# Should I85s be allowed to help with pain managment?



## EMT91 (Jul 4, 2012)

I was recently thinking about how awesome and useful it would be if, as an I85, I could administer something, be it Ibuprofen or some other non-narcotic pain medicine be it via IV or PO. Do you think I85s should be allowed to administer something for pain?


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## usalsfyre (Jul 5, 2012)

Personally I don't see the danger of narcotic admin at the I85 level..


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## EMT91 (Jul 5, 2012)

usalsfyre said:


> Personally I don't see the danger of narcotic admin at the I85 level..



I would love to be able to administer narcotics but I felt that many would be like "oh heck no!" I was thinking pain management of like minor to moderate issues, bad headaches, strains etc.


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## Doczilla (Jul 5, 2012)

The problem is paperwork. Most ALS systems require a paramedic to sign the narc log--- which stems from state DOH regulations. Alot more would have to change than just scope of practice. 

The only non opioid that would really be worth it would be toradol, which is very effective for some stuff. Other non opiates like nubain work well but I haven't seen them utilized stateside for prehospital care. 

As far as PO meds are concerned, I doubt a MD would sign off on it for beurocratic and practicality reasons. As with many things, you have to ask if what you are doing will truly make a difference within your continuum of care.


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## EMT91 (Jul 5, 2012)

Doczilla said:


> The problem is paperwork. Most ALS systems require a paramedic to sign the narc log--- which stems from state DOH regulations. Alot more would have to change than just scope of practice.
> 
> The only non opioid that would really be worth it would be toradol, which is very effective for some stuff. Other non opiates like nubain work well but I haven't seen them utilized stateside for prehospital care.
> 
> As far as PO meds are concerned, I doubt a MD would sign off on it for beurocratic and practicality reasons. As with many things, you have to ask if what you are doing will truly make a difference within your continuum of care.



True true. I guess I was thinking PO meds because we administer ASA for cardiac related chest pain.


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## Melclin (Jul 5, 2012)

I don't see why you shouldn't be allowed to administer any drugs that people can administer to themselves after trotting down to the local drug store. 

Acetaminophen/codeine preparations, ibuprofen etc. 

IV acetaminophen is pretty affective. 

Really though, I don't see why it would be an issue to use IV morphine or fent. I guess if the DOH is problem then there is more to it than the clinical issues, but there isn't really a lot IV opioid management. If they're so worried about ODing pts, they can introduce a guidelines that is very conservative and expand it as people become more confident. 

2.5mg IV q5 to a max of 10 or something. Better than nothing at all.


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## exodus (Jul 5, 2012)

What about just giving them nitronox?


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## Tigger (Jul 5, 2012)

I would like to see the intermediate level provider have narcotic pain management at their disposal, as well as ACLS in its entirety. I think that would be a fair trade for eliminating endotracheal intuabation and sticking with "rescue" airways. I'm totally sold on how they did it in New Zealand (not to sound like a broken record). Three year bachelor's degree gives one the ability to practice at the ILS level with the scope as above. The degree has 24 classes, of which only two can be electives. Chem, Bio, Psych, English Composition, the works. After the first year I think class credit could be received for doing ride/hospital time. Every urban ambulance has at least one ILS crew member, most have two. Advanced Care Paramedics were in flycars, they had the same scope as what one would find at a progressive paramedic agency here, but had at least another year of schooling to go with ACP level.


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## JPINFV (Jul 5, 2012)

Melclin said:


> I don't see why you shouldn't be allowed to administer any drugs that people can administer to themselves after trotting down to the local drug store.



...because there's a huge difference between taking something on your own accord and taking something because a medical professional told you to take it.


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## JPINFV (Jul 5, 2012)

EMT91 said:


> True true. I guess I was thinking PO meds because we administer ASA for cardiac related chest pain.




...but you don't give ASA for pain management.


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## Veneficus (Jul 5, 2012)

EMT91 said:


> True true. I guess I was thinking PO meds because we administer ASA for cardiac related chest pain.




I think this demonstrates wy intermediates are not permitted to administer it.

It is unfortunate that prehospital pain management in the US has to be a narcotic or nothing most of the time.


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## Melclin (Jul 5, 2012)

JPINFV said:


> ...because there's a huge difference between taking something on your own accord and taking something because a medical professional told you to take it.



How? I can understand if this is some BS legal argument but aside from that I don't get how this isn't a person choosing to take a medication.  

Oh you've got pain? Hey I've got these pain pills, same as you'd take for a headache etc. Want some? Oh you do? Okay.


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## JPINFV (Jul 5, 2012)

Melclin said:


> How? I can understand if this is some BS legal argument but aside from that I don't get how this isn't a person choosing to take a medication.
> 
> Oh you've got pain? Hey I've got these pain pills, same as you'd take for a headache etc. Want some? Oh you do? Okay.




So if your neighbor tells you to take an OTC pill it's given the same weight as a physician telling you to take an OTC pill? Granted, EMTs and paramedics are not physicians, but the average patient isn't going to draw that line. Then, of course, there's the issue of if there's any adverse reactions due to the patient's history and other medications (if any). Your neighbor can't be sued. The EMT can be. I'm not against giving some OTC medications to EMS providers, but it shouldn't be "Walgreens" in terms of breadth of medications.


