1/13/2010 09:23:00 AM 0 comments

How good is End Tidal CO2 monitoring?

The following is the definition per Wikipedia "Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care. It is usually presented as a graph of expiratory CO2 plotted against time, or, less commonly, but more usefully, expired volume. The plot may also show the inspired CO2, which is of interest when rebreathing systems are being used.

The capnogram is a direct monitor of the inhaled and exhaled concentration or partial pressure of CO2, and an indirect monitor of the CO2 partial pressure in the arterial blood. In healthy individuals, the difference between arterial blood and expired gas CO2 partial pressures is very small, and is probably zero in children. In the presence of most forms of lung disease, and some forms of congenital heart disease (the cyanotic lesions) the difference between arterial blood and expired gas increases and can exceed 1 kPa.

During anesthesia, there is interplay between two components: the patient and the anesthesia administration device (which is usually a breathing circuit and a ventilator or respirator). The critical connection between the two components is either an endotracheal tube or a mask, and CO2 is typically monitored at this junction. Capnography directly reflects the elimination of CO2 by the lungs to the anesthesia device. Indirectly, it reflects the production of CO2 by tissues and the circulatory transport of CO2 to the lungs.

When expired CO2 is related to expired volume rather than time, the area beneath the curve represents the volume of CO2 in the breath, and thus over the course of a minute, this method can yield the CO2 minute elimination, an important measure of metabolism. Sudden changes in CO2 elimination during lung or heart surgery usually imply important changes in cardiorespiratory function."

Capnography has been an up and coming measure of function in the human body for some time now though it has gradually become more frequently used as technological advances permit it and as we learn how incredibly valuable it can be as a tool to predict, before it presents outwardly, what is going on at the cellular level and overall as well. It should be noted that Capnography is of greatest value when both good wave form and numeric readout are used. It has been my experience that how useful this is to us in the prehospital environment is largely the result of how knowledgeable we are about Capnography as well as our ability to accurately interpret the wave forms and the numeric readings too.
Generally speaking the care provider can get a very good picture of what is happening in their patient, with respect to perfusion and function at the cellular level. We all should know and understand that without adequate perfusion and function at the cellular level, our patients will not do well. Our ability to accurately recognize not only what is happening but WHY it is happening is the first step in correcting the prevailing issues. Surely nobody can argue that the single most important attribute of any care provider is Good Assessment. It is with this thought in mind that that I suggest we in the care provider professions aggressively pursue and become proficient at using Capnography. Of the many avenues available to us that assist us in diagnosing the issues with our patients Capnography is probably one of the best tools to help us get ahead of the curve and stay there. It should go without saying that this is also in the best interests of those that call for our service.
I was first advised of Dr. Baruch Krauss, MD many years ago who at the time (and I believe this is still true) a very well informed and strong advocate of Capnography. More about Dr. Krauss by following this link. http://www.childrenshospital.org/cfapps/research/data_admin/Site2625/mainpageS2625P0.html
I had the benefit of viewing some of his lectures on Capnography and was amazed at the wealth of information that could be gleaned from this technology.
If you are interested in being a great care provider, I would strongly encourage you to do some research on capnography. Become proficient and see the remarkable results.
For more information as provided by "Capnography.com" check out the following link; http://www.capnography.com/outside/911.htm and here too is search results that also has a lot of additional information.
Google Search Results for Capnography

Thank you for your time. Stop by my website at www.rcmedic.com
1/06/2010 11:50:00 AM 0 comments

What should be the appropriate behavior?

What should the behavior be?
I have been in EMS for over 25 years and it continues to amaze me that so many of the providers seem to have a grossly jaded view of what EMS is all about. Too many seem to be of the mind that EMS is short for “Earn Money Sleeping” and further seem to be offended when a call drops out for them. While I concede that most of EMS is anything but an emergency, a significant portion of the newest providers of care fail to recognize that regardless of acuity, it is our job to safely and quickly respond to those who call for our service. Additionally I find it remarkable that a lot of the providers are apparently without the compassion that is so important in our industry. As an industry I believe that we would do well to initiate a pre test, if you will, that measures aptitude. Such aptitude tests should be designed around the realities of EMS today.
Anyone who has been in our business for any length of time realizes that the majority of our calls are for relatively minor issues that do not require emergency service or assistance at any level. One would also note that in calling for EMS when it is not truly a matter of life, limb or eye sight results in decreasing the available resources that might be available for those who really need them. Interestingly, I have observed over the years that as a “Rule of Thumb”, those who should call 911 don’t and likewise, those that should not, do call 911.
If this is not already bad enough, it is equally true for air services as well. The air service with which I am familiar also suffers from being called when alternative means or modes of transportation would be more prudent. The difference in this case though is that the caller for service is most often one of those who should know better, specifically field emergency crews and physicians.
As our country continues to struggle with Health Care issues, a major portion of which is the cost, I am amazed that those in decision making positions do not take steps to first educate folks on the reason and rationale for calling for any service and then follow with implementing solid game plans for dealing with inappropriate calls for service.
I am not ignorant of the concerns of the private sector “For Profit” companies nor their concerns for superior Public Relations coupled with Superior service. It is my observation that too often, we as a society tend to need immediate results and more specifically greater profits, presumably resulting from greater market share that usually brings greater revenues. What I fail to see all too often is that in the push to increase market share, revenue and profit, there seems to be less if any attention paid to the consequences of an exclusive focus on such goals. In particular I mean that if you go for greater market share, revenue and profit without simultaneously seeking to assure greater efficiency and effectiveness you never really effect any change regarding the system abuse.
It is my thought that if we aggressively address the system abuse issues, the end result would be greater profit rather quickly and then when one increases market share and subsequent revenues the profit margins would be much greater relative to where they are now.

