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Protocols, cookbooks, recipes.... comparing cooking to EMS is something many of us do. It's a great analogy and I'm wondering how far it carries over into real life. Are MCI's just the big unplanned barbeque of life and how many paramedics and EMTs are as serious about cooking as they are about trauma. I love to do both, memorized the textbooks and them left them on the shelf.

Excellent thread. I feel for the EMT who wants to live by protocols. The newer any provider is, the closer they should hew to the letter. That said, even the protocols open with the admonition that nothing in the protocols is intended to replace good clinical judgment. And that said, a wonderful quote from aviation..."Good judgment comes from experience... and experience comes from bad judgment." What an MCI allows, is for the provider to take a different perspective on evaluation/triage. What is best for 'the patient' is supplanted by how can we do the most good for the most people. Part of that is the provider not working past his or her abilities. Be it fire fighting, high angle,or EMS, we all need to be aware of what we are allowed to do and also to be aware of what we are capable of doing. Big picture/small picture, global/local, call it what you will, the challenge is to see both while not losing focus of either and still respond appropriately. Cooking is a great analogy. Dinner for two is done differently than dinner for 12. The standard we want may be nutritionally balanced and 3 courses, but the best we can do may be snacks for everyone and a hamburger for the fellows who need it. What one calls the event is not so important. How one responds to it is. Assessments change, needs change, so communicate early and often. The person who can get you resources can't help if they don't know what you need. Manage people's expectations and revisit the big picture as often as possible. What individual providers need to do is think hard about how each of us will manage, not necessarily to a plane crash, but a six patient MVA. We never have the resources we want exactly when we need them. We should all know what we will do with what we get. The last one of these I responded to was 6 pts, rollover, some gruesome injuries, walking wounded, a trauma center just over the horizon, one ambulance, one medic, one EMT and a language barrier, so we really couldn't tell how badly everyone was hurt. ETA for a second ambulance, no EMT, was 15 minutes. You work with what you have and keep it basic. A medic ought to be able to manage 2 major trauma patients [without airway issues] with bystander assistance to package and alone to transport. It's not ideal, but yeah, genuine multiple system trauma needs a trauma center sooner rather than later. I'd rather have to explain why I left a broken wrist with a fire chief than explain why I left a skull fracture on scene waiting for more help to arrive. If one has done their job, the person with broken wrist will understand this and you will leave with his blessing.

Has anyone considered a "Snorkel Team"? Except under special circumstances, a dive team will be a recovery team. With limited training a novice can pull on a wet suit, don a mask and snorkel, and go down 15 ft for a couple of minutes. That's long enough, if preplanned, to hook a bumper or axle and have a truck winch the car out. I wouldn't do that in place of a dive team, but while waiting for one, it might be a time saving option. I recall an ice rescue years ago where a large gentleman went through while ice fishing. Spouse and I [ both fire fighters and high angle trained] responded to the scene, had our climbing gear and a collapsible ladder in the car. Safely roped in and with other FF's on shore I scooted out on the ladder close enough to toss him another rope while he was still able to tie it around himself. They landed the fish and had him cleaned by the time the truck with the dry suits got there. That wouldn't work in all situations, but in this case, it got a person out of frigid water 15 minutes faster and before he became hypothermic and at no time was it unsafe. EMS talks about the perfectly packaged corpse. Level of rescue response needs to be tailored to timely action. 'What can we do that is OSHA safe?' and 'What can we do in the time we have?' may have different answers. Does snorkeling have a place in the fire service?

Interesting. In both BLS and ALS capacities I've 'stabilized' patients in position found. If the patient is neurologically intact I think it a fine idea to leave them as you find them, pad the voids and if the ER wants them supine, then let them do it where it is warm and dry and there are many hands to help. I believe I'd lift the patient up and inch in line, slide a board in and manage from there, or scoop. The scoop is fabulous and under used. the absolute LEAST movement of patient or object should be the goal. If she is neurologically intact and the airway is patent, there is not not much to improve pre surgery and some huge down sides. Great quote attributed either to Chinese tradition or Bugs Bunny... " Don't just do something, stand there." If there is already spinal or airway compromise, then it is a different scenario.

