RedZone

Ah. I've been to them all, but the last time I was in Peninsula or St John's Episcopal was in the mid-90's when I still worked for TrashCan, I mean TransCare (not exactly the same company as the one out there now, only the paintjob is the same). No longer familiar with that area anymore. Last time I even passed thru the rock was when I dated a girl in LI, which turned out to be just too much of a hassle to get to.

Respect. I'll second everything said here. I've also heard some great things about Jacobi. They have a bank of every known antidote and some of the leading experts on envenomations. But the McDonald's next to the hyperbaric chamber? Never understood that one! I guess it's job security.. lol. You work in Jacobi area, Rich? I brought a CO poisoning pt. to Dr. Dau the other day. I had instant respect for him, that's rare for me.

Be careful... many cath labs in NY hospitals are diagnostic only, they're not authorized to treat. Not the same as a PCI capable cath lab.

Well, I came across an answer to my question. It appears in May 2007 issue of JEMS in an article titled "Specialty Center Boom: Is transport to the closest ED a thing of the past?" Quoted from Marc Eckstein, MD, FACEP: Cardiac center designation is currently in vogue. Good science supports treating ST elevation myocardial infarction (STEMI) patients with emergent percutaneous coronary intervention (PCI) instead of fibrinolytic therapy, as long as the door-to- balloon time is less than 90 minutes. However, the American Heart Association has not yet formally supported EMS diversion of STEMI patients to cardiac centers. Rather, it recommends having an internal process to get the door-to-balloon time under 90 minutes if PCI is available, or else have a formal process in place to rapidly transfer STEMI patients to PCI-capable facilities. I guess my system is actually in compliance with recommended guidelines. As I realized myself, hospitals are making internal changes as recommended. The article does explain that many EMS systems have begun adjusting their own procedures despite AHA's lack of formal support. Definitely an article that answered a lot of my questions!

You're talking about a much different scope of practice. An RT has a hell of a lot more training than a medic does. A medic might get a one hour lecture on how to operate a vent, an RT will have a few years. An experienced interfacility medic will be able to "tweak" settings, but generally that's probably pushing on a fine line of stepping outside of our scope. I am also not referring to medics who have taken advanced critical care programs. But not all regions utilize this level of training. Also, medics don't stabilize patients for transport, we either stabilize as first line of care (pre-hospital), transport to facilities for stabilization (e.g. - pt unable to be stabilized without specialty care), or transport already stabilized patients. Patients becoming unstable during transport would probably fall under the pre-hospital care category. Post-op stabilization... outside of a medic's scope.

I try to learn about things. It's in my nature. When I have a question, I find someone qualified and ask them. But, if your service is like the ones I've worked with, they'll offer you little training. Here's a few pointers: First off, ALWAYS carry an ambu-bag with you. You probably won't have to worry about prescribing any settings. You're transferring a patient and maintaining them on their prescription. Always get a verbal report of the patient's vent settings, preferably from the respiratory therapist. ALWAYS carry an ambu-bag with you. If you notice mild signs of hypoxia or a dropping oxygen sat, increase the FiO2 ALWAYS carry an ambu-bag with you Keep the connection between patient and vent visibile. That is, don't cover the trach with a blanket. The vent tubing likes to pop off a lot, so you'll have to replace it. You'll get used to hearing the sound of air leaking, and the vent will "Low Pressure" alarm. ALWAYS carry an ambu-bag with you High Pressure usually means the patient coughed. If it's consistent, suction the trach. ALWAYS carry an ambu-bag with you And, what's the big deal? No reason to be scared at all. If anything goes wrong, all you have to do is bag the patient. You did carry an ambu-bag with you, right? As far as all the settings.... yes, take the time to learn about them all. And since you're going to become familiar with respiratory therapists, don't ever be afraid to ask them questions... they know a hell of a lot.

Yes! We have chilled ampules of Coors, Corona, Heineken. Of course, there's Budweiser on Drip.

