# About EMT intermediate



## word2yamutha (Sep 7, 2009)

I was wondering why the state of Missouri doesn't recognize EMT-I's?  Basically here In MO you go from basic straight to paramedic.


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## Ridryder911 (Sep 7, 2009)

word2yamutha said:


> I was wondering why the state of Missouri doesn't recognize EMT-I's?  Basically here In MO you go from basic straight to paramedic.



Because they were smart. They foreseen what other states did not and do not have multi labels or half excuses, it's either all or nothing. So many get caught in the trap of ..."almost like or similar to" in comparison to Paramedic level. 

I discussed this over 10 years ago with MO State EMS office and wished my state had went that route as well. Now, almost every other state is considering the same idea (especially if there more money). 

R/r 911


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## akflightmedic (Sep 7, 2009)

It is a good thing, Florida does not recognize Intermediates either.

It is basic or medic....period.


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## Sapphyre (Sep 7, 2009)

neither does California (with very few exceptions).


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## Lifeguards For Life (Sep 7, 2009)

agree with ak and rid. in florida, and i like there no being any middle ground, all or nothing.
I think someone on this forum had said that getting an EMT-I only shows you want the skills but not the knowledge of why you're doing these skills. I don't support the idea of multiple half way levels


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## 8jimi8 (Sep 7, 2009)

in defense of intermediates.

i think it is good as a way to begin practicing very basic "paramedic skills"

not that you aren't getting any education for it.  Can you honestly claim that intermediates learn nothing to back up these "skills?"

And as practice i mean... while you are continuing on to the paramedic level.  It will take most intermediates at least a year after completing intermediate to get to the paramedic level. 

So why not have a year of starting IVs, intubating people and beginning to interpret ECGs to make the transition into being a paramedic smoother?

Just so you don't have someone who's only been a basic stepping out into the paramedic role like a deer caught in headlights.


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## Lifeguards For Life (Sep 7, 2009)

8jimi8 said:


> in defense of intermediates.
> 
> i think it is good as a way to begin practicing very basic "paramedic skills"
> 
> ...



why not jump straight into medic class? as my state does not recognize I's everyone in paramedic class has more or less jumped straight in. I went straight from emt to paramedic. Took the NREMTB about a week after paramedic school started. I like the views generally supported here about needing the knowledge, knowing when and why you perform a certain intervention, not just doing skills under supervision of a medic. To me it seems that if one understands why they are perfroming a skill, learning the physical skill would be the easy part


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## Flight-LP (Sep 7, 2009)

8jimi8 said:


> Can you honestly claim that intermediates learn nothing to back up these "skills?"
> 
> So why not have a year of starting IVs, intubating people and beginning to interpret ECGs to make the transition into being a paramedic smoother?
> 
> Just so you don't have someone who's only been a basic stepping out into the paramedic role like a deer caught in headlights.



From the mouth of a Texas educator, yes I can ascertain that the intermediate level focuses mainly on the skills set and not the pathophysiology behind electrolyte disturbances and the carbonic acid buffering system. Electrocardiography is nowhere in the "I" curriculum.

So why not have people out there playing "intro paramedic"? For one, it isn't needed and honestly the time spent in an intermediate class can be spent in a paramedic class with no additional time spent and no worries about getting a partial half a$$ed education. Secondly, there is absolutely no need to dip the student's toes in the water. They can dive right on it! Thousands of students have gone straight into Paramedic school without an issue. Its done every year, it is my personal recommendation to all of my EMT-B graduates, and it allows for a reduced number of ignorant habits based on the personal opinion of the student vs. sound medical facts and reasoning.

You can soften the blow as much as feasible, but I have yet to see a new medic NOT have the "deer in the headlight look", myself included when I was first released to kill people on my own. I would be more frightened of one who doesn't have that look. Then it would tell me that either they don't care or are a cocky cowboy that needs to be heavily supervised............


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## MrBrown (Sep 7, 2009)

Personally I am in favour of as few levels as possible; we're moving from five to three (Ambulance Technician, Paramedic and Intensive Care Paramedic).

The intermediary level (Paramedic) is the pretty much the defacto standard for career entry-to-practice, there are some paid AOs (Techs) but it's the exception rather than the rule here which is fine by me!

From what I have seen your Intermediate level (from the national scope of practice model) isin't all that great and if we can get as many people up to ALS level provided they are properly educated and deployed I don't see the need for an Intermediate level.


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## bunkie (Sep 7, 2009)

I don't believe my area has I's either. I believe my instructor was saying around here they didn't. I could be wrong though. However all the agencies that teach P require a year of B before you can get in and you usually need to be sponsored by your agency as well. I asked why the year was necessary and quickly hit a very sore spot on that instructor. :glare:


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## VentMedic (Sep 7, 2009)

bunkie said:


> I don't believe my area has I's either. I believe my instructor was saying around here they didn't. I could be wrong though. However all the agencies that teach P require a year of B before you can get in and you usually need to be sponsored by your agency as well. I asked why the year was necessary and quickly hit a very sore spot on that instructor. :glare:


 
If you are talking about Washington State, this is an example of what a state should NOT do.

*First Responder*
*EMT-Basic*
*IV Technician*
*Airway Technician*
*IV/Airway Technician*
*IV Intermediate Life Support Technician (ILS)*
*EMT-Paramedic*


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## tcripp (Sep 7, 2009)

8jimi8 said:


> in defense of intermediates.
> 
> i think it is good as a way to begin practicing very basic "paramedic skills"
> 
> ...



As an NREMT-I in school to earn my paramedic patch...I really have enjoyed the ability to work at a slightly higer level than first reponder to continue to reinforce what I have learned. I wouldn't have done it differently.

Now, what gets my goat are those who only have a basic patch but then are granted permission by their medical director to do things such as starting IVs and didn't get the additional 2 semesters of education to back it up.  Here's where the multi-levels really muddy up the system.


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## Shishkabob (Sep 7, 2009)

You really think you need 2 semesters of school to learn how to start an IV?


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## Lifeguards For Life (Sep 7, 2009)

Linuss said:


> You really think you need 2 semesters of school to learn how to start an IV?



i may be wrong, but when i was donating blood, the attendant had told me i believe, that it is a 16 hour course they take to work at the blood bank. and they can start iv's for instance when you donate using the Alyx. As a physical skill it is not hard to learn how to start an iv, there may be some pt. that area harder sticks than others, but it is not a hard skill to learn


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## MrBrown (Sep 7, 2009)

Lifeguards For Life said:


> i may be wrong, but when i was donating blood, the attendant had told me i believe, that it is a 16 hour course they take to work at the blood bank. and they can start iv's for instance when you donate using the Alyx. As a physical skill it is not hard to learn how to start an iv, there may be some pt. that area harder sticks than others, but it is not a hard skill to learn



You should also be learning about fluid compartmentilisation, osmolarity, tonicity, diffusion, facilitiated diffusion, Pouselles law and fluids in shock as well.  

That may take more than 16 hours ... I still don't get some of it


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## Lifeguards For Life (Sep 7, 2009)

MrBrown said:


> You should also be learning about fluid compartmentilisation, osmolarity, tonicity, diffusion, facilitiated diffusion, Pouselles law and fluids in shock as well.
> 
> That may take more than 16 hours ... I still don't get some of it



agreed. as everyone else was saying learning how to make the stick is not hard. i think she said 16 hours not sure, but was very suprised the lack of training and education at the blood donation center. from the way she explained it one could gather that they learned the skill (starting an IV) with little to no education on what is happening inside the body


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## Ridryder911 (Sep 7, 2009)

Linuss said:


> You really think you need 2 semesters of school to learn how to start an IV?



No, actually longer. I bet I can ask you questions regarding IV's and their complications that most 2 year Paramedics cannot answer. 

Let me ask you all honestly, can you immediate point out to me were & which one is the basilic vein?... 

