VentMedic

Rid, did you read the full article? They did identify some of the problems as they did describe the system. They also identified alternatives. But this is not new since other systems are also looking at alternatives especially for management of trauma. Some in EMS don't want to take the initiative to provide their own studies or just use the very few agencies like Seattle to say this is how EMS really is but yet they know it isn't. They would rather criticize those that do actually collect data than do the work themselves. As well, some of the studies done in Seattle have been disputed. If you understand anything about medical literature you would know its purpose it for debate and further research. If all those in EMS do is dismiss an artcle as BS then they have truly not understood the information. What some also fail to see is this study was done because "trauma" consists of a system and every piece in that system must be up to par to make it work. What happens in one area may affect that patient throughout the system. When weak areas are identified, a better way must be found. There are already other studies to show that the minimalist way might be best for dealing with trauma patients. Again, this article should be thought provoking to reflect on where EMS has been and where it should be going. Medicine is constantly evolving. The LMA is even big in the ORs now where 10 years ago no one would have thought anything but ETI should be used. Central lines were big in EMS but now that has been reconsidered. Hypothermia for ROSC was a disaster when trialed in the 1980s in prehospital but some still believe it can work with better methods available now. We've had many procedures removed from EMS but it was NOT punitive or because someone thought the providers were not capable. Research is done to see if they are necessary and at what step of the process. No one is out to punish EMS providers and one shouldn't put so must emphasis into one skill where you feel like it is a punishment. ETI was something EMS has always been proud of especially in Miami but things have changed and possibly methods must be changed to reflect the direction things are going. It doesn't mean the whole system is bad. Fire Based EMS will be around for a long time and regardless of your attitude toward FDs, there are non Fire systems that would probably have the same results if studied. I would like to see the numbers for the areas that have EMT-Bs intubating. I would also like to see why a couple of states discontinued allowing EMT-Bs to intubate. We have a broad mix of education levels and certs in U.S. EMS so where do you want to start addressing the issues?

Rid, do you not realize why I am commenting about this study? My world was a lot more perfect when the FDs were selective about who rode as Paramedic. And yes I do know what CRNAs are but in our area there is not much need for them. There are other schools that teach the CRNA program in areas where they use them. You also still have LVNs in your area but we don't have many of them around either. I also spent 30 years working as a Paramedic consistently while you were a nurse many of those years. I didn't run off to be an RRT during that time but rather got the education and experience many years ago to improve upon what I do as a Paramedic. My dislike right now is because I have seen what has happened to systems like Dade, Broward and Palm Beach. If you had actually worked as a Paramedic during all of those 30 years you too might have seen the changes. You also speak as if Oklahoma is the only state that knows anything about EMS. I do have positive remarks about those in EMS but usually not on these forums which are full of paitent bashing and rants about having to do quality care when shortcuts are so much easier. How many threads have you seen lately asking about the quickest way to be an EMT or Paramedic? triemal04 This was not croaker260's quote. It was Bledsoe's. The was collected as it presented so it was not bad. The way the area has allowed anyone and everyone to do the job of a Paramedic is bad. Fire EMS in this area at one time was excellent and still can be.

At least they were able to put the whole article on that site on Google. From the article: Bryan Bledsoe's comment: If you think having a Paramedic getting only one intubation per year is fine then I guess the study is worthless. If you want to continue to make excuses for the esophageal intubations that went unrecognized then I guess the study has little merit to you. If you want to make excuses for the Paramedics that didn't know what damage they could do with any of the airways and made hamburger out of the patient's cords and throat, then I guess there is no need to see if anything needs to be corrected in EMS. It seems most here believe EMS is perfect in every way and will find fault with anyone or any group that dares to say there is room to improve. This study does have data which is useful and hopefully will call for a change. While saying that ETI may no longer be acceptable for prehospital might be a wake up call for some. However, it seems that most will believe ETI will always be around and the same practices will continue. BTW, check out the list of references at the end of the article.

If you note the term "rescue" is used with LMAs/Combitubes which also means this device was used after attempts at ETI was used and not necessary as a frontline because they deemed the tube difficult by assessment. The other study was in central Florida near Orlando and yes that did not have good numbers either. Both studies were done after major changes to the departments. Again, one would have to know Dade county a few years ago and their successes to where no one would ever have questioned ETI to what it has become now.

