captainstandup

I think spenac is on to something, the garbage folks have mob backing. Perhaps if EMS had mob backing reimbursment would be a lot better or they would "bust heads" plus we could hang out at the "baaddaaa bing" when not on calls. Hey we might even be able to increase our earnings by "taking care" of their victims. At least the mob has some degree of code in the way they do business

Not only should manpower be one of the issues here, IT IS, the issue here. This isn't only true in terms of warm bodies to fill open shifts, but should actually be competent educated, professional, articulate warm bodies with at least rudimentary clinical judgment and skills. A question for AnthontM83. Why should volunteer first responders respond for free to do the heavy dirty work for a money grubbing private ambulance company? Not to hijack the thread or anything of the sort, but practically speaking how can a community expect or demand the highest quality of prehospital care from folks that must focus on their primary job and merely serve in EMS as a hobby, for lack of a better way of describing it? Pay attention to the next five prehospital folks. The most arrogant will likely fit into one of three categories. The first category includes those providers that I refer to as mutts. The ones that never pick up a book or attend classes beyond the minimum, The second category are providers, educated and uneducated that failed to learn humility and grace as a child. The most arrogant we have are the flight medics in a local hospital system nearby. with few exceptions these folks are often critical of EMS, unkind to each other and certainly to their colleagues. These folks have one of the most sought after jobs in EMS and in return they give back crap. Finally many of the most arrogant and uncooperative are often covering up incompetence and absence of skill.

I'm in North Carolina, the local municipalities haven't evolved to the robotic collection vehicles yet. I'm not saying our patients are trash, I'm just trying to start a semi - humor based dialogue on the similarities. I should be concerned about offending the "sanitation engineers" (trash men). Some of these guys make a lot of money. Especially the unionized folks. And they aren't nearly as invisible as EMS folks.

Garbage Truck = Haul off things no one else wants to deal with. Most dangerous work at night and in areas most people are wise enough to avoid. Serious risk posed to crews by criminals, and the motoring public. Potential for exposure to substances and items that can kill them. Back injuries, rotator cuff injuries common malady. Underfunded and often underequipped to meet demand for service. Frequently provide service to those less than grateful Often exposed to sights and smells that are nauseating to say the least. Work holidays and weekends At least garbage folks only handle their refuse once. How often do you think they are called to return garbage to residences? Feel free to add similarities

Why in the hell would anyone want the volunteer fire departments involved in ALS protocols? In our area of NC the local fire chiefs are a bunch of rednecks, three of them never graduated high school and one is virtually illiterate. I realize you said STATE Fire Association, but practically speaking I feel Fire should focus on putting out fires and leave caring for sick and injured people to the pro's. With this said I realize there are fire agencies, such as FDNY EMS who are responsible for ALS, and their involvement in scope of practice / environment of care decisions is crucial. I honestly can’t name a single VOLUNTEER agency that is the primary provider of ALS services. For those agencies with ALS (Paramedic level) and Transport responsibilities I feel their input is appropriate. For those who merely dabble in ALS care, leave the decision making to the educated providers. CBEMT's example defines one of the key reasons we are still considered ambulance drivers. The decision makers in his / her area are for the most part untrained and seemingly uneducated. Their motivating factors are likely greed, power and keeping things "the way we have always done it" Its really difficult to outlive a system that by design is ignorant, if not stupid. And the comedian Ron White says it best "you can fix stupid". Its no mystery as to the reason our best and brightest simply give up and move on to disciplines with professionals in them.

Perhaps mstovall is right! Until the government (another way of saying open your wallet and bend over!) provides alternatives for the poorest, oldest, substance addicted, illegal (man that one angers me), uninsured, and more often that not lazy criminal looser segments of society, EMS will continue to represent little more than a glorified garbage service. Our mission is often little more than ferrying the trash from one point to another and back again. This isn't to imply that everyone we care for is trash.

I had no idea the situation was that "political" wasn't EMS in the city freestanding (separate from fire) at one time, then absorbed or taken over by fire? If this is so what year did the takeover occur? Finally, were you there when it happened?

