# Rsi?



## fcfiremedic (Aug 19, 2008)

just wondering if this is a standard in other parts of the country. Here in kentucky, only *two* ground service throughout the whole state have it written in their protocols. of course we can always call for it, and its pretty much a standard on the flight services, but i was wondering if its more used in other parts of the country.


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## Lisa (Aug 19, 2008)

*Rsi*

My service has a protocol for it and it gets used! Most services around my area also have protocol for it. Very rural area.... sometimes 25 min to the closest hospital and even then it is not a Level 1 Trauma center. Closest trauma center is about a 12-18 min flight. The service I work for probably averages 20 a year and that is guessing on the high side.


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## Epi-do (Aug 19, 2008)

We don't have it, but I am only about 12-15 minutes from 3 Level 1 trauma centers (2 adult, 1 peds).  I do know that counties farther out from Indy do have it in their protocols though.

RSI is a scary thing.  Most medics don't intubate enough as it is, and it shows in study after study.  That is why as a whole, we have such dismal statistics.  If you are going to RSI someone, you had better be darn sure you are going to be able to adequately maintain their airway or they don't stand a chance.  I am not saying that it doesn't have it's place, but looking at it with the perspective of someone working in a urban system, it isn't something that would typically/routinely need done in my area.


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## Ridryder911 (Aug 19, 2008)

Just to add, RSI is great but has to be used with extreme caution and only to those with in-depth education and QI.

R/r911


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## Ridryder911 (Aug 20, 2008)

I too agree if one would just search a little one will find out this as well many topics have been talked about way in-depth. Although, I have to admit at least I find it more interesting than what pair of boots, pants or even what number your NREMT test stopped at (like that really matters, since it has no base value the way the test is graded).

I do wish there were more emphasis on searching before posting. Again, there are much information that maybe given and answered, and the post may not even be needed.  

Although, there is always new research it is really a mute point. It has been out for over nearly three decades and so many act like it is a brand new procedure. What many still fail to recognize is that it is not a bad procedure, nor do most Paramedics perform it poorly. It is the circumstances that is associated with the procedure. 

The problems identified is poor skill retention (along with intubation in the field) due to the number of Paramedics that are able to intubate.  I find this ironic, since there is such a shortage of Paramedics yet.. we have too many to perform skills? ... Yes, confusing unless one is too identify most of those studies were conducted at ... Yep, large FD's. Again, one needs to really look at the number of Paramedic or even ALS providers per rescuers. Is it really necessary for everyone to be a Paramedic or even half  or maybe just two per responding companies. 

What type of Paramedic training or education was conducted as a base level before introducing more advanced airway? Was it an in-depth program or a trade school 10 month program? Was there additional clinical requirements as well as detailed quality assurance program to monitor the development... good and bad? Was there actions taken? Is the Medical Director active in participation of such protocols? 

Those are the points that one need to address even before implementing RSI. Not that it is not needed, or even the medications used, rather the whole process of utilizing and implementing a dangerous procedure. 

R/r 911


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## VentMedic (Aug 20, 2008)

Ridryder911 said:


> What type of Paramedic training or education was conducted as a base level before introducing more advanced airway? Was it an in-depth program or a trade school 10 month program? Was there additional clinical requirements as well as detailed quality assurance program to monitor the development... good and bad? Was there actions taken? Is the Medical Director active in participation of such protocols?
> 
> 
> R/r 911



So let's see if any of the newcomers have something new to offer to your questions.   

While the search function is great, there are some new members to the site that may want to talk about their system also.  They, too, should be given a chance.  And, they may have seen the threads where someone was criticized for reviving a thread from the past. 

There are some EMS systems that are acquiring new Medical Directors with new ideas on education and training.  

Of course, there are also systems that are considering eliminating ETI all together and just using the King Airway.



fcfiremedic said:


> just wondering if this is a standard in other parts of the country. Here in kentucky, only *two* ground service throughout the whole state have it written in their protocols. of course we can always call for it, and its pretty much a standard on the flight services, *but i was wondering if its more used in other parts of the country*.



