VentMedic

Does every hospital have a cath lab?

Making some aspects of the job fun can definitely be acceptable. However, getting your jollies at the expense of a patient is not acceptable. Luckily California has redesigned their EMSA site that makes it easy to report and track people who abuse their title of EMT or Paramedic in ways that is not in the best interest of the patient or the profession.

Banagas, you just stated this:

You can't figure out why this is?

It doesn't take that much to get a job in the mines or some industrial factories pulling in a decent wage for a 40 hour week. Even CNAs with minimal entry cert requirements in hospitals can gain a few extra skills and make more for a 40 hour week than most EMTs or even Paramedics working their 24s. They also have the opportunity to do doubles or 12 hours shift at 1.5 after 8 or 2x pay after 12 hour 7 days a week if they desire since they are in demand and still sleep in their own bed a few hours/day. People who attended the 110 hour junior manager training program at Burger King have had their dreams of being a millionaire crushed also. That is old when compared to the other medical professions that have passed EMS in education and credentialing at a national level. Even nursing did not start to get its professional recognition until the late 1970s when it started to eliminate the diploma schools. EMS had every opportunity at that time to establish itself before nursing. If you notice, many of us from the 1970s have our Associates in EMS which we obtained at that time when the push was on to establish this profession. Pick any of the allied health professions and you will find they have developed into a profession at a national level over the past 20 years from being non-existent. That includes Radiology, Respiratory, Nuclear med, Radiation medicine, etc. Speech, Occupational and Physical Therapy are a minimum of a Bachelors with Masters and Doctorates preferred. You also have to consider we don't know what to even call those in this "profession". We have over 50 different titles recognized differently in each of the 50 different states for something resembling EMT and Paramedic. Even those terms are not always used in some states. Other professions don't have this identity problem and have narrowed their licensing down to a couple different levels and a handful of specialty credentials. It is a very sad statement that in 40 years EMS is further from establishing itself than it was in the 1970s. I don't get the religious angle you are stating. While there are a few 2 year degree programs in CA, they are rarely completed since the certificate is good enough and that is what most obtain even at the community colleges. The minimum hours in California to be a Paramedic is still 1070 hours. The only difference is even the PDQ medic mills must be accredited by CAAHEP/CoAEMSP. Unfortunately their statutes had previously not defined that their clinicals must be done on a transport vehicle and many have done their rotations on an ALS engine for 24 hours at a time. Thus, 13 weeks can be obtainable. Florida also had that situation and as of this year it was emphasized that an engine is not a transport ambulance suitable for clinicals regardless of how many paramedics you can squeeze onto it. In northern CA, the FDs may be separate from EMS and even when they are together they are separate. There is also no shortage of Paramedics but rather just a lack of appropriate allocation or use of resources.

Pick just about any of the industrial trades and you can easily earn that much. Although, even many welders now have college degrees. Heavy equipment operators, coal miners, auto workers, commercial divers, ambitious salespeople etc can all make that amount with just a regular work schedule and have no need to work 2 or 3 extra jobs. You also have to factor in that the wages for for EMS on not based on a 40 hour work week. There is also something to be said for the professionals that can make that much in 40 hour work weeks and have a quality personal life to match a rewarding professional career.

Once you get your nursing degree and critical care medicine experience, you may forget all about the paramedic thing. There are way too many opportunities and directions to take in nursing including CCT and Specialty transport that require much more education and many more skills than the Paramedic.

If you got paid just on the national average for Paramedic education in the U.S. as the "hours of training" stands currently, you would have a hard time justifying barely more than minimum wage. This is the only licensed medical profession that does not require at the minimum an Associates degree for entry. Even the very few certified medical professions left require a year of education for a certificate. These are nationally accredited and accepted standards for other medical professionals. Other professions have learned that through education, they can get reimbursement. Other medical professionals may be able to list all the "skills" the Paramedic possesses plus many of their own as well as the education to back up everything they can do. Why should insurances pay more and think that will make the 13 week patch medic get a higher education or improve the quality of care provided? What national oversight agency is going to ensure that? What quality control standards has EMS instituted as a profession to adequately monitor consistency of care? Even with those that are in place, rarely are they adhered to because of poor oversight of the industry or the failure to police our own. Raising the pay without raising the education standards will only encourage people to seek out quicker medic mills to get a chance at the higher paying jobs. Haven't we learned anything from the FDs? Higher paid and pretty trucks does not always equal better EMS or patient care.

