NWFDMedic

I wish I would have read this thread 2 days ago. I just threw out the statistics on the large scale "selective spinal immobilization" protocol. From memory, the bounds of the study were as follows: (1) the patient must not complain of neck or back pain on palpation, (2) the patient must be conscious, alert, and oriented, (3) there must not be a distracting injury, (4) I forget the fourth criterion, but I vaguely seem to remember something about penetrating trauma. EMT's and paramedics were allowed to board any patient based on their judgment of the mechanism, regardless of whether the patient ruled into these criteria if I'm not mistaken, which may skew results a bit because the skill level of providers does vary. The bottom line was in something like 20,000 cases, only 1 patient was not immobilized who was later found to have an unstable cervical fracture. That would be 0.005% of the cases and I believe the footnote said that this case was even not noted on the initial x-ray in the hospital, but don't quote me on that. There were also a handful of patients that were not immobilized who had stable cervical fractures, ones that apparently pose little risk of being worsened by lack of immobilization. The last I heard about selective spinal immobilization was that it was in front of SEMAC and they were hammering out the particulars of a protocol that the lot of doctors could agree upon.

Wow, I've heard some of these stories before, but I never knew it was as bad out there as you guys are saying. I'm lucky enough to work for an agency that has stations for the crews, some more fancy than others, but they all provide shelter. From time to time, the system requires that we post, but it's rarely for a long period. I guess I shouldn't complain when I don't have cable in a station after reading about what of some of y'all are going through. Anyway, my little comment was supposed to be on system status management. I know we don't do SSM as the book says it should be done in my area, but it seems to work pretty well. We put the trucks where the people are and in the primary contracted areas. I would imagine that every service does it that way. Of course it doesn't always work... it seems that sometimes as soon as you move a truck back to a population center, a call will drop in the area from which it just left, of course in the most outlying of outlying areas.

I was reading this article and I couldn't help but think that a 500 lb. patient shouldn't require such an elaborate setup. Then again, I wasn't there, I don't know the condition of the stairs, the apartment, etc. The agency I work for provides bariatric services with 5 of our larger ambulances equipped with Ferno stretchers with LBS (large body surface) add-ons. I've had relative success moving patients on these stretchers at weights in excess of 600 lbs. We don't have any specialized lift gates or anything on the ambulance, so getting the stretcher into the ambulance is still a manual task, but many hands make (relatively) light work. The only issue I have with bariatric transports is that we are getting more and more of them and as a profession we really don't have any training in lifting and moving bariatric patients other than what we had in EMT class. I've found that when you get to the scene of these calls, improvisation seems to be the normal mode of operation. You have to stand back, assess the situation, and figure out a way to complete the task at hand. Maybe it's time that we start looking at some of these various improvisation techniques, refining them, and coming up with some tips, training and guidelines for moving bariatric patients. The good news... good EMS providers are usually good at improvising.

You've got to love New York State, only a few years behind the times. It's not all Westchester's fault, getting protocols through SEMAC is apparently not the easiest thing in the world. I'm surprised that diltiazem is now a standing order without any apparent restrictions. I've had several doctors that would rather evaluate a stable patient in a rapid A-Fib than have them treated in the field. (Unless of course, the fact that it's under "SVT" means that the rate would have to be 150 or greater to give the diltiazem under standing orders.) The other thing that surprises me is the lack of proofreading. There are a few spelling errors and this one that caught my eye: "UNSTABLE denotes no signs or symptoms of POOR PERFUSION, including acute altered mental status, ongoing chest pain, hypotension or other signs of shock." If that's true, apparently I'm unstable right now (my altered mental status is far from acute).

There is no advantage in time for placing a Combitube versus an endotracheal tube, so I really don't get your argument here. The equipment takes longer to assemble and the same time to insert/inflate. There are obviously cases where the ETT is necessary and the Combitube is inappropriate, so why would you even think of using a Combitube on an "uncomplicated cardiac arrest"? There are three things that generally make a provider better with his ET intubations. The first is technique. If you don't have that, you need practice. The second is experience. The third is confidence, which usually comes as a result of good technique and experience. I don't ever want to see the day where we're placing Combitubes in cardiac arrests without attempting an ETT, because we'll be losing the techniques, skills, and confidence that medics require when you get that really tough tube on an anaphylactic patient. (Of course, you shouldn't be spending time trying to get a tube that is that difficult when you have alternate methods.) As far as time is concerned, where do you get the idea that seconds count in an uncomplicated cardiac arrest? By the time you get to inserting an ETT, you should have already applied whatever electrical treatment is necessary, and the patient should already be oxygenated and circulating to the best of our CPR ability. The tube (or any advanced airway) is more of a luxury and convenience than anything else, it's not a lifesaving tool in cardiac arrests.

