RNEMT26

Who wants to sit here and have a pissing match with people about the same stuff over and over again. Im currently pursing my masters in a specialty aspect of medicine and the forum I am on is amazing...why ? Because we push each other to try different things and we can ask for and get amazing advice from the 11,000 or so members instead of it getting derailed by someone with a piss poor attitude. Everyone that is in this particular specialty loves their job and we are always trying to find new and better ways to do it. Do we disagree on certain things, well yea. Not everyone is going to like what you say, but there is an exceptional level of professionalism on that forum that isn't anywhere to be seen here.

Unfortunately, here it's always the same stuff and the same people with the same crappy attitudes, who wants to deal with that ? Not me. It's sad to see this site become a shadow of its former self.

. I guess MLSS came into the Town Supervisor's office for a secret meeting and brought some nice Irish Whiskey, some imported cigars and a few free games of golf at a local country club. There was no recent relationship between the Town of Chester and MLSS, so in order for MLSS to even be considered, they must have come forward with something sweet for the Town Supervisor. MLSS works behind the scenes and thru backdoor deals. Back when Chester VAC wanted to dump MLSS in favor of Regional as the ALS provider for Chester, MLSS admins came and met with the Town Supervisor for a secret meeting.

- For real?? Those are some prettily brazen statements to make, guy. There's a lot of people who work for them on here and I'm pretty sure they'd disagree with those statements. MLSS is a business and it's run like any other business, to make money. Your comments are just ignorant.

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This question is directed to RNEMT26 or any other ED nurses we may have on the board. As someone who is on the other side of the stretcher do you feel calling every patient in as opposed to only the critical notifications that require a room and ED team ready and waiting on arrival make a difference. Does granny coming in with the runs x 3 days or Bill who has had the flu for a few days recieve any different treatment by being called ahead as opposed to just being wheeled in silently.

- Honestly, in my opinion we like to have a heads up of whats coming in and if we need to move people in order to open up a bed it's a lot easier to do it before you get there. Calling in a report doesn't necessarily change the treatment, but it can allow us to be a little bit more prepared for what is coming in, regardless of whether the patient is critical or not.

As an ER and ICU nurse, don't bore me with information that does not matter. Most of the time we do not have time to sit by the radio and listen to a 10 min long report when you could have easily condensed the info into literally 2 minutes and a couple of sentences.

I had a patient who coded 2 separate times, the first tim he became bradycardic and then asystolic and was brought back. And then he coded again and had CPR preformed for almost an hour and a half, they did also use a automated compression machine. Long story short, he was crashed down to VA ECMO, required 13 drips, and continuous dialysis for a week or so and he walked out of the hospital a couple weeks later with a fully intact mental status.

Anyone under the age of 18 is not emotionally equipped to handle some EMS situations.

- Sorry but I have to respectfully disagree with you..... I started as a CFR at 16, and I saw a lot of really awful stuff. And it taught me a lot about myself, the fragility of life and a host of other things.

Was it difficult to bear witness to that stuff?...Of course, some of what we see and experience are things most people wont ever see or encounter in their life. I agree with the fact that some people may not be able to handle it and they either need to mature or be taught about to deal with that stuff and not compartmentalize it like so many people like to do with the thought that it's the right way to deal with emotionally difficult situations. I think that younger members maybe more at risk for ineffective coping mechanisms because a lot of them (like myself at one point) do not want to seem that they 'can't handle it' or are being 'weak'. We as senior members need to help them out and talk to them about it and let them know that it's ok cry/be upset/ or sad about things. And that these feelings are normal and expressing them is far better than suppressing them.

People died, young kid/adults died. To sit here and have a discussion about, ventilation and whether or not what those good samaritans was right/wrong, good or bad goes beyond words. Those people did what ANY of us in emergency services would do, HELP. Isn't that why we are all in this anyway ? To help people ? You can't fault someone for just trying to help to lives. To even attempt to go into a burning building with out any gear takes more balls than I could ever have, and those people should be given a pat on the back just for trying to get in there to save those people. This discussion makes me sick and im just as guilty to engage in this, nonsense. RIP to the young lives that were lost in this tragic incident.

Dutchess 911 to ________ respond for a person with a self inflicted gunshot wound, to the rear, at xxx"

- to the rear??? and by rear he meant his asssss bahaha

This isn't a solely a 'college' problem, this is a societal problem. Screwed up people with access to firearms, and no one ever says anything because it's always the famous line of 'well we didn't think he would really do it" Unfortunately, we as a soceity will never be able to eliminate the possibility of some deranged person grabbing a gun walking over to the local mall and killing everyone in sight. Unfortunately, it's something we just have to live with, take away all the guns then maybe you have some possiblity of decreasing how often things like this occur. But if the gang bangers can get them illegaly then obviously anyone else can, so is there a good way to fix all of this? Don't think so. It's something that can happen anywhere at anytime, and if it does while you're around...duck.

