ckroll

http://www.krpc.com/proffed/snake/Snakebite.cfm This is an excellent overview, and it comes with a test. Sounds like self study credit to me.

As for protocols, I know of none. It is a poisoning or toxic injection. You can call poison control. Any agency that has resident populations of venomous snakes ought to discuss what their options are. The concern is not so much the bite itself. Loss of circulation, pain, long term infection secondary to a large open wound are all bigger issues.

I've got a query into HVHC. I know as a certainty that they had antivenin several years ago. By no means should all snakebites go to Jacobi. Confirmed hot bites in children and small adults, yes, but a lot of snake bites are ordinary water snakes. Venomous exotics and, in Florida, coral snakes are elapids and the venom is neurotoxic, so there will be only minimal pain. We are fortunate to have as natives only copperheads, [a docile snake], and Timber Rattlers, who are both crotalids--pit vipers-- that have hemolytic venom that destroys tissue and is very painful. Shortly after a 'hot' crotalid bite, there will be bruising at the point of injection and incredible pain. Swelling takes hours to develop, so there is a larger window for initial treatment... assuming it is a first bite. Subsequent bites may trigger an allergic reaction that can be fatal if not treated, so in these circumstances, the closest hospital is the best. As people who get bitten once have habits that often get them bitten twice, that is something to consider. Keep in mind that both copperheads and rattlesnakes are upland vipers that live in high, dry, wild terrain. They tend to come down some in dry years if their prey has moved down. Anywhere near water in New York, the greatest likelihood is that the large snake is a harmless water snake... who suffers mightily by being marked somewhat like a copperhead. In 20 years I've seen 3 copperheads locally, and that's looking for them. As for snakes... they are the sweetest of creatures. I relocate snakes for those who do not want to live with them. I ask if they have had a mouse problem....and the answer is invariably yes. I ask if the mouse problem has gone away recently and the answer is yes. I ask them if I had the perfect mouse trap... one that resets itself, is silent, turns mice into small brown pellets, moves itself to areas of greatest infestation if they would want one and they ask yes where do you buy them. I tell them it's called a snake. If you have a snake it's because you have mice. Love them and learn to live with them; they are a gift.

On a lighter note: Ravel's Bolero for seizure calls Beethoven's 9th for chest pain Holst's The planets abdominal pain Respighi's Pines of Rome for EDP's and without question Rolling Stones... I'm so hot for you and you're so cold .. for CPR in progress.

Hot button issue. It's about the patient and responsibility getting there and getting back. Music should be prohibited in emergency response vehicles. Might I suggest a career with the postal service?

It's a loss that we'll all feel. I know that at one time the state police helicopter had to be a choice of last resort in that the state does not compete with private companies. When response times get longer, I don't know if that changes. I wonder if Hudson Valley Hospital no longer having helicopter landing capability played into the decision to drop service in the area. Who really knows what helicopter resources we have left and what response times we might expect to Westchester and Putnam? It is what it is, but we need to have a good working model of what the options are now.

And the thread is officially hijacked......Westchester protocols now have etomidate for all medics and above the medical control line at that ?

Have we been checking our own scales, guys? Some days it looks like 'bariatric ambulance' refers to the crews, not the equipment. Let us lead by example on this one.

Excellent points. What QA/QI is almost never based on is patient injuries/outcome. In 20 years doing this I've gotten feedback [other than what I read in the newspaper] maybe a couple dozen times. The agency that I work for that is hospital based is pretty good about it, but other agencies have no handy feedback capability. What with the push to make records electronically accessible, should there not be an effort to get existing information back to providers? Even lab rats get a treat for pushing the right buttons. How do we get better at this if we don't get timely information about our decisions? Can you imagine if doctors treated patients but weren't given access to information about whether or not it was the right thing to do? That 'the EMTBravo QA/QI committee' works on generalizations is how it should be. There really shouldn't be detailed discussion of specific facts of a call on an open forum. Such discussions should not happen outside the primary care givers. Ergo, assumptions about will be made. Thank goodness that out in the field we never have to make assumptions, as all the facts are readily available.