Agreed with the "proceed with caution" and "expedite". I have lobbied to have an expedite button put into all of my ambulances, but it has yet to happen. There are 2 modes, emergency and non-emergency. In both modes, you should be proceeding with caution. As far as the law, I hope I can quote it to you guys exactly. It "should" be in my files from a law and the fire service seminar I went to that was taught by a fire department lawyer type guy. If I tried looking through books of Town Law, I might be able to get you an answer by the year 2050.

Actually, it is not incorrect, and it is not the origin of all fires law. The fire chief is responsible for the safety of all property upon dispatch to the location. It is the fire chief's responsibility to make sure the property is safe before it's turned back over to the property owner. If the fire chief illicits a cancellation from a police officer relating a false alarm and 2 hours later the building burns down because of a fire in the walls that was not investigated and kills 3 people, you can bet for sure that the fire chief and fire district are going to be found liable.

Hey, if you really want to cringe, there are agencies in both counties that I work in that will respond code 3 even if the call is EMD'd to a code 1 response. Every call gets lights and sirens. I can understand at times where you may be familiar with the patient and have reason to believe the call may be more severe, but I would be calling dispatch and telling them that I am going to respond code 3 based on past history and the possibility of the call being a true emergency.

I can answer this easily and most people won't like the answer. If you negligently cause an accident, then you are liable regardless. If you acted with due regard and it can be shown that you did, but still get in an accident, your liability will be increased if you are not responding to a "true emergency". A true emergency would be one that you have reason to believe that there is a significant risk to life and property. If you are told that you can 'cancel', you should be responding code 1 because there is very little chance of an imminent risk to life and property that could be mitigated by your code 3 response.

I can get you the exact wording next time I'm in my chief's office, but the long and short of it is that the fire chief is responsible for the property that the fire department is dispatched to upon dispatch. It is the responsibility of the fire chief to insure that the property is safe before it is turned back over to the property owner.

Why would the FD get called back to this? The tow company is there, shouldn't the spill be their problem?

Should a Police Officer/Police Dispatcher cancel a responding Ambulance or Fire Apparatus to the scene of a call if he/she feels they are not needed? No and by state law the police officer cannot cancel responding fire apparatus. In obvious cases, (ie. an MVA dispatched that turns out to be a disabled vehicle) the police can advise the responding units and allow them to decide at their discretion. Should a Fire Chief who is responding and not yet on scene cancel responding units to a report of a structure fire,smoke in a structure, car fire, car accident, etc if notified by dispatcher the alarm has been downgraded? (i.e. reported structure fire extinguished by the homeowner) This should NEVER happen. I have no problem slowing units to code 1 or continuing the first engine and manning other apparatus in quarters, but as a fire chief you are just plain stupid to take the dispatcher's information without seeing it. How many times have we heard of trained firefighters putting out a fire and finding out that it wasn't out and you are going to trust the word of a homeowner? Should a Fire Chief who is not a CFR, EMT, or Paramedic cancel Advanced Life Support? This should never happen, unless of course it's the false medical alarm type call. If there's a patient and it's dispatched ALS, it's ALS until a qualified medical professional says otherwise. I'll address my feelings about this in the next questions. Another question... Should an EMT cancel Advanced Life Support that has been dispatched to a call because they feel it's BLS? As EMT's we can however why not keep them coming in? The EMT cirriculum is designed to teach providers patient assessment that will identify apparent life threats. Good EMT's should have the assessment skills to decide if they are comfortable with a patient or not. Of course, if the paramedic is not comfortable with taking the cancellation based on dispatch information, he/she has the authority to continue in regardless of whether he/she is canceled. Any liability involved if you do cancel ALS that was dispatched and the patient condition goes bad? Why not CYA and let the Paramedic evaluate the patient if ALS is dispatched and responding? Actually the liability can rest with the EMT, the BLS service, the paramedic, and the ALS service. However, good assessment should protect you in most of these cases if you did what a "reasonable practitioner" would do. I'd reverse this question... why would you want to continue a paramedic on a call that is clearly BLS? There are not paramedics on every street corner and they don't need to be taken out of service for CLEARLY BLS patients. If it's borderline, by all means, keep them coming, but otherwise, put them back in service. Some agencies have a policy once a unit is on the road and responding you CANNOT cancel them. If an agency has that policy, I'd hate to be their lawyer when an unnecessary piece of apparatus gets in an accident and kills someone. If you don't need them, turn them back. GO GIANTS! - agreed!!!

