the 100% directionless thread

So, as the new school year is about to start, I find myself coming up on a personal crossroads in the not-terribly-distant future.

So I've managed to find my way to a literally-perfect school schedule for attacking a Master's by being one of the only people who likes 12-hour posting shifts at my employer (which lets me essentially design my own schedule)- to the point where I won't do most 24s because there's real and relevant fatigue problems and I'm one of those snowflakes that believes in sleeping at fairly regular, lengthy intervals and doesn't like working stand-up 24s routinely. I don't make bad money doing this, and I am an in-charge paramedic in a busy, relatively high-functioning 911 EMS system, but I also feel that there isn't a whole lot of room for advancement (particularly if I maintain my fixation on not working stand-up 24s), and as much as I love what I do, I also want to use some of this fancy book learning and be a better leader than I've had. I've heard a lot of good things about a few local and regional agencies that do pay better and care for their people to a greater extent than my current (already decently-high-functioning) employer, but as great as they sound (and their solutions to fatigue, pay and lifestyle are legitimately better), I don't know if I want to go through the hoopla of NEOP and clearing again at a "better" agency for essentially the same job, in slightly better conditions. On the other hand, I like my current job, I love what I do, and at least one of these alternates not only pays more and has some vastly better policies (for example, they don't write sick employees up for being sick); they have college-incentive pay, Powerloads + vents and county benefits, and if I want to be a field medic, they're pretty sweet- to the point where I think that I could see it being a career place. It's not terribly far from where I am either, so moving wouldn't be required. On the other hand, my heart really isn't in this area, and I miss desert skies, seasons, family & friends, and places that aren't swamps. There's a fear of getting so comfortable at Potential Local Alternative Employer that I settle for PLAE, and I don't know if I want to do that. (Complicating the issue is that multiple good PLAEs are hiring or soon will be and I've been approached by multiple PLAEs about applying).

However, I want to run somewhere, and do it well, and that's not likely to happen in a large agency anytime soon, especially without running somewhere smaller first. At Current Employer, I have essentially no chance at promotion, due to my aversion to 24s and a long and very-interested list of people more senior than I, and I'm fairly OK with that, because I really don't want to be a field supervisor outside of clinical issues and operations and such- I want to be the director, the head honcho or at least a medium-size neck or upper chest honcho, etc, and I've seen that there's not a need to do years as a supervisor to find a position as a director- it would be a transitional role, and Current Employer's supervisors are essentially terminal positions due to the glacial pace of managerial turnover. I could see myself as a very happy camper as a senior medic or a CCT medic, a la the MedStar CCP program or something, but those positions also tend to take years to get through and don't address much of my desire to direct an organization. At Alternative Employers In the Area, I would make a little more money and have slightly better equipment than I do now, but I don't know if I could continue to work with my school schedule to the same extent that I can now, but it would still essentially be more of the same, with the added stress of having to go through clearing again and still not getting to run somewhere- plus, it would be yet another job on the resume, and I do think there's something to be said for longevity at a place (not to mention the ethics of starting somewhere you have every intention of moving on from in a lot less time than the 'decades' they want to hear and legitimately work hard to help you achieve).

I know my best shot at running someplace is to find somewhere smaller, likely-rural, and stepping right in and I'm OK with that and the work it requires, so I kind of have a guess as to where the next real stop on the career train is- but I am sort-of confused as to which route I ought to take to get to that point. In either event, school is the priority- a master's in healthcare administration (finance, business, practices, management, etc) and maybe building it out to an MBA, plus a bachelor's in education, plus paramedic with all of its assorted hanger-on certifications, and a solid decade of 911/IFT experience ought to make me at least reasonably competitive for running places- but the school is going to be over in around 18 months, which is totally doable at Current Employer and would still have me as a fairly new employee at PLAE when I start looking in earnest for a leadership role. A lot of me wants to stay at Current Employer until it's time to get off the train and run somewhere, but a lot of me also wants to try PLAE-flavored Kool-aid and extra $$$ and somewhat better treatment for the short-term. Any advice?
 