More technology does not necessarily equate to more education. Even the pulse oximeter is poorly understood and misused by some as a crutch to replace inadequate physical assessment. Many use devices such as the ETCO2 for only one purpose such as confirming a tube but often the education stops there. The 12-lead can have a computerized print out for the interpretation which has been the down side of it. We've already seen many of the misadventures of RSI as well the benefits. Ventilators vary from ATVs to some really sophisticated machines. However, without adequate education, even the most expensive machine is little more than an ATV and can cause just as much if not more harm to the patient in the hands of poorly educated and trained. On the forums that have so called advanced providers of Critical Care transport and Flight, you will still find people asking very basic questions that should have been answered in a classroom long before they touched a patient with advanced procedures. Or, they still want a recipe for some devices or shortcuts to critical care protocols. Others still ask for memorization tricks for complex protocols or procedures that are best learned through education. Some are clueless as to the differences in the technology to even know why or why not it is appropriate for different patients. Many companies get talked into too much or too little technology for their service due to inadequate preparation through education. You could compare it to shopping for an expensive high performance car. If you don't do your homework, you could still end up with a Yugo.

Unfortunately EMS is changing differently than other medical professions and facilities. It is reverting back to the "Public Service" mentality rather than advancing as medicine. EMS is the only medical profession that has managed to maintain or decrease its standards for job entry and patient care. What initially started out to be a two year degree program in the 1970s is now measured merely by a few hours of training. The skills that made us proud to be extensions of the physicians in the field have now been watered down by lack of education and adequate training. While the 12-lead may have been the standard for some Paramedics for over 20 years, it is not heard of for many. Those that do attempt to incorporate it do so haphazardly (ex. LA county) with bad results and frustrated hospitals. If Paramedics did have some of the very essential basics in physiology, the 12-lead would be little problem to introduce with some proficiency for interpretation in a timely manner. Many services are abandoning ETI for alternative airways that require less education and hours in a lab or OR to perfect. Too many have so little of the fundamentals that it makes something like CPAP a struggle to initiate in some services. We could also use the ETCO2 monitor as an example. Too few understand it and just use it for the pretty wave forms to "check a tube". So, maybe this profession should rethink itself if it continues the path it is taking with medic mills and FDs training their own again in minimal time for just the bare minimums required and states are not agreeing on any one or two levels. The profession as a whole has failed to police itself and thus has allowed this to happen. It has failed to monitor the very essentials that made this profession unique and now having taken the easier route. A person with as few hours of training as many Paramedics in this country would not even be allowed much patient care responsibilty in most hospital settings where education, knowledge and competency are expected. If this profession continues to turn back to the "public safety" days, maybe it should streamline and accept the fact that many areas will not ever be able to increase their standards, knowledge or skills because to the mentality that exists. As long as the insurances continue to pay for an ambulance ride regardless of quality, there will be little incentive to improve. As long as tax payers are footing the bill for the FDs to provide EMS without the ability to hold them accountable for their medical knowledge and expertise with immunity statutes or tying the hands of medical directors, there will be little progression. Thus, as long as we have people providing this service who have no ambition to be medical professionals doing a few "ALS" skills and merely wanting a paycheck knowing they cannot be fired with union protection, this profession will continue to fall to the lowest denominator in the eyes of the government, insurances and tax payers. Unfortunately, the hospitals will continue to bear the brunt of the responsibility because the path EMS is choosing will be of little help. Those EMS systems that have raised their standards should be applauded because they did so with little help from their own profession. They will also struggle to continue even if their system works because someone will always want to break what isn't broken just to get by with the expectations of the lowest denominators.