R/r 911


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## EMSLaw (Sep 7, 2009)

Ridryder911 said:


> No, actually longer. I bet I can ask you questions regarding IV's and their complications that most 2 year Paramedics cannot answer.
> 
> Let me ask you all honestly, can you immediate point out to me were & which one is the basilic vein?...
> 
> R/r 911



It's the big one on the inside of the arm, as opposed to the cephalic vein, which is on the outside of the arm.  But that's more A&P stuff, rather than any EMS training I've received.  

This reminds me of how my mother, who was an experienced BSN, was always worried about hitting a nerve when giving IM injections, whereas her less-theoretically educated associate or diploma-school colleagues never seemed to worry about it.  Perhaps because they didn't know enough to realize there was something they /should/ worry about hitting?  

I agree that getting a 'stick' isn't a hard skill to learn.  But if you want to move beyond being a technician to being a technologist, who knows not only how to do the skill, but why, then that requires more time and study.


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## audreyj (Sep 7, 2009)

We have intermediates here in the rural areas, which is pretty much every thing outside Chicago and the surrounding metropolitan area.  EMT-Is are very rare where I'm at, it's all or nothing, Chicago Fire Dept. *might* take an intermediate, not totally sure on that (they were the only ones taking the EMT-I exam at testing).  I personally don't understand why one would get an EMT-I over going straight for paramedic, just seems like an unnecessary step.

I went straight from basic to paramedic school and the only thing I would recommend is that if you struggle with A&P, then take a course, it will help in medic school.


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## tcripp (Sep 7, 2009)

Wow, you guys are brutal around here, aren't you?  

For those who had my back...thanks.  

For the others...no, it doesn't take two semesters to learn how to take the catheter and stick it in the vein.  As a matter of fact, we probably covered that in about two classes including practice sticks on each other.  

But, it's not just about the invasive procedure.  It's knowing how to choose the correct size catheter for the job.  It's knowing when and when not to start a line.  It's knowing how much or how little fluid to infuse...and which fluid type you should be using.  It's knowing how to ensure that you've not caused further damage by infiltrating the vein or by shearing the catheter.  

But, to clarify...the two semesters is the length of time required to become an intermediate and all that implies....not the length of time it took to learn this one skill.  

Side note...even phlebotomists spend a single semester in training here in Texas.


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## Ridryder911 (Sep 7, 2009)

tcripp said:


> Wow, you guys are brutal around here, aren't you?
> 
> For those who had my back...thanks.
> 
> ...



Amazing, not one Intermediate discussed osmotic gradient changes or hypertonic fluids and cellular shifts with fluids? Yes, it takes more than the 60 hours to really know about the job. 

R/r 911


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## EMTinNEPA (Sep 8, 2009)

Unfortunately, Pennsylvania just took a step backwards and is apparently preparing an "Advance EMT" level. :glare:


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## dragonjbynight (Sep 23, 2009)

audreyj said:


> We have intermediates here in the rural areas, which is pretty much every thing outside Chicago and the surrounding metropolitan area.  EMT-Is are very rare where I'm at, it's all or nothing, Chicago Fire Dept. *might* take an intermediate, not totally sure on that (they were the only ones taking the EMT-I exam at testing).  I personally don't understand why one would get an EMT-I over going straight for paramedic, just seems like an unnecessary step.
> 
> I went straight from basic to paramedic school and the only thing I would recommend is that if you struggle with A&P, then take a course, it will help in medic school.



One reason to get your I, something I am personally considering once done basic is here in Indiana, you can't take a medic program without being sponsered in by an ALS provider....Which is beyond my ability to understand, but thats the way it was told to me when I signed up for basic. I would rather go Medic...but unfortunately, I don't have the backing yet.


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## fortsmithman (Sep 23, 2009)

Why not get rid of basic and intermediate and just go paramedic.


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## TransportJockey (Sep 23, 2009)

fortsmithman said:


> Why not get rid of basic and intermediate and just go paramedic.



This what I hope to eventually come about.


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## daedalus (Sep 23, 2009)

Linuss said:


> You really think you need 2 semesters of school to learn how to start an IV?



Two semesters to cannulate someone? No. Two semesters (at least) to learn when fluids are needed and how much? Not even close enough to what is needed. 

With the latest research from Iraq and Afghanistan, we are learning more and more about fluid resuscitation and EMT-Is are not qualified to determine which patients should receive an IV let alone fluids.


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## daedalus (Sep 23, 2009)

Ridryder911 said:


> Amazing, not one Intermediate discussed osmotic gradient changes or hypertonic fluids and cellular shifts with fluids? Yes, it takes more than the 60 hours to really know about the job.
> 
> R/r 911



And what about auto-resuscitation and hematocrit? What about abdominal compartment syndrome? What about clotting factors and the coagulation cascade? What about cardiovascular physiology, ICP, CPP, and edema? What about plasma proteins? What about diffusion, osmosis, ionic dissociation, colloids, suspensions, and crystalloids? Acid base balance? Compartments? 

What about the fact that a patient can live or die by the level of understanding of physiology in trauma situations? I dare these people who say EMT-Is should be giving fluids to visit a surgical ICU.


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## ResTech (Sep 23, 2009)

> Two semesters to cannulate someone? No. Two semesters (at least) to learn when fluids are needed and how much? Not even close enough to what is needed.



Disagree. It does not take two semesters to learn which patients need fluid and how much and why. You can easily learn the positives and negatives of fluid administration in less than two semesters... especially when you also are required to take A&P. Were not studying to be surgeons... just Paramedics! Chastise me all you want for that comment.... but pre-hospital fluid resuscitation is not that complicated!

In the middle of a trauma.... Daedalus yell's to his partner... "I think were giving too much fluid... quick, what's the hematocrit???" non-degreed Paramedic partner replies.. "boy, wtf you talk'n about"... Daedalus then goes on... "I think we have some ionic dissociation occurring and plasma proteins are expanding".... stat, hand me the ottoscope"... lol...

EMT-I's have been safely giving IV fluids for decades.


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## ResTech (Sep 23, 2009)

> Unfortunately, Pennsylvania just took a step backwards and is apparently preparing an "Advance EMT" level



I'm still undecided if this is to be considered a step backwards. Advanced EMT is a cert level included in the National EMS Scope of Practice. Can't be worse than the majority of ambulances rolling out BLS only in South Central, PA. Least with Advanced EMT, some increased level of care will be onboard. 

It's yet to be seen how EMS systems in PA will incorporate them. If Paramedic units still respond along with them I see it as a good thing.


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## Flight-LP (Sep 23, 2009)

ResTech said:


> Disagree. It does not take two semesters to learn which patients need fluid and how much and why. You can easily learn the positives and negatives of fluid administration in less than two semesters... especially when you also are required to take A&P. Were not studying to be surgeons... just Paramedics! Chastise me all you want for that comment.... but pre-hospital fluid resuscitation is not that complicated!
> 
> In the middle of a trauma.... Daedalus yell's to his partner... "I think were giving too much fluid... quick, what's the hematocrit???" non-degreed Paramedic partner replies.. "boy, wtf you talk'n about"... Daedalus then goes on... "I think we have some ionic dissociation occurring and plasma proteins are expanding".... stat, hand me the ottoscope"... lol...
> 
> EMT-I's have been safely giving IV fluids for decades.



A couple of points:

A. A&P is not required for the majority of Intermediate students.
B. Its We're, not were. Not going to chastise you, but will point out your inappropriate grammar useage since we are on the education subject.
C. ........just Paramedics. How can you honestly write those words yet blow smoke about supporting advancing the education needed to be a proficient provider?
D. Maybe the degree does matter. I possess a degree and would not respond "wtf", I'd run a 'crit on the IStat. Sorry for the sarcasm, but you really "wow" me sometimes in your inconsistent stand on the topic.

So bring the evidence. Show us the statistics of safety in fluid administration from EMT-Intermediates. My suspicion is that you will not be able to produce the statistics just as I would not be able to present the statistics covering the number of patients who experienced a negative outcome from the hands of the same population. Am I incorrect?


