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Actually, no. New York State law limits what EMS coordinators can do, and it's not much. Law limits it to training activities. Coordination or regulation of delivery of services is not permitted. OSC Opinion 89-52 says in part: 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.

If memory serves, one of the three injured individuals not immobilized per Fresno was a 19 month old with an altas/axis fx...mother noticed he would not turn his head.... who had a full recovery with immobilization. The only adverse outcome was an elderly individual at the chiropractor with significant history. Maine has had extensive review with the older population tagged as at risk for under immobilization. Clearance apparently is questionable at both ends of the age spectrum with very young children being unwilling or unable to report pain and the elderly either having ongoing pain or neuropathy that interferes with reporting. Otherwise, spine clearance using 5 or 7 point criteria, in the field or at hospital without radiography has had very good results. One article makes the excellent point that pre-hospital it should be considered opting out of immobilization rather than clearing of the spine as only a physician can diagnose and treat. We, in fact are not clearing the spine, just opting out of a treatment option, having established that the treatment was not in the patient's interests. Something like 33% of immobilization is unwarranted.... which means even given a clearance/opt out protocol, most patients will still meet criteria for immobilization. Children are the nightmare. I had a youngster who pulled something heavy down from a height, needed some stitches to the back of his head and in fact probably met criteria for full spinal immobilization. But he had been running around after the accident and was happy in his mother's arms had no idea he was hurt, so I opted to fashion a horse collar out of a towel for soft support and leave him happy on the grounds that hard collaring and boarding would have lead to thrashing hysterics with much higher chance of adverse outcome if there was underlying injury. The doctor took it off without comment, but that is his choice. I don't much mind boarding and collaring the otherwise healthy patient for whom the overkill is only an inconvenience. I think a lot about when the collar and board may do harm, which are the same populations at risk for under immobilization. What would be useful and maybe this site is just the place is a convenient way to do literature searches. Punting back to "GOOD CLINICAL JUDGEMENT" is nice wiggle room, but wouldn't it be great if practicioners had ready access to someone who could search some of this stuff? Now that would be good clinical judgement. Could someone qualified volunteer to be "Ask the Doctor."?

Annals of Emergency Medicine June 2001 Stroh and Braude Can an out of hospital cervical spine clearance protocol identify all patients with injuries? [Also known as the Fresno protocols, it is an early classic study advocating clearance in the field.] Academy of Emergency Medicine March 1998 Out of Hospital spinal immobilization: its effect on neurological injury. [Another early work comparing 2 university hospitals, one where trauma does not get immobilized on a backboard and one where it does and there was slightly better outcome without immobilization.] A search for " spinal immobilization" "fresno" and "retrospective" will get to a lot of literature. There are two related threads here, clearing spines in the field and the value of immobilization. Spinal injury, especially c-spine injury, needs to be stabilized for extrication. How we do it is another story. As the vast majority of trauma has no spinal component, the vast majority of patients do not need immobilization. Which is not logic enough globally to dismiss immobilization. The patient who needs it , needs it. The patient who doesn't, doesn't. How we make the distinction is unimportant for the 99% who are uninjured but critical to the 1% who are. As EMS professionals we just cannot afford to get it right 'most' of the time. It all gets back to practice, experience and good judgement. Never pass up the opportunity to think about what you are doing. That said, it would be hugely helpful if the bureaucrats would give us a little spinal support here and write clean protocol for clearance in the field. And thanks Chris192 for the positive feedback.

