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See kids, you really need to listen to the voice in your head that says don't transfer an unstable patient. You may get a lot of grief/retaliation from your supervisor. Might even get fired when the ER director calls your company's owner. There are other EMS jobs down the road. The crew could have insisted a neonate nurse and a respiratory therapist accompany them. Maybe they were a young crew, just glad to be there. It's not worth it.

By your "wheezer and seizer" remark this will probably be a waste of my time. It seems you already have your opinion about any efforts to save these babies. Doctor, in the past 3 years I have posted link after link about scientific studies and statistics. Do you know what I found? I wasted my time because very few people who reply to my posts never read the links and really don't give a rat's ass about stats or ANY of the information in those links unless it has been verified by JEMS. Doctor, this is probably one of the easiest piece of information to research. You can borrow an NRP book from an L&D nurse or RT if your hospital has L&D to look at the references listed in it. You can also talk to a neonatalogist from a level 3 NICU and they will be more than happy to share THEIR stats with you. The advancements in that field is something many are proud of and it is constantly evolving to improve with new technology, meds and lobbying for better prenatal care by way of outreach clinics. Thus, I am just surprised that someone who has access to this information wouldn't understand the factors when stats are quoted at 50 - 80% with the low end being less than ideal and the high end being ideal. In the part of Florida where this took place, for over 30 years they have had access to Level 3 nurseries and transport teams that can provide high level of care. Unfortunately many Paramedics are not even aware of how they are utilized because the teams fly or drive in by way of their own vehicles with their own pilots and drivers who are generally from a transport division of the hospital and not an EMT. If an ambulance is contracted to transport a specialty team, they are given very little information so the drive will be safer with the EMT(P) not feeling the stress of a critical transport. So when a Paramedic gets a call like this, those who are young and inexperienced may think it is the first time this has ever happened and its time for them to throw caution into the wind and spring into super medic mode to save everyone without realizing they are risking everyone including themselves. Look at the many threads we've had on this forum about the dangers and ineffectiveness of L&S/speed. You now have a situation where they will be running fast for almost 70 miles with a pregnant woman about to give birth in the back without much expertise and meds to calm either or prepare them for a high risk transport if that was even possible. I want some to find out what resources they have in their area and not put the patient(s) or themselves at high risk by not even knowing what equipment or expertise they should have. I am again going to waste my time and put up links with stats that no one gives a rats ass about and that probably includes you DOCTOR since you picked one number out of all the other information to bitch about. YOu also seem to have a difference of opinion about Paramedics being cowboys since you may have been one. Maybe your area does not have any level 3 NICUs or any type of advanced CCT, Specialty or Flight and diesel is still the only way to transport. I don't know why you have chosen to just keep coming back at me when I explained in other posts about how the 50 - 80% stats can be derived. Also if your area does not have access to ANY of the advanced care and transport you statistics may be much lower and your area may not even attempt to work any baby less than 27 weeks. That would be a shame since our team can fly several hours to another country or the islands and get a premature baby that has been stabilized in a hospital with very minimal resources. One would think that should be possible here in most parts of the U.S. with the exceptions of some regions. I hope you can appreciate the differences in the research since my area does not give up on the 25 week gestation baby regardless of where they were born until the tests are in and then the parents can be part of an informed decision. However, these babies do deserve a chance and their survival rate should not diminished because an over eager ambulance company does not even begin to know the basic preparation for a 70 mile transport. For this incident, the statistics will be very low since the baby was not even given a chance due to lack of warmth, which greatly affects resuscitation, and lack of an advanced airway to adequately provide oxygen and ventilation which again is made very clear in even a simple course like NRP. So it doesn't really matter about the national stats since this baby was not given a chance by MEDICAL PROFESSIONALS. I would also hope you can get past the urge to encourage cowboy medicine by taking unnecessary risks on an IFT in an area where there are several alternatives and resources. Here is a link to the March of Dimes website which has decent general information http://www.marchofdimes.com/professionals/14332_1157.asp#head5 If you look at the reference section you will see where they got their numbers from. Here's an interesting study from London. I'm not posting the actually research article since it seems you or someone else who is even remotely interested in preemie stats probably can not pull it up on their home computer. If you also look at some of the research in other countries, you will find the U.S. is lagging in survival and minimal defects as well as having a higher infant mortality rate. http://www.sciencecentric.com/news/article.php?q=08020114 Canadian study for the early to mid 1990s for survivability of 24/25 week gestations. http://www.ncbi.nlm.nih.gov/pubmed/12135208 Here's a study published in 1998 with data taken several years before the Volusia incident. http://pediatrics.aappublications.org/cgi/content/full/102/2/e20 Again, if you look at the bottom of that article, you will find several more references to studies. Here's a link to many studies by way of google scholar. http://scholar.google.com/scholar?q=neonatal+survival+statistics&hl=en&as_sdt=0&as_vis=1&oi=scholart Also, I posted a link to the "baby first" website in this thread that explains what factors affect infant survival and it still pertains to what is done initially by the MEDICAL PROFESSIONALS. Failure to do even the basics correctly like warmth and oxygenation/ventilation (both of which just about any ED in the U.S. should have the capability of doing) will make whatever stats quoted for survival useless if the baby was not even given the chance. Look at how many links to articles, references and statistics I have posted over the past 3 years only to find that those who replied to these posts never even bothered to read the articles. Do you honestly think that is a fair statement made by ERdoc? However, it seems you also have not bothered to read any of the links to research I have posted over the past few year either. So as I stated earlier, I just waste my time posting research stats. And, this is something one can easily google. For some here, if it isn't in JEMS there is just no truth to it.

