ckroll

Totally inappropriate, not once, but twice.

Outside of the northeast, snakes are a different story. Cotton mouths, coral snakes, or king of the desert Mojave Rattlesnake can all be killers or inflict grievous injury and deserve a lot of respect. Neurolytic venoms found in exotic species are painless and can shut down respiration, even days post bite. Australian snakes are known as one steppers or 2 steppers..for how long you have to walk after getting bitten before you die. Snakes in cold climates are pretty straight forward; there's only one kind of venom. Hemolytic venom, as in our crotalids, is extremely painful but damage tends to be localized. You know if it's a 'hot' bite and even when you have been bitten, treatment is routine. What made many bites so deadly to our ancestors is the infection that often follows a bite. It is analogous to a full thickness burn and needs to be treated as such. Prior to reconstructive surgery and antibiotics, a venomous bite could have disasterous consequences. Now it's just a lousy way to spend $15,000. If someone is really concerned about bites, a sawyer extractor is a great kit for about $15. It will reliably remove almost 50% of the venom, but needs to be applied several minutes post bite. More people die or receive serious injury from dog bites, but none of us refuses to go into a house with a dog in it, or kill it just to be safe. Cat scratches are far more painful than snake bites and carry a higher risk of infection. Talk about deadly and dangerous... there are things growing in 'all you can eat' salad bars that give me nightmares. And yeah, what is it about spiders.... they make me scream like a girl.

1. Snake bites don't hurt. I used to get wrapped by my 50 lb python all the time... and he could get all the way around my forearm. The teeth are very small and and very sharp, you can't even feel it on the way in. It will hurt a little on the way out if you don't unhook the properly. Never once got an infection. 2. Whatever education you got, get your money back. You can spend years looking for 'hot' snakes around here and never find one. 20 years in the Valley I've seen 3. I put one in the bath tub to clean her up before a photo shoot and she still didn't get her ugly up. 3. Newsflash, no one at a medical center can identify a snake. I mean, they can tell it's a snake, but that's about it. Lose the fear and get good information.

Corn snake or milk snake. Eastern Milk's are more common to the area, but I lean to corn in this case. Without it in hand can't make a positive ID. It looks nothing like a copper head, who at that length would be easily as wide as the stripe in the road and has wide, triangular markings more the color of chrysanthemums. Markings that cry out 'candy cane' will be milk or corn. If memory serves, scales on corn snakes are weakly keeled [ have a ridge up the center]. Anal plate is single in milk snakes, divided in corn. Snakes are remarkable animals that do not deserve our fear or contempt. They are no threat to humans, save the drunk adolescent who thinks it would be fun to poke a rattlesnake and frankly, getting those people out of the gene pool is a service to mankind. There have been no fatalities in the Northeast from snake bites as long as anyone living can recount, that were not due to improperly handled imports. They are quiet, dutiful mousers and insect eaters who will bother no one if left alone. To truly like and enjoy the company of snakes is to have moved past childish and irrational fear and to know genuine inner peace. So let go the inner monkey and curl up with something that knows how to curl up. They are soft, friendly, if not affectionate, they smell really good and are great listeners. Putnam has about one reported venomous bite a year, usually a rattlesnake in the highlands. EMS issues if anyone is interested: If a bite is painless and has no swelling it is non venomous or is a 'dry bite' from a venomous snake. Venoms from copperhead or rattlesnake are hemolytic and will cause bruising, swelling and intense pain. Always call ahead and take the victim of a snake bite that is presumptive for venom to a hospital that has antivenom in stock. Last I checked HVHC still stocked but it is expensive so stocking changes as perceived needs change. Envenomated bites to face or hands probably need to be airlifted to Jacobi Medical Center which is the snake bite center for the East Coast. Beware anaphylaxis which is rare in first bites but may be an issue in repeat bites. No sucking, no cutting, do not restrict blood flow as this will increase local tissue damage and keep bite at the level of the heart. DO NOT KILL THE SNAKE. If it is non venomous, it is not necessary and if it is a rattlesnake, it it federally protected. Taking a live snake to the ER guarantees you will be seen immediately and will be remembered for a long time. In fact, they are only going to treat symptoms, anti venom is only given for cause. For upland vipers which is all we have locally, there is only one course of treatment and it is only initiated if there are definite signs of envenomation or allergic reaction.