That would also have to include L.A., Orange and San Diego Counties, the AMRs, volunteers and Washington D.C. We could also toss in a couple of counties from Florida like Collier and I'm sure we can find a few other large agencies to add to the mix to offset some of the better ones. Of course you will have good and bad but again why make excuses or believe the 3 - 9 months of training the average U.S. Paramedic is the best.

CRNAs are rare around these parts. I can assure you our doctors do not need to troll the ambulances looking for money. If the EJ was removed from your protocols it was probably because someone cannulated something other than the jugular or really mucked it up. So Rid you believe there is no problem with teaching 2500 Paramedics in one county to intubate? That doesn't even include the many Paramedics working private ambulances or Flight services. This study was done as a wake up call for some to realize that just maybe there might be a problem. I know I've given many examples in my threads of things gone wrong and I haven't scratched the surface. I can post the whole article when I get back to my own computer next week unless someone with a subscription or university access can paste a copy. We can continue to make excuses or we can also address the problems. I have been in the ED when some of these patients have come in and no, the tube didn't "just" come out of place. I am looking at this as a Paramedic, RRT, Researcher and Educator. There are many factors here. However it seems some in the profession start to get all offended or mushy when a county is asked to answer for the data collected. Since the full article is not readily accessible, many are making a judgement without reading the entire article or knowing the culture of the area. I personally applaud this study since I have followed it and I do hope that Miami can save its reputation. This is just one area that needs to be addressed. Unfortunately, if the other problems were actually presented in another article some here might have a stroke without even knowing where Dade County Florida is.

U of M/JHM has an elaborate training center. However, there is no way to get 2500 paramedics into the ORs even with a hospital as large as JMH. The other issue is this is not the whole article. There are several more pages that qualified the reasons they did the study with certain factors involved. This small abstract or summary does not do the whole article justice. However, I'm sure only a summation of this part will be presented in JEMS for sympathy. However, unless the FDs can see where they need to improve, the decline of their once good reputation may continue to slide. The solution would be to go back to selecting those with an interest in being a Paramedic to work the EMS side and not continue with making all 3500 FFs become Paramedics in that county.

The system in the U.K. also utilizes a nurse in some areas. I am not anti-education. However, we now have too many in this profession who did not invest but the bare minimum (500 - 1000) hours to become a Paramedic and then have little interest in maintiaining what skills they do have. As well, the areas where the U.S. Paramedics are the weakest or display the least interest is medical issues. If all the patients to triage were trauma or "exciting" then they might show some ambition towards learning more. And yes I do fault the FDs are now making every FF become a Paramedic while utilizing their own PDQ mill or some other 3 month wonder mill. Right now we do have a considerable number of people wearing a Paramedic patch who have no interest in medicine or patient care and will not be the best judge of who deserves medical attention at the ED. It will be more of a "personality contest" rather than something based on a medical assessment. Some fail to put their attitudes in check when they get a call to a familar address or "one of those" neighborhoods with "those kind" of people. Look at the studies with MI patients. There is enough concern out there that some aren't getting assessed or taken seriously because of their gender or race.

Not always Rid are the studies skewed. The hospital has nothing to gain by taking ETI away from Paramedics except when problems have developed. Even the expensive/extensive training center at U of Miami/JMH that allows for more training and education of Paramedics is not able to keep up. I have made reference to this study in my other posts and have mentioned examples which have been severe enough that a closer look had to be done. This study was done over a 3-4 year period and the Paramedics knew the study was ongoing. When you and your department know that you are being watched, normally people do try to improve. However, there was also a "let's see if we're really that bad" attitude that is prevalent. Some believe a 20% - 30% failure rate is satisfactory. Artickat ETCO2 is available in many areas but not all. If one was to look at its use throughout the entire U.S. you might be surprised at the numbers that do not utilze it. Just because the LP12 is capable of ETCO2 that is no guarantee it will be used or that the Paramedics will be trained on it. The same can be said for 12-Lead EKGs. I am still rather surprised at the number of departments even in the larger cities (mostly West Coast) that have no intention of using 12-lead EKGs.

