JJB531

In other parts of the country, prehospital use of induced hypothermia is routinely used by paramedics working in progressive systems. White Plains ER successfully used it in the recent past to resuscitate a cardiac arrest with very positive results.

I think that the point system is beneficial to the forum. It encourages members to contribute positive, constructive posts. It also encourages some members to put a little more thought into their posts, and these posts should be recognized by other members of the forum. So far, the majority of the posts I have seen with positive rep points have been excellent posts, and well deserved by the poster. The benefit I see to the negative rep point is it might keep certain posters "at bay" so to speak from posting certain things in the forum that could be construed at utterly ridiculous. I haven't seen too many negative rep points given out. I have been on the receiving end of a negative rep point for two of my posts, one which I can understand, but the other I felt wasn't necessarily warranted because my post was not in any way "ridiculous", but instead quite factual. But am I going to lose sleep over it? No, I have more important things to worry about in my life. Perhaps the EMTBravo group can somehow design the negative rep point so in order for someone to give a negative rep point, the rater has to #1) Identify themselves, and #2) Describe why the negative rep point was issued to the member.

Although this is a discussion for a different thread, if someone wants to RMA and is of sound mind and judgement, they have every right to, regardless of the condition they present with to the EMS provider. As an EMS provider, you can not force an individual to seek medical care unless you can document that the individual was not of sound mind (at a minimum alert and oriented to person, place, and time) and therefore incapable of refusing medical care (i.e. altered mental status). Obviously attempts should be made to convince an individual to seek medical attention, and that includes contacting medical control and allowing the ER physician to speak to the patient to convince them to seek treatment at the ED. Documentation is more important with RMA's then any other PCR an EMS provider will ever write. Important points that you should always document on your PCR: 1) That you advised the individual the consequences to refusing medical care, including the possibility of death 2) That Dr. (insert name) from (hospital facility) spoke with the patient in an attempt to convince patient to allow treatment 3) That you informed the patient to call 911 in the event their condition worsens or they change their mind and do wish to seek treatment 4) At a minimum, the patient should follow-up with their private physician or seek other means of transportation to the ED if they do not with to be transported by EMS. 5) Document anyone else (family members, clergy, coworkers, family, police, fire, etc.) who attempted to convince the patient to seek tranport/treatment. 6) After all of the above measures were attempted, the patient still refused treatment/transport despite fully understanding the consequences to the RMA.

No worries and no hard feelings... I was not making a reference as to the curriculum teaching all EMT's to give Aspirin to every single chest pain. I was offering two real life scenarios where EMT's hear the words chest pain and right away they shove aspirin in someone's mouth, or they hear altered mental status and are shoving globs of insta-glucose down someones throat. Instead of having a good knowledge base and good clinical judgement skills, they hear the words "chest pain" or "altered mental status" and that's all that registers in their minds. When I was teaching EMT/Paramedic students, a few of the EMT instructors always taught their students to "play it safe". Is there anything wrong with playing it safe? No, not at all. But after a while it gets a little out of hand with certain scenarios, and EMT's (and even Paramedics alike), don't do a detailed assessment and obtain a good history of the illness, and instead just follow through with protocol to "play it safe", even if certain interventions are not warranted or indicated. It's like using spinal immobilization on someone who tripped and fell on a sidewalk, and who has absolutely not the slighest indication of a spinal injury. Why do we do it... well usually just to "play it safe". I think the simple parts of the problem are: 1) Not enough time is spent dealing with real patients who present with a chief complaint, and learning how to differentiate and/or make a field diagnosis of the illness in order to provide the correct and proper treatment. 2) Too many EMS providers are cookbook providers. They follow the protocol from A to Z without utilizing good diagnostic and clinical judgement skills. You can chalk up some of this to inexperience, but when I come across providers who have been through 2 or 3 refreshers in their time and are still following the "recipes" we talked about here without performing a good, solid patient assessment, who do we blame them for their skills as a provider? 3) The curriculum has definetly been dumbed down considerably. As long as an EMT student can run through a very basic patient assessment scenario without getting nabbed for a critical failure for something like not using BSI, most students will pass the patient assessment scenario without any real knowledge of how to actually perform a patient assessment. Now in the field, I see EMT's performing this basic "cookbook" patient assessment on every patient they come across. Why is it that I still see EMT's checking pupillary response on a cardiac chest pain? Because that's what they learned and has been forced into their heads in patient assessment. I would rather see EMT students take the time to learn how to perform vectored patient assessments, where they are actually learning how to assess patient who present with certain disease processes. Check for pupillary response on patients who may present with neurological conditions (AMS, stroke, head injury, etc.), not someone complaining of chest pain.