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## Aidey (Jul 5, 2012)

Melclin said:


> I don't see why you shouldn't be allowed to administer any drugs that people can administer to themselves after trotting down to the local drug store.
> 
> Acetaminophen/codeine preparations, ibuprofen etc.
> 
> IV acetaminophen is pretty affective.



Acetaminophen/Codeine preparations are not OTC in the US.


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## Melclin (Jul 5, 2012)

JPINFV said:


> So if your neighbor tells you to take an OTC pill it's given the same weight as a physician telling you to take an OTC pill? Granted, EMTs and paramedics are not physicians, but the average patient isn't going to draw that line. Then, of course, there's the issue of if there's any adverse reactions due to the patient's history and other medications (if any). Your neighbor can't be sued. The EMT can be. I'm not against giving some OTC medications to EMS providers, but it shouldn't be "Walgreens" in terms of breadth of medications.



As I said I grant you the legal part of it in your country at least. I don't agree with it. 

We have minimally educated providers handing out paracetamol willy nilly often without even an assessment. Whats the difference between a person going to an FR/EMT and saying, "I'm in pain, can I something for the pain?" "Oh you've got some Tylenol? I know what that is because who doesn't (granted I didn't. I had to google what American for panadol was) so I'm going to make a _choice_ to take it _myself_ that would be equally as informed as if I went to the 7/11 200 metres down the road. Whats the difference? Nobody is telling anyone to take anything. A drug that everyone is familiar with is simply available should a person chose to want to take it.

I should perhaps have been a bit more clear in my wording, I wasn't suggesting the entire contents of the drug store be piled into the ambulance. Just that I don't see a problem with any single (or a few) OTC medication being used. I'm pretty much exclusively talking about tylenol but I can see a use for a few others. In any case, there is a reason these drugs are OTC. They're pretty damn safe. Besides I/85s are involved in med administration right? So whats the big deal about adding a safe, incredibly cheap and effective drug to the list?



> Acetaminophen/Codeine preparations are not OTC in the US.



Ah. My mistake. 

My sympathy goes out to you all when you are hungover.


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## Veneficus (Jul 5, 2012)

JPINFV said:


> So if your neighbor tells you to take an OTC pill it's given the same weight as a physician telling you to take an OTC pill? Granted, EMTs and paramedics are not physicians, but the average patient isn't going to draw that line. Then, of course, there's the issue of if there's any adverse reactions due to the patient's history and other medications (if any). Your neighbor can't be sued. The EMT can be. I'm not against giving some OTC medications to EMS providers, but it shouldn't be "Walgreens" in terms of breadth of medications.



Along the same lines, I give out mortin 800s all day long. After I have assessed a patient and decided on a treatment plan. 

That assessment does not require a host of adjuncts like labs and xrays all the time, but it does require knowledge and responsibility.

Sorry, but most of the US EMS providers are simply not capable of safely deciding a patient doesn't need a hospital or can make due with an OTC.

In other countries that require more education it is not an issue. In countries where the provider signs the chart and is held accountable to those decisions without pointing the finger at the doctor when something goes wrong, that is not an issue.

But the US is the most simplistic of protocol medicine in EMS. It is one size fits nearly all with just a few sizes in stock.

It would benefit not only the patients, but the economics for US providers to be at the same level as their counterparts in other modern nations. 

But it is not a popular view on EMTlife, in the real world even less.


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## NYMedic828 (Jul 5, 2012)

Veneficus said:


> I think this demonstrates wy intermediates are not permitted to administer it.
> 
> It is unfortunate that prehospital pain management in the US has to be a narcotic or nothing most of the time.





EMT91 said:


> True true. I guess I was thinking PO meds because we administer ASA for cardiac related chest pain.



I know medics who don't know that either though Ven. (on the bright side, if the patient has inflammatory chest pain than it may help )


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## Melclin (Jul 5, 2012)

Veneficus said:


> Along the same lines, I give out mortin 800s all day long. After I have assessed a patient and decided on a treatment plan.
> 
> That assessment does not require a host of adjuncts like labs and xrays all the time, but it does require knowledge and responsibility.
> 
> ...



An EMT giving a pt paracetamol wouldn't be deciding against transport, simply providing some safe and basic analgesia along the way.



> I know medics who don't know that either though Ven. (on the bright side, if the patient has inflammatory chest pain than it may help )



*and Vene:*

Whats wrong with EMT91statement? Isn't he just saying they have PO drugs, they're familiar with the process of PO drug administration, contras dosages, allergies, 5 rights and all that, so why can't they apply the same idea to something as simple as using a safe OTC analgesic like tylenol.


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## Veneficus (Jul 5, 2012)

Melclin said:


> An EMT giving a pt paracetamol wouldn't be deciding against transport, simply providing some safe and basic analgesia along the way.
> 
> 
> 
> ...


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## Melclin (Jul 5, 2012)

Veneficus said:


> Melclin said:
> 
> 
> > An EMT giving a pt paracetamol wouldn't be deciding against transport, simply providing some safe and basic analgesia along the way.
> ...


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## Veneficus (Jul 5, 2012)

Melclin said:


> Veneficus said:
> 
> 
> > He said cardiac related chest pain. Whats wrong with that as a basic indication?
> ...


