iStater

ROP primarily pertains to "premature" infants and abnormal eye vessels to which prolonged hyperoxgenation can be an issue. For a full resuscitation or a term infant this will not be an immediate issue.

The chewing out of the resident might have been due to not following the current guidelines from NRP which may have been instituted in that L&D. The gestational age will also play a role as to which oxygen pathway to follow as will hx for CHD, fetal monitoring, the delivery and of course presentation. If a resident is to be present for resuscitation in L&D they need to already know the basic protocols. Blue initially does not indicate oxygen immediately. It depends on where they are blue , tone, hr and respiratory effort after stimulation. The pulse ox is also a guide now where as before it was the APGAR score components.

With these new terms I would like to give a word of caution. When some hear the word "early" they will still relate it to premature. This could cause unnecessary anxiety on top of an anxious situation.

This article pertains to term birth rather than preterm. Premature or preterm is considered before 37 weeks.

For preterm we also have labels such as late preterm is 34 weeks to 36 6/7 weeks. This had been called near term but that is like saying almost but not quite.

These were terms those working in L&D and NICU had been using for awhile based from other literature but it takes a published statement from the American College of Obstetricians and Gynecologists to make the terms official for term infants.

The grounds for a law suit on the other hand are questionable.

Lawsuits are not always the idea of the person involved.

They often stem from others who are part of organizations which defend people who they feel have been victimized.

We often have children who have been victimized in some way and often the kids or the parents will just want whatever to go away and be left alone. However, the DA, DSHS/CPS, doctor, RN or some patient advocate group might want to make an issue out of it. The person then gets caught up in a whirlwind of legal issues stirred by others. Ever watch an ADA or CPS go after parents or try to force a child to say somebody they trust did something really, really bad to them? But, it still can come right back to the person who did wrong to begin with. Had this EMT been a professional, the photo would not have been taken and this woman would not be called a cow on EMS forums or causing the media to print what is news.

This person does not deserve a comment like this or any of the other comments about her size from someone who has an EMT license.

The cow in the photo should have a escort chase vehicle with flashing lights.

This lady did not attack EMTs as a profession. Her attorney is going after the one EMT who put your profession in a bad light.

Gamzon's lawyer Robert Goldberg blamed the EMT for “making a mockery out of his job,”

Read more: http://www.nydailynews.com/new-york/nyc-emt-sued-wide-load-tweet-woman-article-1.1460381#ixzz2fT4wtARy

There is no need to go on and on about how everything is her fault including her weight especially when what happened to her has helped get someone off the street who didn't belong as an EMT.

By the time the media got this the investigation was probably well underway. This photo was passed along on other social medias because some one probably thought it was a neat thing.

The was before before any investigation or news headlines. Putting black.e towards the media or this woman is not called for since it does bring to light a serious issue.

I only got involved with this forum a few months ago when an EMT posted too much information about a patient. Both the EMT and the patient were easily identified even without their names. The posts were removed and no further action was needed unless the ambulance service did their own discipline.

_{Also have to wonder if the lady in question will sue the New York Daily News...you know...since they posted the same photo...}

Unfortunately by the time the NY Daily got the photo this had already gone viral early this year in the Social Media networks. It was also lumped into NY's other photos which created headlines. Chances are this lady was contacted by EMS and the fire department during that investigation. Once the lady filed, much of the information had been made public. I also believe there was a statement released about what not to do and this is being used in many training sessions in health care. Most privacy laws by State and institutions are written as "which might give the identity of the person". It does not have to be a name or SS#. If this was your loved one and this hit the media in your area, there is a good chance you will recognize them. Some can recognize a person at a distance just by their standing position. In this case you also have race as an issue. I only read a few of the posts when the photo first hit the media and stopped in disgust. But, regardless of skin color this was not appropriate for a health care worker of any license. If this was a random person with no health care license then there might not be such consequences. But, once you get a license in health care, regardless of its level there is some expectation to the patient and the public that you will conduct yourself in an ethical and professional manner.

