FredG

I saw that ad! I love the throw in of the SonicCare toothbrush! Is it a subtle hint that if we're going to do Mouth to Mouth we better make sure we have fresh breath? LOL Seriously, I would have to think twice about buying any serious medical device from a big box store. However, seeing this is BJs and they do sell a lot of business services, I can see this as a new approach to getting businesses to install Public Access Defibs in their offices. If it gets more AEDs out there in offices and other workplaces, then I'm all for it.

My VFD runs 2 BLS ambulances. Of the 5 Fire apparatus, only the Rescue Truck has medical gear. That truck has a full BLS jump bag, O2, set of splints, boards and collars. Basically, it meets the state's requirements for a First Response Vehicle. Our department allows members who sign up to be fire only, EMS only, or both. We have 22 EMTs, of which 12 decided to cross train for Fire and EMS and we have 2 FF who are CFRs. So, the Rescue always rolls with at least one CFR or EMT aboard. Of course, our SOPs are that whenever the Rescue responds (within district, Mutual aid calls expect the M/A dept to supply the ambulance unless they also call for our rig), one of our ambulances go with it. Two neighboring departments also have ATVs setup for EMS response. If we need those units, they have to be towed on a trailer and will usually take the ambulance crew aboard upon arrival. Several VFDs in the region have set up their brush truck or mini-pumper to also handle EMS and a couple of the VFDs that don't run ambulances still have a brush truck setup for responses to priority 1 or 2 calls in their district coinciding with the transporting agency. I personally like the brush trucks setup for EMS because they are 4x4 vehicles and prove to be useful when we can't get an ambulance up into the woods or some unplowed long driveways. The best setup I have seen is from one of our neighbors, who has a quad cab pickup setup with the fire pump, tank, and other brush fire equipment in the bed of the truck with the hose reel offset to one side so they can secure a stokes basket on top of the tank. The EMS equipment is all situated behind the driver's seat in a rack and they can still respond with 3 to most calls.

It's even worse when your partners give you directions like that! I had a response a while back where my partner, who is a long time resident of the community, started giving me directions like "make a right turn on the road past where old-so-and-so's barn burned down 15 years ago". I didn't even live here 15 years ago, how am I supposed to know where some old barn burned down back then. I hear directions like that from other old time members of the department. What's really sad is that the house that my wife and I bought 8 years ago is still referenced by everybody by the previous owner's name.

NYC is a strange beast in many ways. There are 30 or so community based volunteer ambulance services and 4 or 5 community volunteer fire departments that cover portions of the city alongside paid units. These volunteer squads have Certificates of Needs to cover their specific communities and they usually have fairly close ties with members of those communities. The VFDs usually cover areas in the outskirts of the city where FDNY Fire coverage is limited. In the outer boroughs of NYC, there is still a strong sense of local communities. In fact, in Queens, the Post Offices are still named for the local communities, not the city or borough. So, if you mail something to someone in Manhattan, you address it "NY, NY", but if that person were in Queens, it may be addressed "Howard Beach, NY" or "Hollis, NY", depending on the community. I have been out of that system for several years (I actually used to ride with WHBVFD's volly neighbor to the North), but these squads used to log on with FDNY as an additional EMS unit in the system. They also receive direct calls as well. Most do 3rd party billing and as 501C3 non-profits apply for grants as they come up. The volly squads in the city used to be (maybe still are?) a good training ground for many of the paid EMS services. I know a lot of people who started out in a volly squad and went on to go to FDNY EMS or one of the hopsital based units.

I don't want to revive an old post, but I just came across somethign that was relevant. Here's a link that you may find interesting...I saw a mention of this in EMSWorld magazine and here's the link: http://www.nasemsd.org/documents/Resolution2010-04NationalCertificationandProgramAccreditation20101013.pdf from the PDF: "be it resolved that NASEMSO supports January 1, 2013 as the beginning date for the NREMT to require graduation from a nationally accredited paramedic education program as a requirement for personnel to gain national EMS certification" There are a few other recent resolutions from NASEMSO that may also help. This looks like it may be a good starting point. With a national EMS organization passing this kind of resolution, you may find it easier to work with them to try to improve NYS Paramedic training program. Once that is accomplished, work on the other levels.

