Kiwiology

I know I'm preaching to the converted mate but all I can say is ....

Ah ... San Francisco, much nicer than LA, know it well. The monocular vision should not be a problem, you can probably get it waived. Check with the Federal Motor Carriers Ssfety Administration http://www.fmcsa.dot.gov/documents/safetyprograms/Vision/vision-exemption-package.pdf

While I still don't agree with Fire based EMS I'm pleased to hear that your guys dont go to the local patch factory only to rot away on an engine.

Your left is 20/200 (if you can read the E only) Most states are 20/40 for a drivers license in at least ONE eye, Nevada is 20/50 and TN is 20/30 California requires a CDL which is 20/40 both eyes however I believe monocular can get a waiver. National Registry has no requirement they are not a licensing body Four questiins 1. Where are you? 2. What is your right eye correctable to? 20/20, 20/40 etc 3. Do you have a drivers license? If so, does it have any restrictions beyond glasses? 4. When you say no depth perception do you mean left only or at all?

Which should not be an excuse to keep EMS within the fire service But do they offer the same level of service in terms of instutional knowledge, skill and competence as a health professional; not can they stick in an IV or push a drug. Most of it comes down to education; those departments who force firefighters to become paramedics tend to opt for the quickie medic mill education and treat is as just another cert. But alot of it also comes down to exposure to workload and continuing competence. Contrast the clinical competence and knowledge of one of our Intensive Care Paramedics who has a Post Graduate qualification, has to submit evidence of at least 40 hours of CCE per year and undertake re-validation in each skill every two years to one of the "Firefighter/Paramedics" who might intubate one patient a year because they ride on a non transporting "ALS Engine". Your department sounds slightly more switched on than this but still .... saving money at the expense of patient care is in my view, not worth it.

Didn't we have something like that a while ago? Anyway I'd be keen to get in on this

So why not just call for a fire truck if you need hands lifting or doing CPR? Look at all the problems places like Naples, Los Angeles County and Miami have with non transport ALS engine medics. This should not be used as an argument for Fire Service based EMS; if they were properly funded and had adequate industrial representation out of the fire service these problems would not exist. I bet you our friends from the UK, Australia and Canada don't have these problems. Again, this is not an appropriate agrument to support Fire based EMS. If the EMS union was as strong as the IAFF well we wouldn't be here discussing this in the first place!

Agreed, you have to fund for a certian level of constant capacity. Sounds like you are the exception rather than the rule then but again you are a fire based system; I bet you many non Fire based systems would not have this. I know people who complain thier trucks break down, thier PPE sucks, thier station is a tin shed, they only have one set of defibrillator batteries etc. Why should the service have to be run by the fire service to ensure adequate infrastructre So the fire truck medics rotated to an ambulance? Is this mandatory or can they choose to sit on a fire truck and do squat? What kind of continuing education, clinical skill revaladation and clinical audit/QA or CQI does your system have? I only ask because we all know of the typical "firemedic" who rides a non transport ALS engine and treats one or two patients a year and has his thumb up his ass; just look at Los Angeles County and Naples as examples of Fire EMS gone wrong While that may be a fringe benefit of working for the fire service its easily found outside the United States at many third service agencies. New Zealand, Canada, Australia, the UK etc all have systems where the Paramedics can earn a livable wage and retire only having ever been an ambo. Union representation and industrial issues are mainly around patient care or provision of service and not pay and working conditions although there are a few of those here but that's anywhere. This is really a moot point and to use it as an argument FOR the fire service really isin't valid I don't think. While I understand why you take your position, and if I was you I surely would, it really reflects the poor state of industrial representation in the US. I mean, I don't see the IAFF/IAFC and the Teamsters having problems with working for minimum wage and not having a pension. Sounds like a plan

Didn't you get that memo? BEST MOVIE EVER

From a uniquely New Zealand perspective Volume: around 250,000 emergency 111 (911) calls per year and growing at about 7% pa Cost: $160 million NZD and growing Size: 1,100 paid and 2,500 volunteer Ambulance Officers If you want to look at our system vs. the United States it may provide some comparisons to draw - The generic term for ambulance professionals is "Ambulance Officer" and not EMT - We do not have "medical control" and are autonomous care providers that do not have to speak to a doctor - Ambulance services' here are not intergrated with, and totally seperate from, the Fire Service - A Bachelors Degree is the minimum education requirement for entry to the career - Volunteers require the equivalent of an associates degree Our system uses three levels of Officer: - Ambulance Technician, requires an associates degree; can administer 7 medications and perform automatic defibrillation - Paramedic, requires a Bachelors Degree (3,600 hours); can administer an additional 5 medications (including morphine) and start IV lines - Intensive Care Paramedic, requires a Post Graduate Certificate in addition to the Degree; can administer additional painkillers and cardiac medications as well as insert breathing tubes, decompress collapsed lungs and infuse medicine/fluid into bone (intraosseous or IO). Some have the ability to put patients to sleep and paralyse them in order to insert a breathing tube. - Expanded role as a community healthcare provider and not just an emergency responder - Increasing use of technology and new treatments; e.g. intransasl medication, rapid sequence intubation, 12 lead ECG - Need for increasing industrial and political representation and parity of conditions - Improved education Um, the best advice I can give, even tho it's a bit abrasive .... don't make a tard of yourself.