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## VentMedic (Sep 23, 2009)

ResTech said:


> ... just Paramedics!


 
As long as this attitude exists amongst those who are EMS providers, at any level, and the education/training for the Paramedic remains at just a few hundred hours, EMS may never know what what it can accomplish.


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## ResTech (Sep 23, 2009)

> Its We're, not were.



This would be considered a typo not a grammatical error. 



> .... just Paramedics. How can you honestly write those words yet blow smoke about supporting advancing the education



"just Paramedics" was not intended in anyway to minimize their role... I intentionally antagonize sometimes because a few seem to micro-advocate and think "out here" is the same as being in a hospital... and its not. As I have commented before, I do believe it is possible to do too much in the field and over think patients. If people want to do a full 360 from start to finish with their patients care, than EMS is prob not for them. Become something that allows you to work in a hospital. 



> I'd run a 'crit on the IStat



This is the micro-advocating I mentioned above.. using an IStat in the field is the exception, not the rule. Do we even have time to consider using an IStat in the 15-20mins we have a patient? 

I don't have statistics on EMT-I's and fluid administration just anecdotal observation and reading.


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## VentMedic (Sep 23, 2009)

ResTech said:


> I don't have statistics on EMT-I's and fluid administration just anecdotal observation and reading.


 
Were these observations made as an EMT-B and before you started Paramedic school?

Once you finish Paramedic school and hopefully continue your education with college level classes, your observations will probably be very different.


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## daedalus (Sep 23, 2009)

Actually restech, I was speaking about developing a fund of knowledge on the structure and function of blood, not getting field hematocrits. Knowledge of the concept of hematocrit is needed because you are changing it with fluid administration. Initially after acute hemorrhage, hematocrit is normal, however as time passes and the body engages in "auto-resuscitation", it refills the vascular space with fluid, which produces a drop in the hematocrit. Same thing will happen if saline is infused into the blood after hemorrhage.

I will never agree with letting people alter homeostasis with drugs and procedures unless they have a good foundational knowledge of physiologic concepts that allow them to base their decisions on science.

** also bet you didnt know that your fluid administration practices can adversely affect the patient down the road as they fight for their life in the ICU. When I become a medical director, people with sarcasm towards serious issues in trauma resuscitation like yours will not be tolerated in my system.


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## ResTech (Sep 23, 2009)

D... I was just messing with ya... its all good.. I do like to push buttons now and then


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## daedalus (Sep 24, 2009)

I knew you couldn't possible be serious with the otoscope comment, but I did find it slightly humorous to imagine myself yelling at my partner for an otoscope in an emergency. 

By the way, as a teaching point for all, supra-normal fluid bolus in trauma patients is associated with an increased incidence of abdominal compartment syndrome, increased amounts of returns to the OR, and increased incidence of death. This is not as simple as running some saline to correct the blood pressure. When my family is in trouble, I want the prehospital provider to know about this before they blindly start an IV because they got the skill from a 10 hour cert class. As for further reading on this, Acute Care Surgery by Britt and Trunkey is my reference, however you can also listen to Dr. Guy's podcasts as he likes to hit this point home.


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## ResTech (Sep 24, 2009)

> This is not as simple as running some saline to correct the blood pressure.



The same can also be said about oxygen use. I have had preceptors tell me with almost conviction like tone that all MI or ACS patients get 15lpm of O2 no questions. Unless a patient has hypoxemia, why are we wasting oxygen? Oxygen has no clot busting capability. I got my ACLS manual in the mail today and was flipping through it and happened to read the part where they recommend ACS patients only getting 4lpm unless other factors present like hypoxemia, cardiogenic shock, etc. 

And they recommended no oxygen to little oxygen for CVA patients... unless signs of hypoxia. The high-flow O2 thing is a pet peeve I have. If its needed give it... don't give it just because 

Good point though D.


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## MrBrown (Sep 24, 2009)

ResTech said:


> The same can also be said about oxygen use. I have had preceptors tell me with almost conviction like tone that all MI or ACS patients get 15lpm of O2 no questions. Unless a patient has hypoxemia, why are we wasting oxygen? Oxygen has no clot busting capability. I got my ACLS manual in the mail today and was flipping through it and happened to read the part where they recommend ACS patients only getting 4lpm unless other factors present like hypoxemia, cardiogenic shock, etc.
> 
> And they recommended no oxygen to little oxygen for CVA patients... unless signs of hypoxia. The high-flow O2 thing is a pet peeve I have. If its needed give it... don't give it just because
> 
> Good point though D.



When I first read our procedures around oxygen i thought they where whacky as;  but oxygen in high concentrations causes blood vessels to constrict and this reduces blood supply to organs, particularly organs that already have a reduced blood supply. 

There is nothing ‘magic’ about oxygen and in general we give oxygen to many patients that do not need it, usually using flows in excess of what is required


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## FireResuce48 (Sep 24, 2009)

MrBrown said:


> When I first read our procedures around oxygen i thought they where whacky as;  but oxygen in high concentrations causes blood vessels to constrict and this reduces blood supply to organs, particularly organs that already have a reduced blood supply.
> 
> There is nothing ‘magic’ about oxygen and in general we give oxygen to many patients that do not need it, usually using flows in excess of what is required




Do you have any links about the negative effects of high flow o2. I would like to read that.

My area doesn't overuse o2 that much but unfortunately thats because we have a whole lot of lazy providers.


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## daedalus (Sep 24, 2009)

FireResuce48 said:


> Do you have any links about the negative effects of high flow o2. I would like to read that.
> 
> My area doesn't overuse o2 that much but unfortunately thats because we have a whole lot of lazy providers.



I am no expert on oxygen therapy (we do have a resident expert who I hope will chime in), however the science of o2 therapy is not exact and in fact we still do not know what the best practices are for some situations (oxygen can be harmful)

I think it is safe to say that oxygen therapy should be guided by the clinical condition of your patient and pulse oximetry. A patient with chest pain with no dyspnea and a normal spO2 probably does not need 15 liters.


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## MrBrown (Sep 24, 2009)

daedalus said:


> I am no expert on oxygen therapy (we do have a resident expert who I hope will chime in), however the science of o2 therapy is not exact and in fact we still do not know what the best practices are for some situations (oxygen can be harmful)
> 
> I think it is safe to say that oxygen therapy should be guided by the clinical condition of your patient and pulse oximetry. A patient with chest pain with no dyspnea and a normal spO2 probably does not need 15 liters.



*This big paper from the British Thoracic Society*http://www.brit-thoracic.org.uk/Por...Emergency oxygen guideline/THX-63-Suppl_6.pdf (click for the PDF) on pg. 22, 26-27 does list the consequences of hyperoxemia.

The old "too much of anything" whodathunkit is probably a good one here (as with anything really); I know it's not randomized, double-blind prospective or peer reviewed in nature but I thought it'd put it in there.

In 2007 we made a change (I don't know what it was previously) and now basically it goes like this 

- not everybody gets oxygen and we only give oxygen if the patient as an abnormal airway, shock, chest pain or SPO2 <95% on air (except COAD)
- 2-4lpm on a NC or 4-6lpm on a simple face mask should be fine for everybody except NRBs or nebulizer masks (8lpm) and BVMs (10lpm)

I mean in reality I think we confuse oxygenation and ventilation or rely too much on pulse oximetery or confuse hypercarbia and hyperoxemia/hyperventilation which are all very different concepts and I wouldn't trust SPO2 totally just like I don't trust somebody who has no other S&S but whos ECG says the printer says has an MI.

In reality however I would also plug that there is a psychologycal benefit of non-medically indicated oxygen at very low rates (say 1-2lpm max on a nasal cannula) for select patients; e.g. the elderly.  I've found a litre of oxygen on a cannula can do wonders for nana and the family who all want us to "do something".


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## VentMedic (Sep 24, 2009)

All of you that just posted need to review some basic factors of Oxygen especially about the constriction and dilation of blood vessels.  Hypoxia induces vasoconstriction.  

