ckroll

Hubster asked me to post a link to "No hands across America". http://www.cs.cmu.edu/afs/cs/user/tjochem/..._home_page.html See the journal. 2797 miles at 59.6 mph. Not bad for a 'one eyed four month old'.

Educating distracted drivers is an excellent idea; it ought to be for more than a week though. Oops, gotta go, the light changed. Any suggestions for how I shift my standard?

OK, so here I am minding my own business when dispatch asks me if I'm busy..... turns out I'm 2 blocks from an 'unknown medical'. with a language barrier. Cops are on location, outside, tell me the woman is having a baby. Does not speak English. No problemo, seniora..... except this lightly built, blonde woman speaks something eastern european and the german, french and spanish I might have pieced together are useless. She is in excellent physical condition and pacing back and forth, has no use for me and does not need her blood pressure taken or an EKG or oxygen which is about all I have to offer a woman on the run. The ambulance arrives, I ask the kind officer if maybe the next time she paces towards the door we if we could pace her into the ambulance. I call the hospital to ask them if they're prepared for delivery and a language barrier and they ask is she going to have it, I say I don't think anytime soon, but yes, she looks full term and mad as....well, lots of things. They say "Sure." And to their endless credit, they cleared a double bay and ordered down an infant set. I ask if anyone speaks the language and an officer finds me a neighbor to accompany. The patient and neighbor start chattering like starlings, but no one talks to me. We manage something about 2 children, but I am not sure if she's had 2 or is having 2. Contractions are close and the moment we get her in the ambulance she howls like a coyote. No crowning, so I tell the EMT we're OK. I start a line between contractions, she does it again. No crowning. We pull onto hospital grounds and she does it again, I check and say 'Well, hello there.." EMT looks stricken, asks what do we do and I say drive like hell and unload and go. We push her through the doors at a trot, tell the staff we've got 1.25 patients. The nurse shoots back 'You, told me she wasn't going to have it' and I reply, 'Well, I lied.' We go to move her over to their bed and I stick my hand under her rump, it is real wet and warm. She's shot the bundle almost to the end of the stretcher and the only thing that stopped it was the end of the umbilical cord. MD runs over for a clamp and cut. It's over. Beautiful baby in the bassinet. So, yeah. babies have been squirting out of women for years with no assistance whatsoever. It's a baby, not an emergency. Unless of course, it is. Like any other call, if the hair on your neck stands up, you've got a 'worker'.

This network has personality, and as part of the collective we are all responsible for it. On good days we can be very good and on bad days we are cranky and childish. I come here for the good things, but then something mean and ugly happens and just like the newspaper, I end up reading it, salacious details, and reports of bad behavior.... then I go back later to watch the fight, maybe post some righteous indignation, hope someone else will get mad and pull the plug on it. Well, we can do it ourselves. Bad behavior looks for an audience. When we go there and reply we not only diminish ourselves in responding, we give life to the beast. There is a philosophical practice known as 'closing the Dharma doors' which refers to being mindful of what we let into our thoughts. We think the hatred and mean spirited discourse doesn't affect us, but directly or indirectly it does.... but only if you read it. If we want control of the the site, go to the good stuff and let the snivelling tripe just sit there. It doesn't need to be killed off, it can be left to expire, lonely, unread and undignified by comment. In this way we can protect the freedom to speak, and our freedom not to listen. I think this is a great site and a good forum. We should all support it by posting well and walking away from the trash. In this case, yes ignorance is bliss.

Obviously, it has to be paid for, one way or another. County lines are arbitrary distinctions. Parts of Putnam Valley would be better served by a medic coming out of Westchester than one coming out of Carmel or Philipstown. Cortlandt is a fine system under WREMSCO. I don't know if crossing regional lines makes a difference. I think we should be looking at all options and Cortlandt is an excellent one. [i am a medic in Cortlandt and Putnam.]

Holy [expletive deleted] Batman, PONIES!!!!!

