Bernhard

Let gravity do the work - turn the patient to the side to let the blood run out. Otherwise suck like hell and get a tube as soon as possible. CPR with a lot of blood running into the mouth and no other airway management device than suctioning? Bad, even if kinda unrealistic (read: most probably won't happen). Again: Suck like hell and get a tube as soon as possible. Never had it in this extreme, though. Always remember: all bleeding stops...eventually.

Our ambulance's central door lock is irreparably damaged for some reason (we bought it used, it already was defective). So the driver has to run around the vehicle when locking it. Looks funny...but we do it, when we leave the car unattended in a crowded area. It's too easy to just get in and catch something more or less randomly. The new ambulances out of our statewide central ambulance design/purchasing program meanwhile all are with central locks. Here, both crew members have the key. Some newer ambulances even have the descripted engine idling switch (but, if you ask me, it's rather complicated to remember: something like "press brake, turn key twice when door opened, then draw a dead cat around the cemetry by moonlight"...). If I sometimes manage to think of it, it could be useful, yes. But when I need the engine running even if I'm not in it, it's usually because I want to have the blue lights on as a warning - and that's mostly on a traffic accident scene where I'm in view range of my ambulance and the public has no real access, so it's OK for me to leave the car unlocked and the key in.

What makes me wonder in this "joke", is the impression that a mosque's contrary is sex, meat & alcohol... This suggests "them = religion vs. we = sex/fat/drugs". Interesting view.

www.abbreviations.com may help in such cases. It still is a guessing, but works most of the time for me. An explanation of acronyms in the text at the first time used sure is a help and makes reading easier. Remember: a posting sure is read more times than written - so one should take some care to write it for all those reading it.

To counter "The 2c4 protocol": Never when I thought something like this, I had to use a tourniquet. Especially with this girl so smashed after an MVA that the first arriving fire chief just stated "she's dead", lying there completely covered with a blanket (the girl, not the chief). I just thought (and probably said) all of 2c4's sentences at once when I lifted the blanket from her head and found her still breathing. Without a tourniquet on any of her sub-partial amputated and multiple open fractured legs (the picture of "chicken legs" someone portrayed here just fits) but with e.t., analgetics and two i.v. lines she was helicoptered away 15 minutes later. On another occasion I treated an under-aged boy who illegally and rather unsuccessfully tried to prepare for his drivers license exam on a motorbike. My assessment revealed an open fractured ankle joint and large lower leg flesh wounds with severe bleeding and shock. A rope around his thigh was all the bystanders did for him (they then left him laying alone and stood some metres away). I cut it against the first aiders protest and instantly the bleeding stopped. The only time I really used a tourniquet was >20 years ago, when I had my very first call on my very first shift (!) as responsible medic. The patient stood at the sidewalk with a towel wrapped around his hand, constantly dropping blood. No indication for the 2c4 protocol...but the bleeding (severe cuts in the hand) couldn't be controled either way and he developed shock signs, so I (beside i.v. access) applied a sphygmomanometer to his upper arm for the ~10 minute transport time. Since then, I never used or saw a tourniquet used even in severe trauma cases (see above). However, we have triangular bandages in our disaster response group's mSTaRT triage equipment for this purpose. Just recently, a German Bundeswehr combat medic gave me a C.A.T. tourniquet. I find it quite useful, maybe we buy some for our disaster euqipment because in triage it's all about quickness and the C.A.T. is way faster to apply than a cravat. But personally my second use of a tourniquet in a real emergency still waits to happen...I would prefer the sphygmomanometer then again if possible. P.S.: just found a warning about faked C.A.T.'s here.