The research of harmful effects centered around free radical formation and toxicity.   Both conditions take longer than 30 minutes to be of concern.  Since there many other factors that you do not know in the field, many medical directors still cover the all the bases with O2 therapy.  

Factors you do not know are the lactate level, SvO2,  Hb and the content or component values of total saturation.   As well, for chest trauma with the suspicion of a pneumo, N2 washout theory is still exercised.   

Every patient in the ICU is on a different O2 protocol whether it is neuro, ARDS, COPD, Trauma or Sepsis.   We do NOT do blanket orders.  No two neuro patients may be the same and the neuro surgeon usually has his/her preferences and that may be different with each patient depending on labs and other diagnostics. 

While not every patient needs a NRBM one must assess all factors of the patient to determine the correct therapy.   If I have a nursing home patient that was peeing mud and has altered mental status,  they will get a NRBM regardless of SpO2 until I saw their lactate level.  If that number reveals sepsis, they would be on a high FiO2 until the lactate started trending down and the SvO2 was stable.   



> 4-6lpm on a simple face mask


Your package insert generally says  no less than 6 liters and I suggest you follow that recommendation.  CO2 retention in the mask WILL dilate cerebral blood vessels or push that CO2 patient over the edge. 

For the NRBM, you choose the liter flow by the patient's VT and MV. Setting the liter flow DOES NOT set the FiO2.

Understanding basic equipment is another area that EMT(P)s just don't get enough education on. They get "training".  _Put prongs in nose and turn flowmeter to 2 and that gives you 28% Oxygen.   _

They are not taught that the patient's tidal volume with each breath influences how much FiO2 the patient receives.   The nonrebreather mask is called a high flow device because _it takes a whole lot of oxygen to run it._   Few are ever taught the actual definition of high flow device or know which devices are considered high flow. 

We could also discuss the Pulse Oximeter.  I personally believe no one should use it as a "diagnositc" tool unless they thoroughly understand the  oxyhemoglobin dissociation curve.  

The ETCO2 monitor should also be used for more than just seeing a pretty wave after intubation.  Some do try to treat by the numbers and yet have no clue about V/Q mismatch or deadspace ventilation.  They also don't know much more about their wave forms except they see one.

So some have  a lot to learn about pathophysiology and some simple human processes before making blanket statements.  There is a lot of literature out there and every center and doctor have their own beliefs.  It is weeding through the literature to see if it holds up to validity with sample size and METHODOLOGY.   This is why I always encourage those who read a review or fluff article in JEMS to pull up the original.  Quite often the authors of the original may have a very different view or the meaning is lost when in the effort to translate it into simple terms to those in EMS.


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## MrBrown (Sep 24, 2009)

VentMedic said:


> They are not taught that the patient's tidal volume with each breath influences how much FiO2 the patient receives.



I don't get that ... regardless of size of TV are you not breathing the *same* mixture of oxygen dissolved in the air? If my TV is say 10ml of air or 100ml of air it's the *same* air; be it 2.8% or 28% 

Mind you I was taught FiO2 is the inspired level of O2 (which I take to be how much you breathe in) *not* how much disperses across the alveoli and into the plasma (PaO2/ABG) or binds to Hbg (SPO2) ... bloody hell all these O2s! ... breathing is a bit more complex than breathe in, breathe out eh, whodathunkit?



VentMedic said:


> We could also discuss the Pulse Oximeter.  I personally believe no one should use it as a "diagnositc" tool unless they thoroughly understand the  oxyhemoglobin dissociation curve.



*scurries away go look it up



VentMedic said:


> There is a lot of literature out there and every center and doctor have their own beliefs.  It is weeding through the literature to see if it holds up to validity with sample size and METHODOLOGY.   This is why I always encourage those who read a review or fluff article in JEMS to pull up the original.  Quite often the authors of the original may have a very different view or the meaning is lost when in the effort to translate it into simple terms to those in EMS.



I think JEMS is a useless piece of rubbish not worthy of the title of a "journal" that I personally would not wipe my arse on.  We subscribe to it and i read it now and again, but honestly "Journal of EMS" makes it sound like up there with the Lancet, NEJM, JAMA etc; you know a proper scientific publication.  While there are some very intelligent MD/DOs, BSs, MPHs and PhDs who write for JEMS most of the articles IMO are trash that should see it renamed "Good old timer trade journal of gurney jockeys to read on the toidee or sit your coffee mug on".  

I have spent the last three years picking through scientific and business journals writing university level (up to 5,000 word) research papers and have a university research methods class under my belt so I can read a research paper.  Does that make me some sort of super-smart know it all, not at all, I can barely understand the lab value sheets I have been given by physicians to take to the ER but I do know what is flawed research and what is not (might have to look at the PowerPoints from my research methods class again) but still .... *emergency medical services involves medicine, medicine is founded in science (not that I agree with it all) so hey lets teach some science and scientific methods here .... WHODATHUNKIT?*


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## ResTech (Sep 24, 2009)

> Hypoxia induces vasoconstriction.



From a research article.... http://ajpheart.physiology.org/cgi/content/full/292/2/H776



> Absent the use of perfluorocarbons, significant hemodilution, or pulmonary compromise, hyperoxia causes little change in the oxygen content of blood. However, hyperoxia normally causes a vasoconstriction, which may itself provide a salutary effect by improving perfusion of some critical vascular beds through venoconstriction (9) and a favorable redistribution of the cardiac output (CO) (10).



I have been taught over the years that oxygen has vasoconstriction properties and that it is the hypoxia that results in vasodilation and increased vascular permeability due to rises in acid production. 

I always thought hypoxia only caused vasoconstriction in the pulmonary vessels (ie pulmonary hypoxic vasoconstriction).

Looks like the oxygen free radicals causes a release of thomboxane (what gets inhibited by ASA) and prostaglandins which both cause vasoconstriction....


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## VentMedic (Sep 24, 2009)

ResTech said:


> From a research article.... http://ajpheart.physiology.org/cgi/content/full/292/2/H776
> 
> 
> 
> ...


 
Did you read the whole article and understand what is meant by "hyperoxia" and O2 content? 

The FiO2 given does not necessarily mean that is what is present in the blood which is why we measure O2 content, PaO2 and calculate PAO2. The A-a gradient will tell us more about perfusion which is also why we monitor the SvO2. 

This article is also written about shock from trauma in rats. It gives not reference to human data.

It is difficult to take on section out of a research article, especially when it is about animals, and expect to correlate it to a broad statement.   Once an article like this is published, the ground work is now laid for other scientists to test their theories or challenge this data.  That is how research works.  This is also how it was found that the MAST and intracardiac epinephrine did not work as well as what was initially thought.


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## ResTech (Sep 24, 2009)

Well here is more supporting data that oxygen causes vasoconstriction... and hypoxia causes vasodilation.

From Wikipedia - Hypoxia (http://en.wikipedia.org/wiki/Hypoxia_(medical))


> In most tissues of the body, the response to hypoxia is vasodilation. By widening the blood vessels, the tissue allows greater perfusion.
> 
> By contrast, in the lungs, the response to hypoxia is vasoconstriction. This is known as "Hypoxic pulmonary vasoconstriction", or "HPV".



From Cardiovascular Physiology Concepts (http://www.cvphysiology.com/Blood Flow/BF008.htm)


> Decreased tissue pO2 resulting from reduced oxygen supply or increased oxygen demand  causes vasodilation. Hypoxia-induced vasodilation may be direct (inadequate O2 to sustain smooth muscle contraction) or indirect via the production of vasodilator metabolites. Note, however, that hypoxia induces vasoconstriction in the pulmonary circulation (i.e., hypoxic vasoconstriction), which likely involves the formation of reactive oxygen species, endothelin-1 or products of arachidonic acid metabolism.





