VentMedic

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.

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.

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.

Let me tell you how the conversation would have gone: ED physician to OB at higher level facility: Can you accept a maternal transfer with 25/26 week premature labor? OB: "Sure, can you arrange for transfer or do you need us to send out our team?" ED physician: "We have a Paramedic ambulance that states they are qualified for this transfer." Or, the OB assumed the sending doctor was utilizing one of the more advanced teams to transport the patient such as those that may have RN/RN crews with a variety of experience. ED physican to ALS ambulance: "Can you take a woman in labor with a 25/26 week gestation baby." Paramedic: "Sure no problem. Our scope of practice states we can deliver a baby and intubate/resuscitate." Thus, the ED physician may not have known the questions to ask or assumed too much of the Paramdics by the way they agreed to the transport. He may have thought if they weren't qualified, they would have refused as teams with more expertise may have done with other patients after weighing the risks. If a neonatalogist had also been consulted, it would have been advised to deliver the baby and when birth was closer, they would have put their team enroute. This ED has the capability of maintaining basic life support of an infant. For maternal/infant transports we do not rely on "hindsight" except to learn from past mistakes. We now have networks, teams and state statutes in place for all health care professions that pertain to appropriate transfer of these patients. These transports have been happening for many years so a lot of lessons have been learned. It is unfortunate when the ball gets dropped and someone in that mess should have questioned the appropriateness before this took place. I'm sure (in fact I am very sure) that Fish Hospital has re-educated its physicians and licensed staff. I would only hope EVAC has done the same but if they can not see where they could have done things differently, nothing will be learned and it is actually the EMS providers that will suffer from this mentality. This was also not just a run across town where they might have successly gotten the mother to the other hospital. This was a 70 mile transfer without the appropriate skills and equipment. If you checked out your truck in the morning and found your ETI bag and cardiac monitor were missing, would you accept even a cross town ALS IFT? Would you not be expected to be held accountable by the hospitals to provide at least the bare minimum required for that transport as ALS? Just because this is a 25 week baby and some assume it will not survive or can write off any consequences as predictable, does not mean that baby does not deserve a chance. I have seen many 25 weekers grow to have no deficits and one may never know they were a preemie. Several of those I picked up at much smaller hospitals in very rural areas where the mother just came in to deliver without realizing the hospital did not have a L&D. If you have never had much contact with a specialty team or a specialty hospital, you may not understand the differences in the level of care. For both adults and kids, we will initiate meds that are within our guidelines and protocols that the physician may not have or risked discontinuing certain drips because they thought we were just like the regular ALS trucks and could not take certain meds. We also look at lab values and CXRs that might be of concern for a long distance transport. We will trust the sending doctor just so far and will rely on the expertise of our medical director and the rec'g physician. They wrote our protocols and guidelines as well as trained/educated us for these transports. Since this has happened Florida has been rewriting its IFT statutes to allow the higher level of care physician determine the appropriate transport and not an ED physician who may not know not all ambulances are created equal. For any transport involving a baby, the Paramedic must meet experience requirements even if an experienced RN is accompanying. This is an example of another case and you can see how extensive the care can become. However, you must be able to prove as a provider that you met the requirements to at least provide oxygen even if the lungs are diseased. http://www.5dca.org/Opinions/Opin2008/102708/5D07-1806.op.pdf Florida (401.252) (2) A licensed basic or advanced life support service may conduct interfacility transfers in a permitted ambulance if the patient's treating physician certifies that the transfer is medically appropriate and the physician provides reasonable transfer orders. An interfacility transfer must be conducted in a permitted ambulance if it is determined that the patient needs, or is likely to need, medical attention during transport. If the emergency medical technician or paramedic believes the level of patient care required during the transfer is beyond his or her capability, the medical director, or his or her designee, must be contacted for clearance prior to conducting the transfer. If necessary, the medical director, or his or her designee, shall attempt to contact the treating physician for consultation to determine the appropriateness of the transfer. However, in Florida, for babies less than 28 days of age, they are considered neonatal transports and these requirments must be meet for IFT. No more emotional cowboy scoop and runs by EMS ambulances. Click on: Notice/Adopted Note on this document as to how the wording has changed especially about "ALS" ambulance and sending/receiving physician. https://www.flrules.org/gateway/readFile.asp?sid=2&tid=7331471&type=1&File=64J-1.001.htm I had also posted this link in an earlier post. As I have stated before, this is a good time to have a converstion with your medical director. Do NOT take just take the advice from those who "want to do the right thing but have no clue what it might be but running real fast seems right". If your decision is a bad one, your medical director will end up with the mess in his/her lap.