If this had been a nurse, the BON would already have been involved. Nursing takes this very serious regardless if that person is still a patient. If this person had been this EMT's patient or within the walls of any medical facility, this is just plain unprofessional. Also, with all the GPS coding on photos by many cameras and cellphones, it is not difficult to determine the location and when it was taken.

https://www.ncsbn.org/NCSBN_SocialMedia.pdf

^{I thought countries like Canada, Australia, UK, and NZ all had higher education for Paramedic. My mistake if that is not correct. I know my state does not require any type of degree or even college to be a Paramedic and the clinical hours are not very much either. I get a lot of my info about other states in EMS from the transport EMTs working with us. Thank you for correcting me about the US Paramedic education level. I just took it to be more of a certificate like my state's Paramedics since most of the firefighters have their Paramedic license. I guess I'll have to give them more credit for their dual role requirements.}

^{In Canada the two year program is a practical nurse. The UK and Australian nurses are also more like the BSN and some with an expanded scope since there are not all the allied health professionals you have in the US. I believe this is true for several other countries as well. RTs are not heard of in any countries except the US and Canada.}

^{Have you not had any problem with reciprocity getting a Paramedic license in other countries you work in? In many countries the nurse is not listed as being a high demand profession to get a work permit or visa. Other countries also prefer RNs to have a BSN or MSN. Even the US military sets it entry for the RN at BSN.}

^{You also have to remember that some degrees we think of as a Bachelors taking 4 years in the US may only take 3 in other countries because of the differences in their elementary and high school systems. Their HS seniors are probably more like our community school grads in some ways. Now there are statistics available to show the education in the US basically sucks for some of our school children whose scores are lower when compared to the equivalent in other countries.}

RN programs requireing CNA, what the hell is this world coming to?? OH the humanity. But I digress.

Anywho, I hope the guy found what he was looking for. If it was simply and strictly a means to an end and he truly needed it like JG Wentworth "I need my class and I need it now" then hoo rah and all the more good on him.

But I don't want our new folks who are just coming into this field to think that the 6 week emt or the 5 month medic mill is the way to go because it simply isn't.

For nursing, the CNA is a reality check. Some will spend over 2 years on a waiting list for a nursing program and then run away screaming once they get in. They had visions of big money and didn't get the message about all the patients and responsibility. That then leaves a vacancy which could have been filled by someone who really was wanting to be a nurse for the patient side of it. The CNA also covers many of the basics which that time can then be used for other education. I have read and heard some nursing students complaining about repetition and lots of boring stuff with very little action. They also spent too much time watching medical soap operas and TV shows.

The EMT might get more excited especially when you give a 19 y/o a uniform, big ambulance, lights, sirens and the ability to speed.

The length of the program is also a good comparison. There are still some in nursing who see no need to get the BSN even though the profession is rapidly reaching the 50% mark for higher degreed and employers are preferring it. Their short cut is the ADN or the private school Associates. Until it is mandatory, no amount of preaching will change the mind of some since the minimum standards are still too low for nursing when compared to other countries. I think EMS is seeing this also. If you can do the same things with 6 months of training and education, some might say more time is not useful.

My response was not directed at the cheap cheap I want it cheap part, I thought his attitude of coming here after he said he had already done all his searching and that he knew it all already but just hadn't found the right stuff attitude.

He struck me as a zero to hero type of person that didn't want to spend the effort in a class that would teach him anything, he just wanted a class that he could get in and out of to get on to his next phase.

While that might be good for his particular career path, I don't really feel comfortable telling someone who is off the street that Hey you know what, there's this quick 6 week emt class that you can take, it will teach you the basics (just barely enough for you to pass the class but NOT A GOSH DANG BIT MORE) and you too can be among the ranks of EMT's. Do you really want an emt like that taking care of your family or you? Not me.

I have always been against having to be an EMT first and then getting your medic as I don't know of really any other profession that requires you to be a basic and then go to school to become a professional. Do you have to be a LPN in order to be a RN? Do you have to be a RN in order to be a MD or DO or DDS? We are the only healthcare profession that requires our people to get their basic license prior to the next advanced level.

Sure the MD needs to get a bachelors degree but don't we scream about getting a bachelors degree or Associates degree based medic here?

I agree with you. But it is sometimes difficult to know exactly what someone is thinking especially if English and writing are not their strong points. Some might want to come across as eager but could also be mistaken for being a slacker if they want something fast. This generation is also a "me right now" one and they want instant gratification. Different cultures (not necessarily foreign in origin) and different generations can influence the interpretation of the written word. We spend hours in school trying to interpret what someone is getting at and the same in our careers as we try to get through all the research.

There are now RN programs which require the CNA since that world has become so competitive.

Is a $2,000.00 class going to be better than a $200.00 dollar class? Almost certainly. Will there be exceptions? Sure. But the books for EMT B and an instructor's time will be worth more than $200 for the time it takes to teach a class, and if they're not, then, no, I wouldn't bet on the quality of the program.