The original post inquired about who was using RSI.    It didn't ask should or should not.   It would be interesting to see what education, training and oversight are being done if the posters wish to include that.


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## fma08 (Aug 20, 2008)

No RSI here, we have PAI where we are allowed up to 10mg Versed to assist... the benefits/shortcomings of PAI vs. RSI are already in another thread.


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## ffemt8978 (Aug 20, 2008)

Okay,

Now that I've removed 16 posts to get this thread back on topic, I'm only going to say this once and it is directed at all of those that had their posts removed from this thread.

KNOCK OFF THE PERSONAL ATTACKS!

If they continue, both parties will get a short vacation from this forum.


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## EMT-P633 (Aug 21, 2008)

hey, I am frm middle TN, and we use RSI, as do 7 other counties in my region. testing / certification required by my service include, ample monthly inservices, in which we normally include atleast 1 mega-code on the maniquine, aside from our inservice topic. Our RSI check-offs are done bi-anually, (every 6 months). Our medical Director is present and is the one to sign off on our skills / knowledge.

Hope this is what you were lookin for.


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## rmellish (Aug 30, 2008)

One of the services Is the 911 provider for a rural area, and do *not* have a protocol for RSI. Because of this we end up calling for air evacs more frequently than at my other service, primarily due to airway management considerations. Really it comes down to the medical director and the amount of liability they are willing to incur. Most of the neighboring counties have protocols for it.


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## grumpy1 (Sep 8, 2008)

State I live/work in does not have RSI for ground services, RSI is for air services only.  Don't see that changing anytime soon.  Our medical director does not see RSI as a skill that is needed in the field due to the training and proficiency needed to accuratley utilize the skill.


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## VentMedic (Sep 8, 2008)

flyingdad23 said:


> State I live/work in does not have RSI for ground services, RSI is for air services only. Don't see that changing anytime soon. Our medical director does not see RSI as a skill that is needed in the field due to the training and proficiency needed to accuratley utilize the skill.


 
You listed yourself as a Critical Care Paramedic. Are you ground or flight? If ground, do you do CCT with paralytics? Can you start and/or maintain them for ventilation?   What about the flight service?  HEMS and/or interfacility?


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## rmellish (Sep 8, 2008)

flyingdad23 said:


> Our medical director does not see RSI as a skill that is needed in the field due to the training and proficiency needed to accuratley utilize the skill.



Its really too bad that protocols are written for the lowest common denominator instead of a service simply increasing their training and education requirements. 

What's the contraindication for a patent airway?


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## grumpy1 (Sep 8, 2008)

VentMedic said:


> You listed yourself as a Critical Care Paramedic. Are you ground or flight? If ground, do you do CCT with paralytics? Can you start and/or maintain them for ventilation?   What about the flight service?  HEMS and/or interfacility?




Ground - Get the needed drugs (sedatives, paralytics etc) from the sending facility; right now we do interfacility only.

Air - HEMS/interfacility.  Full RSI protocols used, hypocritical yes but each flight service uses an extensive process getting filghts crews signed off on RSI and intubations.  Each RSI is QA/QI'd by the medical director and its all online medical direction.


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## VentMedic (Sep 8, 2008)

flyingdad23 said:


> Ground - Get the needed drugs (sedatives, paralytics etc) from the sending facility; right now we do interfacility only.


 
This is the part I can not understand about some "CCT" teams. They are virtually useless unless the ED or ICU nurses set everything up for them including the pumps and the ventilator. The paramedics can only monitor and not make any changes to the drips. Some probably don't have any idea what they actually have running. Some Paramedics have even been know to ignore or shut off a pump that was beeping "air" because they were not able to do anything else. If meds are hung in the ED on a patient heading for the cath lab in another hospital, many times an RN will have to ride along with the Paramedics. And if the Paramedics have a ventilator, it might be some simplistic piece like an ATV or something that only barely qualifies as a ventilator because it pushes air/O2 into the patient. It is easy to see why many hospitals are now going with RNs as part of their own CCTs.