My assumption came very easily when you agreed at a statement bashing me for a statistic that was initially posted in the JEMS article which was linked by Dust and also a newsfeed article. Did either you or ERdoc bother to email the author of that article to post his source for that statistic? This is a serious conversation and I don't appreicate you bashing me for something that has directly affected the way IFT transport is provided here in Florida. And, again, if you had bothered to read a couple of my links, you would see what exactly I have referred to.

The sending doctor and hospital realized their errors and did not want a jury trial. Even critical care and flight teams that are considered advanced level care can abort a transport if they feel the patient can not be moved safely by their resources. A Paramedic ambulance definitely can in an area where there are other resources. Yes, the fault falls to the doctor but the Paramedic failed to inform they were not the best option for transport or realize they were in over their heads. Maybe the eager cowboy attitude also gave the doctor a false sense of security that the Paramedic was a super hero with a "sure, no problem" attitude. Just on the fact that this ambulance could not even provide the basics for neonatal resuscition puts fault in their corner and their failure to realize their actions or inaction contributed to the outcome of this baby when the other parties already settled can be taken as just arrogance and ignorance. Arrogance will never win over a jury and ignorance is not a good defense. It will also be interesting when another major case of EVAC's goes to court. If they go with a jury, I don't believe that case will end well either especially given the age of the woman and the Paramedic's alleged comments to the patient.

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.

Here's an idea for both you an ERdoc...talk to a neonatalogist. See if a 25 week baby is viable. Did you not read what I stated about the NRP which is also stated in the course? The hospital knew they could not keep a 25 week baby. However, they could have kept the mother if she delivered. If this was an area where there were no transport options for hundreds of miles...maybe. But if that is the case you damned well better have some way of keeping a neonate alive. Just, "oh well, if they live, they live" is not acceptable. Please tell me which hospital in California does NOT have a pedi code cart in the ED or within easy access to the ED. Do they have a big sign at the ED entrance stating "Absolutely NO children allowed"? There would be a few agencies that would love to have this information. If you don't want to state it on the forum you can PM me and I will see that someone in that hospital knows the importance of having a pedi cart. Even in purely adult hospitals they must have resuscitation equipment available for all ages. Again you fail to see the difference between what is your "scope of practice" and what you are able to do. Just because it states "intubate" in a statute does not mean YOU can do the skill. Haven't we already seen enough of this with ETI in the adult world or in pedi in CA to where ETI is no longer part of some agencies' scope. ECMO is also within an RN's and RRT's scope of practice but that doesn't mean anyone can do it or can do Mobile ECMO if asked out of the blue. However, in Florida a Paramedic can intubate a baby. Why did this Paramedic fail to do so on this transport? The statute clearly states intubation is allowed. Right there you have just presented an argument to hang that Paramedic. If this person holds a Paramedic patch they should automatically be proficient at intubating a 25 week baby. How many Paramedics have even seen a 25 week baby in person? Paramedic school does not prepare you for everything and some things are left up to your company especially if they are telling you to transport these patients. The transferring doctor has a right to know if you have ever worked with a certain med, a piece of equipment, special ETT or when you last intubated a pediatric. No I am not seeing this hindsight since I have participated in calls like this. There are other ways to keep a baby warm without the isolete such as a portable heat pad. There are some with the chemical gel and other that can run off the ambulance's electricity. We keep a couple of packs just incase of equipment failure although 70 miles might be a stretch even in Florida's heat. Specialty teams are also patient people. If the Maternal High Risk team was dispatched first, they could evaluate when the neo team could arrive if it was not safe to transport. Again, EMT(P)s are always in a hurry which makes them not a wise choice for specialty transport. Speed is not the answer for all patients. A neo/pedi team may spend several hours at the hospital stabilizing before transport. Read my above posts and all the previous ones. ETI is still just one part. The baby will die from exposure if temperature is not maintained. There are also other factors that go with S.T.A.B.L.E. It's done in the U.S. everyday. Some places have good Flight and ground programs. I would much rather have a patient stablized in a hospital rather than running real fast down the highway in an ambulance with a crew with limited abilities. Ever hear about the effectiveness of CPR in a moving ambulance? As I already stated, as an EMT-B you do have the opportunity to call for ALS or 911 yourself. You don't need a nurse to dial the phone for you. However, this call should never have gotten as far as it did with all the known factors involved. The ambulance was called. They know what the call was about and accepted. They were not called by 911 to an "unknown medical". Hospitals are turned down by ambulances everyday for a patient being out of what their protocols cover. There is a good chance the ambulance service you work for has turned down a few calls that you as an EMT should not be on. And again, I will repeat, CCTs and Flight teams have been turned away because they showed up clueless about needs of the patient they were called to transport and the teams have also refused a patient after contacting their medical director because the patient was unstable or it was something the just were not trained for. It seems those with the more experience and education can weigh the consequences more effectively and aren't inclined to think "we're the only ones" or from some other emotional argument.