I agree with the points that EMT155 posted and I also like your revisions. My original EMT was 160 hours and that didn't include Defib...that was an additional 10 hour module at the time (which included teaching basic rhythms). When NYS reduced the number of hours for EMT-B, they did the public a disservice and the quality of newer EMT-Bs was obvious. Realistically, what's another 30-40 hours of class time....another 4 weeks of evening classes? I don't consider that a hardship for an original EMT-B class. In my neck of the woods, our paid Paramedic units and volunteer BLS ambulances get along very well. Not only do we only have 2 ambulances covering over 55 square miles, we also have a 50+ minute drive to the nearest trauma center which, I believe this is part of the reason why there is a good working relationship between volunteers and paid providers...we have to work together as a team for the patient. Based on my 10 years as an EMS provider in NYC and 8 years in rural Western NY, I think that there should also be a module in the EMT-B curriculum to cover assisting a Paramedic. Many of the departments in my region run periodic drills taught by paramedic providers to Basic EMTs on how EMT-Bs can assit ALS. This kind of module would also give a basic EMT an understanding of what ALS brings to the table and possibly be an introduction to the idea of further advancement towards Paramedic.

I took a similar scene safety seminar a few years ago that was run by a retired LEO. They did scenarios and pulled attendees to walk into a scene and approach the patient, but to call out any hazards or other safety risks. The fake needles, hidden guns, etc were all easy to find and most everybody got that right, but one scenario really stuck in my head. That scenario was a rape victim. The scene looked safe, no weapons visible, law enforcement on scene, no civilians, etc so the EMT attendee approached the patient to begin assessment. The victim was curled up with a blanket and sobbing. When the EMT approached, she pulled a mock knife out on him from under the blanket. The instructor did a good job of building up the scenario and the performance byt he victim was really good, but the point that he got across at this seminar is that you not only have to look at external threats, but an unstable patient (even a victim) may become a threat. When I run scene safety drills for my dept, I usually do a half hour powerpoint covering the basics, then break out into groups and do physical scenarios. We also get a town cop or a locally based state trooper to stop in and discuss recent safety issues that they have seen in the region, as well as to review how they would like us to respond to a tactical call (staging, light usage, etc)

I remember those back breakers! I think the last time I used one of those was when I used to ride with MetroCare about a decade ago. I left there when they were switching out, at the time every unit newer that a 96 had a Ferno 35. Even the volly squads switched over to the 35s around then. Funny thing about those old 30s...they tested trousers. I remember a call when my partner and I knelt down to lift and we both heard a loud rrripp. As soon as we handed off at the ED, we headed out to my partner's house for a change of pants.

We installed GPS in our units. Most of our members know our response area pretty well, but we find them useful for the Mutual Aid responses in the neighboring districts. One pitfall that they we have run into is that, being in a rural area, we have quite a few seasonal roads. The GPS units don't always show what is seasonal and what isn't. It may be the GPS map that is in our units, but even the online maps (google, mapquest, etc) do not agree on which roads are seasonal and which aren't.

Better educational standards for EMS will benefit patients. I don't think there is much of an argument there. But, you cannot look at this in a vacuum. Any change to the system will have a ripple effect across the entire environment. Ok, let's say that NYS decides to implement a degree based certification program. Here are some of the issues that you will need to figure out: - How will you transition the current cadre of EMS providers into the new system? - Will there be any grandfathering of older EMTs and Paramedics that have been in the system for 3 years? 6 years? 12 years? - How long with the transition period be between the current classroom educated EMTs and the College educated providers? - How will you differentiate, during the transition, between the classroom providers and the college educated providers? - How many colleges will support this educational program? - How much will an EMS degree cost on average? Will the state sponsor all or part of the classwork like they do now for EMTs? - How will recertification be handled? - How will new curriculum be handed down to the field providers if there is no recertification requirement? - will there be retesting on a periodic basis to replace the current recertification systems? - Will Medical Doctors support such a program? - Will the degree program be recognized nationwide? Can I take this degree and go to a different state and apply for a job without having to challenge against the local certification? Ultimately, this is the kind of change that a committee made up of Medical directors, EMS providers and financial experts from all parts of the state should be formed to investigate.