Putnam Hospital is supposed to have one Weds July 11 at 7pm. It is listed on pcbes.org under training and call audits. I think a certain number of CA's can be out of region, but you'd need to check. It's good for two hours, but gets canceled regularly, so check with Putnam 911 before going.

thanks, but ...she has the food grade saw.

Up in the 'valley, asking about chain saws is kind of like going to an NRA convention and asking if anyone owns a gun. The department owns a lot of saws, but they don't get used enough to keep them safe to use. Most disasters we BYOCS. Personally we keep a long saw, a general use, both stihl's for the kick back feature and we have a 'food grade saw' that we keep vegetable oil for chain lube so we can use it for cutting wood we use in the salmon smoker....I keep a cute little electric one for indoor use. It isn't enough to train on a chain saw; users need to be regular users that have hundreds of hours practice. Chains need to be sharp and users ought to be wearing chaps. The opportunity for disaster is huge.

Wow. If you think people suck, you need to find a profession that involves less contact with people than EMS has. It is not ours to judge and we do not know what life experiences have brought people to the place they are. Difficult people are difficult for a reason. If you're only in EMS to help the nice, clean, grateful, people, you need to let go your disgust for humanity or perhaps sell cars for a living.

The act of asking permission from the existing patient is a courtesy extended to make the first patient aware of what is about to happen and to make him or her part of the process. Needing emergency medical treatment is hard enough on a person and creates a feeling of loss of control. As with all medical care, let the patient know what is going on and get approval before doing things. No stable patient is going to deny us the opportunity to provide care to another human being. Explain that something bad has happened to someone else, that they, our first patient is and will remain our top priority, but we need them to understand that it is necessary to stop and help, if it is OK with them, and you will receive a resounding yes. By communicating and building consensus with the first patient .. if the situation goes to hell, and you do need to load and transport a second patient... and divert to a trauma center or a landing zone.... at this point, you need the cooperation and understanding of the first patient. The reason to stop to assist is that it may be something bad, and if it is, you and your first patient may get tied up. It's not likely, but it's not impossible either. You have a legal commitment to the first patient and a moral/ethical commitment to any that follow. Allow the first patient to share in the sense of doing what is right and compassionate by involving them in the decision to help others. Everyone goes home happy. EMS is much like whitewater rafting. Things can go badly, and it happens quickly but in very foreseeable ways. Read the rapids before you run them and plan for unexpected turns. A few corrective strokes early beats pulling against current later.

One definition of an MCI is more patients than resources. A full ambulance passing an MVA would seem to me to be a reasonable extension of this. Different standards apply in that situation. Someone has to control the scene and triage. Absent a life threat in the back of the passing ambulance, I see an argument for stopping and staying until some one of authority is on location. In an MCI we can be called on to make the life/quality of life decisions and not always for the same patient. Sometimes it is necessary to perform a rapid extrication on one person to get to someone else gravely injured. If I were put in the situation of passing an MVA, I would explain and ask permission [of my stable patient or potentially unstable patient] to stop, then triage and make care decisions based on how I could render an appropriate level of care to the most individuals. If the loaded patient is stable [and as an ALS provider, I really should have seen to that already], then what the passing ambulance can bring to the MVA is radio communication with EMS dispatch and evaluation. While any number of motorists may have called in the 'car in the woods', trained personnel reporting 3 victims, need for extrication, expedited response and maybe launch a helicopter, is a huge value add. If establishing an airway or controlling bleeding, or just keeping a panicked well intentioned bystander from yanking the kid with the neck injury out of the car to save him from a leaking radiator is absolutely priceless. And none of this is knowable if you do not stop and triage. It shouldn't take more than 10 minutes for back up to get there and then you are on your way. Years ago I was in the position of transporting a nosebleed in an elderly gentleman when my corps failed to field a second ambulance for a child with an obstructed airway from a dislodged trach tube. Mutual aid was not assigned and help for this person was at least 20 minutes away, the hospital 8 minutes. We had to drive by the home of the second call. I asked permission of my patient's family, we stopped, we picked up the second patient. The fix took 3 minutes to suction, reinsert the tube and deliver blow by O2. The radio report to the hospital was complicated. While I fully expected to get reamed out by some authority somewhere, it never happened. Right there in the front of the BLS protocols it says nothing in the protocols is intended to replace good judgment. A case can be made for stopping, and a case can be made for not stopping You can hide behind the protocols or you can make them work for you, it's your choice.

Stop to make sure there are no life threats, Drop off manpower and equipment if appropriate and Get rolling to the hospital with patient number one... Stop, Drop and Roll,...it's got a nice ring to it.