Do you not think that is a valid question since JP may be in that position some day? I have worked several areas in healthcare. I have moonlighted in those little EDs when a mother comes in ready to bring out a preemie into the world. I have been in a major medical center where ambulance crews have ran in with L&S where they are limited to even fixing an occluded IV line. The pumps were also set up by an RN who is trusting the patient will arrive safely or he/she may be drug into a bad mess. Truly not a good situation for all involved. I have seen an ICU attendings and ED doctors throw out a CCT team that failed to bring in their cardiac monitor or even O2 and continue care until a more appropriate team can be found or staff to send. I have been questioned without mercy about my qualifications by doctors before they have allowed me to transport a critically ill patient and I am not in the least offended. Many times RNs and RRTs as well as the MDs have asked for some guidance from the statutes and lawyers as to where we stand if care is released to a crew that is not properly trained or equipped. How many times have we "made do" with what is right there rather than make special arrangements? How many times have you known on a transport you will not have a chance in the court room with any defense if something happens during that transport? How many times have you been pressured by a physician to do something that is out of your scope of practice? The Medical Director of an ED just recently caught one of his doctors allowing an EMT-B student to intubate. That physician will be reprimanded and the school that the EMT-B attends may be on probation. In the doctor's defense the EMT-B student did not make it clear what type of student he was and what his skills consisted of. However, the doctor also did not make it a point to check. Two wrongs do not make a right. If a physician gives you an order for a medication dose that could be lethal, do you blindly follow orders? What do you do if the doctor orders or pressures you into doing something you know is not correct? Will JP realize since he is arguing there is nothing wrong with an unqualified team taking a mother and neonate? He may also have done this himself so would he expect the same from other EMT(P)s when he is a doctor? I do believe that is a valid question. This comment by JP is probably the most misunderstood by many and it is frightening. I believe I may have also mentioned it earlier as well and am again repeating myself. Because it is allowed in your scope of practice does not necessary mean you have been properly trained or educated to do so. RSI might be allowed by your state but does that mean every Paramedic is competent to do RSI. Just having it as part of your state scope does not make you competent. Some Paramedics many never do or even see a live intubation on any age before they graduate from Paramedic school. The Paramedic should know their limitations. One should take professional responsibility for skills and knowledge expected of you. It would also be in the best interest of the patient to inform those trusting you of your limitations will not enable the physician to make a more informed decision about the proper transport. I saw this on another forum. There's some good info here especially about thermoregulation. http://www.babyfirst.com/