> Hydrogen ion increases when CO2  increases or during states of increased anaerobic metabolism, which can produce metabolic acidosis. Like CO2, increased H+ (decreased pH) causes vasodilation, particularly in the cerebral circulation.
> 
> Lactic acid, a product of anaerobic metabolism, is a vasodilator, although in large part because of its pH effect.



I have never known of hypoxia to cause vasoconstriction except in the pulmonary vessels. If hypoxia caused vasoconstriction, then why is it critical to not allow TBI patients to become hypoxic? The rational is to prevent hypoxia to mitigate increasing intracerebral swelling from the vasodilation that occurs as a result of hypoxia.   

I'm still trying to see where your getting this data from to support hypoxia causing systemic vasoconstriction. Could you post some sources?


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## MrBrown (Sep 25, 2009)

I (at least) am saying *hyperoxemia* causes vasoconstriction because that is what we are taught and what our medical director is saying; I'll see if I can find something more concrete


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## Shishkabob (Sep 25, 2009)

MrBrown said:


> I (at least) am saying *hyperoxemia* causes vasoconstriction because that is what we are taught and what our medical director is saying; I'll see if I can find something more concrete



We've always been taught ventilate to 30 EtCO2 to cause vasoconstriction.

:wacko:


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## MrBrown (Sep 25, 2009)

Linuss said:


> We've always been taught ventilate to 30 EtCO2 to cause vasoconstriction.
> 
> :wacko:



Foregive me ... but this is one of those Circle of Willis things or what, because that makes no sense! :unsure:


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## VentMedic (Sep 25, 2009)

MrBrown said:


> Foregive me ... but this is one of those Circle of Willis things or what, because that makes no sense! :unsure:


 
CO2 is a cerebral vasodilator which is why *hyperventilation* has been indicated for TBI. However, we no longer go past 30 or even 35 as taking the CO2 level below that can cause constriction to where it limits blood flow regardless of what the PaO2 is. 

However, it is also good to know that CO2 is a vasoconstrictor as well as a dilator to some degree in the cardiopulmonary system in some patients which is the opposite of cerebral effects. 

Hyperventilation and Hyperoxygenation are two very different things. This is why EMS has been questioned for their preintubation method is questioned as they "bag real fast" thinking they are hyperventilating to give more oxygen. 

Also one has to look at the whole disease or injury process. You will not know in the field what the oxygenation is at tissue level without an SvO2. For TBIs and sepsis, that is how we adjust the FiO2 and the pressors or fluids in the ICU. 

Do you know some of the treatments for pulmonary hypertension for infants or adults? Do you know why 100% O2 is used? And then nitric oxide? 

Take NRP? 

Ever study some of the CHDs in infants especially the cyanotic heart lesions? Do you know why these infants are sometimes given an FiO2 of 0.16 (16% Oxygen) to keep their SpO2 and SaO2 between 75%-85%?

In your search, look up PVR and SVR. Gain your knowledge through learning hemodynamics.

There is a lot to learn out there and different applications for different patients.  One recipe does not fit all patients.


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## VentMedic (Sep 25, 2009)

ResTech said:


> From Wikipedia - Hypoxia (http://en.wikipedia.org/wiki/Hypoxia_%28medical%29)


 
Wikipedia?

This could have been written or edited by an EMT who thinks he/she now knows all about the subject after reading a few paragraphs in a couple of research abstracts or JEMS.

But this oxygen discussion has been great as it also shows how much there is to know out than and how this pertains to EMT-Is giving fluids with little to no understanding.


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## VentMedic (Sep 25, 2009)

MrBrown said:


> I don't get that ... regardless of size of TV are you not breathing the *same* mixture of oxygen dissolved in the air? If my TV is say 10ml of air or 100ml of air it's the *same* air; be it 2.8% or 28%
> 
> Mind you I was taught FiO2 is the inspired level of O2 (which I take to be how much you breathe in) *not* how much disperses across the alveoli and into the plasma (PaO2/ABG) or binds to Hbg (SPO2) ... bloody hell all these O2s! ... breathing is a bit more complex than breathe in, breathe out eh, whodathunkit?


 
If you are giving 2 Liters of oxygen by nasal cannula, will it provide the same concentration or FiO2 when the patient is breathing 12 normal breaths and then 20 rapid deep breaths?

Do you know the Venturi principle of air entrainment? 

http://books.google.com/books?id=bt...turi principle air entrainment oxygen&f=false

There are several pages here that discuss venturi and FiO2 calculations which are generally based on a 500 cc VT. It also explains what the difference between a high flow and a low flow system is. But, still for EMS testing purposes, a NRBM is a high flow device because it requires a whole lot of O2. For RN and RRT testing purposes, that is an incorrect answer. 

I will make one correction about O2 and neonates, high concentrations of O2 will cause vasoconstriction in the retina.  Embrology and neonatalogy are sciences that have to be studied extensively and adult world assumptions can not be made. 

However, I will repeat again, the effects of CO2 and O2 in the body will be dependent on the body system and whatever chemical or physiological process is occuring in the body as that time. Examples: lactate levels, pH etc. Not all properites have been determined but there are a few that we know such as pulmonary hypertension and CHD. We do know about O2 toxicity and HBO therapy is still being studied for CVAs as well as other disease processes.


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## MrBrown (Sep 25, 2009)

VentMedic said:


> CO2 is a cerebral vasodilator which is why *hyperventilation* has been indicated for TBI. However, we no longer go past 30 or even 35 as taking the CO2 level below that can cause constriction to where it limits blood flow regardless of what the PaO2 is.



Our clinical procedures state



> 3.3 TRAUMATIC BRAIN INJURY
> • Perform primary survey.
> • Gain large bore IV access.
> • Intubation is not a priority but if the patient is deeply unconscious with poor airway and/or breathing, intubate them *but ...avoid hyperventilation and ventilate to end-tidal CO2 of 35-45 mmHg*.



By your logic our procedure is incorrect as we should not be ventilating past 35mmHg EtCO2?



VentMedic said:


> Hyperventilation and Hyperoxygenation are two very different things. This is why EMS has been questioned for their preintubation method is questioned as they "bag real fast" thinking they are hyperventilating to give more oxygen.



I have personally not seen this procedure however my argument is no matter how fast you bag a patient you're still only delivering the same 28% oxygen and if you hyperventilate a patient they may become hypocapenic so it's probably not a good idea but I could be talking out my arse.  



VentMedic said:


> Also one has to look at the whole disease or injury process. You will not know in the field what the oxygenation is at tissue level without an SvO2.



Do you look at SvO2 alone or compare SaO2 and SvO2? My thinking would be the difference between the oxygen in the arteries and veins is what's in the tissues but something tells me thats not right 



			
				VentMedic said:
			
		

> Do you know some of the treatments for pulmonary hypertension for infants or adults? Do you know why 100% O2 is used? And then nitric oxide?
> 
> 
> Take NRP?
> ...



The definition I got of PVR was something about pee! I'd take a gamble at systemic and pulmonary venous resistance however.

Nitric oxide is a pulmonary vasodialator.

Other than that I am having a look at some critical care websites and whatnot; this is rather interesting.  

May I sugest http://www.ccmtutorials.com/rs/oxygen/index.htm

Or I could suggest you just put that patient on the the stretcher and take 'em to the hospital! :lol: :lol:


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## VentMedic (Sep 25, 2009)

MrBrown said:


> Our clinical procedures state
> 3.3 TRAUMATIC BRAIN INJURY
> • Perform primary survey.
> • Gain large bore IV access.
> ...


 
I stated


> Originally Posted by *VentMedic*
> 
> 
> _CO2 is a cerebral vasodilator which is why *hyperventilation* has been indicated for TBI. However, we no longer go past 30 or even 35 as taking the CO2 level below that can cause constriction to where it limits blood flow regardless of what the PaO2 is. _


 
Look at your own protocols. It clearly states 35 - 45. That is a normal range. We usually don't go lower even in some TBI situations. But then, if we do go lower it is not below 30.