I think we all suspected... /humor

Ok, I'll grant that the driver violated company policy by backing up without a spotter. But..... You'd think that in 79 years that woman would have realized that when vehicles are backing up, you get the hell out of the way! OSHA requires commerical vehicles to have backup alarms on them. If you hear that telltale 'beep beep beep', that means GET OUT OF THE WAY, SOMETHING IS GONNA MOVE! If she hasn't figured that out, (along with always pass in front of a vehicle with limited rear view), it makes you really stop and wonder how she got to 79! While the driver was negligent in following company policy, the woman was also negligent in using common sense! I highly doubt that the ambulance was backing up at a high rate of speed, so I'd be willing to bet that even at 79 years old, she had not only warning that the truck was backing up, but also some warning that the vehicle was about to move.......

The baby was at a hospital which offered a more stable environment for the birth than the back of an ambulance even if the hospital staff were not comfortable with it. As a hospital, they are still required to have a code cart with the necessary equipment and staff with at least the basic NRP cert as well as some expertise in their professions. The mother was in labor with a preterm infant. You have two patients with the potential need to resuscitate both of them depending on the cause of the preterm labor. The Paramedic knew this was a 25 week preterm infant about to be born and even in ideal situations that is a sick baby which requires special care. Just a little knowledge of NRP is not enough for the acceptance of this patient. Preparation for the birth of the infant must be given consideration for a 60 mile trip by ambulance or any mode of transportation. You are leaving a hospital that at least provides some of the necessary equipment and staff. The American Academy of Pediatrics has guidelines that suggests stabilization and transport should be done by a specialized team. In this area there are at least 2 teams that have OB/Neonatal teams who can also get access to a helicopter if needed and could probably reach the referring hospital in the same time it would take the ground ambulance to have been called and run real fast to Orlando. The specialty physicians at the receiving hospital who are involved with the transport teams can generally talk even the most freaked out general practice doctor in an ED or tiny ICU through some emergent steps to stabilize the mother and baby until the team arrives. However, the details concerning how much conversation was done with the hospital in Orlando are sketchy or if they were given a chance to send their team by EVAC already starting to roll. I believe the other hospital, Halifax, which was the first destination is still just a Level 2 NICU. AAP website with some good information: http://www.aap.org/ In this situation the mother and baby ended up at another little general hospital emergently because the ambulance diverted and the Children's hospital still had to come for the baby. The sending physician(s) should not have been the one making the decision as to what was best for this patient and her soon to be born baby for transport. The physician(s) may not have known the abilities of the Paramedics or were led to believe transport was no problem either due to greed, ego or lack of adequate training/education/experience to where they didn't know how little they know. Diesel can not be relied on to treat a preterm baby especially when you are accepting a known situation and taking a patient from what might already be a more stable environment. This is where lack of adequate education/training/experience will allow emotions to take over and poor judgement may come to play. This may also make for a very unsafe transport for the crew, patient, baby and the public with the use of L&S for 60 miles. And you know the legal ambulance speed may not be adhered to. Even some Flight and CCT transports must be aborted at the sending facility due to lack of appropriate equipment or expertise as well as a very unstable patient and no means to stabilize them for a safer transport. Neonatal/Pedi Specialty teams may spend hours at the sending facility doing what they would do in their own ICU with their protocols and guidelines to stabilize the baby before transport. They are in no hurry to move unless surgical intervention is needed because they are the higher level of care with the equipment and expertise. But, even for the cardiac babies that will require surgery, they will not go to the OR until certain other problems are stabilized. Here is the rewrite for the Florida statutes that was initiated after this incident. The accepting physician with specialty expertise will now determine how to transport and not the sending physician who just wants the patient to go some place fast or an overly eager ambulance service and crew. http://www.doh.state.fl.us/DEMO/EMS/RulesStatutes/RulesPDFS/NoticeChangePublishedFAW12112009.pdf This may have also come about from some of the several other incidents with poor outcomes due to a scoop and run mentality that is practiced by some ALS/CCT and even Flight teams which are not all created equal. In EMS some are quick to criticize the EMT-B who does not call for an ALS intercept but then these same people will accept a CCT to where even as a Paramedic they are little more than an EMT-B when it comes to the level of expertise and skills required to move that patient safely from point A to point B. This situation is also not much different than the scenario thread, "Threw up and can`t breathe", DartmouthDave started with the unstable airway. Disclaimer: I have no direct involvement in this particular case but it has initiated several conversations and changes in Florida as well as the OB/Neo/Pedi medical professions. The AAP has also been taking notes but then this is the type of situation they have tried to prevent from occurring for many years.