For goodness sakes JP! Do you not know how to search for neonatal statistics? The stats quotes at 50% came from JEMS. It just took a few quick checks to see where he pulled that number from on the internet. I never made any direct statement as to where he got that information because JEMS was not part of the trial. Just look at the reputable neonatal websites and you can read all about neonatal stats. I also take NRP which is full of fascinating stats in the reference section that makes taking the course over and over again worthwhile as they are being updated as medicine evolves. Like ACLS or any cert class on has to realize its limitations. However, if you do not put forth ANY effort to acquire at least the bare minimum of training, how can you even justify being capable of handling a neonatal transport. This baby did not get intubated during resuscitation. If a company wanted their employees to do neonatal IFTs, they should have seen that they got the training by whatever means. Bashing NRP still does not make it right. As least the NRP would show they put forth some effort if they can not come up with any other proof of competence. Also, when you do get the chance to take NRP you will find they make the same disclaimer as any other cert makes like ACLS or PALS. It does NOT replace proper education and training. If they had actually taken the NRP, they might have known this and realized their limitations. Some physicians are better than others. Quite possibly if another physician has been on during this particular incident, the outcome might have been much better. I do many specialty transports from these little hospitals and I do find most doctors are not stupid. They also seek out advice from the higher facility and now for neonatal transports, the receiving doctor at the higher level of care will be deciding who and what is needed. This change came from the lesson learned from transport disasters like this. If you advocate for a system that continues to fail and just want to make excuses, other ambulance personnel will be put into the same position. Realize the mistakes and move on with proper education and communication with your medical director. See my previous comments about certs. EMT-Bs deliver babies. Mothers deliver their own babies. However, the mother is just part of the equation and in no way is a preemie self sufficient unless someone can provide the minimum comfort. I am repeating myself but EDs in the U.S. have a pedi/neo code cart, warmer, infant ventilator and a variety of staff that can offer some level of expertise in their own specialty be it lab, nursing or respiratory. S.T.A.B.L.E. is also taught at the hospitals in that area and this is something that EMS providers generally are not aware of. And AGAIN, we do neonatal transports from these little hospitals with very few problems that can't be handled with doctor to doctor communication prior to our arrival. The babies will also do well provided there not other complications but I can tell you it is a very rare occasion we find a baby in an ED without an ETT and under a warmer. That is the bare minimum. Even when we go to less privileged areas both in and out of the U.S., certain minimums are done. So, why do you feel it is safer for the baby, mother, EMS providers and the public to have an ambulance running L&S for almost 70 miles without someone who can intubate a baby to provide oxygen and provide adequate warmth? If the hospital stuck by a decision not to transport with the local ambulance because they were calling specialty teams, there is still a chance they would have been sued but by showing the ambulance was not capable of providing a safe transport alternative, their damages would have been less. The ambulance had good reasons not to accept. Then you should realize that defending mistakes made by the ambulance only justifies they have all the training they need and there is nothing more they should do to improve patient outcome. Arrogance should not replace education and ignorance is not a good defense. The hospitals and physicians knew where they screwed up. This ambulance service should have realized their limitations and had their medical director be more proactive for them to prevent them from being placed in this situation. It is not like there were no other transport teams and those with access to helicopters that could have at least provided someone who could establish a neonatal airway. There is also a good chance if that mother delivered in that ED that someone would have been able to do ETI on a neonate and under a warmer. And again, if an advanced team felt it was unsafe to move the patient, they would have remained until stable or additional resources could arrive. Any other health care professional would be held accountable and if they accepted something they were not qualified for, they would have to answer for it and why they made the decision. Why should EMS be the exception? So JP, when you become a doctor, are you going to pressure EMT-Bs and Paramedics to accept transports that put them outside of limitations? Are you still going to rely on L&S and a real fast ambulance ride to get critical patients from point A to point B? Do you also not have the ability as an EMT-B to call for ALS? Hasn't this been discussed over and over on these forums? Again, there is also a difference between some adult airways and that of a neonate. The adult can be managed by BVM. However, the 25 week neonate that is coding requires an ETT. You may not have enough education in this area to understand this which is also what happened in this situation. I also find it absurd that I am being criticized for explaining changing that have evolved from mistakes made or that I am suggesting some should know their limitations while establishing a line of communication with their medical director. I also find it unsettling that some would just let their emotions out weigh their common sense on an IFT to run with anything just because they think it sounds good without really understanding what they are getting into and the minimum that should be expected.