Excuse the rant, not being critical of you or your service. Just a few observations I've been making over the years.  CCT and CCEMT-P are my pet peeves if one doesn't have the education and skills to back up the letters.


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## marineman (Sep 9, 2008)

The service I'm riding with does RSI. I'm not really sure what their protocols are for it so I'll have to ask next time I'm in. I know the stipulation from their medical director when he added it said every medic on the service had to perform 50 successful intubations each year or he'd yank the protocol. Now there's almost always medics in with the anesthesiologist for major surgeries ready to put the tube in.


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## Flight-LP (Sep 9, 2008)

Well said Vent!

My personal pet peeve is when medical directors focus all of the aspect on just a successful intubation (i.e. dictating X number of tubes) instead of focusing on the kinetics and dynamics of RSI. Especially the indications for when to use it vs. just doing it because you can. I always hear medics saying "I RSI patients all the time". That statement scares me as most have no clue what they are really doing to the human body or why it needs to be done.


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## KEVD18 (Sep 9, 2008)

marineman said:


> The service I'm riding with does RSI. I'm not really sure what their protocols are for it so I'll have to ask next time I'm in. I know the stipulation from their medical director when he added it said every medic on the service had to perform 50 successful intubations each year or he'd yank the protocol. Now there's almost always medics in with the anesthesiologist for major surgeries ready to put the tube in.



wow, 50 tubes. it probably should be up that high, but thats the highest ive ever heard.

in mass the bare minimum is 20 tubes per medic per year


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## marineman (Sep 9, 2008)

Yeah our med director was trained in the Army, became a flight surgeon through them so he is very open and willing to give the guys a long leash but he also keeps an iron fist on the other end of the leash.


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## VentMedic (Sep 9, 2008)

50 intubations in nothing compared to what members (RNs, RRTs) of some specialty transport teams do in addition to their other advanced skills along with a few hundred hours of continuing education/training each year. Once you know that is what is required, you just do it as it becomes part of your routine.

That is why those teams have incredibly good protocols.


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## grumpy1 (Sep 10, 2008)

VentMedic said:


> This is the part I can not understand about some "CCT" teams. They are virtually useless unless the ED or ICU nurses set everything up for them including the pumps and the ventilator. The paramedics can only monitor and not make any changes to the drips. Some probably don't have any idea what they actually have running. Some Paramedics have even been know to ignore or shut off a pump that was beeping "air" because they were not able to do anything else. If meds are hung in the ED on a patient heading for the cath lab in another hospital, many times an RN will have to ride along with the Paramedics. And if the Paramedics have a ventilator, it might be some simplistic piece like an ATV or something that only barely qualifies as a ventilator because it pushes air/O2 into the patient. It is easy to see why many hospitals are now going with RNs as part of their own CCTs.
> 
> Excuse the rant, not being critical of you or your service. Just a few observations I've been making over the years.  CCT and CCEMT-P are my pet peeves if one doesn't have the education and skills to back up the letters.



No offense taken, well not much anyway .

All I can say is non-progressive protocols tie hands.


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## Melbourne MICA (Sep 25, 2008)

*Rsi*

Hi all

My first post so I'll keep it brief.

We RSI in Melbourne (Australia). Traummatic head injured pts (part of a trial 2004-2008 312 Traummatic HI pts now completed), non-traummatic HI pts, pts susceptible to secondary brain injury from hypoxia eg , hangings, drownings, brief cardiac arrest - epileptics and severe hyperthermia (on consult). All these pts have to have GCS<10. We also STI, respiratory failure pts unresponsive to drugs and BLS ventilation strategies.