http://www.nbc-2.com/articles/readarticle....d=22889&z=3 Collier County EMS Q & A Originally posted on: Friday, November 07, 2008 by NBC2 News Last updated on: 11/7/2008 4:28:42 PM Q & A with Collier County EMS over aborted emergency call Answers to questions from NBC2 Investigator Kara Kenney What is Collier EMS's version of the events? Why did you stop the call? On September 04th, Dr. Tober requested all fire departments to provide records to assure Collier County’s compliance with Sections 401.265 F.S. & 401.281, F.S. A deadline was established for October 1st, however the City of Naples requested an extension. It was extended by 15 days. By 4:00pm, on October 15th, the City of Naples still had not provided all of the necessary information. More alarming was the fact that a spreadsheet (attached) provided by City of Naples Fire Training Officer, Battalion Chief Torrella, shows that only 4 of their 33 firefighters comply with the State’s minimal driver’s training requirements (16 hours). (Florida Chapter 64E(J)-2,.012, (2)). Surprisingly, there was also a notation on the bottom of Torrella’s spreadsheet stating “Those members lacking the certification (EVOC) will be instructed within the next 45 days”. Obviously, I had an immediate concern that the City of Naples may be having problems maintaining their driving standards similar to their struggles with medical certification. Immediately, between the hours of 4:30 – 5:00pm, I called BC Torrella and left a message expecting a call-back. I was hoping that he could confirm this was just another clerical omission, and we could settle the issue over the phone and move on. Around 7:30am of the following morning, I had not heard from Torrella and called again. No answer. I then attempted to contact Chief McEvoy on his cell phone but was forced to leave a message. I called his secretary who informed me he was in a meeting at City Hall. At this point I had exhausted my only regular points of contact and chose to contact our Battalion Chief Bill Peplinski to find out who was scheduled to work on the ambulance. I was informed that Firefighter Kofsky was scheduled, who is somebody I do not know and was listed as ineligible to drive an ambulance. After a short discussion of our options, I instructed BC Peplinski to place himself out-of-service, drive down to their station and replace Kofsky until we could either remedy the situation or find another replacement. I also authorized overtime to be expended by our department so we could back-fill the City of Naples’ employee. I understood the choice to use overtime was outside my normal scope of authority, however we were attempting to exercise any/all options to find a remedy to the City of Naples’ dilemma. Throughout all of this confusion and despite the fact the crew on EMS Medic Rescue 2 was told that Kofsky could not drive the ambulance, he did it anyhow. Being that no direction was given to place the unit out-of-service, a call was dispatched for an incident at an assisted care facility. Both EMS Medic Rescue 02 and City of Naples Rescue 02 responded from the same station. During the response, BC Peplinski called Medic Rescue 02 and asked if Kofsky was driving, he was told “yes” because they thought the matter was remedied. BC Peplinski explained otherwise and instructed them to have another unit handle the transport and they would be placed out-of-service. Even though the crew was almost to the scene, they interpreted the order as they could not finish the drive to the call, but instead the crew chose to drive back to the station. Despite the claims within the City of Naples’ memo, proper certification was never confirmed for Kofsky. Actually, over the next hour, I juggled several other phone calls between Chief McEvoy’s secretary, and Naples Battalion Chief Matt Reed. By 9:45am, BC Reed assured me that Kofsky had the proper certification and claimed Torrella’s list was erroneous. I explained to Matt that while I trusted him, it would be in our best interest if he could provide either a copy of Kofsky’s EVOC certification, or an updated list that corrected the mistakes within their original document. Around 30 minutes later, I was informed neither could be provided and the City of Naples would rather replace Kofsky with another firefighter, Steven Garrity. They immediately faxed a copy of Garrity’s certification and to my knowledge, Kofsky was never placed back onto the ambulance. Throughout the day, it was apparent that Matt Reed was working diligently to provide the proper documentation necessary for State compliance. He called me several times, however by 3:00pm, they were unable to produce certificates or compile an updated list that assured the appropriate driving hours/curriculum was ever taught. At 3:37pm, I received a memo from Chief McEvoy that explained they still needed more time to finalize a “forthcoming” report. Once again, I spoke to Reed who offered his personal assurance that anyone placed onto the apparatus would only be selected based on the fact they had queried/confirmed their training information. Not until the following week did we receive their report and copies were placed into all of their employee’s files. It is worth mentioning that as of this date, there is still information that has yet to be provided by the City of Naples. According to the Records Custodian; None of their firefighter’s drivers licenses have been provided Two have not provided either an EMT or Paramedic license One employee’s BLS certification is expiring this month 3-What was the condition of the 92 year old woman? ( The patient was stable on the arrival of the EMS unit. Although the initial O2 sat was 88, the rest of her vital signs were excellent = pulse rate of 64, respiratory rate of 18 and blood pressure 120/80. An O2 sat of 88 accompanied by these vital signs is not indicative of an emergency. For example, long time smokers routinely have lower readings than 88 and readings can also be altered by poor circulation in the extremities such as can be caused by a patient being cold or by finger nail discolorations, either yellowing and thickening which can happen in the aged or with nail polish. The rest of the vitals are not alarming, particularly for an older patient. Once oxygen was in place, her O2 sat went to 96%. Any estimate as to how much longer this woman had to wait for care and/or a transport based on this mixup? [WatsonWayne] There was no delay in care. Rescue 02 was on scene, and provided all of the care ever rendered to the patient. No addition treatment was necessary when the ambulance arrived. An EKG was applied, however no other medications or care was needed beyond the capabilities of Rescue 02. Being that the City of Naples did not complete an official Patient Care Report (another violation being investigated) the best I can discern is that it took 8 minutes from the time the City arrived on-scene until the ambulance arrive to provide transport. Did Kofsky have a valid EVOC certification or not? It was not provided until the following week. Actually, as written above, the City of Naples chose to replace him with other firefighter. Have there been problems with firefighters not having their certifications? What are the issues? We were again facing the possibility of having to self report to the State each transport violation where an unqualified crew member was on board a licensed transport unit. What do you say to NFD firefighter 's allegation that the political turmoil is "endangering citizens" and negatively impacting emergency care? As proven, this issue, while unfortunate and unnecessary, did not endanger the patient. Defining the County and City of Naples' attempts to police administrative discrepancies as "political turmoil", including the potential insubordination of a crew who was advised to not allow Firefighter Kofsky to drive an ambulance is a misrepresentation of the facts. There are no cases where revisions to protocols or any other administrative issues have negatively impacted a patient. The Medical Director has explained in several forums that clinical evidence supports the concept of good Basic Life Support saving more lives than Advanced Life Support. He is simply acting prudently in monitoring the licensure of persons operating under his medical license and stressing need based training and medical care. Another article: http://www.nbc-2.com/articles/readarticle.asp?articleid=22890&z=3

