mfkap

Another site of interest for hybrid ops is from GM, they have a guide for cutting up some of their hybrids. Very interesting, and gives some information on cutting hybrids that I think would carry over to all makes and models. http://www.gmstc.com/courses/available_courses.asp

Do you have a source or two for this? As I was taught, part of doing correct CPR is allowing the heart time to refill. Creating a vacuum would not work without pumping the heart, because the blood would stop at the capillary level, wouldn't it? I don't see how creating a vacuum works in a closed system, only an open system. Also, your coronary arteries come off of the aorta directly above the aortic valve. If you were creating a vacuum downstream of the heart, then there would be no pressure (or even negative pressure) into the coronary arteries, and you would have a dead heart, no? I might be wrong on this, but I have not heard of this before. Perhaps you are referring to the vacuum created on the right side of the heart? That vacuum is being created by the left side pumping and the pulmonary valve not allowing backflow. However, if your pumping wasn't ejecting blood from the left side of the heart, you would have no vacuum created. I am not sure if this is correct. If you are doing CPR on someone, and the blood is circulating, their O2 levels in the lungs will drop below 16%. Hemoglobin has a high affinity for O2 at low O2 levels and can readily gain O2 at relatively low O2 partial pressure in the lungs. This isn't to say that there isn't sound science behind the decision to go compressions-only, I am just not sure that your facts are correct. I think that the hope is removing the mouth-to-mouth from CPR will help increase the amount of people who will be trained and act in an emergency, and they have proven that the loss of mouth-to-mouth is less significant if the chance of early compressions is increased.

There certainly is "soft billing", but your relative was not being soft billed. I know of certain agencies that set up a policy with their billing company to send a bill, and then send a reminder (for a total of 2 bills). There are no phone calls or collection agencies. However, there is an exception. Some insurance policies only pay the patient directly and then the patient is expected to pay the hospital and/or EMS themselves with that money. If the insurance company notifies the billing company that the patient was paid for the ambulance costs, our billing company goes after the insurance money from the patient. There are some frequent fliers that pay their rent by calling the ambulance once or twice a month, get paid by their insurance, and stiff the ambulance and keep the money. If you do that twice a month for a year, that adds up to a pretty penny.

When considering "expanded operations" for an EMS crew, training is an issue. Is it better for the patient if no one forces entry until the FD gets there, or an EMS crew who does it once a year does it, and does it wrong? In rescue I would think that the "late but correct" beats the "quick but wrong". Most FF's I know have forced a few dozen doors in training, and still quite a few aren't "experts". Now you are going to have an EMT and a driver, with little to no training, trying to force a door? What if they just mess up the frame and it makes it harder for the FD? What if they hurt themselves? What if they delay calling the FD because they think they can do it themselves? I mean, the FD would be mad if you called them and then popped the door before they got there, right? I miss the days when my bus carried a set of irons, and we could have used them on a few jobs since then, but we also are made up of 50% firefighters. I don't think I would want two of the non-firefighter EMT's trying to force a door with a set of irons.

That is true... I mean, the Democrats, had a sex scandal... not like those clean "I crap with a wide stance" Republicans. At least Spitzer was with a woman instead of the 12 year old boys that the Republican leadership has as their "core" audience. And we ALL know that the Republican mayor of NYC was very faithful... to his mistress. I can go on.. I have around 16 more Republican stories that happened in the last 10 years if you need em, like the Speaker of the House, etc. And I just because you start a sentence with "I don't want to offend anyone" it doesn't cancel out the offending you do immediately after. As a general rule in life, if you have to start a sentence with "I don't want to offend" then, if you actually do not want to offend, stop there.

Our VAC allows non-medical crew. They are there mainly to help carry, to gopher, and to drive the paramedic flycar when the paramedic rides along. For your questions: Yes, they are trained in how our stretcher operates, but are not left to move the patient alone No, if they take vitals that guide your treatment and they are incorrect, it is your a$$ on the line. We let EMT students take vitals, and if we are suspicious of them we can retake them. They gather non-medical info from the patients, such as name, address, etc. They sometimes write down things as the EMT interviews, such as past medical, meds, allergies, etc. You need to have BBP and CPR to ride. We also have a fairly in-depth training rotation set up, for them to learn how to operate the stretcher, stair chair, where things are in the bus, decon, etc. We do not require them to have any interest in advancing (this is something I personally disagree with). Currently, they can be a member for years and never join an EMT class or have any interest in the medical side of things. Duty Belts and badges, doesn't matter to me. They can waste their money on whatever they want. We provide every crew member, EMT, driver, or aide, with a badge. If they want to play Batman, go ahead. They sometimes do cause problems or overstep their limitations. I have found that it is usually the younger, newer members where this is a problem. Also, there are a few people that do not quite have the ability to (ever) pass the EMT-B class, and those people are usually disruptive on the call just because they are like a lost dog and require too much instruction to be helpful. Hope this helps.