When it comes to a $2000 course I think of the flashy ads on TV for entry level careers. Those schools probably everything but most of the profit goes for advertising and the owners of the schools. I believe community colleges can also offer quality education for a certificate at much less and have more resources. The state community colleges will usually be accredited and transfer of credit will not be a problem if you take additional classes. The teachers may also be required to have at least an Associates degree in something related to that profession while a private vocational school may only require the instructor to hold the same certificate level. For example, the CNA program at the college will have an RN with a minimum of a BSN and at least 2 years experience going over to the CNA program to teach while also teaching some classes in the RN program. The private vocational school will have an RN or LPN overseeing the program but may not be doing the actual teaching. I also know an RN who is also an EMT and teaches at a volunteer squad.

For the length of time, if more than 6 or 8 hours per week is too much for a student to handle, that would mean all the Associates degree programs should take over 8 years to complete. Even high school students have more time each day in a classroom. Some have also taken the EMT course while in high school while taking other courses. I really don't think time should be a barrier especially for a vocational class. Some people try to get entry level job training because of being laid off or they need to support themselves for whatever reason. Some think it is also bad because many do take the course because it is a requirement for the fire department application. I also know many who rush through additional certs or testing just for the sake of having the letters to apply for a CCT or Flight job and don't really have all the experience necessary.

I am puzzled by some believing you have to go to an expensive class in order for it to be good. More expensive does not always mean better. I would not consider hiring a CNA who paid almost $2000 for a 200 hour course anymore or less than I would someone who paid $200 for the same course someplace else. In fact, I would probably give more credit to the CNA who shopped around for one which left money for some college credits later. An RN who went to a state university and paid $40,000 for a BSN has the same career opportunities and earning potential as the one who paid $120,000 at a private college. If one accelerated the process by taking more credits in the first two years or even started while in high school, so much the better if they can handle the load.

EMT is also an entry level course. I remember telling people that they could get involved in EMS by volunteering for the local ambulance and have their EMT training for free. They took the same test as someone who paid $2000 for it in the city. I have also seen the EMT course offered in high school along with their other studies. The total hours were the same.

I don't believe we should discourage people from entry level jobs by making them so expensive they can not afford it or will be too much in debt to advance later. I also believe someone can start college to work towards a degree in something and not be forbidden from doing so. Nursing does not discourage a new CNA from applying to college to work on the prerequisites to the RN program. A new CNA can also apply to the program if they have all the prerequisites. I know most Paramedic programs don't have prerequisites but that does not mean you should limit yourself by not taking college classes. A lot could happen in a year to change your mind.

Accelerated is also relative to the person. I will use the CNA again although much of it is learned in a clinical situation with only about 60 hours in the classroom. If someone can do 40 hours of clinicals per week and get through the class faster than someone doing only 8 hours, I really don't see anything wrong with that. I don't believe you should be restricted to the 3 hour classes twice a week if you can do more. Full time college students go many more hours than that. The average nursing student may put 40 hours per week in the classroom or clinical setting along with that many more expected outside of the classroom. I don't believe the EMT (or CNA) course even comes close to the expectations of nursing or other health professions when it comes to academics or clinicals.

But shouldn't any ER doc worth his salt be able to at least initially be able to interpret a EEG to determine if the EEG is a good EEG or a BAAAAAAAAAAAAD one? I mean flat line EEG or one with spikes that is a viable EEG for a patient.

I would sure hate to get an EEG done in a small town ER and then have the ER doc look at the EEG and have it have no spikes or whatever they have on them and there be no electrical activity - and that doc still send the patient on to the receiving center. That would look REALLY REALLY Bad on that doc wouldn't it?

The departments which manage the EEG technology have very strict standards they must adhere to especially when it comes to interpretations. Their medical director who is responsible for overseeing the skill of the technologists and the interpretations must be a board certified neurologist and certified in multichannel EEGs.

A single channel EEG would also be a waste of resources unless it was solely for the purpose of monitoring a known epileptic. At minimum 8 channels would be utilized. Some want 64 channels and some may run 128 depending on the goal of the testing. Few if any ED physicians are up to that challenge. Even those for sleep medicine are out of the range of their education.

EEG monitoring in the ICU would also be continuous. But, it is difficult to get a perfect EEG tracing with a patient on a hypothermia protocol. Even without obvious shivering, some artifact will be present on the tracing.