Are we perhaps confusing incident command and unified command? Unified command is not single command but various resources coming together. What is unified is the goal. Every 'incident', be it a 17 car pile up or spilled milk on the kitchen floor needs a responsible party. Too much is made of command structure, especially at small incidents. Anyone serving in any emergency capacity needs to know what their job is and should be doing it with or without a person in a white hat. Any situation that can be resolved in a couple of hours by three agencies does not need command super structure if the individuals involved are acting like adults. An incident that will take several days and involves 50 people needs command super structure, but I would have called it a Coordinator. Fewer people would have their short hairs up over who's coordinator than they do over who's the commander. You heard it here first...NIMS is a total crock and a waste of time.

Almost. We 'phoned a friend' who confirmed our suspicions (couldn't get close enough for a fingerstick) that the mean, uncooperative person with a monster left hook we were called for was a diabetic. After that the cops gently restrained the person with a sheet and an amp of dextrose later we were all best friends.

Obviously you do not practice as a paramedic in the Hudson Valley region where ALS protocol SCP-4 Emergency Incident REHAB sets the standard for patient evaluation. Westchester has nothing like it and as protocols are up for discussion at the moment, do people think that Westchester should address REHAB? I'm also not quite sure how ALS rehab is supposed to work in the Hudson Valley region as it is left unclear who is responsible for setting up the framework for rehab. As a matter of personal practice, if I'm on duty, I 'go out for coffee' if the FD in my territory is dispatched for a structure fire and drink it in the general proximity of the incident until I know that a BLS ambulance is on location. The first few minutes of an incident can be the most dangerous. Most areas have ALS now. Is it an option to have ALS units unassigned but proximally located as an interim measure?

Putnam Valley does not track the numbers. It's not required by DOH and with keeping rigs maintained, the station clean and the motherload of required paperwork flowing to Albany, tracking response times is icing our cake doesn't have. If we did, what would we do with the information? Useless numbers give useless data, and 2 calls a day will not pay for paid crew. If county gets ahold of EMS, we will get shorted on BLS just like we get shorted on ALS now. Units would go to higher traffic areas. One still has to decide what to track. We can take 15 minutes to assemble a crew and another 15 to get them there. Until the subcellular transporter is up and running that's what happens in a town that's 46 square miles. How many people have been killed or maimed by waiting I do not know, but it is a small fraction. If there were a county wide effort to have agencies track time to contact and time to intervention, we might identify ways to reduce contact time (keep a medic in town and send medics to all calls.) or time to intervention ( more BLS gear in private vehicles, more training for PCSO) that might improve outcomes. In times of financial crisis, every improvement comes at a cost and any cost may be too high if not justified. We need to know if what we have is a problem before we ask towns and counties and taxpayers to ante up for more. I'll talk to our number cruncher when he comes back to see if I can get numbers for you, but it will take a while. I can tell you right now that if we track something meaningful that one of the largest districts in the state will have scary looking numbers.

We're not covering any new ground here. Maybe we need new vocabulary. Response time needs to be defined in a way that is useful, and I think that has to mean useful to the patient. Once a term has more than one meaning-- and 'response' is whatever you want it to mean-- then the debate shifts to semantics, not performance. Consider 'Call to contact' and 'Time to intervention'. Almost irrespective of emergency, 'call to contact' matters. Stabilizing a scene and evaluating a patient in person, if only to look at them and say 'sick, or not sick' is an important benchmark. We don't measure this and we should. Next we should look at time to intervention, which is a harder number to pin down. Perhaps look at 'chief complaint' and measure the time until that is addressed. For chest pain that's aspirin and oxygen and perhaps the medic, for an ankle fracture, that might mean a police officer and a pillow. The last and arguably most important piece of data is a correlation of time to definitive care and outcome. 30 minutes on scene with an alert/stable older individual who has fallen overnight and wants to use the bathroom and go to hospital in fresh clothes is not at all unreasonable. Rushing the call to meet some arbitrary standard is cruel.... even if it was dispatched as unconscious/unresponsive. The information to which we have scant access is outcome, and this is where management can and should be insisting on data. If the outcome is good to excellent, then the call times were appropriate. We can't make good decisions without good data and what I see here is that we don't have good data. Why don't we come up with a set of times WE think matter, put it together and get it out to interested agencies as a follow up sheet and start tracking some of this stuff? Good decisions need good data and that takes good research. If we start now, in a year we might be able to have an intelligent debate on the subject. How do we get started?

