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Just STOP. Reset the OODA loop for a minute here. Not a good way to start your first post on a professional forum. There are medics in the Army, Air Force, and Navy. The Marines are supplied medics by the Navy. There are also special operations medics, which include PJs, 18D, SEAL corpsmen, and others. The term "medic" in the military is fairly generic. All are to some extent trained to be "combat medics", i.e., work in the field as an organic part of a unit, but also may work in hospitals or clinics. Pararescue is a specific special operations MOS in the Air Force. If you know ALL about it, and decided it's not for you, you may ask yourself why that is. If you're so geeked by the military, and want to do high speed medicine in dangerous places, PJs are essentially the epitome of that. If the arduous nature of their training concerns you, then you need to question your motives. No. If you enlist and go the medic route, your EMT-B training will be provided to you in your initial training. Which position is ideal? Depends on your goals. If you are an RN, it is unlikely that you will be used as a combat medic. There are however many positions for RNs in various military settings. They are good if you have extensive field experience or military deployment experience. CAP does not count. Without those experiences, you could possibly get a contract with a small company, but unlikely to be one with a good reputation. Very unlikely you would get a field job with Blackwater, Triple Canopy, KBR, Dyncorp, or any other sizable company with decent street cred. Yes, you get your college paid for, but it doesn't come free. It comes at the price of service. "The military" and "money" do not go together. You will not make as much in a military occupation as you will in the equivalent civilian job. They don't call it "service" for nothing. Lacking in your post is any thought of service to your country or others. CAP is NOT the same as being in the active duty military. You are in for a kick in the teeth when you get to basic if you think so. Your image of PMCs is somewhat skewed. The reputation that BW has in the industry is a very good one. Despite what you might read in the mainstream media, PMC work is not the key to boatloads of cash, nor is it equivalent to the military. Pictures of PMCs wandering around in khaki 5.11s, Oakleys, with M4s might look cool, but you have to remember a few things about them. These men have cut their teeth on actual deployments, often with special operations units, already having extensive training in the given field as well as maturity. The ones who are paid well have earned it because of their qualifications. They look like mercenaries, able to do whatever they like and put boot to ass for fun, but PMC work is hot, boring, dusty, dangerous, and thankless work. It is also extremely detail oriented, and a high degree of professionalism is expected of them. The career outlook for these positions is not that good either. Folks who do it long term are subject matter experts in their given field, which comes from many years of experience, usually in the military. There are positions overseas with PMCs that do not require this background, which do pay decent, but those are typically in support roles such as logistics and supply. And no, you will not carry an M4 and shoot bad guys. SLOW DOWN. Focus on the 25 meter target. Finish school, get good grades. If you want to make boatloads of cash, that will not come without extensive experience and education. If you want to be an RN, go get your RN. If you want to get combat experience, then go join up in a combat arms MOS, and realize that you are still unlikely to get any. 'zilla

I wrote this for school, but I think it is an interesting topic for field providers. Feedback and discussion are encouraged The Role of Emergency Medical Services in the Emergency Medical Treatment & Active Labor Act: Innocent Bystanders or Culpable Party? By Candice Ryan, EMT-P, AS February 22, 2011 Nova Southeastern University BHS 3160: Health Policy Abstract The Emergency Medical Treatment & Active Labor Act (EMTALA) governs patient access to emergency medical care with respect to the hospital and emergency departments. At the most basic level it guarantees all patients who present for emergency care the right to proper screening and stabilization and governs patient transfers to other facilities. While the specific role of Emergency Medical Services (EMS) is not directly addressed by EMTALA, it does govern EMS and hospital interactions and regulates the actions of hospital in those instances. This paper will discuss four key EMTALA related issues which involve EMS providers, including hospital diversion, inter-facility transfers, ‘parking’ of patients with EMS crews within the emergency department, and ambiguity surrounding when a patient formally presents for emergency care with respect to ambulance transport. The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 and was designed to prevent disparities in emergency care for those lacking the ability to pay for care. It is a federal regulation applying only to hospitals participating in the Medicare or Medicaid program. Only a small number of private specialty hospitals do not participate in these programs, such as Saint Jude’s Children’s