Alex, I applaud any attempt to improve patient care, but I must say that you have a very "downstate" point of view on things. My county is over 1400 sq mi and at night we have 2 trooper cars on for the entire county, with a couple of villages that put their own cars on the road as well. The county sherriffs up here start at $24K per year. The Paramedics running R/M flycars up here are getting paid just over $9/hour. My town's entire budget for Fire and EMS is under $150,000. And that's for 2 ambulances, 2 Engines, 1 squirt, 1 Rescue, and a brush truck. There are no electric stretchers and the building is over 40 years old. Heck, the dept can't get a larger Squrt because the ladder won't clear the building and there's no money or plans for a new building or even a rehab. Look at the tax rates by county as a percentage of home value: http://www.taxfoundation.org/research/show/1888.html My county is 9th on the list, nationwide! Property taxes on an $80,000 property come out to about $2600. when you look at Rockland county, it is 89th on that same list. Yes, taxes there are a higher dollar amount, but the salaries are also higher. Having a .5% increase in the budget of a densely populated county like Rockland can provide a decent amount of money towards better fire and EMS, but adding .5% to the budget of a rural county like when I am now would bring in an extra $225,000 per year....not even enough to pay for 1 24x7 dual EMT ambulance (based on 8.6 FTEs)...and that would need to cover over 1400 sq miles. My town is currently involved in an EMS consolidation feasibility study between 3 different volunteer ambulance services. The results should be reported sometime by middle of next month. That study is only covering a portion of the county, about 150 sq miles, currently covered by 4 ambulances. I would be happy to share the results with you, once we get them. Now, look at the problems facing hospitals when they try to hire doctors and nurses. Facilities across the country are understaffed. But, it is worse in rural areas due to lower revenues, etc. By bringing EMS up to a college standard, you may inadvertantly affect many rural areas throughout the state. Talk to the members of the State EMS Council and see what they say. Find out what the current volunteer response times are and look at potential response times for fewer (but paid) units, look at surge capacity for major incidents (how long will it be before additional transporting units can be on scene of even small scale MCIs). Then look at the payor mix differences between rural and urban environments (or in our case upstate and downstate NY), and compare the un-insured and under-insured rates to look at financial feasability. Like I have said, I am all for improving EMS and increasing training standards, but we have to ensure we are doing that without making a negative impact on the services that are already available. I also think there's also a huge room for improvement in the current system, as one poster earlier pointed out regarding the lack of consistency between EMS class providers. Problems like that need to be fixed first before we go to a higher educational standard and expect colleges to take our educators and students seriously.

I don't have a problem with the basic ideas presented. However, before EMS certifiactions turn into college degrees, we need to get EMS standards to become pretty much standard across all states. There also should be a provision for any EMS provider with a college level degree or classwork to easily work across state lines. I have another concern based on seeing the EMS system from both urban and rural settings. I have been an EMT since 1994, 10 years in NYC, then going strictly volunteer in a rural upstate town. By making EMS a degreed program, we will essentially be forcing all of the volunteer squads to go paid. There is nothing wrong with that, on the face of things. However, there is an increasing difficulty in getting medical professionals to live and work in rural areas and by moving EMS into a degreed system, we would probably see the same shortages in EMS staffing in rural areas as there are for doctors and nurses. Another issue I see is the way NYS breaks up the state into different Regional Medical Councils. The regional medical council that I deal with up here is, to put it bluntly, backwards and poorly run. The regional council to the North of my current area is quite progressive and NYC REMSCO is well organized and also fairly progressive. I would love to see the state drop the Regional Medical Councils and go to one statewide council (or maybe 2, one for NYC and one for the rest of the state). Basically, what I am saying is you have to consider the impact of a statewide or nationwide educational standard change on multiple EMS systems, each with different challenges and needs.