Most of the MICA guys in Melbourne who have been around for ~= ten years would have quite a few ETT's under their belt from all these categories.
I've been on MICA 12yrs.

RSI's of any kind are NEVER taken lightly by any MICA types. If it goes south your pt winds up arrested or criked - both undersireable outcomes.

We NEVER RSI on the move - really dumb idea - theres just too much to do and to pay attention to. There's also too much that can go wrong.

Our ETT/RSI success rates for the trial averaged about 98-99%.

We also of course ETT arrests - resp or cardiac. Without being flippant or sounding cocky, cardiac arrests are the ones where you get your practice on technique, approach, scene management etc. A supine immobile non-breathing pt with cords (most of the time) on view grade 1 or 2.

Enough for now. My two bobs worth. G'Day all!!!

Melbourne MICA


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## Zippo1969 (Oct 12, 2008)

A couple ground services RSI in central MO, but I'm not too sure about the rest of the state, and as with any invasive procedure, should be monitored closely by medical directors.



VentMedic said:


> ... virtually useless unless the ED or ICU nurses set everything up for them including the pumps and the ventilator. The paramedics can only monitor and not make any changes to the drips. Some probably don't have any idea what they actually have running. Some Paramedics have even been know to ignore or shut off a pump that was beeping "air" because they were not able to do anything else. If meds are hung in the ED on a patient heading for the cath lab in another hospital, many times an RN will have to ride along with the Paramedics. And if the Paramedics have a ventilator, it might be some simplistic piece like an ATV or something that only barely qualifies as a ventilator because it pushes air/O2 into the patient. It is easy to see why many hospitals are now going with RNs as part of their own CCTs...



The medics I work with are able to set up vents, change drips / rates, know what and why they're pushing and actually use the education and skills learned in the CC programs...it's kind of depressing to hear that this is your experience with your (I'm assuming) local CC teams - But I don't think throwing RNs on the truck is the answer here - it seems to me that some more active medical direction is needed to get these teams you're talking about up to speed.  I certainly would not want to ignite the "RN v Medic" fire here, but with the proper motivation / training / protocols / clinical experience and oversight there is just no reason those programs couldn't function better.  I think I would call the CC program medical director and tell 'em to get off their duff and get involved...maybe not those exact words tho...


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## VentMedic (Oct 12, 2008)

Until there becomes some standard to the Paramedic education and until "CCEMT-P" is truly something more consistent than a patch, it is safer for RNs and/or RRTs to accompany some patients. This is a nationwide problem and not just in one area. 

Why do you think RN/RN and RN/RRT teams are used almost exclusively for specialty teams? Paramedics do not have work experience in high acuity critical care patient management. 

For other Flight teams, RNs are usually partnered with Paramedics and are very valuable due to their many years of experience with a variety of drips and technology.

Many Paramedics have stated they can "set up" a ventilator and then pull some type of ATV out of the bag. 

It is the Paramedics who think they can do everything and believe they have seen everything that are more likely to know the least.


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## Zippo1969 (Oct 12, 2008)

For the record, I DO work side-by-side with RNs for a CAMTS certified Helicopter Service, and I am not implying that all paramedics are equally proficient at their jobs - nor are RNs, MDs, short order cooks or dog catchers, for that matter.  

My question is: why aren't the "many" paramedics who you refer to held accountable?  Ditto for the "some" who "probably have no idea what they actually have running"? They (should) have medical direction and oversight, just as RNs do.  If it's 'standards' we're after, we should look no further than the physician who signs his or her name to the protocols and procedures of that service, or perhaps their Clinical Supervisor (providing there is one...)
If anyone - Medic or RN - is out there ingoring or turning off pumps because they don't understand them, that indeed is a problem, and needs to be addressed.  Just as an RN has to learn those tools, so should a medic who works with them...again, I submit that this is a medical oversight problem, not a paramedic one.