Maine has had a spine clearance protocol in effect since 1994 without undue loss of quality of life. Good clinical judgment is key, which requires good feedback. The practicioner needs to look at each patient and ask how do I rule IN immobilization, not rule it out. If one is looking for a reason not to do something, he or she will find it. If one approaches the patient looking for reasons to immoblize and finds none, then that patient is a good candidate for clearance. And yes, immobilizaton on a backboard can do harm. I respectfully disagree on just about everything that the author has to say on KED's. Those who find them time consuming and bulky are not practicing enough with them. I am unmoved by arguments that one does not know how to use equipment and therefore finds it hard to use. The KED only helps the c-spine, so yes, there will be rotation at the hips. Nowhere in protocols does it say, put a cervical collar on here or splint a leg here, or use a KED here, yet we do not use this as reason to abandon them. Consider c-spine immobilization, at least as I practice it, means if the patient still sitting in a vehicle has neck and or back pain and he or she is not unstable, a KED with a collar is the only thing that constitutes adequate c-spine immobilization. KEDs really limit rotation which may be key. A c-spine can tolerate a fair bit of front to back motion partly because it is sitting on top of a long flexible spine. Side to side and rotation is governed by the atlas/axis the major neck muscles. Rotation is almost guaranteed to dislodge an unstable c-spine. A collar alone can act as a fulcrum, limiting the ability to move the neck except at the atlas/axis and by the major neck muscles. It is why we collar and still stabilize. Anyone who thinks they can hold adequate rotational stabilization on an injured c-spine while directing a patient to swing from face forward to out the door and then rotate them down onto a board, pull that board out of a car and then block and spider the patient....well, I think that person overestimates their abilities. A KED keeps the patient from looking at you and using their shoulders to assist in getting out, or ducking their head, which is what makes a KEDed patient such a challenge. Those are also the motions that will dislocate an unstable cervical spine. My advice is to practice with a KED until it works for you...and for the patient.

Then 2 of us were there. Go Big Red. And I saw/heard Lamb lies down on Broadway....on Broadway. It was a masterpiece of a concert. Both Collins and Gabriel have magnificent voices, love them both, but for me, I think Gabriel defines Genesis. They are one of the best bands ever. OK what was everyone's first concert? Mine was David Bowie, Rise and fall of Ziggie Stardust, 1972 Tower Theatre Philadelphia. Very good.

Yes, I am aware. There was no criticism actual or implied of dispatchers. Better dispatch information would help, but I did not blame dispatchers for its absence. Perhaps we need better communication all around. The first agency to deliver a patient to a hospital on diversion gets told about it and that agency should be telling dispatch, who should be passing it along to the rest of us. If there isn't a system in place to do this, then let's make one. Trying to cut everyone a little slack here, EMS agencies living in the shadow of the hospital do feel a much larger increase in transport time, at least on a percentage basis, when they go out of town than do those of us who practice in the outlying areas. It would be nice, especially with a redesign of the hospital on the boards, to have decreasing diversions as a priority, but in the mean time those of us in outlying areas who can divert our patients have an ethical obligation, at the very least, to try to honor it. It goes back to how we approach EMS in the first place. We are constantly given rules and then told to use good judgment. Our response to this freedom can be to take the position that 'I don't have to. You can't make me.' or we can ask what we can do to help. I've seen crews that would not make a peep over going to WMC for a trauma patient pitch a fit over going to WMC for diversion. Same distance, same down time, just different reason. If a hospital says they need it and they ask you not to bring in a patient, that ought to be compelling reason to find a better place to park the patient.

First, and I hate to nit pick, but it's NIT PICK, derived from removing the eggs of lice from a hair follicle; grandma's sweaters have nothing to do with it. Second, vertical rescue is inherently dangerous. One cannot simply take a course and go out there. If you are serious about it, join a team and practice with a team. Your life, and that of your patients' may depend on it. Local agencies ought to know where their rescue challenges are and ought to have a plan in place. Keeping current with high angle is hugely time consuming and not many providers have the time to stay current on EMS and vertical rescue. Question. How many vertically capable paramedics are there? Does anyone keep a list? Third, useful training ideas. How about strategies for extricating and packaging patients. Getting patients out of houses is no small skill, certainly as patients get larger. 90% of the time a crew does not even put spider straps on correctly. On scene times might be reduced if crews practiced together and had plans for getting patients out of tight situations. I'm sure there's a few great stories out there of less than conventional approaches to getting patients to an ambulance. And how often should you just walk the patient out?