Thanks for the site roofsopen. My department is doing a drill on ropes and knots Monday night and it will be something nice to add into the class.

Putnam Hospital is a stroke center as of June 01, 2007 per the HVREMAC website.

I believe at stroke centers, the ER doc is qualified to do the assessment for stroke thrombolytics. The only thing that needs to be done by a neurologist is confirmation of the CT scan, which is generally done by computer with a service that has 24 hour docs to read the scans. The one interesting thing I've noticed from the Westchester medics here is that their protocol seems to include large bore IV access. We still have some doctors up here that say that they don't want IV catheters bigger than a 20 ga. in patients that are candidates for thromoblytics. We all understand it is relatively inconsequential, but I have had a couple of doctors give me an attitude about starting 18's. Finally, I went to a CME last year and apparently a study was done that the CCS criteria will correctly identify a neurological insult (CVA or TIA) in 72% of the cases, assuming you rule out hypoglycemia (and I'd assume drug/alcohol influence). The Hudson Valley Region has a prehospital suspected stroke form that was supposed to be in all ALS rigs quite some time ago.

That 9 week thing is far from an aberration. I took on site for my original paramedic certification, but in the 4 times I've refreshed either my EMT or Paramedic, I've never received my results in less than 8 weeks and my last refresher results took almost 14 weeks. I just took the paramedic refresher in January; it will be interesting to see how long those results take (although if you're a paramedic taking a refresher and were given that test, you shouldn't be worried about it).

The last thing I want to do is bring a patient to a hospital that is on diversion. Not only is it bad for patient care, it is bad for my blood pressure when having to deal with facility staff that thinks diversion means that they are all of a sudden no longer a receiving hospital. My first comment about diversion is that it's very rare that a hospital in the Hudson Valley is actually legally allowed to go on diversion and they rarely do it properly anyway. Hospitals are not allowed to go on diversion because there aren't any beds upstairs. They also aren't allowed to do on diversion if there isn't another nearby appropriate hospital (unless of course the ER is on lockdown or potentially contaminated, etc.). They should really stop issuing diversions and start issuing "high volume alerts." With that being said, my job is to take the patient to either the closest appropriate facility or the facility of their choice if the patient condition allows. I will inform my patients that the hospital of their choice is on diversion if (1) I happen to know about it, (2) the patient's condition will allow me to take them to a further hospital, (3) the hospital on diversion is not the only appropriate hospital in the area (ie. Vassar for heart issues, Horton for suspected acute surgical cases at night, etc.). I will inform my patient what is going on and why it's going on and explain to them that another facility would be the best option for their prompt and acute care and they could arrange transfer later if necessary. I've actually had charge nurses come to me in some facilities and ask that we try to take patients to another local facility because of the high volume, but they weren't going on divert and I will do my best to help. Lately, I've taken quite a few patients to Putnam Hospital and we don't get informed that they are on diversion until we make a radio report to the facility. After I've driven from East Fishkill or further, informed the patient's family we would be going to Putnam, and now am within minutes of the hospital, they're getting the patient. I've had the same issue with HVHC transporting patients from the Highland Falls/Fort Montgomery area. I've also walked into a hospital or two that will have an empty ER with floor nurses handling the holds and the ER complains that we bring them a patient. Sorry, but there is NO reason that a patient cannot receive appropriate and acute ER care in that situation.

OK, I happen to agree with your point, but I don't agree with your "more holy than thou" attitude. Have you ever been to NYC on St. Patrick's Day and seen what idiots career firefighters make out of themselves in uniform? That's not just in bars, but in the streets in public and it isn't just the FDNY; it's several area department members that either parade or come down in uniform. As a volunteer fire officer, I would have an absolute fit if my department was involved in antics regarding alcohol and the fire apparatus after a parade. The guys drink after parades, which is fine, and I personally think that most in the public don't mind it so long as it's well policed. After all, these are the men and women that get out of bed to protect our communities; they deserve a couple days of fun (I know other areas have more parades, but we generally only have a couple per year in Orange County). However, there is a line. Alcohol on the vehicle or things that threaten the safety of our personnel and equipment would not be tolerated. If you think we let this happen and allow members to "go to the next fire or parade", you're wrong.

It's not really just semantics. Although eventually you may get some of the staff that you had, as of Feb. 1, you will have all new people unless they work for both companies. I would imagine the proposed merger is still 6 months to 18 months from completion. It makes good business sense for the NDP to take over these contracts because after the merger is complete, all contracts signed with Alamo will not be binding but contracts signed with NDP will continue to be in effect.