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## Melclin (Jul 5, 2012)

Veneficus said:


> Melclin said:
> 
> 
> > when I read it, I was thinking about the mechanism.
> ...


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## Dwindlin (Jul 5, 2012)

Melclin said:


> Ohhhh I see where I got my wires cross.
> 
> I hope you you won't mind me saying that I hope you're wrong. I'd hate to think that there are providers out there that think we give aspirin for pain relief in acute coronary syndromes.



I can assure you there are, work with them frequently.


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## Melclin (Jul 5, 2012)

Dwindlin said:


> I can assure you there are, work with them frequently.



Ohhhhhhh.

I'd better get another drink.


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## Veneficus (Jul 5, 2012)

Melclin said:


> I hope you you won't mind me saying that I hope you're wrong. I'd hate to think that there are providers out there that think we give aspirin for pain relief in acute coronary syndromes.



I hope I was wrong too, but apparently not.


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## EMT91 (Jul 5, 2012)

JPINFV said:


> ...but you don't give ASA for pain management.



...I know. Its for cardiac a d may relieve associated pain.


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## EMT91 (Jul 5, 2012)

Veneficus said:


> Melclin said:
> 
> 
> > when I read it, I was thinking about the mechanism.
> ...


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## Veneficus (Jul 5, 2012)

EMT91 said:


> You did. I was speaking simplisticly; it has to do with the enzymes and making them non sticky. However in the end the patient may tell you his pain is reduced. I should have been more clear. Its hard to give a lot of detail when typing a reply from a tablet ^_^ I was merely thinking that pain relief may be a possible by action or result. For instance viagra is used for ED but it can also be used to treat pulmonary hypertension.



No medication for EMT-Is

the prosecution rests.


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## Tigger (Jul 5, 2012)

Veneficus said:


> No medication for EMT-Is
> 
> the prosecution rests.



Right, because the words of forum member should decide how we go about things. I get that this is all probably somewhat in jest, but you yourself (rightly) call for studies to back up a so-called "n=1" conclusion. So how is it fair to judge in reverse, you cannot say that one person's postings accurately reflect a group as a whole.


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## Medic2409 (Jul 5, 2012)

Veneficus said:


> In other countries that require more education it is not an issue. In countries where the provider signs the chart and is held accountable to those decisions without pointing the finger at the doctor when something goes wrong, that is not an issue.



The flip side to this is when something does happen, the doctor can lay all the blame on the Medic, with no recourse for the Medic to pursue.




> But the US is the most simplistic of protocol medicine in EMS. It is one size fits nearly all with just a few sizes in stock.
> 
> It would benefit not only the patients, but the economics for US providers to be at the same level as their counterparts in other modern nations.
> 
> But it is not a popular view on EMTlife, in the real world even less.




Popular view from where I stand, although, sadly, we are in the minority.


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## JakeEMTP (Jul 5, 2012)

Medic2409 said:


> The flip side to this is when something does happen, the doctor can lay all the blame on the Medic, with no recourse for the Medic to pursue.



In the US the Paramedic has become reliant on their Medical Directors and other doctors to make their decisions. In other countries the Paramedic has achieved the privilege of being able to make the necessary medical decisions through education and extensive internships. They are accountable for their actions and must come up with reasons beyond that's what the protocols say or the state says I can because it is in my scope of practice. They must be able to differentiate the difference between can do something and should do something.


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## Veneficus (Jul 5, 2012)

Tigger said:


> Right, because the words of forum member should decide how we go about things. I get that this is all probably somewhat in jest, but you yourself (rightly) call for studies to back up a so-called "n=1" conclusion. So how is it fair to judge in reverse, you cannot say that one person's postings accurately reflect a group as a whole.



I would say it is partly in jest. But not all.

(Next part no jest)

I have no doubt there are many exceptionally knowledgable, skilled, and experienced EMS providers of all levels. 

But when I was actively a medic (I am still a medic on paper and still teach medics), these providers were few and far between. 

I have not noticed a significant population level change in the quality of EMS providers. 

Actually, over the years it has become more skills focused and the clinical accumen of providers has by in large appeared to go down.

If you don't want to be judged by the lowest common denominator of EMS provider, it is your responsibility as one to raise the lowest standard. 

It is not about 1 poster. It is about 1 poster who happens to represent what in my experience seems to be the vast majority of EMS providers.

I think it is surely possible to train EMT-Is to administer pain meds, both narcotic and otherwise, but we simply are not there yet.


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## EMT91 (Jul 5, 2012)

Then please,  explain how I was wrong and teach me what is proper.
This is @ ven.


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## Veneficus (Jul 5, 2012)

Medic2409 said:


> The flip side to this is when something does happen, the doctor can lay all the blame on the Medic, with no recourse for the Medic to pursue..



I find such behavior not only revolting, but completely unacceptable of somebody calling themself "doctor" without exception.

When a doctor or anyone else is in charge, they are responsible. That includes accepting blame and responsibility for the faults of those who work under them.

A doctor should never be blaming a provider who that same doctor signed off on as qualified and fit to practice under them. 

They deserve to be sued for all they have and lose, including their license for such behavior. 

Nobody forces a doctor to be a medical director. They accept the position, they accept the responsibility. Whether they are paid or not.


