# Need For Definitive Care



## Sasha (Feb 17, 2009)

Okay. I may have to eat my words a little, but I feel this illustrates even further the need for 100% ALS, even IFT wise, BUT.

Today on a clinical we had a patient brought in for pulmonary edema. The patient has a pulse of 103, temp of 101.2, rales in all fields, AMS, lethargy.

The patient came from a nursing home RIGHT next to the hospital. Literally a two minute drive and half of that is due to the fact you have to make a U-turn. The patient was brought in by an IFT company. 

Initially the patient had a BLS response for "chest congestion" to that patient, the BLS crew assessed the patient and turned down the call for one fo their ALS units to come and pick the patient up. The ALS unit will take about an hour. The nursing home wouldn't call 911. Per nursing home staff's relay to the ALS unit, confirmed by the family, the BLS unit wouldn't take the patient because they didn't want to look like an idiot from bringing in an ALS patient on a BLS truck.

Now. Keep in mind the nursing home is two minutes away from the ER.

Upon arrival this patient was put intubated and put on a vent.

The doctor was furious. Actually called up the company.

Now for all you nurses and RRTs, med students, all you hospital folk, would you prefer a BLS crew recognize the need for definitive care over field intervention and get the patient to the hospital? Would you think less of the crew for transporting?

EMT's, would you have called for ALS and left or transported stat?

I was disappointed while discussing it with fellow students that most would have waited for the ALS unit. One said he didn't want to lose his license. Can you lose your license for a situation like this, transporting an ALS patient BLS?


----------



## redcrossemt (Feb 17, 2009)

Sasha, you've got it right.

Documentation is always the key to not using your license. After you write up your IPS/whatever, you should document something like "Decided to transport pt after ALS requested and dispatch informed us they were 60 minutes out. Hospital approximately 2 minutes away." You'd be much more at risk for losing your license for letting the patient get an hour closer to death.

From the hospital ER/ICU experience point of view, TRANSPORT! Making this patient wait so the crew doesn't look silly is detrimental to the patient. If you are really worried about looking silly, let ALS tell us the story about how the stupid basic crew let the patient suffer for an extra hour. If we ask why ALS didn't transport, tell us they would have taken longer than the time it took you to get the patient here.

From my experience on a basic truck, TRANSPORT! I would absolutely transport if the ALS crew would take longer to arrive (or intercept) than it would take to get to the hospital (that obviously provides ALS). If you wait for the medic truck, you are actually delaying ALS care to this patient!


----------



## Shishkabob (Feb 17, 2009)

Anyone that says wait for ALS would be wrong, simple as that.

If the situation is that dire, you are that close to the ED, and ALS is that far away, you do far more harm waiting for ALS.


I say just transport ASAP on BLS.  There isn't a damn thing you can do in the 2 minute drive to the hospital that would change their condition.



But thats going off the info you gave only.


----------



## JPINFV (Feb 17, 2009)

Sasha said:


> I was disappointed while discussing it with fellow students that most would have waited for the ALS unit. One said he didn't want to lose his license. Can you lose your license for a situation like this, transporting an ALS patient BLS?



There's a reason I used to keep a copy of the protocol I'm linking to in my clip board. Yes, I have left copies of it for RNs who got upset at me for not calling paramedics in a similar situation. Working as a basic, my goal is to get my patient to advanced care as soon as possible, be that advance care from paramedics or an emergency room. 



> First responding BLS units may transport unstable medical cases to the nearest [paramedic receiving center], while providing appropriate BLS interventions, if the estimated time for ALS arrival exceeds BLS transport time to the PRC.


http://ochealthinfo.com/docs/medical/ems/treatment_guidelines/i40.pdf
Page 2.
Note: It's been slightly reworded since I've left. There did not used to be a reporting requirement or actual criteria for an unstable patient.


----------



## VentMedic (Feb 17, 2009)

What did this BLS crew for the hour they were with the patient? Could they not have done the same thing in the back of their truck? Do they not have any commonsense protocols for activating 911 themselves or if their ALS is more than 10 minutes away and the hospital is less than 10 minutes, BLS transport? If the patient coded would they have done CPR until their ALS truck arrived or would someone have had the sense to call 911? An AED probably wouldn't have done squat for this patient. 

I understand the contracts that some NHs have been forced to initiate with private companies at the insistance of the municipal 911 service but in most of these contracts there is also a clause that if the company fails to perform within the guidelines agreed upon, plan B or C goes into effect.


----------



## Sasha (Feb 17, 2009)

> I understand the contracts that some NHs have been forced to initiate with private companies at the insistance of the municipal 911 service but in most of these contracts there is also a clause that if the company fails to perform within the guidelines agreed upon, plan B or C goes into effect.



I was under the impression nursing homes can't call 911 without orders from a doctor.


----------



## daedalus (Feb 17, 2009)

Tell the crew to pick up their own cell phone and dial 911 themselves. I have done it many times. Or, transport the patient to the ER. This is a no-brainer.


----------



## Shishkabob (Feb 17, 2009)

Sasha said:


> I was under the impression nursing homes can't call 911 without orders from a doctor.



I guess it depends on the NH, as in Dallas they have contracts with AMR, while in Ft Worth, they just dial 911.


----------



## Hockey (Feb 17, 2009)

Here, if you are <5 mins from the hospital, protocol does not require you to contact ALS.  In fact, I was 3 mins from the hospital yesterday, had an overdose that went unconscious, and ALS was 4 minutes the other way.  I transported P-1 BLS 

Wasn't second guessed.  Put in the report that per protocol, <5 mins from nearest hospital


----------



## VentMedic (Feb 17, 2009)

Sasha said:


> I was under the impression nursing homes can't call 911 without orders from a doctor.


 
That is not always the case. Often it is due to the contracts they have entered with the private and municipal services. Some cities/counties encourage the contracts while others try to fight it. 

Before it is an emergent emergency, the NH should call the doctor to get transfer orders. Once it becomes immediately life threatening, that _usually_ goes out the window. 

Example:
http://www.boston.com/news/local/ma.../05/27/firefighters_sue_over_ambulance_rules/


----------



## spisco85 (Feb 17, 2009)

As a basic that disgusts me. Common sense says get the patient to the hospital. They did assessment and realized they couldn't do much for the patient themselves and I give them props for that but they went from being smart to altered mental themselves when they just sat there.

In the past two weeks I have transported patient's out of the same nursing home that we determined needed ALS intervention. (my partner is an intermediate but in CT that just means IVs) We load that patient and start enroute to the hospital on a priority 1 and call for an intercept. No problems and the patient got to the hospital faster than us saying "well she/he needs a paramedic call and get an ALS rig here"


----------



## JPINFV (Feb 17, 2009)

daedalus said:


> Tell the crew to pick up their own cell phone and dial 911 themselves. I have done it many times. Or, transport the patient to the ER. This is a no-brainer.



Meh I just ask to borrow the phone so I can use e911. The SNF won't know that I called 911 until its already dialed.


----------



## TiCo (Feb 17, 2009)

Wouldn't a quick phone call to the hospital solved the problem? The medical director could give permission for the BLS unit to transport the patient, right?  Or the doctor on call?


----------



## JPINFV (Feb 17, 2009)

^
A situation like this is so basic (no pun intended) that if you need online control for this decision then you should lose your certification.


----------



## Epi-do (Feb 17, 2009)

While still working as a basic, we were always expected to transport a critical patient if we were closer to the ER than to an ALS unit.  It rarely happened, but on occassion it would.  Typically, you would hear the BLS unit call the hospital and let them know what they were bringing in.  When getting to the ER, if asked why certain things were not done, we would just tell them that we were BLS and that we were closer to the ER than to ALS.  The ER's were usually pretty cool about it, and would much rather have you get the patient to definative/advanced care than wait for the medics to show up.

On a side note, but sort of similar, I was taking a difficulty breathing patient in the other night that wasn't moving much air at all.  Breath sounds were diminished with very faint wheezes.  We got the patient into the truck and headed to the ER.  The patient didn't respond to the albuterol and continued to get worse so I ended up bagging the albuterol in for her.  I had my partner give the ER a short report to give them a heads up.  When we got there, they asked me if I had gotten a line on her.  I told them that I was by myself and since I ended up needing to assist ventilations I didn't get anything else done.  They were completely ok with it.


----------



## medic417 (Feb 17, 2009)

Sasha said:


> I was under the impression nursing homes can't call 911 without orders from a doctor.




Yes they can call 911, but it costs more.  Nursing homes establish prices with transfer services for much less than a 911 transfer.  So it is about the money not the patient or the law.


----------



## emtfarva (Feb 17, 2009)

*Wtf*

If I was working Chair Car I would have brought this PT to the Hosp. Ok maybe not if I was working CC. I had a Pt one night that was in resp. distress. This was from a SNF. I walked into the room and asked my partner to call for ALS. I didn't even talk to the Pt and I already was asking for ALS. I was even teching the call and I asked for ALS. At the Pt's side I placed her onto a NRB and attempted a pulse ox. I couldn't get one. We found out that there was no Als. Transfered the Pt to Stretcher and transported to ambulance. GOT a B/P of 50 SYSTOLIC. We transported to the Hosp approx 1 min away. called it a P2, should have been a 1. Got to the hosp and the Pt was put on bi-pap. *I was told that Als would have to come from the other side of the city, I DIDN'T WAIT, I TRANSPORTED. THAT IS WHAT THE CREW SHOULD HAVE DONE FROM THE OP.*


----------



## marineman (Feb 18, 2009)

Working as a basic there is no such thing as waiting for "ALS". If it's a priority patient I sometimes won't even call for ALS until we're loaded and en route depending on exactly how rapidly this move needs to be made but I never wait for ALS. I'll call for them and gladly let them know where I am and what route I'm taking, then it's up to them to find me and intercept.

The only exception I could possibly see is an extended transport time (>30min transport) where ALS is 10 minutes or less behind you in the opposite direction, in that case they will never catch you (at least not how I drive) but could potentially do something more to stabilize this patient prior to ED arrival.

I now work on an ALS rig and the medics I work with expect any service their intercepting with to do the same thing, "we drive fast, we will catch you, don't delay the patients transport to the hospital" - actual quote from one of my partners a few weeks ago. It's incredibly unfortunate that common sense is such a rarity these days however piss poor protocols and even worse lawyers have a major impact on decisions like this.


----------



## CAOX3 (Feb 18, 2009)

I dont even get it.


----------



## CAOX3 (Feb 18, 2009)

Let me rephrase that its called neglegence.

Unbelievable an ambulance refusing to take a sick person to the hospital.


----------



## Sasha (Feb 18, 2009)

VentMedic said:


> That is not always the case. Often it is due to the contracts they have entered with the private and municipal services. Some cities/counties encourage the contracts while others try to fight it.
> 
> Before it is an emergent emergency, the NH should call the doctor to get transfer orders. Once it becomes immediately life threatening, that _usually_ goes out the window.
> 
> ...



From my very limited experience... Once an emergency becomes immediatly life threatning the nursing home can't seem to find the "11" key. 

It's unfortunate the patient had to suffer. I'm wondering though if the hour would have made a difference and kept the patient from being tubed. Either way, Critical Thinking should be a pre-req for an EMT class. It's amazing how far some basics/medics will go to justify refusing to think about the bigger picture and not just the next 10-20 minutes of patient care.