JP and ERDoc, I already provided links to Volusia County and the court documents. Sorry but I am not going to spoon feed either one of you and you will have to click on the links yourselves. ERDoc, Are you comparing your education and training to a Paramedic with 6 months of training and very little baby or peds education? Even without NRP, as an ED physician, did you not do a rotation in the NICU or L&D? Did none of your training and education address this? If you wanted a cardiac patient transferred out of your ED to a center of higher care and the Paramedic showed up without a cardiac monitor or O2 tank because the truck they were on didn't have the equipment for a 60 mile transport, would you be okay with this? JP: that is a silly argument and you know it. If they didn't take the course to begin with, you can't even begin to argue competence or no competence. Knowing the EMT and Paramedic courses are very weak in neo and peds, would you not want staff to at least make some attempt to get more information about these age groups? Or, do you believe the Paramedic program makes you more than qualified to do high risk delivery transport and neonates? Hell, even doctors must get some additional education even if it is not NRP to be proficient for working in areas they will come into contact with these patients. If they choose not to, they will have to explain their actions if something goes very bad. If they have some additional training, explaining the consequences might be a lot easier. Why is it both of you are arguing it is okay to show up for a critical transport with little to no preparation as far as equipment and personnel? Why is this acceptable to you? ERDoc, if your patient required a Specialist OB consult, would you settle for a GP because the OB was busy? Would you feel you did right by your patient? This area has access to at least 2 hospitals that have helicopters and specialty teams and that didn't include Halifax. Contrary to what you are believing about the public, not everyone is out to screw over the poor EMT or Paramedic. However, there comes a time when they can not always hide behind the old way of just providing a fast trip to the hospital or that people will automatically think they did a great job because they are a Paramedic and as EVAC keeps stating, "must put up with suffering everyday". EVAC accepted a transport of almost 70 miles with very little resources. The hospital goofed by sending that patient out without a PROPER TRANSPORT team to provide for both the mother and baby. Not every child that suffers the effects of prematurity or will have a family that sues if it does. Usually the neonatalogist can explain the circumstances well enough to where they accept the fact EVERYTHING was done that could be done. However, even the best neonatalogist in THAT AREA of FLORIDA would have a difficult time explaining why an ambulance crew accepted a baby without proper preparation. ERDoc, do you honestly believe the U.S. is not capable of saving 25 weekers? We've been saving 23 weekers since the 1980s. If you look at the literature you will find the stats run from 50% to 80% depending on the level of care closest to them. If the baby is born outside of the hospital or a hospital, the stats will be at the low end. In this situation, it was chosen to take a chance or accept the lower stats when the decision to put mother and child on an ambulance. Also, if you want more impressive stats, pull up the numbers from Canada and other countries of civilized medicine. BTW, ERDoc, what do you do when a Paramedic brings you an ETT in the esophagus and then blames it on you when you try to explain how it could have happened or give him/her some pointers on assessment? Or, do you just ignor it or cover it up because the patient only had a 50/50 chance of survival? Would you allow a cardiac or any patient to have drips discontinued just to accomondate a crew with less training take your patient to an ICU in another hospital? Would you not expect to be scrutinized by your peers? I've also wasted too much time trying to show where those in EMS may be held accountable for their actions and the "underdog" "they're picking on us" mentality will have to go away to be replaced by one that resembles a medical professional. Diesel medicine and just providing a real fast trick from point A to point B will have to be replaced with critical thinking, education and more training especially for the CCTs or ALS IFTs. Have either of you noticed the level of training/education required in other countries for a Paramedic to be on a truck for IFT critical care transport? There are literally thousands of babies born in Florida each year. While there are lawsuits, compared to the volume of deliveries, including those that require a specialty team to get the baby at some little general, there truly are not that many. Most can be settled and do not drag into a jury trial. Yes, the risks are high especially in neonatalogy but there are still many health care professionals that assume the responsibilty to work with that population and know what it takes to be successful in that career. However, this is why I am an advocate for taking a patient to the more appropriate facility to begin with if at all possible. As I have stated several times before, getting the proper IFT can be a pain and take hours. In some areas, a BLS truck may have to do and the patient will have to go without meds or a monitor to a higher level of care from a little general. That is a sad statement the U.S. but that does not mean we should settle for this as a profession every time or continue to make excuses.