I just want to state for the record that I am not a huge advocate of the Combitube, but more of a person who sees people operate with blinders on. I have personally seen time wasted by medics where a combitube could have done the trick. I have also seen more than 2 or 3 of the "tubes shifted" incidents, which I am sure everyone has. And I am not a paramedic, but a medical professional as well. I have a similar volume of training and experience when compared to a medic, and enough training to know what is right and wrong when being done by a paramedic. Now on to the questions: They aren't used in the hospital setting because it is not an ideal piece of equipment. It has its problems, mostly when left in for prolonged periods. Also, as a medic, I can guess you might tube someone once a week if I am being generous. Most code teams in a hospital have an anesthesiologist on it, and they do, conservatively, more tubes as a resident than a paramedic does in their career. If you are talking about the ER docs, doctors have ego's too. Oh, and some have the video laryngoscopes. As you say, you are a medical professional. And I am sure you have read the 3 peer-reviewed studies that indicate that epi has the same level if it is put in the lungs or the stomach, if the stomach dose is exactly 10x the lung dose. So I am not sure how the meds down the tube argument matters. And the timeline probably has to due with the second shot you take at putting in the ET tube vs. the combitube, as well as the time taken in placement of the ET tube. Again, I am not saying that combitubes are better. I am saying that putting in a combitube is considered "weak" and a poor performance, and this has more to do with ego than current medical research. If I am the person that is coding on the floor, and my arthritis makes it hard to see the chords, I would rather you spend 30 seconds getting a combitube in than 3 minutes with a medic trying to get the right angle for the ET tube.

There is a new breed of bariatric ambulance that is around. They have ramps and winches to load the stretcher up to 1300 lbs. (http://www.transaferamps.com/) and stretchers that can hold up to 1600lbs (http://www.stryker.com/en-us/products/PatientHandlingEMSandEvacuationEquipment/EmergencyCotsChairs/AmbulanceCots/MX-ProBariatricTransport/index.htm). I read something about NYC looking into it (http://publicsafety.com/article/article.jsp?id=4408&siteSection=7) but I don't know the outcome. I also heard that there were a few operating in Westchester, but am unsure where. As is obvious from the comments here, the "professionals" in Westchester don't feel that obese people are in fact human, and really we should just throw them out the window and laugh when they go splat. Maybe set up some pins at the bottom of the stairs and then go bowling. It is really disgusting to me that people who consider themselves professional, and in the business of helping people, would publicly post jokes and insult obese people, who call us in their time of need, when they need help the most. Hey, as long as you can feel better about yourself, because you aren't THAT fat. For the people involved in emergency services that care about their patients, and not just the in-shape, attractive, young ones, I have a question: Is there a paid service in Westchester that has a bariatric ambulance? Our agency was talking about this last night, and it would be great if we could get an agreement or information so if we have an extended extrication of a bariatric patient from a residence, we could have the bariatric ambulance respond from a distance for transport? It seems that most places don't have a plan, such as the PD scrambling for a moving van (which is ok, at least they tried and treated the person with respect for their condition) but I think that working on a plan would be a good idea. Maybe we can put our powers for good and actually put together a plan that can be distributed to agencies? Maybe get the county in on it? Actually HELP people who need help? Just a thought.

I wonder why you say that alternate airway devices don't top an ET tube? Aside from times when it is not indicated, the combitube has been proven to be statistically identical to the ET tube in blood O2 levels(1), and they have the advantage of being statically faster from start to O2 delivery(2), and have a higher success rate in placement(3). You also can avoid the problems of tubes moving, misplaced tubes, etc. Also, OPA and BVM has been shown to have much worse patient outcomes and lower blood O2 levels (1,2,3). Yet when I have seen a medic who can't get a tube, they don't reach for the combitube, they sit there and try to tube 2 more times? I understand the reasons to not lose the ability to use an ETA, but at some point it seems like the EMS ego takes priority over patient outcome. For an uncomplicated cardiac arrest, when every second counts, why is the combitube not reached for first (or immediately second)? (1)http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=8214838&cmd=showdetailview&indexed=google (2)http://cat.inist.fr/?aModele=afficheN&cpsidt=14650396 (3) http://www.ncbi.nlm.nih.gov/sites/entrez?d...;indexed=google

As not having used one before, I am asking from a position of the uninformed: What is the resistance against the combitube? Why do people feel it doesn't work as well as a ET tube for short-term airway management? Shouldn't it, ideally, do the same thing without the potential for oropharyngeal trauma that ET placement can cause?