----------



## BLSBoy (Feb 18, 2009)

marineman said:


> Working as a basic there is no such thing as waiting for "ALS". If it's a priority patient I sometimes won't even call for ALS until we're loaded and en route depending on exactly how rapidly this move needs to be made but I never wait for ALS. I'll call for them and gladly let them know where I am and what route I'm taking, then it's up to them to find me and intercept.



Before I jump down your throat with both feet, I am going to let you explain this statement.


----------



## BLSBoy (Feb 18, 2009)

Sasha, I am going to go out on a limb, and guess that the agencies ambulances were white, with slime lime graphics, and are in the process of getting the boot from Orange County, and Orlando for the same types of actions?

If I were the MD, I would be hunting for those 2 EMT's heads. 

Brainless dolts are about the only words I can come up with to describe them.


----------



## Foxbat (Feb 18, 2009)

BLSBoy said:


> Before I jump down your throat with both feet, I am going to let you explain this statement.


I don't know your or marineman's local protocols... But our state says:
"If transport time by BLS to an appropriate receiving facility  can be accomplished before ALS can initiate care, then the BLS service should transport as soon as possible and should not request or should cancel ALS; BLS services should not delay patient care and transport while waiting for ALS personnel. If ALS arrival at scene is not anticipated before initiation of transport, arrangements should be made to rendevouz with the ALS service".

The exception protocols make is for long transports with ALS coming from opposite direction, if waiting for ALS for a short time will significantly decrease time to ALS care. Otherwise, it's what marineman said.


----------



## TransportJockey (Feb 18, 2009)

I've had patients like that when I worked an IFT truck. I would get them loaded, support w/ BLS skills (although in NM that includes combitube and narcan, great for duragesic patch overdoses), and transport code to the ED. We had one SNF that was literally right across the street from an ED, so I've done this type of scenario before.


----------



## VentMedic (Feb 18, 2009)

Sasha said:


> From my very limited experience... Once an emergency becomes immediatly life threatning the nursing home can't seem to find the "11" key.


 
You will probably never get the butt chewing these nurses get many times a week from the doctors, owners of the NHs, families and the EMT(P)s. Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be. That was on a routine transfer. There is little wonder why NHs can not keep good nurses. Those with the patient's interest at heart will find it a daily struggle. They are danged if they do and danged if they don't. With their license and title comes a crap load of responsibility that is not worth the money NHs pay RNs or even LVNs. 

As for the EMTs in this situation, if they were clueless, why did they not call a field supervisor or anyone for advice? They also had the option of calling 911 themselves even if their company would lose the fee. Just like your statement I quoted above, they had no thought process going on for the greater good of the patient.


----------



## Sasha (Feb 18, 2009)

> Sasha, I am going to go out on a limb, and guess that the agencies ambulances were white, with slime lime graphics, and are in the process of getting the boot from Orange County, and Orlando for the same types of actions?



Negative. The agencies ambulance were blue and white and are in the process of helping the lime graphic company out of the area by taking all their contracts.


----------



## Sasha (Feb 18, 2009)

> Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be.



I've seen that before too, and been the partner going "I'm so sorry!" once the yeller had stormed off. It's terrible, there's never a place to yell, but on the flip side not every nurse is so innocent, and scream at the IFT EMTs/Medics for being late when they had just gotten paged for that call 5 minutes prior and had been running around three different counties. There is a HUGE Us Vs. Them.

Nursing home nurses have a tough job, I have the utmost respect for MOST of them, it has to be overwhelming to have that many patients at once all day every day. But then I run into nurses that kind of spoil the whole bunch.. I've gone to pick up a patient and have the nurse tell me that the patient has no DNR and she's not even sure if the patient is still alive. 

But my comment was inapprorpriate, I apologize. It was late (or very early.) and I wasn't thinking clearly.


----------



## JPINFV (Feb 18, 2009)

VentMedic said:


> Even in our SNF I have walked in on an EMT screaming in the face of a nurse half the EMT's size because the paperwork was not immediately prepared like it was supposed to be. That was on a routine transfer.


[tone of disbelief and bewilderment]
That won't happen on my ambulance. I'd be on the phone with the crew chief so fast it wouldn't even be funny. Oh noes, the paperwork isn't ready? Then package the damn patient and take a 5 minute break and calm the F down. [/tone]

I weep sometimes for the state of EMS in this country.


----------



## mikeN (Feb 18, 2009)

I've had a few similar calls like this recently and I requested ALS and never got them.  We didn't even think to wait.  Load and go.  If I waited like that I'd probably get fired. then again I work in the Boston area where you can through a rock and hit 2 or 3 hospitals, so hospital transport times are super short and getting ALS is a longer than the transport.


----------



## VentMedic (Feb 18, 2009)

JPINFV said:


> [tone of disbelief and bewilderment]
> That won't happen on my ambulance. I'd be on the phone with the crew chief so fast it wouldn't even be funny. Oh noes, the paperwork isn't ready? Then package the damn patient and take a 5 minute break and calm the F down. [/tone]


 
You don't think I didn't make a call? But first I had security and one of our LEOs sit his arse in a room well away from hospital staff and patients. 

We've had a few get belligerent in the ED when they don't think they are getting attention fast enough. Since we do have a heavy LEO and security presence there, it doesn't get far. Most know not to start anything with our ED staff. They take enough crap from some of the patients. 

When you have as many ambulances in and out of a facility as ours does, the odds are there will be some idiot that doesn't do justice to the uniform. This is not just with the private companies, we have a few FF/medics that could use some anger management classes also. We just don't see the problems as much becasue they will be dressed down quickly by their superiors. 

I know you have read some of the angry post toward nurses and even doctors on the forums. A few don't handle people they believe to be inferior giving orders to them. A bad week at home along lack of sleep from 24 or 48 hour shifts and it doesn't take much to set someone off with a short fuse. This profession also attracks strong personalities. I've dumped a few partners during my years in EMS for serious anger problems toward anyone, including the patient and nurses, whom they thought to be just looking at them wrong.


----------



## JPINFV (Feb 18, 2009)

VentMedic said:


> I know you have read some of the angry post toward nurses and even doctors on the forums.



I don't think it's quite fair to compare something that happens on scene to what goes on on the internet. I'll admit, not all of my interactions with other health care staff has been full of rainbows, flowers, and puppies, but if I need to vent over someone's apparent stupidity, there's always after the call in private or the internet.


----------



## VentMedic (Feb 18, 2009)

JPINFV said:


> I don't think it's quite fair to compare something that happens on scene to what goes on on the internet. I'll admit, not all of my interactions with other health care staff has been full of rainbows, flowers, and puppies, but if I need to vent over someone's apparent stupidity, there's always after the call in private or the internet.


 
Not comparing what happens on the internet. I just recognize some of the same angry statements I have heard in this profession and others as well. You pick up on certain key words in conversations especially at scene and start checking your exits. 

Stress can create many problems and has many causes. That is why I do not support CISD or some support groups that have no professional leadership. Everybody comes with their own bagage and set of individual problems as well as their own unique wiring. 

Right now we have several employees who have been working OT trying to keep their homes from foreclosure and many who have already had their homes foreclosed on. Talk about the stress. Then, in San Francisco, the DOH laid off some healthcare workers and cut the pay of others. In Florida, we have been running stretched very thin for help because the hospital didn't bring in as many travelers for the season. During all this, some on ambulances expect  everyone to greet them as if they are the most important person in the world. Yeah, I know this since I used to think that way also. It didn't take long to see another side.


----------



## BLSBoy (Feb 18, 2009)

Foxbat said:


> I don't know your or marineman's local protocols... But our state says:
> "If transport time by BLS to an appropriate receiving facility  can be accomplished before ALS can initiate care, then the BLS service should transport as soon as possible and should not request or should cancel ALS; BLS services should not delay patient care and transport while waiting for ALS personnel. If ALS arrival at scene is not anticipated before initiation of transport, arrangements should be made to rendevouz with the ALS service".
> 
> The exception protocols make is for long transports with ALS coming from opposite direction, if waiting for ALS for a short time will significantly decrease time to ALS care. Otherwise, it's what marineman said.



I have no issue with the rendezvous thing. I do it all the time. 

Its this...





marineman said:


> Working as a basic there is no such thing as waiting for "ALS". *If it's a priority patient I sometimes won't even call for ALS until we're loaded and en route depending on exactly how rapidly this move needs to be made but I never wait for ALS*. I'll call for them and gladly let them know where I am and what route I'm taking, then it's up to them to find me and intercept.
> 
> The only exception I could possibly see is an extended transport time (>30min transport) *where ALS is 10 minutes or less behind you in the opposite direction, in that case they will never catch you (at least not how I drive)* but could potentially do something more to stabilize this patient prior to ED arrival.


----------



## CAOX3 (Feb 18, 2009)

VentMedic said:


> As for the EMTs in this situation, if they were clueless, why did they not call a field supervisor or anyone for advice? They also had the option of calling 911 themselves even if their company would lose the fee. Just like your statement I quoted above, they had no thought process going on for the greater good of the patient.



I really cant understand this, it seems quite simple to me.  Both EMTs should have the certs revoked.

They Failed to provide treatment and transportation to a pt in need.

End of story.


----------



## RESQ_5_1 (Feb 18, 2009)

Not being  a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE. My previous partner was actually working his first shift as an EMT-A with me when we got called to a lady who fell off her toilet. So, it got dispatched as a fall with priority response (17-D-1). My partner auscultated lung sounds initially and heard nothing. He was just about to get a BP while I was supporting her from the back (she was sitting on the floor). She stated she was dizzy and slumped back against me. I gently lowered her to supine and my partner started getting a BP while I started getting some O2 ready. Keep in mind, this is all within the first 2-5 minutes on scene. So, we are trying to determine the cause for dizziness which resulted in the nose-dive off the toilet. 

Her son was there with us and stated that she wasn't breathing. Checked pulse and there was none. Apparently, pt got dizzy and slumped back due to cardiac arrest. We immediately started CPR and proceeded to move her to the rig. Her son told us (after she coded) that she had been short of breath with occasional dizzy spells for the last 2 weeks since she returned from Australia. We immediately suspected PE from there. And even with a Paramedic and 2 EMT-A's running the code, she was pronounced at the hospital. It was about a 20 min transport time. 

Up until she went into cardiac arrest, she had a GCS of 15, A/Ox4, no apparent respiratory distress. We were initially thinking TIA until the son mentioned the trip to Australia. 

Are there any other indicators we might have missed?

As far as the BLS crew that didn't transport and waited for ALS, I would rather explain why I felt the need to transport instead of waiting than to explain why I delayed treatment for an hour.


----------



## OzAmbo (Feb 18, 2009)

> Working as a basic there is no such thing as waiting for "ALS". If it's a priority patient I sometimes won't even call for ALS until we're loaded and en route depending on exactly how rapidly this move needs to be made but I never wait for ALS. I'll call for them and gladly let them know where I am and what route I'm taking, then it's up to them to find me and intercept.