Dade County has undergone some changes over the past few years that has seriously hurt its reputation for providing quality EMS. When the many smaller FDs came together to become a mega county FD it grew too fast. The fact that the FDs do want Paramedic certs to weed through the 1000s of applicants has also presented problems. Medic mills have mass produced Paramedics just before a big department has a hire date announced. Hundreds of hopefuls get the cert but don't get hired during that round and keep their regular jobs flipping burgers or construction until the next year. If they do work on an ambulance, it may be on a BLS truck. Thus, by the time they do get picked up by a FD, a few years have pasted since they have done their 5 tubes on a manikin. Hospitals are also getting more reluctant to allow the poorly prepared students from the medic mills or even the community colleges' "EMS Academies" intubate in their EDs/ORs. Even if the FDs do try to give a refresher, the odds are against them due to time lapsed and the number of Paramedics in these mega departments. It wasn't always like this and Dade County had at one time been a leader in EMS with many FDs do EMS very well and with pride. The two year degree in EMS was respected and medic mills were thought to be for losers who couldn't get into a college. We even had competitions amongst the departments to prepare for State and National EMS competitions.

Several studies in the U.S. say differently. Can paramedics using guidelines accurately triage patients? http://www.ncbi.nlm.nih.gov/pubmed/11524646 CONCLUSION: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field. Can paramedics accurately identify patients who do not require emergency department care? http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed CONCLUSION: In this urban system, paramedics cannot reliably predict which patients do and do not require ED care. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed CONCLUSION: Paramedics cannot safely determine which patients do not need ambulance transport or ED care. Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport. http://www.ncbi.nlm.nih.gov/pubmed/1090564...ogdbfrom=pubmed CONCLUSIONS: From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety. Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols. http://www.ncbi.nlm.nih.gov/pubmed/1164258...ogdbfrom=pubmed CONCLUSION: These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage. Prospective determination of medical necessity for ambulance transport by paramedics http://www.ncbi.nlm.nih.gov/pubmed/1458210...ogdbfrom=pubmed CONCLUSIONS: Paramedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low. Can paramedics using guidelines accurately triage patients? http://www.annemergmed.com/article/S0196-0...5311-2/abstract Conclusion: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field. This was an interesting study that was referenced by one of the others. The stats it shows reflect the areas of interest of the Paramedic and they are not always the ones that can make for a provider who is knowledgable in many areas that are required to determine appropriate deposition of a patient. Trauma is a leading interest while medical conditions are not. As well, JEMS is the most popular journal which is not surprising but disappointing. http://www.acep.org/workarea/downloadasset.aspx?id=4814

Did I strike a nerve? Read some of your own posts. There is very little I have to assume after reading what you have written for over a year. Once I point out something you back peddle. You say one thing to impress the boys here but when questioned about it you go to pieces. Do you have any original thoughts of your own?