Thanks goose, I'm still trying to figure it out myself.

I think you need to double check my post instead of my recipes. I offered two real life scenarios where emt's performed interventions based on a chief complaint and not on physical assessment. I didn't make these scenarios up, they are actual encounters i have had as well as the responses I received from the emt treating the patient.

I think the problem with new EMT's who are insufficiently prepared for EMS lies with the EMT curriculum and not so much instructors pushing students through the program. I don't believe there is enough emphasis placed on field training/rotation hours spent actually working on an ambulance encountering real patients. Role playing in a classroom or performing skills on a mannequin is a good start, but you truly learn "the job" by encountering real life situations, treating real life patients, and overcoming real life problems that may come up on "routine" calls. Of course, then there are inherent problems with field training, such as finding a qualified EMT/Paramedic to act as a FTO. With the high turnover rates in EMS systems, finding experienced, competent providers can be a challenge all in its own. The other problem with the cirriculum is that it's too cookbook. EMT's are not taught to think, they are taught a cookbook form of medicine which doesn't fly in real life scenarios because nothing is routine, and each call presents its own unique set of circumstances. Two real life examples I can think of: #1) EMT responds to a reported chest pain. EMT arrives on scene and finds a patient complaining of chest pain. Patient states they fell a week ago and has been having chest pain ever since. EMT administers aspirin because, well in EMT class, they are taught chest pain=aspirin. Would be correct if we were talking suspected cardiac chest pain, which this is not. #2) EMT responds to an unresponsive. Arrives and finds an unresponsive male in front yard of house. Patient was installing roof shingles in the middle of July while downing a couple beers. You can cook a steak on the patients body, but in EMT school, we learned that unresponsive=oral glucose. EMT is seen shoving tubes of oral glucose down the patients throat. The reason as it was relayed to me, he's unresponsive and we're taught to give oral glucose to unresponsive patients (which is incorrect all in its own, but that's for a different discussion). Two examples of cookbook medicine at its finest. Hopefully a CIC can correct me if I'm wrong, but I believe the EMT programs do receive money from the State based on the number of graduates from their programs... I'm not sure how much of that money goes directly into a CIC's pocket though. I know when I was teaching as a CLI, my pay, as well as the CIC, was based on the training institutions pay scale, not based on how many students we graduated.

What about a Street Smarts course for EMS providers? A couple sample topics: Drug Recognition Dealing with Emotionally Disturbed Persons Violent Encounters/Basic Self Defense Crime Scene Awareness Scene Safety Make it interactive/hands on. More of a scenario based training experience in addition to classroom lecture.

I stand corrected, I was under the assumption that it was a traumatic arrest they were working... either way, great job overcoming the conditions they were faced with.

I would assume if the Paramedic can articulate why the decision was made to transport a critical patient in a vehicle other then a DOH certified ambulance, I don't see a huge problem with this. I transported a patient one time in the back of a Mt. Pleasant PD Tahoe. When asked why I articulated my reasons and it was a non-issue. As long as it is done for the right reasons and/or under extingent circumstances, I don't think anyone would go after any EMS provider for doing so. In this case an individual in traumatic cardiac arrest needs an operating room and nothing else. If the paramedic can articulate that the delay in Ambulances response was due to the scene being inaccessible to the responding ambulance and waiting on scene would have meant another 10 minute delay, the decision to transport in another vehicle was made with the patients best interests in mind. Sometimes you have to adapt and overcome when certain situations present themselves, and as long as it is done in good faith, I don't see a problem with it.