Generally we're the "patient's attorney" and almost in any case bound to professional secrecy, if it's not the patients intention to get police involved. Naturally, if the EMS provider has to be protected for some reason, it's allowed. If there's an ongoing crime/danger (i.e. an attacker still attacking others) most laws allow, even force anyone (including medical personnel) to call police. Details then depend on the local (state) law and protocol: minors, drug use, specific crimes, potential high risk areas, ... If the patient is unconscious enough to not making clear that he/she doesn't want the police we could assume that his intentions are to get police involved as soon as possible to protect his rights (at least by catching the offender). So, in such a case we're on the safe side if we call police, because in a normal situation this is what a "normal" victim would have want. Yes, mainly because movies tell them, that if there is a crime involved, police has to be called and/or given detailed information by the EMS staff. However, in most cases that's not the case and EMS staff even could be prosecuted for denying the patient's non disclosure rights. Plus: it's not very interesting to us "who hits whom and why" (as long as our scene safety is not involved), but we need "how, where and with what" to provide help. To me, in this context, most common would be the following dialogue: Me: "Did you drink/take drugs?" Patient: "Ummm....ahhh...hmmmm...." Me: "Tell me, I need it to get an idea what's your medical problem. I'm not allowed to disclose it to police or your parents, anyway!" Patient: "OK, <beverage/drug list>". Me: "Whow. Anything else?" Patient: "Oh yes...<additional beverage/drug list>, you should try, it really kicks!" Me: "Ummm....ahhh...hmmmm...." Good that they still believe us more than you. Check the topic "Do you have a duty to report ?", there was a similar discussion with some interesting view points. Hope this helps.

I talked about washing my hands and taking a shower. It costs not much and sure has some benefits at least in social life. To be serious: taking hygienic precautions is proved to work. If for medical personnel (disinfecting hands before/after patient contact) as well as for patients (wound cleaning). And talking about general hygienic procedures: clean water, sewerage management, sanitation requirements for food products etc. is a clear step forward from medieval plagues - in countries with no possibilities for such basics the risk of dying from infections still is much higher (see cholera spread in Haiti). I think, I don't have to tell you more. Would be interesting if you want to argue this. And yes I'm aware that hygienic procedures could be harmful if done wrong, under- or overdosed. But that's something with almost all things in life... To close the circle to the original posting: the hand cut may not get infected even if not treated because the original poster lives in a time and a country, where regular hygienic precautions already cover the most of the risks catching an infection in the first place and even if, due to high standards his health state is probably good enough to deal with the remaining infection risks. Some other place, some other time and he would have a much higher probability to die from even a small hand cut... If the extreme chlorination (sp?) of drinking water is more part of a problem instead of a solution I personally can't decide from here - they don't use chlorine or anything here in my home town, having an almost sterile natural water source from the alps. They have a very close watch (hygienic precautions, again!') on it, though.

Sure, but now you have (the ability) to choose, if you're working on a better individual/personal outcome for you and your family or if you're working on the further random evolution process of the whole human race. I already did my part for the latter, now I'm trying to get old enough to see what's going on with this personal part of evolution - even if it means to perform hygienic procedures regularly. ("You" as general, not specific you)

I hate it to say, but...the death rate and "shortness of life" rate due to infections was significantly higher the last ten thousands of years than since 1847. I really don't like this kind of argument in (emergency) medical context. Don't take it personally.

Hello, two friends of mine will visit Australia (starting in Sidney) from September, 5th to December, 5th, 2011. They want to visit the country but also to get some work insights in the australian EMS and hospital field. One is "Rettungsassistent" (german paramedic with 2 year paramedical education) and currently attending university to become a physician (at the moment finishing her second year of medical school). The other then is a freshly certified nurse (3 year education), experienced "Rettungssanitäter" (540hr EMT training) and certified first aid trainer wanting to go to "Rettungsassistent" school (see above) after the journey. Both have an european truck driving license and a water rescue license. They kindly asked me to ask here for some contacts to Sidney EMS and hospitals, where they may get an insight in the countries medical system - if it's a paid internship of any kind, it would be even better. A temporary work permit is available, as far as I understood them (some agency organizes this, but not especially for the medical field so they will do some burger job or such if nothing else is found). Even if there is no pay, they would like to take some shifts in EMS/hospital as a ride-along. Anyone interested in those nice girls? However, I want to have them back here for my unit afterwards! Offers for jobs or ride-alongs, questions and any other tips & tricks would be great, please answer in this forum or give me a personal message. Thank you! Bernhard (if you're interested in coming to Bavaria, feel free to ask me for the same!)