US jury favors hospital that deported immigrant July 27, 2009 - 9:12pm MIAMI (AP) - A hospital that sent a seriously brain injured illegal immigrant back to Guatemala _ over the objections of his family and legal guardian _ did not act unreasonably, a jury found Monday. Deputy Court Clerk Carol Harper said the unanimous six-member jury found in favor of the hospital and against the guardian of 37-year-old Luis Jimenez, a Mayan Indian from Guatemala. Health care and immigration experts across the country have closely watched the court case in the sleepy, coastal town of Stuart. The hospital had cared for Jimenez, who was uninsured, for three years. But it was unable to find any nursing home to take him permanently because his immigration status meant the government would not reimburse his care. "Hospitals are not intended to become long-term housing," said Linda Quick, president of the South Florida Hospital & Healthcare Association. "The issue is that there are no long-term providers required to take people for whom they know they are not going to be paid." She said that as a result of the case, hospitals will likely begin planning for discharge as soon as they admit patients they suspect cannot pay and could require long-term care. The lawsuit filed by Jimenez's cousin and legal guardian sought nearly $1 million to cover the estimated lifetime costs of Jimenez's care in Guatemala, as well as damages. The hospital said it was merely following a court order _ which was being appealed at the time _ and that Jimenez wanted to go home. Jimenez's cousin, Montejo Gaspar, was named his legal guardian because of his brain injury. Gaspar's attorney Bill King said he was extremely disappointed with the ruling and was reviewing all options including whether to appeal. "There is no doubt that the state government and the federal government has to address the situation," he said. "They can't let something like this happen again." Martin Memorial Medical Center's CEO and president Mark E. Robitaille said in a statement the hospital was pleased with the ruling. "We have maintained all along that we acted correctly and, most importantly, in the best interests of Mr. Jimenez," Robitaille said. But he agreed lawmakers must step in to ensure hospitals are not put in the same position in the future. "This is not simply an issue facing Martin Memorial. It is a critical dilemma facing health care providers across Florida and across the United States," he added. Robitaille, who was not yet head of the hospital when Jimenez was send back to Guatemala, said he was concerned that none of the health care reform proposals being debated in Congress address the issue. Like millions of others, Jimenez came to the United States to work as a day laborer, sending money home to his family. In 2000, a drunk driver crashed into a van he was riding in, leaving him a paraplegic with the cognitive ability of a fourth grader. The man who caused the accident _ which killed two people _ was driving a stolen van. An insurance policy ended up paying a total of $30,000 in compensation to Jimenez and the families of the three other victims. Under federal law, hospitals that receive Medicare reimbursements are required to provide emergency care to all patients regardless of their ability to pay and must provide an acceptable discharge plan once the patient is stabilized. But the hospital couldn't find anyone to take Jimenez. Eventually, backed by a letter from the Guatemalan government, the hospital got a Florida judge to OK the transfer to a facility in that country. Fearing the Guatemalan letter held an empty promise, Gaspar appealed. But without telling Jimenez's family _ and the day after Gaspar filed an emergency request to stop the move _ Martin Memorial put Jimenez on a $30,000 charter flight home early on July 10, 2003. Gaspar eventually won his appeal, with the court ruling a state judge doesn't have the power to decide immigration cases and that Jimenez should not have been sent back. By then, Jimenez had been released from the Guatemalan hospital and was living with his 73-year-old mother in her remote one-room home in the mountainous state of Huehuetenango. King said he believed some good had come from bringing both the initial appeal and the most recent case. "We've shown that state judges cannot authorize what is tantamount to private deportation of undocumented immigrants, and that hospitals have to follow the federal requirements that are in place for the discharge of all people, including undocumented immigrants," he said. http://www.wtopnews.com/?nid=104&sid=1723818

What I mentioned about the Haitains and Cubans is very legal. The process is clearly written but separately for each country since there is a specific "Wet feet - dry feet" process for Cubans. Wet feet, dry feet or no feet, it doesn't matter for Haitians. They are repatriated. Deportation is another matter and has its own process again some are specific to country. If depends on the country if they get the choice to come to the U.S. legally. Many cannot even get a permit to visit sick family. I seriously doubt if the mother of this patient was ever given that opportunity. I do not always agree with the way the laws are written for people from different countries but one country is accepted differently than others. I am the last one that is going to discrimate against someone that needs medical attention.

When a Haitain who comes to this country illegally or a Cuban with "wet-feet" arrives and are in need of medical care, it will provided. Then, they will be immediately repatriated to their own country to suffer whatever consequences. Essentially, the medical provided may only allow them to live a little longer because they may face execution or imprisonment for many years in some cases.

Okay you've made your point as you have in the other threads. You hate the homeless and illegals.

While this was all being decided during the course of the patient's care from 2000 - 2004, he, his guardian and family had some right to privacy. The patient did not need all of his medical care open for public viewing and it is unfortunate that many of the medical details are now available in the court documents. Some counties and states do made their deportation records available especially for those who are in the criminal justice system. There are probably sources to follow online as well if that is your thing. However, for this patient, this was a different circumstance and he did have immediate family to care for him when he got back to his own country. We do repatriate patients after they get medical care quite often under many other circumstances. Deportation is another issue.

If you read the article, this was not done overnight and it may have been mentioned several times when talking to the legal guardian as an option. The legal guardian may also have though it was a bluff or had bad legal counsel. I do put a large part of the responsibility to the legal guardian to work with the hospital and Case Managers to find a reasonable solution. We also have American families who think they can just leave a family member who is a patient in the hospital forever and refuse every option offered to them until the Ethics committee or the hospital lawyers get a court order or take legal action to assign a court appointed guardian to remove the responsibility from the families.

If it wasn't for the political problems between the U.S., Cuba and the South American countries, Cuba would not be a bad alternative. Contrary to propoganda fed to Americans, Cuba does have a decent medical education and training for their physicians. However, I think this patient is better with his mother since his life expectancy is probably running its course even if, and especiallly if, he was in the U.S. Somewhere the U.S. has failed to enforce its borders and looked the other way to fill jobs that Americans felt they were too good to do even though we have a very high number of able bodied people on welfare. Now some want to blame the illegals for almost getting an invitation to get a job in the U.S. because of lazy American syndrome?