Not from around here, are you? We're not rich. We have decent ambulance service, both ALS and BLS. Some towns have excellent service. An agency covering something like 2 calls a day cannot make money staffing full time crews. It isn't acceptable to cover 'most calls' and the logistics of arranging for vollies on the busy days escapes me. Something like 6 ALS ambulances, properly spaced across the county is a workable solution. That however, would require all towns participating in a combined district or a change to NY law, neither of which is likely to happen.

Safely for me or for the worker because it is entirely different scenarios. If the hook still worked, I'd send it down take two harnesses a rope some carabiners an eight and my ascenders. I'd ride it up, throw the rope the last distance to the bucket, secure it, ascend up to the bucket, harness up the worker, lower him, reset and rapell down.

In times of fiscal crisis-- and if we are not there already, we will be soon--, the only entity that can 'fix' a deficiency in services is the entity that is responsible for providing them. It is a question that no one wants to answer and perhaps it is time to ask NYS exactly what the answer is. My understanding from this site is that 'home rule' means a county cannot supersede a town. If so, then the county cannot arbitrarily step in and take over. If not the county, then is it the town who is responsible or is it the agency who is providing the service? To use an analogy, think of this as a neighborhood with nice lawns. The 11 homeowners can each cut their own grass or they can hire someone to do it, or or the community as a whole can agree on a standard and have someone come in. Without some sort of standard and without knowing who's responsible, if Mr. Neat thinks grass should be 1/2 inch high and Mr. Messy doesn't care how long his grass grows.... then by what authority does the short grass homeowner tell the long grass homeowner that his grass is too long? He doesn't. That said, if Mr. Messy comes over 5 times a week to ask Mr. Neat to cut his grass, and eventually Mr. Neat can't cut his own lawn because he's always next door...... then Mr. Neat needs to tell Mr. Messy to find another way to get the grass cut. What started out as a very good idea, Mutual Aid, has evolved into something else entirely. No one entity can afford to staff resources for the rare days day when 4 auto accidents happen all at once. But 3..2...1? When does a helping hand become welfare? Neighbor helping neighbor was never intended to address the situation of one neighbor no longer able to take care of his family. The county apparently cannot tell a town what level of service they should have. BES does write and administer the mutual aid plan. The ability to provide service to a certain level needs to be a prerequisite to entry into the mutual aid agreement. We all ought to have to put into the system in order to draw from it. Once a town is asking for aid on a regular basis and cannot provide aid to others, then they should lose access to the system. Or we should have a buy in option. A town 'pays' for mutual aid by providing it to the system 1 for 1 or it makes a cash contribution, say $1,000 a call. The county then gets vollies for free or the money to hire more county contract service. If we did this, then a town who wants calls answered has to carry its own weight except on really bad days, and a town who likes things the way they are can opt out of the mutual aid system. Obviously, we cannot leave people to suffer. I think it would be wise for the county in addition, to arrange with a commercial vendor so that agencies who do not participate fully in the mutual aid plan are entitled to assistance from the plan only for immediate threats to life [ delta/echo]. All Alpha, Bravo, Charlie calls will be forwarded to a commercial service who gets there when they get there. This would reduce pressure on neighboring towns, it wouldn't cost the county anything in overhead, it would provide revenue to commercials paid for entirely by the user, and if a town or its residents don't like the level of service they can find a way to pay for better. It might look like this: Town A participates 1 for 1. If they can't field a crew, they get mutual aid coverage from the system for free. Town B couldn't cover a call if it was the second coming and Christ twisted his ankle. They don't get free coverage. Either they 'buy' coverage from the county by kicking $1,000 into the system or they get diverted into the commercial system where as soon as a bus is free, they'll get one right over.... sometime in the next 3 hours. If that isn't soon enough, the homeowner can call a taxi or drive POV to the hospital. When the irate homeowner in Town B storms town hall, they get an application to join the volunteers or they can petition the Town B to pay for better service. Then Town B sits down with its fire department and fire department B explains why coverage as it is is OK.