If the emergency health care provider is committed to respecting diversions, the patient usually will be OK with it. No one likes being told that they will not be going to their favorite hospital, but no one likes waiting hours for treatment or spending 2 days warehoused in an ER hallway either. At the very least, a direct discussion of probable outcome--extended delay in treatment-- will manage the patient's expectations. I've had good luck calling the ER to ask the nature of the diversion. If the problem is beds upstairs or a particular piece of equipment isn't available, and I've got a 'treat and release', then I've never been given a hard time for calling first and bringing it in. If the ER just can't handle another patient, then the patient or his family needs to know that. Knowing what the hospital can do is part of an informed decision and as advocates for the patient, we ought to be guiding the patient to what will be a good decision for that patient. It's certainly easier to advocate for a longer drive and out of service time when I'm on the clock than when it's volunteer time I'm giving up, but if we are putting the needs of the patient first, then an extra 30 minutes of our time that saves the patient hours is a small inconvenience to us. A couple of things would make the decision process easier, better dispatch information and updates and agency policy. If I don't know about a diversion, I can't plan around it. What also would be useful would be for volunteer agencies to have a policy on respecting diversion requests. As an ALS provider, I find myself in the position of not knowing what a vollie ambulance will say when it gets there. I can tell a patient that a hospital is on diversion, but they don't know what that means and if a transporting agency shows up and says that they don't care, it gets complicated. If I've just coaxed a family into using a different hospital and the crew says they don't do it, usually quoting 'it's policy', well we all end up looking like idiots in front of the family, which does not inspire confidence in prehospital care. Neither does telling a family that I don't know where we will be taking the patient until I know who the crew is. Individual crews should not be setting corps policy. If agencies don't want to honor diversions, then come on out and say it. If agencies choose to honor diversions, it should not be up to individual crews arbitrarily to say yes or no, absent some other crisis. I remember an auto accident, with a whole bunch of bumps and bruises, HVHC was diverting because the ER was jammed up, I was willing to go to another hospital, the other ambulance from my corps was not and it would mean splitting a family, so we all went to HVHC after a tense discussion in the middle of the street and caught some grief for it at the hospital, which I thought was well deserved. It's not like the ER has control over patient load. Nurses have a right to be grumpy if you've just left another patient to sit in a hallway with scant hope of ever seeing a bed. My understanding, and if anyone knows details, please chime in, that the number of hospital beds in a given region is regulated and that this region is already thought to have too many. I was told by someone I trust that the HVHC 'expansion' will not result in a significant number of new beds for this reason.

What I learned in college, was that instructors do not teach you; they provide the opportunity and you teach yourself. Having done undergrad in the epoch before computers and power point, everything was hand written and there is some evidence that writing assists in memory. In the era of everything powerpoint, especially if the the 'instructor' does not take the time to teach, the information will go by too quickly. If there are handouts, don't rely on them. Find a note taking strategy that works for you, but absolutely take notes. If the material goes by too quickly to copy, ask the instructor to slow down. If you can't keep up, other students aren't either. Read the textbook assignments BEFORE class and come in with 3 questions you want to ask on the material. If it doesn't make sense, say so. Mark Twain...or HL Mencken said that education is the only thing where people are happy when they don't get their money's worth. Don't accept days off or getting out early. Someone is paying for instruction and the instructor owes you good hours of it. Make your instructor work as hard as you do.

It's a slippery slope. Quality of care is often in the eye of the AEMT, who may be overestimating what he/she has to add. Best benefit to the majority of patients is getting the patient off scene with solid BLS skills being performed. Unless one is on duty in an EMS capacity, and this applies to A and B EMTs, one has no standing to practice. My experience is that 85% of good ALS is good BLS. Helping a BLS crew set up to run a successful call and coaching, if necessary, probably has as much or more benefit to the patient, especially in the short transport environment. The ALS role in educating/assisting BLS is undervalued. Good assessment is the same BLS or ALS. BLS is just as capable at recognizing and addressing basic respiratory and circulatory issues. If a BLS provider needs an assist, use the opportunity to teach. The EMTs we ride with today we will ride with tomorrow. Make them better at what they do and they will be there for you [and the patient] when the going gets tough.