Had some patients talking with me before going into severe shock or intracranial bleeding...(one actually died just after I took his data, at least we were able to finish our office stuff completely soon after - to be not misunderstood, in that case I wasn't the responsible provider, just an additional aide for collecting patient data, getting the job done just at the right time). Back to the initial question, I carry following emergency related things... ...ON DUTY: gloves sometimes trauma scissors and a pen light (if I don't forget the holster somewhere, the stuff is in the jump kit anyway) shift pager gloves handkerchief some gloves pen Not to forget the gloves! All the other stuff (plus spare gloves) are in the ambulance and/or jump kit. ...OFF DUTY: 0-2 pair of gloves (depending on actual clothing) a face shield mask on the key ring vollie pager small swiss knife mainly for tracheotomy because it has a toothpick inside. To be honest, things changed (and got far lighter) over my past 25 years in EMS. I know the "phases" of having everything on the belt and jacket until the point, when the belly alone is far enough to fill the belt and jacket. My private car is packed with first aid kit required by traffic law (sealed in foil and never touched until replaced when due, police will control this and give you a fine if not carried or over due time) a very light jump kit including mainly gloves, sterile swabs, an i.v. set, a cheap sthetoscope and sphygmomanometer (which is handy when visiting relatives) and gloves. Used this (especially the gloves) a lot of times giving first aid. Did I mention gloves? a whole lot of emergency scene commander stuff (non-medical), too, but that is related to the fact, that they don't issue off-duty cars to us volly scene chiefs. Since last year we have a large command van in our county, so the load on my private car will be reduced sometime. Most probably I will stuff in more gloves instead.

It's part of our orders, too. But as long as nothing changes significantly the given setting or needed resources (BTW that's why I want to know what dispatch seems to know and which resources are on the way, to counter Dwaynes point of view), I usually delay this until first patient setup/care is done. It may be a problem when beeing in danger or not able to call for needed help. It's good that you want to get rid of this. I wouldn't second that, it's exactly opposite to my view of things: no rule changes! It stays the same: we're responsible for the complete (medical) scene, if 1 patient or more. Would love to discuss this with your captain... "Anything less than 50 patients is fun"...

Practise, practise, practise. Multi victims drills help a lot, if they're good and if you're really willing to learn something. Another good way is to prepare just mentally: take self experienced situations, drill settings, stories of co-workers, out of EMS magazines/forums and even public news stories, then go through them with a little bit of "what if" imagination. After such an incident (or drill) critique yourself, maybe by writing a detailed situation report, even if you keep it to yourself you will learn something. There is always at least one point to improve. And if you're don't anxious enough to keep the report for yourself, post it here. On the practical side: on scene counting to 10 and taking a deliberate breath is a good advise, already given. Try to improve your detection ability of "things going wrong" (= you getting tunnel vision). Train to get back to the Plan–Do–Check–Act circle, even if you loose it for a second. Be confident in your abilities and your tools, and always be able to apply basic procedures. That saves time when really having to take care for multiple patients, it gives you time to think more about organization. Then, you can save the world!

I almost don't dare to say, that I would prefer a Larynx Tube instead of this device...(I already use the LT as replacement for the mask when bag valving). The dilemma described in the article almost certainly could be resolved. However, it may be another tool in the box for a distinct problem (if LT and e.t. don't go in). So I will see, if I can get hands on such a thing. BTW, the breaking news that it receives "European CE Mark" is not that great..."CE" is a self (!) given mark and just a statement by the company, that all relevant european laws are met. There is no special authority approvement or testing required for "CE".