Excellent question. It's highly cultural. Some cultures/languages use sacred as profane Great Heavens!, others body parts, or reference to copulatory or excretory function. What constitutes profane has to do with the bug a boos of different societies. Insults, on the other hand, the grown up version of the epithet almost all suggest that the individual has failed meet with local custom or that their immediate ancestors have not negotiated a marriage contract prior to engaging in reproductive activities. Curiously, intimate contact with farm animals is not the basis of either epithets or insults, probably in that either the linguistic invention of profanity pre-existed domestication of sheep or that interactions with livestock were a lot more common and not considered out of the ordinary. I'm not sure we can debate the issue here without running afoul of regulations. Profanity, at its essence, is an expression of anger or shock that takes up space while we get our thoughts together. It serves a better place in conversation, which has an element of spontaneity than it does in written discourse, where we ought to take the time to choose our words, or at least edit before we hit 'send.' My objection to salty language, if there is one, is it reflects emotion, not intellect. I'm not interested THAT someone is angry, but in WHY someone is angry. And like salt, its effect is diminished with overuse. A joke: [i made it up myself, let's see if it gets through...] Scrabble is played around the world, but the letter sets have to be language specific. 'Q's are worth 10 points in English, but only one point in Spanish and one gets only a point for using a 'Z' in French. [This is all true.] That said, the Scrabble company made up a special scrabble set for the fire service...... It has 38 'C's, 38 'F's, 38 'K's and 38 'U's. "Ooh, Ooh, I can spell something!"

I favor the municipal model for Putnam insomuch as the west side of the county does not see the county services that the east does, even though we pay for them. Fewer taxpayers means less interest. Municipalities are better suited to addressing local needs. Putnam has two distinct populations East side is suburban, West side is rural. They are better served by different approaches, at least for the present. Nothing precludes municipalities banding together, much like Town of Cortlandt and City of Peekskill to provide services. That said, I'm certainly open to changing my mind if the County came to its residents with a compelling and well thought out plan for provision of services.

Well said. The Rolling Stones weighed in on the issue in the 70's, to some popular acclaim. Several years prior, the Buddha made it a central tenet of his philosophy. Essentially, everything is a 'want'. Aside from air, water, and shelter from the storm, the rest is all things we crave so badly we think we can't live without when the majority of the world has never even known them. Along with ALS, and BLS for that matter, we can live without tv and oversized cars and air conditioning. We can live in 1000 sq ft houses, heat with wood, and raise chickens. [ If one splits that wood, one no longer needs a gym membership, either.] The logic can be taken so far that for a person at peace with his existence who does not fear death, that even life is a want and not a need. Death waits for all of us. So as we debate how many minutes it should take and what it should be when it arrives, remember that just one lifetime ago, at least in my town, there was nothing here but hard farming and a lot of rocks. It was only the 1960's that the DOT came to the opinion that dying, horribly mangled, in an automobile wasn't OK. The purpose of government [ if it has one at all], is to do things, especially those things individuals can't do alone, to promote safety, improve the quality of life, and to set standards. It all comes at a cost, and I think the better argument might be "What is the value added to our lives by ALS/BLS and is it worth what it will cost?" We know what it will cost. BLS costs about $25 per household per year, with volunteer labor. ALS will cost an additional $10 per person, about $40 per household. We currently pay about $45 a household. Is emergency medical service and transportation at $65 per household per year still worth it? Is the entire EMS package worth one dinner at a restaurant ? Is it worth carpooling to work 10 times a year? One haircut? A pair of shoes? Is it worth waiting an extra 2 weeks to trade in an 'old' car on a new one? Political grand standing aside, we all want the legislators to save us money. but do we want them to save us this money? And if we do.... then every rescue squad should be broken off from every fire department and re organized so that it can bill independently, so that a significant part of what it costs to provide BLS/ALS can be billed to insurance companies. If the legislators want to save us money on ALS, then the local agencies should control the cost of BLS and the county should control the total cost of ALS by billing, rather than having outside organizations set the cost of service. For the majority of Putnam residents, we are already paying through our health insurance for access to ALS/BLS. Local government, both town and county, needs to structure the services so that the insurance we are already paying for is contributing its share to the cost of health care. Many people in essence pay twice for the same service. Fixing this is a great job for government, and legislators who want to provide us with more service at lower cost ought to start there.