A couple of things.. I would guess that things have changed. These discussions help current decision makers and just as important, future decision makers, come up with a rationale for the decisions that they do, or will, make. One of the good aspects of these discussions is that when we need to make the decision in the field we have 10 or 15 seconds to make a call and endless time here in threads to play with it. I know I make better decisions having had the time to think about it after reading these threads. When I saw we'd brought out the medevac topic again, my first thought was that it was one of two other calls that happened this week. I had the opportunity to talk to principals on both of them, and both sounded like very good decisions. Without question, air service has a place in EMS, even with otherwise short transport times. Critically injured patients may present a situation where there are NO good options and we have to pick the best of the bad ones, and in those situations having air service as one of the options is invaluable. Think of air service as a treatment modality, which it is. Cost/benefit/risk is a vast topic, especially given the current health care issues. There is danger attached to helicopter use, just as there is with, say, surgery. The good needs to outweigh risk to the crew and patient, the price of the good needs to be compared to the options. Using up the resource needs to be balanced with the odds that someone else more deserving will go without. And let us not forget to pile on 'the price of a life'.... and the inevitable litigation that ensues if the outcome is poor. We cannot sit at the side of the road puzzling through this stuff. As providers we need to return to BLS that starts with GOOD CLINICAL JUDGMENT, [NYS emphasis, not mine]. Sometimes that decision, in the long fullness of time, will be shown to be correct or incorrect, but that in no way reflects on the judgment made in the heat of the moment. If all indications are that there is significant injury and time, or airway, or smoothness of the ride, or the capabilities of the medic are ,in the judgment of the medic, worth the risk then it is a decision well made. If the injuries were so profound that I didn't think I could properly manage a patient by myself for the ground trip, then I hope I'd have the humility to call for added help, most likely air transport. If the patient were one pothole from permanent paralysis, I think I'd ask for a helicopter. If the patient was clenched, projectile vomiting and needed full immobilization, I'd call air. What we can't do is simplify the arguments to 'Any chance is too much of a chance therefore it all goes by air.' or 'There's never a situation that can't be met by ground transport.' It's why I never tire of this thread. Nasty or nice, here and now is the absolute best place to have this discussion. Here is where we ask questions and build framework for our own decisions out in the field.

Each case should be judged on its merits, or lack thereof. I believe that is what NY does. If time has been served, I see no reason why EMS should not be a career option... with adequate supervision. I'd be queasy about stalkers, serial killers and foot fetishes.

According to the county structure, Alpha is 'BLS cold'. Bravo is 'BLS hot'. Charlie is 'ALS cold',and Delta is 'ALS hot'. Echo is really really hot At one time it was the intention that ALS not respond to Alpha or Bravo calls, but given the relatively low volume in the system, it was decided that medics could be dispatched to Bravo level calls. It's a poor system. Any system is only as good as its weakest part. At some point a hysterical, untrained, civilian[ the caller] is part of the process. In the end, EVERYONE has difficulty breathing, and bleeding is always severe. EMD adds 3 to 5 minutes from time of call to time of dispatch, and adds nothing to the process. For a while, as an experiment, I kept a bag with weighted choices [ 5 alphas, 4 bravos, 3 charlies, 2 deltas] and drew one for each call. Randomly selecting a response is about as accurate for what the call actually turns out to be as it is using EMD.