So you think the back of an ambulance is better for almost 70 or even 17 miles with virtually no specialty equipment or even something to keep the baby warm? Or how about NRP and intubation skills? Almost every ED in this country, even the smallest, have a Braslow code cart, an infant warmer, infant ventilator and at least one person somewhere inhouse who has taken NRP. The Children's Hospitals sponsor NRP at these local little hospitals and invite their RRTs to their NICU to get some airway and ventilator management skills. It generally does not take long for one of these neo teams to reach that hospital once delivery is progressing and usually the outcome is good. At least the baby is intubated which it appears to not have been according to some of the information now being released. The problem in this situation started with the sending physician attempted to arrange for a transport without knowing all the options. EVAC said they could handle it. By the time the sending facility realized they goofed in a big way by sending mother and a baby about to be born, EVAC was already trying to find a faciity to divert to. Now, it will be the rec'g hospital (higher level of care) that determines the appropriate crew. The physicians and hospitals knew they screwed up and in the case of a child, they would only make themselves look worse if they tried to put the blame on the mother and child to relieve themselves of their share of the guilt. EVAC decided to make the trial about them which turned the jury off. It appears they are still doing this in the news articles they have been appearing in as they prep for the appeal. I'm actually very surprised the amount was only $8 million. If everyone else has said it was a bad call to transport and yet the least trained/educated providers are still holding themselves out to be the "only ones who could save the day" I would say your lawyer and company have failed to do their homework to see where they might have been part of the problem. Also, as pointed out in the JEMS article: That statistic was for 25 weekers born out of a controlled environment including at home and in an ambulance. The rate for those born in a hospital, including little generals that can call a neo specialty team, is greater than 70% and an 80% for those born near a higher level NICU. Is it fair to write off the baby by saying it only had a 50/50 chance of survival to justify any shortcomings of the EMS crew? Should the 50% that do survive be left for dead or not worthy of any chance like at least intubation and warmth? Would blame the baby for being born prematurely and not the crew who didn't have the proper equipment or training? Again, the hospital and physicians knew they screwed up. Most of Florida heard about this 7 years ago and again about EVAC in 2006 with the phenergan/artery incident which I believe is still to be settled. It also wasn't so much about the medical mistakes, since they can happen to even the most careful of providers, but rather the way they attempted to displace the blame elsewhere. JP, as an EMT-B, would you accept a patient with multiple drips that needed ETI or would you politely tell the ED that is not appropriate for your training? Why should this be any different? Teams who are considered advanced will abort a transport if the patient is too unstable or is best served by remaining in the sending hospital until stabilized or even until they die. Why transport someone who is coding 2 hours by air transport? In this case, until the baby is born. No NICU and/or OB team would have suggested loading that patient in an ambulance if the contractions were close and could not be controlled. Some EMTs have a difficult time understanding why a neo team on transport because we may take hours of stabilizing the baby until we are ready to move. Diesel is not always the answer to every medical situation.

I have not seen this show yet although I know it is supposed to be modeled after the Ryder Trauma Center (Jackson Memorial Hospital). Here's a decent article about the inspiration for the show. http://www.tvguide.com/news/miami-medical-rock-1016874.aspx I also believe most of the filming will be in Southern CA so just like Miami Vice, watch for the sun to set over the Atlantic Ocean on Miami Beach. The only show I like that is supposed to be Miami based is Dexter. I guess you might say it involves some major surgery or at least the cutting part. Other than the original 1960s Flipper series and The Jackie Gleason Show there hasn't been a decent show made here.

What exactly are the requirements for nurses to work on an ambulance in most areas of your country? Can you post some links?