Richard: I wasn't suggesting that EMS workers consider striking. I was merely pointing out that in other professions, unions don't combat each other during a conflict, they support each other. I used nursing strikes as an example. UFT won't encourage their RN members to bash 1199 RN members. If UFT nurses strike, 1199 might even encourage their nurses to assist with picketing efforts, take out ads in newspapers, and SUPPORT the efforts of the other union. Even unions aside, other professions have much greater unity among colleagues than EMS workers do, at least in NYC. Personally, I feel EMS (as an industry) is still growing, and much needs to be done to advance the field. Maybe one day we will be better respected by the public and other healthcare professionals. Maybe then we can lobby (this would require cooperation) for professional status. Warning: strong opinion follows. This isn't an attack on individual members. Or maybe FDNY brass and the FDNY*EMS unions can keep brainwashing their EMS workers into believing: 1) that they offer superior patient care 2) all other EMS providers offer substandard care

Dumb question??? HELL NO!!! I love this question! It lets me do some free thinking. This will depend on whatever other qualifications you have (or willing to acquire) as well as your ability to market yourself. *Consultant (various fields) *All sorts of safety related jobs: Site supervisor, inspector *Politician (some of us get a lot of experience with BSing) *Various healthcare administration jobs *First Aid / CPR instructor *Sales Rep (Defibs, First Aid Supplies, pharmaceutical, ambulances, etc.) *Private practice (Don't ask me how, but I know of one medic that does this) *Clinical assistant (e.g. for a Dr. in private practice) *Medical Billing *Technical advisor for movie studio *Writer (Bringing Out The Dead, several other published books) *Research *Crime-scene clean-up (I came across this article just last week)

I know it's been overstated already, but: I became an EMT in 1994. Back then we were taught the "Brand New CPR guidelines" In 2000, new guidelines were issued. In 2005, even newer guidelines were issued. Call "The Antique Roadshow" and see if that book is worth anything. Some things will never change. Our anatomy stays pretty constant. The most effective way to resuscitate a patient seems to change all the time. Maybe dead people are like viruses, they tend to become resistant to therapy with time.

Wow. Seems to me as if there are enough debates going on here to warrant 14 different threads. Good thing I'm bored. Knowing this is such a heated issue and it would be best for me to step away..... I still insist on chiming in... Hate me if you want. First off: tskstorm, you are misinformed. Private ambulance companies (i.e. TransCare) do not dispatch 911 dedicated units to assignments. All 911 assignments are dispatched through FDNY-EMS communications. They will NOT send a "transport" ambulance to a 911 call nor will they send a 911 unit to a privately requested call. Many private ambulance companies DO respond to emergency calls through their business relationships. For instance, many skilled nursing facilities (including those owned by NYC) prefer to use private ambulances as opposed to calling 911. Hospitals (including city hospitals) will also request emergency transfers from private ambulances when a patient requires immediate services not available at that hospital. FDNY prefers not to be involved with interfacility transfers, makes it difficult to request such service, and refuses to provide ALS service for interfacility use. So, a head trauma patient wheeled into walk-in triage will require emergency transfer by private ambulance to a trauma hospital. Hatzoloh (or however they spell it). All I'll say is that they definitely play some funny games. Without getting into it in detail, they've been around my entire career, and they don't seem to be going anywhere. Why stress out? People have a right to choose who they want and who they don't want to care for them. If someone prefers to call Hatzoloh, let them! If someone refuses a 911 unit, let them! If you witness ANY ambulance crew violating a regulation, and it really irks you, report the details. There's not much else you can do. Is EMS treated like the "bastard child of FDNY"? Tell you the truth, I don't think that is the main issue. EMS, in general, has practically zero public relations. When Bloomberg was busy shutting down firehouses, FDNY administration along with their unions, got the media's attention to involve the public. The front page of every major newspaper reported each and every firehouse closing. Multiple articles filled the front sections of these papers for weeks. TV news spent countless resources reporting this "outcry". People responded by protesting, and some were arrested for physically resisting the removal of fire trucks. During this same period, numerous FDNY EMS tours were cancelled. A small, one to two paragraph article was well hidden somewhere in the Daily News. The EMS unions simply continued to spread their age-old propaganda that employees for voluntaries and metro-scare were nothing more than scabs who threatened the jobs of every FDNY EMS worker. Not ONE FDNY EMS worker lost their job. I will even agree with what was said earlier in this thread... FDNY EMS workers have probably the MOST SECURE EMS employment in NYC. Since when does a union encourage their members to shun other union employees (most voluntary hospitals are union shops)? When a nursing union strikes, OTHER NURSING UNIONS SUPPORT THEM!! The state of EMS in NYC is, in my opinion, disgusting. And the FDNY EMS union is more concerned with spreading hatred among their members than working together to improve EMS as an industry.