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## JakeEMTP (Jul 5, 2012)

Veneficus said:


> I find such behavior not only revolting, but completely unacceptable of somebody calling themself "doctor" without exception.
> 
> When a doctor or anyone else is in charge, they are responsible. That includes accepting blame and responsibility for the faults of those who work under them.
> 
> ...



_Originally Posted by Veneficus  
In other countries that require more education it is not an issue. In countries where the provider signs the chart and is held accountable to those decisions without pointing the finger at the doctor when something goes wrong, that is not an issue._


I thought your previous post was about other countries with Paramedics having a more independent practice. I don't believe other countries are reliant of a Medical Director.  

In the US the Medical Director provides the protocols and should see that the Paramedics have a measureable amount of competency by some means. But, if a Paramedic defies protocols or acts negligently, that Medical Director is not solely responsible for the actions of the Paramedic. That is where licensure comes in that the Paramedic has a share of the responsibility. You can not put your incompetency or screwups solely on the back of your Medical Director. That is just an excuse for you to have some of the fun but none of the accountability


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## NYMedic828 (Jul 5, 2012)

EMT91 said:


> Then please,  explain how I was wrong and teach me what is proper.
> This is @ ven.



That's the problem. You can't leave something open to teaching it after the fact. Your educational program did not fully address pharmacology as in depth as would need to be done for informed administration of medications. Yes there are people more than capable at the EMT and EMT-I level but you cannot do something based on the few when the many are not ready or capable.

Unfortunately there are also paramedics who don't know any better either. But it is assumed that the scale is the opposite and most are educated "enough" and will make decisions in their scope for the right reasons.

As far as aspirin goes, we don't give aspirin for analgesia. Ever. Yes ASA can relieve pain and inflammation, yes it reduces fever, But that isn't what we have it for.

As you already stated it inhibits platelet aggregation. The whole purpose of this is to distupt the clotting cascade to either reduce the chance of coronary blockage in those taking daily aspirin, or in our case to reduce further blockage. Aspirin does not break up already formed clots but it will help prevent them from enlarging worsening the condition.

We only give aspirin for suspected MI. If the patient simply has chest pain, and the suspect is not infarction 2nd to blockage than aspirin is no longer in play.


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## EMT91 (Jul 5, 2012)

I know all of that its writtten off to the side in my basic book. I was merely using asa as an example of a medication we give po. I was not saying we use it for pain. I know we use it for the anti coagulant properties. I think a great misunderstanding took place here. I apologize for that.


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## Veneficus (Jul 6, 2012)

EMT91 said:


> Then please,  explain how I was wrong and teach me what is proper.
> This is @ ven.



The answers you seek can be found here:


http://www.amazon.com/Guyton-Hall-T...2&sr=8-1&keywords=Guyton's+medical+physiology

and here:

http://www.amazon.com/Robbins-Cotra...=1-1&keywords=Robins+and+Coltran+Pathological


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## Veneficus (Jul 6, 2012)

JakeEMTP said:


> _Originally Posted by Veneficus
> In other countries that require more education it is not an issue. In countries where the provider signs the chart and is held accountable to those decisions without pointing the finger at the doctor when something goes wrong, that is not an issue._
> 
> 
> ...



In the previous post, I was pointing out that the medics in other countries do not rely on protocols from medical direction. 

By default, that makes them both the in charge and responsible party. (as anyone in charge must be responsible, there can be no authority without responsibility) 

Those medics do not follow protocols and then point the finger at the doctor or protocol when things go wrong.

If something were to go wrong where I work, then I am responsible. It doesn't matter what nonmedical provider made the mistake or why. It is still unquestionably my fault and my responsibility.


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## Handsome Robb (Jul 6, 2012)

exodus said:


> What about just giving them nitronox?



Intermediates can give nitronox. Well at least here they can :unsure:


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## DrParasite (Jul 6, 2012)

a civilian can give over the counter pain meds, why can't an trained medical provider (EMT, I-85 etc)?


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## usalsfyre (Jul 6, 2012)

NVRob said:


> Intermediates can give nitronox. Well at least here they can :unsure:



As mentioned in another thread, good luck finding a blender .

IN fentanyl is safe, mostly effective and aside from controlled substance concerns, easy to use.


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## EMT91 (Jul 6, 2012)

Veneficus said:


> The answers you seek can be found here:
> 
> 
> http://www.amazon.com/Guyton-Hall-T...2&sr=8-1&keywords=Guyton's+medical+physiology
> ...



Nice. I ask however that you explain to me the particular topic under discussion as an experianced medic to a newbie,  please.


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## TransportJockey (Jul 6, 2012)

EMT-Is in NM can administer IV Fentanyl and Morphine w/ MCEP orders. Did it quite often as an EMT-I running an ILS 911 transport truck.


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## Melclin (Jul 6, 2012)

EMT91 said:


> Nice. I ask however that you explain to me the particular topic under discussion as an experianced medic to a newbie,  please.



Not to answer for Vene, but from my point of view the problem from the start is that these things have been explained in single sentences or paragraphs. 

Its more complicated than that. 

Thats why I gave links in my PM and not answers. I myself couldn't do the topic justice. IMHO the description of the clotting cascade in guytons is brilliant because it describes things in more detail than any other general text I've read but does it in a way that is both enjoyable and easy to understand for just about anyone. I read several other books and I didn't really get it. When I read guytons, I actually got it. PM me and we can probably sort out a copy if you're genuinely interested.