Right now the jobs are competitive and the better positions have always managed to attracted over 1000 applicants and now with this economy, that number is very high. San Francisco FD were just hiring for FF. It was rumored they got close to 10,000 applications. Of those, and this is from their HR website, 6,196 took the test, 5,200 passed. They also had a few vacancies on the EMS side and I don't know how many applied and tested for that but I would imagine quite a few since there is no shortage of EMTs and Paramedics in most of California. A couple years ago Oakland FD had open hiring for 20 FF positions and 10,000 people showed up for applications. Even with the Private ambulance companies, finding a job is very competitive. There are not many services that are strictly 911 EMS. Even for IFT, the Paramedic is not always utilized as the RN is on the Critical Care Transport trucks with 2 EMT-Basics in several counties. The ER Tech positions get over 200 applications for each position and they may also require additional certs such as CNA (Cert. Nursing Assistant) and Phlebotomy (requires around 140 hours of additional training). However, not all is lost as there are some counties such as San Mateo and San Joaquin that may have opportunities for a Paramedic but again the competition will be very competitive. Many parts of California are Fire based EMS and the FFs are Paramedics. For those who want to be a Paramedic only and not a FF will be flocking to the areas where that is available and there will be an abundance of applications there as well. Another thing to consider with some private ambulance companies is contracts are won and lost. Hiring and layoffs are a way of life in some parts of California (Bay area) and other places in the country where there are several ambulance companies competing with each other for even a nursing home contract. Those that land contract with the big hospital systems for their IFT are good until the contract is over and the goof balls they hired as EMTs and Paramedics lacked professionalism to where it is not renewed. Private ambulances that have 911 service contracts also face renegotiations and there is always the possibility of another private service offering something better or the FD waiting for a take over. To see if you really have an interest in medicine to be a "career" Paramedic somewhere, sign up for Anatomy and Physiology over the two summer sessions if they are available. You girlfriend can help you pick the classes that she needed for nursing school. Actually, I would recommend all the prerequisites and other science classes she had to take for nursing school. You might decide you like it and may even want some profession that requires much more than just the little over 1000 "hours of training" it takes to be a Paramedic. The Paramedic certification requirements are listed as "hours of training" as no degree is required (although available) and it is considered a "tech trade" that can be taught at a trade school. However, I would recommend a community college for your Paramedic education to save money and obtain transferable credits toward future endeavors. You might also decide you don't like it but those science credits will not be wasted as they might be useful for a wide variety of professions or just a better understanding of your own body. With your background you might also find an interest in Physical Therapy or Exercise Physiology. Both require a Masters degree but with your previous college background, your have a great start. Becoming a Physician's Assistant could also be within your reach. Although, I will say in California those jobs are very competitive but that doesn't mean you have to stay in California. Heck you might even like nursing and there are programs designed to people who already have a Bachelors degree. Don't stereotype nurses as there are many different opportunities including Critical Care Transport, MICN (Mobile Intensive Care Nursing), Flight, ED and trauma centers, ICUs, OR, outreach clinics etc. Of course right now the job of your choice might be hard to find but that will change or again, you can go to where the opportunities are. Of course don't expect your girlfriend RN to make what California nurses make in other parts of the country. Even the wage difference from the Bay area to San Diego varies with a difference of over $30/hour. There are many health care professions, although not as "glamorous" as the Paramedic and/or FF are made out to be, but they do serve the community they live and work in. Some professionals will actually see many more patients each day than a Paramedic might see in 2 - 4 shifts or more. There are also professionals who will be at the patient's side for the long haul after a traumatic event such as a car wreck or stroke. Ever wonder what happens to the athlete who breaks his/her neck or gets hit with a fast ball or bat? How about the recovery process of all the soldiers wounded in war? Ever think about the whole process from the ball field to the ED, the ICU, step down units and the whole rehab process which may start while the patient is still in the ICU? If it wasn't for the many different health care professionals involved who care, there would be many young people placed in nursing homes rather than participating in life with their families. In California, unfortunately, your role as a Paramedic may be to provide a speedy ride to the hospital without alot of protocols for intervention and those you have may be read to you by a MICN at the base hospital. However, again you can go some place where the Paramedic can excel at being a professional with a quality department. One more thing, don't sell the idea of being a coach short especially in an area like Fresno which has way too many gangs for young people to get involved in. While your dream opportunity might not come along nor would the big money, your coaching skills could definitely be put to good use. You may prevent many young people from ever needing a Paramedic or seeing what other health care professionals do. I can't think of anything that could be more giving when it comes to your community then stirring someone from a path of harm to themselves and others. But then there is the retirement plan issue and California has no job security anywhere in any occupation. California was in failure long before the economy crisis across the nation.

Undecided? California? Something even more silly than FF/Paramedic? How about this job: http://www.sunnyvaledps.com/recruiting.htm The Money: http://sunnyvale.ca.gov/Departments/Public+Safety/Recruiting/ Public Safety Officers have had their place in history and there are still several communities throughout the U.S. that utilize them.

Here is a good example about California I borrowed from the "other forum". http://www.emtlife.com/showthread.php?t=17693

Is it any more difficult than a Paramedic who has very little A&P and only has the minimum required hours to complete a Paramedic course? (speaking of the U.S.) Many of these new grads come out of the programs with very little live patient experience for even their skills such as IVs and intubation which is the meat and potatoes of theri profession. Working as an EMT-B only gives them very limited patient care experience. As it stands now, many Paramedic programs have too few clinical hours. After certification they are then given a couple of shifts with a preceptor and made "lead" medic with an EMT as a Partner. Of course we do have some EMS schools and companies much better but still, in many areas the expectations are low. For Harold's country it would depend on the long term plans for patient care outside of the hospital with serious consideration as to how much nurses can save in the long run with their broader knowledge of medical problems and not just the emergent. One issue in the U.S. as studies have shown is that the Paramedics underestimate the seriousness of some medical problems as well as some trauma especially in the elderly.