I agree with most of the above post with the exception of this:

Not to hijack the thread and start an "us vs them" match, but I would caution strongly against statements like this. I actively practice in both arenas (15 years urban 911, 11 years critical care RN in various specialties), and consider myself a proficient provider in both roles. I would never claim to be smarter than anyone - it's just asking for a "humbling" experience. Just my two cents.

Back to your regularly scheduled discussion...

Ive been in a couple humbling experiences actually but ya know there are some pretty stupid medics and emts and also some stuid nurses with whom i wouldnt let touch my dead dog

No pocket guide can ever replace common sense and a gut feeling. The way you get good at it is by doing it as much as you can and asking questions when there is something going on with a patient that you dont quite understand. Some medics love to teach, other do not. Me personally I like to teach new EMTs because I enjoy what I do, outside of EMS and FF I also work as a Critical Care RN, so I'm a bit smarter and have a considerably deeper knowledge base than the average EMT/Medic. The best thing to do is learn not only what to do, but whyyyyy you're doing it. Too many people come into EMS and simply just do things because the protocol says to do it. I'm a big believer in that no protocol is a substitute for common sense. Always trust your gut.

I would like to first say that i agree that you need to provide good clinical care for patients. I think if you look at the history of the part 800 equipment list in o2 therapy over the last 15 years the push to go to 100% high flow O2 has to do with lack of training / understanding of what is going on with the patient. ( to much I see this I do this).

I have only been involved in EMS since the early 90's so i will not make comment on training earlier then that. In the 90's we had simple (rebreathing) mask, venturi masks (colored plugs able to deliver different concentrations of O2) non-rebreathing face masks, and nasal cannulas. and the great demand valve mask.

O2 administration for non-rebreathing face mask used to be litter flow should be adjusted to keep bag inflated during patient respirations. too often then not people did not pay close enough attention to the patients respiratory status and the bag would not be filled thus not providing any O2 to the patient. Protocol change made to make it 10LPM same above problem occurred protocol change made to 12 and so her we are with cookie cutter mindset to protect the most amount of patients that are out there with minimal harm to the small percentage of patients that would be adverse.

nothing will change till we will only accept good clinical judgment and retrain or purge those who can not provide it

I totally agree and that's what I was saying before and some people got their undies in a bundle about it. Unfortunately some EMS workers fail to understand the 'why' part of what we are doing, or trying to accomplish. And people just do things and their excuse is "because it's protocol' right, however in every protocol ive ever worked with in the hospital or anywhere, here is usually a little caveat that says it's not written in stone and that the protocol is no substitute for good clinical judgement. Unfortunately some people dont get that.

Medscape has an excellent article on the same topic that I believe references the same work. [Jan, 2011]

Chronic Obstructive Pulmonary Disease and Emphysema in Emergency Medicine

http://emedicine.medscape.com/article/807143-overview#a0104

Among other things, it serves to remind us that COPD is a basket of comorbidities. Do knowlegable people out there have experience with CPAP/BiPAP with respect to bronchitis vs emphysema?

At present, HVREMAC allows for CPAP in COPD, but WREMAC does not. Obviously different physicians have different opinions as to the value of CPAP for COPDers. Is it perhaps more effective with one type of COPD?

I also think a take home message is that before intubating the conscious patient, or letting that patient deteriorate that CPAP is worth a try. Worst case, we take it off, correct?

I have not seen may people need CPAP/BiPAP for bronchitis. Of course there are exceptions to everything and people have gone into resp. fail and required intubation, strangely enough those patients usually have COPD but it's usually comlicated by Pneumonia and sepsis.

IMO, CPAP is ok. COPDers have BOTH Chronic Bronchitis AND Emphysema. Now there are other forms of COPD- Bronchiectasis and CF, but for simplicity sake and reality sake I think most of what we see and treat in the field is the regular COPD and by that I mean Chronic Bronch. and emphysema. Im sure maybe someone working in NYC or another major metro area may have seen the other diseases I mentioned but out in the suburbs I highly doubt it. Either way you slice it, CPAP gonna increase oxygenation, but you gotta make sure they can get the air out too. BiPAP attempts to do that, with 2 levels of pressure, 1 to help the air in, and a lower one to 'help' the air out. PTs with Emphysema 'air trap' which leads to increases in CO2 and eventually leads to Resp. acidosis and a host of other problems, which is why they tend to have a 'barrel chest' if you've ever noticed.

