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Notes from JEMS

Notes from JEMS

PC, from Street Watch: Notes of a Paramedic, posted some of his notes from the JEMS EMS Today conference. Found most of this interesting. Thos of you who are certified in CPR pay particular attention to the first section. Several months ago the AHA changed the compression to ventilation ratio to 2:30 for all CPR. The old ratios were 2:15 for one and two rescuers which was an additional change from 1:5 for 2 rescuers. At first I questioned why they keep changing the ratios, but some of the research makes the change seem like a good idea.

Here are PCís notes:

Studies show half the time in CPR compressions don’t get done.
When you stop compressions, all blood flow ceases.
Studies show paramedics, doctors and nurses all ventilate at rates from 30-40 a minutes.
High ventilation rates screw up the intrarthoracic pressure preventing effective blood flow.
Normal people breathe through negative pressure. We ventilate people with positive pressure. Too much positive pressure inhibits blood return.
Our ventilations should be fewer and less both in terms of volume and duration.
Studies showed uninterrupted compressions increased survival by 300%.
Anything that interrupts compressions is bad.
You can delay intubation for patients in vfib. They should have a good supply of oxygenated blood in their body that will last for five minutes or so.
You could monitor their status by using a nasal end tidal CO2 cannula while using a bag mask.
When you do intubate try to keep compressions going while you pass the tube. If you need to stop compressions, stop only for a brief moment
In a study when pigs were put into arrest, 6 of 7 pigs survived when they were ventilated 6 times a minute, only 1 of 7 survived when they were ventilated
at 30 times a minute.
Keep tidal volume to 400 on ventilations.
There are two ways to hyperventilate: Too many respirations and too much volume in a single respiration.
Most pulses that emerge after a shock don’t show up for 60 seconds. So keep doing compressions.
One speaker joked ďKeep doing compressions until the patient wakes up, grabs you hand and insists you stop.Ē
There are fewer v-fib codes today than several years ago because of the better cardiac care people receive from their doctors. Most codes are sicker people.
Epi has a IIb rating because they cannot do a study where epi is used against a placebo. No ethics board would allow it. Without such a study, there can
be no Level I rating. Its one of the quirks of the evidence rating system.
One of the reasons, cardiac arrest discharge from hospital rates are so low is because the post resuscitation care at the hospital is so poor — it often
consists only of trying to make a person a DNR.
Other notes:
On cardioversion — if the patient can remember what you look like after you have cardioverted them, don’t cardiovert because they probably don’t need
it.
I asked the Dr. responsible for the tachycardia algorithm about the new phrase ďSeek Expert Consultation,Ē and he said, it means if you don’t have to give
a patient drugs, don’t, wait for the hospital.
On Intubation, a doctor said the FDA would not approve intubation today based on existing studies that show how badly it is being done and its negative
effect on patients. A group of doctors said for people to keep intubating, their program needs a solid QI program and people need to go to the ER if they
are not getting enough tubes. One doctor said, “a misplaced tube is a travesty. It means, your patient would have done better in a Yellow Cab.”
They said never intubate a child unless you absolutely have too.
The adult IO is great for cardiac arrest, it may not have a place in trauma.
Studies have shown that morphine actually helps the surgeon do an abdominal evaluation. We should be giving morphine to patients with abdominal pain.
In trauma, we should practice permissive hypotension Ė the BP can be kept around 70 for trauma patients and fluid should only be administered if the pressure
gets below 40.
Gunshot wounds to the head without neuro deficits, do not need cspine.
Magnesium is great for severe asthma — 2 grams in 100cc over 1-10 minutes.
Instead of doing one breathing treatment followed by another, do a continuous treatment, which is basically dumping two treatments in the neb to begin
with.
CPAP for CHF is outstanding.
Be very cautious with lasix. Never start with Lasix and never give it unless you are also giving nitro because lasix’s initial action is as a vasoconstrictor.
For anaphylaxis, give epi IM in the thigh
Everyone intubated should have end tidal Co2 monitoring.

If youíre interested in what life as a medic is like, check out his site. Lots of good stories about life on the street.

KNFB Reader

KNFB Reader

I canít wait to get my hands on this. And I will soon. Iíve been told in the next month for the beta testers.

– – –
Kurzweil-NFB Reader: Device provides† words to  live by
By Frank D. Roylance

Baltimore Sun, April 14, 2006

Hand-held reader that can convert text into synthesized speech may increase independence for the visually impaired

Not long ago, James Gashel was on Capitol Hill, waiting for a meeting to start, when he realized that he needed some numbers from a chart he was carrying. That was a problem. Gashel is blind, and so was his companion. And the chart was not in Braille. Gashel was reaching for his cell phone to call someone at his office to retrieve the numbers, when his colleague stopped him.