Hmmm, I have had the opposite experiance...but lets not sideline this discussion..... For what its worth, if anyone is interested, here is one of my canned presentations. I hope that some of you may find it useful. http://www.slideshare.net/croaker260/child-abuse-389911 Now, in my experiancre, having dealt with a number of cases, I have found that pediatric cases are sometimes more difficult since I have young children (a boy and a girl) simply because if I dont force myself to ignore it...sometimes I se emy little kids in their place. The closer they are in appearance the harder it is. Thats the hard part. Doesnt make much sense, but what can you do? But I have 19 years in this buisness, keeping focus is what we do. And I get the job done. Thats what we all do if we are worth our salt.

If Vent wasn't on a call, whatever the crew did was stupid, dangerous, and contraindicated. If Vent wasn't in the hospital, it's mere luck that the patient somehow managed to survive to discharge. One of these days, you guys will come to the realization that Vent is always right, about everything, and always has been. Your lives will be so much less frustrating once you stop trying to have an opinion in any thread she is involved with, because you can't. It's not allowed. And she'll spend 6 pages telling you so.

It seems you and I were typing at the same time. It is actually not a term of endearment but rather used by residents who hate NICU rotation or at least not in all parts of the country. It is sorta like the term GOMER but in neo land. If the neo attendings hear a resident using that term, the rest of their rotation will not be pleasant. In the past families have over heard less than thrilled residents talking about the babies and any disrespect to the babies or their families in the NICU will not be tolerated. What they do or say off campus is of course their own business. So you do have a specialty team. You don't rely on EMTs and Paramedics to bring neonates or high risk mothers to your hospital? That is my point I just made about NRP. If some only have the little info in a Paramedic textbook or confuse infant CPR with what is required to resuscitate a neonate, there will be confusion and they may actually have the information to make an argument or even decide what is appropriate for transport. Thank you and apologies for some of my remarks. I now realize that neither you or JP have taken NRP to know some of the stats just as the AHA provides in CPR which are taken as somewhat reliable since like NRP, they provide the references. I totally disagree and this comes from doing specialty transport for over 20 years. The receiving physician can also say a patient is stable enough for ALS. That is done all the time with cath lab transfers. However, with a neonate you don't just swaddle a 25 weeker and place them in the back of a truck with those who may have a cowboy mentality and get caught up in an adrenaline rush. As you know not all ED physicians are the same and they should accept the advisement of the receiving physician. I also posted a lawsuit that was recently decided on. This hospital has a warmer and a pedi cart for resuscitation. They have an infant ventilator. They had enough staff for baby and mother. That is much more than the ambulance had. Unfortunately the Paramedic programs can meet only the minimum amout of hours of training required or they can have a 2 year degree if the Paramedic puts some effort into it. Michigan is also one of the states that does not want any part of accreditation for Paramedic programs. The training for intubation could have consisted of just tubing a manikin 5 time successfully. The class may only have consisted of the A&P and meds in a Paramedic text. The ambulance service may not have a decent monitoring system in place. More focus may also be on Adult resuscitation than the rare baby they run across. Now in Florida, it is known that 50% of the Paramedic programs are medic mills that cater to the FDs. We are largely a Fire based EMS state and almost every FF is a Paramedic. That is an expectation at hire or within one year of hire. Some have held a Paramedic cert for several years while trying to get on with a FD and have worked in other professions like construction or Burger King. Until Paramedics can achieve some type of respectible standards for education and even experience two work lead on a truck, the state will have to at least protect the babies the best way they can. Our Chidren's Hospitals also go out to teach NRP (and beyond) at the little hospitals they pick up from. They also invite the staff such as the RRTs to come to their hospitals for some experience. I would hope your transport teams and hospital do the same where you are. This also gives the attendings/medical directors of the receiving hospital an idea about who and what they are dealing with when they made decisions about transport. Unfortunately, many Paramedic students no longer have access to L&D and NICU in some areas after some very bad incidents and it is unfortunate it had to affect even the serious students. The experience they do have available is generally observational with no hands on. NRP or many of the classes offered by hospitals that could provide excellent information are not popular unless it is required. Some Paramedics show no interest in NRP because they do not meet the requirements to become an instructor and for those collecting titles or patches, that is a big deal. Again, apologies for some of my offensive remarks but I have spent a lot of time trying to direct those who want more information to the sources. For this, the 50% used in JEMS was less of a "stat" but more of an argument about justifying outcomes to distract from the real issues.