You really don't know when to stopping yakking do you? I and everyone else read what you stated about the calls in your area. Because of those demographics you have determined their medical needs are BS without leaving your recliner.

Thanks to all of your enlightening posts I think everyone knows way more than they ever cared to know about the Memphis Fire and the sad picture you have painted of it for us. The citizens of Memphis also deserve better and not have those who are there to provide medical assistance judging their calls before they even see them. If you are doing this by location, I believe there are a few terms for that and the people of Memphis should not be judged by you on where they live, what color or economic status they are. Recruiting Paramedics? Dude, that made headlines on many news wires and thus the discussion! I seriously doubt if any of us would have cared about MFD if it hadn't made the news with its answer to the Paramedic shortage. The newspaper article is from October 13, 2008. http://www.commercialappeal.com/news/2008/...ass-in-session/ The study was sent to me by members of your department knowing I would post it and they would not have to worry about retaliation from you as their Lt. Your statements still make many things mentioned in that study very relevant.

MFD can't figure out why they have had a problem recruiting Paramedics over the past few years? I can see the EMT not being recognized in the pay scales since many departments do require that and it isn't that big of a deal to get as a certification. At least the other FDs departments in this country that do attempt to do EMS well know how to make their pay and career ladders for some incentives. And yes those departments are also union so you can not blame your department's problems totally on your union. You have definitely done a good job at exposing your department's problems. There are times when you should learn to stop yakking.

Right now the scenarios or projects we're running in the allied health programs are about budgets cuts. Essentially it centers around a given budget that they had initially helped develop with all of the essentials as well as a feel extras and then it is cut by 5 - 10% depending on the program . The decision is who or what would you cut from direct patient care and still be able to provide quality care. Even a 2 or 3% cut for a budget scenario is an eye opener for some. They also get a good overview of the American medical reimbursement system and how that can change at any given moment with various legislation and consolidations/mergers or a change in the tax base population for some areas. We find the students enter the workplace with not only a better understanding but an appreciation for the costs of many aspects or to the people including the taxpayers and patients. There is then no disillusionment in their chosen careers when they work for different agencies or facilities with some being the "haves" and some being the "have nots". Too many come into the profession and become disgruntled easily because they have no idea how their system works and how many factors control it.

Comparison of 15 Transport ventilators http://www.rcjournal.com/contents/06.07/06.07.0740.pdf Some of the ATVs and simplistic vents seen in EMS and unfortunately some CCT/Flight programs http://www.lifemedicalsupplier.com/resusci...=0&sort=20a Great source for reading Respiratory reviews and research (The journal for RTs) http://www.rcjournal.com/ Good overview of oxygen and ventilators as well as other critcal care items of interest. http://www.ccmtutorials.com/rs/index.htm

Maybe straight CPAP on a trach but with a nasally intubated child, no less than 5 cmH2O of PSV to overcome the resistance. No need to make the little one stuggle for each breath and increase the work of breathing. Modern ventilators were invented to alleviate suffering. Let's not give people the wrong idea they can try this with some ATV in the field on a child. The face mask to ETT stuff is bad enough without ETCO2 monitoring in an acute field situation.