Do you want me to post what you have said on the other forums? You usually come across as a disgruntled ex-cop or ex-FF who has not love for either profession. Just get over it Dust. This is freakin' one cop and you have make it sound like they're all out to get EMS providers with the many, many posts on this subject. Why don't you get this upset when an EMT(P) rapes a child in the back of his ambulance? Why aren't more in EMS calling for the certs of some of our own serious offenders? How many refuse to believe it is true even after they are convicted or the state has completed their investigation? Are the professional expectations not as high for EMT(P)s? Yes, maybe LEOs are the professionals and should be held to a higher level of accountability if we can't expect it from some of those in EMS. But don't worry Dust, Obama will probably just make a TV appearance with White, tell him how much he loves him and say the cop acted stupidly. That'll be the end of it and White can collect his huge settlement to buy that fancy car and house he so deserves. That yellow cat seems to be well trained in martial arts by the stance.

Not on the forums we are on together. I think he had more than some"one". But it also establishes character which he'll need when he goes to court. However, the more he and his partner talk to the media the harder it will be for them to keep their stories staight. That is where they will screw themselves. They've filed their complaints and there is no need to continue with the attitude on the news as if they are also judge and jury like you. Their egos seem to be their own worst enemy now rather than the cop in question. He still played a huge role in making this a serious confrontation. The cop knows his role in this mess, has made apoloigies and has not gone on TV or to the newspaper. In my opinion, that makes him the better of the two right now. However, it seems White and his partner are still being the agressors with keeping it alive in the media. White needs to now let his attorneys handle it. He'll get his money and probably won't be concerned about EMS or LEOs again. Actually, as it was also already mentioned including myself, it is now not an EMS issue but one of race.

You've made you opinions very clear on the forums. It is possible what you are trying to say and what come across the screen are different. You do tend to occasionally lump FFs and LEOs into a very not so flattering viewpoint. The link to the article is in one of the threads. It might still be on that OK news channel link that was doing all the updates. Did you see the medic's TV interview? Grandstanding right after the incident just doesn't do one's credibility much good.

Disrespectful?!! Where do you get that? Rid belongs to several forums and you never know which one he is going to show up at and when. He keeps his need on the invisible mode so you never know when he is around. It is even a little joke in some of the chat rooms. I don't get your comment about disrespect at all. If anything you are just being ridiculously oversensitive to this issue which is a hideous display of egos on all parts. Great so all I need is to get someone to call me something derogatory, like I haven't heard already, and I can go on TV and make my fortune? Tempers flare in levels of stress. Yes this wasn't the best of situations but do you really want to hold such a vindictive grudge and hate LEOs or cause turf wars? Cops probably don't want this LEO as the poster child for law enforcement anymore than I want this Paramedic to be the poster child for EMS. I believe his motives are self-serving and probably has had every chance to meet with the LEOs to settle this but has already gotten a sniff of money. The fact that he is using the race card instead of using a medical professional argument gives him a broader audience with certain members of the black community to his backing. Sorry but in all of my years in EMS and the discrimination I went through in the 70s, I still did not feel compelled to use my ethnicity or gender as a reason to cry foul when something didn't go my way. Dust, I already know your attitude about cops. Like I said, I don't agree with the way this cop handled himself in this situation but now the issue has become how they have handled themselves since. The Paramedic is going to burn himself when motiviated by greed and race issues.

Yeah I know, Rid has posted that on every forum he haunts. However that is not the one where he talks about donations to this guys legal fund. I don't know if you get CNN where you are but they are talking about it right now with one of the black rights leaders so you got your wish. It will be totally a race issue as if we didn't expect that. I guess if you don't expect to win one way, the race card is the easiest to play.

Do a quick search. It is either on a newslink or youtube. I saw it when it was on one of the earlier newslinks. It isn't his money. He'll spend nothing. This medic didn't have the greatest record either. If it hadn't been this incident it would have been another and that one might not have been in his favor. His cert might have been in question. I don't send money to someone just because he's black or a Paramedic. In this case it take two to tangle and the Paramedic was not without his part in this mess. Don't try to make him out like an angel just becaue he's a Paramedic. There's more to the man than just a patch.