Opinion 2005 - 1 This opinion represents the views of the Office of the State Comptroller at the time it was rendered. The opinion may no longer represent those views if, among other things, there have been subsequent court cases or statutory amendments that bear on the issues discussed in the opinion. AMBULANCE SERVICE -- Fees (retention of by service provider) CONSTITUTIONAL LAW - Gifts and Loans (collection of unpaid ambulance fees) GENERAL MUNICIPAL LAW §122-b; STATE CONSTITUTION, ARTICLE VIII, §1: Towns may fix fees for ambulance services, to be paid by persons requesting the use of such services. Although the town, by rules and regulations, may provide for the collection of such fees by the entity providing services under contract, the fees collected belong to the town and may not be retained by the service provider for its own use. The town, by modification of the contract, may pay an additional amount to the service provider above the amount set forth in the service contract, but only in exchange for additional consideration to be provided by the service provider. To avoid contravening the constitutional gift prohibition, it is incumbent upon the town to take reasonable steps to collect unpaid ambulance fees. This is in response to your inquiry concerning the provision of emergency medical service in a town. You indicate that the town currently contracts with a not-for profit organization for the provision of emergency medical service to town residents. Pursuant to the contract, the town pays a fixed consideration to the not-for-profit organization. The town is considering charging a fee to users for this service. You ask: (1) whether the emergency medical services provider (the “provider”) may retain as its own monies the user fees imposed by the town for the emergency medical services; (2) if the provider is not permitted to retain the fees charged, whether the town may pay additional amounts to the provider above the amount of consideration stated in the contract; and (3) assuming the fees belong to the town, whether the town is obligated to pursue the collection of unpaid fees from users who fail to pay for ambulance services. Section 122-b of the General Municipal Law authorizes towns to provide emergency medical service, general ambulance service or a combination of such services for the purpose of providing prehospital emergency medical treatment, or transporting sick or injured persons found within the boundaries of the town to a hospital, clinic, sanatorium or other place for treatment (General Municipal Law §122-b[1]). Under section 122-b, towns, inter alia, may contract with one or more organizations to supply, staff and equip emergency medical service or ambulance vehicles suitable for such purposes and operate such vehicles for the furnishing of prehospital emergency treatment (General Municipal Law §122-b[1][c]). Towns may fix a schedule of fees or charges to be paid by persons requesting the use of apparatus and equipment in the provision of emergency medical services or ambulance service (General Municipal Law §122-b[2]). Further, towns may provide for the collection of the fees and charges or may formulate rules and regulations for the collection thereof by the organization furnishing services under contract (General Municipal Law §122-b[2]). Although section 122-b authorizes the town to provide, in rules and regulations, for the collection of the fees and charges by the contracting service provider, the fees, as noted, are imposed by the town and, therefore, in the absence of anything to the contrary in section 122-b, constitute town monies (see 1998 Opens St Comp No. 98-9, p 22; 34 Opens St Comp, 1978, p 204; 1975 Opens St Comp No. 75-49, unreported; 25 Opns St Comp 1969, p 90). 1 With respect to the payment by the town of additional monies to the service provider above the amount stated in the contract, we note that article VIII, §1 of the State Constitution prohibits gifts and loans of monies by towns to or in aid of any individual, or private corporation, association or undertaking. If the town were to unilaterally pay the service provider additional monies, whether derived from the user fees or otherwise, above the agreed upon amount stated in the contract, such payment, in our opinion, would constitute a mere gratuity and gift in contravention of article VIII, §1 (see, e.g., 1988 Opns St Comp No. 88-69, p 137). On the other hand, if the contract were modified so that, in exchange for paying the provider an additional amount, the town were to receive additional consideration, such as enhanced services beyond those already required under the current contract and with a value commensurate with the additional payment, the payment would not constitute a gift (see Opn 88-69, supra). As to pursuing the collection of unpaid user fees, there is case law indicating that the failure to seek recoupment of monies owed to a municipality may constitute a gift in contravention of article VIII, §1 (see, e.g. Oneida County v Estate of John A. Kennedy, 189 Misc 2d 689, 734 NYS2d 402; Nance v Town of Oyster Bay, 41 Misc 2d 446, 244 NYS2d 916, mod on other grounds, 23 AD2d 9, 258 NYS2d 156; see also 1978 Opns St Comp No. 78-684, unreported). Therefore, to avoid contravening the constitutional gift prohibition, we believe it is incumbent upon the town to take reasonable steps to seek recoupment of unpaid ambulance fees. What constitutes a reasonable step may vary from case to case. In general, however, collection efforts may include, as appropriate, sending dunning letters2, imposition of a lien on real property (see Municipal Home Rule Law §10 [1][a][ii][9-a])3 and commencement of civil actions. We also believe that in determining how to proceed, the town may take into consideration an analysis of the costs involved, as well as whether a given claim may be uncollectible as a practical or legal matter, such as when a claim is barred by the statute of limitations, or in the case of bankruptcy or lack of attachable assets (see Opn No. 78-684, supra). Accordingly, towns may fix fees for ambulance services, to be paid by persons requesting the use of such services. Although the town, by rules and regulations, may provide for the collection of such fees by the entity providing services under contract, the fees collected belong to the town and may not be retained by the service provider for its own use. The town, by modification of the contract, may pay an additional amount to the service provider above the amount set forth in the service contract, but only in exchange for additional consideration to be provided by the service provider. To avoid contravening the constitutional gift prohibition, it is incumbent upon the town to take reasonable steps to collect unpaid ambulance fees. February 15, 2005 Jeffrey A. Siegel, Esq., Town Attorney Town of Duanesburg