That said together with the ongoing citation of studies wonders me a bit... Here, since some years, it's very common to have a larynx mask in the OR (applied by real anesthesists). I see the LT as a replacement for the simple face mask when bag valving in the first place - it's fast enough to apply, needs not so much further attention and makes one hand free. Secondly it has the advantage to provide a very safe airway almost the same as with an e.t. tube (according to scientific study surveys), making the e.t. unnecessary in many cases. The LT is far faster to apply, doesn't need assistance (cricoid pressure, handing the tube over), no additional fumbling with stylet/lubrication and it's safe enough if applied correctly (which is simple). It's in place when others still try to get a view on the vocal cords. Sure, I have my e.t. tube as the tool, if LT is not working or not indicated (i.e. in massive oropharyngeal bleeding). I recall two cases last year, where the LT didn't fit - it then was a mess with the e.t. either...(each involving more than one experienced provider, including anesthesists). I simply prefer the right tool for a situation, based on acceptable/adequate effectiveness, time needed (the faster the better) and risks involved (the less risks, the better). To propagate "one solution for every situation" is too short sighted, I think.

Sorry, ERC guidelines (usually based on a very broad survey of studies) say otherwise... Not that I don't have seen guidelines change multiple times, but the above are the most recent ones and I'm more or less bound to them. Additionally my personal experience is the same: a LT is a very sufficient airway and absolute quick & easy to apply. And usually I'm not bad with e.t. either plus was very suspicious about the LT at first. Unless ERC guidelines say otherwise, I take the LT as soon as I would have taken the mask for bag valving.

The following is from our standards (European Resuscitation Council, Guideline 2010, Section 4 "ALS") - original in german since I couldn't find the full english text, so I (lousily) re-translated it. "Staff trained in advanced airway management shall intubate the patient without interrupting thorax compressions. A short pause in compressions may be necessary to get the tube into the trachea; this pause shouldn't be more than 10 seconds. To avoid interruptions of compression, alternatively the intubation can be delayed until a ROSC is reached." "Up to now there is no study that shows a raise in survival rates after endotracheal intubation." Thus weaking the influence of (e.t.) intubation. Then there is a chapter on airway management, and there it says: "Immediate action is needed to control airway and ventilate the lung. Only this prevents secondary, hypoxy generated damages of brain and other vital organs. Without adequate oxygenation it could be impossible to get a ROSC." "Give oxygen during resuscitation as soon as available". "Give patients with insufficient or no spontaneous respiration artificial ventilation as soon as possible" On passive oxygenation (O2 without active ventilation) even in case of non-blocked airway, the guideline states: "Until there are more results, the passive oxygenation without ventilation of the patient is not recommended as a routine procedure during CPR." OK, what does this say, at least for european ALS providers (ERC is the european guideline factory)? compressions shall not be delayed by intubation intubation could even be done after ROSC additionally important to compressions is an early and active application of oxygen (i.e. by bag valve) In several other chapters, the guideline tells something about alternative airways, including larynx tubes etc. which may be easier and quicker to apply than e.t. tubes with the implicit advantage of not needing to interrupt compressions. That's the way we do it here. However, I'm a bit surprised to read that a larynx tube may be good enough even for automatic respirators and/or "asynchroneous" compressions, since we were told that this always would require an e.t. tube. But the random amount of lost air (if compression and respiration comes at the same time) obviously is not a problem according to the guideline. Good to know, thanks for this discussion making me re-read the guideline much closer. So, I would suggest to check your actual guidelines (AHA, others?) closely...

To be honest: I don't like this argument. Performing a not really needed task (here: if something easier is available) only because to stay in training? That view would open a lot of more doors to things not really needed to be done. Training is something to be done in classroom and in hospital when a patient needs the task done in a controlled setting. Experience is something to be gained, when the patient really needs the thing but not just only to get experience points for the provider. Some internship in a hospital may help to get a larger set of patients in such need than on the street.