This was all I could find right now regarding the IC of Highway Incidents... this statute deals with hazardous material incidents on the California highways. CALIFORNIA CODES VEHICLE CODE SECTION 2450-2454 2454. (a) The authority for incident command at the scene of an on-highway hazardous substance incident is vested in the appropriate law enforcement agency having primary traffic investigative authority on the highway where the incident occurs. Responsibility for incident command at the scene of an on-highway hazardous substance incident shall continue until all emergency operations at the scene have been completed and order has been restored. ( Notwithstanding subdivision (a), the local governing body of a city, whether general law or chartered, which has jurisdiction over the location where an on-highway hazardous substance incident occurs may assign the authority for incident command at the scene of an on-highway hazardous substance incident on local streets and roads, other than freeways, to either the local law enforcement agency or the local fire protection agency. However, the department is responsible for incident command at the scene of an on-highway hazardous substance incident on all highways where the department has primary traffic investigative authority. Any law enforcement agency having primary traffic investigative authority may enter into written agreements with other public agencies to facilitate incident command at the scene of an on-highway hazardous substance incident on local streets and roads other than freeways. © For purposes of this section, "incident command at the scene of an on-highway hazardous substance incident" means coordination of operations which occur at the location of a hazardous substance incident. This coordinating function does not include how the specialized functions provided by the various other responding agencies are to be performed. The incident commander at the scene of an on-highway hazardous substance incident shall consult with other response agencies at the scene to ensure that all appropriate resources are properly utilized, and shall perform his or her coordinating function in a manner designed to minimize the risk of death or injury to other persons.

Not for nothing, but at both of my jobs there are always situations on a daily basis where Supervisors with less time and experience than other field personnel are the Incident Commander of a scene. We have 20+ year police officers answering to and taking orders from 5 year sergeants and 8 year lieutenants or paramedics with 15 years experience answering to and taking orders from a Paramedic Supervisor with 2 years experience. So I don't see how you find it so unbelieveable that a junior, possibly inexperienced individual could be the IC of an incident, when it's a common daily occurrence? Secondly I think CHP Officers are more then capable of handling accident scenes without compromising scene safety. They patrol the highways every day, they handle considerable more highway incidents then the FD does, they handle far more accidents on the highway then the FD does, since every accident does not require FD response, and they conduct traffic stops multiple times a day on the highway, so I think that they are more then capable of operating on a highway.

1) I don't think the law regarding CHP makes them the Incident Commander... I believe CHP Officers have authority over a Fire Chief regarding traffic control and other issues related to closing lanes on the highway. Since CHP doesn't have authority over direct firematic operations, this really isn't a chain of command scenario, more of a scenario of an individual (unfortunately a Fire Officer) disobeying a lawful order by a uniformed police officer. Should this scenario been handled differently, absolutely. Police Officers (especially Highway Patrol Officers) like to keep the flow of traffic moving and try to keep a lane or lanes of traffic shut down for a minimal period of time and are often subject to stress from the higher-ups to do so. 2) Once again, I don't think that the law states the CHP is necessarily the Incident Commander, therefore they don't need training in fire suppression or hazmat operations. I believe that the CHP is in charge of the overall scene at highway incidents in regards to lane closures and traffic management, not direct fire suppression or firematic operations at an incident.

My link Interesting to see Westchester County is ranked #5 only because the median income is higher then the top 4, so the ranking is based on the "Taxes as a % of Income". When you look closer, Westchester County actually has the highest median property taxes paid on homes.