Hospital and Shiners’ Hospitals (Wolfberg, 2006). Under EMTALA, all patients who present to hospital for care have the right to a medical screening exam by qualified personnel to determine if an emergency medical condition exists without regard for ability to pay. The law does not specify the level of training which the person conducting the screening must have, leaving hospital policy to make this determination. If it is determined that a medical emergency does exist, the patient is entitled to treatment to stabilize their condition and the condition of an unborn child, also without regard to ability to pay. EMTALA also imposes heavy regulations on the transfer of patients to other hospitals (Scully, 2003). In considering the role and responsibility of Emergency Medical Services (EMS) under EMTALA, we find that both the original 1986 laws and subsequent revisions give EMS no implicit responsibility. It does make very specific provisions for interactions between EMS providers and hospitals, but it mandates the actions of the hospitals and emergency departments, rather than EMS providers. In order to be patient advocates, EMS providers need to be aware of EMTALA issues as they affect us and our patients. There is the potential for legal liability if we are party to an inappropriate transfer or illegal diversion, particularly if it results in patient injury or death. EMTALA specifies that any patient presenting to a hospital emergency room (ER) is subject to regulation. The original law was vague in terms of what actually constitutes presentation for care, making no specific provision for patients transported to the (ER) by ambulance. According to a regulations revision in 1994 by the Centers for Medicare and Medicaid Services (CMS), a person in an ambulance owned by the hospital is considered to have presented to the hospital for care even if the ambulance is not located on hospital property. A person in a non-hospital owned ambulance is not considered to have presented to the hospital, even if radio, telephone, or telemetry contact has been established (Scully, 2003). Hospital owned ambulances operating in the community response capacity are subject to additional guidelines, such as local EMS protocols. These local guidelines may mandate that patients be taken to the closest facility or hospital that is able to deliver specialized care in cases of a particular patient condition. If a patient is brought to the ER by that hospital’s ambulance service, they would be considered to have “presented for care” and as such are subject to EMTALA requirements for medical screenings, stabilization, and transfer regulations in order to be taken to a different hospital. In an updated ruling by CMS, a person in a hospital owned ambulance is not considered to have presented to the hospital if that ambulance is “operating in a community response capacity and functioning under community-wide protocols which dictate hospital destination” (Scully, 2003). In this case, the person is considered to present for care when the ambulance arrives on hospital property in the same way a non-hospital owned unit would. This ruling also extends to air ambulances and medical helicopters owned by hospitals (Scully, 2003). There is an important exception to the rule of air ambulances. If the hospital is being used solely as a meeting point for ground transport and air transport, use of the hospital helipad does not constitute the patient presenting for care despite being present on hospital property (Wolfberg, 2006). EMS may proceed in turning over care directly to air transport, without being subject to EMTALA regulations for inter-facility transfer. Another important issue known as patient “parking” is responsible for a great deal of conflict between EMS providers and ER staff, so much so that it has been the subject of several recent memos published by CMS and a target of legislation in the state of Nevada. CMS stated that they have received multiple disturbing reports of hospitals “routinely preventing EMS staff from transferring patients from their ambulance stretchers onto a hospital bed or gurney. Reports include patients being left on an EMS stretcher (with EMS staff in attendance) for extended periods of time” (Hamilton, 2006). The problem seems to stem from hospital staff mistakenly believing that EMTALA regulations are not in effect until they formally assume care of the patient from the EMS crew. Not only does this compromise patient care, but the community also has to pay for the continued patient care by EMS. EMS workers are also at risk of being liable if they don’t assert their patient’s rights under EMTALA and the patient suffers a bad outcome (Wolfberg, 2006). One particularly disturbing example is report of EMS crews waiting six to eight hours for ER staff to assume care of patients in Las Vegas area hospitals (Ludwig, 2006). To address this issue, the CMS published several memos in 2006 and 2007 asserting that “the EMTALA responsibility of a hospital with a dedicated ED begins when the individual arrives on hospital property (ambulance arrival) and not when the hospital ‘accepts’ the individual from the gurney. An individual is considered to have ‘presented’ to a hospital when he/she arrives at the hospitals dedicated ED or on hospital property” (Hamilton, 2007). The CMS further condemns