Where is the Clevland EMS Commissioner? I'm sure he could offer us his limpwristed poitically correct phrase.

JVD is, in my opinion, a virtually useless sign (unless distension is clearly present) considering the variability of the human form. The degree of obesity prevalent in the US makes it very challenging to accurately assess jugular vein tone. We have always been taught; and taught to students the mantra of ACLS, ITLS, PHTLS the varying value of "flat, distended, or normal" jugular veins. Given the difficulty of accurately assessing jugular vein tone accompanied by the myriad of other assessment factors that must be combined in making a solid field diagnosis, I feel precious scene time could be more effectively used in other areas of assessment. As I eluded to in the first paragraph of this post, I now simply teach students that the presence of JVD is potentially significant but it's absence is meaningless. OK Dust, I'm sure you, ridryder or spenac are "takin me to the woodshed" on this one. I'm ready, I think er perhaps not...................

"You" cannot inspire this person to do anything. Inspiration comes from within the individual and they either have it within them to remain current and to expand their knowledge base or they don't. Its probably no coincidence that inspiration and education seem to rhyme. Oh and huge kudos to you anthonym83 for being "standup" since thats my bag. I would love to take a pick axe to every television in every EMS base on earth. You can always tell who the mutts are, they never check the truck, never pick up a book and attend only the mandatory training. These folks redefine "minimum standard" We can only hope they can manage to be decent drivers as they have no business attending to sick or injured patients. A BLS nursing home return patient deserves better than these folks offer.

Asysin2leads, what percent of the calls you respond to in the big apple would you say actually meet your definition of medical necessity?

Fatasses have overwhelmed us! Run up the surrender flag and staff each ambulance with three or four personnel. Volunteer First Responders aren't going to help with repeat offenders and why would they? Contrary to misguided assertions in this thread, the patient’s wellbeing is SECONDARY to our own. Destroying your lower back or trashing your rotator cuff is just as career ending as getting badly burned, stabbed or shot (assuming you survive the latter). We must consider patient size and location as a logistical challenge that has to be managed safely. If the patient cannot be safely be evacuated with two personnel then they should be treated in place, until adequate resources can be mustered. This must be adhered to regardless of patient acuity. If this means someone dies while waiting on adequate resources, then so be it! We will do the best we can with available resources and in my opinion the remaining responsibility rests on the patients and the community's shoulders. Perhaps people will someday understand that the impact of improperly staffing EMS and Fire agencies. Patients must understand that it may not be the best option for a 500 pound person to live in a third floor apartment with stairs and narrow halls. Regardless of the level of public or patient understanding, EMT's and Paramedics simply do not bear responsibility for bad life choices by patients or poor political funding decisions by the "powers that be" Just remember, at the end of the day, we must return home in the condition in which we left in.

Protocols should be considered guidelines. There is no conceivable way that a written document could be so broadly written as to cover every patient situation. EMT City is arguably one of the best resources I have encountered in almost 16 years in this business. With this said I may incorporate things learned here into my practice, but I would never change or alter a protocol based treatment on what I read in these threads as they are often opinion only. Just remember the folks on EMT City will not be there if the Medical Director decides to review the call.

EMS has been overtaxed since the "white paper" was written in 1966. We began behind the eight ball and have never caught up. As the population has increased and stratified into scum, parasites, working poor, lower middle class, middle class, upper middle class and wealthy groups so has the demand for services anyway. We are overwhelmed with calls in minority and white trash neighborhoods where crime, violence, diseases (treated and untreated), poor nutritional habits (the malnourished or morbidly obese) drugs and a prevailing attitude of entitlement to services from the man, is perpetuated through generations. These neighborhoods typically "consume" far more resources than all other socioeconomic classes and often pay nothing for services received due to their being uninsured, illegal, wanted by LE or simply not giving a damn. Response time goals are often a "pie in the sky fantasy" in most metropolitan areas. I have friends in several cities and they relate stories of getting back into the rig only to find a dozen or more priority 1 calls waiting. These may include choking children or cardiac arrests all the while ambulances are tied up taking some fat lazy, wouldn't work as a taster in a pie factory, looser to the hospital because she has a rash on her legs that onset two years and 150 pounds ago! We desperately need a national model for proper utilization of EMS resources. It must include education and a serious public relations campaign. We must be empowered ( i hate that word) to deny transport to patients that do not need it without the fear of reprisal. There are a great number of calls that should end with the paramedic referring the patient to their personal MD, a clinic, the ER, but not by ambulance. The argument that reduced calls will result in reduced funding doesn't hold water. As I stated earlier most of the folks dont pay a dime for services.