Yes, an Ethanol IV Drip is indicated for treatment of methanol poisoning. As I remember from medic school, methanol itself is non-toxic; however, its metabolites can be lethal. Since the liver has a much greater affinity for metabolizing ethanol, medical treatment requires "getting the patient drunk" until the kidneys excrete all the methanol. Would mixing up a bag of D5W and Everclear get you drunk? Most definitely. Would it be safe? I'm not gonna try it!! I'd be more afraid about injecting the unknown impurities into my bloodstream.

Well, it's good to see that many regions don't have this same problem we do. Even the case of one region requiring a machine interpretation is still more than our regional council recognizes.

Recently, the cath labs I'm familiar with are available, and patients do get expedited in 24/7, virtually 100% of the time. If our EMS system recognized a cardiac specialty referral and the lab had to be closed (say, for equipment failure), the hospital would have to report it and be placed on cardiac diversion.

You say this is a recent study, but just curious as to how recent. It sounds as if those recommendations are how we have done things here as well. From what I understand though, AHA now considers this to be an outdated philosophy. No longer is it "the big one" that requires immediate cath, but virtually ALL acute MIs (ST elevations + clinical presentation = cath ASAP). Several hospitals here that are NOT capable of PCI still have cath labs used for diagnostic purposes only. So, if a pt is diagnosed with an MI at 3AM on a Sunday and considered "stable", they would have been given lytics, placed on Heparin (maybe Tridil prn), admitted to CCU, and have a cath scheduled for Monday or Tuesday. Too often on Monday or Tuesday, I would respond to that cath lab to take that patient from their table to a PCI capable cath lab when it was discovered that one or two arteries were 75 to 100% occluded (assuming they weren't CABG candidates). Sometimes, it was suspected that these patients were still infarcting. So, yes my opinion is biased, but I agree with the new AHA guidelines.

I agree 100% that my regional standards differ from AHA guidelines. This wouldn't be the only example of such. And that is why I am curious about other regional standards. From what I am seeing (this site, and elsewhere), it is a fairly common problem in many systems. According to one person, this exact issue was discussed in a critical care class "majority of the systems still transport to local ED's" Suing the system? Good luck! If it's that easy, I sure hope someone is doing that already.

Well, yes, in a way you are lucky to not have to be concerned with destination decision! As far as lawsuit, you need injury due to negligence. Whether I agree or not, the accepted standard here is: AMI to closest ED. The 90 minute standard is probably being met, even when the patient requires transfer. A year or 2 ago, not every STEMI got an emergency cath here. I don't know the exact criteria used, but many were given thrombolytics, admitted to CCU, and scheduled for a cath a day or two later. If I were to do that same call today, I'd call telemetry and say, "Hey, it makes more logical sense for me to go an extra 5 minutes out of the way with this guy, but I need your ok."

Interesting indeed!! From what I heard (I guess technically that's only rumor), there was a trial done in NYC 10 years ago where one voluntary hospital experimented with TPA prehospitally. Don't know the results, but it never made it on the bus. We rarely have a transport time greater than 10 minutes, and eventually all emergency departments were mandated to have thrombolytics. But it sounds like you have a much higher scope of training and practice than we do. Awesome!

