kristo

Each position that has to be covered 24 hours a day means about 720 hours per month (30 x 24). A well-run business does not rely on overtime for day-to-day operations, so when calculating how many employees you need for that post, simply divide 720 with the number of hours that (in your area) constitute a full-time job without overtime. Around here, a full-time job is 8 hours a day, five days a week. In an average month, you have 22 working days, so that's 176 hours (22 x 8). This means that in my area, a post that has to be covered 24 hours a day needs 4.1 employee. Now, in the real world, things aren't that simple. Employees take time off. They need their summer vacation (here that's at least 4 weeks paid vacation per year). There's holidays like Christmas, Easter, Independence Day, etc. There are maternity/paternity leaves (here that's 3 months per parent plus another 3 months the parents can divide between the two of them as they see fit). Then there are sick days (especially if the employees have young children). It's really hard to believe how much time employees do take off until you see it with your own eyes. I would go by 5 employees per post. That should cover day-to-day operations, even with all the time off. Also, that may give you some elbow room for those extra shifts that always seem to come up. In some months, you may not strictly need five full-time employees per post, but I believe you will benefit from it in the long run. You'll avoid burn-out, be able to minimise employee turnover, and probably also, on a yearly basis, save money - it's expensive to have to pay overtime every time something comes up.

I'd like to second the opinion previously expressed that what works in one EMS system may not be the best for another one. That being said, I noticed a few points that I happen to have an opinion on: 1. Administering nitrates prior to 12 lead EKG. This is not a good idea. Comparing this to when people take their own nitro at home without an EKG is not a just comparison because those patients have experienced something that made them call for EMS. The instructions (I hope) they received along with those pills was to take them when they experience their familiar chest pain, but have a professional health care provider evaluate them again if something out of the ordinary happened. This is now. That health care provider is you. Another reason I read on this thread to administer nitrates prior to an EKG was pain relief. No one has ever died from pain. I'm all for pain relief, but I'm OK with delaying it for two minutes to make sure it won't send my patient into shock. If you can't even wait for an EKG, I'm guessing you don't have an IV up either, right? 2. Someone mentioned being careful with fluids in right MI, as it may become pulmonary oedema. Of course, you are administering fluids to a cardiac patient, so you should keep this in mind, but in general, this is extremely unlikely to happen in a right sided MI. It is, however, very important to give ample fluids to keep the blood pressure up. 3. Bypassing the ED based on pre-hospital STEMI finding. I'm sitting on the fence on this one. This would have to be based on your local system. A couple of thoughts come up, the proficiency of your paramedics in interpreting EKGs correctly, the capabilities of the cath lab to handle the patient if it turns out it's not a STEMI (can they keep the patient for observation for the ~ 6 hours needed to get double enzymes? Chest X-rays? What if it turns out to be pneumonia? Do they call for another transfer somewhere else? Etc. etc.). Another thought would be STEMI-equivalent, a left bundle branch block - that's a transmural infarct until proven otherwise, UNLESS there's an older EKG showing this to have been present previously. At the ED, they can often find old EKGs and hence decide whether or not the patient should go to the cath lab. Another note here; with all due respect to well educated pre-hospital professionals everywhere, circumstances out there don't always allow for a "good" EKGs. There's movement, etc. I'd think a system that did this would need highly trained paramedics and a cath lab that also had something similar to an ER... 4. Pre-hospital thrombolytics. Again, sitting on the fence. Usually, if you can get to a cath lab within 40-120 minutes (based on other factors), you want that and not thrombolytics. Hence, most EMS systems (not all, obviously!) shouldn't need thrombolytics. I'll assume those who think it would be beneficial work where a cath lab is not accessible in this time frame. In those cases I'd like to ask...have you ever been involved in administering thrombolytics? You need a very detailed history to see if there has been any bleeding (or if bleeding is likely)...preferably you need to be able to administer LOTS of fluids very quickly, this can get messy in more than one way. This is best done in a well-lit building with ample room and staff. In some cases, we want a short endo- and sigmoidoscopy prior to administering the treatment. Another note to consider is cost. If I had to guess, I'd guess that thrombolytics cost about $3,000 USD per case. Do we want to equip every truck with such an expensive drug, if we're not sure it's helping? In cases where transport is longer than...well, 10-15 minutes, I am however all for starting the treatment en route. Give aspirin, clopidogrel, heparin, maybe even GpIIb/IIIa inhibitors. For prolonged transport times (on the scale of an hour or more), those would definitely help, regardless of the end-point treatment (PCI/thrombolytics). Of course, this is just my opinion, but at least, I think it's reasonable.