I have to admit, the first time I read the account of the drunken party and the missing finger I thought "Wow, that system really works." Unless it's a thumb, an amputated finger isn't a big deal. [ so long as it's someone elses, obviously] Reattachment is dicey, certainly not a life threat. That said, a dispatcher should have told the callers immediately how the system works and maybe called them a cab. Putting drunks on the road is a really bad idea, but how far is a society supposed to go to protect citizens and visitors that don't care to protect themselves? A cab might have been good middle ground. The one time I got caught doing something really stupid.... and it was really stupid. .... I was, A. sober [ double shame on me] and B. embarrassed enough by it to drive myself with the one good hand to the ER. OK, the second time I got caught doing something stupid....also sober... I recall a sign posted in the ER that read, " Stupid is supposed to hurt." Which it did, and when it gets cold, still does. If an AMI got the same treatment, that is not good. A finger might have been a decent call.

Indeed. Don't go there. The reeve's stretcher or scoop make excellent sleds if properly padded. Consider putting some rope or better yet webbing cut to fit on your ambulance for retrofitting what you have with useful grips. Once, we had a woman who anteriorly dislocated her hip falling hard in the middle of a steep and impossibly treacherous driveway. She got scooped, manually stabilized by a person riding behind her and we sledded to the bottom of the drive. The only problem was she was laughing so hard by the time we got to the bottom that she was having a hard time catching her breath. Safety tip. You cannot drop a patient who is already on the ground. I agree with those who find automatic chains useless. They are worse than useless if they give a driver the false security to drive beyond his/her abilities in deteriorated conditions. In treacherous conditions it is especially important to drive conservatively because, if you put a rig off the road and out of service, there may not be a second rig coming any time soon. If you require an ambulance for yourself or close a road, well that is a disaster. No matter how long it takes to get to the scene and to the hospital, it is a huge savings not to screw up with the first due rig. Back to V and T law, the moment we use lights or sirens we accept full responsibility to move through traffic "so long as it is safe". EMS is held to a higher standard than the general public, in the sun and in the snow. Don't panic drivers who are already at or past their limits in bad weather. And I'm a huge fan of taking the rig out to a vacant lot and doing obstacle work in the snow. Not only is it a lot of fun, almost everyone is shocked by how fast the back end cuts loose and how far it goes when it does. It's also possible to crank the wheels on a stuck ambulance, gun it and swing the back end off the greasy stuff onto tractionable surface, but it's best to practice this before you have a patient on board.

Interesting observation. I think there are two issues here. If by fire based EMS, one means municipal EMS vs corporate/commercial EMS, then I think that municipal service is preferred. Cor/com by its nature, looks to maximize revenue and I question whether the greater good is served by focusing on maximizing revenue stream. EMS management ought to be looking at response times and level of service, training, equipment, and call it, maybe, community contribution. What are times to transport and is ALS available 9/90, are at risk populations being served and are there cost effective bells and whistles that will improve patient outcome? A municipality can ask the question, "What do we want to provide in terms of service?". Cor/com has to ask,"How can I cut costs and squeeze out a profit?". To some extent, speed, efficiency and value are shared goals. At the end, the question becomes "Did we make money today?" or "Did we meet the needs of our citizens?". So I would like to rephrase what I said before. I think, in my heart of hearts that well run municipal EMS ought to be the model. If that means the choice has to be fire based or cor/com, I'd enthusiastically support fire based EMS, which without debate provides professional, compassionate care. If the choice can be municipal EMS provided as a stand alone entity whose primary focus is community health or EMS provided as a secondary service by another agency, I prefer EMS as a separate agency. That said, a mixed model might work very well. Dedicated EMS for minimum coverage needs and supplemented by fire based EMS for high volume periods might be good middle ground. **** It reminds me of a story. Years ago I invited a logger to look at our 'back 40.' Actually, he was at the door begging and on a lark I decided to see what he had to offer. He told me how I really needed a professional to manage my mature woods and how I could get good money for it, no hassles just a fat check in the mail. He promised to take care of things for me. I said it sounded great..... but I wanted him to manage it for sustained harvest. He could only take the largest trees, thin the trash trees, process the waste and stabilize the roads, replant as necessary. Can you do all that for me? He snorted as if I were being foolish. "Yeah, Lady, I can do it right, but then I can't pay you for the lumber." Maximizing for profit/savings can be entirely different than maximizing for quality. Given current reimbursement rates, even if the Schumer sponsored bill is passed, I don't think there's enough income available without municipal involvement to get us the standard of care most of us would like to see.