the hospitals actions, stating that they raise “serious concerns for patient care and the provision of emergency services within the community” (Ludwig, 2006). As if there weren’t enough concerns around EMS and EMTALA, another topic subject to much debate in the medical community is that of hospital diversion. When hospital emergency departments make the determination that they lack the resources and capacity to accept any additional patients, they divert ambulances to other hospitals. It is important to note that this procedure does not relieve them of caring for patients who present to the hospital. Even if EMS providers disregard diversion orders, the hospital must still accept the patient as this constitutes presenting for care (Ludwig, 2006). Ambulance crews are faced with difficult choices when diversion status interferes with hospital destination protocols. EMS systems suffer decreases in efficiency as they are forced to transport patients to further hospitals and system status can be adversely affected if areas are left underserved due a lack of available units. They can even face potential liability involving hospital diversions, such as in the case of Arrington v. Wong. In this case, an ambulance carrying a patient in severe respiratory distress was diverted to a further hospital by a medical control physician and the patient died en route. The EMS crew was implicated in the negligence lawsuit in addition to the hospital and medical control physician, although the case was not actually taken to trial (Kuehl, 2002). Lastly, community based EMS providers and private medical transport providers must be aware of the EMTALA rules and regulations surrounding transfer of patients from the ER to another hospital. EMTALA regulations require a specific form to be filled out and signed by the transferring physician. Before the transfer can take place, the receiving hospital must be aware of the proposed transfer and another physician at the receiving hospital must formally accept care of the patient. The patient must be stabilized prior to transport and the risks of the transport must not outweigh the benefits. On the EMS side, only appropriately qualified personnel can conduct the transport, meaning that the ambulance must be equipped and staffed at a level that can reasonably meet the necessary standard of care (Scully, 2003). Basic life support ambulance units are obviously not appropriate for patients requiring advanced interventions or monitoring and such transports would be in violation of EMTALA regulations. Additionally, according to a 2007 memo by CMS a receiving hospital cannot condition their acceptance of an EMTALA regulated transfer based on the utilization of a specified transport service (Hamilton, 2007). For example, a receiving hospital cannot mandate that patients being transferred to their facility must use the receiving hospital’s own helicopter or ground transport service. As briefly demonstrated in this discussion, the Emergency Medical Treatment & Active Labor Act has a massive impact on EMS systems and practitioners. Many of the EMTALA-related issues between EMS and hospitals are addressed in the regulations, but ignorance of both the hospital practitioners and EMS practitioners can create situations that are at best in a gray-area or at worst are in direction violation of EMTALA and put patient care at risk. From the perspective of an EMS practitioner, the best course of action is to be explicitly knowledgeable of EMTALA and always be your patient’s strongest advocate. The Centers for Medicare and Medicaid Services are also helping to address the more difficult issues, like patient parking, with their own explicit guidance and interpretation. References Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2006). EMTALA-"parking" of EMS patients in hospitals (S&C-06-21) Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2007). EMTALA issues related to emergency transport services (S&C-07-20) Kuehl, A.E. (2002). Prehospital systems and medical oversight. Dubuque, IA : Kendall Hunt Publishing. Ludwig, G. (2006). CMS opinion frees up ambulances. Journal of Emergency Medical Services, 31(4), 22. Scully, T. A. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2003). Clarifying polices related to the responsibility of Medicare-participating hospitals in treating individuals with emergency medical conditions (CMS-1063-F) Wolfberg, D.M. (2006). Ems caught in the crossfire: EMTALA and ER diversions. Texas Department of State Health Services, Retrieved from http://www.dshs.state.tx.us/emstraumasystems/Wolfberg_CaughtCrossfire.pdf