Adding to the complexity is that both CE and PLAE have great reputations and I believe will be good launchpads for future endeavors- sort of like asking if I want to get a Mercedes or a Lincoln. 6/1, half-dozen of the other.
 
@RocketMedic, I think you're in an enviable situation, in a way!

Personally, I'd stay where I am until the degree is done, then make moves to a role closer to where you want to end up (director-type role), but that's just me. Better to stick with what you have right now - and the knowledge that you can work + do school - rather than try something untested. However, if you could get it in writing from the potential alternative employer that you'll be OK to do school & work 12s, then you're safe from that perspective, too.
 
Chase said:
ETCO2 is so much more than just ET tube placement. A patient can be synchronous with no vent alarms but still profoundly hypercapnic. Or just as importantly as a marker for perfusion.
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Even though ETCO2 has those capabilities, no one in-hopsital that I've seen/worked with will use it as such. Hypercapnic? Draw an ABG. Worried about perfusion? Drop an A-line/CVC/Swan.
 
MonkeyArrow said:
Even though ETCO2 has those capabilities, no one in-hopsital that I've seen/worked with will use it as such. Hypercapnic? Draw an ABG. Worried about perfusion? Drop an A-line/CVC/Swan.
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Why jump to invasive procedures when ETCO2 can give you that information? It can take a while for the RT to get an ABG and the lab to result it. You usually aren't getting ABGs more frequently then every 2 or 4 hours. A lot can change in that time. Most physicians are reluctant to drop an a line or especially a swan. Not saying that's not how a lot of hospitals operate but that does not mean it's appropriate.
 
@Chase correct me if I am wrong, but ETCO2 isn't without its limits, and obtaining a PaCO2 still very much carries value, and accuracy beyond that of exhaled CO2.

I understand there may be infrequent, or inaccurate draw times, which may hinder treatments, but I was under the impression that ETCO2 is by no means a really reliable factor in the critically ill patient when much more invasive, or even accurate measurements are available. Basically definitive markers, which I didn't think ETCO2 is, or was considered.

I can certainly see where it could fit into trending, much like any other diagnostic tool utilized, but at least at the paramedic level it seems more of a necessity to appease the ever so doubtful hospitals assessment of our ETT placement, and rightfully so.

Perhaps this is why intensivists, or even many EM physicians aren't so reliant on them?
 
MonkeyArrow said:
Even though ETCO2 has those capabilities, no one in-hopsital that I've seen/worked with will use it as such. Hypercapnic? Draw an ABG. Worried about perfusion? Drop an A-line/CVC/Swan.
Click to expand...
Ive talked with some flight paramedics about it and they told me the reason they don't use it in the hospital is simply that they don't realize how good it is. the paramedics I talked to use it in the helicopter all the time
 
VentMonkey said:
@Chase correct me if I am wrong, but ETCO2 isn't without its limits, and obtaining a PaCO2 still very much carries value, and accuracy beyond that of exhaled CO2.

I understand there may be infrequent, or inaccurate draw times, which may hinder treatments, but I was under the impression that ETCO2 is by no means a really reliable factor in the critically ill patient when much more invasive, or even accurate measurements are available. Basically definitive markers, which I didn't think ETCO2 is, or was considered.

I can certainly see where it could fit into trending, much like any other diagnostic tool utilized, but at least at the paramedic level it seems more of a necessity to appease the ever so doubtful hospitals assessment of our ETT placement, and rightfully so.

Perhaps this is why intensivists, or even many EM physicians aren't so reliant on them?
Click to expand...

A single ETCO2 reading really isn't all that useful since there can be a pretty wide range of PaCO2-ETC02 gradients in critcall ill patients. It is however very useful as a trend and once correlated to PaC02. So if you intubate a patient and their ETC02 is 30 their PaCO2 may be 34 or it may actually be 55. But once you get that ABG and know the gradient you can pretty accurately predict going forward. But when your patients ETCO2 drops from 35 to 12 you instantly know you have an issue long before you even think about getting an ABG.