Weezers and seizers was a term of endearment I learned from one of the NICU attendings at one of the hospital where I work. We have a 67 bed, Level III NICU that is the only one in western Michigan and the upper penninsula so we do know a few things about premies. As for transport, we have our own helicopter service which is staffed by doctors and nurses. We do not have a ground transport service but have a private service such as AMR pick up the team. I, personally, was never a paramedic, only an EMT and I admit I had a cowboy tendency when I was an EMT. It scares me now, knowing how much I didn't know. As for issue of providing links, when you post a statistic to further your argument, it is up to you to provide a source, regardless of how many people do or do not look at it. I agree that it is foolish to keep going back and forth on this, so let's agree to end it here. As for the JEMS link, I did not go to it. I, personally, do not look at much from JEMS. As for your other links in other posts, I have looked and them many times and have found them to be helpful and educational. Just because someone may not comment on a link you post does not mean they are not being looked at. Looking at your reputation, people obviously find your posts informative. I would encourage you to continue providing links. It only helps to prove that there may be hope for bringing education and not just training to EMS. The onus of the transport is on the sending physician. The receiving physician has not evaluated the pt and can only base their decisions on what the sending physician says. I think the Florida lawmakers response to this incident is an uninformed kneejerk response (would you expect anything less from politicians). There are times when waiting for a fully staffed, more equipped ambulance to arrive may be detrimental to the patient. These situations are judgement calls and should not be legislated. This is where the art of medicine comes from. Some times judgement is wrong, there is no way to avoid that, including trying to legislate it away. Sometimes, there is nothing you can do to change the outcome. Let's say this kid had a fully staffed NICU transport, would the outcome have been different? There is no way to say but it is very possible. As I said before, how do we know this kids was not oxygen deprived while mom was laboring in the hospital waiting for the transfer. Would waiting another hour for a fully staffed unit to come have made the situation worse? As a sending physician, when I call for an ambulance I expect that the paramedic that takes my pt has met the qualifications to be a paramedic (although I do keep in mind that the guy who graduates last in his class is still called a paramedic).

I honestly don't have the time right now to pour over statistics for your arguments. If you have easy access to the statistics, then just post them. You brought them to the table, it's your job to provide a citation. So until you decide to post the source, this is going to be decisively a [citation needed]. If I'm bashing NRP, then the AAP is bashing its own program. Of course, everything stated here could just as easily be stated about the hospital. Maybe the hospital realized their limitations in caring for this patient? There's a big difference between advocating for a particular system and realizing a "damned if you do, damned if you don't" situation. Stopped reading here as ERDoc has already posted a refute to this. Not every hospital has those devices. Strangely enough. I'll ask again, since apparently you didn't see it. Is neonatal intubations within the scope of practice for paramedics in Florida? If it is, then the baby was with someone who should have been able to intubate the patient. Are you going to expect a little miniskills exam in the hospital prior to every transport? What would you do if you were on a CCT and the first thing the physician said to you was, "Intubate this manikin"? Furthermore, if a neonatal recovery team arrived, then they aren't going to be transporting anyone until the baby is born (which, in reality, could take a while. Remember, we're seeing this with 20/20 hind sight) because I highly doubt that they're going to be able to transport the mother in the same ambulance as the isolette. There simply isn't enough room for the isolette and a stretcher in the same vehicle. So if it had taken 2 hours instead of 15 minutes, then the team would be standing around for 2 hours in the ER. Again, damned if they do, damned if they don't. That's a good idea... Let's deliver the baby in a helicopter at 5,000 feet. Also, (I'll ask it again in this thread, in case you missed it), if paramedics are allowed to do neonatal intubations, then the paramedic supposedly has the ability to establish an airway. If the mother is not progressing or has contractions pharmaceutical suppressed, how long do you wait until you transport? It's all situational dependent. As I've said earlier, the trauma patient at the little community hospital may require procedures outside the scope of the transporting crew, however you aren't going to just let the trauma patient sit at the local community hospital with no trauma services all day long. Similarly, and since we're talking generalities, I'm not going to expect the hospital to send one of the 2 nurses in the ER or the only physician available for a 2 hour ride when there is no other options. Sometimes both ends of the stick are dirty. Additionally, you use the resources you have available, not the resources you ideally want. To properly compare this, if an EMT-B crew assesses a patient as outside of their ability, they should go to the nursing station, tell them to call 911, and then leave. That is what is being advocated in this case and I guarantee you that any EMT-B who does this (just ups and leaves telling the SNF "no") will be hung. If a paramedic is allowed to do something then they should be trained and educated to do it. Period. Otherwise remove it from the scope of practice. The transferring physician doesn't know what each and every paramedic's competency level is and has no real method of checking said competency. Furthermore, if the physician can't be sure what part of the scope of practice any crew is comfortable with or not comfortable with, then why even have those providers?

