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I agree that you have to sort out what you want your full time job to be. I'm not in tactical medicine but have a lot of EMS experience, and my sense is that the vast majority of of people who do tactical medicine don't do it as a full time job. They are either full time medics who respond to call out with their SWAT teams, or they are full time police officers who have additional medical training. The big police departments have full time SWAT teams but most people who do SWAT are not in NYC or LA.
The best place to start would be to figure out a few cities you would think about living in and search online for info on SWAT, the then contact the departments directly. They usually have someone in charge of recruiting.
It's worth noting that there are plenty of people who get killed by people they think they "know." Like psychiatrists who get killed by their patients, you'd think they would know how to read them and figure out that its a dangerous situation.
Sure I've gone into situations that maybe others would wait for the cops, and there are times that I've waited. It's worth keeping in mind that you can run 5 calls on someone who is "just a drunk," and the sixth time they show up with a gun in their hands. What I was taught was that about 40% of suicidal patients are also homicidal.
So if you want to go in go in, but I would keep it in mind when you are approaching the house, where you park the rig, where you stand when you knock, where you stand when you are talking to the patient.
1: Trauma cardiac arrests don't cost the system much. Most of these people aren't transported, the system isn't build for these people because even if they were shot in the head or hit by a bus physically in the operating room, most of them would still die.
2: Part of the issue with having a perfectly efficent system is fire departments. I have big problems with a huge fire truck showing up to all these calls, but I understand that you have to give fire departments something to do if you want to be able to call up 50 guys for those structure fires.
3: Sure I've run on plenty of people who should have had someone drive themselves to the hospital. But I also think about the cases where the patient isn't that serious, but the family is freaking out. I wouldn't want those people driving like crazy people through the street. Safer for us to show up and transport. Also you get the advantage of those people being brought in with their meds, directly to a bed. It's pretty disruptive to the ER when people are brought POV and people have to run outside with a stretcher or wheelchair to bring them in.
4. Is the only point of EMS to get the patient to the hospital alive? Or is it to safely transport people and make them feel better enroute? I'd say that it's less than 10% of my calls where I go "this is total crap, this person is using me as a taxi." There are a lot of things we do like give albuterol to asthmatics, pain control to fractures etc that may not save lives but make people feel better.
I don't think you have to go change the whole EMS system. You have to come up with a good system, backed by evidence, where the medics can show up, do an assessment, and say "this is crap, we're calling a taxi." Denver actually used to have something similar (not sure if they still do) where there was a drunk truck staffed by one EMT, who when the medics found someone who was just an intox they would call the X car and they would take all the drunks to the hospital.
I haven't taken the class. But I would add that people should be aware of the burns that may not look bad, but have high morbidity and mortality, and generally should cause you to think about taking someone to a burn center. Off the top of me head:
Those are classic indications. I would also be very worried about electrical burns (ie lightning) where there may be hidden internal injuries.
There are two things the jump out at me from the report.
1: I've never heard of starting transport with a living patient,having them die enroute, and returning to the scene of the accident and leaving the patient there. Everywhere i've worked either the patient is pronounced on scene or you complete the transport to the hospital.
2: It strikes me as a little sketchy having someone not from the responding ambulance department drive the ambulance. Is that person covered by insurance? Do they have EVOC? It would be very messy if there was an accident on the way to the hospital and some random ski patroller or cop was driving the ambulance.
These two issues may have been okay under state rules and ambulance company rules. But they seem strange to me.
1: You have any data that patients have better outcomes in countries with a 6 year residency versus 4 years? You can assume more time is better, but why not just have a 10 year residency? I'm glad I'm not spending 6 months doing anesthesia, you don't need that much time to learn how to intubate. And most of the other stuff you do during those months don't really apply to emergency medicine (I don't whip out much isolflurane in the ER)
2: I think it's a bit insulting to call an emergency residency "vocational training." Therefore a pedatrics residency is just vocational training for treating kids, surgical residency is vocational training for surgery etc. You are also putting too much stock into what someone can do after just an internship, sure you can write perscriptions but you aren't going to get hired anywhere.
3: Sure medicine is tough, but I think if you can't learn to safely treat patients in 7 years of training (med school plus residency) you are doing something wrong. There is always more to learn, which is why many people spend another 1-2 years in fellowship. I would also remind you how expensive medical education is in the US. When you are $200,000 in debt, a system where you don't start making real money until you are 40 doesn't sound so good.