Damn Dust, "color by the numbers" your brutal! Correct, but brutal! Keep fighting the good fight. asyn2leads said: Its a scam, people, it is. The reason we haul a-holes with minor emergencies from the ghetto and the trailer park is because we gets paid when we do. He is right, it is a scam, but the fallacy here is that if DMA or CMS or many of the private insurers decide that transport by ambulance was not medically necessary, they will deny payment.

Unless "Bagel boy" has signs of significant blood loss, continued bleeding, nerve or function impairment, or some rare psychosomatic response to the sight of blood or finally is under age, he doesn't need an ambulance. Bandage and have friends or family ir even a taxi transport him to ER triage or even an urgent care clinic for sutures. Critically ill or injured patients are frequently tied up with bullshit routine nursing home transfers for foley replacement, or transporting meth head loosers for the 15th time this year. We had a woman in a low rent housing complex that called for an ambulance 231 time in three and 1/2 years. She was nasty, vulgar, abusive as crazy as hell and may have actually needed an ambulance on three occasions. It took me three and 1/2 years to get her committed but finally with the assistance of DSS and adult protective services and through my filing charges against her for misuse of 911, the court put her in a facility. People with valid conditions suffered because of this woman misusing 911 and we had two medics hurt their back while carrying her to the truck. We never carried her again after the last one was injured. An earlier post implied I would be negligent in walking someone with ACS to the truck, or at least out of a difficult position within a residence. Consider the harm caused by the three pack a day smokers that treat bacon as an individual food group. We routinely see patients in excess of 450 lbs and the heaviest in our community was 923 but fortunately natural selection took care of him. It is not the fault of society that patients become 200, 300, 400 lbs overweight. Society is forced to suffer the cost of taking care of them in many ways. Injured EMS employees cost taxpayers millions annually and often result in disability or early retirement / career change for medics and remove skilled practicioners from an already tight employee market. We carry people because we are "trained" to react rather than think based on education. Most providers are driven by the fear instilled by employment practices and lawyers that blindly blame everyone for the patients condition rather than holding them accountable and responsible. This isn't to imply we are to be punitive or abusive but by the same token we have the ultimate responsibility to ourselves and our safety. It is unacceptale to take unnecessary risk to move someone out of your safe range of ability regardless of the severity of their condition. Always wait on assistance, always. You may be forced to wait for a long time. First responders have virtually stopped answering call in our county, other EMS units are frequently tied up and most law enforcement wouldn't dare. So here we are, faced with remaining on scene with sometimes critical patients or choosing to attempt to move them or finally act in the manner we have been taught for years. Ensure scene safety!

I agree but submit that the decision should be based on clinical judgment as opposed to fear of litigation or stupid policies. we live in a mountainous area where three level stairs are common. 350 pound patients are common as well. There are situations where the patient, even acs patients, simply must walk down the stairs to the front door. The first responders in our county generally suck and wont respond to a medical call. 350 - 400 pound patient 110 demure pound female partner, difficult stairs = patient walks to door or dies

Traditionally in EMS we carry people right? A good friend of mine traveled to England three years ago and he actually was allowed to ride along with EMS in London. He said the most interesting thing he witnessed was the fact that medics in Europe rarely carry anyone from the residence. Even patients experiencing chest pain walk to the ambulance. He also said that back injuries are virtually unheard of in European EMS. I just thought it could be interesting to discuss the benefits vs risk of as fiznat says ABC. Unfortunately patients are conditioned to be so fat and lazy and have a lawyer on speed dial that we carry them in fear of being accused of worsening the patients condition. We dont have a polcy but i submit that most ems agencies in the US take the stretcher to the patient even when it isnt necessary.