Wow, this statement is so incredibly negligent :excl:

YOUR JOB is to bring the best available care to a patient, how you do that varies from service to service and situation to situation, and sometime given constraints it may not be possible and a quick dash to hospital with minimal care may be the best option at the time, but the arrogance of calling ALS after you have loaded and not when you have assessed the pt as needing more advanced intervention is just mind boggling.:wacko:


----------



## VentMedic (Feb 19, 2009)

RESQ_5_1

This is a good scenario so why don't you copy and paste it to its own thread? That will give the chance for good discussion on assessment and treatment without distracting from Sasha's original post



RESQ_5_1 said:


> Not being a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE. My previous partner was actually working his first shift as an EMT-A with me when we got called to a lady who fell off her toilet. So, it got dispatched as a fall with priority response (17-D-1). My partner auscultated lung sounds initially and heard nothing. He was just about to get a BP while I was supporting her from the back (she was sitting on the floor). She stated she was dizzy and slumped back against me. I gently lowered her to supine and my partner started getting a BP while I started getting some O2 ready. Keep in mind, this is all within the first 2-5 minutes on scene. So, we are trying to determine the cause for dizziness which resulted in the nose-dive off the toilet.
> 
> Her son was there with us and stated that she wasn't breathing. Checked pulse and there was none. Apparently, pt got dizzy and slumped back due to cardiac arrest. We immediately started CPR and proceeded to move her to the rig. Her son told us (after she coded) that she had been short of breath with occasional dizzy spells for the last 2 weeks since she returned from Australia. We immediately suspected PE from there. And even with a Paramedic and 2 EMT-A's running the code, she was pronounced at the hospital. It was about a 20 min transport time.
> 
> ...


----------



## Aidey (Feb 19, 2009)

As much as I would like to lambast the Amb crew for this, when you are a basic it can be hard to argue with someone with more training/education/letters behind their name than you. I definitely think that the BLS crew should have said "eff it" and transported the PT, but I also think some responsibility lies with the NH staff. 

I agree with the above sentiments that it can be hit or miss with NH staff. We were called the other day to one of the local NHs for a "flu" patient. They had already transported 6 other patients for "flu" (which turned out to be Norovirus). Anyway, we get there and the lady has ronchi from 10 feet away, was breathing 58 times a min, and cyanotic around the lips and she had 3+ bilat pedal edema. 

I was pretty irritated with the NH staff, if they hadn't had the "flu" outbreak how long would they have waited to call for this lady? It's times like that I was to give them a piece of my mind, however I've also been to NHs where the staff was really on top of things and very proactive.


----------



## OzAmbo (Feb 19, 2009)

Aidey said:


> As much as I would like to lambast the Amb crew for this, when you are a basic it can be hard to argue with someone with more training/education/letters behind their name than you. I definitely think that the BLS crew should have said "eff it" and transported the PT, but I also think some responsibility lies with the NH staff.
> 
> 
> 
> ...


----------



## marineman (Feb 19, 2009)

BLSBoy said:


> I have no issue with the rendezvous thing. I do it all the time.
> 
> Its this...



It's very rare to package prior to calling for ALS however major multisystem trauma especially MVC's come to mind if there's not a wait on extrication my priority is getting the patient out of there and on their way to proper care. These patients require care above the scope of ALS and as some (questionable) studies show ALS for trauma patients may not do as much good as we all like to think. If I roll on scene and the FD has the patient ready to roll we roll and place the call enroute. 

As for the ALS not catching you not sure what the problem with that is, take away the joking comment about the way I drive and it's nearly impossible to make up 10 minutes time on 2 vehicles running the same direction. On a 30 mile transport to catch me at the hospital door you would have to be going 20mph faster than me. To catch me half way to the hospital you would have to average 40mph faster than me. It's not probable for them to catch you unless you wait which is the reason why that's the only time I would wait. 

I'm a medic student, believe me I get all amped up about ALS just as much as you but we all have to realize it's limitations and realize that expeditious transport will do the patient more good than waiting for a medic so he can start an IV that the hospital will replace.


----------



## OzAmbo (Feb 19, 2009)

ah, im glad you qualified that marineman because at a glance your previous post about this smacked of arrogance

I'm settled now B)


----------



## VentMedic (Feb 19, 2009)

The goal of ALS field treatment and the initial treatment of the ED are the same. 



marineman said:


> I'm a medic student, believe me I get all amped up about ALS just as much as you but we all have to realize it's limitations and realize that expeditious transport will do the patient more good than waiting for a medic so he can start an IV that the hospital will replace.


 
The hospital staff is not going the pull the Paramedic's IV out as you roll through the door and with good reason which I will answer below. But yes it will probably be changed in the ED or within 24 hours. That doesn't mean you use that as an excuse not to do one if warranted. 



> Originally Posted by *RESQ_5_1*
> 
> 
> _Not being a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE._


 
People code due to hemodynamic instability. For any unknown, both the Paramedic's and the ED staff initial responsibilty will be to maintain hemodynamic stability until a definitive dx and/or treatment is started. That is done through fluids and pressors. You want to maintain an adequate BP MAP to supply O2 to the tissues. This is true for almost every scenario. Refer to the shock thread. PREVENT THE CODE FROM HAPPENING. 

The BLS limitation is, without a cardiac monitor, the pulse you are feeling may only be the perfusing beats. The patient may have a HR of 240 but a palpable pulse of 80. Treat the hemodynamic instability: break the rhythm if possible and support BP through fluids and pressors. BLS does not have any of those capabilities. 

Paramedic at scene of *RESQ_5_1's* scenario:

O2
History/meds
IV 
12-lead EKG 
- occasionally a PE will present with specific changes
- MI? initiate that protocol
Support the hemodynamics through fluids and pressors to maintain stability and prevent the code from happening.

The goal of any scenario is to maintain adequate oxygenation and hemodynamic stability by whatever means available. As well one should recognize the limitations for some situations and time such as trauma but the goals are the same. However, what can be started enroute will probably be benefiicial. 


In the situation from the OP, whoever was closest, the Paramedics or the ED can initiate appropriate treatment to maintain hemodynamic stability for perfusion and oxygenation which is the goal for the patient regardless of who starts it.


----------



## amberdt03 (Feb 19, 2009)

medic417 said:


> Yes they can call 911, but it costs more.  Nursing homes establish prices with transfer services for much less than a 911 transfer.  So it is about the money not the patient or the law.



i heard that everytime a nursing home called 911, they get investigated by the state. not sure if its true or not, never really checked into. i once ran a call from a nursing home on a bp of 60/40. dispatch gave an eta of 30 min(we were the only als truck that night) and the nursing home said that it was ok even after dispatch suggested they called 911.


----------



## rescuepoppy (Feb 19, 2009)

In regards to the original post this sounds like a good place to use a little common sense. Just consider the times, hospital is two minutes away ALS is an hour out, this patient is going in BLS. The hospital can start the definitive treatment. I am not going to risk standing in front of a judge explaining that I was afraid of looking stupid if I took in a patient without waiting for ALS to start their treatment.  In my area if a BLS crew needs ALS assistance it is acceptable to start transport while rolling toward an intercept or if transport to the hospital is quicker to go ahead and transport there. The bottom line is what is the quickest and safest method to get the patient to a more advanced level of care.


----------



## medic417 (Feb 19, 2009)

But a thought to ponder is would it be legal to downdrade the care from the higher level of a nursing home RN to a basic crew?


----------



## Aidey (Feb 19, 2009)

I was just thinking about that myself medic417. It probably depends on the exact situation and what equipment the nursing home has vs the BLS ambulance.


----------



## JPINFV (Feb 19, 2009)

Well, you're transfering care from a transpot incapable unit to a transfer capable unit. Also the greater good of the patient is being accomplished by a temporary downgrade in order to get the patient to an even higher level of care.

If this was an issue, then an RN shouldn't be downgrading a patient to a paramedic led CCT team.


----------



## CAOX3 (Feb 19, 2009)

medic417 said:


> But a thought to ponder is would it be legal to downdrade the care from the higher level of a nursing home RN to a basic crew?



Legal, It happens all the time.  I would question isnt it also a  downgrade from an RN to a paramedic.

Hospital transfer pts all the time they cant treat.  They are downgrading care, our they not.  This is a neccesary evil to get the pt to difinitive care.


----------



## medic417 (Feb 19, 2009)

CAOX3 said:


> Legal, It happens all the time.  I would question isnt it also a  downgrade from an RN to a paramedic.
> 
> Hospital transfer pts all the time they cant treat.  They are downgrading care, our they not.  This is a neccesary evil to get the pt to difinitive care.



The downgrade of care is still supposed to given to someone caple of providing X care.  In this case BLS could not provide X care so they were to low a level.  Other times patients are stable and only need transfer so Basics can do it.  

As to Paramedic vs RN I'll leave that to another day.  

Common sense says get patient to ER by BLS or 911.  Neither applied common sense.  But legally this is a case of darned if you do darned if don't.


----------



## emtfarva (Feb 19, 2009)

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.


----------



## amberdt03 (Feb 19, 2009)

medic417 said:


> The downgrade of care is still supposed to given to someone caple of providing X care.




have you ever actually talked to a nursing home nurse? i don't know how they are in your area but they ain't so great in dallas and surrounding areas. so i don't think that it would be a downgrade to a basic if the original care came from a nursing home nurse.


----------



## amberdt03 (Feb 19, 2009)

VentMedic said:


> The hospital staff is not going the pull the Paramedic's IV out as you roll through the door and with good reason which I will answer below.





there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)


----------



## ffemt8978 (Feb 19, 2009)

emtfarva said:


> SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.



Since when did EMS become about "power"?


----------



## VentMedic (Feb 19, 2009)

amberdt03 said:


> there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)


 
This is not just one hospital but many across the country. This is nothing new. Have you not read anything about Medicare and acquired infections?

Considering the conditions that some EMT(P)s even brag about starting IVs under or how they don't have to follow all that cleaning stuff done in the EDs, would you trust EMS IVs for any great length of time?


emtfarva





> SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic.


 
Wow, someone is on a power trip...

Ever count the things a nurse can do that EMT(P)s can't? You might find that to be a very long list.

If the nurses could leave their patients and go to the hospital with them, there might be a few less jobs for some EMT(P)s. Oh wait, RNs already do IFTs as part of their job on CCTs especially if the EMT(P)s aren't qualified to handle critical patients with a variety of drips that are not part of the Paramedic's scope. Some RNs and RRTs may also have to leave their hospital to accompany a patient that the Paramedics can not transfer by themselves. For whatever the Paramedic can't handle on these transports, the RN does. 

The nurse in the SNF call EMT(P)s to do a job which they know they can not do nor can they leave to transport. It is your job and your specialty. If you want to seriously get into a power struggle with a nurse who just wants his/her patient provided with emergent care and transferred to a facility for a higher level of care, you will lose. As well, your company may lose that contract which may also put you looking for another job. Feel the power now?


----------



## Sasha (Feb 20, 2009)

amberdt03 said:


> there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)



Have you ever asked why?

The hospitals I do clinicals with and deliver to on rides pulls EMS lines if it's non-emergent, (ie the line is not needed to stabilize, even then they pull it as soon as they establish their own.) Why do they do this? Because the field is very dirty, you start IVs in people's houses or trucks, we clean our own ambulances and people get lazy and don't clean it properly. They don't know if you've changed your gloves, done it with out gloves, used an alcohol prep, etc. EMS lines are dirty lines. People get infections from them, and sepsis has a disturbingly high mortality rate.



> SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.



Way to perpetuate an "Us Vs. Them" mentality, yet again. Nurses are far more educated than EMTs and Medics. I'd love to hear how you taking control of a code with a nurse on board works out. Saying nursing home nurses aren't trained for emergencies is BS. If things go south, I'd rather have a nurse than an EMT any day.


----------



## ffemt8978 (Feb 20, 2009)

The hospital I worked at pulled ALL field IV's within 24 hours of them being established for the simple reason of reducing infection.  Generally the ER would establish a new IV and pull the field one just before admitting the patient and transferring them to the floor.  If the patient was going to be a treat and street, they didn't pull the line until the patient was discharged.


----------



## Aidey (Feb 20, 2009)

emtfarva said:


> SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.




I wouldn't bet on that 100%. My aunt was a nurse for years, and when she retired from the ICU she worked at a nursing home for several years as a transition into retirement. Even after being out of the ICU for a few years I bet she still knew how to run a code. 

As for RN vs MICP during a code, it would totally depend on the MICP and the RN. Some RNs could run a code with one hand tied behind their backs, others wouldn't know epi from Excedrin. Same with some medics. 

There is also a difference between a MICPs scope and their standing orders. We have to use RNs occasionally where I work for IFTs when the patient has something that is within the MICP scope, but not within my agencies standing orders, such as a nitro drip.


----------



## VentMedic (Feb 20, 2009)

Sasha said:


> . Saying nursing home nurses aren't trained for emergencies is BS. If things go south, I'd rather have a nurse than an EMT any day.


 
Taking care of a patient in an emergency may actually be easier than caring for 25 patients at one time so that they don't have an emergency.  

Nurses DO know their limitations and will allow someone better suited to handle what they can't. Some in EMS have yet to learn the limitations of their own education/training or believe a 110 hour couse is all there is to medicine. There are also those that don't know what they can do or should do. I believe the scene illustrated in the OP demonstrates this.


----------



## emtfarva (Feb 20, 2009)

Nurse's can't ETT a Pt. I didn't mean to sound like I was on a power trip. The ICU nurses that you are all talking about have this in their standing orders. A nurse has to have orders to increase O2 on a Pt. I have standing orders to increase O2 if clinically indicated. A nurse can not run ACLS protocols. Basically, A nurse can only run HCP CPR, if they don't have standing orders for it. Also I haven't seen a SNF that has ACLS drugs. Yes nurses have a hell a lot more training than I do, but the nurses that work in SNF deal with more long term issues. They care for daily needs not emergent needs. That is why Pts are sent to the hosp. They have no way to manage emergent situations. They do not have RTT on staff (unless they are a rehab hosp). I have been to SNF where nurses don't even take VS on emergent Pts. They also tend to use nurse's on a stick. Not one call for hypotension or HTN that I have been on has a B/P done manually. Something that comes to my mind is cases that I would transport Pts from a L&D to a higher level care L&D. The nurse would come with us so the Pt could cont. on LR, and also to monitor the fetus. If the Pt crashed we would be responsible for Pt care. The nurse would also be there if the Pt decide to deliver her child. Maybe the word power was wrong but I think we would provide a higher level of care than a nursing home nurse. We can also transport a Pt to a higher level of care. There is a debate about this same situation in an area near me. A private company, per their company policy can not transport a priority 2 or above Pt, they have to wait for Fire. It doesn't matter if it is AMS or cardiac arrest. This in my opinion is very wrong. Per statewide treatment protocols, Bls providers should transport ASAP with or without Als. They go against the states treatment protocols. I am sorry if I offended anybody with my little power trip. I, again, didn't mean it as some of you presumed I meant it.B)


----------



## Sasha (Feb 20, 2009)

Who lied to you? Nurses can tube, etc.

And be careful, I think the T in RT is therapist not tech, you might offend some people on this board. And I've been to quite a few nursing homes who have had them on staff, and not just rehabs.

And so they use a vital machine? You have ONE patient when you come to the nursing home, the nurse may have a dozen all of which may be needing care at that point in time. Many EMTs wouldn't even do a manual BP if their truck came equipped with a vital machine.


----------



## emtfarva (Feb 20, 2009)

CCT nurses also do not have any power in a pre-hospital setting. They receive their orders form a doctor prior to transport. CCRNs are great, don't get me wrong. They just have no power pre-hospital.


----------



## JPINFV (Feb 20, 2009)

emtfarva said:


> A nurse has to have orders to increase O2 on a Pt. I have standing orders to increase O2 if clinically indicated.



So, let me get this straight. You're saying that a nurse needs an order to increase oxygen. You're also saying that you need an order (need, by virtue of saying that you have such an order) to adjust O2. I don't think that saying you're a higher level is best exemplified by saying that both you and the RN need an order for oxygen.


----------



## Sasha (Feb 20, 2009)

emtfarva said:


> CCT nurses also do not have any power in a pre-hospital setting. They receive their orders form a doctor prior to transport. CCRNs are great, don't get me wrong. They just have no power pre-hospital.



Technically neither do you, as an EMT. So you can increase O2. Big deal. What can you REALLY do? CPR? A finger stick? Put on an AED?

Your orders come from a doctor too... You know.. the guy you call med control.


----------



## emtfarva (Feb 20, 2009)

MOST Rn's can not tube (oops). I am saying that I can increase O2 without paging a Doctor and waiting for a call back. I already have an order and can increase IMO if needed. No, this an example that I could readily think of off the top of my head. If I sat down longer I could think of more reasons that we have more abilities than SNF nurse in a emergent situation.


----------



## AJ Hidell (Feb 20, 2009)

emtfarva said:


> CCT nurses also do not have any power in a pre-hospital setting. They receive their orders form a doctor prior to transport. CCRNs are great, don't get me wrong. They just have no power pre-hospital.


Speaking only for MA, I'm sure, because you are definitely very wrong in most states.

Regardless, Sasha is correct.  You too are bound solidly by doctors orders.


----------



## Aidey (Feb 20, 2009)

Sasha, your normal run of the mill everyday nurse can not intubate. Nurse Anesthetists can, flight nurses can and a few others can, but it's because they received special training in it after nursing school. One of my cousins just graduated from a 4 year nursing school and we were comparing what we had to do for our clinicals and she specifically told me they were not allowed to intubate. 

The biggest difference between your run of the mill RN and an MICP is that MICPs are classified as medical providers, while RNs are not. We generally work under standing orders with some online direction, while most RNs only work under online direction. 

However, this situation changes greatly when you are talking about Nurse Anesthetists, Flight nurses etc because they are working under standing orders, and their orders are often expanded compared to those of an MICP.


----------



## emtfarva (Feb 20, 2009)

Right, I have Doctor's order's for emergencies. Hence the Emergency Medical Technician. And you are all right about CCRN's. I forgot about Medflight and such. I was thinking about our ground critical care team when they are needed for a 911 call. Sorry didn't mean to offended any CCRN's out there.


----------



## emtfarva (Feb 20, 2009)

Sasha said:


> Who lied to you? Nurses can tube, etc.
> 
> And be careful, I think the T in RT is therapist not tech, you might offend some people on this board. And I've been to quite a few nursing homes who have had them on staff, and not just rehabs.
> 
> And so they use a vital machine? You have ONE patient when you come to the nursing home, the nurse may have a dozen all of which may be needing care at that point in time. Many EMTs wouldn't even do a manual BP if their truck came equipped with a vital machine.


My point is that the nurses themselves do not check VS, they send in the aids to do it. and no, I don't trust nurse-on-a-stick inside a moving ambulance. I will trust what i hear or feel, not just reading the numbers off the machine.


----------



## AJ Hidell (Feb 20, 2009)

Medics send in EMTs to do their vitals.  Nurse Aides have the same amount of training as an EMT.  So what's the difference?


----------



## emtfarva (Feb 20, 2009)

It doesn't even matter what I think about what we can do over a nursing home nurse. The Pt from the OP should have been transported without delay and should have been brought to the hosp without Als. The SNF called for the Pt to be transported to the ER. They transfered care to the EMS providers. Those providers were wrong and should not have waited.​


----------



## AJ Hidell (Feb 20, 2009)

emtfarva said:


> The Pt from the OP should have been transported without delay and should have been brought to the hosp without Als. The SNF called for the Pt to be transported to the ER. They transfered care to the EMS providers. Those providers were wrong and should not have waited.


Absolutely agreed on that point.

Unfortunately, there are systems where IFT units are prohibited from doing so, and required by law to call for EMS.


----------



## ILemt (Feb 20, 2009)

Getting back to the original problem...
I would transport immediately, wouldn't even bother dispatch concerning ALS given time/distance.

The EMT's on that call should lose their cert permanently, for putting Pt outcome at risk like that. The NH staff should likewise be fired. 

The dispatcher should be suspended for not insisting BLS transport.

If BLS is 5 or less from ER, run the call BLS at whatever priority the situation dictates.


----------



## OzAmbo (Feb 20, 2009)

> I would transport immediately, *wouldn't even bother dispatch concerning ALS* given time/distance.
> 
> The EMT's on that call should lose their cert permanently, for *putting Pt outcome at risk* like that. The NH staff should likewise be fired.



interesting


----------



## ILemt (Feb 20, 2009)

AJ Hidell said:


> Absolutely agreed on that point.
> 
> Unfortunately, there are systems where IFT units are prohibited from doing so, and required by law to call for EMS.




Any EMT *IS* EMS, regardless of whether or not you are working for a private company or municipality so long as your vehicle can transport.
That is FEDERAL Law.

A HUGE *HUGE* *HUGE* Liability suit if I was a lawyer.
I'd own the entire service by sunset.

(No I'm not sue happy, just anti-stupid )


----------



## ILemt (Feb 20, 2009)

Oz... the highlights in your quote are off. An ER supplies ALS care. The key in what I said is "given the time/distance" [in the original problem, the ER was 1 minute away vs 60 for a MICU ]

It is NOT to say I advocate against calling for ALS.


----------



## VentMedic (Feb 20, 2009)

emtfarva said:


> CCT nurses also do not have any power in a pre-hospital setting. They receive their orders form a doctor prior to transport. CCRNs are great, don't get me wrong. They just have no power pre-hospital.


 
You are greatly misinformed. 

Did you know that several states now have specific PreHospital certifications for RNs? There RNs can work in both scene response and CCT IFT if needs. As well, do you know how many RNs do 911 scene response on HEMS? They provide the same skills as a Paramedic with the knowledge of an ICU/CCU/ED RN. I could also tell all about what Specialty (Peds, Neo) RNs do to stablilze a very long distance transport like from the islands or another country. 

CCT RNs receive a report before they leave a facility. For the RN working under another facility of higher care, will also work under another physicians protocols and standing orders. A doctor who may be a lower level provider may not be able to write the orders necessary to some transports even if they wanted to. That is why the called to get the patient to another facility. Often the CCT team, whether flight or ground, may spend much time stabilizing a patient for transport. This may include doing their own RSI for intubation. 

You think doctors anticipate everything that goes wrong during a transport. You have a lot to learn about medicine and other professionals. 

There are of course exceptions. Since Paramedics may not be able to administer or even monitor some medications, the RN will either accompany or the hospital will give the med before the team leaves. If the Paramedic can "watch the pump" but not do much more, The sending facility's physician will issue an order for that med, it will be set up and included in the med list. 

