stcommodore

I've found that my partner and I working in an urban SE Pennsylvania city (mentioned before in this thread) do most of our care on scene. The hospital is typically 5-15min away depending on diversion, location, traffic and working on scene gives us the chance to get the most acomplished for the patient. Obviously for the time critical things like STEMI, stroke, and Trauma on scene time is limited but showing up at the hospital empty handed just because its 5min away pretty much defeats the point of being advanced providers, right?

I want to add do that what we do is for the benifit of the patient and not for the hospital as some have seemed to confuse here. While what we do can assist the hospital (bloods, etc) we don't treat based on what they are going to do we treat based on what the patient needs.

I'm shocked to see people use 2 straps let alone this facy stuff in my poor urban ems system. You'd be happy to know to now that CIDS, or taping the CIDS is optional in patient packaging. The new method! Simply place the patientin whatever they are wearing (including a facy sunday hat) onto a lsb, secure with litter straps, put collar on patient and present as a trauma transport to the ER and you wonder where the systems reputation came from...

For what its worth I belive that a paramedic responder system in the urban setting, and ideally with two paramedics per unit should be the gold standard.

These are pretty much in line with the PA state protocals. What I ask the group is who considers "loss of consciousness" with a fall, etc to be trauma critera? Or the simple "fall from standing"? I think the over triage by some hospitals and lack of a true trauma standard has caused alot of issues in the pre-hospital setting.

The EMS Providers Bill of Rights:

5-The Right not to be called to Bus Accidents for obivously non-injured persons

4-The Right not to be exposed to the creatures that crawl on homeless people

3-The Right not to have patients dumped on you by transit or city police

2-The Right to have 30sec to take a piss when necessary during your shift

1-The Right to get paid and have your pay increased yearly!

---Oh and its a total joke to think you have to put every patient on a stretcher.

transport to "closest apropriate" facility...

I've worked in the van style ambulance in the 'low volume' county ems system without an issue. But in a extreme high volume urban ems system I would see issues in the amount of equipment we carry in a type III that could be lost in the van.

In those "no als, long transport" situations PA protocals have a section that cover even this. It says something to the effect of if the AED continues to suggest "no shock advised" and you've done x rounds of BCLS then contact command for field termination.

On the other part of the topic, you really need more then 2 providers to work a cardiac arrest correctly. We know the current protocals call for the person doing compressions to be rotated often so its impossible for two people to do everything necessary in a Code and rotation doing CPR. In my county ems and city ems expierence we get support by either another squad, Engine Company, or both on a cardiac arrest.

i have no idea what he's even asking, urban ems maybe? :roll:

The entire story sounds like a rather rough call, sorry but welcome to the job. In regards to working with an EMT as a new medic, you may be new and I'm not far from where you are but being nervous is one thing but it shouldn't keep you from being competent on the call.

In regards to RSI, for all the people that seem to be talking your system down its not as commn as they make it seem. But CPAP/BiPaP is the standard of care and the service should be moving toward having the ability to provide that to a patient.

Real life case...

Called for an "assault" and find a 30's female who had a few minor abrasions on her hands from getting in a fight with a roomate and being cut by a glass bottle. Patient had no active bleeding, and no real emergency condition. Police on scene have the roomate, and somehow ems was called into the situation.

I say "you really don't need to go to the hospital for a few cuts on your hand"

and she says "but I'm a diabetic and I'm afraid I'm gonna fall out if I take my medicine"

me "do you fall out everyday you take your medication?"

"no..." her

me "then your not going to fall out today"

her "well I'm feeling dizzy now"

me "fine, lets go"

Did this patient need to go to the hospital?

We have no offical "ems refuses transport" but the loop hool would have been to call this call "handled by police" or "no services needed" and for better or worse that would have been the end of it.

I've begin to realize that the stock and resupply system grows based around the system you work in. In a county system the trucks can live off resupplying IV's, fluids, drug box from the hospital from call to call. Basically when your only running 4-6 calls a day that system will work. Come to the city where you won't see the station for 14 hours and that won't work. You need a full cabinet of back up ALS supplies. The problem is that life in the city means sometimes the morphine shipment hasn't come in yet and everyones morphine is expired. Or you make shift change and 3 of your batteries are gone and all you have is one full battery to work with until you can steal new ones.

I understand the complaint about "cosmetic lsb" but imagine your basic alcohol/assault/mvc/fall with "neck pain". Is the patient true trauma criteria? Heck no. But with "neck pain" and a simple MOI you try bringing that patient to a University Trauma center and not get strange looks.

Work 2 ten hour days, (08-1800) then 2 fourteen hour nights (1800-0800). My unit is in the downtown section of the city and we typically to 8-10 calls during the day and 14-18 calls at night. No sleep, no safety naps. 24 hour or double shifts are not permitted.

