not recognize them?? Just a question to ponder....
  17. "What I think is funny is watching these paragods we find on sites like this get so stressed out that their heads nearly explode when you 'remind them' that they ARE an EMT-P! " LOL now what are we going to say when the new Agenda for the Future and Education Standards are released, and EMT-P goes to plain old Paramedic
  18. Mass Does have a CCT (Critical Care Transport) excemtpion. The CCEMTP course is considered the standard entry level training for 1 large CCT provider in mass. There is only 1 ground based (only) true CCT (RN/MEDIC) unit in Mass, and they use the CCEMTP course as there initial training tool. Also, in the program it has 2 separate "certifications" CCEMTP (critical care emergency medical transport program) or CCEMT-P (Critical Care EMT- Paramedic). I know there are some posts that state that there isn't anything about this on whatever site they looked at, but my CCEMT-P "Certificate" from UMBC says "CCEMT-Paramedic". Now should they be wearing/using these letters: #1 there are many medics who have completed this program who are not working in a CCT system; if they are not, why use it? I can tell you there are those in my state is looking into a transport rule for people who have completed CCEMTP/FP-C to allow these medics a larger Scope of Practice, but if your not in a CCT program, as of now, in all of New England, there is no point in wearing it..... IMHO... (I don't see a legal problem with it however (signature issue); as long as they have completed the program it seems defensible.
  19. saboats

    Plavix

    I do not know of any ground services in New England giving Plavix, though I ovibously do not know all of them. Aero-Med services are giving it here in STEMI.
  20. Like the idea of a spin off for phenergan IVI. We dilute 12.5mg in 50cc NACL and infuse at 10cc/min, limits the risks, and discomfort for the paitent. Great idea to through this into the post...
  21. p.s., I am not trying to start a fight here. We are very aggressive with our treatment of AMI. eg, O2, 12/15 lead, MSO4 /Fent. ASA, NGT IVI, LMW Heprin, Plavix, GP2B3A Inhibitors, Beta Blockers, ect. As long as the treatment is given in a timely manner, that's all that matters. JakeEMT: if this was taken in anyway as an attack, I appoligize, that was not the intent. I was looking for reasons for Rx differences, and answer a questions posted to the group.
  22. That isn't what I said... I believe I said... "You DO need to assess your patient 1st, and make the decision that the pain is of cardiac origin, then treat... " It appears that I stepped on someones ego. It was a simple disagreement about the steps. Yes you assess, and Yes a 12 lead is part of that assessment. I belive that is what I said. I just personally don't think you should delay ASA admin. by waiting until after the 12 lead. Your ongoing or secondary assessment is also part of your assessment, but you would begin Rx prior to this. I think this is some ALS Rules mentality. ASA is a simple BLS RX for chest pain of suspected Cardiac Etioligy. I personally don't care if you get the 12 lead then give the ASA. If you work in a system were you are in a medic interept vehicle, hopefully your BLS ambulance crew would have given the ASA before you get there. Are they wrong because a 12 lead wasn't aquired prior? Really, do it anyway you would like, the science, (eg, pharmacodynamics, pharmacokinetics of ASA, and the pathophysiology of Cardiac Chest pain) does not in anyway require a 12 lead before RX with ASA. That's all I was saying. I simply asked him "why" he would wait, he answered that question. chbare: I guess the answer to your question: "Perhaps he considers assessment a priority? We do not start cramming interventions down our patients throats without a proper assessment. Is a 12 lead not part of a proper assessment? is YES a 12 lead is absolutly part of a propor assessment...and early recognition and intervention is also. And if that point of the question was to try and point out that you can not do a propor assesment without a 12 lead, again I agree. I simply don't agree with waiting for a 12 lead to begin treatment. That's it.....
  23. I agree that 1 min is going to change things, but... A neg, 12 lead means nothing, and they are neg, >50% of the time. Of course you would not give ASA to GERD however, as I stated, it's use is in Chest Pain of Suspected Cardiac Origin. If you rule out chest pain being of Cardiac Origin based on a neg 12 lead, then you (general, not picking a fight with you personally) need re-training on the pathophysiology and treatment of chest pain. Yes, a minute is ok, my point was you do not base your treatment on the 12 lead (when negative) so what's the point of delaying the only treatment proven to decrease M&M for it??? I live by the rule treat your patient not the monitor. You DO need to assess your patient 1st, and make the decision that the pain is of cardiac origin, then treat... I just don't agree that the 12 lead showed LEAD your treatment, but be an adjunctive tool in your assessment and treatment...
  24. Aspirin: inhibits platelet formation Coumadin: inhibits clotting factors II (prothrombin), VII, IX, X Plavix: blocks ADP receptors, ADP causes platelets to bind Heparin: binds to antithrombin III This is all correct, sort of. Asprin does not actually inhibit platlet formation, it inhibits platelet aggregation by blocking the formation of thromboxane A2 (Ta2) {Ta2 causes to aggregate by basically making them sticky, and it causes arteries to contrict}. ASA is the only treatment, save angioplasty/CABG that has been proven to reduce mortaility is association with AMI. NTG hasn't/GP2B3A inhibitors (integrillin) hasn't, MSO4 hasn't. Only ASA. Now as far as giving ASA pre/post IV. Give it as soon as your protocols allow as soon as you recognize Chest Pain thought to be associated with AMI. It's onset is 5-30mins, so the sooner you get it in, the better off the patient will be. I can not think of any reason to withhold ASA for IV placement, as it is a BLS skill set in many states, and a true BLS Standard of care in most areas. ?To give when on "other blood thinners" YES, unless local protocols say otherwise, give it, and give it early. JakeEMT: you stated that you would not give it prior to the 12 lead; I have to ask, why? With it's delayed onset of action, and the pharmacokinetics of the drug, it will have no impact on your tracing (O2 may flatten out ST Elevation, sometimes) but ASA will not have any impact on the tracing. And remember that >50% of all MI patients rule in by enzyme markers in the hospital and have no ititial ECG changes. I would say, give the ASA, the 12 lead won't change... My 2 Cents.....
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