iStater

Ruff meister Please accept my apologies for not replying to you. I thought from our previous messages that you were finished with the conversation. I have not replied to you because I am not always on these forums. I don't care to get any notifications about this site. I work fulltime and I do have a life outside of work and forums. At work I do not get much computer time except for charting. I am not Ventmedic nor do I know who that is. Thank you for telling me who Triemal and ER doc are. I only got on this site because of an EMT who posted identifiable information about a patient who was an IFT. I hope I prevented him from losing his job. Hospitals do take their patient confidentiality seriously.

island EMT There was nothing when I signed on with the name iStater that it was already in use by someone else. I will take your comments as an attempt to discredit my concern about profanity being directed at a 14 YEAR OLD on a public website which has EMT in the title. If you do not want children on this website you should have the entrance like a liquor website. It may not prevent them from entering but it might deter a few. I will do my part to get our IT department to filter this site out of the Children's hospital internet which should help for your mission of little children should be seen and not heard from. Your comment should help make this easier to accomplish.

Why do you feel the need to vent against this 14 YEAR OLD triemal04? Why can you not type without cursing or insults? I could have offered advice to the OP but that would have probably just made you more angry and wanting to carry on your venting at this 14 YEAR OLD and probably at me too. If you swear at kids to shock them....

By the post make by island EMT, not much is off limits here when it comes to addressing kids. I am not just sticking up for this 14 YEAR OLD KID. I am sticking up for kids. You adults with professional certs and licenses should know better. The first post gave his age. You should have adjusted your posts accordingly. I will restate, YOU are the adults responding to a 14 YEAR OLD kid regardless of the topic. EMS is not in very good shape if a 14 YEAR OLD kid who is wanting to be an EMT but needs some guidance is reflecting negatively on you.

The only ego at stake here seems to be your ERdoc. As I said, give it a rest. You have beat up this 14 YEAR OLD enough. Even if you use the abbreviations, a 14 YEAR OLD will know what they mean when it comes to cursing. I am still not so concerned about a 14 year old who wants to be an EMT and hasn't learned all the legalities of it as I am about someone who should know better than to go after a 14 year old on an EMT forum in the manner you have. If someone hears a 14 YEAR OLD make a statement about being an EMT, those are in his area might know he left off the "junior" or explorer part. I doubt if it warrants a cursing. But, if others were to over hear the conversation posted here directed at a 14 YEAR OLD, I would hope any responsible adult would intervene regardless of your patch.

We are hearing how he understands this as a 14 YEAR OLD. He may know only what the card issued to him but no one has told him about all the ins and outs of state and the NREMT or if his state uses the NREMT. A quick search on this forum also shows people who say they are EMTs an Paramedics but are also confused about the new levels and the NREMT or their state certs. He will learn more about the legalities of a "title" when he gets into the EMT class. Until then, you could have explained it to him without attacking him and the profanity. I have stated that the NVFC has a program and participants are "registered" with them after completing the training. New York is one of the leaders in these programs. But, unless you participate in youth programs you probably won't know much about them but that does not mean they don't exist for ages 14 - 17. My main issue here is with the bullying and abusiveness by the profanity which is directed at someone who states he is 14 YEARS OLD. Coming from those who claim to be Paramedics and EMTs, this is inexcusable. If you thought the OP was bogus, you could have chosen not to respond and report it the moderator of this forum. You did not have to engage in an attack with profanity with someone claiming to be 14 YEARS OLD. Regardless of the subject, don't use profanity at a 14 YEAR OLD and definitely not when you are an EMT or Paramedic in public or on a public forum. ERdoc, give it a rest. You have shown us you know more than a 14 YEAR OLD.