Yes, you can. I was only speaking from my experience as a switch hitter. Working both sides, I hit south from north more than I hit north from south, but I do not hear Westchester fire medic dispatch, so you may well be correct about cross border ALS overall. In any event, debating numbers is without merit, they are what they are, so I will withdraw my observation pending hard numbers. Also from ALS: " There are times where you will have extended response times when your down to 2 units covering all that area. 10 minutes is not all that reasonable in my opinion and you still have to factor in driving safely, what the road conditions are etc. Its not about driving fast and just getting there, how come we never see statements that while it took 12 or 15 minutes the care the patient received was superb? " Excellent points. I do not know how those response numbers got to print in the Journal, but it should be obvious to all that when Putnam County is down to 2 medics that response times will be extended. I know I've logged response times close to 20 minutes as Medic 2 out of district. I do not know why that apparently is not reflected in the county statistics. Prudent driving is essential. It is even spelled out by PCBES: Alpha=BLS cold, Bravo= BLS hot, Charlie= ALS cold, Delta= ALS hot. Response times just can't be reduced by adding more accelerator. What the patient gets when the medic gets there is an important part of EMS and arguably the most important part. The importance of quality and quantity of medic and equipment cannot be overstated. If the outcome is good, time to service becomes irrelevant and that appears to be lost from this discussion, so thanks for bringing it back. If one sets as the only priority how little can be spent for ALS, we might well not be getting the ALS we need. Hence my comment some time ago that I saw the best options as doing ALS well or not doing it at all. When the 'fat' gets trimmed from ALS, we lose the tools, not required by part 800 or REMAC that often can save a life. A legislator who says " I got you ALS for 50 cents per person less a year, but you're going to die of shock because the medic can't fix that when he or she gets there." Well, that is not a good way to save money. Time to definitive care, not cost and not response time should be driving the ALS debate. Sometimes that's a hospital and most times that's a well equipped medic. Either we get well trained, well equipped medics to scene in time to make a difference, or we let it go.

And another thing. There's medic number fudging going on on both sides of the border. Putnam has 4 except when they don't..... 2 of them may be driving for BLS calls. Northern Westchester has 2 or 3 except when the fire based medics are on fire calls and then there's one. On paper it looks like 7 medics when in practice two slip and falls in Brewster and an oil burner backfire in Peekskil and all of a sudden a vast expanse of humanity has 3 medics serving them.

To be fair, Putnam and Westchester provide mutual aid for each other. I have no numbers, but working both systems, it sounds like ALS MA in and out is about a wash. In Putnam, Alpha level calls [and I believe Bravo when things get tight] do not get medics either in county or requested MA. Putnam has 4 medics on 24/7. The region, both Putnam and northern Westchester, needs more ALS buffer, but how does one do it? It crosses county and regional lines and involves both contract and municipal services. The question that NEVER gets answered is who is responsible for provision of EMS, at either the ALS or BLS level. There are economies of scale [ town/county] , there are geographical issues [travel /intercept corridors], but at the end of the day, who is responsible for providing the service to residents and what level of service are they responsible for providing, and at what level of availability? Follow the money and the responsibility. Until it is established what has to be provided and by whom, there will be no resolution.

Several individuals pushed the idea aggressively, but Putnam County leadership beat it to death with a stick and burned the remains. Very negative response. It did and still does make more sense than what we are doing.