Can you hear me now? The use of lights and sirens is a topic that surfaces with regularity, but we seem to let it drop at usage… do we or don’t we. Monty asked a great question in another thread: Can we outrun our sirens? At first blush, it sounds unlikely. We don’t go faster than the speed of sound. On exploration, I found the answer is surprising. I followed up on his post, and searching ‘siren effective distance and emergency’ found the same source, “Lights and Siren: A review of emergency vehicle warning systems.” at www.naemd.org/articles/warningsystems1.htm that is worth reading. 10 to 15 mph is the recommended safe speed to enter an intersection. Another, under the title “The Alarming Sounds of Silence” is also a good read. It comes to the same conclusion. The information is old, but the physics hasn’t changed. Sound pressure drops off as a square of distance from its source [as does light]. It is diminished [attenuated] as it passes through objects. The sound threshold is the range where a sound is audible up to where it inflicts pain. For this reason sirens are usually restricted to 118 dB at 30 feet. [to protect the user]. To be detectable, sound needs to be 8 to 12 dB above ambient noise which in an otherwise quiet car [70 dB] with windows rolled up is about 78 dB. A screaming child is 90 dB [ I know, we all thought it was more than that.], so close to 100 dB is needed for detection of a siren. The math that falls out of this is that, best case, sirens will only be effective [inside a quiet, closed car] up to 30 to 50 meters [90 to 150 feet]. If it is a well insulated car or the kids in the back seat don’t like the movie, it will be less than that. Assume a driver in a closed car with no distractions hears a siren when it is 150 feet away. Perception/Reaction time to unexpected events is roughly 1.5 seconds. [ So if the vehicle with the siren is closing on a common point with another vehicle at a speed of 100 feet per second, then the vehicles collide at the moment the second driver reacts to the emergency. That is definitely outrunning the sirens.] If one assumes that a total of 5 seconds is necessary to perceive [1.5 secs] and to execute [3.5 secs] a ‘see and avoid’ maneuver, then the maximum closing speed over 150 feet, [if the collision is to be avoided] can only average 30 feet per second. That’s 20 mph. Other braking distance models put the initial speed closer to 30 mph. Wow. Anything faster than that as a differential speed between a closed car and a siren may technically be outrunning the ability of sirens to inform the general public of our approach in time for them to take meaningful evasive action. Assume any distractions, assume a little weather, assume there’s noise in the vehicle, assume an older driver, or one eating lunch, and all of a sudden a maximum entry speed into an intersection of 10 to 15 mph sounds reasonable, and a full stop sounds even better. Thanks, Monty, for bringing it up. Does anyone have any better numbers on the subject? .

You asked a good question. I also was out and about without my pager on today and, in a closed car with no radio thought I heard something. I was stopped at a red light and it was 5 seconds later the ambulance crossed. [At about 20, with the passenger watching for cross traffic. [Well done Putnam Valley.] 5 seconds at 20 mph is in line with the physics. I think chasing the goal of defeating insulation as car makers continue to make it harder to crack the nut is not going to be a winning strategy. Given the remarkable advances in technology, On Star, GPS, EZ Pass, and avionics standard in IFR rated airplanes, I'm thinking that ES vehicles ought to transmit a signal that could be received by a unit mounted inside a car that sets off a light on the dashboard telling the driver to look up and look out there is an emergency vehicle closing in. When the collision avoidance monitor lights up in the plane, small as it is, it really gets your attention. [ Glitch in the system, it occasionally 'self reads', pilot knows better but it scares the stuffing out of me. The little planes overlap and the screen turns orange, telling you that you have about 2 seconds to live...] No trees or buildings up there, but maybe the technology could be applied at reasonable cost. That still does not address the worst case of a poor driver not paying attention. I think focus ought to be on educating ES drivers to keep it safe, after all, we KNOW when there's going to be an ES vehicle running a red, the other guy doesn't. I smell an invention.......

Mr. Cuomo contacted me directly to tell me that the bid for 2005 was based on 4500 EMS calls, 1500 ALS calls. He asked that I correct my post.