Now back to the care provider. We as an industry should be much more conscientious about aptitudes of those that we are bringing into the fold. Most I believe would agree that a large part of the care we provide is better received and often more effective too than the same care provided without compassion and real concern. How? Positive, relaxed patients generally respond better than those who are anxious and everything else except positive.
My point is simply this….. In all of the cases above, if we behaved as we would if the people we were serving were our mother, would we not all be better off? Would we call for EMS when we really did not need to if our mother would not have those services available because we are using them? Would we subject our mother to the huge expense of air service over ground service if it were not prudent and a truly time sensitive issue.

Thank you for your time. Stop by my website at www.rcmedic.com
1/04/2010 08:49:00 AM 0 comments

What are they Thinking???

We have been watching our political system trying to tackle a host of issues, all of which are truly important and do indeed need to be addressed. Chief among them is the health care system. While I strongly support the idea that the system is broken and in need of being revamped at the very least, the numbers just don’t add up with the current model being manipulated in the house and senate.
Being a working part of the health care system for over 25 years I find it appalling that our representatives believe that they can fix it. They are entirely wrong. In support of this thought process I offer the following facts.
1. Our political system has constantly failed to repair the Medicare and Medicaid systems or even make a slight improvement.
2. Our veterans continue to be poorly cared for post service if they get any care at all.
3. It has historically been proven that the government in general is unable to fix even the simplest of problems.
Private sector efforts have historically been much better able to turn things around whether it is concerning manufacturing industries, finance, or I suspect, even health care.
It has been my experience in life that if you wish to fix any problem regardless of the issues or focus, one must first complete a thorough assessment. Such has not been demonstrated for the health care industry. While most everyone agrees that the health care system is in fact broken, I contend that you cannot get where you want to go if you do not know where you are starting from. Having this thought in mind, it is my observation that beyond a painfully superficial review, those in decision making positions have failed to clearly identify the issues and would be hard pressed to identify with certainty the good, the bad or the indifferent. Secondly, the efforts that have been forced through the highest levels of government have been largely completed without the benefit of knowing the contents of the entire package. The additional insult comes when one recognizes that much of the content of the bills passed to remedy the situation have a myriad of unrelated “add-on” features that only serve to further exacerbate our fiscal problems.

Good managers and leaders recognize that a focused approach affords much smoother navigation to the intended goal than does the “shotgun approach”. It is also true that such an endeavor requires less energy. Additionally any good manager recognizes that they have strengths and weaknesses. Accordingly they choose others who excel in the area of focus as opposed to plowing ahead making decisions and taking actions that affect others without really knowing what the outcome is likely to be. Such is the case with most of our politicians. As a rule, none of them will be susceptible to living with the end result of the efforts to fix our ailing health care system.
A significant portion of our politicians are lawyers and very few have any working knowledge of healthcare in general never mind the intricacies associated with its successful delivery. It is equally true that few if any of them understand the cost associated with any part of the delivery of care to those who need it.
It has been repeatedly stated that there is tremendous waste throughout the health care system, in some cases resulting from the ordering of unnecessary tests. This too is true and largely the result of our litigious society. Hospitals and physicians frequently order tests largely to help assure that they are not sued because they may have missed something instead of ordering that which is reasonable and follows the expected clinical path.
Getting back on track, we must take note of the fact that if we continue on the current path in just the health care alone, we are creating fiscal complications for our children and our country too and in the end will fail to achieve the intended result.
Our self serving politicians need to be held accountable. We must ensure that their choices if not actions are the result of accurate global assessment coupled with realistic prognosis that demonstrates sound fiscal responsibility not only to ourselves but to those who will follow after us, namely our children and their children.

We struggle each day to make sure that we meet the obligations that are ours individually, the consequence of which is that we often if not chronically miss what is going on at the global level in spite of the fact that those issues too affect us all.
We should all endeavor to be more cognizant of the bigger picture and make sound efforts to assure that those in decision making positions are in fact making good decisions. If in any case this fails to be true then we should collectively assure that we replace those decision makers with others that will. We all know that too many say one thing and do something quite different, usually best serving their own interests instead of ours as the people who voted them into those positions in the first place.
One final thought…. Consider too that career politicians chronically fail to understand (in the first person) the realities of life for all of us out here in the real world. The best way to prevent that is to replace career politicians with new blood from those among us in the regular population that have a firm grip on the realities that result from the decisions made in the house and senate of our nation never mind the more local governments.

Thank you for your time. Stop by my website at www.rcmedic.com
1/02/2010 03:38:00 PM 1 comments

Everything Motorcycle

Here is the first of my efforts. I will cover a host of topics and issues. If you take a look at my profile you will no doubt get an idea of a few of the things that are important to me. Though not reflected on my web site at this time, I am equally if not more interested in Critical Care Paramedicine and following our all too screwed up politicians and their misguided selfish endeavors. Each of these things will be discussed on this blog.

Which issue or topic I choose to comment about will be dependent on any or all of several issues which will include but not be limited to: Current Events as they are presented by media, my own experiences, how I feel, and as a result of input and communication with others.

When it comes to politics, I do not as a rule subscribe to any party or any other partisan label. Never really have decided exactly where (as if one cold accurately graph such a thing anyway) but I do know that I come down right of center in most all cases. I am neither radical nor fanatical by any definition and generally believe that those who are should be summarily dismissed without recourse. In short, I believe in God and country. I am proud to call both "Mine".

Thank you for your time. Stop by my website at http://www.rcmedic.com/