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## Doczilla (Jul 6, 2012)

I'm confused, are you asking for a physio lesson on how asprin works? In the time it takes to demand a response, you could easily look it up, then discuss your findings with us. 

The best providers are self-improving and self motivating.


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## STXmedic (Jul 6, 2012)

Doczilla said:


> The best providers are self-improving and self motivating.



Quoted for emphasis.

Getting spoon-fed tidbits will not serve you nearly as well as you researching it yourself.


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## Veneficus (Jul 6, 2012)

EMT91 said:


> Nice. I ask however that you explain to me the particular topic under discussion as an experianced medic to a newbie,  please.



I will address this by PM.


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## EpiEMS (Jul 6, 2012)

TransportJockey said:


> EMT-Is in NM can administer IV Fentanyl and Morphine w/ MCEP orders. Did it quite often as an EMT-I running an ILS 911 transport truck.



Were these already in place on a pump or something of the sort? Or were you guys pushing them?

Just thinking out loud here: if nitrous oxide is part of the national scope of practice for the AEMT, then there must be several places that use it, no?


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## VFlutter (Jul 6, 2012)

You also have to remember that the cardiac dose (160-325mg) is lower than the typical dose given for analgesia (325-650mg).


Here are the two books I use on a regular basis. If you buy them new you get the Ebook along with it that you can put on your iPhone which is awesome for clinicals. 

http://http://www.amazon.com/Mosbys-2012-Nursing-Reference-Skidmore/dp/0323069177

http://http://www.amazon.com/Mosbys-2012-Nursing-Reference-Skidmore/dp/0323069177

Great book for the price, easy to read and understand but is not as advanced as some others.


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## TransportJockey (Jul 6, 2012)

EpiEMS said:


> Were these already in place on a pump or something of the sort? Or were you guys pushing them?
> 
> Just thinking out loud here: if nitrous oxide is part of the national scope of practice for the AEMT, then there must be several places that use it, no?



Nope, pull tjem out of the safe, call for orders, and draw and push the narcs


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## Handsome Robb (Jul 6, 2012)

usalsfyre said:


> As mentioned in another thread, good luck finding a blender .
> 
> IN fentanyl is safe, mostly effective and aside from controlled substance concerns, easy to use.



True. 

We have lots of them but if the VSTs don't like the way you are handling it you'll get screeched at for reasons you pointed out in that thread. 

Agreed about fentanyl, it would be a good option at the ILS level if there wouldn't be an uprising about it.


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## EpiEMS (Jul 6, 2012)

TransportJockey said:


> Nope, pull tjem out of the safe, call for orders, and draw and push the narcs



Didn't realize that EMT-Is could give narcs. Thought it was medic-only. Interesting!


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## VirginiaEMT (Jul 6, 2012)

Veneficus said:


> I think this demonstrates wy intermediates are not permitted to administer it.
> 
> It is unfortunate that prehospital pain management in the US has to be a narcotic or nothing most of the time.



You are referring to I-85s aren't you. As a I-99 I have Morphine and Fentanyl in my box as standing order drugs. Is this not the case most places?


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## EpiEMS (Jul 6, 2012)

VirginiaEMT said:


> You are referring to I-85s aren't you. As a I-99 I have Morphine and Fentanyl in my box as standing order drugs. Is this not the case most places?



True, true, neglected to consider the I-99. AEMT is somewhere in-between, I suppose. CT doesn't really use any EMT-I/AEMT skills other than IV placement, which is unfortunate, because EMT-Is/AEMTs have lots of useful skills in the National scope.


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## EMT91 (Jul 6, 2012)

Veneficus said:


> I will address this by PM.



In response to you and the others I am and have been for the past four days or so been working on an essay of sorts explaing asa. I do wish to expand my knowledge and if I seemed rude or demanding I sincerely apologize.


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## Doczilla (Jul 6, 2012)

It's not rude, but you're making a common mistake. The best way to remember meds is understand the concept, not just memorize facts. Understand the physio first, then your medication in question will make sense. If you understand the concept---  indications , contraindications, and adverse effects become obvious. 

If you just memorize drug facts, you will dump it in an emergency. Trust me on this.

After you know this medication, answer me this please: 

Why is ASA a vasodilator?


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## Craig Alan Evans (Jul 7, 2012)

Pain management in the prehospital setting has been classically under dosed and underutilized. Systems are sending BLS units to fractures, abdominal pains, an back injuries. These are three things that almost always require some form of pain management. Anything we can do to allow more providers to administer pain medications will benefit the system and the public we serve. So yes, if you can start an IV then you should be able to give pain medications through the IV. I'm sure you carry nalaxone so realistically the risks are minimal. And everyone should be using nitrous oxide. BLS providers can very safely administer nitrous oxide.


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## Veneficus (Jul 7, 2012)

Craig Alan Evans said:


> And everyone should be using nitrous oxide. BLS providers can very safely administer nitrous oxide.



Tell the FDA that. They are the ones that made it so restrictive nobody carries it.

Also if I could just comment on narcan as a reasonable treatment.

If you reverse opioids you were administering for pain, then the pain comes back and the patient will probably have to suffer the 20 or so minutes until it wears off.

It is never done post surgery anywhere I have been for that very reason, best to just ventilate the pt.