People with Bronchiectasis produce large amounts of sputum daily, almost 250cc. And the same goes with people with Cystic fibrosis, hence why these are termed 'obstructive pulmonary diseases' the major problem with them is the 'obstruction' on the bronchi and smaller air passages with sputum/phlegm etc. So if CPAP is all you got then you use what you have and make due. It will help with oxygenation, but what they need the most is to clear their airways. Which is why some of the CF PTs wear chest percussion vests to help with that.

please if someone can clarify for me...kinda thought CPAP could help someone with COPD.

It depends on the situation. Im not sure of how much you know about BiPAP/CPAP but it has obviously 2 settings a IPAP (inspiratory) and an EPAP (expiratory). Usually we set it @ 10/5 with most patients and tweak it as necessary. The EPAP is lower and is supposed to help with exhalation. CPAP it just what it says Continuous Positive Airway PRessure, so a COPDers have a problem with air trapping, so it's getting their out not, not necessairly getting it in.

Now if it's somone who is in resp. failure then chances are this person is gonna get intubated at some point, which in all honesty is sometimes the best thing for them. We usually rest their lungs for 2-3 days and then wake them up and pull that tube. If the situation is more in the CHF realm then you can us BiPAP or CPAP with diuretics and nitrates (sometimes) to help clear their lungs up.

The hypoxic drive theory has been show to be a myth. See:

http://paramedicblog.wordpress.com/2009/11/19/hypoxic-drive-theory-myth-the-why-and-how/

http://respiratorytherapycave.blogspot.com/2008/06/hypoxic-drive-theory-debunked.html

Also, it looks as though the article is trying not to discredit the use of O2 in the field, but rather the use of high flow oxygen, as titrated oxygen (i.e. through a N/C) can be just as, if not more effective, in raising and maintaining oxygen saturation levels in patients with difficulty breathing.

The only part of that which is debunked is that giving a COPD PT high flow O2 will cause them to go into Acute Resp. Failure. However, the hypoxic drive is known to exist.

My comments are not in relation to the reasearch. I caution against advising people to disregard the protocol. It's one thing if you are going to do it your self but there may be some impressionable people on here that can apply your advice in a wrong matter. Plus in any event their treatment was quetioned they are much better off having followed the protocol over advice they recieved on a bulletin board. If you feel strongly make your thoughts know to those who make the protocols.

I wouldn't say I'm advising people to go against protocol, do what you gotta do. And secondly, if someone was to apply what they read here to real life situation then that's just stupid.

While the reasearch seems compelling I would caution against bashing people for following the protocol. I think it is more stupid and dangerous if we get people who decide to disregard the protocols based on the latest article they read.

Listen I could sit here and have a pissing match with you on the issues with giving somoeone 100% O2. And just because it's protocol, doesn't necessarily make it the right thing to do at the time for in a particular situation, but we could sit here and talk hypotheticals all day. And people need to always take what they ready with a gain of salt, just because its proven in research does not necessarily make it the best practice.

What you are referring to is called a Hypoxic drive. Normally we breath because our bodies pick up on the concentration of CO2 in our blood on the arterial side of the system via chemoreceptors located in various, but specific parts of our body. High levels in our PCO2 will cause us to breath faster in order to 'blow off CO2' and low levels in the PCO2 will cause us to breath in deeper and at a slower rate in order to retain CO2 to keep our Ph in between 7.35 - 7.45. The body must maintain this range in order to keep everything working optimally, too high or too low and things can get whacky, esp if it's for a prolonged period of time.

(On a side note, COPDers problems lies in that the are chronically hypoxic, and they are CO2 retainers because their problem isn;t necessarily getting the air in, it's getting the air out, called 'air trapping'. )

A hypoxic drive is when the body has changed over and is now monitoring the PO2 instead of the PCO2. So theoretically if the person reaches 100 % saturation then you've knocked out the stimulus to breath because the body thinks, oh well I'm 100% I guess i dont have to breath. COPDers are as i said, chronically hypoxic, so their drive to breath is because their normal PO2 is low, therefore signals to the body to breath. This hypoxic drive accounts for a low percentage of the population something like 9-10%. Recent studies have no found that COPDers are not soley dependent on this hypoxic drive. So while this may decrease morbidity/mortality, you won't necessarily 'knock out' a COPD PTs resp drive by giving them high flow O2.