Fire based EMS makes almost no sense to me. Requiring medics to be firefighters limits who will want to be a medic and for no obviously good reason. Be it strength or temperament, the fire service is almost exclusively male and I think women can make excellent medics. Fire and EMS are different skill sets. Why arbitrarily limit medics to those who fight fire? I recall group hysteria at the suggestion that fire service be asked to mow lawns somewhere. Yet paramedics should fight fires? Fire fighter and paramedic are both great jobs. I just think EMS is important enough to be treated as a profession that stands on its own, not as an afterthought.

[Email This Page] [Printer Friendly Page] Legislation > 2007-2008 (110th Congress) > H.R. 2164 H.R. 2164: Medicare Ambulance Payment Extension Act Bill Status Introduced: May 3, 2007 Sponsor: Rep. Michael McNulty [D-NY] Status: Introduced Go to Bill Status Page You are viewing the following version of this bill: Introduced in House: This is the original text of the bill as it was written by its sponsor and submitted to the House for consideration. Text of Legislation HR 2164 IH 110th CONGRESS 1st Session H. R. 2164 To amend title XVIII of the Social Security Act to provide for an extension of increased payments for ground ambulance services under the Medicare Program. IN THE HOUSE OF REPRESENTATIVES May 3, 2007 Mr. MCNULTY (for himself, Mr. REYNOLDS, Mr. ALLEN, Mr. PICKERING, and Mr. ENGLISH of Pennsylvania) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to provide for an extension of increased payments for ground ambulance services under the Medicare Program. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE. This Act may be cited as the `Medicare Ambulance Payment Extension Act'. SEC. 2. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR GROUND AMBULANCE SERVICES. Section 1834(l)(13) of the Social Security Act (42 U.S.C. 1395m(l)(13)) is amended-- (1) in subparagraph (A), in the heading, by striking `IN GENERAL' and inserting `FOR THE SECOND HALF OF 2004 AND FOR 2005 AND 2006'; (2) by redesignating subparagraph ( as subparagraph ©; (3) by inserting the following after subparagraph (A): `( FOR 2008 AND 2009- After computing the rates with respect to ground ambulance services under the other applicable provisions of this subsection, in the case of such services furnished on or after January 1, 2008, and before January 1, 2010, the fee schedule established under this section shall provide that the rate for the service otherwise established, after application of any increase under paragraphs (11) and (12), shall be increased by 5 percent.'; and (4) in subparagraph ©, as redesignated by paragraph (2)-- (A) in the heading, by striking `APPLICATION OF INCREASED PAYMENTS AFTER 2006' and inserting `NO EFFECT ON SUBSEQUENT PERIODS'; and ( by adding at the end the following new sentence: `The increased payments under subparagraph ( shall not be taken into account in calculating payments for services furnished after the period specified in such subparagraph.'. ***** About the Medicare Ambulance Payment Extension Act The Medicare Ambulance Payment Extension Act (S. 1310, H.R.2164) was introduced on May 3 in the Senate by Senators Charles Schumer (D-NY), Trent Lott (R-MS) and Kent Conrad (D-ND) and in the House by Representatives Mike McNulty (D-NY), Tom Reynolds (R-NY), Chip Pickering (R-MS) and Tom Allen (D-ME). The legislation would implement an across the board Medicare increase of 5% to all ambulance service providers regardless of the state or area in which the transport originated. The two-year relief would apply to just the base rate and not mileage and would commence on January 1, 2008 and expire on December 31, 2009. The legislation is being viewed as an extension of the relief lost from the expiring provisions of the Medicare Modernization Act (MMA)and would not impact the relief currently in place including the 50 plus mileage bump, the regional fee schedule adjustment or the super rural bonus payment. If enacted, S. 1310 and H.R. 2164 would result in an estimated $341 million in additional Medicare relief to ambulance service providers.