So long story short an initial ETC02 is of limited value since there potentially can be a fairly significant difference in actual PaC02. For most patients without lung disorders it's within 4-6 mm/hg. Having said that it does not negate the benefit of having second by second monitoring and early detection of changes in ventilation and perfusion.

From a paramedic stand point, besides tube placement, it's a great objective guide for resuscitation.
 
Chase said:
A single ETCO2 reading really isn't all that useful since there can be a pretty wide range of PaCO2-ETC02 gradients in critcall ill patients. It is however very useful as a trend and once correlated to PaC02. So if you intubate a patient and their ETC02 is 30 their PaCO2 may be 34 or it may actually be 55. But once you get that ABG and know the gradient you can pretty accurately predict going forward. But when your patients ETCO2 drops from 35 to 12 you instantly know you have an issue long before you even think about getting an ABG.

So long story short an initial ETC02 is of limited value since there potentially can be a fairly significant difference in actual PaC02. For most patients without lung disorders it's within 4-6 mm/hg. Having said that it does not negate the benefit of having second by second monitoring and early detection of changes in ventilation and perfusion.

From a paramedic stand point, besides tube placement, it's a great objective guide for resuscitation.
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I don't disagree. I'm just happy that the threads, and posts have come back down to planet earth:).
 
NYMedic453 said:
Ive talked with some flight paramedics about it and they told me the reason they don't use it in the hospital is simply that they don't realize how good it is.
Click to expand...
I'm not too sure about this.
NYMedic453 said:
the paramedics I talked to use it in the helicopter all the time
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Most paramedics (ground and air) utilize, and understand its importance quite well.

In the helicopter, particularly of the "scene-variety" your diagnostic, and trending tools in-flight are extremely limited so of course they appreciate its value that much more.
 
NYMedic453 said:
Ive talked with some flight paramedics about it and they told me the reason they don't use it in the hospital is simply that they don't realize how good it is. the paramedics I talked to use it in the helicopter all the time
Click to expand...

I don't think it's that hospitals don't realize how good it is. I think these guys don't realize that any good ICU will generally have many more precise tools to measure metabolic and ventilatory states.

VentMonkey said:
@Chase correct me if I am wrong, but ETCO2 isn't without its limits, and obtaining a PaCO2 still very much carries value, and accuracy beyond that of exhaled CO2.

I understand there may be infrequent, or inaccurate draw times, which may hinder treatments, but I was under the impression that ETCO2 is by no means a really reliable factor in the critically ill patient when much more invasive, or even accurate measurements are available. Basically definitive markers, which I didn't think ETCO2 is, or was considered.

I can certainly see where it could fit into trending, much like any other diagnostic tool utilized, but at least at the paramedic level it seems more of a necessity to appease the ever so doubtful hospitals assessment of our ETT placement, and rightfully so.

Perhaps this is why intensivists, or even many EM physicians aren't so reliant on them?
Click to expand...

Your comments hit the nail right on the head, VentMonkey. In EMS we tend to be plagued by the "when all you have is a hammer, everything looks like a nail" mentality, and as a result I think many of us tend to overstate the reliability and clinical utility of Etc02, just like we do lots of other things.

What does capnography tell us? The amount of C02 being exhaled as a partial pressure of or a percentage of the total volume of expired gas. What does that measurement depend on, or indicate? Lots of things. Potentially a useful piece of information to be sure, but a very incomplete picture of what is going on with the respiratory and metabolic systems. In a spontaneously breathing patient, the morphology of the waveform can indicate certain states. But this is an insensitive and somewhat subjective measurement, and tells you even less in a mechanically ventilated patient. The sicker a patient is, the more potential confounders exist. Shunt physiology, low perfusion states, or anything that impairs alveolar gas exchange will render capnography less reliable.