How many of you are required to physically carry a patient from the residence, regardless of difficulty or dangers to personnel? To clarify, is anyone permitted to "walk patients to the rig" if they are physically capable of doing so?

If you are ever sitting around wondering why EMS is for the most part a dead end career, think of this idiot EMS Commissioner. Limpwristed bureaucrats like this guy continue to placate special interest groups and sell us out as an extension of public health. We are an emergency service; you know the one’s called when the Shinola hits the fan. The EMS system "in as much as there is a national EMS system" is overloaded and broken. Politicians, insurance companies, hospitals, Dr. Offices all want someone else to care for the uninsured, underinsured segment of society. God help them is they are among those considered mentally ill! How difficult is it for us, as health care providers, to get an appointment to see our family doctor in less than three months? I use the ER as my family doctor because the care is better, lab, X-ray and most specialty services are open 24/7.and in the same building and if I go to my doctor he is going to send me to the hospital for what? That’s right, lab work, X-rays, special services. My copay is less for the ER or urgent care than for my family doctor. If it’s late at night or weekend the hospital will issue enough meds to get us through until a pharmacy is open. I can empathize with the patients who have no insurance of family doctor and live in squalor, needing to use the ER as their only access to health care. If they try to go to the health department they will be 300th in line behind an endless stream of illegal Mexicans. The situation is identical in most faith based free clinics and they can simply forget a private physician willing to accept someone without insurance. As I have stated in other threads, there is already NO surge capacity in the US healthcare system in event of a pandemic event. Hundreds of thousands will die and many will do so without any attempt to care for them. There will simply not be enough ambulances, ER, clinic, MD office beds to care for even 5% of the surge. Now return, if you will, to this idiot vomiting forth his "we need to take care of everyone" drivel. He and his kind are making the system a great deal worse by conditioning the public to believe its fine to call an ambulance for any situation. Solutions to these problems are complex but I have a few suggestions: 1. An honest national effort toward tort reform to make it a great deal more difficult to sue EMS providers. 2. A national effort to implement EMD and include the Omega response option. 3. Educated prehospital providers competent in detailed assessment and capable of intelligent communication with MD’s and PA’s to allow alternative “routing” of patients. 4. Utilize technology to improve on-scene decision making. Pay a physician to be available for crew consult. Incorporate real time video/audio and integrate monitoring data to allow a team approach. 5. STOP transporting nursing home patients to hospitals for routine x-ray and lab analysis. Make it financially viable for them to utilize bedside imaging services and send lab techs to the patient’s location. 6. Create financial incentives for nursing homes to incorporate a "facility physician" or at least a PA who has regular daily hours in the facility. Make care available to staff which will aid in lowering health care insurance costs and help attract better employees. These may be grandiose suggestions, but if you consider the negative impact of an overburdened emergency health care system and the cost of providing those services, It seems at least a portion of those costs could be offset or shifted through appropriate utilization of available resources.

Is there an opportunity for you to further your education and in doing so, move on to a paid service? Even if it means taking one class at a time, start in the local community college and set goals of where you want to be in the future. You seem to have a sincere desire to serve in this industry, and I feel you and your future patients will be wonderfully served if you begin your education. Begin with English and be willing to take the lowest entry level classes offered if you need them. Then progress to the more advanced classes. I remember taking a humanities course on the civil war. When I signed up for it I had an overwhelming sense that it would be the most boring ridiculous class I had ever taken. As it turns out, this was by far one of the best classes I have ever taken. The most important classes I have taken, in my opinion, were the anatomy & physiology classes. Each was a semester in length, included labs and actual professors as "instructors" In their finite wisdom North Carolina OEMS doesn't require traditional A&P. OEMS requires "A&P for EMS", which is a dummed down version of A&P and doesn't even last a semester. As you would assume, this class has no labs and pretty much anyone with an OEMS teaching credential can teach. Just remember, ill mannered uneducated mutts bark and snarl, but that’s all they have to offer. You, on the other hand, have the insight to ask questions and spend time learning. Education is an awesome experience and as you travel along your journey you will develop better grammar and spelling skills then the good stuff!