“Why don’t you try the reader?” he asked.

Of course.

Gashel, an executive at the National Federation for the Blind in Baltimore, was carrying the world’s first hand-held reading machine for the blind – just developed by NFB in collaboration with Kurzweil Technologies Inc. of Wellesley, Mass.

Combining a 5-megapixel digital camera with a personal digital assistant, or PDA, the 13-ounce Kurzweil-NFB Reader converts digital images of text into synthesized speech.

Gashel pulled out his reader, snapped a picture of the chart, “and within aminute I had the numbers I wanted,” he said. And he didn’t have to bother anyone else to get them.

Now in final field tests before its release for sale by Kurzweil this summer, the device was officially unveiled last week at ceremonies at NFB headquarters in South Baltimore.

Thanks to the new reader, Gashel and 75 other blind product testers across the country are sorting through their own mail, reading restaurant menus, identifying packages in the freezer by the labels and discovering many other tasks they can now do without assistance.

It’s liberating, Gashel said. “You start to think about your capabilities differently.”

In addition to many of the nation’s 1.3 million blind people, he also predicts a demand from older people with failing eyesight, and young people with dyslexia or learning disabilities.

The NFB’s collaboration with Kurzweil began more than 30 years ago, when founder Ray Kurzweil, a pioneer of character recognition and text-to-speech devices, came to the federation’s offices, then in Washington. He had developed the first Kurzweil Reading machine. The size of an office copier, it could scan a document and read it in a synthetic human voice.

“That was very revolutionary,” Gashel said. Until then, blind people were pretty much limited to live readers, or the limited number of publications available on tape or records, or transcribed into Braille.

The Kurzweil reader was big and expensive – $50,000 each, Gashel said. It couldn’t read photocopied matter and it had problems with pages crowded with pictures.

But it was clearly a breakthrough. So the NFB bought six, and began working with Kurzweil to improve them. “This was the first time an inventor of a product had ever come directly to us,” seeking input from the blind in the development of an “access” machine, Gashel said.

Eventually, Kurzweil began to sell improved versions to schools, libraries and rehabilitation agencies. But even though prices fell over the years, the reader remained too costly for individuals.

Just as importantly, “There was always a need for something portable,” Gashel said.

By the mid-1990s, the advent of desktop computers and scanners enabled Kurzweil to develop a PC-based reader – the Kurzweil 1000. Character-recognition software was improving, too. And laptops made the hardware required smaller.

But one problem remained: “You would have to have a scanner – it would be quite a bit of paraphernalia to carry about,” Gashel said.

Digital photography provided the needed breakthrough; that, and the miniaturization of computer power in the PDA – the hand-held computer that millions use to organize their lives.

The Kurzweil-NFB Reader, which is expected to cost less than $3,000, marries a small, 5-megapixel Canon camera to an ASUS A730 PDA. They are wired together and held by a vinyl case about 6 inches by 3 inches by 2 Ĺ inches. It’s all operated with just nine buttons, with voice prompts from asmall speaker or through earphones.

Holding the device about 16 inches above a sheet of paper lying on a table, Gashel lines up the shot. He is guided by a sort of audio viewfinder: “Right, bottom edges are visible … two degrees counterclockwise relative to page.”

The camera speaks in an oddly Eastern European male voice, but it’s one that’s familiar and comfortable for people who use electronic readers.

Gashel pushes a button and the shutter clicks. A few seconds later, the device is reading the release aloud, flawlessly.

Tests on a business card and an ATM receipt are rougher. The device misses some lines of type, and mistakes some characters for others. But it does better on a second try, “learning” as it goes along.

Had it been his own ATM slip, Gashel said, “I would have known what I withdrew, and I’d know most of the information, even if it didn’t hit it right.”

Many times, he said, “you’re not going for perfect; you’re going for ‘What is this?'”

Jim McCarthy, 39, director of governmental affairs at the federation, has also been testing one of the readers. A new office arrangement has left him without a nearby assistant, so something as simple as sorting through papers on his desk becomes an issue.

“I’m probably 25 feet from the closest person,” he said. It’s not a big deal to walk around the corner and ask someone to identify a piece of paper, “but it seems like a waste of time.”

The reader “allows people to sort pertinent documents in a way a lot of us aren’t accustomed to. That is pretty liberating,” he said.

Lou Ann Blake, 46, a visually impaired research specialist at the federation, has also been a test-driver. “I read the cooking directions on a bag of pasta,” she said. “It was plastic and I kinda had to flatten it out. But it did quite well.”

Videotape labels, bills, letters, 401(k) statements – it read them all.

