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#1 tmuhler

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Posted 25 December 2009 - 03:51 PM

Currently, in my agency we are using the Auto vent 4000 with CPAP. Our protocol to use CPAP requires our patients to have a Spo2 of less than 90% on a Non-rebreather. My personal opinion is that Spo2 is a very unreliable numeric value that has many variables that can affect the value. Example: CO poisoning will show a 100% reading with a good waveform. The main reason I am asking is that I had a patient recently in left sided heart failure where I was unable to obtain access as well as another medic. We auscultated rales in the lower lobes bilaterally. The patient was tachypneic with a respiratory rate of 34 and shallow. The patient was hypertensive with a blood pressure 178/72, SPo2 94%, and EtCo2 38. Without IV access, we treated with nitroglycerin and Albuterol. I wanted to do CPAP, however, our protocols only permit us to use CPAP with the patient with a Spo2 under 90% on a Non-rebreather. Will do well in patients with heart failure by increasing the pressure in the alveoli and pushing the fluid back into the circulation out of the alveolar-capillary membrane. I am aware that CPAP will decrease cardiac output by increasing pressure the chest. Being that the pressure in the chest is normally negative. In my opinion, this patient was well suited for CPAP, and without IV access to give lasix or morphine. Overall, I am looking to try to give my Operating Medical Director some recommendations in changing our protocol. Mind you that we are both suburban and rural with transports up to an hour to get to the hospital. Any help is greatly appreciated!
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#2 Gila

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Posted 25 December 2009 - 05:38 PM

I am not familiar wit the Autovent 4000; however, your protocols are strange to say the least. Who developed your protocol and can you talk with your medical director and medical committee about their thoughts regarding the protocols? As stated pulse oximetry as an endpoint for "traditional" therapy is strange to say the least. While you have concerns about the reliability of pulse oximetry, I think the most important consideration is pulse oximetry in a vacuum is not a reliable indicator for the presence of respiratory distress or respiratory failure. In fact, many indications, considerations, and contraindications exist for CPAP use.

It sounds like comprehensive education regarding the physiology, indications, contraindications, and use of CPAP is in order, assuming your medical director is open to going down such a route. I rather prefer guidelines where you have to meet inclusion criteria and lack contraindications. Then, you can look at transitioning to non-invasive ventilation according to actual patient presentation and steer clear of CPAP based on defined contraindications rather than a pulse oximetry value on a NRM. Strange, because I would not even expect a NRM to really help a patient in respiratory distress as a NRM is generally considered a low flow device that may not even meet the patients inspiratory flow demand in the first place. Again, this really comes down to good education prior to instituting new changes.
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#3 LearRRT-CCEMTP

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Posted 26 December 2009 - 02:47 AM

First, I must ask if you are a ground or air CCT program utilizing the Autovent 4000 for your primary ventilator? It is NOT a ventilator but rather a resuscitator and has no place as a primary vent in CCT. It's fine for ventilating codes in 911 when you don't have an extra set of hands. But it does not have the flow capabilities nor an adjustable I:E Ratio that is required for sick patients. I also have a real issue with your protocols. Your current protocols are treating the monitor not the patient. Pulse oximetery is one of the worse inventions in medicine simply because it has caused people to stop being able to look at a patient with their senses and determine hypoxemia! I have known medics that walk in on a very cyanotic patient and they will break their neck to place the patient on a pulse oximeter before O2. Please write your new protocols based on patient's complaints and symptoms and NOT numbers! Also keep in mind that CPAP is ONLY indicated for Pulmonary Edema and not obstructive or reactive airway disease. The Autovent 4000 does not offer Bi-Level NiPPV which is what truly is needed for these disorders.
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#4 insen...

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Posted 26 December 2009 - 12:36 PM

Not that this addresses the protocol or device issue, but if you want a more reliable indicator than an SpO2, you could use an I-Stat or EPOCAL device and measure a venous or capillary blood gas.
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#5 Gila

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Posted 26 December 2009 - 03:18 PM

I do not think the OP is working for a CCT service.
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Christopher Bare
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#6 FloridaMedic

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Posted 26 December 2009 - 04:20 PM

Currently, in my agency we are using the Auto vent 4000 with CPAP. Our protocol to use CPAP requires our patients to have a Spo2 of less than 90% on a Non-rebreather. My personal opinion is that Spo2 is a very unreliable numeric value that has many variables that can affect the value. Example: CO poisoning will show a 100% reading with a good waveform.