Why not speak to some active paramedics working fly car systems in Westchester County. Most will be more then happy to tell you plenty of specific instances where they have had to wait an extended period of time for an ambulance to arrive on scene. I refuse to "shout out" specific agencies here in a public forum, nor do I think anyone should "shout out" publicly a specific agency to satisfy your request. Without naming the agency, just last night I had to wait almost a half hour for an ambulance, on a Saturday night, when everyone is supposedly home. How does that happen? First, it was a BLS level call. No big deal, I like BLS calls, less work for me to do! While I'm stuck on scene waiting for an ambulance, another request came in for a neighboring jurisdiction which I am responsible for to respond to an ALS level call. Sorry, but I was unavailable to respond because I can't abandon a patient once I initiate care. Had an ambulance been on scene, I would have been available to respond. So now the second paramedic working had to respond mutual aid to the second call and was no longer available to respond within his primary area of response. The second ambulance then had to respond mutual aid to the call that I was tied up on, so now an entire town is without EMS coverage because one agency couldn't get a crew together for a call in their district. It's basically a snowball effect that affects more then just the patient laying on the floor waiting for an ambulance. Based on the patients condition as a result of an old injury, there was really not much that I can do in the prehospital setting other then transport the patient to the hospital for diagnostic and continuing medical care. One problem, need an ambulance to transport. So now I'm left doing a song and dance in front of the family asking when I plan to pick up their family member off the floor. While I refuse to intentionally "bash" an agency to a patients family, I have to be honest with them and tell them that an ambulance is coming from further away then their own town because their ambulance is "unavailable" to respond. Fortunately this was in fact a BLS level call. Although the patient was in significant discomfort, by no means was he in need of any immediate life-saving interventions. That doesn't make it acceptable though. My simple BLS call could have been a train wreck medical patient who required aggressive prehospital medical treatment and rapid transport to an emergency department. What happens then? This is not a "once-in-a-while" occurence in Westchester. It happens more frequently then most people think. And with most systems, they go through months of horrendous service, and then begin to improve when they get new membership, more EMT's, etc., and then cycle back to horrendous service when they start having manpower issues again. The only way to solve the manpower issue is to hire per-diem or full-time EMT's to staff ambulances in the event the volunteers are unavailable. Harrison did it, and they have a functioning system. Port Chester/Rye/Rye Brook did it, and they have a functioning system. Ossining did it, and they have a functioning system. A lot of places have recognized the problems inherent within their own agencies and taken the appropriate steps to correct it. Unfortuantely, a lot of other places are merely hanging on by a small handful of active members, but what happens when those members move onto bigger and better things? If you would like specific agencies and occasions where I have had to wait upwards of 45 minutes to an hour for an ambulance, please feel free to PM me and I will be more then willing to provide you with the specific information you have requested.

So, because of a social event, Mohegan (and I say Mohegan only because that was the agency mentioned) has acknowledged that they will be unable to cover EMERGENCY calls within their jurisdiction, and has depleted another agency of both fire protection and EMS coverage. Personally, I don't see how this is beneficial? Perhaps a better course of action would have been to have this event within their jurisdiction (if that is possible, depending on the type of event I guess) so they can roster a sober crew (if alcohol is being served at this event) to man their first due fire apparatus (I guess, I don't know the first thing about fire department operations) and their first due ambulance. If the event is outside of their jurisdiction, unfortunately some members should be rostered to cover their first due fire apparatus and ambulance, instead of attending the event. Which takes priority, the social event or providing fire protection and EMS coverage for the residents of our respective districts?

http://www.nypost.co...kvqwCo6INdiSjSP

Great post Remember, and you're right, it is getting to a point where a lot of us don't want to bite our lips anymore because over the years, while we have seen minor improvements, overall the system is still extremely flawed. I know that certain volunteers commenting in this thread are up in arms over certain comments that myself or others have made, but it is the unfortunate truth. Alot of us speak from experience, and nothing that any of us say is meant to be solely anti-volunteer because there are plenty of problems inherent in paid agencies as well. But as I have said before, and I'll say again, it is the system (or lack thereof) as a whole that is flawed. The lack of coordination, lack of available training, lack of equipment, lack of uniformity amongst agencies, lack of information disseminated to providers, lack of interest by providers to further their training/knowledge/capabilities, lack of interest from political figures to improve EMS within their communities or at the county level. The list goes on and on. It's unfortunate because Westchester has the potential to be a model system. There are some very talented prehospital medical providers working and/or volunteering in Westchester, and alot of individuals who have a lot to offer EMS. Unfortunately until we get away from the concept of this town is my kingdom and I am "el Capitan" of the Ambulance so don't step on my turf without permission, things here will never change. We also have to lose the "good ole boys" club of EMS who may or may not have their own agendas which are not doing much to improve the system as a whole.

Having bad experiences like waiting 45 minutes for ambulances here in Westchester is 100% avoidable outside of extingent circumstances. Even one situation where a patient has to wait 45 minutes for an ambulance, once again, outside of extingent circumstances, is completely unacceptable here in Westchester.