Nurses in almost every work situation have protocols and standing orders. No they do NOT call the doctor for everything. Again, you don't understand how much there is to medicine besides just "O2". The basic first aid standing orders that EMTs have, almost any licensed professional in healthcare has.


----------



## emtfarva (Feb 20, 2009)

VentMedic said:


> You are greatly misinformed.
> 
> Did you know that several states now have specific PreHospital certifications for RNs? There RNs can work in both scene response and CCT IFT if needs. As well, do you know how many RNs do 911 scene response on HEMS? They provide the same skills as a Paramedic with the knowledge of an ICU/CCU/ED RN. I could also tell all about what Specialty (Peds, Neo) RNs do to stablilze a very long distance transport like from the islands or another country.
> 
> ...


I restated my quote on CCRN's. Answer this though, Why on most of my calls at SNF for Diff Breathing, do I find a Pt on a NC at 3-5 lpm from a concentrator rather than some type of mask on a O2 bottle? What I was taught in EMT school is if you don't have airway, you don't have a Pt. I took that for not only a patent airway but for O2 admind also. Maybe I am wrong because I don't have the education like you. Please explain how I am wrong.


----------



## CAOX3 (Feb 20, 2009)

This post went to hell quickly.

This place is a riot.  Medics continually bash EMTs in the head due to their lack of education, yet when the subject is broached about the relativity between nurse and paramedic everyone gets their panties in a bunch.

Their is no correlation between the two an RN is educated through traditional means most EMs providers are trained and thats a stretch.

As far as the original post, the thing that bothers me most is the fact that the crew *REFUSED *the call.  I dont know,  I work in a 911 system, is it common practise for an IFT ambulance to refuse calls because they dont feel comfortable with the situation?  I dont think there is a difference in training/education is there.  

Lets say A guy on the corner takes two in the chest, aint much me as a BLS provider,  you as an ALs provider, hell the community hospital down the street are going to do for this pt.  Do I have the right to say sorry bud your on your own here this is out of my realm of treatment?  No.  We treat and transport to the best of our ability.

There our a a million complaints that cant be handled by EMS providers.  We still transport, we dont leave them there because we dont feel comfortable.

This is insane, transport the F'n pt., treat to the best of your ability.  When done hand in your uniform because your an ______ ! (fill in the blank.)


----------



## VentMedic (Feb 20, 2009)

emtfarva said:


> I restated my quote on CCRN's. Answer this though, Why on most of my calls at SNF for Diff Breathing, do I find a Pt on a NC at 3-5 lpm from a concentrator rather than some type of mask on a O2 bottle? What I was taught in EMT school is if you don't have airway, you don't have a Pt. I took that for not only a patent airway but for O2 admind also. Maybe I am wrong because I don't have the education like you. Please explain how I am wrong.


 
Do you know what a concentrator is?

Do you know why patients in NHs and homecare patients are on concentrators?


----------



## amberdt03 (Feb 20, 2009)

Sasha said:


> EMS lines are dirty lines. People get infections from them, and sepsis has a disturbingly high mortality rate.
> 
> Saying nursing home nurses aren't trained for emergencies is BS. If things go south, I'd rather have a nurse than an EMT any day.



i agree that ems lines are dirty, but hospitals aren't much cleaner.  as as for nurses, i'd rather a nurse work a code than an emt too, but not a nursing home nurse. They are 2 way different levels.


----------



## VentMedic (Feb 20, 2009)

amberdt03 said:


> i agree that ems lines are dirty, but hospitals aren't much cleaner. as as for nurses, i'd rather a nurse work a code than an emt too, but not a nursing home nurse. They are 2 way different levels.


 
Have you read the hospital policies for starting ANY line inside a hospital?

Are you saying a hospital is dirtier than a ditch or homes you've been in? Where do you work? Is it in the U.S.? Do they not have accreditation? Or, are you also trying to just be insulting to hospital staff? 

There are many regulations as to why a NH does not have a crash or code cart. The nurses may once have been ICU trained/educated and ran codes but they must abide by the rules for the facility they work. The same goes for ambulances and EMS. Different states also have different licenses for IFT vehicles and EMTs can be found on many of them. 

The crew in the OP displayed little to no knowledge of *EMS*. But, should they be the blanket statement for ALL EMTs just like some have done here with nurses or hospitals? 

CAOX3





> This place is a riot. Medics continually bash EMTs in the head due to their lack of education, yet when the subject is broached about the relativity between nurse and paramedic everyone gets their panties in a bunch.


 
There is a huge difference between bashing and pointing out the inadequacies of EMS education. If you think EMTs have been bashed on *THIS forum*, you have truly led a sheltered life or have very thin skin. 

When some who have NO hospital experience and are in no way familiar with CCTs, HEMS, RNs or CCRNs but can state with their own perceived authority that they know exactly what these individuals can and can not, there lies the problem. Again, that dirty little word "EDUCATION" for some in EMS needs to be applied.


----------



## amberdt03 (Feb 20, 2009)

VentMedic said:


> Have you read the hospital policies for starting ANY line inside a hospital? Are you saying a hospital is dirtier than a ditch or homes you've been in? Where do you work? Is it in the U.S.? Do they not have accreditation? Or, are you also trying to just be insulting to hospital staff? There are many regulations as to why a NH does not have a crash or code cart. The nurses may once have been ICU trained/educated and ran codes but they must abide by the rules for the facility they work. The same goes for ambulances and EMS. Different states also have different licenses for IFT vehicles and EMTs can be found on many of them.



first of all, you need to take a chill pill. second of all I work the *biggest* ambulance company in the USA. Third of all, i never said anything insulting about hospital staff, but maybe towards nursing home staff. And last of all, I never said hospitals were dirtier than ems, i just said that they aren't that sterile as you make them seem.


----------



## Sasha (Feb 20, 2009)

> second of all I work the *biggest *ambulance company in the USA.



Cookie for you, then. Biggest doesn't always mean best, but that's beside the point.

Bash the nursing home nurses all you want, but remember when it comes right down to it, they still have more education than you. And as Vent stated, they could have way more emergency and critical care experience than the person they're handing their patients too.


----------



## JPINFV (Feb 20, 2009)

^
What does what ever size company you work for have anything to do with this? There are a ton of other people who work for AMR as well, and just being one in a herd of people doesn't bestow any sort of special authority to your posts.

edit: Damn it, Sasha, you snipped my post.


----------



## CAOX3 (Feb 20, 2009)

VentMedic said:


> When some who have NO hospital experience and are in no way familiar with CCTs, HEMS, RNs or CCRNs but can state with their own perceived authority that they know exactly what these individuals can and can not, there lies the problem. Again, that dirty little word "EDUCATION" for some in EMS needs to be applied.



Did I state that?  I dont think I did.  I stated there is a perception that paramedics and nurses are similarly the same.  There not.  There is a difference between education and training.  A biiiiiiiiig difference.

Dont misconstrude that a paramedic/EMT class held in the back of a garage on tuesday and wednesday nights in anyway constitutes education.   I may be some things, what I am not is confused in that reguard.


----------



## VentMedic (Feb 20, 2009)

CAOX3 said:


> Did I state that? I dont think I did. I stated there is a perception that paramedics and nurses are similarly the same. There not. There is a difference between education and training. A biiiiiiiiig difference.


 
You do realize RNs can challenge the Paramedic cert in many states? 

Or, they can take a transition program in the other states consisting of 100 - 200 hours for either a Paramedic cert or a PHRN (title varies per state). The field clinicals may be different as well as the extrication techniques but the majority of the medical skills are the same. RNs may also have a stronger medical education foundation than the majority of medic mill paramedics. If you want to close the loop holes that allow RNs to use your credential as a "cert", you need to support advanced education throughout EMS and that also includes raising the education for EMT-Bs.


----------



## Sasha (Feb 20, 2009)

> edit: Damn it, Sasha, you snipped my post.



But you worded it a lot better than I did, and with out the sarcasm!


----------



## BossyCow (Feb 20, 2009)

So am I the only one who's thinking that a little common sense and respect would have gone a long way on this call? Instead of following the letter of the law, and using their head for something other than a space holder for their ears, the EMS responders should have transported the pt. When we get all bent up about the ego issues of who has power in which situation or who has better skills in a given area, we are losing perspective. An emergency requires doing something right now. If I remember back to my initial ARC FA training.. that's how they define emergency. Should that action be done by an RN, EMT-B, EMT-P, Doc or NA? Are you suggesting that if a pt codes, we should all compare certs before beginning CPR???? No, the important thing is that CPR is initiated and quickly. 

I am going to be professional, courteous and respectful to everyone I run into on a call. I am going to be as polite to the CNA as I am to the Doc. Then I will do my job on the call. Doesn't seem all that difficult to me.


----------



## RESQ_5_1 (Feb 20, 2009)

Thanx for the info Vent. As far as how an ALS crew would run that call, the only thing I can't do is interpret the 12-lead. I can provide O2 (which we did). And I can start an IV (which occurred after the code). I can interpret 4-lead (not sure if that is definitive in this case. Could you elaborate). 

But, the pt crashed quickly. Within 2 minutes of our arrival and before we could even complete our first set of vitals.

As far as pulling IV's, our Hosp staff doesn't do that. I'm not sure how it's taught in the US, but we use aseptic techniques. ALcohol swab at the site, Don't touch the needle, don't remove the cathlon from the packaging until you are ready to use it, prevent the line from touching the ground, no contact with the IV bag at the point of line insertion as well as the part of the IV line that goes into the bag, etc, etc, etc. 

The OP's call is one where I would have transported as rapidly as possible to the ED while providing what care I could. If an ALS crew clears up that is close enough, then they can intercept. I don't see the point in delaying definitive care because I was uncomfortable with the call and felt it should go ALS.


----------



## RESQ_5_1 (Feb 20, 2009)

AMR is the largest Ambulance service in the US and owned by Laidlaw. Laidlaw is the largest *TRANSPORT* company in Canada. They also run school buses.


----------



## amberdt03 (Feb 20, 2009)

whatever i give up. i'm tired of people trashing me when all i am trying to do is state my opinion(thought that was the purpose of a forum) but i'm just a "stupid basic that doesn't know anything." for some reason people think that because i'm "just a basic" that i care nothing about education even though i'm constantly looking for ways to further my education.


----------



## CAOX3 (Feb 20, 2009)

VentMedic said:


> You do realize RNs can challenge the Paramedic cert in many states? .



Yes they can, however the medic cannot challange the RN. That was my point.


----------



## AJ Hidell (Feb 20, 2009)

amberdt03 said:


> whatever i give up. i'm tired of people trashing me when all i am trying to do is state my opinion(thought that was the purpose of a forum)


So you would deny others the right to give their opinions of your opinion?



> ...people think that because i'm "just a basic" that i care nothing about education even though i'm constantly looking for ways to further my education.


It's not hard to find those ways, especially in Dallas.  How long have you been looking for them, and what have you found?  What have you done to further your education so far?  I am very familiar with the Dallas area and would be happy to help you find ways to further your education.


----------



## AJ Hidell (Feb 20, 2009)

CAOX3 said:


> Yes they can, however the medic cannot challange the RN. That was my point.