If you CPAP is using a venturi to entrain air, thus not giving you an FiO2 of 1.0, it may not be the best for CO poisoning. If you are running at an FiO2 of 1.0, your O2 tank may not last very long.

Work of breathing and the patient's clinical condition should be a guide. However, as already mentioned, CPAP is just one level and can actually increase work of breathing leading the patient to failure quickly.


The main reason I am asking is that I had a patient recently in left sided heart failure where I was unable to obtain access as well as another medic. We auscultated rales in the lower lobes bilaterally. The patient was tachypneic with a respiratory rate of 34 and shallow. The patient was hypertensive with a blood pressure 178/72, SPo2 94%, and EtCo2 38. Without IV access, we treated with nitroglycerin and Albuterol. I wanted to do CPAP, however, our protocols only permit us to use CPAP with the patient with a Spo2 under 90% on a Non-rebreather. Will do well in patients with heart failure by increasing the pressure in the alveoli and pushing the fluid back into the circulation out of the alveolar-capillary membrane. I am aware that CPAP will decrease cardiac output by increasing pressure the chest. Being that the pressure in the chest is normally negative. In my opinion, this patient was well suited for CPAP, and without IV access to give lasix or morphine. Overall, I am looking to try to give my Operating Medical Director some recommendations in changing our protocol. Mind you that we are both suburban and rural with transports up to an hour to get to the hospital. Any help is greatly appreciated!


You are confusing basic respiration priniciples and what CPAP actually does for venous return and upstream venous resistance. And... CPAP does not push fluid. Review the prinicples of basic cardiopulmonary physiology and hemodynamics.

CPAP should not take the place of IV access. If a patient requires CPAP, they probably have many other issues going on besides just a low SpO2. Is the patient in failure due to a pump that is no longer working and has an EF of 6%? Has changes in the SVR for a variety of reasons?

Concerning IV access again, let me repeat: CPAP is just one level and can actually increase work of breathing leading the patient to failure quickly. Thus, you may need to be ready to intubate at a moment's notice and one should have an IV established for intubation or the capability of administering meds by some route other than an ETT.
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#7 Speed

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Posted 26 December 2009 - 06:23 PM

Anybody using StO2 in the field?
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Posted 26 December 2009 - 08:57 PM

Currently, in my agency we are using the Auto vent 4000 with CPAP. Our protocol to use CPAP requires our patients to have a Spo2 of less than 90% on a Non-rebreather. My personal opinion is that Spo2 is a very unreliable numeric value that has many variables that can affect the value. Example: CO poisoning will show a 100% reading with a good waveform. The main reason I am asking is that I had a patient recently in left sided heart failure where I was unable to obtain access as well as another medic. We auscultated rales in the lower lobes bilaterally. The patient was tachypneic with a respiratory rate of 34 and shallow. The patient was hypertensive with a blood pressure 178/72, SPo2 94%, and EtCo2 38. Without IV access, we treated with nitroglycerin and Albuterol. I wanted to do CPAP, however, our protocols only permit us to use CPAP with the patient with a Spo2 under 90% on a Non-rebreather. Will do well in patients with heart failure by increasing the pressure in the alveoli and pushing the fluid back into the circulation out of the alveolar-capillary membrane. I am aware that CPAP will decrease cardiac output by increasing pressure the chest. Being that the pressure in the chest is normally negative. In my opinion, this patient was well suited for CPAP, and without IV access to give lasix or morphine. Overall, I am looking to try to give my Operating Medical Director some recommendations in changing our protocol. Mind you that we are both suburban and rural with transports up to an hour to get to the hospital. Any help is greatly appreciated!


Travis, as you said yourself Spo2 is a poor indicator of ventilatory status. So the biggest suggestion I would offer your medical director is to re-word the indications for CPAP in your protocols. Work of breathing should be the primary indicator.

Another thing is IV access - do you carry an IO device for when you are unable to get an IV? If not, that would be another suggestion.

Has your agency looked into getting a machine that does BIPAP? It is a mode of NPPV that offers the benefits of CPAP but with different pressures for inspiration and expiration. Comfort is improved and work of breathing is lessened. People tolerate it better. I don't know offhand if there are any prehospital BIPAP devices available - I imagine there must be - but the LTV series vents from Pulmonetics can do it.

One important caveat for NPPV is mental status - the patient must be awake and alert and able to protect their airway. I have actually seen docs order NPPV for unresponsive patients who then suffered massive aspiration.