The problem with this is that the media then depends on the police to give them permission to do their job. Write an article about the PD and their questionable use of funds, you have to take your pictures from the next city over from then on. If you need the police permission to exercise your constitutional rights, again, it is no longer a right. They aren't privileges granted by the constitution, they are rights. Oh, I know that most police officers are far too noble to hold a grudge like that, and welcome any and all inquiries into their operation, but ya know, it could happen. I am a firefighter and EMT, and I understand issues at a fire scene. I also have never seen someone arrested for crossing the tape. Here is a question for all you fire photographers. You get to a fire scene three towns over, throw on your turnout coat, and cross the line. Should you be arrested? Or are you a "firefighter" so you know how the be safe on a fire scene?

Lets say that people are protesting something and the police want to break it up, but their methods are questionable. Can they put up a police line two blocks away so the press cannot observe it? If you start letting arbitrary rules decided by a single person impinge on the freedom of the press, it is a very slippery slope. If the police don't want you to leave your house, can they put police tape across your front door and then arrest you when you leave? It is extreme, but some might think that a 2 block radius of protection to keep out the press from a fire is also extreme. Revoking the constitutional rights of someone is not something to be taken lightly, or else they will be revoked frequently. Even if the photographer is never tried, the cop won because the photographer did not get the pictures she was trying to. She was already tried and convicted, because the penalty was executed before any trial. If the photographer was standing on top of an engine or walking over stretched hose it is one thing, but to set up an arbitrary barrier and then use it to enforce the law sounds like it might be a cop with a chip on his shoulder. "The man who trades freedom for security does not deserve nor will he ever receive either." - Ben Franklin

First word of advice: take pictures as max quality. Unless you have a (really) big card, you aren't going to be able to take 1300 pictures @ 7.1. You can transfer your pictures whenever you want so the max quality and max size are what you want. Second, go take a look at this review of your camera: http://www.dcresource.com/reviews/fuji/finepix_s700-review/ . In this review it gives you a lot of camera-specific details for using your camera. After that, take a LOT of pictures, of anything. Take 10 pictures of something, changing settings and recording what you did. Then put them on your computer and look at them print-size. Figure out what works. Photography is an art form. A lot of the learning is by doing.

My agency just spent WELL over $100K on a new bus. I was told that they couldn't afford a backup camera. I am guessing that is because the thing looks like a christmas tree, is the size of an African elephant, and it has a massive airhorn onboard. Obviously, a camera is neither bright or loud, so it was cut. And it was explained to me by someone on the truck committee, "If you need a camera to back up, you shouldn't be driving". Also, keep in mind that this is a type-I ambulance that is MUCH larger than our previous large ambulance. As long as you have the lowest common denominator designing your ambulances, you will be blinding oncoming traffic and backing over people. The problem is, the people with more ego than brains seem to outlast the rest of us. UPS doesn't have cameras because they have tens of thousands of trucks and it would cost millions and millions; ambulances don't have cameras because the people designing them have a cranial GI impaction. If only the cameras made noise or were shiny...

This is the basis of the difference between Fire and EMS. For an EMS call, there is a 99.9% chance that you are going to have a patient, have to work, and get tied up for close to an hour. For a fire call, there is a 99.9% chance that there is no fire, you are going to have to work for about 5 minutes, and can be back in 15 minutes. It is a lot more fun to drive the big red (green?) truck with lights and sirens, with that being the main thing that you are doing for the entire call. For most fire calls, getting there is the most exciting part of the call. For EMS, the lights and sirens thing is not the most important thing you are doing (depending on the moron behind the wheel), and really, how is it fun if you aren't running people off the road in a vehicle bigger than theirs?

I think that originally the state focused on the unique Purchase response plan because of the Alumni Village (the Commons?) fire two years ago. Someone set a couch on fire, it took campus PD like 5 minutes to have someone walk over, go inside, see smoke, dispatch, etc... it was minor as putting it out and structural damage, but it took something like 2 weeks for people to be able to go back in and get their stuff, and a semester or two for that floor to be cleaned up enough to have people live in it again. And then there was the whole issue of the overhaul and recovery company's employees stealing CD's and going through the girls underwear drawers....

http://www.latimes.com/news/local/la-me-bo...=la-home-center Summary: Guy crashed into a building, extricated by LAFD, transported to hospital. Family wonders what happened to grandma, found still in car at impound lot the next day. Scene size-up is an important EARLY part of responding to a call. Check the rest of the car, the trunk, and the other side of the guardrail when you get to a bad MVA. If (when) there are 12 people standing around watching the extrication, if you are in the "outer ring" give a look around instead of gawking. Even if she was already deceased when they arrived the first time, it is a lot better for the family to not have to deal with grandma's body being left in a car for a day.