I've been involved in plenty of disastrous EMS situations right here in Westchester. Waiting 45 minutes for an ambulance when I can see the EMS building from the patients house. Waiting until the dispatching agency was 3 or 4 agencies down in the mutual aid list before an ambulance would respond. Showing up at the scene of a reported pin job to find that everyone ran to the fire engines and rescues and no one bothered to staff the ambulance, and then having to wait for a mutual aid ambulance. Ask any paramedic who has worked a fly car system in Westchester and the overwhelming majority will have disaster stories for you about waiting on scene for an ambulance. You can't compare Westchester County with certain areas upstate, where you have significantly more rural communities where response times are extended simply because of the geographical layout of these areas. What type of area are you referring upstate? Once you have experienced different EMS systems systems here in Westchester over 10 years or so, then you will understand that EMS in Westchester can be just as bad as your experiences upstate at school.

Some agencies are doing things to make the system work within their own community. Some agencies are supplementing personnel with per-diem EMT's such as Hawthorne and Valhalla. Some agencies are establishing tax districts and hiring full time EMT's and Paramedics, such as Ossining. The only reason the system works countywide though is because we have been able to adapt to the fact that there is no real countywide system. Things may work fine at certain local levels, but overall the "system" is non-existent countywide with the exception of countywide unit designations. A lack country-wide... in certain areas, yes, there is lack, but overall other parts of the country are considerably more advanced when it comes to prehospital emergency medical care and EMS systems when you compare them to the Northeast, especially here in the NY Metro area.

At no point did I say it matters whether the provider receives a check or not. It's easy to say whatever it takes to get the patient the care he/she needs and get them to the hospital, but it has to be said with some level of accountability or performance standards for EMS agencies (volunteer and career), which there currently is a lack of in Westchester.

There are so many vollie agencies in Westchester County because EMS is still a very young field when compared to Law Enforcement and the Fire Service, and paid services were obselete for a very long time in Westchester. EMS still is not a priority to a lot a communities in Westchester. As long as an ambulance shows up from somewhere, I personally don't believe that the politicians in a lot of these towns and villages really care how their own EMS system is doing. Especially now that the whole county has ALS level service available, any agency can look good in the eyes of the public when a paramedic unit arrives on scene before an ambulance and initiates care.

I don't think anyone is second guessing the officers involved in this incident or their professionalism, nor should anyone because without being there we don't know what transpired. But unforunately this incident, as well as the New Rochelle incident does send the wrong message to the general public. When police involved shooting incidents occur, I frequently see questions being asked by people along the lines of, "Why couldnt they shoot the gun out of his hand?", "Why didn't they just shoot him in the leg?", and now, "Why didn't they just Taser him?". Unfortunately, when it comes to force-on-force encounters, the general public only knows what they see in Hollywood and the occasional reality TV show such as Cops. Obviously, if true police officers possessed the skills of Steven Seagal, Sylvester Stallone, or any one of the many "action hero" police officers in Hollywood, all we'd have to do is look at criminals and they would surrender. And reality shows such as Cops rarely show force-on-force encounters which result in the use of deadly physical force. In fact, I can only recall one episode where a police officer in Massachusetts shot a perp who charged him with a knife in the middle of the roadway. The problem with applying a less lethal option against an armed adversary who has threatened deadly physical force is that it looks all great in the paper and in the eyes of the public, but what about the next Police Officer who appropriately applies deadly physical force to an armed adversary? Members of the general public, especially critics of Law Enforcement, as well as the media, will drag that Police Officer through the mud, questioning why he/she couldn't just disarm the perpetrator. Law Enforcement today has become more concerned with looking good in the eyes of the public and critics of Law Enforcement tactics, which in turn is jeopardizing the lives of Police Officers, as well as the reputation of certain Police Officers who use appropriate tactics and follow the use-of-force continuum. With that being said, the Officers involved in this incident should be applauded because they did do a great job. They were able to disarm and apprehend an armed subject without injury to themselves or any members of the public. Remember, it was our fantastic current Governor who, prior to being Governor, introduced a bill that would have forced Police Officers to "shoot to wound".

http://www.ignatius-piazza-front-sight.com/2010/01/18/ignatius-piazza-stop-screaming-start-shooting/#video The video link was taken from a dashcam from a Deputy's patrol vehicle in Georgia. I'm sure a lot of you have already seen this video, and it has unfortunately become a popular training video for law enforcement. It is perfect proof that the threat of deadly physical force needs to be matched with the same, not a less lethal option.