For coral snakes native to the US it's "red on black, venom lack..." There are coral snake species from central and south America that do not follow this pattern. It's a misnomer that there is no available antivenom - the FDA extended the expiration date on the remaining stock until the fall of this year and there is available supply. Without antivenom, a severely envemomated patient might need prolonged ventilatory support. I caught this thread very late and am glad that the original poster did not have any problems, but I thought I'd comment about some of the practices some of the respondents seem to be supporting for bites by pit vipers (subfamily Crotalinae), which includes rattlesnakes, copperheads, and water moccasins. Tcripp, you asked about "what to expect" - it depends on the species, location of bite, patient comorbidities, and other factors. Many patients early on will have pain and local tissue swelling. Some develop signs and symptoms of systemic toxicity (e.g. nausea, parasthesias, etc) early on. Shock is usually from third spacing of platelets and plasma volume. Very rarely, someone who has been sensitized to proteins in the venom (e.g. someone who has handled snakes or venom or been previously bitten) may have a true anaphylactic reaction. We sometimes see anaphylactoid reactions with rapid onset shock and airway edema. Many patients develop coagulopathy, which can range from isolated thrombocytopenia or a syndrome of defibrination or a combination of the two that is DIC-like. Neurotropic findings, which can include neuromuscular blockade, can occur after bite by several species of rattlesnake, not just Mohave rattlesnakes. In terms of first aid, do not apply tourniquets or lympathic constricting bands, or ice packs. Maintain the bite in a neutral position (some medical toxicologists think elevation is reasonable - others thing neutral until antivenom is started and then elevate. Do not apply any kind of suction. If a tourniquet, pressure bandage, or constricting band has been applied, do not remove it in the field. In general, when this is done, we get big lines in the patient, give them volume, and start antivenom before releasing this. At least one IV should be started. Give fluids for hypoperfusion (obviously), but patients with intact perfusion and extremity swelling also need fluid boluses. Extremity swelling early after a bite is usually from the effect of polypeptides in the venom, and these cause tiny cracks in vessels that are large enough to allow platelets to leak out, but not large enough for red cells to leak out. This third spacing can be significant very early and cause significant hypovolemia and hemoconcentration. Very often, we see patients with rattlesnake bites who don't get enough IV fluid in the field. Give antiemetics for nausea, and treat pain (if you have fentanyl, I think it's preferred over morphine as the histamine release from the morphine can cloud close monitoring for development of allergic response to antivenom). The destination hospital may not necessarily be the closest hospital, or even the closest hospital with antivenom, but this would obviously be region-specific. I have seen horrible outcomes when patients are taken to hospitals where arrogant physicians refuse to consult a toxicologist - we've seen patients diagnosed with compartment syndrome who get unnecessary fasciotomy and even amputations that were likely totally unnecessary. Where I work most hospitals have antivenom but we have centers available to us that have onsite toxicologsist and very large supplies of antivenom and we fly our patients to these centers. The 2010 guidelines from AHA and ARC actually mention snakebite first aid, and they advocate using a pressure immobilization bandage for Crotalid envenomations. This recommendation is based on no evidence of any quality - in fact, one of the studies they cite as supporting the practice actually demonstrated worse limb outcomes when pressure bandages were applied (in a pig model). This practice turns what is very rarely a life threatening event into a limb-threatening one. This should be addressed locally, and hopefully administrators and medical directors will consult a medical toxicologist with snakebite expertise when establishing local or regional protocols. Pressure bandages seem reasonable for eastern and texas coral snake bites, and are standard for bites by neurotoxic snakes that cause rapid development of symptoms in Australia, but they will likely worsen injury when applied to victims of Crotalid snakebite. Finally, you can not diagnose a dry bite (fang puncture mark without envenomation) in the field. This requires observation for at least 8 hours (and labs). Especially after Mohave Rattlesnake bite, patient can have a life-threatening, potentially fatal envenomation event with minimal local tissue injury, sometimes without significant pain. Patients with probable Mohave bites are admitted and watched for 24 hours at the tertiary center we work with.

So have him dump it down the toilet prior to transport. Still no reason to involve the police. It would be the same for any substance. Whether we're "public safety officials" or not is massively up for debate (although I get the feeling from your positions that's the direction you think EMS should go). A meth LAB is an entirely different ball of wax. First off the scene and the patient are very possibly contaminated (i.e. not "safe"). Then there's the fact that a lab represents a danger to a whole lot more people than just the patient. I'm not sure why your so interested in sicking the law on your patients. As noted however, in one situation laws may not have even been broken depending on jurisdiction, and your simply imposing your personal morals on others. In the other case your viewing the patient as a lawbreaker who needs to be in jail rather than a patient who needs treatment. Neither one has a place in modern healthcare, which EMS is a part of. If you want to put people in jail, I'm sure there's a PD near you hiring. If your simply playing devil's advocate I apologize...