Well said. We lack perspective on emergency health care. Response standards are based on high population density models. Few people in Montana, Wyoming, or the Dakotas would expect to see an ALS unit in 9 minutes or less. One does not have to go farther than the Adirondacks to find vast populated areas that have no paramedics. Putnam is a rural system that looks for urban level service. I think the choices are to abandon ALS altogether or accept that we have to pay a premium for the service. As a provider, I'd like to keep my job so I am enthusiastic about ALS. As a healthy resident who would rather drive than get caught in an ambulance, I question its value, given the cost.

Why not have lots of classes? Einstein class for those who make scientifically accurate and important posts, EBWhite class for good grammar, spelling and creative syntax, DorothyParker class for posters who are brutal but so witty and charming when they do it that you still have to love them, the EFHutton class.... when EFHutton posts, people listen. Maybe add some stick to the carrot. Hindenburg class for incendiary posters that go down in flames. Oboe class for blowhards; the Mr. Ed class is self explanatory. Consider having threads that are restricted to real name posters, and maybe a post blocking system so I can set my computer receive Einstein-Parker-White-Hutton posts and keep out the Hindenburg-Oboes?

You know you're a buff if you write your own wedding vows and title them SOP's.

You know you're a buff when you name your pets 3491, 3492, 3493.......

Let's get serious. If Alpha member is supposed to mean something, I want to know how they look in a bathing suit... .....and a kilt.

Real names as user names? Ridiculous idea, it would never work........ If you won't own up to it don't say it.

Below a certain age [and that may be 30] upper level primates have have had insufficient experience to exercise good judgment. There is a maxim in aviation that good judgment comes from experience... and that experience comes from bad judgment. If one feels that individuals below the age of reason should be consuming alcohol, one must also accept that a number of them will die doing it and that their death will hopefully serve as an example to the others. Thirteen to fifteen year olds get into alcohol, can get blindingly drunk and then need to hide the body. The drunk kid ends up in a closet, the basement, or in cold weather the decision gets made to pitch the unconscious one out in the back yard in 30 degree temp rather than, forbid, they throw up on the rug and the host gets caught. I've hauled bunches of them. Respirations are depressed to the point of hypoxia, airway is unmanageable and all the friends care about is their mom's not finding out. If kids drink, some of them are going to die or suffer brain damage. As long as this acceptable and getting the losers out of the gene pool is a good idea, then let the little angels drink as much as they want. If as a society, we choose to accept responsibility for the well being of others, sometimes to make decisions in the best interests of others when they are unwilling or unable to make those decisions themselves, then we may have to accept that some of us will get our neck hairs up over youngsters drinking. And last I checked, no cop was breaking down the doors on thanksgiving to see if Johnny had sipped grandma's wine. If a party is so out of control that neighbors know about it, and the cops get called and find obviously drunk children and do something about it, this sounds like the right thing. What am I missing? Last I checked, if a parent wants to get their child plowed, no one is stepping in. When a parent wants to get other people's children plowed that's an issue, and it should be.