They can.  It's just not as simple as sitting down for a half-hour test.  You have to actually get real education first.


----------



## amberdt03 (Feb 20, 2009)

AJ Hidell said:


> So you would deny others the right to give their opinions of your opinion?
> 
> 
> It's not hard to find those ways, especially in Dallas.  How long have you been looking for them, and what have you found?  What have you done to further your education so far?  I am very familiar with the Dallas area and would be happy to help you find ways to further your education.




i believe that there is a big difference in giving an opinion and talking down to someone. I can understand if it was someone whose fresh out of emt school, but i've been on the streets for 3 years now so granted i obviously don't know everything but i sure know alot more than someone fresh out of school. 

so far i've taken a&p1, pharmacology. i am currently taking a&p2 and microbiology. i am also interested in taking pepp and phtls(don't have time to take these till after this semester) and i've been reading a book given to me by my old partner about ekgs(want to get a head start) but i haven't been able to read it due to this semester of classes. Oh and i have a medic textbook that i started(again for a head start)  and thanks for being nice, any advice i'd gladly take.


oh and i have a question, did you get your medic first or rn? i want to get my rn since it takes longer and then the medic. just was wondering what you think about that?


----------



## reaper (Feb 20, 2009)

amberdt03 said:


> whatever i give up. i'm tired of people trashing me when all i am trying to do is state my opinion(thought that was the purpose of a forum) but i'm just a "stupid basic that doesn't know anything." for some reason people think that because i'm "just a basic" that i care nothing about education even though i'm constantly looking for ways to further my education.



Someone may disagree with your opinion and that is fine. Everyone has the right to their opinions and everyone has the right to argue against it.

You are doing great by furthering your education. Kudos to you on that part.

Bringing up AMR is not going to get your posts any more credentials. Sorry, but they have been a joke for years. They are a great company to get a start at, while you work your way to a better place!


----------



## AJ Hidell (Feb 20, 2009)

amberdt03 said:


> i believe that there is a big difference in giving an opinion and talking down to someone.


Unfortunately, in the written environment of the Internet, it's almost impossible to disagree with someone's opinion without causing some level of offense or insult.  That's the nature of it all.  You can't take every disagreement personal. But, on the other hand, I agree that there is no excuse for blatant disrespect.  We can have disagreement without disrespect.



> I can understand if it was someone whose fresh out of emt school, but i've been on the streets for 3 years now


In my world, three years is "fresh out of EMT school", lol.  Three years -- or even ten years -- of EMT experience means nothing.  It is the quality of that experience that holds the possibility of meaning something.  We (or at least I) don't know what that experience really consists of.  Personally, I give you a LOT more credit for the education you have achieved since EMT school (which significantly surpasses even most paramedics) than I do for your experience.  Education provides the foundation for your knowledge and experience, not driving an ambulance.



> ...so granted i obviously don't know everything but i sure know alot more than someone fresh out of school.


Not necessarily.  Some EMT schools turn out well trained and well prepared providers.  Other EMT schools turn out people without a clue, and they remain clueless through five years of driving an IFT van.  Again, time as an EMT really doesn't mean anything on the surface.



> so far i've taken a&p1, pharmacology. i am currently taking a&p2 and microbiology. i am also interested in taking pepp and phtls(don't have time to take these till after this semester) and i've been reading a book given to me by my old partner about ekgs(want to get a head start) but i haven't been able to read it due to this semester of classes. Oh and i have a medic textbook that i started(again for a head start)  and thanks for being nice, any advice i'd gladly take.


Excellent!  You are doing all the right things.  Every student can always reach down deep and give their education a little more effort.  Do that now, while you are establishing your foundation.  If the sciences come easy for you, don't settle for that minimum effort necessary to pass the tests with a good score.  Strive for excellence.  Strive to be the very best that you can possibly be.  Get the most out of those courses, because there is no second chance to build a foundation.

As for the "head start", EKGs is really the only topic that I recommend for students to start early.  This is because so many schools just really suck at teaching them.  They overcomplicate it with poor educational technique.  The orange "Rapid Interpretation of EKGs" book by Dubin is the only teacher you will ever need for EKGs.  Seriously.  It's a self-paced, programmed learning text that takes you from the very basics, all the way through advanced 12-lead interpretation, in as quickly as a couple of days, depending upon your pace.  Each page builds on the learning of the previous page, like a workbook.  There is no easier or better way to learn EKGs.  Other than EKGs, the only head start that you need, or that I recommend, is that provided by A&P, Micro, Pharm, Algebra, Communications, Sociology, and Psychology.  After all that, paramedic curriculum should come very easily to you.  Any attempt to "get ahead" by randomly reading the textbook ahead of time -- out of order and out of context -- can prove counterproductive, so I do not recommend it.



> oh and i have a question, did you get your medic first or rn? i want to get my rn since it takes longer and then the medic. just was wondering what you think about that?


You are spot-on in your thinking.  Paramedicine is a very narrowly focused and specific education and practice style.  Nursing is very broad based, intending to establish a foundation for practice on all persons, to be focused later by the individual practitioner.  By choosing nursing first, you enter paramedicine with that broad foundation to build upon, and it makes you ten times the practitioner that you would ultimately become without it.  Paramedics are taught a very myopic, cookbook approach to patient care, having very little true understanding of the conditions they are treating, or even the rationale for that treatment.  As a nurse entering paramedicine, you will have that foundation, making it MUCH easier to grasp the concepts of paramedic practice.  As a nurse entering paramedicine, you won't have to worry about the quality of your school or instructors.  You won't have to worry if they know what they are doing, or if they are just teaching you to pass the test.  You already know more medicine than them.  All you have to learn from them as a nurse is simple skills, and how to function in the field.  Nursing school before paramedic school is the very best possible course for professional preparation.  In fact, I have come to believe that it should be a requirement, as it is in countries where EMS blows the US completely away.

Unfortunately, I was a paramedic for many years before I went to nursing school.  I didn't think I needed all that book learnin.  I thought they should just give me a nursing license, since I already had teh aw3some skillz.  I was wrong.  I didn't know jack.  And if I had it to do all over again, I would have gone to nursing school right out of high school, before EMT school or paramedic school.  There is absolutely no disputing that it is the best possible way to prepare a pre-hospital provider.

Best of luck!


----------



## amberdt03 (Feb 20, 2009)

AJ Hidell said:


> And if I had it to do all over again, I would have gone to nursing school right out of high school, before EMT school or paramedic school.



when i first went to college, i was pre nursing, this was before my emt days. i came from a high school that i really didn't have to study to make b's so i never really learned how. my first year was an eye opening experience. i ended up dropping out after my first year and taking a year off. that is when i decided to go to emt school and work my way up. and a lot of the advice i've gotten from the nurses i work with now, was the same. do nursing first, then medic. 

what do you think about the pepp and phtls classes? and is it possible for an emt to take an acls class, granted i know that i wouldn't be able to truly use it, but thought it would be cool.(yeah i'm a nerd)

oh that is the book that i was reading about ekgs. its funny cause he said the same thing about it being the only book i would need. lol.


----------



## amberdt03 (Feb 20, 2009)

reaper said:


> Someone may disagree with your opinion and that is fine. Everyone has the right to their opinions and everyone has the right to argue against it.
> 
> You are doing great by furthering your education. Kudos to you on that part.
> 
> Bringing up AMR is not going to get your posts any more credentials. Sorry, but they have been a joke for years. They are a great company to get a start at, while you work your way to a better place!



oh i am totally fine with someone disagree with my opinions, its the basis of life, it just seemed like sometimes people were degrading towards me(although i am a female, and i'm probably over reacting ) 

thanks, do you have any suggestions on what else i can do to further my education(other than going to medic and nursing school)?

and i'm not trying to get brownie points by mentioning that i work for amr, its just ventmedic p*ssed me off. and i agree that amr is a joke, but at the management level, not the emt or medic level. the upper management only cares about how they can screw over employees, and make more money. i think a better company to work for would be Medstar(which has a closed contract with Fort Worth) they make their emt's know how to read strips, so if the medic is busy tubing or something else, they can tell them something doesn't look right. they also expect them to know indications and contraindications for all the drugs even though they can't use them, but they will know which ones to grab without the medic having to tell them. the only problem with them is that they won't hire you if your in school, and they won't work around your school schedule, and my education is more important to me than getting better experience.


----------



## Sasha (Feb 20, 2009)

> thanks, do you have any suggestions on what else i can do to further my education(other than going to medic and nursing school)?



I have one.

Learn from others around you. VentMedic "p!ssed you off" but she's extremely intelligent, educated and very helpful if you ask her questions instead of looking for an insult in her posts. A lot of people who post here are helpful and phenomenally smart, but they're not there to hold your hand and give you fuzzies. If you can't take the heat...



> although i am a female



What does that have to do with ANYTHING?


----------



## medic417 (Feb 20, 2009)

Sasha said:


> What does that have to do with ANYTHING?



We all know females are bad medics.

Actually I think she was joking as was I.


----------



## Sasha (Feb 20, 2009)

medic417 said:


> We all know females are bad medics.
> 
> Actually I think she was joking as was I.



Aren't you a female?


----------



## BossyCow (Feb 20, 2009)

Sasha said:


> Aren't you a female?



I've always assumed Medic417 was female... it would certainly explain the PMS.


----------



## medic417 (Feb 20, 2009)

Sasha said:


> Aren't you a female?




Not based on the A&P education I've gotten.  :wacko:


----------



## medic417 (Feb 20, 2009)

BossyCow said:


> I've always assumed Medic417 was female... it would certainly explain the PMS.



Well we know what assuming does.  Makes an a.. out of U and me.  No PMS for me I just come accross a little brash at times.


----------



## amberdt03 (Feb 20, 2009)

Sasha said:


> I have one.
> 
> Learn from others around you. VentMedic "p!ssed you off" but she's extremely intelligent, educated and very helpful if you ask her questions instead of looking for an insult in her posts. A lot of people who post here are helpful and phenomenally smart, but they're not there to hold your hand and give you fuzzies. If you can't take the heat...
> 
> ...



yeah i was just joking. and i know she's intelligent, i've already have learned from some of her posts and from others. as medic417 already knows, i tend to react about certain things harshly before actually thinking about what was meant.


----------



## amberdt03 (Feb 20, 2009)

medic417 said:


> No PMS for me I just come accross a little brash at times.



Men, can't live with them, can't kill them. lol.


----------



## JPINFV (Feb 20, 2009)

medic417 said:


> Not based on the A&P education I've gotten.  :wacko:



Klinefelter's syndrome maybe?


----------



## medic417 (Feb 20, 2009)

JPINFV said:


> Klinefelter's syndrome maybe?



Ouch now I will go cry then return and terrorise you.


----------



## AJ Hidell (Feb 20, 2009)

amberdt03 said:


> what do you think about the pepp and phtls classes?


Sure.  Those are very fundamental classes, and the information in them is beneficial at all levels.  Highly recommended, especially the PHTLS.