4: None of this really has to do with what's being discussed. The fact that a paramedic didn't know hypotonic doesn't have much to do with how doctors are trained in our two countries. I agree there is a big gap in the education between paramedics in the US and other countries. But I don't think how doctors are trained really comes into that.
Most NYC EMS ambulances spend the day posted out on the street. So bringing ground coffee doesn't help much as the guys are spending 98% of the time out on the road. Better to just bring cups of coffee, or buy some when you are out on the street.
I think it depends on what your expectations are for the interventions. I don't think it takes that much training to show up and say "i know you aren't having an emergency today, but I want to go over:
1: What medications you are taking? Do you have a list of them?
2: What hospital are you followed at?
3: What is the name of your doctor?
4: When is your next appointment?
5: Are you in the process of getting home health help? No? How can we work on that?
6: Do you have a recording of your fingersticks?
Pretty simple. Now it's a very different skill set to have someone show up and say "I know you called 911 because you think you are having an emergency, but I'm going to decide that you aren't having an emergency and leave you here."
In the first case you are mainly providing social support to the patient and ensure that they know what they are supposed to be doing, that their medical information is gathered in a readable way. In the second case you are making diagnosis.
Now the question of if that second case is doable in the US is a different issue from the first case. The big problem in the first case is funding. If you target high system users it is cost effective. But maybe not expanding it beyond that.
I'd also point out that I don't think it's much cheaper to have a medic go around and do this than having an RN or social worker do it. Maybe it makes sense in places with low volumes where you could do some of this while in service.
My issue isn't that people volunteer, it's that they are volunteering by trying to jump calls rather than being part of a 911 system. I understand that a lot of volunteer groups were there before FDNY came in, but if the community isn't saying "we need more coverage, lets have a volunteer service" then something has to change. And I think it is. Look up what is going on with FDNY and Aviation Fire Department.
It seems like there are groups that are volunteer and have a decent system in NYC. Columbia EMS for the university, Central Park Medical, Hatzola. People call them directly, bypassing 911. Which I think is fine. But I don't think I'd work for a service that's operational plan was "let's listen to a scanner and try to get there first."
As a side note, I would think there would be legal issues to jumping calls. I could see a lawyer argue if something went wrong on a call "this person called 911, they expected an ambulance to show up. You arrived from your volunteer ambulance, that patient assumed that you were sent and thats why they agreed to treatment from you."
Not saying that the vollys are more likely to do something wrong. But from a legal stand point one could argue that you as protected as an agency that was requested by the caller.
I feel the frustration for the people who are volunteering. I looked into it years ago and was annoyed I couldn't just work on an ambulance in the summers during college in NYC, that I had to either go full time with FDNY or try to get on with a hospital that wanted more previous 911 experience.
My advice is to say out loud what you are doing and seeing. This is helpful for a few reasons
1: It calms you down
2: It reminds you what you are doing (by saying what you are supposed to be doing at that point in the intubation it reminds you to do it.
3: You get more time to try the intubation if the person supervising hears that you know what you are doing, and if things are going well, they know what you are doing to correct the situation and are not just staring and the esophagus. Example:
"I'm opening the mouth wide, inserting the blade to the right and sweeping the tongue. I'm clearing the lips, I'm lifting to the opposite corner of the room. I see the epiglottis, I'm advancing into the valecula and pulling up. I see the cords, tube please. I have a grade 1 view (if you do), I see the tube passing through the cords. (hook up bag) I see chest rise, I have tube fogging, I have good C02 capnography. Equal breath sounds over the lungs and nothing over the belly."
Sounds dumb but that's what I was doing in anesthesia and I wasn't having people bump me out of the way after 5 seconds like some were.
Like I said. Are there other places in the US where there is a volunteer service that is scanning the radio and trying to beat the official 911 system to calls? In most areas of the country if you were jumping calls based on scanning the radio you'd get arrested. (Not saying NYC vollys should get arrested, just that it's a weird way to run a railroad.)
It seems like it would make more sense for FDNY to say "hey, you guys have this 10 block area, you have the same computer system in the your bus as we do, you guys are 15 Victor, and we'll dispatch you from FDNY coms." That would allow them to move a FDNY truck somewhere else that it was needed.
I still don't really understand volly EMS in NYC. It seems like a lot of them are in places that are covered by FDNY, where they either monitor the radio and try to "jump calls," or else they are called directly by people because they don't want to deal with the city EMS. Anywhere that you are trying to beat the 911 ambulance to a call is sketchy.