A plethora? Small towns in the US don't always have a college, a big library or lots of EMTs. Even EMTs or students in the big cities complain about their resources or seek out help on the forums. Why does anybody ask questions on the internet? Maybe he just wants to branch out a little or network to see if all EMS is just like the volunteer and maybe partially paid organization he is familiar with. I doubt if the paid EMTs have that many calls to their name in a very rural situation. Several small communities start junior EMT and FF programs to increase an interest in EMS since there are not that many other ways to gain an insight but still resources are limited. He may also have limited access to the paid EMTs if they conflict with his school hours. He even stated he was asking this to gain information from more experienced people. There are also many websites just dedicated to EMT study questions but some are good and some are really bad. Young people today also like to use the internet for meet and greet. Maybe if the discussion had be directed more towards what part of studying for the EMT he was interested in before starting in with profanity to prove a 14 y/o wrong, it might have been interesting to hear from a young person who takes an interest in EMS including the mechanical aspects of truck maintenance which is somehow overlooked by a few as the headlines have pointed out in recent months. I doubt if many 14 y/os have this much of a grasp of what EMTs or FFs do. This 14 y/o was telling you as he understood it and as he was told. A lot of paid EMTs don't understand their certifications or state and national agencies. So much for all of the teach the public stuff. How many members of the public, after seeing this discussion, would be eager to ask questions about EMS if you tell a 14 y/o to STFU?

This young person asked for advice for studying for the EMT exam. Why not clarify a few things first about his certifications before cussing at a kid out on a public forum? To the OP: Are you part of a junior volunteer program which is part of the National Volunteer Fire Council - NVFC? The word National can be misleading as Federal but this is a National program available to all states with similar recognized standards. This is a program which is available to communities/departments for ages 14 - 17. Each state has a part in regulating what participants can do per labor and child safety laws. The participants are "nationally registered" meaning they are listed as junior FFs and junior EMTs. The card they carry will use that terminology also. There are also explorer programs by departments which may fall under a different category and standards outside of the NVFC. Their training is similar to the regular EMT program just like the Boy Scouts' program although the Boy Scouts' program usually exceeds EMT training by including wilderness first aid as an option among other survival skills. The uniforms are often the same as the regular FFs and EMTs which means you have to look close to see "junior volunteer". They are allowed to participate in public events, at first aid stands and to ride in the ambulances. Some of the things the junior members are allowed to do can be a little disturbing to have a young teenager doing but are often defended by the Medical Director, the Doctor. An example would be a 15 y/o junior EMT removing the bra from a woman or young girl and placing the ECGs electrodes. When the ED staff questioned this the Medical Director told us the juniors had to get used to nudity if they wanted to be an EMT. The US Department of Labor and each state have child labor laws. The OP did state he worked with a mechanic and not as the chief mechanic. A lot of kids get jobs at 14 or 15 especially in rural areas. As long as no child labor laws are violated, I say good for them.

Decreasing the tidal volume prior to transport could lead to problems. The ABG was 7.40. Transport ventilators do not compensate for compressible volume loss. If yoy have a PIP of 36 cmH2O this could mean a loss up to 72 ml. If the patient decompensates mid transport from a significant decrease in tidal volume plus the compressible volume loss you will have a difficult time regaining previous staus and may cause damage with the reopening pressures. Making several changes on the meds just because you can before knowing how and why this hospital got to those settings can lead to a crash. Sometimes attitudes of the transport team towards the sending facility gets their patient into the most problems. Since it is still not clear about the type of flu, practice strict precautions o prevent airborne contamination. Transport ventilators are difficult to isolate. Make sure you have adequate filter at the ventilator outlet and one to prevent or minimalize exhalation spray. Even with that masks for the caregivers would be advised.

Of course there is concern which is why I asked about it earlier as did someone else. You also asked about the CT angio earlier. The OP just told us about the leak stopping when pressed. The post I wrote about ARDSnet ant ventilator settings, that was in response to the OP's question. That also is a very brief explanation.