I'm not going to be an appologist for paramedics who think they "can do everything and believe they have seen everything", as we all know how dangerous that can be.  However it is not solely paramedics who act this way.  I have seen many the cocky RN get schooled in the field as well.  *Numerous times involving RSI, not so surprisingly*.

I don't mean to be argumentative - but when I hear phrases like "some paramedics", or "many paramedics" I feel the need to defend my profession.***

As for me, I am well aware the more I know, the more I realize I don't know.  And I will have seen everything when my own ECG goes, "beeeeeeeeeeeeeeeeeeeep".

                         *** "All broad sweeping generalizations are wrong"


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## VentMedic (Oct 12, 2008)

Zippo1969 said:


> *** "All broad sweeping generalizations are wrong"


 
The only thing broad in my post is the fact that there is no standard foundation for education in EMS. That is *broad* across the U.S.   You can have the 3 month wonder or the 2 year degreed.   As a medical director it would be very difficult to give very broad privileges to some Paramedics who have only the bare minimum requirements and from educators who would not be educators in any other profession even to teach A&P.   There may be some who have only put 3 months effort into obtaining their Paramedic that may not be willing to put that much more effort into advancing the education later to extend their practice. 

If the Flight job says 3 years of experience in EMS, busy service or not, their experience will be as broad as their educational differences.   The RN will have at least a two year degree and flight jobs are usually very specific about the number of years, where and what specific type of meds and technology the RN is experienced with.   It may be hard to ask the same of many paramedics that are from states or counties (California) with limited scopes.    

The certifications for RNs are also nationally recognized with the standardized requirements.    

There are Paramedics wearing a CCEMT-P patch after an 8 hour inservice in the back room of their ambulance company. This is NOT just my area.  This is on both coasts and inbetween.  

EMS has over 50+ different certs and licenses for the numerous levels recognized besides the "specialty" certs that some states and organizations make up without any national testing or credentialing criteria.    Heck, the NREMT is not even recognized in all 50 states. 

There are "broad" differences between being trained, educated and experienced. 

*It is a paramedic problem if they feel they are "entitled" to certain privileges after just doing the bare minimum to get their patch and continuing to do the bare minimum to keep the patch. *

Flight can have a little more control and medical oversight, but if you notice in my original post I referred to CCTs which can be just about any type of ALS truck. A truck with an EMT-I can also be called ALS in some areas.  There are few stanards for some ground crews and they are much more affected by their state's or county's scope of practice. For some flight crews, there is also a problem with with some companies just hiring warm bodies for Paramedic positions. 

If a flight company hires an RN that cannot manage a med pump, then that company was probably just looking far someone with a license to fill a position and not a professional.


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## Zippo1969 (Oct 13, 2008)

...the phrase "all broad sweeping generalizations are wrong" is itself a broad, sweeping generalization... that's why the smiley face is next to it - didn't mean to offend.

I don't know where anyone's getting a CCEMTP patch in 8 hours, but the programs are very closely monitored by UMBC (the actual CCEMTP, I can't speak for others) I know this because I've coordinated one - huge pain in the $#@.  Alas, there are now bridge programs online for RN that can, and have been finished in 4-6 months - if you have the money.  If ANY CC program - flight or ground - is only hiring warm bodies there's a problem.  No argument there, I guess I'm fortunate to not work for one of those.  

Just so we're comparing apples to apples, and oranges to oranges, know that I do agree with you - to a point - that there needs to be a more comprehensive standard nationwide for Paramedics.  There are way too many out there (yes, I said "many") that gripe about not being treated as professionals, and yet do not consistently behave that way.