That is the point with this argument: it doesn't really happen - and if it happens one rare occasion, it would be just another valid reason (from a fire chiefs point of view) to get more fire trucks! This would be even a good argument to get more firetrucks in advance because run reports clearly show, that the trucks are outside the station doing duty for the public. So, they simply need more firetrucks/-fighters! That's one of the basic argumentation lines fire associates follow. If made clear and loud then neither the public nor some politicians get the real reason... To prevent misunderstandings: that's not my state of mind - I just cite fire arguments. And: I'm not against fire fighters! But I want them to be able to do their fire fighter job perfect and safe and at the same time I want to have a high quality level for emergency medical service - which simply doesn't mix. Lucky me, in my state that's more or less the status quo, but it requires constant arguing...(and in some other german states, the case is lost already). Yes, but I wouldn't blame the IAFF (only), it's a general understanding of fire dept's self-importance, rather implicite with beeing a fire department. I even see the real reason behind (at least here in Germany), because fire departments are an integral part of every city and village public authorities, mandatory to exist (large city: paid/career, smaller city or village: volunteer, but equipment always funded by the city). So, they have an important political weight just by existence, beeing an integral part of the city system. Private organisations/companies are trusted a little bit less, naturally... I even know one fire association political representative personally, beeing a close neighbour. He exactly knows the reasoning and is aware that fire departments argument's are weak if viewed closely. He even is against medical involvement of fire departments...but only in private! In the public he never ever would agree to that and he always would be an engaged lobbyist for "fire departments should do anything!". I could tell stories about discussions we had, as well in private as in public... What's the solution? Better political work, public relation and a good standing of local EMS organizations plus coordinated lobby work on all political levels. However, we face several implicite difficulties with that but mostly, we just seem to miss real self-confident superiors or willing EMS associations. Instead we have shy superiors afraid of disturbing relationships and multiple EMS associations fighting each other. Media awareness helps, but it should not give weak arguments (as those false cost calculation). All in all this is not the picture we should present to the public as professional and high leveled emergency medical care providers. Nobody outside the field understands it anyway. No wonder, any good organized fire association can play on their own rules...

Yes, a concept often misunderstood... The system includes emergency physicians on scene, yes. And yes the primary intended role of a "Rettungsassistent" is to assist a doctor (hence, the term "-assistent" in the title). But only in specific cases (described in a standard operations procedure) dispatch will send an emergency doctor along with us. And often enough even then we're the first on scene for several minutes. So, a "Rettungsassistent" is capable, allowed and even required to do a lot of the invasive stuff as well. Our education includes (beside the anatomy and pathophysiological knowledge) several invasive procedures, and we do it regularly. It may depend a bit of local circumstances (actual density of emergency physicians), but usually it is common to do a lot without a doctor initially available. The only real restriction by law is, that we have to hand the patient over to a doctor and we're not allowed to finally "heal" a patient (this is clearly restricted to doctors and licensed alternative practioners). So in the german system we additionally have the option to call an emergency doctor to scene (if not already dispatched), call a general practioner (they still make house calls here!) or transport into a hospital or a doctors office. Until handed over, the life supporting is our responsibility to all extends. Our common invasive procedures (beside the usual BLS/ALS things) are defibrillation, i.v. access, e.t. intubation, medication (analgetics, epinephrine, glucose, beta2-sympathomimetics, benzodiazepine for anticonvulsive therapy, nitro). Not so standard would be other medications, i.o. access, thorax tubing or tracheotomy. Those are not covered in EMS school but may be trained in additional courses (for example, i.o. access and Monaldi thorax tubing are common meanwhile). If the provider knows how to do it and it's the only thing to help the patient, he even has to if needed...(and exactly those would be the points someone has to explain to a judge, if lucky he can show some recent training certifications to proof his ability, but it's not legally required in the first place). Only medications we're strictly not allowed to give by own decision are some specific opiate derivates listed in narcotic substances law (morphine and fentanyl are some of them). But even this could be argumented, if there would be no other way to help the patient until a doctor is on scene. Problem is, this broad range of possibilities often is not understood by the public or even by some EMS practioners, mostly those older ones who still have in mind that there was a time before the profession of "Rettungssassistent" came to effect in 1989. And naturally, the doctor's professional association more and more wants to regulate the allowed procedures of non-academic healthcare workers, but they have no legal effect (only public relation power - far more than the shabby EMS-workers associations, I'm very sad to say). So, in reality we're relatively free to do what is needed, even invasive procedures. Sure, we then have to take full responsibility (and that's a critical point for some, since the profession is far too underpaid if taken this into account). But additionally in the german EMS system, we're able to have an emergency doctor in our team directly on scene, thus giving a much broader range of medical possibilities. Hope this short reply helps, a more intense description of specialities, procedures and such of our system would be something for an own thread or personal communication. Feel free to ask.