MrBrown said:


> I have personally not seen this procedure however my argument is no matter how fast you bag a patient you're still only delivering the same 28% oxygen and if you *hyperventilate a patient they may become hypocapenic* so it's probably not a good idea but I could be talking out my arse.


 
Why are you giving only 28% Oxygen? Do you blenderize your O2 in the ambulance? 

To* hyperventilate* is to make the person *hypocapenic*.




MrBrown said:


> Do you look at SvO2 alone or compare SaO2 and SvO2? My thinking would be the difference between the oxygen in the arteries and veins is what's in the tissues but something tells me thats not right


 
If your FiO2 is already 100%, you will need fluids and presors to maintain adequate SvO2 as if you are on transport there will be limited things you can do with a transport ventialor. The SaO2 will of course be important but normally we will monitor the SvO2 and not do too many ABGs during transport unless we have ventilation issues. The SpO2 monitor will suffice. In the hospital we will use all numbers for our calculations to determinine hemodynamic status.




MrBrown said:


> The definition I got of PVR was something about pee! I'd take a gamble at systemic and pulmonary venous resistance however.


 
Are you a Paramedic? I would hope this was at least mentioned in your program since you do give meds like nitro and epinephrine.




MrBrown said:


> Nitric oxide is a pulmonary vasodialator.


 
Yes and if you assist in transporting specialty teams you may see it frequently now on the ambulances. As well, you will also see it in the homes or outside of them as patient now carry the little tanks of Nitric Oxide with them. So, don't assume that tank is O2. As well, the nebulizers a person (could be a child also) takes at home may be a pulmonary vasodilator and not "albuterol". 



MrBrown said:


> Other than that I am having a look at some critical care websites and whatnot; this is rather interesting.
> 
> May I sugest http://www.ccmtutorials.com/rs/oxygen/index.htm


 
That is a very good website as you probably have noticed I have linked to it many times in my posts on this forum. 



MrBrown said:


> Or I could suggest you just put that patient on the the stretcher and take 'em to the hospital! :lol: :lol:


 
I guess when asked to do an IFT transport from one hospital to another you just turn on the L&S and drive real fast.

These are reasons why some CCTs as well as a few flight teams run into serious problems and fail their patient miserably.


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## eveningsky339 (Sep 25, 2009)

akflightmedic said:


> It is a good thing, Florida does not recognize Intermediates either.
> 
> It is basic or medic....period.



The smarter thing to do is recognize only EMT-I's.  No Basics needed.


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## VentMedic (Sep 25, 2009)

eveningsky339 said:


> The smarter thing to do is recognize only EMT-I's. No Basics needed.


 
After reading some of the posts, I believe for the BLS trucks it should be CNAs/PCTs since they are more familiar with medical patients.

Florida has all ALS services so the Paramedic will remain as the standard for 911.


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## ResTech (Sep 25, 2009)

What posts are you referring to as ignorant? 

Hypoxia causes vasodilation... except for pulmonary hypoxic vasoconstriction.  

Oxygen causes vasoconstriction.

Information was posted to support that... and not to mention its taught everyday. 

Can you please post facts that states hypoxia does not cause vasodilation? And some factual info that states oxygen does not cause vessels to vasoconstrict. 

And please stop trying to make people feel stupid, its not working.


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## VentMedic (Sep 25, 2009)

ResTech said:


> What posts are you referring to as ignorant?
> 
> Hypoxia causes vasodilation... except for pulmonary hypoxic vasoconstriction.
> 
> ...


 
You take little statements from Wikipedia and try to pass them off as fact. Do you not understand the different body processes? Do you not understand the different effects for different conditions that are present within the body as any given time during a disease process? Do you not understand the difference of oxygenation and hypoxia at tissue level? Do you not understand what SvO2 means? SaO2? O2 Content? Do you not understand what sepsis is? Do you not understand V/Q mismatch? Deadspace ventilation? How about deadspace ventilation as it pertains to pulmonary vasoconstriction? 

But of course, what is you favorite line to use? ....just Paramedics? 
There is nothing to do but drive the patient to the hospital and knowing all of this book learnin' stuff is of little use.

General blanket statements you have made are not correct. Did you not even read my posts with examples? How about the CCM tutorial link MrBrown posted? If you don't understand the terms I have posted, look them up on a reliable source and not Wiki. You are stuck on a couple of words and can't seem to get past them. 

Stop reading Wikipedia and take some college level classes like A&P and pathophysiology but of course that would probably be of llittle use to you with your attitude. I also read your conversation on neuro assessment. Do you really believe the Paramedic should not know anything but their "protocols" or recipes?

You can also stop trying to bring others such as Rid, daedalus, JPNIFV and myself down to match your level of "training". Some in this profession have moved on and want to continue learning. You just want to argue and really could care less about what facts are even when they are spoon fed to you. It is too bad you don't understand what some of us have written or just don't care to.

I suggest you do a little "googling" on a medical search engine where Wikipedia won't keep popping up.

*Also, STOP looking for RAT studies.  Learn basic physiology first. Then learn how to read research literature.  The results of the studies with then be more meaningful to you and you won't take things out of context.*

You might try that for IV therapy also since I'm sure you have a whole bunch of blanket statements for that also that you found on Wiki.


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## ResTech (Sep 25, 2009)

YES or NO...

These are the questions....

Hypoxia causes vasodilation... except for pulmonary hypoxic vasoconstriction.

Oxygen causes vasoconstriction.

?????????????????

I posted one thing from Wiki... the other was from actual research.. both concluded the same thing. 

Don't try to side step the questions with put downs... just answer the questions... yes or no. 

And I did take A&P (which I believe I have mentioned prob like 100 times now) which is why I'm not buying what your saying because it is opposite what I have always been taught on the subject in A&P and other classes over the years... and not to mention recently in Paramedic school.

If science has proven recently that hypoxia does not cause vasodilation and cerebral edema and the research I posted is wrong, than I would be interested to read the new facts on the issue... so post them.  

If science has also proven that oxygen has no vasoconstrictive properties then please post the new facts. 

Your direct statement was "hypoxia causes vasoconstriction"... and then as always... everyone else was wrong.


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## VentMedic (Sep 25, 2009)

ResTech said:


> Your direct statement was "hypoxia causes vasoconstriction"... and then as always... everyone else was wrong.


 
LOL!
Again, you took one sentence from one post but didn't bother to read the rest. Did you see what I was making that reference to? Blanket statements. 

Did you not see the comments about SvO2? Lactate? pH?  Can you justify what conditions the hypoxia will cause vasodilation?  Is it by itself or in conjunction with other factors?  

Do you not see the part about 16% O2 and babies? RLF? I gave examples of both vasoconstriction and dilation depending on the circumstance. Do you know what nitric oxide is? Pulmonary hypertension? For babies? For Adults? Even hear of congenital heart disease? Factors of RDS? ARDS? 

READ the posts and don't stop at the first word. If you don't understand the terminology, look it up or ask even if you want to PM me as others have done. 

You also need to learn the different types of hypoxia. 

Sorry but if it is a recipe for O2 therapy, I can not give you one. But, just follow your own EMT protocols and you should be okay.


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## ResTech (Sep 25, 2009)

*Support for hypoxic vasodilation*
http://www.cvphysiology.com/Blood Flow/BF008.htm

http://www.medicalnewstoday.com/articles/27840.php

http://www.circ.ahajournals.org/cgi/content/full/117/5/594



> Hypoxic vasodilation is a conserved physiological response to hypoxia that matches blood flow and oxygen delivery to tissue metabolic demand. This fundamental physiological process has been characterized for >100 years since the initial description by Roy and Brown1 in 1880


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## ResTech (Sep 25, 2009)

> about SvO2? Lactate? pH? Can you justify what conditions the hypoxia will cause vasodilation? Is it by itself or in conjunction with other factors?



What about it? A Paramedic has no way to determine that in the field nor do they have the time to. That stuff is not helpful to me as a Paramedic student... it really isn't. 