Calculating tidal volume is like calculating medication. You don't just pick random numbers or say "ARDSnet" unless your data backs it up. Some hospitals and transport teams may use a different protocol depending on their research or review of the literaure. Transport teams may need to use a protocol which adusts for the compressible volume loss of their ventilator circuit. This can be anywhere from 0.5 ml/cmH20 - 2 ml/cmH20. Studies have shown a 10% variation from set tidal volumes. Check the compressible volume factor on the circuit you are using. You also do not just start with 6ml/kg. The recommendation is to start with 8 ml/kg, get your data including ABG waveforms, PIP and pPlat. For this woman here extra 30 kg of obesity must be considered since that may affect numbers. Your waveform is analyzed by the mode, wave delivery pattern selected and variations of that wave for delivery by adjusting flow and/or rise and termination. You have an ICU vent in front of you. There is alot of data to be obtained which can help you set up a transport vent. The changes in tidal volume from 8 ml/kg to 6 ml/kg are done slowly over 4 hours. You must take into concideration of the MV and may need to adjust the rate up to 35 bpm. This is where waveforms are vital and also where some transport vents fail. Their flow delivery is inadequte to meet demand especially at high FiO2. But, before making any changes to meds or the vent, you do need to ask questions. The nurses flow sheet is a wealth of info for you and the nurse to review. Experienced transport RNs can scan a flowsheet in 30 seconds and formulate a plan for meds and ventilator. The questions include What happens when they triec to wean the sedation? How they got to the vent setting is important even if it is just to chase numbers. Did they try to run a high PEEP ARDSnet protocol and had to abandon it? Did the sending hospital increase everything in anticipation of this transport. This hospital may have had a previous experience from another transport.

Nurses usually measure ventilator patients for a more accurate height. If not, it only takes a few seconds to do. You still need to know what the PIP is and the pPlat if it is possible to obtain with the air leak. Graphics are again impotant. This will guide you in dropping the tidal volume. But, make to many vent changes and taking off sedatives and/or paralytics is a recipe for something happening which you won't be able to correct. Going into a low tidal volume vent setting is no fun for the patient and their body will respond to this setting in not a good way.

I would rather know what the nurse's flowsheet says. The RT sheet seems to be questionable for the info given about this patient. The settings looks random like they were only chasing numbers. I suppose there is no point in asking about the graphics either but waveforms are a very impotant part to consider and very useful to monitor if your transport vent has this ability. What is the fluid amount in via IV? Output? Can the fuids be reduced? Acid base can make or break oxyegenation. I take it the base and HCO3 levels are normal on the abg since the pH is 7.40. Knowing acid base will guide you wiggle room when transferring to a transport vent. Obviously no ARDS protocol is being done for vent management. However that does not mean you shouldn't prepare for acid base issues which might arise from a transport vent. In a patient like this we would not strive for a 7.40/40/3 digit PaO2 if it means crashing the BP and blowing another pneumo. This is why the ARDS protocol expands extensively in acid base. I would still be very careful with weaning too much on the sedation or even the paralytic for transport.

There is nothing simple about this patient. Wean too much too fast and you won't get back the lost ground especially with a transport ventilar. Patient dies. A paralytic would be the easiest to re-establish but deep sedation should be maintained if BP permits. You don't want to risk dys or asynchrony. Still awaiting blood gas verification to see if something creative can be done with the PEEP and other settings. But the transport vent may have vaiations for PEEP and tidal volume if single limb. How tall is this woman?

Still awaiting verification of labs. I would be very cautious about blood products now given the positive fluid balance. If labs were drawn after lots of fliud the number could be misleadingly low. Given the status of the kidneys and positive fluid balance, the paralytic should be the first to go if BP and ventilator holds steady. You also do not want this patient to wake up and buck the vent at any time during transport. You might ask the sending physician if this is his or her thoughts in preparation for transport. No need to repeat past mistakes. Also, considering the fluid balance, is the lactate trending down and was the high lactate attributed to the cardiac arrest or sepsis? Is the sending facility thinking dialysis to happen upon arrival at receiving facility? ECMO? Still dependent on clarification of ABG.