> and is it possible for an emt to take an acls class, granted i know that i wouldn't be able to truly use it, but thought it would be cool.(yeah i'm a nerd)


Depends on the course and course coordinator.  Some let anyone in.  Money is money.  Others are selective, because they don't want to get bogged down answering questions that the students should already know at that level.  Regardless, I don't particularly recommend ACLS for basics.  Not because it is over your head, but because it simply is not a teaching course.  They don't teach you anything.  They very rapidly review information that you are supposed to already know from reading the text ahead of time.  They check you off on skills you are supposed to already know ahead of time, then they give you a card that really means nothing.  If ACLS were run as a truly educational instruction course, as it was in the old days, I might feel different about it.  Unfortunately, today it is going to only leave you with a lot of questions, and very few answers.  They're not going to teach you to do any skills.  It's really a waste of time for a basic.  And the basics I've seen do it come out with an attitude that they are "qualified" to do everything a medic does, and the medics end up hating them, lol.  It's just not worth it.



> oh that is the book that i was reading about ekgs. its funny cause he said the same thing about it being the only book i would need. lol.


No doubt.  There is always more to learn.  And there are a few other books that go deeper into the pathophysiology, as well as the more obscure conditions, and you should check those out after medic school.  But for a foundation that is better than most medics in this country, finish that book a couple of times, and you can sleep through EKGs in school.


----------



## amberdt03 (Feb 20, 2009)

Sasha said:


> I have one.
> 
> Learn from others around you. VentMedic "p!ssed you off" but she's extremely intelligent, educated and very helpful if you ask her questions instead of looking for an insult in her posts. A lot of people who post here are helpful and phenomenally smart, but they're not there to hold your hand and give you fuzzies. If you can't take the heat...



another thing is, maybe some of you medics shouldn't think that every emt is the same. granted when it comes to the amount of medical care that can be provided is the same, we are not all the same when it comes to education. so don't think that every single emt is stupid(i use that word, cause i can't think of a better one that will get my point across)


----------



## amberdt03 (Feb 20, 2009)

AJ Hidell said:


> And the basics I've seen do it come out with an attitude that they are "qualified" to do everything a medic does, and the medics end up hating them, lol.



who wouldn't hate them if they had that mentality? lol


----------



## JPINFV (Feb 20, 2009)

amberdt03 said:


> who wouldn't hate them if they had that mentality? lol



Because it's like a paramedic walking into an ER and thinking that they qualified to do everything a physician can. Unfounded arrogance is not a good thing to have.


----------



## JPINFV (Feb 20, 2009)

amberdt03 said:


> another thing is, maybe some of you medics shouldn't think that every emt is the same. granted when it comes to the amount of medical care that can be provided is the same, we are not all the same when it comes to education. so don't think that every single emt is stupid(i use that word, cause i can't think of a better one that will get my point across)



You have to treat every EMT-B you encounter but don't know as you would the average EMT. For example, I don't go around expecting to do more than I already do because I'm an EMT-B with an undergrad and working on a graduate degree. There isn't an EMT-JPINFV level (yet), therefore if I'm working with someone I don't know, it's reasonable to for me to expect to be treated the same as any other EMT-B. To be honest, frank, and serious, unfortunately having an EMT-B certification isn't much to hee and haw over. In the health care world, it simply isn't that hard or demanding of a certification/level to achieve.


----------



## emtfarva (Feb 20, 2009)

RESQ_5_1 said:


> AMR is the largest Ambulance service in the US and owned by Laidlaw. Laidlaw is the largest *TRANSPORT* company in Canada. They also run school buses.


AMR is not owned by laidlaw anymore. They bought themselves and became EMSC.


----------



## emtfarva (Feb 20, 2009)

VentMedic said:


> Do you know what a concentrator is?
> 
> Do you know why patients in NHs and homecare patients are on concentrators?


Do you always answer questions with a question?

A concentrator takes the 21% O2 in the air and concentrates it so it becomes a higher % of O2, but it does not provide 100% O2. Yes, 'cause it is cheaper and easier to use electricity than using bottles that have to be refilled. But my Question was why are Pt's with diff breathing are not placed on 99% O2 by NRB instead of being on a concentrator at 2-5 litters when every SNF has O2 bottles?


----------



## AJ Hidell (Feb 20, 2009)

Because few, if any patients need 99 percent oxygen.


----------



## emtfarva (Feb 20, 2009)

Someone that is breathing 35 times a minute with a B/P 50 systolic and can not speak? This person does not need at least a mask. UOA the Pt was found on a simple face mask at 6 lpm. Or someone breathing 4 times a minute, doesn't need to be bagged? This person wasn't even on O2. The call came in as a sz. Where was the O2? I was taught to Provide O2 for these Pt's. I am not bashing you personally, but why do not LPNs and Rns at SNF just use common sense.


----------



## DevilDuckie (Feb 20, 2009)

I still don't get why we need to put people on 15L of oxygen.. As long as that bag is full... It's not like we can shove more down their throat.


----------



## emtfarva (Feb 21, 2009)

DevilDuckie said:


> I still don't get why we need to put people on 15L of oxygen.. As long as that bag is full... It's not like we can shove more down their throat.


It is not about forcing it down, it is about keeping the bag full. If you can keep the bag full at 10 l then use 10.


----------



## reaper (Feb 21, 2009)

Yes, some NH pt's need more O2, but you may only have 10 pt's a year that really need a NRB @ 15L. EMT's are pushed on High Flow O2 and that is the biggest joke of all!


----------



## DevilDuckie (Feb 21, 2009)

emtfarva said:


> It is not about forcing it down, it is about keeping the bag full. If you can keep the bag full at 10 l then use 10.



Exactly, that's what I do.. I just don't believe in giving every patient "High Flow O2", it's like the instructors are too lazy to teach anything else.


----------



## VentMedic (Feb 21, 2009)

emtfarva said:


> Do you always answer questions with a question?
> 
> A concentrator takes the 21% O2 in the air and concentrates it so it becomes a higher % of O2, but it does not provide 100% O2. Yes, 'cause it is cheaper and easier to use electricity than using bottles that have to be refilled. But my Question was why are Pt's with diff breathing are not placed on 99% O2 by NRB instead of being on a concentrator at 2-5 litters when every SNF has O2 bottles?


 
Asking questions is the best way to test one's knowledge.

Where to begin with O2 therapy?

An O2 concentrator scrubs the Nitrogen from the air and leaves behind the O2. Units can deliver between 50 - 95% O2.

However, do you know what determines the amount of inspired FiO2 for either a NC or NRBM? 

*DevilDuckie*


> Exactly, that's what I do.. I just don't believe in giving every patient "High Flow O2", it's like the instructors are too lazy to teach anything else.


A NRBM is by definition not a high flow O2 device. EMT(P)s just got into the habit of saying that since it sounds like a whole bunch of O2 when you say 15L/m and that is the definition EMS providers have adopted. Unfortunately this makes it very difficult to teach the very basic prinicples of CPAP, ventilators or just ventilation. It can hard to retrain someone into a more scientific and appropriate definition.


----------



## ffemt8978 (Feb 21, 2009)

And it wasn't till about two years ago that Basics in my area were allowed to give anything OTHER than 15LPM via NRB per protocol.


----------



## AJ Hidell (Feb 21, 2009)

emtfarva said:


> I was taught to Provide O2 for these Pt's.


Wonderful.  But were you taught the physiological basis for doing so?  Were you taught how to determine how much they need, when they no longer need it, and the pathophysiology of why they needed it in the first place?  Your questions indicate that this may not have been the case.


----------



## DevilDuckie (Feb 21, 2009)

I'm a fan of the simple mask my self.


----------



## VentMedic (Feb 21, 2009)

DevilDuckie said:


> I'm a fan of the simple mask my self.


 
That piece of junk needs to be banished. Who only has a minute volume of 6 - 10 L if they are an adult and if they are in distress?  I have used one in 5 years in the hospital and definitely not on Flight.


----------



## Sasha (Feb 21, 2009)

VentMedic said:


> That piece of junk needs to be banished. Who only has a minute volume of 6 - 10 L if they are an adult and if they are in distress?  I have used one in 5 years in the hospital and definitely not on Flight.



Don't mind him, he's just trying to up his post count.

What device in the hospital/flight do you use to deliver high flow oxygen?


----------



## reaper (Feb 21, 2009)

I have not seen one on an ambulance in years?????


----------



## VentMedic (Feb 21, 2009)

Sasha said:


> What device in the hospital/flight do you use to deliver high flow oxygen?


 
The OxyMask which can go from 1L to 15L using the same device.  

For comfort in the hospital, we may use a High Flow NC which can go up to 32 Liters per minute.  There is also a model that can go up to 40L/min.


----------



## Sasha (Feb 21, 2009)

VentMedic said:


> The OxyMask which can go from 1L to 15L using the same device.
> 
> For comfort in the hospital, we may use a High Flow NC which can go up to 32 Liters per minute.  There is also a model that can go up to 40L/min.



Doesn't that dry out their nose pretty bad?


----------



## VentMedic (Feb 21, 2009)

Sasha said:


> Doesn't that dry out their nose pretty bad?


 
Heated humidification close to the body's norm....

If you blow hard against your hand, that is about 350 - 400 L/M but you don't feel it because it is warmed and humidified to a tolerable level by your body.


----------



## amberdt03 (Feb 21, 2009)

i have a question. it seems like regardless what i do, it seems wrong. i've came across a COPD pt with diff breathing(according to the NH). They are on 2LPM O2 via NC with sat's at 86 and RR at about 26/min. now here is where i have a problem. do you leave them on the canula at 2LPM, or do you put them on a NRB and up the flow. i've txp with the canula and when we got to the er they put them on NRB and i've txp after putting them on NRB and got to the er where they put them back on canula. granted i do know that high flow O2 is bad for COPDer's but my understanding was that if it was bad only if you had them on high flow for an extended period of time.


----------



## CAOX3 (Feb 21, 2009)

Never withold oxygen.

There are two differnet kinds of COPD pts.

Some rely on hypoxic drive, others rely CO2.

In theory if you give to much oxygen to a pt that relies on hypox drive you can cause the to to stop breathing.

Most COPd pts rely on CO2.  So it shouldnt be an issue.

The best answer is to titrate the O2 till the pt is comfortable.  These people usually live in the high 80's low 90's.  So there is no need for SPO2 of 99%.  Just until comfort is achieved


----------



## medic417 (Feb 21, 2009)

ffemt8978 said:


> And it wasn't till about two years ago that Basics in my area were allowed to give anything OTHER than 15LPM via NRB per protocol.




Wow surely you joke.  Even as a first responder many many years ago I could place on O2 based on need rather than a set amount.


----------



## amberdt03 (Feb 21, 2009)

CAOX3 said:


> Never withold oxygen.
> 
> There are two differnet kinds of COPD pts.
> 
> ...




right i would usually only put them on 10lpm and their sat's would usually go up to about 95 and i'd be happy with that.


----------



## Sasha (Feb 21, 2009)

VentMedic said:


> Heated humidification close to the body's norm....
> 
> If you blow hard against your hand, that is about 350 - 400 L/M but you don't feel it because it is warmed and humidified to a tolerable level by your body.



How often do you have a patient that actually requires high flow oxygen as oppose to a cannula at 2lpm? Is that something they'd continue after discharge from the hospital?


----------



## CAOX3 (Feb 21, 2009)

amberdt03 said:


> right i would usually only put them on 10lpm and their sat's would usually go up to about 95 and i'd be happy with that.



Right.  Just keep them oxygenated.