I saw this on TV tonight, kind of got me thinking. Basically, it shows an ambulance bringing a patient in to an ER. The ER staff takes the patient, it's all very dramatic, they roll into the hospital, everything looks like the public perceives an ER, they roll into a trauma room and trauma room, well, not up to standards. The commercial ends with text asking the viewer if it's his/her part that's missing.* A good idea for an ad, very striking. Plus, they used an actual Reykjavík FD ambulance and it's crew (I know the EMT-I (yellow background on the star of life patch) featuring in this one). If you'd like to take a look, it's a short video and can be found here: Icelandic anti-tax-evasion commercial featuring Icelandic EMS Don't worry, it doesn't include any significant dialogue, the Icelandic text in the end is simply the "Is it your part that's missing?" described above. * I'm not trying to start a discussion on social healthcare, but in order to understand the context, I'd like to remind you that we have a single-payer system here for healthcare, including EMS.

Just noticed, Eyedown was talking about physician extenders, not actual physicians. Anyway, we don't have any such midlevels, so this is close enough.

An interesting post, Eyedown. It just so happens that what you described pretty much fits this little town where I'm working this summer. This town has about 900 people, counting the farms and small villages around, it's probably about 2000 on the whole. We have a small "hospital" (actually, about 36 nursing home beds and 4 for "acute"). This hospital is not equipped for anything else than general internal medicine. A small lab for basic blood tests, X-ray, no CT or anything like that. The hospital also runs a primary care clinic staffed by two physicians. They also tend to this "hospital" when needed. Now, those two physicians take turns being on-call. That means the general public (or hospital staff) can call them outside office hours for advice or acute problems. Depending on the case, they will come in and see the patient or ask them to come in the morning. Often, they will come in the middle of the night to do sutures, etc. EMS here is provided by paid staff. One of them is a full time employee of the hospital, as a handyman/EMT (EMT-I), he is in charge of EMS here. He has a group of EMTs, including himself, who take turns being available for calls, two at a time. They get a modest hourly wage for simply being in town and available for calls. If there's a call, the hourly wage goes up to standard overtime rate for four hours or the duration of the call, whichever is longer. Now, here's the twist. Since we have no paramedics, only two EMT-I's, a few EMT-B's and a few that do not have formal EMS training, the on-call doctor is always notified when there's a call (112 (European version of 911) notifies him). The doctor will then decide if he goes with EMS or not. For most priority 1 or 2 calls, the doctor goes with the ambulance. We have about 100 calls per year here. Since our hospital is not really equipped or staffed for severely ill patients, transfers will go to either a large-ish hospital 1,5 hours away or to the country's capital, Reykjavík, to a large hospital there (2,5 hours). I've been here for a month, and this actually works pretty well. Most of the EMTs are very experienced. The doctors direct patient care, EMTs assist and depending on the individual EMT and how well the doctor trusts him, do direct patient care. Sometimes, doctors will decide not to join the ambulance when taking patients to the larger hospitals, after evaluating the patient. This will of course depend on the patient and how well the doctor trusts the EMTs on the transfer.

Add a few band-aids and an IV kit w/ normal saline (to treat hangovers) and you should be fine.

Sounds like abuse of the 911 system. You could discuss the issue with the nurse, or the patient if he/she is mentally capable. Explain that this is not what 911 ambulances are for and recommend that they reconsider their request. If they don't, well, follow your stubbed-toe protocol. Maybe online medical direction would be in order. My guess would be that if the nurse insists on transporting the patient, you will probably end up transporting him/her. Set up a line en-route, oxygen, make the patient comfortable. The nursing home director will be thrilled when he/she get's the invoice from your company...and additionally, hopefully, a fine for abusing the 911 system.

In my system, the third patient would be classified as green. The rationale is, as many have mentioned, that this patient is extremely unlikely to survive. If we have limited resources, we would like to use them where they count. Someone mentioned putting him in black ("expected"?). While that's one idea, we don't do that here, as black is reserved for people who are already dead (injuries incompatible with life/rigor mortis/etc. or pronounced dead by a physician). Other than that, I agree with most. Put the first one in yellow, and the pregnant lady in green. Green means that he won't be taking resources away from those that would more likely benefit from them, but once resources become available, the patient will be treated.