Also, do you guys use an IO device for when you can't get an IV? CHF'ers are a category of patients that can crash very quickly. If you treat someone with CPAP and/or nitro and they don't get better or start to get worse, you need an avenue to provide other meds.

Good luck.
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#9 FloridaMedic

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Posted 26 December 2009 - 11:24 PM

Anybody using StO2 in the field?


That's a good adjunct if you don't have SvO2 monitoring capabilities which we generally do on transport. However, in the OP's situation it would be good for him to know the SpO2 or SaO2 rather than knowing where he stands if the StO2 is 75%. If he is not familiar with tissue oxygenation monitoring that might get a little confusing especially if he has no IV access established to do pressors or fluids.
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#10 Speed

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Posted 27 December 2009 - 05:08 AM

That's a good adjunct if you don't have SvO2 monitoring capabilities which we generally do on transport. However, in the OP's situation it would be good for him to know the SpO2 or SaO2 rather than knowing where he stands if the StO2 is 75%. If he is not familiar with tissue oxygenation monitoring that might get a little confusing especially if he has no IV access established to do pressors or fluids.


Guess so. It's hard to put into words your unconscious assessment of WOB and efficacy of treatments. I mean, after a while you can pretty much guess someone's CO2 pretty close, guess an the I-stat does make you feel better about it? It just takes experience to know that "magic moment" when the trial of bi-level is over or when to skip it all together. I do like the toys though, working all together they do validate the sinking feeling in your gut sometimes.
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Posted 27 December 2009 - 05:45 AM

Guess so. It's hard to put into words your unconscious assessment of WOB and efficacy of treatments. I mean, after a while you can pretty much guess someone's CO2 pretty close, guess an the I-stat does make you feel better about it? It just takes experience to know that "magic moment" when the trial of bi-level is over or when to skip it all together. I do like the toys though, working all together they do validate the sinking feeling in your gut sometimes.


You brought up StO2 and quoted my response to refer to guessing CO2? StO2 is a whole different process that requires the ability to do something about it if you are going to monitor it which includes having an indepth understanding of SvO2 and tissue oxygenation.

It is not just about skills and toys. It is not a guessing game but one that involves some knowledge about pathophysiology and what exactly the technology you are using does to make the results happens or not. If you use StO2 or SvO2, you should not be guessing and you should be held accountable for your actions with the numbers obtained as you should with any therapy you initiate. Both BiPAP and CPAP are more than just toys that if you have the "skill" to fasten the mask and turn a couple of knobs just to see "oh wow look at them breathe or not". One also has to have some knowledge about the disease processes that could be going on and anticipate the patient's reaction. Thus, the need for an IV if plan B is also anticipated. One also should know their technology as two different CPAP machines will have different flows and resistances as well as the variations if they are internally driven or just an external valve that is a flow retard.
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#12 FloridaMedic

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Posted 27 December 2009 - 05:56 AM

Has your agency looked into getting a machine that does BIPAP? It is a mode of NPPV that offers the benefits of CPAP but with different pressures for inspiration and expiration. Comfort is improved and work of breathing is lessened. People tolerate it better. I don't know offhand if there are any prehospital BIPAP devices available - I imagine there must be - but the LTV series vents from Pulmonetics can do it.


The LIV for non-CCT? That would be an expensive endeavor especially if they have several trucks. Besides the initial cost they would need more training/education. That could get costly if there are 100 - 2000 Paramedics. For 911 calls, the LTV would not be put to its best use just ventilating the near dead or used as an expensive CPAP generator especially if their transport times are relatively short. The Autovent is cheap and its only uses would be ventilating the near dead (someone not requiring sedation sedation) and as a CPAP generator.
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#13 ST RN/PM

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Posted 27 December 2009 - 05:16 PM