PCBES 2006 lists 4,400 dispatches of medics, so that is about right. As a homeowner in the Adirondacks, I can tell you that there is very little ALS in the north country and what there is is provided by EMT-CCs, not paramedics. There is not the call volume to sustain it and the distances are huge. REMAC protocols tend to be restrictive with some regions not permitting any interventions on a child beyond CPR without contact with medical control. Most will let you clear a spine in the field, however. For practical purposes many areas don't even have what we would consider useful BLS. And if you have ever been caught in a "Boot Drive", you see ambulances so old that we wouldn't even use them for extrication practice. What we pay for 1 vehicle represents 10 years of total budget for some agencies. Rigs too old for them get sent down South. [Don't have cable either, or garbage collection, or town parks, or senior centers, or zoning, or planning boards. Got guns and snowmobiles and great roads. Quizzically, the taxes are about the same.] That said, Saranac Lake has volunteer helicopter service, North Country Life Flight. YES, you can live without ALS.... You can die without it also.

Ahh, if memory serves, year end 2005 is when the PCBES put out its famous [locally] year end report based on its brand new numbers from its brand new CAD system that said there were 48, 437 emergency calls in Putnam County in the year prior. Most agencies were credited with 2 to 3 times the calls they actually answered and it was later explained when the tones were hit, it counted as a call. That said, if an agency were bidding based on call volume and used county numbers at that time, they might have been off by a factor of 2 or 3. Just a hunch.

This post makes good points, and as there are A LOT of people out there who feel this way, lets address it. Back in 1994, and it may have been earlier than that... I was a vollie EMT [ still am] with 500 over calls who woke up to the news we were getting bumped off the 'good calls' by Paramedics and said just what this person said, Don't need it, don't want it, almost never makes a difference. And I continued to feel that way right up the time a 45 year old fellow with young children was having a massive heart attack. That was when I recognised that I didn't need a medic and that I didn't want a medic. The patient did. If we are here for ourselves, then ALS gets in the way of the fun, if we are here for the patient, then ALS is a tool we cannot afford to lose. I was first in with nothing but oxygen and good intentions. That this man was dying in front of his family was as obvious to them as it was to me. For a second we looked at each other and all started to cry. I picked up the house phone and told dispatch to expedite everything. The medic walks in, says Yeah, it's a heart attack, "But I can fix that." He called for orders, pushed meds and by the time the ambulance got there the fellow was pink and out of pain. When you've stood there wanting to help and watching someone slip away, then you are a convert to ALS. It's going to be maybe $5 more per person in the county, that's $20 bucks a family. That's not lunch at McDonald's. That's certainly not a trip to the movies. Ask any person in this county... 'Will you donate $20 to help a family whose child was struck by a car, to help a family who lost their father to a heart attack, to help an elderly woman who has fallen down the stairs?' and I think they would say yes. If a person would do that, then a person should understand why ALS is what a compassionate and caring community provides to all its residents. However you feel on the issue, find your voices and make yourselves heard.

Even in jest to put forward the idea of injuring oneself or others to prove a point is irresponsible and something none of us can afford to condone. If the legislature is to be swayed back to reason, we must all be professional in our actions and our words. Thoughtless, emotional behavior on the part of elected officials is no excuse for our own, no matter how good it feels. Someone in this debate needs to keep their focus on community welfare and it apparently is not the 'Magnificent 7'. On all the boards and posts, please, make sure what we say is something we can all be proud of and that reads well even when taken out of context, which we all know it will. Don't we all have stories [that can be cleansed of identifying details] of lives we've improved by prompt care? Here is not the place, but meetings of the legislature are. We can ask to be put on the agenda and we can speak to legislators privately, we could...gasp...even write letters. As for county run.... unless or until there is competent management, and we are in this mess for a reason, I think that Putnam has shown itself incapable of managing something as critical as ALS. Contract out to people who know what they are doing.

I'm not so sure about mutual aid. If a municipality does not offer a service, it is not mutual. I don't know if medics can be requested into an area that does not provide the service. I believe General Municipal Law may address the point. In county intercepts, perhaps, but by then the hospital is only a few minutes out so the value is less. There's still a lot we can do with old technology up in the hills. I've got willow bark, foxglove, deadly nightshade, monk's hood right in the front yard. That, single malt and eye of newt..... I can only hope that the County Exec or the legislature comes to its senses. Please, everyone, work the phones. We have 53 days. Orpi has a good point as well. Absent ALS we will need an opinion from DOH as to whether we can keep our 'BLS' drugs. That would be just awful to lose medics and the ability to compensate.