Was the PIP of 36 (cmH2O) a typo? Or is this a high kPa? A PIP of 36 cmH20 is great for a PEEP of 22 cmH2O. Did you mean Plateau Pressure (cmH2O) considering the vent setting (PEEP and tidal volume) CXR and fluid status? Or is there a very large air leak. The ABG is also questionable with a PaCO2 of 60 mmhg, BD of -11 mEq/L HCO3 of 9 mEq/L with a 7.40 pH. For HgB, for clarification, that is 80 grams/liter or 8.0 grams/deciliter? Have the results for the type of flu come back?

It was stated earlier that the nurse and doctor were not in public but in a room aside. Attendings can blast a resident for very little things and often in rounds where there are a dozen people from several disciplines to hear all about it. Some residents deserve it and some don't. It is not all butt slapping and hugs like on TV shows. "Birthin' babies is something women have been doing since the beginning of whatever theory you believe. But when a baby gets into trouble at birth we like to know there are highly skilled personnel at the bedside. If your intent was to belittle the importance of neonatal resuscitation and the staff who works in these specialized areas you have clearly succeeded. At no time did I question the ability of an ER physician to perform at their level of expertise in emergency medicine. When it comes to neonatal resuscitation I hope an ER physician does not put ego in front of calling the NICU team. As far as this topic goes, all we have is hearsay from a student nurse. At some point new nurses will learn doctors also make mistakes. It is also this petty gossip on the unit which gets stories spread out of proportion. Then when someone offers a differing opinion which goes against whatever the intent of original gossip, they get criticized. Student nurses need to distance themselves from gossip or discuss it with their mentors to see a broader picture with more angles. This discussion has made a villain out of an RN without getting the full picture. For all we know the RN and resident were also in a sexual relationship and personal issues were present. It might just be "birthin babies" but if they are in a hospital giving birth they deserve to have quality care.

The accelerated BSN programs are pricey. Some may start at $45,000. By accelerated, it means they will cover the same material in a lot less time. You will not be able to hold a job during that time so you will need financial support from someone or take out more loans. You will need all prerequisites done prior to applying and they must be current or done within the past 5 - 7 years. If you go out of state or even here in WA you will need your transcripts reviewed at some college like where you got the Paramedic program. They are usually hooked into a national database which will tell you if and how many credits transfer. The only entry level online program which is accredited is Excelsior. But, WA will only allow experienced LPNs to test. You can get licensure be endorsement after being licensed in another state and documented proof of hours. A few states will not take the Excelsior at all. The BSN is the best route. You will see BSN preferred in almost every ad. There is no nursing shortage and there are many unemployed or underemployed RNs. Some of the bridge programs were designed in the 1980s to encourage other health professionals, including Paramedics, to cross over when there was a huge shortage. Now you will find huge waiting lists before and after nursing school.

I don't see anything unprofessional by talking to a physician in private. We still do not know the specifics of the situation. Don't just assume the RN is always wrong especially if it is in an area where you lack certain expertise. This was in L&D and not the ER where things might be more lax. Residents are not always right even if they have MD after their name. It is the responsibility of everyone to see the patient gets quality and the correct care even of some egos get bruised. This nurse might even have done the resident a favor by correcting him rather than getting his attending involved. That is the nice thing about the teaching hospital I work at. The attendings want to hear about all the screwups the residents make but that can also go badly for the resident.