BUT - and I'm standing by this regardless of what any 'national standard' may someday say, I firmly believe that if any institution is going to slap a 'critical care transport' sticker on the side of a vehicle, they had better be able to back it up completely, with comprehensive credentials, regular testing, regular ICU rotations, etc..  I know of some companies that merely require a week's training to hop on and go - and again, I am fortunate to not work for a company like that (3+ months of full time clinical rotations are required for us )  These are requisites for any CAMTS service, and relying on a national standard is not enough to guarantee that, just as having alphabet soup behind your name doesn't automatically make you an ICU guru.  I think a national standard would be inneffective in most CC programs; in part because of the differences in medical services (type / level) and in part because of different geographical requirements...an Orlando unit could not be expected to know all the intricacies of an Anchorage unit, etc..

It is, as I'm sure you know, very frustrating to work your backside off in this field only to get looked at as a glorified ambulance driver, and I have the utmost respect for MANY paramedics out there who do just that.  Please don't get the idea I'm beating up on RNs either - I'm actually working on mine - in part for the training, in part because of the previous sentence, and in part for making peanuts $$ as a medic.

Question: Are the CC trucks in your area controlled by a separate director / coordinator, or are they a beefed up version of a regular ALS unit under the same supervision as the other trucks?  Just curious.


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## VentMedic (Oct 13, 2008)

Zippo1969 said:


> ...Question: Are the CC trucks in your area controlled by a separate director / coordinator, or are they a beefed up version of a regular ALS unit under the same supervision as the other trucks? Just curious.


 
Both. 

I am also familiar with two different areas on opposite coasts. 

In Florida, you may find private ambulance services as well as FD ALS attempting interfacility with various degrees of proficiencies. 

In California, you may find 1 RN and two EMT-Bs doing interfacility CCT. The EMT-Bs "set-up" the ventilators "by the numbers" which is not always possible since ICU and transport ventilators are rarely similar. Many times there will be a hospital CCT RN on duty to be another licensed person on the transport. 

The base education should have some standards regardless of the scope of practice for whatever state.

UMBC CCEMT-P is still just an introduction to Critical Care Medicine. Very few Paramedics with ground transport will have the opportunity to do a rotation of any length in an ICU. Right now some can not find hospitals that allow them to do intubation rotations. RNs with hospital based CCTs do not have any of these issues.


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## Zippo1969 (Oct 13, 2008)

No FD or private CC services around here - one was tried in Kansas City area some time ago, but flopped for reasons I'm not aware of (maybe due to some of the reasons we've discussed perhaps?) The hosp. based units are usually made up of what I call 'the usual' crews - RN/RT/MD/Perfusionist/Medic/another RN (pick two), and an EMT-B who only drives...and definately doesn't set up vents!  Not really sure why the EMT driver, most likely a state reg.  There's only one 'ALS' provider (RN) on a CC unit?  Don't think I'd want that job...

I whole-heartedly agree with you that even with the nice oval cc patch one's only scratched the surface of CCT, and it's unfortunate there's not more cooperation with the hospitals / anes. depts for intubations and other proceedures.  That's gonna have to change as demand increases, no doubt.  We have had to have some pretty big fights to get to the point where we have all the clinicals and labs we are privy to (cats, pigs, dogs, cadavers, live tubes in surg, all ICUs open to us, Neonatal and OB rotations...the list goes on and on...).

It would be an understatement to say the whole system nation-wide needs an overhaul, especially considering the whole 'boomer effect' on regular and CC EMS.  I do remember reading over a draft of a new national 'scope of practice' standard a couple years ago, but it's late and I can't remember much of it, it did expand (and define) the roles for EMS - much clearer than what's out there now.  Haven't heard anything on it lately tho...might do some digging around for that when I'm not cross-eyed.


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## mycrofft (Oct 13, 2008)

*Stop trying to run a fledgling profession on "certificates".*

Nationally mandated curricula to earn DEGREES.
Oh, and by the way, having once been tempted into babysitting a pt above my level of expertise, alone with a pilot to the Mayo clinic in a light fixed wing aircraft, it was the most ignorant, flattery-sucking and downright silly thing I have done in EMS ever. GD'ed lucky for everyone involved.:blush:


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