KED is still protocol here and is still a required station for EMT recerts. So, we carry and use them. That being said, if there is sufficient MOI, then I'd rather do something that may protect the patient's spine vs not doing anything. Yes, there is virtually no scientific evidence supporting either stance. However, if you take a step back and look at the ever increasing survival rates, I will side with the "we must be doing something right" crowd until some definitive study is performed. Additionally, I will also side with the fact that my state and regional protocols require application of an immobilization device if there is any neck or spinal pain and since EMS agencies operate under our medical director's license, I will abide by his standing orders. In my case, our MD basically signs off on the regional protocols with very little variation, but he is open to discussion for minor variations if we can make a solid case for it. Because immobilization (and KED usage) is so ingrained in EMS protocols, if an EMS provider varies from that protocol without good reason, it increases the risk of a lawsuit. Whenever I have a high MOI, I document the reasons behind every immobilization decision. As for CBEMT's comment, yes, there is a risk of doing anything on a highway. That's why, if there is easy access, most providers do not spend time with the KED and do a "rapid extrication". However, if you're stuck on a bad extrication job, there's nothing you can do except to stabilize the patient as best as you can and ensure that the scene is as safe as possible. Personally, if there is a Engine on scene, I ask the FD to park it 100 feet or so behind the accident. Let the Engine take the 1st hit and with the weight of the truck and water its carrying, it makes for a good barricade.

This is an ongoing issue in EMS. There is a lack of evidence for a lot of what we do in the field. It seems that the only area of EMS that is being actively studied is Cardiac Care and CPR/Defib. Most other facets of EMS are based on protocols that have no solid basis. What clinical studies are there proving the necessity of Longboards? What studues show that longboards are better than a scoop...or vice-versa? How about C-Collar usage? Are the stiffer collars really better than a soft collar? Are MAST really useless in treatment of shock? Were any real studies done before MAST was removed from most protocols? Has there been any studies done to validate the dispatch priorities and Lights and Siren recommendations based on dispatch criteria? Until studies show otherwise (if they are ever done), we have to abide by protocols handed down to us by our medical directors. As far as KEDs and other Spinal Immobilization, logically speaking, they are acting as a splint and are the best devices that we have available right now to act as a splint. From an anatomical perspective, they do not provide proper support for the natural curve of the spine, so they could cause more harm than good, however there are very few devices that would provide that support, so we have to use what we are given and allowed to under our protocols.

I've used KEDs on several occasions. My department carries two on each unit and 1 on the Rescue. It has come up from time to time in my region about the excessive use of "rapid extrication" straight to the longboard. The debate always revolves around two things, whether you should take the time to use the KED for better stability of the patient's neck and spine before any movement and whether there is any justification for rapid extrication on any call. Personally, I can see using the KED on a more severely injured patient or a higher MOI accident simply because the KED does provide better stability over simply rotating and laying down on the board. I use "rapid extrication" on the minor incidents where the need for immobilization is debateable. I find it useful to apply a KED is for extended extrication, if you can get the KED into the patient. That frees up a responder from having to stay in a risky position in the vehicle with the patient to provide head stabilization and also helps protect the patients spine earlier in the evolution of the call. This was much easier in older cars, with newer cars that have bucket seats and center consoles it is harder to get a KED into position without increasing the risk of moving the patient. I also like to use the KED for extrications when the vehicle is down an embankment or at an angle that makes it difficult to put a longboard in place the perform a "rapid extrication". We can KED the patient, then have a longboard on the ground right next to the vehicle, then properly fix them to the longboard while minimizing the risk of dropping the board or having a responder slip and injure themself. In these cases, we usually have the Rescue with us and then place the board into the basket for extra safety. I did have an incident last year that was a bit unusual and required the KED. A patient who fell off a trampoline, then walked to a chair and sat down...upon which lost sensation in both legs. I decided to KED the patient then slide the patient onto a longboard. The reason being that this was no longer a "suspected" spinal compromise, we had positive proof of the compromise and we had easy access to the patient from all angles. So, rather than doing a "rapid extrication", I choose to use the KED to stabilize the neck and spine before we did anything further in order to minimize any further aggravation to the spinal column.