chbare

There is a modest amount of evidence outside of the United States such as the OPALS study in regards to respiratory patients.

Ohh, slippery slope. Is there any literature to support EMS even existing in cases other than early defib, out of hospital cardiac arrest? The trauma literature is pretty dismal.

Agreed, we need to do better job of defining and justifying our existence. The literature is rather scant when it comes to many aspects of out of hospital care.

With all that has been said, is there actually good literature on course length? If we are to mandate 440 hour courses or call out 190 hour courses, do we have the literature and evidence that supports a certain stance?

Fair enough, I am certainly not in any position to argue. Perhaps the OP's concern is more state specific as opposed to national?

Ruff, I can't say for sure, but as with everything else in NY, the requirements to actually run a class may be prohibitive despite those funds being available. An agency has to go through several certifications to be allowed to hold a class and might not have the manpower to do it.

I cannot say anything about NY requirements, so my comments are specific toward national recommendations.

Frankly, 190 hours is not exactly a prohibitive requirement IMHO. I would suggest you spend time looking through the National EMS Education Standards and the national EMS Scope of Practice Model. The requirements are no longer hour based but competency based. 150-190 hours is a suggested range, an expectation value if you will.

Unfortunately, medicine is not nearly as evidence based as we often like to profess. There are many interesting situations. Think about "coma cocktails," tissue plasminogen activator for ischaemic stroke and others that are based on evidence that is perhaps not as robust as we would like.

Fortunately, we can have dialogue and discuss some of these issues. With that, I still believe general guidelines are still generally good and can act as a starting point or a place to run back home to mom when we are completely lost. They also help to put everybody on the same page in critical situations. However, sometimes our care may not be in perfect alignment with guidelines and guidelines can also change.

It's so important to look at the evidence as we are doing here. It's also possible for two very qualified people to come of with different conclusions and that discourse is interesting, relevant and hopefully, productive to discuss.

With the experiences I've had, I would rather provide manual ventilations than go "off label" with something like a ventilator. Individual mileage may vary.

Until something happened and you are crucified for using a machine that was never intended to be used for these patients.

I recently had a discussion with a friend who turned me onto to some new material out of our friends at emcrit (Thanks Ronel!).

The original podcast with Dr. Marik's conclusions can be found here:

http://emcrit.org/po...-fluids-sepsis/

The response to Dr. Marik's lecture can be found here:
http://emcrit.org/po...-severe-sepsis/

I would strongly suggest people go through both the initial lecture and response before replying, but I would love to get every bodies take on this interesting issue.

You need to be very cautious about placing ventilators on a pedestal. Once you start talking about sufficiently complex ventilators, subtle differences can have significant consequences. For example, would you choose the ivent over a LTV 1200 if you had to manage a 7kg patient?

If price is an issue you can obtain a refurbished Oxylog 3000 for approximately the same price as an Autovent 4000.

You would have a difficult time using these ventilators on spontaneously breathing patients, particularly if they are in respiratory failure and require complex support. The Autovents are essentially designed to deliver volume controlled, CMV ventilation. The 4000 allows some basic settings such as inspiratory time, but will not interact significantly with a spontaneously breathing patient. The transports that I did with these devices had me administering liberal doses of midazolam and vecuronium. The situations were sort of desperate and involved working at a small ER with a critical patient and weather that precluded medevac. At that time the only Medevac we had was a MAST helicopter out of Fort Bliss, over 100 miles away or possibly a fixed wing aircraft. We had our own transport bags in the ER and would go with the fire department on these transports. It was an interesting time and I was probably taking on much risk with limited experience as I was a newly minted nurse. Anyway, it was impossible to manage these patients unless they were apneic and essentially unresponsive using the Autovent.

I've transported patients (30-40 min interfacility transports in an ambulance) on the 2000 and 3000 and have a bit of experience with the 4000.Very rudimentary devices that cannot work without a constant supply of compressed gas. Limited options and limited ability to monitor anything useful. May be an okay device for patients who are unresponsive without any underlying respiratory pattern. Not a good option if any degree of complexity is required. However, the cheap price may be appealing.

I do not support giving Narcan to the general public and here is why. Narcan or Naloxone HCL is indicated in the treatment of narcotic overdoses. Narcan can have some serious side effects including vomiting with rapid administration, ventricular dysrthymias and also acute withdrawal. Narcan requires that you have the ability to manage the patients airway and that you have the ability to monitor and treat complications. " Narcan is like a band aid" It does not fix the person or their wounds. Instead of wasting money on Narcan lets instead put funds into education and mental health care.

As already stated, people have to survive in order to benefit from education, rehabilitation and so on. It is also possible that many people will not overcome their addiction; however, I simply cannot accept people dying of an overdose while waiting for EMS to arrive. This is not an "ultimate" solution and such a solution is probably not ever going to occur, but this may save lives nonetheless.

http://emcrit.org/podcasts/intubation-patient-shock/

I think this is a particularly relevant podcast. If the pressure is to believed , you may very well kill this patient during the procedure.

I would be cautious about using Sux in this patient based on the history alone. ECG findings are often not as telling as you may be lead to believe. This patient is also at incredible risk for haemodynamic complications based on the blood pressure, heart rate and the Oxygen saturation. I would be very cautious about proceeding with RSI at this time. Can we see about giving fluids? I understand you have some concern, but intubating with such a terrible pressure is a potential death sentence.

I did a hyperbaric rotation in a multi place while in respiratory school. It was an interesting experience; however, the patients we "dived" were mainly wound related cases.

Are you good on gas laws?

Look at the evidence and cases from states that have such programmes. Try to put bias and presupposition aside and look at how these programmes are working out.

Depending on the pharmacology course, taking chemistry first may be quite helpful. Possibly a survey class that covers a bit of gen chem, O-chem and bio-chem. After this semester I cannot say how important bio-chem knowledge is for upper level pharm, particularly if your class goes ba**s deep into phase I and phase II biotransformation/metabolism reactions.

What content areas are you struggling in? Also, how is your reading capability and do you really understand what the test questions are asking? Do you need to spend time taking many tests? It's probably well beyond our ability to fix on this forum but you will need to do so e research and honest self reflection to figure out what is going on. Best of luck, I don't know your struggles but I'm emphatic as I have had some academic struggling over the past couple of months as well.

I believe that there were or are I/99's in Iowa who are state certified as paramedics?

What does the evidence show? I believe Massachusetts has gathered a large amount of data.

I also think we need to be reasonable about a few things. When people say chemistry, I don't think they mean you need to dive into Hartree-Fock approximation theory to predict energy levels of multi-electron atoms. Nor do I think when people say "advanced" maths that they are referring to stuff like linear algebra and differential equations. I'm not sure of the requirements in Canada, but I doubt the programmes mandate such high level courses. I'd focus on doing well in the required classes. Many places in the United States allow students to take allied health or medical physics and chemistry courses. If applicable in Canada, these courses will probably be fine. Perhaps you will be required to take a sequence if general chemistry or general physics, but I doubt you'll need upper level courses beyond the ones I outlined. Unfortunately, it's easy to misinterpret what people are saying. Good luck.

Man, I remember being sixteen. I didn't want to take math, physics or chemistry. Therefore, I didn't. I ended up having to take a year of "developmental" classes in college before I could be placed in the standard courses. During High School I was more interested in getting lucky with my redheaded girlfriend during lunch. At least you seem to have focus beyond that. Moral of the story, you compromise your college career by not having proper focus and thinking like a little child when you should really listen to us as we know best.

The lesson I learned...totally worth it, no regrets. Wouldn't change a thing in-spite of paying for it with a year of my life. Good luck moving foreword.