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## Craig Alan Evans (Jul 7, 2012)

Veneficus said:


> Tell the FDA that. They are the ones that made it so restrictive nobody carries it.
> 
> Also if I could just comment on narcan as a reasonable treatment.
> 
> ...



The FDA does not have unreasonable restrictions on the medical uses of nitrous oxide.  It is definitely not so restrictive to make it prohibitive for prehospital treatment. I'm not sure where you are receiving your information from but I assure you that is not the case in Virginia. Many states have adopted laws regarding the human consumption of nitrous for recreational use but it remains a main stay in dentists offices, especially pediatric dentists and is a viable option for prehospital use. The limitation as listed above is with the delivery device.  Not the gas itself.  

As for your comments concerning narcan there are inherent risks with ventilating a patient for the 20 minutes needed such as gastric distention, vomiting, and aspiration.  These complications are more prevalent with BLS providers. I believe in the case of administering too much narcotic it is a viable option to slowly reverse the effects to maintain respirations. Why would I want to ventilate a patient for 20 minutes when I can titrate .2-.4 mg of narcan and return their respiratory drive to normal while maintaining the pain reducing effects of the drug.  If your argument holds true for all narcotic overdoses then we should be intubating all of them and just waiting for the effects of the drug to wear off. I see your point but I'm not buying it for prehospital medicine. 

Once again I enjoy the yin yang discussions we seem to always get into.


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## Veneficus (Jul 7, 2012)

Craig Alan Evans said:


> The FDA does not have unreasonable restrictions on the medical uses of nitrous oxide.  It is definitely not so restrictive to make it prohibitive for prehospital treatment. I'm not sure where you are receiving your information from but I assure you that is not the case in Virginia. Many states have adopted laws regarding the human consumption of nitrous for recreational use but it remains a main stay in dentists offices, especially pediatric dentists and is a viable option for prehospital use. The limitation as listed above is with the delivery device.  Not the gas itself..



As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.

Whether or not it is controlled isn't an issue, it is just a logistical nightmare. Between multiple tanks, mixers, off gasing, etc. 

An excellent drug for sure, but I am not convinced the issues it comes with makes it a reasonable alternative.



Craig Alan Evans said:


> As for your comments concerning narcan there are inherent risks with ventilating a patient for the 20 minutes needed such as gastric distention, vomiting, and aspiration.  These complications are more prevalent with BLS providers...



But they are easily remidied with basic techniques and adjuncts. I do not buy the argument we need to administer a medication (in this case narcan) because people cannot proficently do their job.

I agree what you said is true.




Craig Alan Evans said:


> I believe in the case of administering too much narcotic it is a viable option to slowly reverse the effects to maintain respirations. Why would I want to ventilate a patient for 20 minutes when I can titrate .2-.4 mg of narcan and return their respiratory drive to normal while maintaining the pain reducing effects of the drug.



In the prehospita environment, if you are treating for acute pain, chances are if the patient has a hypersensitive reaction which causes respiratory depression, the amount of administered drug is going to be relatively low dose. 

So the chances that you can restore spontaneous respiration while managing pain are rather small. 

If there is a larger dose of opioid titrated, then I must question whether or not the patient was actually in respiratory arrest and not simply impaired?




Craig Alan Evans said:


> If your argument holds true for all narcotic overdoses then we should be intubating all of them and just waiting for the effects of the drug to wear off. I see your point but I'm not buying it for prehospital medicine..



My argument is not about all narcotic overdoses, it is about accidental overdose by a healthcare provider while treating acute pain.

I think it important not to try to use a one-size-fits-all approach to medicine. 

Using a reversal agent on a chronic substance abuser (or even first time substance abuser) is not the same can of worms as an accidental overdose by a HCP.


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## Craig Alan Evans (Jul 7, 2012)

Veneficus said:


> As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.
> 
> Something has changed. The
> device we use is in a small bag and combines nitrous with oxygen at a 50/50 mix delivered by a demand valve which is self administered.  Very easy.  So easy that we routinely bring it onto athletic fields to provide instant pain management from skeletal fractures/strains/sprains while packaging the patient for transport.
> ...



Agreed but the same principals remain.


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## Craig Alan Evans (Jul 7, 2012)

Clearly I need a lesson on quoting and  replying.  Needless to say. Read through and you can see my answers between your paragraphs.


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## jwk (Jul 7, 2012)

Veneficus said:


> Also if I could just comment on narcan as a reasonable treatment.
> 
> If you reverse opioids you were administering for pain, then the pain comes back and the patient will probably have to suffer the 20 or so minutes until it wears off.
> 
> It is never done post surgery anywhere I have been for that very reason, best to just ventilate the pt.



Hmmm, sorry, that's somewhat off base.

We do use Narcan following surgery, although rarely.  Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed.  Regardless, we want the patient breathing at the end of the case.  I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with.  That's poor management.  However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients.  Our Narcan comes 0.4mg/cc.  I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing.  By titrating the dose, I can get them breathing and still keep them comfortable.  That's not possible when giving a full 0.4mg dose or more at a time.

An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.