In Putnam Valley we used to have a prearrangement with Animal Control to do emergency pick up for animals. Animals are often unrestrained passengers in PIAAs and suffer as much, or more, than their human companions in rollovers. As with rescues and evacuations, owners are often unwilling to leave furry family without care. Peekskill Animal Hospital is right next to HVHC, so PVVAC and animal control did package deals where the family could go to HVHC and the pet would get delivered next door. More than once I've done an extrication where pets were involved. It wasn't a problem. You do need a pre-plan, however. Use a pillow case to bag cats and rip a sheet for whatever dog control device you may need. Letting injured owners and especially children know that EVERY member of the family is getting attention can be an important part of patient care. That said, don't pick up what you can't put down. There has to be a way to shelter a pet at point of delivery, so the animal has to go somewhere it will be welcome. If I have to, I'll transport extended family [if I have a plan for what will happen on the other end], hope I don't get caught and take the whipping if I do. I'm with ALSfirefighter, people can be dirtier and smell worse. If crew is allergic and there are no good options, I'd put pup in the front seat on a sheet, with a halo harness made out of a sheet tied into the shoulder harness, and close the door to the box. ... and keep some milk bones in the glove box. Again, pre-plan so it isn't necessary. It's someone else's emergency; it's our job. Then there was the time I took a live snake to HVHC because I refused to kill it for purposes of identification.....

The idea of a county standard is interesting, but I'm not sure it would be helpful. These tend to get promulgated as SOP's or the silly SOG [ It's a Guideline, not a Procedure, so if a person ignores it they're not actually in violation of anything, like that will keep lawyers at bay..]. V & T is clear on the matter as has been pointed out by a few postings. One may exceed the speed limit or go through controlled intersections against the light.. SO LONG AS IT IS SAFE. The moment an accident occurs, well it wasn't safe and the driver of the emergency vehicle is at fault, no matter who was responsible for the accident, and no matter how many lights or sirens were being used. People who read V&T as offering protection,in the event of an accident, to drivers of emergency vehicles are completely mistaken. The cop can't write you a ticket for speeding, or creative use of paved surfaces, SO LONG AS IT WAS SAFE. In exchange for that protection, the burden of safety falls completely to the driver of the emergency vehicle. The moment we turn on lights or sirens, we accept responsibility for all the actions of all the crazy drivers out there, and there are a few of them.

Don't hit people. Don't put yourself in a position where other people will hit you. Good advice for driving; good advice in general.

A couple of things.... Granted I work in a town with 2 traffic lights, but half the time I respond with neither lights nor sirens and respond lights alone unless I'm coming up on someone. Mostly I'm looking to go highway speed and have people yield as appropriate. My experience has been that people will yield to an emergency vehicle with lights on, but tend to do stupid things when challenged by speed, lights and an air horn. It is rare that seconds or minutes make a difference and the EMS vehicle is fully responsible if an accident occurs while responding as if to an emergency. Maybe there isn't such a thing as half a response, but perhaps there should be. I recall someone wise telling me that one of the qualities of a paramedic is that they were the only person in the room who wasn't allowed to panic. Paramedics are responsible for controlling the scene and that includes how they drive and how the ambulance drives to the hospital. If one is clear from the time that an assessment is complete what the level of urgency is and communicates clearly what the response should be, then hold the crew and the driver to it. Some days the crew needs to pick it up and some days they need to slow it down. Be constructive about it, tell them why, treat them like intelligent adults, but let them know what you and the patient need. If the paramedic can't work in the back of the ambulance, then the added speed is a hindrance not a help. EMS has changed since the addition of ALS. Emergent care can happen at the scene. Transport, save for very special circumstances, ought to be non emergent. For the most part I find volunteer corps responsive if you take the time to explain t to them.

" I don't think were in the business of justifying $hit service by saying "meh, 10 minutes wouldn't have changed anything." " Transport time is situation sensitive. I prefaced my remarks by saying ALS was on location providing care. At that point ALS can update dispatch with better information. I can't remember a call I've done where 10 minutes to hospital would have changed outcome. I agree that a standard makes sense but to date, no agency, Federal, State or County has done it. Remember the golden hour, so sacred for so long, was the result of too many beers and a cocktail napkin. There is no science to support it. No doubt, transportation sooner is better, but it comes at a cost that needs to be justified. Rural EMS takes time. ALS on scene in 10 minutes from time of dispatch with transport on scene in 20 minutes from time of dispatch is realistic for most situations. Keep it in perspective. In upstate NY the nearest ambulance can be 30 minutes away, hospitals an hour. When rafting the Grand Canyon of the Colorado River, just activating EMS requires a radio and a wait for a passing commercial plane to pick up the message and relay it to a rim station which sends a helicopter as available to confirm position and waits for rafters to reach an acceptable landing zone. Not that anything hazardous can happen in a 110 degree, mile deep crack in the ground stocked with white water, scorpions and rattlesnakes.