Very nice to hear this! It sounds like this particular hospital realizes the potential of your EMS system and looks for ways to implement the EMS resource to improve patient care. A good model for many other hospital / EMS systems nationwide. A cath lab nurse I was talking with told me she was at a conference recently. What I got from her was that this is something either being promoted or recommended right now. One hospital implemented a STEMI code policy where ANY patient who walks in complaining of chest pain is to be immediately placed on a stretcher and have a 12-lead done right at walk-in triage. If they interpret it as an ST elevation MI, the nurse activates the code. This sounds like a great thing, but it also hits me like a slap in the face a little too. I feel like screaming, "Uh... HELLO!!! We've been evaluating STEMIs for 10 years now! How come you're not at least asking EMS to notify you ahead when bringing STEMIs in and consider that sufficient for activating that code?"

Interesting. For us it is a consent issue. If the patient is not oriented, we have implied consent and may make the decision for them. If the patient is oriented, we have a responsibility to inform them that their decision may be harmful and attempt to convince them. If they insist, we have them sign an RMA and obey their wishes. If they are unstable, it would probably have to be approved by telemetry, but I don't really run into this issue. It's rare that someone will argue with me when I tell them, "that hospital can't treat xxxx condition"

I am not sure how recent that law is. My experience in NYC is quite similar to Richard B's. I've been spit at by a patient in police custody once, and one of the officers actually laughed. I wanted to spit on her. I've had one case where a 10-13 was called, PD showed up, then drove away without ever getting out of the car. There have been other times where PD has been very reliable too. Communication between agencies is lacking, especially for the poor EMS guys. A 10-13 signal entered into the police communication system will automatically generate a PD13 call-type on the EMS side so an ambulance can start responding. But, when EMS calls a 10-13: PD may get a message that "EMS is requesting an RMP (police car)" which could mean anything. Or it might come over as, "10-54(medical call) - EDP" which many officers go out of their way to avoid. And that's assuming PD ever gets notified!

"How long ago did the breathing problems start (this episode)?" "Do you normally lie flat when you sleep?" "Do you have any pain anywhere?" "Have you had any vomiting or diarrhea? Have you been nauseas?" "Have you been feeling sick at all the past few days?" JVD or tracheal deviation? Abdominal palpation? (tenderness/rigidity/ascites/abnormal masses?) Pedal edema? Allergies?

I didn't get a chance to read all the replies. I am basing this on the original scenario, with pt met at curb. I am in NYC. If the person has NO complaint, then they are not a patient. I am justified marking the call unfounded and going about my business. But if they pick up the phone and call 911 again and say, "Send me a different ambulance, that last one refused to take me!" then the dispatcher will likely send a boss who might demand written reports and request an investigation. At the very least, the boss will say, "Just transport the dude." Chances are though, Mr. Lunch Special will just make up a complaint. I'm sure some might even nitpick and argue that "I'm hungry" is a complaint. Now he's a patient. TECHNICALLY, I can call medical control and request not to transport the patient because his condition doesn't warrant it. There is still a disposition code on the books for "patient triaged out at scene." As far as I know, it's just not done anymore here. I guess I would be forced to say... "Hop on."

Ugh! I do a lot of transfers from ER directly to the cath table. Lots of times the patient is freaking out and one of the things I say to help calm them is, "They try not to crack chests anymore if at all possible." Where did you hear about that bypass thing? Once I brought a patient from the Dr's office to the closest hospital knowing that I was going to have to come back and take him to the cath table at another hospital. For ED's here it used to be: cath now if you have the ability or else thrombolytics and arrange for cath later. I don't know if it's a "trend" in all the city, but the hospitals I do transfers for are putting a lot of pressure on the ER to cath within one hour for STEMIs, immediate transfer if necessary.