Well, anyone can bill for anything. Whether or not they will be successful is another matter. When multiple agencies provide service and each feels...and is... entitled compensation, the relationships get complicated. Occasionally mistakes get made. Indeed medicare sets the standard. There is an exception known locally as the Putnam rule as it was ostensibly written for Putnam County, New York that allows an ALS agency to bill [as a non transporting agency], if the transporting agency does not bill [a.k.a. fire rescues], and if the county is designated as rural.. and a few other things. If a county meets the criteria for the exception, then ALS could bill if the transporting agency does not. Otherwise, the ALS agency has to have a relationship with the BLS transporting agency. I can dig up references if needed. On another point queried about counties stealing a vollies cash....not so fast. That entirely depends on how the relationship between the volunteer agency and the town is structured. If the volunteer agency is running bake sales to buy ambulances and not eating from the public trough, then they can bill and keep the money. If the volunteer agency is primarily funded by the town, either as a district or as a budget line [the description given to me was, "if the town chose another EMS provider would the volunteer agency cease to exist?" as a standard], then in point of fact, it is the town who is entitled to the money from billing, since they are the ones funding the service. There is a fair amount of writing on the subject. How it works is that if there is a question about how to interpret a law, the office of the comptroller can be contacted by an official agency [ a town or county, not a private citizen] and a ruling about the law gets issued. These are found under opinions of the comptroller and searched for ambulance and billing. Obviously the opinion can change and it is in an agencies interest to ask again if they don't like an existing ruling. Here is the link: http://www.osc.state.ny.us/legal/index.htm Alternatively a town or county or ambulance corps can do whatever they want and until someone sues, it's no harm no foul. I am no expert on the subject. Read the opinions of the comptroller and draw your own conclusions.

Once it's on the ground, the resources are committed and sending it back empty or full isn't that much of a savings, and local resources get back in service faster. At some point one has to pick a strategy and stick with it. The down side is that we so seldom get feedback about nature of the injuries. It would be so much easier develop a good game if we knew when we sent someone out in a helicopter if timing mattered or if they were a treat and release. I recall a story from long ago that a significant number of patients ended up being treat and release. On the other side...It's a story twice told and not mine, but a woman 7 or 8 months pregnant hit a tree and couldn't remember the accident. The medic insisted on a helicopter for her, got some heat locally for it. He got a phone call a few days later, thought it would be a complaint, but the woman had torn the placenta and an emergency delivery was performed. Apparently right time and right facility had been critical to a good outcome. Since his experience, I've bumped it up a notch for anyone with a viable fetus. A real screw up with a bird..... We left the door open to the pumper at the landing zone on a hot, dry summer day and the rotor wash filled up the cab with sand. And I mean filled it up.

I worked for Alamo in Putnam. I didn't much care for the trucks, but the people were great and the service was excellent. I am sorry to see them go; it was a good company. That said, if you like Alamo, you'll love Transcare. It's well run, professional, no drama. Change is always difficult. You might as well embrace it because it's going to happen. As a resident of Putnam and a Transcare employee there, service is first rate. I f they can repeat up North, everyone will be really happy. Good luck to all.