There are a number of issues here. Response time: The patient sees the time from 911 call to the knock at the door as response time, and if the person at the door has drugs and a monitor, they've got care. I don't see time to transport as all that important so long as ALS, which is the standard of care, is on scene. I can fill 10 or 15 minutes assessing and treating on scene and the patient does not suffer for it. [The occasion where dispatch sent ALS and forgot to dispatch BLS I did need to tell a few stories to pass the time.] Public Education: USELESS, actually worse than useless, it is a threat to public safety. Education implies rational thought, and no one is thinking rationally when they have an emergency. Assuming we could do the impossible and teach every citizen when to call for assistance, and to not call unless it was a real emergency... How is someone who is not medically trained and in the middle of a crisis going to make a good decision? We will still get "Echoed" to emphysema patients who 'can't breathe' because they forgot to turn the O2 back on after their cigarette... and we will have the nice elderly couple who doesn't want to be a bother calling when dad actually hits the floor from the chest pain. The only useful evaluation of a patient is by a trained medical provider on scene, not family, not someone working from a list on the other end of a phone. ALS should assess every patient. You get what you pay for: Yes you do and the public will scream like a cat in a bath tub if you raise their taxes. Divide calls by households and every 7 to 10 years a homeowner calls for an ambulance. Ponying up for service that 'other people' use and he doesn't... not popular. That ends up in a tax or fee for service debate. Then the wealthy/insured will get care and the poor or those on limited incomes won't. My town is 46 square miles and handles 2 calls a day. Money can't fix that. Do we have a problem: I don't see anyone pointing to a single call where time to transport changed an outcome. Mortal injuries are just that, response time isn't going to change it. Respiratory and cardiac events can be treated/stabilized in the field by timely ALS. If ALS can't stabilize it in the field, chances are whether the time to hospital is 30 minutes or 40 minutes isn't going to change the outcome. We have to work with what we have or can afford, guys. Pay ALS to evaluate and initiate treatment ASAP and get the transportation there when you can. You do that with medics in flycars and by pooling volunteer EMTs in ambulances that are staffed and properly located or by enhancing volunteers with a couple of paid ambulances staffed with a pair of EMTs that can float the county.

Excellent discussion. I'm guessing we care about BP because we intend to do something about it if we don't like the numbers. I recall an MD at Hudson Valley making a compelling case at a CA that improperly sized cuffs can give aberrant readings and that treatment decisions need to be based on good numbers, especially with trauma and with those who are medicated to decrease cardiac work load. We don't use what we don't have handy. I got a compact set of 4 cuffs with the quick connect syphgmomanometer and my experience is that BP numbers correspond better with patient appearance when I match the cuff to the patient.

Not only should there be some common sense added to the pot, EMS is drilled to provide right care at the right time.. 'treat the patient, not the machine.' It appears someone needs to add 'treat the patient, not the protocol.'

OK, BLS in,--and I am assuming by 'in' we mean on location-- 5 minutes isn't going to be provided by persons who are not already in uniform and in a running response vehicle... and less than 5 miles from the call. If a town is roughly 100 square miles (10 miles on a side for the mathematically challenged), that's two active response units. As stand alone EMS, the cost is monstrous. It sounds like towns need to consider having all town employees trained to first response, and at least one of them made available day to day. How about the postal employees? I wouldn't mind getting my clipper coupons and electric bill an hour later if it helped out a neighbor? Or put more police on patrol and have them trained to the EMT level and equipped to treat and evaluate? Early, ACCURATE patient evaluation is key to managing resources.. and those of us in the field can attest that EMD gets it wrong more often than it gets it right. Nothing replaces on scene evaluation. So, maybe towns need to hire their EMT's in other capacities and get them on payroll and receiving benefits and doing something useful for the town on their down time...or require the existing employees to share FR duties and compensate them for it?