For brain death there are other criteria to be met. It would be very rare to interrupt a hypothermia protocol and warm up a patient to do a complete brain death challenge. EEGs are used for prognostic predictions in teaching hospitals but it is more for academic and research purposes rather than sharing with the family immediately especially if the patient is getting the hypothermia protocol. You don't initiate a very expensive treatment which is publicly presented as giving hope and also say it is futile at the same time. Most physicians will wait until the patient has been warmed and medications weaned or sedation vacations initiated before making any withdrawal of support determinations. Most organ procurement programs which take donors with or without brain death may want the patient to be off hypothermia before preceding with their discussions with the family although some are called early.

And don't forget Ebola too

We have had our share of scary diseases or symptoms that are just too close to not be a believer in universal precautions. If you live in an area with a busy international airport, you have to be suspicious sometimes.

Someone mentioned carrying gloves in their pocket. Do not do this. Your clothes rubbing against the gloves along with body heat can make these gloves worthless and you might even be aware of it. Consider it like a defective condom which you discover after the fact. Also, every time you reach to your pocket for a clean set, you risk contaminating your pocket. This seemed to be a learned thing passed on from one person to another as a neat shortcut until a whole ambulance service was carrying gloves in their pockets. Some EMTs did end up with nasty infections to their eyes and skin. A staph infection is also nothing to laugh at.

She has a femoral central line. What you consider a VGB?

The femoral central line was noted previously and the ScvO2 would be more closely to a VBG while an SvO2 would be from the pulmonary artery. Yes, a sample from that line would be ok with the differences in measurements known to the care providers.

Monitor the shivering according to BSAS (Bedside Shivering Assessment Scale) and adjust sedation accordingly. Shivering should be prevented since it will defeat the hypothermia cooling.

Hypothermia shifts the oxyhemoglobin curve to the left and there will probably a decrease in oxygen delivery. Vasoconstriction of peripheral vessels which may also affect a pulse oximeter reading.

If CVP monitoring is accessible, CVP and ScvO2 can be utilized.

Maintain an adequate MAP 80 - 100 mmHg or lower depending on etiology.

Correcting electrolyte values should be considered.

Check H&H values to see if low which is associated with malnutrition. Low Hb would also affect pulse oximeter reading.

I disagree with this. I have seen plenty of kids who were in distress just sit there without circling the drain. Sometimes they just feel so crappy that they don't want to move and feel better cuddling with a parent.

I guess that depends on the degree of distress and how long you want to wait for them to circle the drain. The words kids and distress should just not happen in the same sentence but when it does, I believe we should try to prevent a child from suffering for very long if it is at all possible. I guess that is why some of us do specialize in working with children.

Another thing is to be very careful with the paper cup or even some styrofoam cups. They can contain dust particles which may worsened a reactive airway or asthma situation.

OK, if you don't want to go by spo2, which we only use as a tool itself plus condition of patient, then the child was obviously in respiratory distress. If the child didn't have a history of asthma I think the op would have stated it was a call for trouble breathing. So. With asthma you will hear the tell tale wheezing, low spo2 levels from inability to exhale and the child will be in the tell tale positioning for trouble breathing.

So oxygen would be a correct drug of treatment

No days with what we all know about using too much O2, I think not having a pulse ox and using it as a tool is irresponsible for any local protocol. As I said, it is too be used as a tool only.

Let's not forget his cc never questioned his use of O2, just his choice of how he administered it.

I apologize for replying to this forum because I know it is for EMTs only. I feel I must comment on this since I do have experience with Peds and work for a large Children's hospital.

You do not always have the tell tale wheezing with asthma. Also, not all that wheezes is asthma. Children can even be in CHF from a cardiac condition. There are also numerous other disease presentations which can wheeze. Children with asthma may also have intrinsic "peep" from the air trapping initially which gives the impression the patient has great SpO2. If the SpO2 is declining then the downside is coming.

In this situation, the oxygen mask was appropriate. Blow by anything is not good except as a very last resort. Blow by nebulizers are a waste but it makes the provider feel like they have done something.

Kids deteriorate fast. Don't split hairs or waste time on a pulse ox reading initially on a child with signs of distress which is hard as hell to get on most children. If the child is still enough to get an accurate reading, that child is probably in serious trouble. Good by other clinical signs and get to an ER preferably at a children's hospital.

Unless you can provide definitive treatment for this child and have the appropriate oxygen device to meet his needs including ventilator demand, go with what works now to give him some relief. Even a nonrebreather mask is no match for high flow devices which can meet the demands with a fairly consistent FiO2. You might think a nonrebreather mask is giving 100% but for a patient with a high demand from distress that is not true.