There is a big difference between a BLS unit taking an ETOH patient and not waiting for ALS and a medic letting his B partner doc the call/turf to bls.

normocephalic

adjective

1. having a normal sized head; neither macrocephalic nor microcephalic

2. having a normal shaped head; mesocephalic

HPI: Arrived to find a

ABC:Airway patent, no respiratory distress, radial strong and regular

HEENT:Eyes perrl, trachea midline, no JVD

Neuro: GCS of 15, A0x4

Chest:Equal Bilateral expansion, no pain stated

Lungs:Clear and Equal Bilaterally

Skin:Pink, Warm and Dry

Abd:No Nausea, No Vomiting, No Distention, No Guarding

Pelvis:No Pain stated

Spine: no pain stated

extremities: purposeful movements

vitals:

tx:

dispo:patient transported to and placed in room with report given to at aprox and care transferred without incident.

this is my template for most patients, obviously changed as needed.

Just a highlight of some pretty big additions and changes to the PA Protocols....

-Lido prior to med admin via an IO

-Post ROSC, orders for "cold nss bolus"

Ativan dosage reduced to max dosage of 4mg

Benadryl dosage back up to 50mg

CPAP for BLS, CPAP required for ALS by July 09

CHF...lasix with medical command only

Captopril/Enalopril with medical command

Nitro via Infusion

Fentanyl can be "IN" for extremity trauma

Glucagon can be "IN" for diabetic patients

"Crush Syndrome" Protocol

Benzo included in the Nausea/Vomiting Protocol under "Dizziness" for Adults

Ocular Tetracaine for Absorbed toxin

Revision of the Level II Trauma Criteria

Air Medical Use for Non-Trauama/Medical Patients...CVA/STEMI

http://www.dsf.health.state.pa.us/health/c...70&Q=231878 -pa doh website for more info

thoughts? comments?

Most systems can't afford to have a EMS based "refuse transport" protocol. Take for example this morning I transported a 30's male with a laceration to this finger, presented to us with the bleeding controlled with bandages and only needing a ride. He had insurance and would likely pay the bill for service. So if we were to refuse transportation we would not only miss making money, but lose money for generating a response with no income.

As much as we don't like things we need to look at them through the $ sometimes to.

Also don't forget most people don't have primary care and the ER is there source for medical care. As well as the fact that everyone knows that if "the cat gets out of the bag" and they call 911 somebody will show up and likely solve the problem for them. Basically the biggest and most successful government program ever put together, and in systems where 'call screening' from what seemed like 'minor' calls have only turned into major litigation nightmares.

This is a constant debate, its not an issue of "if" the EMT can do the skill its if there is a strong education background for the provider to understand why. The national standard calls for paramedic education to be a degree based/2 or more year length program but we continue to rush through providers from nothing, bls, to medic as quick as possible.

I support a very basic BLS level, no nitro, no asa, no medications unless assisted medications. 80% of calls are BLS and require little of any care and the basic level is probably the most important level there is.

We have protocol for IN Narcan in Pa and the rumor is will soon have a protocol for IN Glucagon. There was a recent publication (JEMS?) that covered the myriad of medications that can be given IN. So in other wards there is no excuse why EMS isn't catching onto this trend.

Ideal practice is to bare the arm and take your first pressure manually. Obviously NIBP shouldn't be trusted with artifact from the road, etc.

Remember 99% of patients will down right strip and get into a gown if we wanted to do so. So take a little effort and make sure you have the arm exposed, cut cloths if necessary.

Ya'll are missing the point. Dynamic deployment means that units are out at specific posts and not tied down at a station during the shift. Having those units out on the road, ideally closer to expected call demand cuts down response time. It also cuts down on "out of chute" time that can be two or more min's coming out of a station.

Lets go back to the heart of the issue, are we willing to cut costs and save fuel at the risk of delaying response times?

It all breaks down to...in a busy something it can happen. Was it right? Probably not but we all know that there are times that you listen to the radio and hear unit after unit go out and know that if the rush doesn't stop we could all see something like this happen.

In the area I work once you go "transport complete" a in county hospital that hospital is considered a location on the box cards that you can be dispatched from. Often times the dispatchers check to see if your ready to take the next call, but its not impossible that a southern unit transporting to a central hospital gets dispatched north, and before you know it miles and miles from its local.

I know FDNY doesn't have set locations for stations but we all know that when volume gets as bad as that sounded then logic should dictate units relocate to cover areas from central locations.

Give me one good reason why Hospitals in NJ should have a monopoly on ALS units when patients are dying on the streets because of the shortage of medics.

Better control of the quality of care and providers.

Take for example the county I work in. X County has aprox 25 separate ALS services that are independent squads separate from the hospital, fire dept, township, etc.

There are 25 chief's, 25 medical directors, and a numerous amount of Paramedics that work in the county. While the county is also a Region that has overall control and reports to the state its still basically every kingdom for its own. You have Paramedics that work for 2,3,4, etc services and easily work up to 72 hours or more strait going from one department to another. Some do it for the love of the job, most though to make enough to get by. None of which is at all healthy!

Now if this was a County Based service, be it hospital based, county controlled or whatever you would solve a lot of problems.

-Central Purchasing for Supplies and Units

-Units Staged/Staffing Levels based on demand and not a static system based on 20yrs of "this is how we have always done it"

-Increased pay for EMT's/Medics because a central service could have better funding and many other reasons

-Better control over work loads of the staff: A medic couldn't get away working 72 hours when it was one service, overtime may not decrease but you could control things better.

NJ may not be perfect but don't blame the hospitals.