Dustdevil, don't take me wrong. I know the issue of firefighters desperate of entering the EMS field from first hand experience here as well. And I'm against it, since EMS is a complete own profession. I'm lucky to live in a state which sees this the same way - there are other states in Germany where fire departments have their hands on EMS. This motivates the local fire associations representatives to long for EMS related business here as well, and therefore I've had my share of discussions on this topic with a lot of people the last decades... This said, I simply warn of bringing the cost argument to top. This is too easy to disprove, in the way I wrote: otherwise idling firefighters and trucks don't cost significantly more when first responding. Correct. My statement is not that I want to have more cost neutral firefighter first responders (beware!!!), but that the cost argument (beeing a large issue in the mentioned article) will easily be disproved. So, for me it's a dangerous argument in the discussion. THAT is an argument in such a discussion. But one of my main arguments remains quality of service and especially the lack of time for training in firefighters core disciplines when they're sufficiently willing to be trained in EMS stuff. This mostly is an eye opener in such discussions, because that's not what a fire chief wants or wants to be made public. I agree, this is totally stupid, but supports my thinking that fire associations are far more political knowledged than EMS or other public services. I do, Dustdevil, I do. I'm very lucky to live in a state, where a dense net of ALS ambulances, helicopters and BLS transport units is required by law ("...within 12-15 minutes each street accessible place must be reached by ALS...") and their effectiveness is reviewed every few years. Plus, it is NOT a business of the fire departments but of private organizations/companies BY LAW (except only one large FD, for historical reasons). BTW: thanks to the U.S. troops covering the southern states of Germany after WW2 (who licensed ambulance business to private organizations instead of FD as in other german states)! But this is tried to be turned around by fire associations ever since. And there are numerous approaches to "infiltrate" EMS - by getting FD's hands on the dispatch centers or by organizing local first responder units (if senseful or not). And especially with all those volunteer departments here (but in principle the same is valid for career depts) the training factor is a very good argument, I often use against them: they simply can't spent as much time on "fire fighter core business" training when they have to spend significant time on EMS training, thus weaking their effectiveness and even their security in fire calls. And if they don't have a certain level of emergency medicine education, then their first responding remains more or less senseless. Logical discussions often stop at this point going over to political arguments... Again, I think, the cost argument as given in the mentioned article is very weak. There are better ones. Is my intention more clear now?

In Germany the "Rettungsassistent" is a protected healthcare profession, protected means no one may call himself "Rettungsassistent" if he has not passed the 2 year education (= certification) and given the acknowledgment (= license) from the state's authorities (most states: ministry for medical issues, some states: ministry for the interior). The license then is valid for all states of Germany, independent from the state you're gaining it - and for lifetime: once you are "Rettungsassistent", you are always. To continue practising, in some states or from some organizations/services there is an annual training required (differs, mostly around 30 hour per year), but it's simply a matter of attending the hours, not an exam. In some organizations the training of resuscitation algorithms including defibrillation has to be repeated annually, this counts as part of the annual training above. In reality, this annual training requirement is not controlled very strictly, not by state nor by the organizations/services - however, I think that most personnel meet the requirement (especially, since the employer has to pay for it). From the state there is no required course or additional cert level system to be allowed something special. As "Rettungsassistent" you're allowed virtually anything in emergency medicine as long as you have the ability to do it (beeing teached in EMS school/clinical internship or somewhere else) and - in case something went wrong - can successfully explain it to a judge (this statement simplifies the legal aspect a bit, but maybe you get the point). There may be organizational/service internal standards restricting this or setting special requirements, though.