The article says that he was transported by ambulance to police HQ... I might be new at this whole EMT thing, but I am assuming that they were dispatched as an emergency call... can you transport a patient to anywhere other than a 911 receiving hospital? I was under the impression that you cannot transport a patient to a non-receiving destination. Perhaps he RMA'd, to avoid the whole abandonment thing, but he is 16 so his mom would have had to do that for him, and since she took him to the hospital I doubt he was RMA'd by her. If they dispatched the ambulance for him, I don't think they can decide he doesn't need medical help after that, and since he is a minor, he can't decide that either. Don't have a really applicable citation, but http://www.health.state.ny.us/nysdoh/ems/policy/98-15.htm talks about the need of a medical destination, and not Section 28 hospitals only in non-emergency calls. I know that if a police officer wanted me to transport a minor to the police station, I wouldn't risk my license and bank account doing it, and that kid would end up in an ER somewhere.

One of these vehicles (sometimes two) are stationed out of NYP Columbia Medical Center on W168th. It is usually parked in the ambulance spots under the Milstein hospital building or on Fort Washington Ave outside Milstein. I don't know the arrangement with the hospital, but it is usually the astrovan and almost always parked there. Red lights on it as well.

Just because someone that is healthy does not become very sick from MRSA does not mean it is not a problem. The already sick patients are at the greatest risk for MRSA infection. We transport a lot of patients that are immunocompromised, and MRSA is a greater risk to them. When you don't decon the ambulance after the first MRSA patient, the second patient who didn't have it could die from it. An infected skin wound with MRSA isn't terrible, but a line infection with it is. In the hospital setting, it is a big deal. Usually in hospitals all staff have to wear a gown + gloves + handwashing (contact isolation) when interacting with these patients, who are usually isolated in a single room. It isn't only for the staff, but when you go from room to room, the bugs can catch a ride on your scrubs. Because it is partially resistant, you have to use stronger antibiotics, which can have a lot of side effects, such as C. diff infection, red man syndrome (from vanco), etc. There are other resistant organisms out there as well, such as VRSA and VRE. By downplaying MRSA as just something that you can fix with golves, it is a disservice to all. It is much better for you and your patients to decon + use correct PPE than to assume you won't get sick, so it doesn't matter. There is a reason that MRSA is all over nursing homes these days. There is a reason people die from MRSA sepsis or complications from its treatment. And it isn't because everyone is doing the right thing.

I am not sure about the parked car, but if you are doing CPR on someone and you get into a minor fender-bender, that NYS DOH policy statement says you have to stay. I don't really think you are going to find an EMT, myself included, that would do more than check to make sure the other driver is not seriously hurt. I tend to put human life before rules, though. This raises other questions as well. What if you are driving to the hospital with an unstable patient in the back, and come upon an accident? If you stop or are flagged down, are you now committed to that scene? Can you leave that scene if there is someone there with a minor injury? I think according to NYS law, that is abandonment. Does this mean that you can't stop for a second to check if they need you to radio for help?

I am not sure about FD, but I was reading the policy statements from the DOH regarding another matter the other day, and the advisory says that ambulances are required to wait for PD to arrive, even if there is an unstable patient in the back. If you follow this or not, that is up to the EMT. It also does not specifically mention parked cars (see below). See http://www.health.state.ny.us/nysdoh/ems/policy/01-07.htm for details from the state DOH. As for the Hit and Run aspect, it appears that since it was a parked car and the owner was not present (apparently) it is not technically a hit and run. See http://www.deadlyroads.com/laws/new-york-h...-run-laws.shtml which states that it must be reported to the PD "as soon as physically possible" which could mean by radio to the PD.

It is a joint venture between the DFFD and the DFVAC. It is not intended to be for patient transport, at least at this point (the DFVAC only owns two stretchers). I also do not think it is certified (no stretcher) but it might be listed as a first response vehicle. The unit number that was assigned to it, 56-B2, has been reissued to the new ambulance, so I do not think it currently has a unit number.

From what I learned as we went through the third-party billing process, "soft billing" isn't illegal but third-party billing is. You can't send a bill to the insurance company without sending a bill to the patient (which is what third-party billing is). So all the third-party billing companies send a bill to the patient but take no collections actions against the patient. That is what the soft-billing is: send a bill to the patient without any follow-up or collections.

The problem with blaming the motorists is that they are something out of our control. If I have the option of adapting my lighting scheme to reduce the chance of me becoming roadkill, or turning my car into one big light bulb and then blaming the motorist after I am hit, I know what I am going to go for. Saying you have to change how people drive is like saying your approach works except for in the rain/snow, so it is the rain/snow's fault if your plan doesn't work. You have to have a strategy that is useful in real world conditions, and this includes correct scene placement, blocking, safe methods by your crew (like staying out of the traffic lane), and lighting that lets you been seen without blinding everyone behind the wheel of a car within a mile. Really, if you think that the person is going to crash into you because you didn't have LED's 19 thru 35, you need to consider something else as your problem.