One more point, I agree with this research and the titration of O2. Too many people I have found will put a patient on 100% NRBFM because "It's the protocol" Well thats stupid, and dangerous. Not everyone needs 100 O2. If someone is 98-100% if you really feel the need to put them on O2 then put them on 2-4 L N/C. And if it's not even a cardiac or resp related call, and their SpO2 is 100%, then can someone please tell me why it's necessary to place them on 100% NRBFM ? Really? Sorry I'm just an ICU/CCU RN, I clearly don't know what I'm doing..lol

Theres not much to do, pull the hose out, and the body will reabsorb the air within a couple of days. As long as the guy doesnt have a tension pneumo, or s/s of cardiac tamponade then you'd be fine. People get subcutaneous emphysema all the time and it goes away after a coulple days...

I live and work in a town here unfortunately there are STILL people who only walk into the house with a clipboard and nothing else. It really grinds my gears and bothers the crap out of me to say the least. Not to mention alot of my fellow EMTs on the rescue squad are "ALS dependent". It's sad honestly. I've witness (and intervened) when a fellow EMT sat there with a PT who was in extremis (resp distress/impending failure) and we heard they were coming from a good distance, after 5 min of everyone standing around with there thumbs up their A**ES, i said I think it's time to get moving and so they did, but of course with moans and groans under their breath. It really seems to me that (and i believe other people have stated the same) that people don't understand the 'why' part of why and how we do things. I've been told by an EMT when I said why are you doing that, their answer was "Because it's protocol" I said just because it's protocol does not mean it is always the right thing to do at that time. It seems to me that they will give any idiot who can pass the class an EMT card (i know you have to pass the test and have some sort of knowledge retention) but really it's a disgrace.

No city of newburgh FD would not respond to medical calls..PD would barely even show up unless it was ur typical psych, stabbings/shootings etc.

Thank you thank you and yes you are right (should have put an etc on the end of that) but i wasnt going to name all 6, most people wont know what the hell they are....lol

As far as field treatment goes, medics dont have invasive hemodynamic monitoring there is not much you can do. If the kid is herniating then it's time for surgery, however by the time s/s of herniation are detected it's already too late. Also depends on the type of herniation (central. uncal, subflacine), if it's a central then good luck with that one. I haven't seen many people come back from those, they usually end up being veggies, trached/peg'ed and off to the nursing home, sounds like fun right? Not the way I'd wanna live.

I honestly don't think that medics should carry mannitol, do you know what the ICP is that ur treating? Sounds dangerous to me. In my ICU we aren't treating with mannitol until they are 15 or so and no coming down with drugs (propofol/Fentanyl/ativan) We usually snow these kids down as far as we can get them, they are usually max at 50mcg/kg/min of propofol and whatever we can give them. We don't often use hyperventilation off the bat, but we attempt to keep the PCO2 near 30.

So how do you help this kid. 1. Pray and 2. Get him to a level 1 trauma ASAP because he needs an emergency craniotomy.

Hypercarbia (high CO2) = Vasoconstriction, less blood flow

Hypocarbia (low CO2) = Vasodilation, more blood flow

I do know nurses who have done the excelsior program and have gotten fine jobs. However, in all honestly, it's difficult for new graduate nurses to land jobs esp, in the hospital without knowing someone. Unfortunately most of them have been stuck doing LTC (long term care) i.e Nursing homes and rehabs. Hospitals are low on cash and some have gone into hiring freezes and are not hiring new grads because it cost a significant amount of money to train them, I mean orientation alone will last at least 3 months or so. And even with that you wont feel comfortable doing things on your own till you have at least a year under your belt.

As for Goose's question on how they the two degrees stack up. That's a good question, I did the traditional classroom bit, but if people have gotten jobs with it then I don't see much of a difference. Alot of it has to do with experiece, whether it be professional (Medic/EMT/PCT), or volunteer.

As far as commitment goes, I mean you can do anything. However nursing school is demanding, the work is hard and studying takes hours. With a 3 months old at home (Congrats btw), I'd say it might be a bit of a challenge, but i guess anything is possible with time management.

From what I've heard (now this is just hearsay) essentially you do all of your testing and stuff online. You do a certain amount of clinicals and within those clinicals you take some sort of practical test and need to score a 100%, altho I am not fully sure what score you need to get inorder to pass, but my gut is that it's 100%. If you do happen to do with online, MAKE SURE WHOMEVER YOU TAKEN THE CREDITS WITH THAT THEY ARE CREDENTIALED, either by the CCNE, there is another agency but i forgot the name of it. Otherwise 1. You wont be able to take your NCLEX 2. You just wasted an assload of money for nothing, so def. buyer beware.

While I am a Nurse I do not have experience with online classes, like I said I did the traditional classroom bit and viola! 6 years later (with transferring and a alot of other BS) I finally earned my degree and now I work in the ICU and have my BSN. Any questions feel free to PM me and I'll try to the best of my ability to answer them. I can ask one of my coworkers who did excelsior how it was ect. Good luck.