I know it's out of context...but really, this is a very familiar approach to EMS...

A recent Canadian study comes to mind, regarding the complications of intubation of the critically ill. The researchers' theory was that the risk of complications in this patient population would be significantly larger than in the usual pre-planned operations in the OR. Here's their introduction: Their results were, at least to me, stunning: Please keep in mind, this is for intubations done inside the hospital, in an ICU, by a mixed population of expert anesthesiologists and non-expert physicians, supervised by the former. There are also other studies with similar results. I strongly believe this is something to think about when we choose airway management techniques for use in the field. The study: Griesdale DEG, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. INTENSIVE CARE MEDICINE Volume: 34 Issue: 10 Pages: 1835-1842 Published: OCT 2008. Link on Web of Science: http://apps.isiknowledge.com/full_record.d...omRightClick=no Full text (may need subscription): http://www.springerlink.com/content/c57827...8/fulltext.html

Hah, actually, I've never been to Baltimore. However, if I do run into you at some point, I'd be more than happy to buy you a beer. Thanks for the compliment on my English by the way, it's my second language. Anyway - anyone with comments on the lesser of two evils? Volunteers vs. combined fire/EMS?

I'm from Iceland. Sorry for the confusion, I'm not used to this new EMT City yet, the old one had the location below my screen name for every post... By the way - I never did get used to the "old" EMT city, either. I miss the circa 2003 EMT City (ems-online.net, as it was called back then).

Now, we've gone through numerous conversations in the past about how volunteers hurt EMS. We all agree on this. Also, it seems to be a general consensus that in order for EMS professionals to be proper healthcare workers, they should not be forced into another profession (fire fighting). Additionally, most of us agree that system-wise, the EMS side of things will often suffer when combined with fire fighting. What I'm asking for on this topic is not another debate on those things. There are a lot of threads for that. In some areas, there is not enough money to have a professional fire department AND professional EMS. Sure, if there's a will, there's a way, if they can afford sanitation services, they can afford EMS...all very valid arguments. Maybe the problem isn't so much that they can't, maybe the simply won't. Anyway. Often, at least in my fairly large (roughly the size of Kentucky) and underpopulated (~300 thousand people) country, this will be the case. Those communities need fire suppression and they also need EMS. Here, municipalities are responsible for fire suppression but the government is responsible for EMS (as part of healthcare in general). The Ministry of Health usually outsources EMS in each community, usually to the local fire department. It may not be a good thing for EMS (or even fire, for that matter) to combine the two, but often it will be enough for the fire department to go from one part-time fire chief with part-time firefighters to a professional department with full-time staff and training. What I mean by part-time firefighters here is people who show up for a minimum of X training sessions or courses per year for a certain fee. If there's a call, they will respond if able/willing at the time (like the US volunteers) and get paid for calls they attend. They will almost always have other jobs. Sometimes they can leave for a call, sometimes they can't. So, the question. Which is better for the community? To have the janitor from the hospital or some local volunteers drive the ambulance (no kidding), often without even EMT-B training, and a part-time fire department, or a full-time combined fire/EMS? They wouldn't get very many calls, so the free time could be used for training. I'm a bit torn between the two options myself. On one side, I'm all for EMS as a standalone healthcare profession. On the other side, I see communities with rather questionable fire suppression capabilities AND well, sometimes it will be less-than-optimal EMS as well, vs. at least slightly better combined fire/EMS. Sure, EMS is being used as a crutch for fire, in a way, but let's face it. The fire department needs that crutch and it is good for the community to have proper fire suppression. To make a long story short; out of two evils, volunteerism and combined fire/EMS, which is the lesser one?

Does anyone else think that posting pictures of one's privately owned huge "72 hour pack" is a bit whackerish? Sure, you may need one because of your status with agency X or whatever, but the comments about handling an MVC until EMS gets there, taking pictures and putting them on the Internet, buying shiny medical kits with the word "tactical" in the name, etc. scores high on my whacker-scale. At the very least, someone seems to have a touch of what we here call shiny kit syndrome.

Interesting. Here, if our patients have been in a medical facility abroad in the preceding 6 months, they are quarantined and tested to find out whether they're carriers for MRSA. Once it's been confirmed by a culture from a nose swab that they are not, they are let out of the quarantine. This obviously only goes for hospitalised patients.