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## Craig Alan Evans (Jul 7, 2012)

jwk said:


> Hmmm, sorry, that's somewhat off base.
> 
> We do use Narcan following surgery, although rarely.  Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed.  Regardless, we want the patient breathing at the end of the case.  I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with.  That's poor management.  However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients.  Our Narcan comes 0.4mg/cc.  I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing.  By titrating the dose, I can get them breathing and still keep them comfortable.  That's not possible when giving a full 0.4mg dose or more at a time.
> 
> An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.



I agree completely. Thank you for the back-up. Slowly and efficiently reducing the effects of the narcotic is much more preferred over waiting for the drug to wear off and risking airway complications.  This can be accomplished safely and easily in both the prehospital an hospital settings.


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## Veneficus (Jul 7, 2012)

jwk said:


> Hmmm, sorry, that's somewhat off base.
> 
> We do use Narcan following surgery, although rarely.  Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed.  Regardless, we want the patient breathing at the end of the case.  I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with.  That's poor management.  However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients.  Our Narcan comes 0.4mg/cc.  I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing.  By titrating the dose, I can get them breathing and still keep them comfortable.  That's not possible when giving a full 0.4mg dose or more at a time.
> 
> An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.



I never suggested extubating and bagging anyone. If there is a tube in, why would anyone remove it? 

I was suggesting managing the airway and bagging for a short period of time when titrating analgesia. 

You are also talking about a dose so small it is never used in EMS. In my EMS experience providers often administered 2 mg narcan as a bolus, more refined providers in a titrating dose. 

How often do you really snow somebody titrating analgesia and then have to wake them up moments later? 

Patient breathing at the end of the case is the obvious goal, but it sounds more like an institutional decision. 

Where I am usually at, the OR schedules are not so tight that a 10 or 20 mminute delay while waiting for a pt to wake up is an issue. 

There is also an anesthesiologist in every OR too though... There are no assistants, nurse anestatists, etc.

I can see the reason for QI, but I think it is quite unfair to call it an adverse drug reaction.


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## ZootownMedic (Jul 11, 2012)

usalsfyre said:


> As mentioned in another thread, good luck finding a blender .
> 
> IN fentanyl is safe, mostly effective and aside from controlled substance concerns, easy to use.



Until they develop wooden chest syndrome :rofl:


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## Handsome Robb (Jul 11, 2012)

SmokeMedic said:


> Until they develop wooden chest syndrome :rofl:



From what I have read and was told by the PharmD for the Level II's ICUs here you *generally* have to slam a huge dose for it to happen. Not to say it isn't possible, but it's also possible for us to manage in the field provided you aren't a total windowlicker of a provider.


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## ZootownMedic (Jul 11, 2012)

NVRob said:


> From what I have read and was told by the PharmD for the Level II's ICUs here you *generally* have to slam a huge dose for it to happen. Not to say it isn't possible, but it's also possible for us to manage in the field provided you aren't a total windowlicker of a provider.



Yes my friend....I was like 85% joking...although I did hear of a 6 yom developing it with a normal SIVP and a standard 0.07 mg/kg dosage. It was in the PICU here in C springs and the RN that told me about was reliable. 

As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents


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## EpiEMS (Jul 12, 2012)

SmokeMedic said:


> As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents



Why do you have to have them on the monitor and have capnography for narcotics administration? Military medics push narcotics all the time without an EKG or EtCo2, no?


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## OzAmbo (Jul 12, 2012)

SmokeMedic said:


> As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents


Capnography? Seriously?

Not having a go at you personaly brother but but if your system needs that much oversight for narcotics i hope they dont let your intermediates use GTN.

Why are people scared about narcs but hand out GTN like tic tacs ill never understand


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## Doczilla (Jul 12, 2012)

This is because we don't carry monitors in our aid bag. 

Also, giving narcs to a traumatic amputee has an extremely low side effect profile. The amount of depression you see usually correlates to the amount of pain they are in.


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## OzAmbo (Jul 12, 2012)

Doczilla said:


> This is because we don't carry monitors in our aid bag.
> 
> Also, giving narcs to a traumatic amputee has an extremely low side effect profile. The amount of depression you see usually correlates to the amount of pain they are in.


I hear ya there Doc, but oin the sae vein, theres those that underanage pain for fear of cardio-respiratroy depression based on "they dont look like they are in pain" :sad:

I'm confused though by the "monitors in the aid bag" bit though, what specifically are you referring to?

Later...


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## Veneficus (Jul 12, 2012)

OzAmbo said:


> Capnography? Seriously?
> 
> Not having a go at you personaly brother but but if your system needs that much oversight for narcotics i hope they dont let your intermediates use GTN.
> 
> Why are people scared about narcs but hand out GTN like tic tacs ill never understand



Doctors all over the world are taught to fear pain control. 

Swing on over to the recent medical school discussions on cardiac toxicity of lidocaine when suturing, they pop up every few months or so.

The US makes it your doctor's fault if you become addicted to the narcs he gives you.

Capnography while administering morphine...

From the country that claims to have the best medicine in the entire world...

At least you are safe.


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## VFlutter (Jul 12, 2012)

It is a policy on one of our med/surg floors that anyone on a narcotic PCA pump has be on continuous capnography (Via NC) .....too bad the nurses have no clue what the readings indicate let alone can tell you the differences between capnography and Spo2 Plethysmography. 