“Some of the pronunciations it doesn’t get quite right – legal terms, Latin terms,” she said. But “it’s amazingly easy to use. I have a harder time using the copy machine here sometimes.”

But the key advance is the new device’s portability, said John Pare, 47, director of sponsored technical programs at the NFB, who started to lose his sight at 35. “No matter where you are, you’re constantly being handed printed material,” he said. “It’s the way the world works. In restaurants, the airport, hotels, at a conference.”

The Kurzweil reader enables the blind to grab an image quickly, anywhere – even in the dark – and “read” it themselves instead of relying on friends or strangers to read the documents aloud.

“It’s been very gratifying,” Kurzweil said. “When we started this project about four years ago, we weren’t … entirely sure to what extent we could compensate for distortion in the images that would occur using a hand-held camera.”

Where a scanner provides a flat, uniform image and perfect lighting, the hand-held digital camera would tilt and rotate relative to the page Ė then the user would move and the lighting would be uneven.

Worse, the pages of an open book are curved, with portions at different distances from the camera.

“So we developed image enhancing software that takes this image and modifies it to get rid of all those distortions,” Kurzweil said. “And we had to fit all this software [along with the character recognition program] into this little computer.”

But it worked. “We have 75 in the field, and hundreds very soon,” he said. “And the feedback from blind users is that it’s having tremendous success.”

If it does well, the federation could eventually profit. Gashel said the NFB owns 40 percent of the rights to the technology. In the meantime, the software will continue to be improved so that the device can read more varied and complex material.

Kurzweil also predicts a time when a blind person will be able to enter a room, snap a picture, and have the reader identify the types and locations of lamps, tables, people and other items in the room.

Also, devices “will continue to get smaller over time,” he said.

Gashel expects the gadget will be crammed into a cell phone some day. But Kurzweil is thinking even smaller.

“In five to seven years, the camera will pin on your lapel and take pictures as you walk around,” describing the scene as you go, he said.

NFB chef and teacher Marie A. Cobb, 59, of Catonsville, who is visually impaired, has been using the reader since January. She has her own hopes.

“What I’m looking for is the day when I can take it into a mall and have it tell me the name of the stores, and the locations on those big directories. I would love that,” she said.

I’m Not the One Not Doing My Job

I’m Not the One Not Doing My Job

I donít know about the rest of you, but when I get essentially reamed out by someone whoís boss reamed them out because their coworkers, and not in fact them, are not doing their job, it makes me a might unpleasant. Read pissy and irritable.

Iíll explain.

When I first moved here I raised some concerns about the bus drivers not following the rules set forth in the Americanís with Disabilities Act. In particular they did not announce bus stops on the fixed route busses. This is actually mandated by the federal government and it really helps those of us who cannot see to know where we are. As I explained to one of the drivers today it puts the responsibility of knowing where to get off in my hands and minimizes the change they will forget to drop you off if you ask when you first get on the bus.

As a result of myself, Tigress, and others with disabilities raising these concerns with Rose View Transitís management and others in the City government, a Riders Advisory Council was formed. We donít have any official purpose, but we meet every couple of moths to give rider input into how things are working with the system. We are not there to make trouble for drivers. Weíre not out to make enemies, but we are seeking to make the transit system as useable and friendly as possible for all riders, not just those with disabilities.

This brings us to Tuesday. Myself and another woman met with the Transit Operations Manager and another City employee. It was our regular meeting, but not everyone could make it. I guess that will be an important fact later. We asked a couple of questions about what the plans were to adjust the routes to compensate for impending road construction and the new shopping center. We also brought up a couple concerns regarding wheelchair securement, and again, announcing stops. I think the ops manager was annoyed with the drivers because she exasperatedly said theyíd just been through training and they all should know better.

Number one, the wheelchair securement issue is just a matter of safety. I donít care how you justify it, placing one strap on a wheelchair will do nothing but spin the chair. Also, it is *illegal* to face a wheelchair passenger sideways in a paratransit vehicle. That, as far as I am concerned, is also a safety issue. The seatbelts are not designed to restrain a passenger who is seated sideways and if the vehicle comes to a hard stop and a passenger, who would normally be pulled forward and stopped by the belt, runs the risk of falling out of their chair. I really wasnít trying to be a pain in the butt however, I do think they should be following the regulations the DOT has set out. You are allowed to face a wheelchair passenger forward or rearward. If facing the passenger rearward, there must be a padded barrier at a certain height.

We also mentioned several drivers by name who are dong things the way they should and who are extremely friendly and helpful. She indicated she would let them know we appreciated their efforts.