Thanks, but I will respectfully disagree with your disagreement. 'No harm done.' is a starting place but it shouldn't be the standard. EMS needs to be outcome oriented. When a 'good' decision doesn't ultimately end up where it ought to, that is reason for evaluation, and for threads like this. The craft in EMS comes in both making good decisions AND in those good decisions also being the right ones. As someone pointed out, the same type of thread emerges regularly and regularly we read of decisions that on their face do not make sense. The sensitive combatant replies something along the lines of 'Well, you weren't there!".....No Shi[p], Sherlock. I wasn't there and the only way I can understand a decision is if people who know more than I do step up. Interest in what happens on calls to which we are not party is not an opportunity judge, but an opportunity to learn. How does a decision get made? I'm surprised this hasn't gotten more traction. Why don't we all step up with a helicopter call that went the way we wanted it to and one that didn't. Surely we all have been in charge of one of each. Or am I the only medic who has ever been repacking the gear while muttering 'That could have gone better..'?

Absolutely. Calling all bird lovers. Make the case for using helicopters. I went in one myself, actually. It was a Peekskill to Jacobi trip and the hospital didn't want to take the risk of an anaphylactic reaction in traffic to the city. That makes some sense. The last time I called for one was 3 years ago, maybe. It was a 12 foot fall backwards through a deck railing onto a walkway with pointy brick edging and deeply unresponsive but clenched. I foresaw airway issues, but by the time we were packaged the patient was somewhat responsive and it was looking more like drunk as a skunk. [ And likely really banged up as well.] Helicopter resources were probably unnecessary, but it was on the ground before that was clear. My bad.

I will speculate it is all part of the learning curve. If a medic calls for a bird, then from a call management perspective, it's over. That's what you do. That said, I'd been to maybe 100 stat flight landings over 15 years before I decided to upgrade to medic and there were children in my class that still had wet ink on their EMT-B cards. I don't know how a medic builds perspective about when to fly or when to drive without both some experience and listening to some lessons learned by others. There is a maxim in aviation that Good judgment comes from experience... and that experience come from bad judgment. A scene can look just awful, and that can justify a decision to consider a helicopter, but then one has to ask, how is this helicopter going to help this patient? If there are demonstrable benefits, then by all means, fly. If the purpose is to make the patient someone elses problem, then it's time to suck it up and consider good skills enroute. In the late 80's, back before medics and before trauma centers, getting good help to the scene was a godsend. With more tools and adjuncts available in the field and more training, one should properly ask, where is the added value? Flying is dangerous. Flying is expensive. Helicopters are a limited resource. Before I ask a flight crew to take to the air, I want to feel that it is absolutely necessary. So how do the old salts make the call on this?

Indeed. This thread needs hijacking. Per the IA it was 26 minutes from helicopter request to enroute to WMC. Obviously, time to ambulance on location, possibly an extrication, status of the airway, are just some of the unknowns, but 26 minutes, an unconscious patient and without movement is a long time. While I am solidly in the camp of those who think helicopters ought to have a VERY small role in transports in the Putnam/Westchester area, I'd love to read a spirited defense for helicopter use when ground transport is under 30 minutes to Level 1 trauma. Anyone want to step up here?

Less is more, actually. When I did t for the Parks, an ideal team was maximum of 7 well trained, and we got someone off the face of Breakneck with 4 people, once when we were racing sunset. Night rescues take more. You need one on the litter, maybe a second for packaging/stabilization, an edge person, someone on the haul system and depending on the mechanical advantage you've rigged for, three to haul. Any more is chaotic and gets dangerous. Key concept in vertical work is you rig your own lines with your own gear. There's not many people I'd trust to rig for me if the drop is over 50 feet. Brings back memories, though. That's high angle, of course, low angle is a different animal, as is cave rescue. Many years ago Put Valley had the same 'nature call' off the overlook on the Taconic just south of Peekskill Hollow Road. Traffic had been tied up for over an hour, and a car of kids pulled over. In the darkness, one apparently mistook the tops of oaks as brush and hopped the wall. He was bumps and bruises; we just needed to direct him to a place we could get him back up. Good thing, too. We were laughing way too hard to have helped him.