I searched " mechanical electronic siren compare" and found your source at timberwolfsirens. It is written by the manufacturer of mechanical sirens and has a bias towards them. The physics is dumbed down to the point of being misleading. The speed of sound and attenuation are constants. Different frequencies will have different characteristics, as will speakers. Yes, a siren will sound different in a football field than it does in the canyons of Manhattan. That said, what matters is performance. The points about bounce off hard surfaces and directionality are well taken. Not so much the comments about outrunning sirens, at least in practice. In a straight line coming at someone is how they measure these things. In that situation your lights will be doing more for you than the siren ever will. Sirens are there because sound gets around corners and light does not, but it does so at great loss. Performance at intersections is not measured or mentioned, in part because there are so many variables, the test wouldn't mean much. All these devices are designed and measured for getting the person directly in front of you to turn around and get out of the way. They are NOT designed to protect your flanks from orthogonal crossfire. Taking the gun analogy....If you only fire your gun straight ahead [sirens in a grille],-- whether it be rifle or shotgun-- you are still going to get smacked up the left side of your head by the dude with the base ball bat standing next to you. So lets do some experiments. Can anyone out there get some measuring equipment and we can test how well sirens work around corners with closed cars????? Maybe we can come up with something that will improve intersection safety.

I do advocate ALS patient assessment as I find EMD does not adequately triage patients. I assume following assessment that the majority of those calls will be turned over to BLS for treatment and transport. I assume that where EMT-Ps and EMT-Bs know each other, that a good 'P will trust the work of a good 'B and that a good 'P can help the new or hesitant 'B to improve his or her skills. I remember being an EMT-B called for a fellow who appeared near death to me and the family. The EMT-P politely gave the call back to BLS, pointing out key signs and symptoms of vertigo/ear infection, which it was. If, as a 'B your skills have been marginalized by your paramedic, then that is wrong and you are owed an apology. The purpose of system management, and EMD is to allocate resources to best advantage while letting as few calls as possible end up underserved, that is, receiving BLS when ALS is appropriate. In busy systems, where calls wait for resources, then the advantage falls to conservative allocation of ALS. In slow systems when the unassigned medic will likely not be assigned another call, then the advantaqe falls to more liberal use of ALS with diversion as necessary. Each system is different and needs to be managed for its own quirks and eccentricities. Originally, the issue was the Putnam system and my comments apply to it. I would refrain from judging a system in which I had not worked.

I didn't follow that all. As someone who was an EMT-B 15 years before crossing over to EMT-P, I value BLS. Good assessment is the bed rock of good care. Those in the field have the unique opportunity to see the patient in their natural environment. The pre-hospital provider can have a large positive impact on care if they have done a careful and thorough assessment. As a BLS provider, I agree that a majority of outcomes will not be changed by ALS pre-hospital. As an ALS provider, I see the opportunity to educate, to reduce time to definitive care, and to improve outcomes in the process. Not everyone benefits from ALS, but many do. That's why I favor ALS assessment when available, and that's why I became an EMT-P.

In Putnam county, well, yes, I do, and maybe that's because it's a low volume system. In high volume situations resource allocation makes sense. In a rural system where time to scene can be 15 minutes, waiting for BLS to get on location and decide it's worse than it sounded delays ALS or puts it out of reach. Patient evaluation is only as good as the person who does it. Mostly, I'd like to see evaluations done by a provider who is paying careful attention and has the experience to make a good decision. An ALS evaluation that includes the EMT is also a teaching opportunity. Explain to the EMT what one is looking for, what one found and why BLS is the right level of service and what would have made the call deserving of ALS. One way to tackle medic dependence is to show the EMT that patient evaluation is not rocket science, but it needs to be done well. My experience has been that on average-- but by no means all the time--one gets better BLS out of an ALS provider than a BLS provider. I think you are correct that the foundation of any system has to be good BLS. And yes, I agree medics are over utilized for care by medic dependent providers, but that is a different issue.