No guidelines are not the law. But, even now we do not know the full story. Was this RN part of the L&D team or the NICU delivery team? The NICU delivery team usually works directly per the neonatologist which trumps a resident. They are highly educated and trained which is why they are called to the bedside of some deliveries even if a cardiac arrest or mec is not present. Did the resident not get the full details of the delivery? Did he not know how to operate the O2 equipment properly and rigged by tearing up something else? That makes me grind my teeth and I will not hesitate to correct. Was this a CHD? Mec? Was any drying or stimulation done before the O2? Did the resident ignore the guidelines or just feel he did not want to follow them with a good reason or with an attitude of being in control regardless of how the situation dictated? Was this resident already known to be a shithead in the unit? The chewing out also was not done at the bedside. That does demonstrate professionalism by the RN. By MSN, would this be for NNP? Sometimes the RNs do know more about the surroundings they are in than a new resident. The resident who fails to use their knowledge and experience in that environment will have a very difficult time and make many mistakes which could easily be avoided. The NICU and L&D situations have RNs and others in that area who are much more aware of their environment and will be more observant of what is happening or doing whatever to the baby. I doubt if many residents have held very many 23 week infants prior to their first rotation in the NICU. Hopefully the RN took the matter to the attending for the delivery or the Neonatologist if it was serious enough.

I think the key work here was "oxygen". With the new guidelines that takes it up a level where as before oxygen was a given for many "normal" births first thing. There is not always an attending watching the resident. Some attendings who have trained the nursing staff as well will trust them to show them the correct way. You will see this if a resident accompanies the transport team as an observer or is placed in L&D to "observe" a mec delivery. There are usually many residents for one attending and it is difficult for them to be everywhere. There probably was an attending with the mother but that is usually another service. If the resident is to learn, he first must know the basics. That includes the guidelines of the unit or department and how to communicate. I don't know what actually happened here but if the RN was to allow the resident to do something which could have harmed the infant, it would also have been the RNs butt hung out for the attendings and the BON. If an ER doctor orders the wrong dose or is about to give the wrong med or do the wrong procedure, would you expect the RNs to allow this to happen? In this case "chewing out" might also be a strong term for what might actually have been "why are you doing that" and expecting an answer so more prep can be done or to just know "why". If the resident can not explain "why" then maybe a further chewing out should be done by the attending. I will tell you that in the NICU and L&D we have high standards and there are expectations for all professionals.

Then the resident may have ignored the basic principle of communication which is stressed in any infant resuscitation. It is imperative for the resuscitation team to work as a team especially if they want to be the doctor and at the head of the bed of a resuscitation. L&D and the NICUs are not as forgiving as the EDs. A totally different world where a miscommunication can more easily produce a very bad event.

Wish everyone had EPIC. The medical world would be so much easier. It is nice to know what happens on each office and clinic visit as well as the hospital. Kaiser does do that well when they made this system popular. CERNER and Paragon are also out there with mixed reviews. The medication reconciliation can still be done and a medical record list obtained. The med list is one thing which should be made available without a hassle by a MR policy. A good EMR system also helps track all those boo-boos even if treated at different physicians or clinics if they are on the same system.

I would say the jelly played a role in getting the glucose up quickly. The milk also if low fat or skim. The pb might be good for stabilizing. But, for digested purposes and a quick response, pb and chocolate would not be the best. ENSURE, which is commonly found in hospitals or long term facilities, is also not the best to give.

We advise against peanut butter because it is mostly protein and fat with very little carbs as frontline. It also can present some aspiration risks in some age groups or varying mentation. Chocolate is also not advised because it contains too much fat to effective raise the glucose levels. The same for whole milk and cheese. Protein and fat can hinder the glucose levels rising as they are needed to.Later after something which will effectively raise the glucose level would be okay. Glucose gel, skim milk, juice and even regular soda are front line. Most hospitals and physician offices are now required to update their electronic medical record system for uniform reporting and record keeping. Hospital and physicians should be able to generate a list of all the medications and pertinent medical history. Make copies but also remember to discard the old ones as the med list gets updated. You can also take a photo of these pages and store on your smart phone and a cloud for easy access. Paramedics should also not take time on the scene to copy the entire list (or bag of med bottles) and medical history while deferring transport. Bring them in. We found meds which have been copied by Paramedics to have not been used in 10 years or they weren't even the patient's meds. They just happened to be on that counter or cabinet at that time with the others. Please be careful and when you can, advise the patient to get a copy of their current med list when they are discharged from the ED or hospital. Many computers now talk to each other and this is possible.