'The teachable moment.'... Yes, someone has to be in charge, and if a medic is assigned to the call, then it's the medic. That said, as medics, we work with the same crews over and over. If you teach your crews what to do and why to do it, then they learn and if you can trust them, they can do a lot for you and have a good experience doing it. When I took my state test for paramedic, the first half was BLS and if you didn't pass it you didn't get certified. Good BLS is critical to every call. If a BLS crew is not up to standard, then it is our obligation as care providers, to get them up to standard. Teach the moment, make your crews better. It's good for the patient, good for the medic and good for EMS. And that said, some days the doors to the ambulance fly open and it's the crew in tights and capes, sometimes its the crew in size 15 shoes, funny hats, and big rubber noses. Either way, there is a job for everyone. EMS is not rocket science. I offer the observation that a medic who needs a great crew may be EMT dependent? Take what you get, make the best of it, and make them better.

It may be old but it's still relevant. A recent post on another thread referred to volunteer EMS as doing it 'for free'. I'm 20 years volunteer fire/15 years volunteer EMS and 6 years paid EMS. As much as I love volunteer service and all it represents, is it for free? When I was captain in 2001 our budget went from 70K to 90K to service 10,000 households. The town is not that much larger, though we now have a bay that will hold 8 ambulances [ parked really, really tightly] and we have a budget that now approaches that of our fire department, [apparently a goal of ours. ] We do not get paid to respond to calls, but our patients get billed and every household pays their share of our budget, as much as $50 a year. When we got $9 per house per year, that felt like we were doing it for close to free. At $50 per house per year, [and this is really rough math] If there are 500 calls a year and 10,000 households, that's one call per household every 20 years. [i've lived here 22 years and called an ambulance once.] 50 x 20 is $1000. And that is more than paid service would have cost me for the one time I needed an ambulance. The responders may feel like it's free, but taxpayers still pay, both in taxes and when they use the system. In my humble way of thinking, volunteer EMS has a cost, and it is rapidly becoming a large cost. 'We will come if we feel like it, and we may look like homeless people when we do it.'....that may have been a fair trade off for service 10 years ago. Now that we bill and we drink deeply from the public trough, [and, yes, we cover more calls], and now that we cost as much or more than a paid service..... I don't think it is at all unreasonable for residents to expect that there will be a crew in uniform in quarters ready to respond. What do I expect from volunteers? As a volunteer, and a paid professional, and as a taxpayer, I expect whatever service my town provides to suck it up and to provide that service in a timely fashion, trained like professionals, a looking like a professional. If that means crews in quarters, then so be it. What do taxpayers in various towns pay, directly or indirectly, for ambulance service? I'm guessing it's not 'free' anywhere.

So true. I vollie and work EMS in Putnam/Westchester, but our other home is in Paul Smith's, New York. Local agencies there are using aparatus we wouldn't deem good enough to cut up for extrication drills. Parts of New York are still living the genuine volunteer existence and I believe providing great service doing it. When one town I pay taxes to spends close to a million on fire and EMS and the other town spends 50K... Yes, the call volumes are much different, as is the level of service, but the results are pretty much the same. So, yes, there are NY agencies out there that are not on municipal welfare and they make us proud.

Chris is right. When Mr. Gary came to Putnam Valley to talk about the project years ago, the one thing he made clear was that the trees and the stone walls were gone and gone for good... and the stone chambers and the character of the road, and pretty much everything 30 ft from the center of the existing road. In practice, there are two times to comment on a project... the first is "Now is not the time, this is merely an informational session." and the second is " Now is not the time the plans have been finalized." The county is doing the best it can to get a project it wants approved and it doesn't want the locals getting in the way. They play the game well and we have to play it just as well. The current proposal is for the section from Oregon Corners to Adam's Corners a.k.a. PHR and Church St. And that said...... this winter a bright pink strip showed up in the middle of the south bound lane by Tompkins Corners marked CTRL which we all know means center line. And there was a reflective strip for aerial photography. And the boys at county deny there is anything at all going on North of Adam's Corners and yet they are shooting aerial photos for a plan that they obviously already have on the boards. I've got to ask another question. Twice since I've lived here they have taken PHR down to dirt, ground it up and completely resurfaced and yet they never straightened or improved it. Why now? What has changed? They had the opportunity and they didn't act on it.