ALS in conjunction with timely BLS is, or ought to be, the standard of care. In defense of those who manage EMS in Putnam, it is not an easy county to manage. That said, it is not impossible to craft an EMS system here that takes into account level of care, response times, and affordability, but it continues not to happen. So long as leadership responds to single driving forces and what should be tertiary concerns --'what is the cheapest solution', 'how do we keep costs out of the county budget', ' how do we get re-elected or keep the legislators happy', 'what can we do that doesn't upset local fire departments'-- then we have scant hope of ever having an EMS system that meets its primary function, which I think ought to be to establish a consistent standard of service across the county that provides appropriate access to ALS and useful response times. I think it is also incumbent upon a county or its towns to address public health issues and craft a system that is responsive to its residents' needs. Standard of care: I think every patient should be assessed by a paramedic. Geography drives staffing levels in Putnam, not call volume, so we have the resources in place to send medics to all calls --with the caveat that they can be diverted or reassigned. [if PD/SO are EMTs, BLS calls can be left in their competent hands pending arrival of BLS transport units if there is another true emergency prior to arrival of BLS.] How serious a fractured ankle, or why an elderly woman is not feeling well is best served by a provider who knows how to do a proper assessment and does it often. Cardiovascular issues can be subtle. Given the 3 to 5 minutes wasted by 911 dispatch on data entry and over the phone evaluation, I think the time and resources much better spent with automatic dispatch of ALS. ALS doesn't need to go lights and sirens, but it ought to go. Quality of care: I think ALS early brings professional care to bedside and ought to be the goal of any EMS system. Any patient who will be admitted to a hospital or will need blood work and treatment is well served by that care starting as early as possible and continuing until transfer to hospital staff. Can most of our patients live without it? Yes, but it is a level of service that can save medical costs in the longer run and brings comfort to both patient and family. Time to service: The county or towns need to set a standard for time to service. ALS, BLS and transport. We don't have it and we can't plan without it. time <=> quality + resources <=> expense. It's a dynamic equation. Set standards, review and evaluate both standards and compliance. Decide what we want, what we need, and strike a balance for what we can afford. Who pays for it: I think a system ought to be primarily user funded with reasonable upper limits, the balance covered by taxes. OK, it's all user funded. We pay for insurance, or through taxes or directly. If a county 'saves' $500,000 by outsourcing EMS, the residents will still be paying the same. The bill will come in a different envelope. One of the fundamental purposes of central government is reallocation of resources. It is like insurance. If residents pay the county and/or town every year, then the resident doesn't get as badly soaked when he has an emergency. If the user sees some of the cost, there is incentive to control those costs by using it carefully. Public health is better served if people are not so burdened by the cost that they cannot/ do not call for aid when they or a family member needs it. How do we control costs: I think towns or counties ought to have direct control over how the cost of EMS is allocated. For the most part, we cannot control what the costs of EMS are. We can control how the costs are allocated, and in doing so, we actually can have some minor impact on overall cost. Contracting out to a for profit EMS provider and walking away is like selling a child into servitude. Yes, care will be provided, but at what cost? I think the county and some towns have abdicated the role as overseers of how care is billed. This is good role for government and it is not being addressed. Who should provide the service: After the county and/or towns decide what service is appropriate, the provider who can provide that service at the least price should do it. Who provides the service is not an issue. If volunteers can do it, great... but they have to do it. If a for profit company is the best bargain, then that is great as well. There is nothing wrong with making money at EMS. There is nothing wrong with asking users to pony up for services. Roads, lawn care, refuse removal, plumbing, carpentry all cost money and we pay for it and pay the provider decent profit for his work. Health care is no different. If the county can provide the service for less, then the county should do that. If the private sector is the best choice, then do that. Expecting, even allowing, private sector to subsidize EMS is questionable management practice, at best. Every year fire departments and ambulance corps and Indian Point and Putnam County put out pamphlets telling residents how to plan for that eventual emergency. Know what to do, plan ahead, know what you need, stock what you will need, plan for how you are going to get together and where you are going to go. Keep some extra cash on hand as well... Then county officials and our elected representatives go back to their offices look aghast when there is a knock on their door and the county needs an EMS system and now it is an emergency. They never saw it coming. As a resident, as a volunteer BLS provider and as a paid paramedic, I am completely discouraged by how much we pay for management in this county and how little we are getting for our money.

If a very large python curls up next to you, it is also a sign of impending death.

Camps have medical directors who outline what you can and cannot do. There absolutely is medical control. No one with any training can touch a patient without it. My take is EMTs are better suited to the task as it tends to be minor trauma and stings.