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.

Good luck, I hope your tour is safe and bings you home without incident.

Take care over there,

chbare.

ERDoc, it is rather complex. As I remember INH inhibits several hepatic pathways that alter Vitamin B6 metabolism. B6 is metabolized to it's active form by the substances that are inhibited by INH. This leads to a reduction of a substance called pyridoxal-5-phosphate (P5P). P5P is needed for the production of an enzyme called l-glutamic acid decarboxylase. This enzyme is critical in the conversion of glutamic acid to GABA. GABA is decreased and glutamic acid increases. (glutamic acid is an excitatory neurotransmitter) The brain is over stimulated and prone to seizures. I will have to do a little research to go into more depth on the pathways and specific pathology. I do know of reports of people having seizures that take therapeutic levels, I ASSumed she may have overdosed. Thank you for calling me on that.

Take care,

chbare.

Edit: PS, sorry I have not been around to post sooner. I just got back from an out of town trip.

Take care,

chbare.

Docomd600, I am an old fan of SOAP notes and POMR. I use a slightly modified version, SOAPE.

S-Subjective

0-Objective

A-Assessment

P-Plan

E-Eval/Re-eval

Take care,

chbare.

Strippel, all feelings about theories of trauma management aside, this looks like a case of people not communicating. You service and medical director need to deal with the surgeon directly and get everybody on the same page.

Take care,

chbare.

Dustdevil, you are correct. You could call NMS a chemical induced type of heat stroke. Securing the ABC's and rapid cooling is paramount married with rapid transport. In addition, I wanted to give the ALS providers something to work with, so the scenario I gave was a very severe case of NMS. In addition, I wanted everybody to see some of the complications of this syndrome and how it would have been managed after the patient left the care of the EMS crew. This case was nearly identical to a case that I saw in nursing school, of course the hospital had an ICU and the patient was simply transported to the unit, RSI'd and managed on site. You bring out a good point that good BLS could have sustained this patient. Not all cases of NMS are this severe and I would bet a few cases fall through the cracks as simply being called viral syndrome or seizure disorder. So, good assessment skills and an understanding of pathophysiology of your patient, their condition, and medications could actually help make the correct diagnosis. I wanted to wait a while before placing this post, so a few more people would see the scenario. And yes, if you service does not have a thermometer that can check rectal temps, they need to do a system check.

Take care,

chbare.

New Mexico has a nearly identical setup. :roll:

Take care,

chbare.

1EMT-P, I believe the Army now requires NREMT-Basic for all 91W series MOS'. I am employed as a nurse for both a hospital and ground ambulance transfer service, neither of which require EMT credentials. I am registered as an I/85 and plan to re register. Plus, I have a special set of scrubs that I wear when I am scheduled to work with Paramedics. The scrubs have the NREMT-I patch on them and, and the going joke is that the Nurse is now only about 1000 hours away from being a Paramedic, and taking their jobs away from them.

Take care,

chbare.

We need human studies on Poly-Heme. We need to find out one way or the other just how effective Poly-Heme and other oxygen carrying fluids are.

Take care,

chbare.

JakeEMT, no problem.

Take care,

chbare.