Capnography can be useful for trending, as Chase pointed out. I don't think that it would do a better job than the ventilator of alerting you to tube dislodgment or obstruction. But any sick patient in the ICU is going to have ABG's drawn regularly anyway, which give you far more information than Etc02. When you combine regular gases with the graphics and pressures available on most modern ICU vents and correlate that with other data, you have a far greater number of (and more precise) data points than capnography provides. I'm just not sure that Etc02 would add much at all.

The one thing that I think capnography probably does better than other tools is to provide early indication of a pulmonary embolism. But still, this depends on several factors. It isn't necessarily a highly sensitive or specific indicator, again depending on the rest of the clinical picture.

In EMS, we usually don't have all those fancy vent graphics or blood gases, so lacking those tools, Etco2 is quite useful. It confirms ET placement and can potentially alert us to changes in respiratory or metabolic status. It can keep us from under- or over-ventilating. It can potentially alert us to impending cardiovascular collapse and to ROSC. It's a good tool, but it's probably redundant in a high-acuity ICU.
 
It is certainly a quarry.
Remi said:
I don't think it's that hospitals don't realize how good it is. I think these guys don't realize that any good ICU will generally have many more precise tools to measure metabolic and ventilatory states.



Your comments hit the nail right on the head, VentMonkey. In EMS we tend to be plagued by the "when all you have is a hammer, everything looks like a nail" mentality, and as a result I think many of us tend to overstate the reliability and clinical utility of Etc02, just like we do lots of other things.

What does capnography tell us? The amount of C02 being exhaled as a partial pressure of or a percentage of the total volume of expired gas. What does that measurement depend on, or indicate? Lots of things. Potentially a useful piece of information to be sure, but a very incomplete picture of what is going on with the respiratory and metabolic systems. In a spontaneously breathing patient, the morphology of the waveform can indicate certain states. But this is an insensitive and somewhat subjective measurement, and tells you even less in a mechanically ventilated patient. The sicker a patient is, the more potential confounders exist. Shunt physiology, low perfusion states, or anything that impairs alveolar gas exchange will render capnography less reliable.

Capnography can be useful for trending, as Chase pointed out. I don't think that it would do a better job than the ventilator of alerting you to tube dislodgment or obstruction. But any sick patient in the ICU is going to have ABG's drawn regularly anyway, which give you far more information than Etc02. When you combine regular gases with the graphics and pressures available on most modern ICU vents and correlate that with other data, you have a far greater number of (and more precise) data points than capnography provides. I'm just not sure that Etc02 would add much at all.

The one thing that I think capnography probably does better than other tools is to provide early indication of a pulmonary embolism. But still, this depends on several factors. It isn't necessarily a highly sensitive or specific indicator, again depending on the rest of the clinical picture.

In EMS, we usually don't have all those fancy vent graphics or blood gases, so lacking those tools, Etco2 is quite useful. It confirms ET placement and can potentially alert us to changes in respiratory or metabolic status. It can keep us from under- or over-ventilating. It can potentially alert us to impending cardiovascular collapse and to ROSC. It's a good tool, but it's probably redundant in a high-acuity ICU.
Click to expand...

I'm not thinking so much high-acuity ICU as I'm thinking generic IMU or floor monitoring.
 
RocketMedic said:
It is certainly a quarry.


I'm not thinking so much high-acuity ICU as I'm thinking generic IMU or floor monitoring.
Click to expand...

It was actually a policy that any patient on a PCA had to be on capnogrpahy after a few sentient events. Good concept but didn't really work well in practice
 
Look like its gonna be a wet week

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Anyone got hot sauces to reccomend? I've been sticking with Tobasco, Crystal, and Louisiana for the longest time and figured I should branch out.
 
I usually use the chipotle Tabasco

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Beyond tired of protests and people using incidents to fit their agenda. And stop blocking traffic.
 
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