Numerous times RRT's are called for patients breathing ~ 4 times a minute and the response from the nurse is always "but his sp02 was fine last time I checked"


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## Veneficus (Jul 12, 2012)

ChaseZ33 said:


> It is a policy on one of our med/surg floors that anyone on a narcotic PCA pump has be on continuous capnography (Via NC) .....too bad the nurses have no clue what the readings indicate let alone can tell you the differences between capnography and Spo2 Plethysmography.
> 
> Numerous times RRT's are called for patients breathing ~ 4 times a minute and the response from the nurse is always "but his sp02 was fine last time I checked"



That is a failure of the hospital to provide proper training and oversight.

That is not the failure of the nurse.


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## VFlutter (Jul 12, 2012)

Veneficus said:


> That is a failure of the hospital to provide proper training and oversight.
> 
> That is not the failure of the nurse.



I agree, a lot of the physicians push for these types of policies to be implemented without the hospital providing  adequate training. 

Another great example is physicians requiring certain patients to be on telemetry monitors on non-cardiac floors on which nurses are not required to be ACLS certified. Therefore I have to call a non ACLS to let them know that their patient is in VT and they ask me what they should do (I am technically a non licensed employee) or calling an RRT for a patient in sinus arrhythmia. But that is a whole different topic.


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## MikeCivitello (Jul 27, 2012)

Correct - pre-mixed 02 and N20 is not FDA approved in the US.  That leaves us with 2 gas cylinders and a device/mixer with demand valve.  Unfortunately there is no way around that.

The biggest issue that I have heard with the pre-mixed gas is that it can potentially separate at low temperatures and there is no way to actually know what % mixture the patient is getting (unless you had them hooked up to a gas analyzer).

The device that was most commonly known in the US will resurface again soon - sometime this fall.  We are manufacturing it.  I can see a lot of benefits of offering nitrous oxide and oxygen for pain management - but also see the challenges of all of the gear that you need to carry.  We will actually be trying to come up with a better / more convenient packaging - and hopefully we can obtain feedback from current and former users - but that would be a discussion for another thread or forum I'm guessing.

Mike





Veneficus said:


> As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.
> 
> Whether or not it is controlled isn't an issue, it is just a logistical nightmare. Between multiple tanks, mixers, off gasing, etc.
> 
> An excellent drug for sure, but I am not convinced the issues it comes with makes it a reasonable alternative.


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## JPINFV (Jul 27, 2012)

Question regarding the O2/N2O mixer. Why not just have a N2O bottle and a mixer that can attach to the O2 bottles already carried like a vent that bleeds in O2? After all, you're always going to have the portable tank that's strapped to the gurney and the large O2 tank on the ambulance.


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## NYMedic828 (Jul 27, 2012)

Disappointed in you guys...

I had to be the first to post this?


:rofl::rofl::rofl:
http://www.youtube.com/watch?v=_C2oaJYuNCU&feature=related


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## MikeCivitello (Aug 1, 2012)

JPINFV said:


> Question regarding the O2/N2O mixer. Why not just have a N2O bottle and a mixer that can attach to the O2 bottles already carried like a vent that bleeds in O2? After all, you're always going to have the portable tank that's strapped to the gurney and the large O2 tank on the ambulance.



Love the video - one of my favorites!

JPINFV - That is the current design.  The "mixer", small cylinder of N20, and demand valve system are packaged in a carry case.  There is an oxygen supply hose with either quick connect or DISS fitting to connect the device to your 02 source - either a cylinder with a regulator or outlet in the ambulance.

Its not heavy - probably 10 lbs - but it is one more bag to be carried along with the rest of your gear.


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## Norbi (Aug 12, 2012)

I want to share what us intermediates are allowed to use for pain control in my humble country of Hungary.We can give up to 1000mg of metamizol IM,80 mg of drotaverine IM, we can administer 50%nitrous oxide/50%O2 with a demand mask( although almost only paramedic or doctor manned trucks have them so it doesn’t count for much ), your usual nitro, and 250mg aspirin.In the hospital we frequented, the docs and nurses had no problems with this unless of course the meds were uncalled for.What bothered them more were things like untidy IV’s and ugly dressings and stuff.( I have yet to work as an EMT but this is what i observed on our half year field practice or whatever).


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## STXmedic (Aug 12, 2012)

What are the training standards for intermediates in Hungary? How much schooling does one have?


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## Norbi (Aug 12, 2012)

High school diploma , then 2 years including hospital and ride alongs. Paramedic comes with a degree after 4 years.Most of us get it financed by the gov't , but the pay, the pay is pathetic.(monthly pay for paramedic:around 120,000HUF depending on experience , price of 2kg bread: 250 Ft)


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## Dwindlin (Aug 12, 2012)

Norbi said:


> High school diploma , then 2 years including hospital and ride alongs. Paramedic comes with a degree after 4 years.Most of us get it financed by the gov't , but the pay, the pay is pathetic.(monthly pay for paramedic:around 120,000HUF depending on experience , price of 2kg bread: 250 Ft)



Christ.  That is around $530 USD, or around $3.50 an hour pre-tax with a 36 hour week.


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## Norbi (Aug 16, 2012)

I guess that's whats up...you also have to consider that stuff is a little cheaper here so that compensates somewhat, but it's still laughable.That's what you get when your country's economy is dying a spectacular death in front of you.


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