I do not find humor in what happened to this baby or what the transport crew had to go through. Their company did fail. I get defensive because I do posts links to support my arguments and give examples. I repeat myself over and over as well as post more links but yet some keep coming back with the same blastings over and over just as what JP did. That is frustrating as I waste time arguing a point already made to someone who can not support their own statements. I realize, again, I only wsste my time on this forum and seriously could be using this time to teach those who do want to hear about medicine and how to be better prepared for those difficult tranports. I was finished with this forum but it was Ruff who sent me a PM that reached me by email which got me posting again. I realize now that was a mistake. I will not change my tone when posting about the life, disability and death of a child to one that is silly and laughing at someone whose outcome could have been better. I can laugh and joke outside of this forum since this forum is NOT my life which some here seem to confuse an anonymous forum with one's own personal life. If appropriate I can make a joke and have even done so on this forum but do not expect me to joke about the proper care of a baby when it causes that child to suffer. Some do get into EMS for the wrong reasons. They believe the medicine part is a joke and worship the cowboy crap on TV. Some may be forced to become a Paramedic such as with the FD. However, for whatever reason, some need to be grounded to the fact that their actions or inaction can affect someone's life to the point of even being the cause of disability or death. And, regardless of why you got the patch, you do hold a license/certification and can be held accountable for your actions or inaction.

Was I also supposed to write thank you for your compliment? I honestly did not believe it was necessary. However, when you agreed with ERdoc who again called me out to show proof to data that had already been mentioned in the JEMS article which is what I took apart, I did feel there was a need to provide a response and question your motive. You did not place a bunch of "smiley things" or provide any other indication that is was intended to be a joke. This point system gives no indication of who gave what. If one had to actually give a reason for the point, either negative or positive, it might acutally mean something. It is way too easy for points to be given or taken away just as a popularity contest. It probably has nothing to do with the quality of the post. Again, I will also make the statement that I clearly stated in my post that the 50% number came from JEMS. My argument around it does not mean you just write a baby off because of some 50/50 stat to justify the shortcomings of action or inaction. However, I will now highlight "this type of birth" from the JEMS quote. I also told ERdoc that NRP provides references to the numbers. Since those stats are generally mentioned in the justification of having people trained in neonatal resuscitation and are collected from many sources, why should I did up more data for someone who should already be familiar with neonatal resuscitation as an ED doctor. Yes, I understand JP was probably just arguing blindly since as an EMT-B he has probably not had to take anything other than infant CPR. CPR also provides statistics about survivability from various sources that gather research from them. Thus, NRP is a good source to get stats from. But JP still was not happy: And then ERdoc is still not happy with the NRP reference for stats. That is when you akflightmedic jumps in even though I mentioned NRP as a reference. How many Paramedics here have not taken NRP and are relying solely on the little blip in the Paramedic textbooks to get them through the resuscitation of a neonate? Or, do some not see the differences between neonatal resuscitation and infant CPR? While NRP is only to demonstrate the process of resuscitation efforts and your employer should be the one to monitor competency, it still makes one aware of the differences. After reading some of the comments made on the forums discussing this, including here, it seems some may see no difference in the preparation or resuscitation of a term baby, an infant that is older than 28 days and that of a very premature baby.