I'm totally agreeing with this sentence. Since two years or so we use LT here and despite beeing very sceptic in the beginning I am totally convinced now. It's so easy and quick and secure enough. And you don't have to waste a thought on the "ongoing compression" discussion, simply put it in... But there remain situations, when a LT simply doesn't work. Last year I had two "can't intubate, can't ventilate" situations (extreme adipose patients), where LT didn't fit, mask was very difficult and questionable, and the whole team (medics and physicians, not to forget the patient) all had a very hard time to insert an e.t. tube in multiple tries. Both times it finally was a death on scene anyway. However, next time in such a situation I want to try inserting the LT with help of an laryngoscope - something we just thought of afterwards. Plus when using auomatic respirators and/or chest compression systems, a 100% secure airway is required (which can stand the pressure of both compressions and respiration at the same time) - the LT is not sufficient for that, only e.t. tubing is the option here, so we re-intubate then. But this is only for transport under full CPR conditions (relativly rare) and sure after the first "chaotic" minutes in a more controlled setting, already having a sufficient airway access (LT). With all this said, the LT is a nice but additional tool in our box, adding to our abilities in meeting specific needs on scene. Meanwhile it's my standard tool of choice, mask remains for assisted breathing or backup, e.t. if nothing other works or a 100% pressure secure airway is needed. But I wouldn't let the e.t. totally out of scope as you suggest in your post. You're welcome. Drop a line next time and maybe we can arrange something!

To be honest, the cost argument is totally misleading: the fire trucks are located to meet a certain time-to-scene on fire calls. So, they are there if there is a fire in this area or not. Since fire/tech. rescue is not as much to keep the firehouse busy they really have the timeslots to perform additional tasks anyway. Since not every thing can be cleaned, painted, trained etc. any time, there is a cool task to fill: additional EMS response! Primarily, this really doesn't cost extra: the people are there anyway, the apparatus too. Just add a little bit fuel to the cost, OK. No, it's not a real waste of tax money to get an already existing fire truck with already existing staff out on the street. Secondly, the fire chief has a lot more arguments to defend the existing units - because now, there are a lot of calls! Call volume is high, you don't really have to clearly point out that the majority is EMS and the fire chief has a statistic to wave in front of city offiicials. Since the time-to-scene criteria becomes a weak one, when it gets into the hands of a cost saving consulter, the fire department simply needs something other to proof their existence all over the city. Plus, intensely running calls with a fire truck provides immediate public attention and is cool anyway... It's not the cost, but the call volume pushing what makes me angry, since fire departments virtually cheat here. If combined with a certain "allmighty" attitude and even underperfomance on scene, it get's worse instead of really beeing a help (BTST). Otherwise, if training level is wishfully high on EMS stuff, this training time almost certainly is shorter for firefighting/technical rescue stuff - especially on rarely used techniques with need to be trained often. This directly affects fire fighter "core competence" and even their safety. Just for statistics? In my opinion, this is the real argument - not the cost. But I've been in such discussions often enough to know that fire departments have far better political relations as other public services and they really know how to use them.

To workaround the whole problem, I suggest a larynx tube (LT) as a real fast airway without need to interrupt anything. I put a LT in as soon as starting with a bag valve and use an e.t. tube only if really needed: if LT doesn't work for some reason or during transport when we use automatic respirator and/or mechanical compression system, requiring e.t. intubation. Since we may declare death on scene, we don't transport every arrest. Then, our process for e.t. intubation usually is: do it during compression and only if this doesn't work, order a short break (seconds) for twiddling your tube in. All the preparing and trying to get a good view always could be done during compressions, as well as blocking, checking and fixing.