chbare

ERDoc, any Hx. of syncope or hoarseness following the accident? Are there any peripheral pulse deficits noted? Is the patient able to describe the sensation to her left foot? Lower leg motor weakness noted? (foot dorsiflexion, great toe extension, and foot plantarflexion?) DTR's intact? Babinski's reflex? Take care, chbare.

What about splitting the difference? I could accept a base level of knowledge somewhere between B and C for entry into practice. Take care, chbare.

I tend to agree with Ridryder911 and some of the others posts. (itku2er and pmedic623) Some people are quick to blame their stressful work conditions for their poor decisions. Infidelity is not like tripping over your feet while walking, it is not an accident, nor is it something that just occurred in a moment of weakness. It is an intentional and deliberate action in which two willing parties participate. Take care, chbare.

FishHawk, I am not sure about the legalities in your area, however, there are flight crews that work this shift in my area of the woods. When I was employed as an EMT-B I worked 48 hours on shift, and then 24 hours on call, followed by 4 days off. When I started nursing school, I just worked 48 hours on the weekends. Looking back, I think it was pretty rough. The service I worked for did a mix of 911 calls and transfers. (heavy on the transfers) Most of our transfers went to a city 120 miles away. This was about a 6 hour round trip. You get two of these transfers in a day and then some 911 calls and you were toast. I am fond of just working my three to four 12 hour shifts a week and picking up extra hours at my leisure. Just my opinion however. Take care, chbare.

Emttut, I understand your point and I agree that in rural areas there are no paramedic level services. I also want to point out that in no way do I think EMT Basics or BLS providers are "ignorant, bumbling idiots." The problem is a matter of education, you can teach anybody to perform a skill, but we are talking about education and not just training. The EMT B NSC is designed to be about 110 hours long, the course may be longer depending on where you train. Unfortunately, the curriculum does not provide a solid enough foundation in anatomy, physiology, and pathophysiology for people to fully appreciate what they are doing to their patient when they perform advanced procedures. You are correct that in the real world things are not ideal, but that does not mean that people in EMS have to accept this fact. We need to push for higher standards and accept nothing less than the highest standard of care. I understand that there is a lack of paramedics, but if a community wants adequate EMS coverage, they have the resources to make it happen. We all pay taxes (well most of us) and we all know that allot of that money goes to support worthless crap, come on expecting a higher standard of care is not impossible. We may have to accept changes that we do not like, heck even I would, because if paramedic level care was the standard, my job as a transport nurse may come to a sudden end. I am willing to accept that for the trade of having high quality EMS care available to all. Again, I am not basic bashing, heck I am not even paramedic, and Nurasgod complex does even sound cool. And finally, do not forget how important good BLS skills are. There are allot of people coming back from a pretty rough sandbox alive because of good BLS. Take care, chbare.

The problem I see is that people think combitubes are effective as primary airway devices. A properly placed ETT is the golden standard period. Sure the combitube is better than bag mask ventilations. However, the combitube is a BACKUP/RESCUE device that the paramedic can use as an option that may keep him/her from taking out a blade and cutting someones throat. We allow lesser trained people to use the combitube as a primary airway device and we do not give the patient a chance to receive the golden standard of care. Do not fool your self into thinking that you can provide paramedic level care because you know how to cram a combitube down your patients throat. PS I am not a paramedic so do not pull that paragod thing on me. Take care, chbare.

Ghurty, are you on a tactical team or are you in a position that requires you to provide TEMS support? If you are, you need to check with your team commander or chain of command to see what they require for tactical medical training. I do not know of any specific courses in your area. CONTOMS is taught around the country in several locations. You can check with DHS. I believe that CONTOMS is taught through ICE and is run by the office of protective medicine. Allot of tactical medicine involves medical planning and intelligence, do not expect to be taught field surgery if you take a tactical medicine course. Don't expect SWAT 101 from a Tac Med course either. If you are looking for trauma training or looking to enhance your knowledge, you are better off taking college level A&P and getting your butt into a BTLS or PHTLS course. Take care, chbare.

Dustdevil and Medik8, I also agree that rural EMS has very unique challenges. (Long transport times/more autonomy) Working at a rural hospital is very similar. If we have a sick patient we need to stabilize them and prep them for transport. The closest cath lab is over an hour away and the closest level I trauma center is an hour and a half away, so we can't just send the patient to OR or the cath lab if they start going down hill. In addition, family practice docs and internal med docs cover the ER, not to say internists or FP's are bad, but their training and continuing education does not focus on emergency medicine. As a health care worker, you need to really stay up on current treatment recommendations and changes regarding emergency medicine so you can help the docs out. On the other hand, I do not get exposed to hemodynamics and advanced procedures as much as I would in a large hospital. (art lines, Swan_Ganz lines, IABP's, etc) Then, you have the business of transporting these sick patients to definitive care. Luckily our area has a service that specializes in inter facility transports and they work real hard at providing a paramedic crew or paramedic nurse crew. Unfortunately, most of the EMS crews are BLS or ILS crews and I have seen patient care suffer greatly because they did not have access to ALS. Take care, chbare.