That said, the full text is more informative. AMBULANCE SERVICE -- Regional Coordination (establishment of county office to coordinate training) COUNTIES -- Powers and Duties (power to coordinate training of emergency medical service providers) LOCAL LAWS -- Preemption (county coordination of emergency medical service training) PUBLIC HEALTH LAW, §§3000, 3051, 3052: A county may establish the position of emergency medical services coordinator provided that the responsibilities of the position are limited to the coordination and facilitation of training activities and do not extend to the coordination and regulation of the actual delivery of ambulance services within the county. 1987 Opns St Comp No. 87-55, p 83 is clarified. This is in reply to your letter concerning the establishment of the position of emergency medical services (EMS) coordinator for a county. You indicate that the county is contemplating the appointment of an EMS coordinator who would be responsible for the development of a "formal quality assurance program", the development and coordination of EMS training, the coordination of continuing education for EMS providers and others, and the recruitment of volunteers. You inquire whether the county may establish such a position. This Office has previously expressed the opinion that a county may not establish an EMS coordinator and advisory board to coordinate the activities of volunteer ambulance corps within the county (1987 Opns St Comp No. 87-55, p 83). At issue in our earlier opinion was a proposal for the establishment of a system for the coordination of ambulance services modeled on the county-wide mutual aid programs for fire and other public emergencies authorized by section 225-a of the County Law. Under that section of the County Law, a county may create a county fire advisory board and the office of county fire coordinator to develop and maintain programs for fire training, fire service-related activities and mutual aid in case of fire and other emergencies. It was, and remains our conclusion, that no existing statute authorizes a county to establish a program for the coordination and regulation of the actual delivery of services of private volunteer ambulance corps as may be done for fire services in mutual aid programs authorized by County Law, §225-a and that a county's home rule powers relative to the regulation of emergency medical and ambulance services have been pre-empted by the Legislature's enactment of Article 30 of the Public Health Law. It also continues to be our opinion, as discussed in Opn No. 87-55, supra, that pursuant to the provisions of General Municipal Law, §122-b, a county and other municipalities in thecounty may coordinate the delivery of services of private volunteer ambulance corps by entering into joint agreements with these corps and including appropriate provisions relative to the coordination of the delivery of services. We note, however, that while we believe that the conclusions reached in Opn No. 87-55, supra, are still valid with respect to the coordination and regulation of actual delivery of services, the role of the EMS coordinator described in your letter appears to be quite different from that discussed in the earlier opinion. As outlined in your letter, the EMS coordinator would not be responsible for coordinating or regulating the actual delivery of ambulance services. Rather, the EMS coordinator in your county would facilitate the training of EMS providers and others, disseminate information to EMS providers, and assist in the recruitment of volunteers. Under Article 30-A of the Public Health Law, the Legislature recognizes "...a need to provide flexible, diverse and high quality training opportunities which are reasonably available, particularly to volunteers who devote considerable time, effort, and often personal resources, to improve or retain their knowledge and skills" (Public Health Law, §3051). To this end, section 3052(3) of the Public Health Law requires the Commissioner of Health to provide, upon request: . . . management advice and technical assistance to regional emergency medical services councils, county emergency medical services coordinators, and course sponsors and instructors to stimulate the improvement of training courses and the provision of courses in a manner which encourages participation. Such advice and technical assistance may relate to, but need not be limited to the location, scheduling and structure of courses. (Emphasis added) We believe that the Legislature's recognition that a county EMS coordinator may have a role in training EMS providers necessarily implies that counties are authorized to establish the position of EMS coordinator with responsibilities with respect to the coordination and facilitation of training activities (see also 10 NYCRR 40-1.52[1] indicating that the coordination of emergency medical services program activities and training programs is eligible for State aid reimbursement when such coordination is specifically identified in the county public health services plan approved by the Commissioner of Health). In light of the foregoing, it is our opinion that the county may establish the position of EMS coordinator provided that the responsibilities of that position are limited to the coordination and facilitation of EMS training activities and, in the absence of a joint agreement pursuant to General Municipal Law, §122-b, do not extend to the coordination and regulation of the actual delivery of ambulance services within the county. In this regard, we note that it is not entirely clear what would be entailed in the EMS coordinator's development of the "formal quality assurance program" referred to in your letter. We caution that, based on the policies and purposes the Legislature has set forth in the Public Health Law, it is our opinion that the county would be pre-empted from unilaterally establishing and enforcing training standards or equipment and communication standards for EMS providers (see Public Health Law, §3000; see also Opn No. 87-55, supra). Opn No. 87-55, supra, is clarified to the extent it suggests that a county may not establish the position of EMS coordinator to coordinate and facilitate EMS training activities. December 15, 1989 Mr. Dominic Mazza, County Administrator Livingston County

My understanding is that if you want better than OSC you need to find it on a stone tablet. OSC is as good as I've got.