SIMV is a mode that provides mandatory breaths, usually volume, and can or can not be used with pressure supported breaths. PSV is a spontataneous breathing mode. SIMV flow delivery and wave pattern is very different from a demand flow PSV breath.

When you have no point to make you resort to personal attacks toward me and Paramedics. EMT-IV vs Paramedic? What do you consider ALS? The ability to start an IV, do a 12 lead and give a couple of meds? Other states call that EMT-B advanced or extended, not Paramedic. Again, if you have no interest in treating patients, both the good and the bad, why bother doing EMS? Your less than professional attitude toward the medical aspects of the job should be a true inspiration for the new recruits in the Paramedic program. Be sure to teach all of them how to make a diagnosis from a recliner chair just as well as you do?

SIMV? You are way too young to remember that old mode even though some of the machines still have it and I actually had one MD moonlighter last year think he was going to order it in the ED. It sets the patient up for asynchrony with the different flow delivery. However, pressure support and tube compensation are utilized with the sensitivity being set for the patient's effort and comfort. I see flight/CCT teams also try to use SIMV when their deceiving little transport machines have no PSV capability. Or, even when it does, they can't understand why the patient is still bucking the vent with each different breath type. Pure assist, by either volume or pressure settings or both, is more popular now with various modes to achieve the correct delivery. In this scenario it is hard to tell if the Paramedics had a poor understanding of the respiratory system or just lazy or both. Either way, I hope they do not get the privilege of adding RSI anytime soon.

MemphisE34a wrote: What part was made up? Look back through you own posts and those of your pals so you can keep your stories straight. Yes, the study was done 4 years ago and it takes a while to fix a department that has let its EMS system go into ruin. It is good to see that MFD is following some of the recommendations. I didn't have to go out of my way to find this study. It came to me from some of your own who know MFD probably better than you or they are seeing it from a working FF/medic role which you can not. I just find it hard to believe a FD that has such a past track record for EMS that had no Quality management or any type of tracking system for different protocols, patient outcome and public satisfaction would attempt to start their own Paramedic school. As the study said, it has to start at the top. However, little will be really fixed until everyone gets the message and the "culture" is changed throughout. This will take a long time to happen. MemphisE34a wrote: This statement quote says you have little idea about EMS and don't understand that many of the calls are BLS. Or, is it that medical calls are just BS? With your limited ambulance time as you have also stated in an earlier post, how would you know the difference between between a BLS or ALS call? If you are echoing the opinions of your superiors, why does MFD still hang on to EMS? And then try to teach it?

Of course, you are from Davie, FL where the downtown still had hitching posts to tie up the horses until the 90s. It is also the home of Davie Pro Rodeo.

It was still puzzling as to why Memphis FD had a difficult time hiring people when other FDs have kids starting to put their names in the hat in 10th grade for a department. Most FDs have an abundance of applications that they must weed through. Miami has a surplus of 6000 applications with the majority of them having Paramedic since it is recognized as a plus. The same with other departments that now only look at applications with the Paramedic box checked. So, I asked the question on a couple of FF forums and got the document linked below. Apparently MFD has had its share of problems with the EMS part being a step child but I think most of us had figured that out by the MemphisE34a's attitude. The new equipment he just spouted off probably came out of this study in 2005 and not out of the kind, caring attitude of the Fire Administration towards EMS. Memphis Fire Department An Assessment of the Emergency Medical Service System http://www.cityofmemphis.org/pdf_forms/assessmentOfEMSS.pdf (Pages 3,4,5 of the document are a list of 38 major recommendations that were made for this FD) Since FDs departments fall within a state immunity clause, these lawsuits had to be the result of gross negligence for them to occur. MemphisE34a is not but still supervises the busiest station for EMS. http://www.cityofmemphis.org/pdf_forms/assessmentOfEMSS.pdf I do want to thank the members of the Memphis FD that emailed me this study. It answers some of my questions and sheds light on their hiring problems. They also made some other comments but I'll take spenac's advice to be kinder and gentler...this time.

How long is the wait at scene for the helicopter?

Now some of them just race up and down the halls of the LTC facilities in their electric wheel chairs with ventilators attached on the back.