CPAP is an appropriate tool for the prehospital environment for "short hops" to the nearest ED when used by competent ALS professionals that use clinical judgement. CPAP is to be used in those patients that are able to generate their own TV and rate.... and if WOB is increased, competent ALS providers (like speed and tmuhler) know to take the mask off and intubate! Florida, Speed is talking about toys and sinking feelings......but not a guessing game. He is talking of that inner voice that competent prehospital providers listen to, the voice that we all had to listen to before there was ever ETC02, portable ventilators, ST02, Sp02.Sa02 Sjo2.......before there were neato tools like CPAP, IO.... there was clinical judgement. And to then have technology that will not only validate your spidey sense, but demonstrate in your documentation clinical proof that your treatment was appropriate. I wish that I could read your posts without feeling that there is a smug sense of superiority, but I cannot. You are clearly a well-studied and sell practiced provider. Read your posts carefully, because in this thread, you come across as a condescending schoolmarm. If you mean to, then have at it, but if you dont.......
CPAP doesn't push fluid so much as it recruits alveoli.....but a simple, dirty understanding of it that isn't totally wrong is that it displaces fluid from the alveolar/capillary membrane, allowing oxygentation in areas that had been previously obstructed by fluid. Tmuhler is also looking to start CPAP as PART of the treatment for suspected Pulmonary edema when he and his partner were unable to establish access. I am sure that he understands that there are often other comorbidities and pathophys. goin on. We are talking about a 10-20 minute stretch......rapid interventions. Also, Stop talking to Speed as though he's an idiot. It's getting old!!!!!! Read Oldschool and LearRRT..... these posts offer constructive advice for tmuhler without a condescending note. This is the way IMHO that posts should read.....offering education without humiliation. You should really try it sometime!
Merry Christmas to all.....Florida, I'm having a crappy holiday, and I may be venting a bit unfairly towards you, but I have valid points...........
Steve
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#14 Speed

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Posted 27 December 2009 - 06:29 PM

You brought up StO2 and quoted my response to refer to guessing CO2? StO2 is a whole different process that requires the ability to do something about it if you are going to monitor it which includes having an indepth understanding of SvO2 and tissue oxygenation.

It is not just about skills and toys. It is not a guessing game but one that involves some knowledge about pathophysiology and what exactly the technology you are using does to make the results happens or not. If you use StO2 or SvO2, you should not be guessing and you should be held accountable for your actions with the numbers obtained as you should with any therapy you initiate. Both BiPAP and CPAP are more than just toys that if you have the "skill" to fasten the mask and turn a couple of knobs just to see "oh wow look at them breathe or not". One also has to have some knowledge about the disease processes that could be going on and anticipate the patient's reaction. Thus, the need for an IV if plan B is also anticipated. One also should know their technology as two different CPAP machines will have different flows and resistances as well as the variations if they are internally driven or just an external valve that is a flow retard.



And I was beginning to think you were a normal person?

You brought up StO2


Because the conversation was discussing tools to determine oxygenation. SvO2 is invasive and indirectly measured near the heart: swnaz in the PA. pO2 is invasive as well and has a lot of variables, and SpO2 is just what it is. I mentioned StO2 to that list because not that it's use is like those for measuring oxygen in blood (and isn't invasive), it is measuring oxygen in tissue and if you know what your doing you can use it in that focus of thought and decision making process too. I use it to gauge perfusion in different types of shock to titrate fluids, or pressors, or dobutamine. I am still learning of course, but it is doing it's job for me and is helping me make better decisions. It has extended my assessment ability. Yes, things happen that surprise me like blood, but that isn't causing harm it's revealing information and giving me a better understand things like viscosity. CPAP and BiPAP are old hat, and if I were having problems with my care (for God's sake) I would be catching hell from every which way but Sunday from all of the RT vultures at the receiving facilities I go to. CO2 is really what I care about just as much as SpO2 or PaO2 you know? And yes sweet heart when you don't have time to screw around and you are forced to start treating aggressively (whether it's non-invasive pressure or tubing them) you're guessing the CO2 along with your natural ability to do an assessment. CO2 is proportional to the end organ oxygenation, or StO2, or SvO2. I have validation that I am competent, and that includes my medical director and feedback from those RT's. I must remind you although I am a paramedic, half of my career has been in the hospital including a few good ICU's.
Why do you like to swoop in and try to attack, I don't understand this? You are trying to look for weakness in those around you constantly, and yes in the medical field you don't have to go too far to find it, but I believe that has lead to you personify yourself with that. It is a negative identity, and is reflective of something somewhere? Anyway, what I would like to get across to you is that you are obviously a good provider, but as a co-worker or team mate do you see any room for improvement? The best people like positive things, and at the top of the list usually comes "good people" which a big part of is attitude. Why not just be a good care provider, or teacher, but how about the whole package; a good person. From a professional stand part it would at least make you more marketable. I'm in no way insinuating that you aren't a strong patient advocate, but I'm not some asshole doc somewhere giving poor care to your patient. I'm just sitting here with a cup of coffee trying to have a good conversation. Now here, won't you have a big cup of shut the fuck up! :wacko:
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Posted 27 December 2009 - 06:48 PM