3/4 of what you preach is not even EMS relevant. Sure, its medical but  most does not relate to what it takes to be an EMS provider. You like to micro-advocate. Don't take your RRT stuff and try to make it into what should be considered common knowledge for EMS providers. 

And "my bad" for infringing on your EMTLife education campaign... I'm entitled to my opinions and always provide FACTUAL support for what I state. I'm not someone who is looking to be a Para-God or impress ne one.. all I want is to be a Paramedic to provide the best care I can within my capability as a Medic... and be very humble while doing so. I'm not afraid to admit when I'm wrong... all I ask is that anyone provide info that is contrary to what I have learned and am reading in black and white on my computer screen. Do that and I'll be humble enough to admit I am wrong. You have not done that.   

You need to start running as a Paramedic again on a 911 truck and come down off your pedestal. How long has it been since u ran 911 as a Medic? I heard its been awhile. You almost seem as if your too good to run calls on a 911 Paramedic unit.


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## VentMedic (Sep 25, 2009)

ResTech said:


> *Support for hypoxic vasodilation*
> http://www.cvphysiology.com/Blood Flow/BF008.htm
> 
> Hypoxic vasodilation is a conserved physiological response to hypoxia that matches *blood flow* and *oxygen* *delivery* to *tissue metabolic demand*.


 
Good article but AGAIN, do you not understand the different types of hypoxia?  Tissue hypoxia?  What do you think I have been saying about SvO2, lactate and pH?   The hypoxia is just one part as the PAO2 and PaO2 can actually be quite high.  

Now you must also differentiate the sytem involved as again and again I discussed the effects on different systems with both O2 and CO2.

Again and again, read the whole article and understand the different terms including tissue hypoxia.  

You're pulling stuff off the net at random without seeing the full story.

I have no problem with the statement hypoxia causes dilation but again that depends on the system we are discussing, the time frame and the other mediators for vasodilation that are released which may be the actual cause.  Correct management of buffers and pressors can alleviate these actions which is why some people with sepsis respond to some pressors and various intervention protocols for maintaining SvO2 better than others. 

Now, look at the points I also makes about pulmonary vasoconstriction.  Can you not differentiate between the different disease processes?  Can you not understand the difference in mediators for the action and reaction?   Can you not understand when I say *the same recipe may not apply to all patients as unlike some in EMS believe, not oall  patients come with just one simple diagnosis?*


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## ResTech (Sep 25, 2009)

> Can you not understand when I say the same recipe may not apply to all patients as unlike some in EMS believe, not oall patients come with just one simple diagnosis?



I understand that perfectly... however, I think you forgot we don't have 12hrs a day with our patients with access to full diagnostic results, direct physician input after they examine the patient, and conditions to do the majority of what you say we should. 

EMS has usually 20mins or less to do their job... in the hospital is a bit different.


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## VentMedic (Sep 25, 2009)

> What about it? A Paramedic has no way to determine that in the field nor do they have the time to. *That stuff is not helpful to me as a Paramedic student... it really isn't. *
> 
> 3/4 of what you preach is not even EMS relevant. Sure, its medical but most does not relate to what it takes to be an EMS provider. You like to micro-advocate. Don't take your RRT stuff and try to make it into what should be considered common knowledge for EMS providers.


 

Wow! Are you insulting Paramedics by saying they should only think within their protocols for a 911 truck! 

None of that book learnin' stuff is of any value? 

No one should ever think about being a flight or CCT Paramedic or even a better 911 Paramedic?

Get over the "just a Paramedic" or Para-God attitude. 



ResTech said:


> You need to start running as a Paramedic again on a 911 truck and come down off your pedestal.


 
Just because I choose to do HEMS/Flight/CCT/Specialty instead of a 911 "truck" does not make me any less of a Paramedic. Just because I chose to get an education along with my patch you find fault with that? At least I have lasted in the profession for over 30 years and also put a decent 20 years in a truck do 911. 

How long have you been an EMT? 

I would hope that Rid's dream of the Paramedic becoming a Practitioner comes true someday but as I see it now, attitudes like yours where you believe an understanding of physiological aspects of medicine pertinent to EMS is beyond the Paramedic will continue to hinder any advancements in this profession.


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## ResTech (Sep 25, 2009)

Much of what I say I think you intentionally take out of context and spin it.

"Book Learn'n Stuff" you say?... I love book learn'n stuff... prob why I carry a near 4.0... if it wouldn't be for that one "B" last semester in the practicum it would be a 4.0. 

I never said don't think outside of protocols. What I said was, in the field you need to be streamlined... there is so much to do in such a short period of time.. cut the filler... get to the point and root of the patients problem.... treat them accordingly... and transport them to where they ultimately need to be. 

The field has limitations... understanding them contributes to a good provider.



> attitudes like yours where you believe an understanding of physiological aspects of medicine pertinent to EMS is beyond the Paramedic



I concentrate on the "pertinent" physiology related to EMS... I come back when stuff way out of the EMS ball park gets touted as common knowledge. It's not beneficial to the many Paramedic students on here to be made feel like they should be on level 10 when really level 3 is the only place they need to currently concentrate on being. Help ppl get from point A to B first without going straight to Z. The basic concepts of physiology need taught before the advanced ones can be understood and appreciated.


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## VentMedic (Sep 25, 2009)

You have so little faith in what a Paramedic can understand or the potential this profession has.   Hopefully you will very soon step aside with your attitude and let a well educated generation emerge in EMS.

I know there are others on this forum that will bring new ideas and a better future for EMS.   You are not one of them.


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## Shishkabob (Sep 25, 2009)

Am I one of them?



*puppy dog eyes*


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## ResTech (Sep 25, 2009)

I have a lot of faith in what a Paramedic can do... if I didn't I would be merely wasting my time right now. I'm just not one to bow down and accept everything that is spoken by somebody else.

My views on EMS systems and roles come from many years of active involvement in different positions. You are one voice out of thousands of providers across this Country and this forum surely does not represent the majority.

LINUS... she is prob referring to the ones who sit in the back corner who keep their mouth shut and don't ever challenge ne thing. The ones who play follow the leader without finding out for themselves.


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## Ridryder911 (Sep 25, 2009)

ResTech said:


> I have a lot of faith in what a Paramedic can do... if I didn't I would be merely wasting my time right now. I'm just not one to bow down and accept everything that is spoken by somebody else.
> 
> My views on EMS systems and roles come from many years of active involvement in different positions. You are one voice out of thousands of providers across this Country and this forum surely does not represent the majority.
> 
> LINUS... she is prob referring to the ones who sit in the back corner who keep their mouth shut and don't ever challenge ne thing. The ones who play follow the leader without finding out for themselves.



I will unfortunately admit you are correct. You do have the "normal" attitude of most EMS providers and thus part of the problem of EMS. We have to "think outside the box"; sorry you acclaim that you want knowledge.... as long as it does not really pertain to real medicine; hence not what the current EMS curriculum has. 

Again, alike so many others acclaiming BLS vs. ALS; it is all rhetoric and unfortunately you do not have the level or the experience to give an authoritative opinion. I don't care how many years one has "working" in EMS, if they are not at the highest level common provider then really that experience is negligible and usually not counted for clinical practice. 

I do hope and really do believe you will see much difference after you become a Paramedic and recognize the short falls of your training and level. I also believe that you will also become a great advocate of such as you have demonstrated such passion for the profession. 

R/r 911


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## daedalus (Sep 25, 2009)

> The basic concepts of physiology need taught before the advanced ones can be understood and appreciated.



See, that is where I disagree with you (civilly of course).

Why do you place so little faith in what a paramedic student can learn? Most other health care professions are made to learn so much more than we are, where a PA will be going to school 5 days a week and taking a load equal to 22 credit hours per semester (average full time college student takes 12). No, I am not saying we should be PAs but why do you think that they have to be better than us? Why do you think that we should not have to learn anything not pertinent to the current way field care is practiced? If you think that we will only need to learn new things when they are placed in our scope and curriculum, you doom us all, because if you do not learn before, we will never advance.