To quote one of the great thinkers of our age, " You can't always get what you want, but if you try, sometimes, you just might find, you get what you need." While I don't think Mr. Jagger was referring to EMS, he could have been. If emergent health care is addressed on a town by town basis, the result risks becoming both uneven and expensive. Towns within counties or consortia of geographically aligned towns need to sit down, sooner rather than later, to discuss what level of care towns want for their citizens and how it should be financed. It is a complicated issue with no good answers. If towns abdicate their responsibilities, they put themselves, AND THEIR RESIDENTS at the mercy of county officials whose interests may be more centered on empire building than on delivery of emergent health care.... As free labor becomes proud history, the full cost of services needs to be allocated just as health insurance providers are cutting back benefits. A system where the user is solely responsible for funding EMS, while attractive to the taxpayer (and therefore, the politician), means that those who use the system most, often the elderly, must make the choice between crushing charges or not calling for service when it is needed. The thought of neighbors suffering, or dying, at home for fear of incurring unmanageable bills should give pause to the even most fiscally responsible person. "I don't care what it costs.." won't give us affordable EMS and offers no assurance that we will get good EMS. "What is the absolute least we have to pay..." won't get us good EMS and offers no assurance we are even getting our limited monies' worth. Local government officials have scant understanding of what services are provided or how they are billed. Everybody lives somewhere. As residents and as EMS providers, we are in a position to shape the future of EMS by getting involved locally and getting our officials educated. Let's start by asking our towns to ask "What level of service do we WANT from EMS?", "What do we NEED from EMS?" Then we ask "Who should provide the service and how should those costs be allocated?" So... What do we want? What do we need?

As one of the last people who thought they'd end up in the fire service, and having been here almost 20 years, I asked the same question once of people and got interesting answers. Those of us with no family history or cultural connection often report an experience with fire before the age of 12. My husband's father's business burned to the ground when he was young and he remembers the experience vividly. I was four when the neighbor's barn went up at the end of haying season with animals inside. Still, if I am in a fire and feel the heat seep in where the nomex hood meets the collar of the turnouts, I get flashbacks. Ask the unlikely firefighters/ems if there ever was a sentinel event you may be surprised how many recall something when they were young. The emotional subconscious is a remarkable thing. You're grown up, minding your own business sipping a double latte and doing the Sunday NYT crossword in ink when all of a sudden something irresistable pops up inside and says "Go out there and DO SOMETHING about fire."

Indeed, the cat was rescued because she was stepped on, by someone else, during overhaul. That the save was accidental makes it no less gratifying to the homeowner, or the cat. My question is, do we/should we assign value to responses? A recurring theme in emergency response is a sense among some that certain situations are more or less deserving. I have yet to be won over to the argument.

Interesting topic. An underlying theme that deserves discussion shows up frequently in both fire and ems: Should we only respond to 'high value' assignments and what constitutes 'value'? I am unmoved by the 'what do you tell the family of a member who dies...' logic which is as emotionally charged as it is meaningless. We respond to wires down, pump outs, brush fires, minor PIAA's. Immediate threats to human life are rare. None of us should be putting our lives on the line for any of it. The implication is that going into a burning building for a sofa in flames somehow has value where going out on ice after a dog or a deer does not... that sounds silly. If we are to restrict responses only to human life threats, it is a slippery slope. Do we then restrict our responses only to life threats that do not involve stupid behavior? Now we're down to one or two calls a year. When a person calls for aid, it is because THEY think they have an emergency. Whether it is large or small to us should not be the issue. Our job is to train, to be prepared so that these things are not a risk to our lives or anyone elses. In almost 20 years as a fire fighter and EMT, one of my finest moments was handing a purring tabby cat [that was brought out not breathing and unresponsive] back to a woman who had just lost her home to a fire. It was the only thing that mattered to her.... and it should be the only thing that matters to us.

Sometimes it makes sense to have a backfill Medic/EMT pick up a job from a medic alone. If a volunteer agency has been toned out and failed to cover, [using the paid EMT and generating the medic alone] and a second call drops for the same agency, then it is highly unlikely that the volunteer agency will cover the second call. In this situation, a medic alone cannot transport whereas the Medic/EMT can. If medic alone and Medic/EMT are equidistant to the call for aid, then it is a better use of resources to send the Medic/EMT to a call where it is almost certain that it will be needed as transport, keeping the Medic alone available in hopes the next call to drop will be with an agency that can muster a full crew. We all know how dynamic EMS can be. Any system depends on those in the field matching resources to conditions and making what hopefully are good decisions.