CPAP is an appropriate tool for the prehospital environment for "short hops" to the nearest ED when used by competent ALS professionals that use clinical judgement. CPAP is to be used in those patients that are able to generate their own TV and rate.... and if WOB is increased, competent ALS providers (like speed and tmuhler) know to take the mask off and intubate! Florida, Speed is talking about toys and sinking feelings......but not a guessing game. He is talking of that inner voice that competent prehospital providers listen to, the voice that we all had to listen to before there was ever ETC02, portable ventilators, ST02, Sp02.Sa02 Sjo2.......before there were neato tools like CPAP, IO.... there was clinical judgement. And to then have technology that will not only validate your spidey sense, but demonstrate in your documentation clinical proof that your treatment was appropriate. I wish that I could read your posts without feeling that there is a smug sense of superiority, but I cannot. You are clearly a well-studied and sell practiced provider. Read your posts carefully, because in this thread, you come across as a condescending schoolmarm. If you mean to, then have at it, but if you dont.......
CPAP doesn't push fluid so much as it recruits alveoli.....but a simple, dirty understanding of it that isn't totally wrong is that it displaces fluid from the alveolar/capillary membrane, allowing oxygentation in areas that had been previously obstructed by fluid. Tmuhler is also looking to start CPAP as PART of the treatment for suspected Pulmonary edema when he and his partner were unable to establish access. I am sure that he understands that there are often other comorbidities and pathophys. goin on. We are talking about a 10-20 minute stretch......rapid interventions. Also, Stop talking to Speed as though he's an idiot. It's getting old!!!!!! Read Oldschool and LearRRT..... these posts offer constructive advice for tmuhler without a condescending note. This is the way IMHO that posts should read.....offering education without humiliation. You should really try it sometime!
Merry Christmas to all.....Florida, I'm having a crappy holiday, and I may be venting a bit unfairly towards you, but I have valid points...........
Steve

So in essence you are saying just keep the bar low for Paramedics so they can continue with protocols that give them recipes by numbers instead of clinical judgement?

And they say I bash Paramedics. I just bash the education standards and those that accept the skills mentality as being the end all to all Paramedic education.

I guess you'll next be stating that lidocaine numbs the heart which stops the irritability as a "simple, dirty understanding of it."

We've got to stop making excuses for the lowest denominators especially if they are doing Flight and CCT. There is no reason some simple hemodynamics can not be taught rather than just saying "pushing water out of the way".

Yeah, let's just keep making excuses for not learning the whys to the equipment and see how far that gets EMS. Look at RSI or even allowing Paramedics to initiate or titrate drips on ALS IFT. Look at how long it has taken EMS to even get CPAP in the field and there are still agencies that are reluctant to allow it. What about 12-Lead ECG? I guess you think machine interpretation is good enough for several of the agencies because it is too much work to teach the Paramedic to interpret. What about the agencies that don't even have 12-lead capability because of the additional "education"? How about ETCO2? Do you really thing every ALS truck in this country has that capability? Ever attend a national seminar with educators and medical directors to learn the reasons why?

Enough with the poor pitiful Paramedic crap where kid gloves have to be used because we don't want to hurt their feelings. Accept some responsibility for your own education and especially when your medical director wants to trust you with some new equipment or protocol. Don't just expect a recipe by the numbers.
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#16 FloridaMedic

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Posted 27 December 2009 - 07:00 PM

And I was beginning to think you were a normal person?



Because the conversation was discussing tools to determine oxygenation. SvO2 is invasive and indirectly measured near the heart: swnaz in the PA. pO2 is invasive as well and has a lot of variables, and SpO2 is just what it is. I mentioned StO2 to that list because not that it's use is like those for measuring oxygen in blood (and isn't invasive), it is measuring oxygen in tissue and if you know what your doing you can use it in that focus of thought and decision making process too. I use it to gauge perfusion in different types of shock to titrate fluids, or pressors, or dobutamine. I am still learning of course, but it is doing it's job for me and is helping me make better decisions. It has extended my assessment ability. Yes, things happen that surprise me like blood, but that isn't causing harm it's revealing information and giving me a better understand things like viscosity. CPAP and BiPAP are old hat, and if I were having problems with my care (for God's sake) I would be catching hell from every which way but Sunday from all of the RT vultures at the receiving facilities I go to. CO2 is really what I care about just as much as SpO2 or PaO2 you know? And yes sweet heart when you don't have time to screw around and you are forced to start treating aggressively (whether it's non-invasive pressure or tubing them) you're guessing the CO2 along with your natural ability to do an assessment. CO2 is proportional to the end organ oxygenation, or StO2, or SvO2. I have validation that I am competent, and that includes my medical director and feedback from those RT's. I must remind you although I am a paramedic, half of my career has been in the hospital including a few good ICU's.
Why do you like to swoop in and try to attack, I don't understand this? You are trying to look for weakness in those around you constantly, and yes in the medical field you don't have to go too far to find it, but I believe that has lead to you personify yourself with that. It is a negative identity, and is reflective of something somewhere? Anyway, what I would like to get across to you is that you are obviously a good provider, but as a co-worker or team mate do you see any room for improvement? The best people like positive things, and at the top of the list usually comes "good people" which a big part of is attitude. Why not just be a good care provider, or teacher, but how about the whole package; a good person. From a professional stand part it would at least make you more marketable. I'm in no way insinuating that you aren't a strong patient advocate, but I'm not some asshole doc somewhere giving poor care to your patient. I'm just sitting here with a cup of coffee trying to have a good conversation. Now here, won't you have a big cup of shut the fuck up! :wacko:

Typical response from you. It really makes it hard not to talk to you like an idiot after some of your previous posts and your profanity.

This is not a classroom. I personally don't care I offend you after the numerous posts you have put up in defense of those who care not to advance EMS or education and the many posts which demonatrate you are usually just grasping at thin nothing when it comes to critical care medicine. You brag about your experience but then it contradicts what you have previously stated in earlier posts. It is a good thing there is an RN who knows what he/she is doing on your transports.

You keep mentioning RT. Are you jealous that some of us can be dually credentialed? Some of us just like to know a little more about medicine than what a 700 hour or even 2 year Paramedic program provides.

If you can't stand the education, there are always factory jobs available but even those are now competitive where they don't just settle for the lowest denominator.
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#17 Speed

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Posted 27 December 2009 - 07:05 PM

It is a good thing there is an RN who knows what he/she is doing on your transports.


No, I'm just that deadly! I work alone.
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Mike Williams CCEMT-P/FP-C

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Posted 27 December 2009 - 07:18 PM

You know, there's a lot of good knowledge here that could be really useful, so can we just skip the personal crap and stick to trying to give useful answers to the guy who asked the question (who at this point is likely wondering why he ever started this)?

More than likely our friend is working at a land emergency response agency, where they ain't gonna carry LTV's (as much as I do really like that vent), and don't need them usually. There are real problems with the protocol he describes, starting with the Robo-medic approach (basing all care on a number from a machine rather than clinical assessment). That's what he's looking for, not a lecture an stuff he is unlikely to ever use, as interesting as that likely is.

Merry Christmas to you all - d'ya suppose we could act like it?

Speed - if ya gotta work alone, I would happily come work with you.
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#19 FloridaMedic

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Posted 27 December 2009 - 07:40 PM

Overall, I am looking to try to give my Operating Medical Director some recommendations in changing our protocol.


Some here are missing the most important part of the equation and that is the Medical Director.

We do not know what the OP's other protocols are like or the reasons they are written as they are by the Medical Director. As well, the MD has the ability to do his/her own research and even has greater access to much more information that will specifically work for the agency. Rarely can protocols just be expected to be copied. Also the lines of communication must be open between the MD and the Paramedics. How many hours of instruction are required for each new device or protocol? How involved is the MD? How many hours overall are required by the MD to education and additional training? What is the average base education/training of the Paramedics? Does the MD feel comfortable in expanding the protocols or does he/she feel specific numbers are required for some reason? It is difficult to say, "This is what X agency is doing and why can we do it also". Again, that didn't work out so well for RSI or even ETI in some areas.

The OP should open the lines of communication with his Medical Director and then use his/her resources. He should also know a little more about what other agencies around him are doing in similar locations and situations. Not knowing your local and state scope of practice is also rather limiting to some just handing out random advice. If you are in California, the advice would be vastly different from Idaho or Florida.
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#20 FloridaMedic

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Posted 27 December 2009 - 07:47 PM

Merry Christmas to you all - d'ya suppose we could act like it?


Wouldn't it be nice if there were not sick patients to take care of during the holidays so no one would ever have to be held responsibile for the patient care they must provide even on Christmas?

Speed - if ya gotta work alone, I would happily come work with you.

Considering the many threads that he has bashed both RNs and RTs, you should be very happy together. However, if you only work ground 911 EMS, he has no room in his heart for "those" Paramedics either.
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