Great job with the trailer Doug and of course we all hope that it never has to be used. I don't work much in OCEMS now, but is there any plan of cooperation for different agencies providing different specialized equipment to regions? I know that on the fire side we have departments that house haz-mat trailers, all terrain vehicles, foam capabilities, cold water rescue, etc. and they are basically for use within the area. It's a cheaper way to provide service without undue duplication and it fosters cooperation between agencies. It's nice to see that some of the volunteer EMS services in the county are starting to progress toward interagency cooperation and communication. It's definitely been a long time coming and it had to be pretty tough to push cooperation from the grass roots. Nothing but good can come from this progress (even if I don't get to meet with your ambulance anymore ).

The EMT-I course is still around and I'd like to see it as a trial class for potential medic students. I took my EMT-I class in either 1997 or 1998, having 4 or 5 years as an EMT under my belt. I don't know if the class is taught similarly statewide, but my class was very intense and it taught a lot of the "why" behind the "what" that you learn in EMT class. I felt that the class was more valuable for the knowledge and assessment proficiency than the skills. If you don't like the EMT-I class, you probably shouldn't be thinking about medic school and wasting thousands of dollars. In the Hudson Valley Region, an EMT-I can only operate within a paramedic system. Loosely translated, the EMT-I can only operate independently if the paramedic resource is not available. I had a couple of instances in multiple patient situations where I was allowed to operate independently as an EMT-I, including a flight job in a remote area where the next paramedic ambulance was going to be forever and a day away. After I went to medic school, I joined a volunteer agency that was operating at the EMT-I level at the time with a mutual aid agreement from a commercial paramedic service. I found the EMT-I system to be more problematic than helpful, but that was largely due to the providers, not the system. When you give EMT-I's a few new tools, they like to use them, sometimes to a fault, causing delayed scene times with patients that needed an ER or a paramedic. I kept trying to stress that IV's don't save lives or improve patient condition, but we still had many providers that would sit on scene to get the stick. On the good side, I thought the volunteer agency had some of the best patient technicians in the area. Also, at the time, the volunteer agency did not bill, so if it was a patient that only needed an IV and monitoring into the hospital, you would still meet with the medic, but the paramedic service did not bill if they did not treat. I'm sure that made a lot of seniors in the community happy. So to end my long rant, I could really care less about the EMT-I skills. An IV isn't going to save a life and neither is an ET tube except in a few extreme cases. Where I think the state needs to move is toward the assessment level for an "ambulance attendant" to be at the current EMT-I level. Providers need to know a little bit more about patient care than an EMT class teaches if they are going to be entrusted with a patient's care to the hospital. The current EMT level is great for a first response agency, but I think the ambulance service needs something more. (I'm not knocking EMT's here, there are tons of EMT's out there that have the clinical experience and do a great job every day, but I don't think we prepare students in EMT class to go out there and assess treat patients.)

I heard through the grapevine that the bond referendum was defeated as well. It didn't really come as a surprise; a $6.8M renovation is quite expensive. I saw the price in the Journal last week and my jaw hit the ground. I've been in the Hughsonville firehouse and they definitely need an upgrade, but looking at my district building a new building and demolishing the old one for $4.9M, I'd think that HFD can find some more affordable options. Hopefully they can restructure the request and get a shovel into the ground soon.

Just arrived yesterday, New Windsor Fire Dept's new Rescue-Pumper R-445. It's not in service, stocked... heck the Commissioners haven't even accpeted yet. The pics were taken inside but I'll get some better ones once it's in service. It's a 2007 ALF Eagle Rescue-Pumper stocked with Holmatro extrication tools.

In a lot of places, it's a volunteer v. career and a union v. non-union issue. However, people need to get past that issue and do what's right for the service as a whole. If you need career staff coverage at your house, they deserve the proper training and benefits afforded to a career firefighter. They also deserve appropriate compensation. The same issue happens in EMS but it's worse... and don't get me started on that. It's my #1 pet peeve.

You can't be more correct. Even if the fire company owns the firehouse, it is/was undoubtedly paid for by contributions of your community. They have entrusted you with a building you can call your own, but with that there is also the expectation that the company will conduct itself properly and provide the service. As far as alcohol is concerned, I've been on both sides of the fence. I was in a department when my grandfather was president and he had to ban alcohol from the house because it was being abused. Fortunately, we aren't having those problems in my current department. Hopefully this will continue into our new building... if everyone conducts themselves as adults, there never becomes an issue.