Today, I get on the bus to head home from the store and practically the first thing the driver says to me is, ďI hear we got Barbecued pretty well at your meeting the other day.Ē It took me a moment to realize what he was talking about and I told him we didnít barbecue anyone, we merely pointed out some areas we felt could be improved for better customer service. I told him he, in fact, was one of the drivers who we mentioned was doing his job and being quite helpful. It didnít seem to appease him at all. He continued to inform me the boss had gone off on the drivers and made them sign some sort of paper saying they would announce stops and things of that nature. He did admit that he had gotten out of the habit of announcing sops, but he said he tried to remember where people wanted off. This is when I explained why it is helpful to have stops announced and while he usually remembered where to let people off, some of his associates are not as well endowed in the short-term memory department.

After getting off his bus and boarding the other one I had to take I noticed that this driver, as his usual, did not announce stops and almost forgot to stop where I asked him to, despite me asking him only 2 minutes before I was to get off.

This whole situation has me pretty irritated. The people who are doing a good job and donít need to be yelled at are getting angry with me for trying to get their colleagues to do their jobs and the people who need to hear it donít seem to care.

I think this is an example of why this type of community gets on my nerves. While it is nice that people know me, know my name, and are friendly, it is also to easy for them to know what I am involved in and this makes it much easier for them to get angry with me.

Iím just frustrated and cranky, so Iíll leave now before my bad mood offends everyone around me. (

I Got My Mouth Soaped

I Got My Mouth Soaped

No Rett, this isnít some kinky game weíve been playing. Although…

Um. Right.

Moving on with the story.

In our bathroom we have on of those matching accessory sets. You know the kind. Matching toothbrush holder, water cup, trash receptacle, and soap dispenser. It is this last item which provides the fodder for tonightís bedtime story.

Having just assisted our Heroine in placing clean laundry in the appropriate clean laundry storage locals, our Hero retires to the futon to watch a rerun of the Gilmore Girls while our Heroine attends to additional tasks around the Royal Castle. Her quest brings her to the empty bathroom soap dispenser where she braves the vile an mysterious creatures who inhabit the nether regions of the bathroom cabinet in search of fresh scented, bacteria abolishing, liquid soap. She completes her task and also retires to the royal futon to enjoy the company of our Hero.

Fast forward an hour or so. Their eveningís entertainment now complete, the happy couple adjourn to the Royal Throan Room to complete their nightly ablutions.

This process necessitates our Heroine using the newly refilled Royal Soap Dispenser. To her great horror she is unable to make the device function within its alleged specifications.

Flying into a Royal rage (otherwise known as a hissy fit, or temper tantrum) our Heroine demands that this problem be immediately corrected else our Hero may just find himself in the Royal Doghouse.

Having previously vanquished the vicious fire breathing dragon (er, uh cranky raccoons) from the Royal Backyard Shanty (shed) he figures this mere piece of household convenience will prove little challenge.

After glowering and making threatening gestures at the Royal Soap Dispenser our Hero proceeds to dismantle the unit. Upon a suggestion from our Heroine he begins to investigate for a clog in the soap outlet mechanism. Finding that water cannot pass through, our hero places the tube against his lips and blows the clog free.

While reassembling the device our Hero notices a slightly displeasing taste on his tongue. Sure enough he has managed to inhale some of the Royal Hand Cleanser.

After hastily downing a much more pleasing Royal Beverage our Hero and a grateful Heroine retire to the Royal Bedchamber for a much needed night of rest.

Bad Roads

Bad Roads

Yipe! Almost every deputy on duty is tied up with multiple, at least 6 separate, 10-50 PDs on 27 and Tingler. Theyíre all in basically the same spot. Glad itís PDO since it appears as if about 15 vehicles are involved.

Itís been like that all morning though. County roads must be pretty slick.

Glad Tigress didnít go to Indy today like she was supposed to.

Child Safety

Child Safety

I am absolutely flabbergasted at the neglect our state legislators place on child safety. This was in todayís newspaper in an article discussing the laws coming from the last legislative session.

Child restraint systems exception

During the Indiana General Assembly’s 2005 session, it passed legislation requiring all children to ride properly restrained in a child restraint until their eighth birthday.

Legislation passed during the most recent session states those earlier regulations do not apply during a funeral procession and the return trip to the funeral home.

Iím perplexed. I know that funeral processions drive rather slowly, but thereís still a chance of an accident. An accident which could cause any unrestrained passenger to be injured.

Indiana already has an exception to the child restraint laws that says if a child is in a cab they do not have to be in a safety seat. Almost every member of the public safety community I have heard, or discussed this with, has indicated their outrage at this. Why are we making it easy to neglect the safety o our children. Spend the $50 on a safety seat! Itís much better than the medical bills youíre going to pay when the cab is broadsided by an inattentive dimwit and your child is ejected from the vehicle and subsequently ends up in a vegetative state from head injuries.