Emt-B_wa, look at the third thing Ridryder911 mentioned. Remember that your heart does not instantly speed up on it's own in response to to dehydration, hypovolemia, etc. (does not usually) When you change positions or when your hemodynamic status changes suddenly, baroreceptors in your aortic arch and carotid sinuses detect these changes and alert the central nervous system to these changes, the central nervous system then sends a signal back, either sympathetic stimulation (faster heart rate and vessel constriction) or parasympathetic .(slower heart rate and vaso dilation) Chemoreceptors also play a role in this system, so if you have any pathology that prevents this system from working you may not see the usual signs. Some examples include, cardiovascular disease, diabetes, hypertension, heart transplant, and many other things. This may explain what you saw. Take care, chbare.

The Hook, have you looked at Brady Critical Care Paramedic. It is not a download, but the book does contain some good information on cardiology. I think there is a prior thread regarding this book if you want more opinions regarding the material it contains. It touches on arterial lines, central lines, Swan-Ganz lines, IABP's, and talks about some of the wave forms and hemodynamics. (ie: CVP and PAWP) In addition, ou get some in depth physiology. These may not be things you would commonly deal with, but the physiology of cardiovascular dynamics is fascinating and helpful in understanding what you are doing to a patient when you push meds and administer treatments in the back of your rig and on scene. Hope this helps. Take care, chbare.

Asrnj77, it looks like you are just focusing on self and buddy aid techniques. Do the units have medical standard operating procedures and immediate action drills (SOP's & IAD's) in place. It may be beneficial if you can get everybody on the same page and focus on teaching a few easy to perform IAD's. (ie apply a tourniquet to a profusely bleeding extremity) It is also crucial to develop SOP's (ie every team member carries a Combat Application Tourniquet and a battle dressing in their left pant cargo pocket) Then, you can spend a couple of days training and getting everybody on the same page. A basic SOP and a few well rehearsed IAD's would be a great start. It would also be helpful to make an IAD check list for skill verification and continuing education. Having hard copies of the SOP and IAD's will help with skill retention. Some people hate SOP's, but it give you a constant variable to work from when everything goes bad, and it is nice to know where everybody has their gear placed. Hope this helps. Take care, chbare.

Randyg, I would not think so. Ativan is water insoluble, so you would have a heck of a time reconstituting it. Take care, chbare.

FireMedic_1979, I do not think advice over the net is going to help you out. This is just my opinion, however, it sounds like you are having some serious issues that are causing allot of problems and harming your personal and professional life. You need to get help and talk with someone who can help you through this. It also sounds like you need to get away from your current work situation quickly, who cares what people think if you take a LOA or talk with your employer, it is more important that you get help and prevent a potential disaster. I do not know where you live or the resources in your community, but perhaps start by talking with your doctor or other primary care provider in addition to getting out of your current work situation. Good luck and please take care of your self, chbare.

I was able to use a pediatric combitube at SLAM a couple earlier this month. I am not sure if it is on the market. I would be curious to see any data on it or hear first hand experience if it is being used. Take care, chbare.

Spock, thank you for your input. I think the web site you talked about is, www.narescue.com. I agree that end tidal C02 monitoring is crucial. People may think I am crazy, but I thow an easy cap on the end of ever rescue airway I come across. I also advocate using esophageal intubation detector bulbs on the combitube to help identify what tube will be ventilated through. Lung and epigastric auscultation alond with chest rise and fall and tube condensation are not the most reliable assessment methods. The technology is available, and it is criminal not to use it. Take care, chbare.

Spock & Dustdevil, you are correct, you can join the Army Guard as an ADN. (must be an NLN accredited school) You start as a butter bar, but you cannot advance beyond O3 and are eventually forced to get your BSN. I have heard that some nursing instructors will give medics a hard time and one of my medic friends is getting pretty roughed up in his last semester of school. I am glad that I had a great experience regarding EMS in nursing school. Our instructors actually had paramedics come in and do a presentation on pre hospital trauma care during the trauma portion of school. We also spent a day with a paramedic crew just to get a taste of what they did and our instructors had paramedics come in and do prehospital scenarios on a dummy just to give us an ideah of what paramedics do in the field. That is one of the things that I loved about nursing school, we rotated through multiple areas and I felt that we recieved a well rounded education. Take care, chbare.

Fire_911medic, I agree with Ridryder 911, you will do ok if you have a diverse medical background with allot of in hospital experience. I still think you need to be very careful regarding net based programs. I think your best clinical experiences and instructor feedback that facilitates learning will come from a traditional type of nursing program. Hope this helps. Take care, chbare.

Austim, it all depends. Where I live and work, people like to work for the city fire/EMS services. Many of the city services offer an insurance package, retirement, and other benefits. Take care, chbare.