My impression of the LMA is that, although routinely used in OR, they are poorly suited for the degree of patient movement encountered in the prehospital environment. I still remember the prehistoric days of the ill conceived EOA. How many patients were killed by those things? Airway management = Appropriate use of BVM in conjunction with an OPA or NPA and proper technique followed by ETT intubation with ET CO2 and SpO2 monitoring along with frequent reassessment and if time and condition permit insertion of an NG/OG tube just to keep things tidy in the rig and the uniform clean. Utilization of a cervical collar or at least head immobilizer for stabilization and to prevent displacement. Backup should include, again in my opinion, a combitube, surgical cric (with three way spreader) and finally the godforsaken and quite useless needle cric kit. I suppose any airway beats "no airway", unless of course I'm the patient and it looks like I may wind up in a damn nursing home. In the latter instance please provide me with two large bore IV's 1000 mics of fentanyl, 50 mg versed, 100 of MS, 5 mg ativan, a nice 100 ml bolus of diprivan, 25 mg vecuronium, 2 grams lidocaine (rapid IV push) and please take about a three hour break.

Thats an ugly accusation dust Ok fine I'll buy a vest. There has been a lot of discussion regarding what type and threat level is appropriate for EMS. In my opinion the level that best protects us from small caliber handgun and to the greatest extent possible knife attacks would be best. I doubt we could practically afford anything resembling the military stuff Dust wears over in the sandbox and if we could would it work with unform attire? Never forget vanity! It appears, at least for now, that the threat of high powered rifle and IED ordinance is very low in the US. This may change if Hillary gets elected and collapses our borders while waving the green flag to those who hate us, but that discussion isn't for this thread. In the meantime we can begin helping our folks obtain the necessary safety equipment. We must stablish a process of conducting better scene surveys and teaching our folks to expect the unexpected. Develop a sense of suspicion and caution. exercise good "economy of motion" while on scene which will permit reduced scene time. This isn't to imply we offer substandard care but simply work more efficiently.

I agree with anthonym83 in that danger in EMS is often unpredictable. There was a Spartanburg SC Paramedic shot in the face a few years ago by a psychotic woman with absolutely no warning or indication of threat. I think in addition to protective equipment we simply must add tactics and self preservation to the education provided to new folks. Simply realizing that we should never permit a patient to move to a position where they are out of sight of the crew. We must remain within a proximity that will permit us to take action. In the South Carolina case the patient simply opened a drawer withdrew a weapon and shot the medic. Had he remained within arms reach perhaps he could have disarmed the patient or at least turned the gun on her. As Paramedics we are often deluded into the "good guy role" and become complacent to the fact that a person may present a real threat to our life. We simply must be prepared to defend ourselves by whatever means possible. The first step is obviously to plan tactically. Never allow the patient or bystanders to block your path of egress. Always be prepared to abandon equipment and retreat to the vehicle, thats why we have insurance on that stuff. Leave the scene immediately if it becomes unsafe and don't be concerned about issues of abandonment. Your safety and right to a safe work place trumps the patient / provider relationship ALWAYS. Carry and be prepared to use whatever means of self defense permitted by law. In most states providers are limited to knives and these aren't considered defensive weapons, but instead are tools. Understanding human anatomy is a great advantage in a defensive situation. Just remember, taking away the assailants ability to breathe is a powerful defensive maneuver. Whether in the form of tracheal occlusion or pneumothorax, an airway problem will usually cause a serious loss of interest in harming you on behalf of the perpetrator.

That is possibly the funniest thing I have ever heard doc. In absence of the ECG, I'm still convinced this may be atrial enlargement. In absence of the ECG it could simply be the bat signal over gotham city. Quick Robin, to the bat cave, its the EKG Riddler poised to strike...................