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## VentMedic (Sep 25, 2009)

Linuss said:


> Am I one of them?
> 
> 
> 
> *puppy dog eyes*


 
Actually you are and you better do us proud.

You're posts show the direction you want to go with EMS.

The nay-sayers for the advancement of EMS just show how hard this generation has to work to overcome negativity to get this profession moving. There will always be those like ResTech who say the education should be "streamlined" which is what has kept the Paramedic with just a few hundred hours of training. 

I will continue to promote education for the Paramedics. Maybe that makes me a minority but hopefully that will change someday.

I also haven't heard many complaints about too much book learnin' from those in Oregon who now have had their education standards with a two year degree for a few years.



> quote by *Restech*
> My views on EMS systems and roles come from many years of active involvement in different positions.


 
But you are not yet a Paramedic so none of those positions have been as an advanced provider so you do not have this experience yet. Job hopping may give you an insight on the way various companies are managed but if you are not working as a Paramedic in those positions, you do not have the same point of view.

Now there are members on this forum who do not have their Paramedic patch but do have higher education that understand the concepts of physiology better than you. You may claim to have some education but you refuse to see what good it can do for you as a Paramedic.


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## Flight-LP (Sep 25, 2009)

ResTech - o.k. time out for a second.................

How can you get to the root of the problem without a thorough understanding of why the abnormality is occuring? O.k. so you can't monitor SvO2, I'll give you that one, but the FACT is that everything else Vent is saying holds water when it comes to the physiology of respiration, ventilation, and perfusion. 

What I see in your typed words is frustration and disbelief that you need to know the depth of her description. Do you have to have mastery to that level to function as a proficient Paramedic? No. An understanding though? He!! yes. Not to mention the knowledge she brings to this forum has the potential for you to show all sorts of cool "how it works" to your friends and co-workers. There is a name for it if I recall............now what was that????????


Oh yeah, CONTINUING EDUCATION! Constant learning increases rote knowledge and recollection. There was a lot of good learning to be had from this thread, I myself benefited from the knowledge. You, however, ignored that good educational writings and went for irrelevant personal attacks. You are trying to prove an assumed point that a. no one really cares about, and b. cannot be proven. Sorry to be the bearer of bad news but your Paramedic student status holds little water against an educated, degreed individual who has been in EMS and Respiratory Therapy since Johnson was in office. 

I don't always like some of her jabs either, but this is going nowhere. Choose the battles if you want to win the war.................


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## ResTech (Sep 25, 2009)

> You are trying to prove an assumed point that a. no one really cares about, and b. cannot be proven



And what point is that? The only thing I was stating was hypoxia causes vasodilation and oxygen has vasocontrictive properties. Is that wrong?



> All of you that just posted need to review some basic factors of Oxygen especially about the constriction and dilation of blood vessels. Hypoxia induces vasoconstriction.



To me, Vent was speaking on a very basic level that hypoxia induces vasoconstriction. This is evident when she made the statement about "reviewing some basic factors of Oxygen". This statement in this context is not correct.


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## MrBrown (Sep 26, 2009)

VentMedic said:


> Look at your own protocols. It clearly states 35 - 45. That is a normal range. We usually don't go lower even in some TBI situations. But then, if we do go lower it is not below 30.



My bad I read that wrong when you said "past 30" I figured > 30 



VentMedic said:


> Why are you giving only 28% Oxygen? Do you blenderize your O2 in the ambulance?



No; we use 100% oxygen; my bad!



VentMedic said:


> but normally we will monitor the SvO2



Can you explain please why you only monitor SvO2 i.e. oxygen saturation of the veins? I really am making a determined effort to understand this; so if the SvO2 (ie amount of oxygen in the deoxygenated arterial blood) is going *down* then the amount of oxygen that the tissue bed is extracting is going *up*? (see here: http://www.ccmtutorials.com/rs/oxygen/page05.htm)

I think I got that right



VentMedic said:


> Are you a Paramedic? I would hope this was at least mentioned in your program since you do give meds like nitro and epinephrine.



No I'm not and no I don't think those terms explicetly are covered in our entry-to-practice qualification (Diploma of Ambulance Practice) but they *were* covered in the A&P classes I've taken.  That's 2am posting for you 



VentMedic said:


> Yes and if you assist in transporting specialty teams you may see it frequently now on the ambulances. As well, you will also see it in the homes or outside of them as patient now carry the little tanks of Nitric Oxide with them. So, don't assume that tank is O2. As well, the nebulizers a person (could be a child also) takes at home may be a pulmonary vasodilator and not "albuterol".



Have you seen No Country For Old Men? I'm only going to worry about people carrying oxygen tanks around if they look like that dude Chigur and if it has a little metal firing rod thing attatched to the end of it! :lol: :lol:



VentMedic said:


> I guess when asked to do an IFT transport from one hospital to another you just turn on the L&S and drive real fast.



I've never seen an IFT go out "priority" (lights and/or siren) and have seen two priority transports back to hospital in 3 years; one was a STEMI and one was a seizure.

This stuff is really interesting; it's like chocolate for my brain! ^_^


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## VentMedic (Sep 26, 2009)

MrBrown said:


> My bad I read that wrong when you said "past 30" I figured > 30
> 
> 
> No; we use 100% oxygen; my bad!
> ...


 
I was wondering what your level of training/education was since many of your posts do appear with a higher level of discussion.

We rarely have the SvO2 monitor for continuous monitoring with us unless we know there is already a line established that we can hook up to. These patients may be from one of our sister hospitals. It is portable but still takes up considerable room. We can however do SvO2 or ScvO2 values from the lines (central preferred) for a data trend with the iSTAT. The SpO2 monitor is of course on as is the ETCO2.

http://ccn.aacnjournals.org/cgi/reprint/24/4/73


Here's some links of interest...hopefully. This is just to wet your appetite for what is out there if you want the challenge.

Pulmonary Hypertension in the neonate 
http://www.ranichildrenhospital.com/presentation/PPHN.ppt

Variety of good articles (Flight)
http://www.ems1.com/Columnists/paul-mazurek/

http://www.med.umich.edu/survival_flight/Conference/Mazurek - CHDrevisitedSFConf..pdf

Adult Congenital Heart Disease (Yes, you will see more of these patients)
http://tchin.org/adults/index.htm

ScvO2 monitoring (Pedi)
http://www.edwards.com/products/presep/pediasatdemand.htm?PediaSatConsumption=1

Currently trialing
http://www.edwards.com/products/mininvasive/flotracsensor.htm

Since I do a lot of neo/pedi transport, we do blenderize our O2 so 28% could be delivered to a bag or NC. For neo/pedi, even the nasal cannulas run off a blender to better control the amount of FiO2 as their minute volumes are smaller and air entrainment will be less. Thus, a 2 liter NC running off a 100% O2 flow meter will give the small childr or infant close to 100% O2 instead of the 28% as "calculated" for the adult.


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## eveningsky339 (Sep 26, 2009)

VentMedic said:


> After reading some of the posts, I believe for the BLS trucks it should be CNAs/PCTs since they are more familiar with medical patients.
> 
> Florida has all ALS services so the Paramedic will remain as the standard for 911.



There are only a couple of ambulance services around my area, but they are all well-respected.  A few are paramedic-level only (with EMT-Is assisting), and they don't hire Basics unless they *know* that the employee is the man for the job.

I can imagine how it is in cities where the market is flooded with cherry Basics, though.  :wacko:


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## daedalus (Sep 26, 2009)

> I've never seen an IFT go out "priority" (lights and/or siren)


Really?? We are requested code 3 (priority) for all sorts of things on our CCT unit. In fact, we respond code for all suspected ACS going from an ER to cardiac facilities per county protocol. Others include brain bleeds, high risk OB, dissecting aneurysms, we get a lot of emergencies on our unit and treat it as such.


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