Fire_911medic, I know what you mean. If it works why mess with it? I remember when I first started working ER we would get allot of EMS patients with combitubes. At the time our towns service was a BLS/ILS service and all codes got a combitube. I remember the first "combitubed" patient I helped take care of as an RN. My nurse preceptor and the ER doc told me that combitubes were crap as EMS rolled the patient into the ER. Then to my shock and horror I saw the nurse grab both pilot balloons take out her scissors and cut the ports off just below the level of the balloons. She then yanked the combitube out and the ER doc intubated the patient. Now if a patient comes into the ER and a working combitube is placed, I guard that thing with my life. The ER doc can intubate around the tube or if we are working with a medic he/she can try to intubate around it. If the combitube was placed related to a failed airway, anesthesia gets a call and the surgical airway supplies come out of hiding. Take care, chbare.

Fire_911medic, it's hard to say. I was an EMT-B when I went to nursing school, so I did not have the benefit of paramedic school uner my belt. I know several paramedics who have turned to the dark side. The medics that went through a traditional RN program said they actually learned allot about health care as a whole, and how to appreciate health care from point of injury/illness through the entire health care spectrum. Of course you get a pretty fair amount of nursing care plans, butt cleaning, and the nursing process, not exactly cool guy stuff. However, nursing home patients have an extensive amount of pathophysiology, so it's all what you put into your education. I have a couple of friends who have done a 1 to 1 1/2 year transition program.(net based) You do allot of self study and get limited clinical time. Be careful about net based programs, as allot of them are not NLN accredited. This may cause problems with obtaining a license in other states or working in the military as an officer. I dont know about doing all of the core prereq courses over again. If you are strong in the subjects you should do ok. You may end up doing allot of research, writing allot of papers, and doing allot of presentations in nursing school, so good english and writing/research skills are a must. Know how to properly refrence materials. (APA and MLA depending on your school) Hope this helps. Take care, chbare.

Fire_911medic, thank you for the info on the King. It looks like a great backup device. I did a thread on it earlier and Spock a CRNA on this site had good things to say about the King as well. Have you had a chance to insert a bougie through the King and then intubate with the bougie? I hear this is something that you can do with the King. Take care, chbare.

Brock8024, I also think the LMA is easy to insert, and this is comming from a nurse, so it must be easy to use. Ridryder 911, I agree with you on the LMA. It is a very fickle device when it comes to staying put. I saw a few case studies on the ILMA, and it seems like it may be a little more stable, and I must say I have been impressed with the results of using it in the static(ish) hospital environment. Initial success with the device was only in the 80% range, (passing the ETT) but with use of the Chandy technique I believe success is in the upper 90 percent. Again, who knows if this can be applied to the prehospital environment. I have had very good experiences with the combitube, and virtually every prehospital combitube that I have seen provided an adequate airway, adequate ventilation, and did not easily dislodge. However, combitubes are a pain to intubate around at best. Nothing replaces the good old properly placed ETT. I have heard that alternative airways are commonly used over seas, (UK & Europe) it would be nice to hear from EMS workers in these countries about their experiences. More prehospital research is needed. If only EMS was more involved as a profession and had Phd programs, I bet we would get allot more pre hospital resaerch done by EMS professionals. ??No spell check, my true idiot colors are showing!! Take care, chbare.

Janmarie3, it could be stress, anxiety, panic attacks, Wolff Parkinson White syndrome, Lown Ganong Levine syndrome, hyperthyroidsm, or any number of medical and psychosocial problems. You need to follow up with your doctor and find out what is going on. Take care, chbare.

AZCEP, you bring up a good point. The combitube does not prevent upper airway (oropharynx) secretions from draining into the trachea if the distal tube is in the esophagus. These devices are supraglottic as well, so pathology below or at the glottis could render these devices useless. (ie; burns, swelling, lower airway obstruction, laryngeospasm) A neat thing occured in my ER last week while I was out. I was told today about a scenario that occured a couple of days ago. A critical patient was seen in the ER and he was prepped for transfer. The flight team arrived and decided to intubate, but could not get the tube in and lost the airway. The ER charge nurse decided to call anesthesia when she noticed the team starting to have problems. An Intubating LMA was placed, and anesthesia was able to place an ETT via the ILMA and rescue the patients airway. I do not know the specific details of this scenario, privacy issues you know. It sounds like the nurse made a good call. No spell check avaliable, I hope my spelling is not too bad. Take care, chbare.

This may be a redundant thread, however, I am curious to see what experiences people have had using the various airway back up devices. I have read threads where people say, "I hate LMA's" or "I have had good experiences with the combi tube." I want to expand and see how people have used these various devices. How did they work, what problems/complications developed, were they used in a unique way,(ie; used an LMA proseal and put a bougie down the gastric tube to facilitate better placement) and how did the pt do after it was all said and done? This question is with the knowledge that an ETT properly placed is the gold standard for airway management. Take care, chbare.