----------



## Ridryder911 (Feb 21, 2009)

I'll throw a monkey wrench into it. How about a Venturi mask? I am sure most were never shown or taught these as well. Personally, I found them much tolerable for COPD patients as well as having the ability to know what percentage I am administering. 

Vent I have not seen them used in years in both settings. Was there a problem with them, that I was not aware of or they fell out of favor due to newer devices? 

In regards to not being taught "15 lpm NRBM"; I don't think its about being lazy. Rather the emphasis is if you want your student to pass the written/practical they better answer such. Again, the reason is because the lack of education the EMT recieves and is perceived it is much better to see the patient with oxygen than without. As I had seen many patients arrive with oxygen per NRBM re-breathing their own Co2. 

The other reason is much more simpler. It is doubtful many of the EMT instructors know much better themselves. As it does not require much to become one; other than an 39 hour instructor course and maybe experience requirements. 

R/r 911


----------



## CAOX3 (Feb 21, 2009)

Ridryder911 said:


> I'll throw a monkey wrench into it. How about a Venturi mask? I am sure most were never shown or taught these as well. Personally, I found them much tolerable for COPD patients as well as having the ability to know what percentage I am administering. R/r 911



Yeah we used to carry them,  they came in very handy.  They have gone away.  Could it be a cost issue?


----------



## medic417 (Feb 21, 2009)

Ridryder911 said:


> I'll throw a monkey wrench into it. How about a Venturi mask? I am sure most were never shown or taught these as well. Personally, I found them much tolerable for COPD patients as well as having the ability to know what percentage I am administering.
> 
> Vent I have not seen them used in years in both settings. Was there a problem with them, that I was not aware of or they fell out of favor due to newer devices?
> 
> ...



Still around.  For those that have not seen them or used them here is a picture.  http://img1.tradeget.com/sudarsurgicals\CM8Q0D6M1product3.jpg







I agree as EMS has been dumbed down and is being dumbed down further by some organizations many procedures that could benefit patients are being ignored.


----------



## medic417 (Feb 21, 2009)

Here is a description from that unreliable wiki.

http://en.wikipedia.org/wiki/Venturi_mask


----------



## CAOX3 (Feb 21, 2009)

When I finally learned the color correlation to the percentage of O2 they were gone.


----------



## medic417 (Feb 21, 2009)

CAOX3 said:


> When I finally learned the color correlation to the percentage of O2 they were gone.




Why gone?  They are still out there.  Used one a couple of weeks ago.

http://www.sudarsurgicals.com/F18971/venturi_mask_kit.html

http://www.resto-medical.com/Venturi-mask-97.html


----------



## Sasha (Feb 21, 2009)

My old service still carried them for trache patients.


----------



## CAOX3 (Feb 21, 2009)

medic417 said:


> Why gone?  They are still out there.  Used one a couple of weeks ago.QUOTE]
> 
> I dont know why we dont carry them any longer.  They were great.
> 
> ...


----------



## ffemt8978 (Feb 21, 2009)

medic417 said:


> Wow surely you joke.  Even as a first responder many many years ago I could place on O2 based on need rather than a set amount.



Nope, it was written in our protocols that basics could only give 15lpm O2 via NRB.  Intermediates and above could titrate O2 to maintain pulse ox greater than 90%.


----------



## medic417 (Feb 21, 2009)

ffemt8978 said:


> Nope, it was written in our protocols that basics could only give 15lpm O2 via NRB.  Intermediates and above could titrate O2 to maintain pulse ox greater than 90%.



That is scary that the medical director would not be willing to require that the basics be educated to a point that they felt they could allow better use of O2 therapy.  

Hopefully that will not be an issue in the near future as education reform takes place nationwide.


----------



## VentMedic (Feb 21, 2009)

amberdt03 said:


> i have a question. it seems like regardless what i do, it seems wrong. i've came across a COPD pt with diff breathing(according to the NH). They are on 2LPM O2 via NC with sat's at 86 and RR at about 26/min. now here is where i have a problem. do you leave them on the canula at 2LPM, or do you put them on a NRB and up the flow. i've txp with the canula and when we got to the er they put them on NRB and i've txp after putting them on NRB and got to the er where they put them back on canula. granted i do know that high flow O2 is bad for COPDer's but my understanding was that if it was bad only if you had them on high flow for an extended period of time.


 
As stated, do not withhold oxygen.

There are many types of COPD patients and less than 5% within this classification are CO2 retainers. Long term COPD patients will almost always have some type of cardiovascular problems which must also be treated by O2 because their potential is more deadly than a person becoming somnolent. You are trained in the use of a BVM for those that do become somnolent or have depressed respirations and it may not be because of the FiO2 you are giving. 

That NC can also go up to 6 L/m. 

If your instructors would take time to explain how minute volume influences FiO2, it would make things clearer.

If a patient is accustomed to breathing at a minute volume of 6 L/m on a NC at 2 L/m and then their minute volume become 12 L/m, the NC may have to be increased to maintain the same FiO2. The textbook values for FiO2 at the different liter flows are for a normal patient breathing a textbook normal minute ventilation at rest without distress. The patient may not need that much more O2 but just enough to keep their inspired FiO2 within a good range. 

For a person with a greatly increased minute volume or each tidal volume, that 2 L of O2 with be diluted to almost 21% or room air. 

If you put that same 2 liters or even 1 liter on a baby by NC, you may be meeting their entire minute volume and are delivering almost 100% O2. That is why blenders mixing air and O2 are used for them when they way NCs. If the blender is set at 28%, a 1 liter NC can give a small baby close to 28% with little dilution from the room air. 

A litte side note, for a patient to qualify for home O2 by insurance standards, including Medicare, we have to document an SpO2 of less than 86% or a PaO2 of 55 mmHg. However, that does not mean they should stay at that level which is the reason for the home O2. Many complications occur if their body stays at a very low PaO2 for any length of time. Some are sensitive very quickly if their PaO2 drops for any length of time if they also have cardiovascular problems.

If you get involved in IFTs of almost any type, you should become familiar with the different classifications of O2 equipment. A "true" high flow device may not always deliver a high FiO2. 
A venturi mask is a high flow device even if it is running at what EMS providers believe to be low flow. This is because venturi masks are able to provide total inspiratory flow at a specified FIO2. A NRBM cannot always do that and is considered a low flow mask.

The amount of oxygen going into the O2 device does not necessarily mean it is a high flow or even low flow device. The device must be able to provide the total inspiratory flow. Thus, devices are classified whether they meet the true definition of flow and by their FiO2 delivery. However, air entrainment systems may have their limitations at some point. 

Study how you O2 device works and you won't have to rely on memorizing a recipe for each situation. Learn gas laws, oxyhemoglobin dissociation curve, venturi effect and bernoulli's principle. 

Here's some good reading:
http://www.dmacc.cc.ia.us/instructors/kegeorge/prac5/Oxygen.htm

http://www.salisbury.edu/healthsci/resp/classes/lrjoyner/fall/RESP301/O2Tx.htm
This is the explanation the medicine world is leaning toward for an explaination for increased PaCO2 in a COPD patient.


> High levels of O2 may disrupt the normal V/Q balance, causing an increase in the VD/VT ratio and a rise in paco2.


 
AARC O2 guidelines for Peds and infants
http://www.rcjournal.com/cpgs/soddnppcpg-update.html

AARC - adults
http://www.rcjournal.com/cpgs/otachcpg-update.html

AARC - Homecare or Nursing homes and LTC facilities
http://www.rcjournal.com/cpgs/pdf/08.07.1063.pdf

Hypoxic Drive theory disputed for other causes
http://www.rcsw.org/Download/2004_RCSW_conf/The death of the hypoxic drive.ppt

Hypoxic drive references for those that might want more reading on the subject.
http://www.rcsw.org/Download/2004_RCSW_conf/The death of the hypoxic drive studies cited in.doc

One also must understand the relationship between ventilation and perfusion to provide effective O2 therapy.

Good Basic powerpoint:
http://www.clt.astate.edu/agrippo/RESPIRATORY DISEASESf03.ppt


http://www.cardionursing.com/pdfs/Ventilation-Perfusion-Diffussion-and-More.pdf

http://www.uams.edu/m2008/notes/phys/pdf/March 22 Ventilation Perfusion Relations.pdf


For those of you who want a more advanced approach to ABGs or acid base analysis:
http://www.rcsw.org/Download/2006_RCSW_conf/Presentation 2006 RCSW Acid Base Analysis.ppt

Medicine is constantly evolving with new research published everyday. There may be not just one correct answer for every problem. However, if you don't understand the basic fundamentals or principles for any device or therapy, you will just be following a recipe.


----------



## VentMedic (Feb 21, 2009)

Sasha said:


> My old service still carried them for trache patients.


 
Venturi Masks are considered high flow devices. That little colored piece of plastic mask is the same device used on their hospital aerosol bottle which uses the venturi principle for air entrainment as well as providing a high flow. If you were to just put a NRBM or Simple mask over the trach, you would be restricting their inspiratory flow since these devices can not provide a high flow to meet the patient's demands. 

The same principle used with all those pretty little colored venturi devices is found in many devices used for respiratory therapy.


----------



## VentMedic (Feb 21, 2009)

Sasha said:


> How often do you have a patient that actually requires high flow oxygen as oppose to a cannula at 2lpm? Is that something they'd continue after discharge from the hospital?


 
High Flow Nasal cannulas are now used very frequently. The work great in neonatal with flows up to 8 liters and can be better tolerated than some other devices.

For adults, we prefer them to masks since the patient can feel less confined and with the HiFlow NC it is easier to achieve an adequate FiO2 and still meet the patient's total inspiratory requirement. 

The pt can also drink and eat with these HiFlow NC. Some patients' lungs have deteriorated to the point where their FiO2 requirements are very high. 

We may also use these devices in comfort care for the patient who is alert and still wants some quality time talking with their family.


----------



## medic417 (Feb 21, 2009)

VentMedic said:


> High Flow Nasal cannulas are now used very frequently. The work great in neonatal with flows up to 8 liters and can be better tolerated than some other devices.
> 
> For adults, we prefer them to masks since the patient can feel less confined and with the HiFlow NC it is easier to achieve an adequate FiO2 and still meet the patient's total inspiratory requirement.
> 
> ...



So in the field would it be easy to identify that the patient is on HiFlow NC rather than the 2LPM or less that many are on?  I have seen what you describe at the hospital but am not aware of seeing one in the home before.


----------



## VentMedic (Feb 21, 2009)

medic417 said:


> So in the field would it be easy to identify that the patient is on HiFlow NC rather than the 2LPM or less that many are on? I have seen what you describe at the hospital but am not aware of seeing one in the home before.


 
At this time HiFlow NC are not common yet in homecare since they have a high O2 consumption and require a 50 psi outlet. However, some LTC facilities may use them. It may look like an IV pump attached to a nasal cannula. Some models may look like a large heated humidifier on an IV pole. Some have blenders either internal or external to adjust the FiO2.

Vapotherm is one example.
http://www.vtherm.com/products/precision/default.asp

Good article on high flow O2 therapy and cost effective concerns.

For hurricane season we also make sure a supply of oxgen conserving nasal cannulas are available. 

Example:
Oxymizer
http://www.mhoxygen.com/images/Oxymizer.pdf


----------