The toughest ones, by far, that I've been involved with, [as a cutter or paramedic] are a 'double wrap'. It takes about 50 mph, a slick road, a tight descending turn... and an 18" diameter tree [ telephone poles appear to break or give first]. I'm guessing the driver oversteers mid turn in response to excess speed, the car cuts loose, slides sideways, hits the tree at the A post driver's side and wraps once to about 35 degrees, holding onto enough energy that it releases from the tree and rolls up along the roof and wraps a second time along the roof. Presentation on arrival is bottom of the car facing out, driver's side to earth with the tree through the windshield, possibly pinning occupants. I've seen it 4 times, almost as identical accidents. Primary issues are: It's highly unstable and cribbing is of limited value given the height of the car. Gasoline is leaking and is an inhalation and fire threat. Occupant seriously injured, perhaps including crush injuries depending how far the tree trunk penetrated. Patient access is only through the passenger door, now facing the sky. If multiple occupants, there are 'stacked' patients with the critical ones on the bottom. Secondary issues are: The battery is inaccessible, and either horn or stereo is on. There isn't time or space to immobilize 'minor' injuries prior to clearing them from the scene to access critical patients. There is almost no working space interior. There is so little structural integrity that spreading and ramming tend punch holes rather than move metal. So.... what do you do now? Obviously, stretch a couple of lines, stabilize the car, probably by tying off to the tree, call for a helicopter and a second ambulance. But how do you extricate the driver on the bottom of the heap with a door in his lap and his feet under the pedals? There's only gone way I've seen to get them out. How would you do it?

OK, someone educate me. Who fills out the CMN? As a 911 medic, I've not been exposed to the transport experience, and never bothered with them. All of a sudden we're being asked to fill out CMN's on 911 assignments. The forms don't seem structured to 911 calls. What is their purpose exactly?

Fair enough. I hope the effort was intended to downplay hysteria, not hygiene. No one here has suggested abandoning good BSI practices. Patients do not come with their exposure risks stamped on their foreheads. Any patient can have anything and we should be taking adequate precautions all the time, not just when the aide tells you that this particular patient carries a pathogen. I do think you can fix the largest and most critical part of the problem with gloves. Use them, change them properly and frequently. Any time a patient is handled, gloves need to be changed before touching anything else. ...cots steering wheels, doors, BP cuffs, opening equipment; it's an endless list. A problem inherent in multiple back-ups is the sense of security if one level fails, that another level will pick it up. That leads people not to treat each level seriously. Half hearted gloving, half hearted suiting up, and half hearted decon, which I see happen a lot, doesn't stop transmission either. If we put enthusiasm into enclosing the patient, and glove technique, then maybe wouldn't be spraying pathogens all over the rigs. In practice, EMS is under huge time and financial constraints. Full body PPE and thorough decon on every call where there is potential pathogen exposure, while a great idea, is asking more than the system can tolerate. Putting priority on initial contact conditions will, I think, give us and our follow on patients the greatest level of protection and be best use of resources. It is important to recognize that protection from pathogens is probably more important to our patients than it is for those of us who are healthy. If we are gloving once and touching surfaces with the intent to keep ourselves clean, then we are doing a disservice. If we glove and re-glove as necessary to limit spread, then we serve ourselves and our patients.

It is welcome to see us handling an emotional issue with respect, and it is an emotional issue. One of the issues with dog studies is that facilities look for animals of a certain size that is manageable and there is quite a market for them. A suitable animal can be worth hundreds of dollars. That makes pets targets and it happens often. Stealing is much cheaper than breeding and two people and a van can make thousands of dollars a day. About the only way to stop it is to dry up the market. Beyond that, live, or dead for that matter, anatomical study on species other than humans has precious little value. While we share general conformation, positional differences are great. Organs evolved during the quadraped period. Bipedalism is quite recent, causing organs to rotate downward in humans. It explains a number of physiological problems humans have and why respiratory patients 'tripod' to reduce work of breathing. The systems weren't designed for optimal function upright. That said, when doing intubation rotations in paramedic school I talked myself into observing a CABG operation and got to watch a chest get opened, a heart stopped, repaired and restarted. That was valuable beyond words. Seeing the relationship between living human organs and how it is managed both physically and with medications is just incredible. And with prior approval, people with medical interest are welcome to watch autopsies. I went down to see the inside of a traumatic arrest I'd worked on and it was remarkably educational. The internet has vast, excellent, resources. Animal studies for human conditions, if they ever had value, lost it in the last decade. If one draws the line for respect for life to include all sentient species, there are a number of organizations, NEAVS, [New England Anti-Vivisection Society], FACT [Food Animal Concern Trust] that work to stop abuse and misuse of our furred and feathered brothers and sisters without making the unfortunate headlines that PETA has. And there is always adoption. Kudos to those who work for what they believe in and those wise enough to look compassionately at a situation and find a better way.