Leaving each county to do its own thing can be a little fragmenting of state control List of Paramedic scope of practice by county. http://www.emsa.ca.gov/paramedic/files/scopechart.pdf Local optional scope of practice: http://www.emsa.ca.gov/paramedic/files/EMTSOP3.pdf Example of "CCT" expanded (?) scope: http://www.emsa.ca.gov/paramedic/files/contracosta_scope.pdf And this is their additional training requirment: I also believe they are only allowed to use ATVs as ventilators which is not appropriate for "critical care transport". Thus, the RNs are on the CCTs with their LTV 1200s. Example of limited use device: It is a good thing most of their FFs are encouraged to be Paramedics. Co-oximeter http://www.emsa.ca.gov/personnel/files/PositionCoOximeter.pdf Another drawback with the county system is that the county medical director can pretty much do as they please for discipline issues. Also, if the medical director likes you he/she can still get you certified regardless of your felony convictions even though the state says it frowns upon it. Convicted Felon Certified as California EMT http://www.emsresponder.com/web/online/Careers-and-Staffing/Convicted-Felon-Certified-as-California-EMT/6$9571 But then he only shook and threw a 2 year old to her death.

Freedom House http://www.freedomhousedoc.com/ MAKING A DIFFERENCE The History of Modern EMS (DVD) By:Jim Page,

That article gave in detail examples of points I was trying to make in my earlier post although I don't believe the author sees it the same as I do. Highlights: Known high risk at 25 weeks gestation. Contractions at 4 minutes apart. Ground transport of over 60 miles. 1 Paramedic. (article only mentions one Paramedic being honored by EVAC for a good job) Must consider both the mother and the baby to be patients and SICK. No fetal monitor mentioned for a 60+ mile transport. Only a silver swaddler with a known possibility of a 25 week preemie being born. 8 minutes of CPR without ETI or a missed tube since the baby "gave a weak cry". NRP is clear about ETI and prolonged resuscitation on a neonate. CPR Had to divert to another little hospital. This was an IFT...not an emergency from field. The patient was at a hospital which is still capable of delivering a baby which can then have a neonatal specialty team transport. The sending hospital should have weighed the risks of sending this patient without more transport preparation. That can be considered an EMTALA violation. Fish Hospital must have realized they mucked up and settled. One would hope the Paramedic had voiced concerns but sometimes when babies and children are involved, people tend to let their emotions lead them rather than good medical practice. Some must also realize the limitations of NRP just like those who take ACLS and expect to be proficient at intubation and resuscitation. Also, when asked can you as a Paramedic intubate a neonate, most will reply yes because it is in their state's scope of practice and they may have a protocol for it. However, that does not necessary mean YOU can intubate if you have never attempted it on a human baby. Considering the distance, the birthing and the resuscitation, this was a transport that could have had an even worse outcome for all involved with an emotional and stressful L&S emergency run. This would also be a good case review to have with your medical director which might get you more education for babies, peds and the many new technology dependent patients such as those with LVADs, various vascular access devices and ventilators. Some good things can come out of situations like this if the opportunity is taken to learn something. Of course as I mentioned earlier Florida has rewritten its IFT neonatal transport statute which some in EMS have criticized because it increases the requirements of the transporting Paramedic who must also have a neonatal nurse accompanying the baby.

No. Not totally true. You can be summoned to court to recall and answer any questions about the care you did or did not provide. That piece of paper is not magic. There is a reason why surgeons make patients write what they believe the doctor just told them before surgery and while they are signing the consent. Several factors will be involved. Who placed the 911 call? The nature of the call? Is there alcohol or drugs (legal or illegal) involved? Does the call concern a safety issue for the patient or others? Are you the one who talked the patient out of transport for whatever reason and is using the "refusal" form to cover your own butt for not wanting to transport? You can make notes on the form and have the patient sign by them as well as on the dotted line. Have witnesses sign the form especially if you are leaving the patient with that person. Sit down and read the AMA form yourself which may include some fine print. Some EMT(P)s have never read it and don't actually know themselves what the patient is signing. Document! Document! Document!

For those of you who may not be familiar with what goes into one of these lawsuit cases, here is the court case number: Case Number: 2004 30861 CICI Court: Circuit Court, Volusia County, Florida http://www.clerk.org/menu/index.jsp Go to: Public Records > Case Inquiry

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.

It is outside the scope of practice for Paramedics in the state of California. This is why RNs are usually found staffing flight teams in that state and not Paramedics.