Absolutely. It helps to have the legs for it, but there is nothing more...invigorating... than a man in a kilt. [i'm proud to wear a Christie and a Caldwell, myself.]

One of the most wide spread and least understood is the OSHA. It can be found in every firehouse and ambulance corps in the country and there appears to be no way to get rid of it. When there is an outbreak, cover the infected area with paperwork and then wash your hands.

[ Has the County resisted a FOIL request for CAD data or are they just stonewalling in the traditional local government manner? I don't think it's malicious at all. The managers can't manipulate the programs to spit out informative data sets. The county might be well served to find a consultant that does not have emotional, financial, or political ties to the county to help us find strategies and set goals. Towns or their agencies might be more cooperative if the harder choices were outlined by impartial individuals. We might consider a proactive approach, asking ourselves where we want to be in say, 10 years, getting consensus on a long term plan, and then looking at the possibly unpopular intermediate steps it will take us to get there. Proud as I am to be a volunteer for almost 20 years, if we look at how much money is spent countywide on ALS and BLS, it is a vast sum of money. If we are spending close to 2 million on BLS and 1 million ALS, that should buy a lot of service, though maybe not service as it looks now.

For another perspective, Putnam County can't make good decisions on resource allocation without good data. A huge issue for us is the inability to get reliable data from the CAD system. It's been years and it either can't or won't provide meaningful data. Some in Putnam, [i was one of at least 2], felt a system based on 4 flycars and one or two EMT staffed ambulances to assist all local corps, not just the chosen towns east of the Taconic would provide better, more uniform coverage. That said, Putnam County management says no and they sit on all the data that could prove or disprove the practicality of such a system. Yes, a significant amount of the time one or two paramedics is/are acting as a driver for BLS transports. And at that, towns west of the Taconic are not offered access to a contract ambulance if they fail to cover a call. In the county's defense, the effort is to assist agencies that need it most and to position resources to serve the most county residents. That means some residents get more than others. The farther up the trough you dine, the better you like the current system. Balance has to be struck between cost and service and where one draws the line is hot for debate. I think a good case could be made, [if cost is the heavily weighted consideration] that any ALS is of limited additional value, certainly when it is used for BLS transport [ the 'no value' condition] . A better case can be made that cost per capita [ roughly 1 million dollars now for 100,000 residents or $ 10 per resident] is the cheapest insurance/ service the county can provide. If a system could be designed that actually got EMS transport to all county residents and ALS to all residents at 9/90 [within 9 minutes, 90% of the time] that it could be worth twice what we are paying now. That said, the other hot debate is who should be paying. Should the county be involved in financing EMS at all? Should the county be subsidizing the towns to provide BLS service? Should/Can it subsidize some towns and not others? If cost is the crystallizing issue, as it seems to be at the moment, one has to ask "Whose cost?". Argument can be made that the county can save itself a lot of money if it takes the position that BLS should be the responsibility of the town and that ALS, probably too expensive on a town by town basis, is better funded at the county level. Of course, that means towns pay more. That makes sense to me. If there were obvious, good answers, I think there are large enough hearts and brains [if not wallets] in Putnam that we would have found them by now. Compromises are a necessity... which is why we need good data and clear vision.

Kucinich 88 Gravel 84 Biden 84 Well, I knew who I wasn't voting for already, so no big surprises. Interesting how seldom the middle of the road choices show up.

Nothing, but nothing..... beats a Mountie. Maybe it's the horse. He's a lumberjack and he's OK.