The only tension up in here will be whether we play four square or rockem-sockem robots, maybe after that we can go watch Rugrats; OK I'm showing my age or lack thereof. It is possible she is having a fresh cardiac event which is causing an irritable ventricular foci or increased cardiac automasticity and wow there's the ubiquidose 400 causes for each of those. The shortness of breath and/or chest pain could be causing increased sympathetic nervous tone which would increase circulating levels of adrenaline (possibly some other catecholamines too) and this may explain the PVCs. Concerning however is the regularity of the ventricular trigeminey .... I would learn more towards some sort of fresh cardiac event here causing increased automasticity, perhaps even an NSTEMI but that'd be a bit of a reach although .... elderly, female, you know where this is going. The hypoxemic infarcting muscle reverting to anaerobic metabolisim releasing lactic acid would cause chest pain and increased automasticity of that particular area creating the ventricular ectopics. Worth a look at the ho'biddle anyway.

LA City Fire deemed them too expensive.

I had a bunch of guys that were terrible; they booked off work, took sickies, bitched and moaned and them doing work was like pulling teeth. The thing was that nobody had actually sat down and listened to these dudes and figured out what the problem was, what they wanted, what we wanted as managers and how to take the two and marry them up. My answer is to do it; sit down with the guys and see what they don't like and what they all want; not money but I bet they say hey we want to come to a place thats happy and enjoyable to be at where its not some boss chaffing and riding thier ass. Culture man, culture is the answer.

The easiest way to increase morale is to find out what the staff don't like it and fix it. Make for them coming to work not "work" but some place the ENJOY coming to. The best jobs I've had are not because of the work but because of the people. I had a job that was a really good JOB but the culture sucked it was just a bad place to work because the people were fucked in the head and it made the day long and hard. Not sure what kind of system you are running, it would be hard to make them enjoy sitting on a street corner for ten hours but you could do something easy like throw a pool table in the lounge; internet; TV etc. If you have walls, tear them down (well not ALL of them) and get engaged with your people, show them you care, show them you're not a person to dole out punishment but somebody who cares about them as a person and not as bums on seats. Things like paintball or orginised sports go down well, the social club here organises them and pays for cable TV at the station. Throw around a couple manakins and let them go nuts if they want to practice skills for example. People who work TOGETHER with common VALUES and mutual RESPECT towards a SHARED GOAL will do more than any other, and that is a proven fact.

Guess he took at new All Nippon flight to Dulles fron Narita huh?

This was my problem too. (see here) Call some of the local Paramedic programs in the area, see if they will let him cross-credit all his Paramedic education to thier class. He might have to take a refresher or like one class to meet the requirement to "graduate" from that school and viola, he can go take the national registry test. If all else fails, Texas is extremely liberal, you literally have to take like one class at the school and can cross-credit everything else and they will say you graduated from that program. Best of luck mate let me know how you get on

That is my ultimate utopian fantasy (as far as EMS goes) and is pretty much how Seattle works with Boston and Tulsa not far behind. I'd like to take that one step further, if I may. Now when I say "Paramedic" here I am referring specifically to Intensive Care (ALS) but in this model we can make excellent use of Community Care (ECP/Paramedic Practitioner) and also alternate referral pathway programs like CARE in NSW, ECPs in the UK and our very own extended care/community paramedic service here in New Zealand (Wellington). In my little utopia there would be lots of guys out and about in rapid responder 4WDs that can be high impact; go to calls and triage, treat and dispose either to self care, a referral pathway, treat and release or transport them somewhere appropriate (which may be, but does not have to be, the ED). It might be entirely appropriate to transport a broken arm in the car and not have to take them in an ambulance which would free up resources for when they really are needed. There would be no "BLS" and no "ALS" there is just one level of a "Paramedic" who is your off-the-shelf standard ALS Paramedic (what we call Intensive Care) and throw in expanded pathways plus one or two select skills; none of thos million extra skills blowout crap just something like suturing and limited independant prescribing for some antibiotics or one or two common GP meds. A complete change in the dispatch grid is also needed; this off-the-shelf AMPDS send everything on a 1 (red lights) is inappropriate and would change. You would have several variants - Somebody in a 4WD + am ambo (for things like a cardiac arrest) - Somebody in a 4WD (either an ECP or an Paramedic) - Send the caller to a phone advice line coz they're not dying anytime soon This is sort of how the UK works; send somebody in a 4WD and get him there quick, assess and cancel the ambulance if it's not needed so it can be sent somewhere more appropriate. While retaining the "emergency" role of what ambo does now I think we need to shift more towards recognising the "community health" role too because lets be honest 90% of the jobs I've gone to are not "emergencies" and the patient needs "care" not "life support". New Zealand's new term for our model going forward is "emergency community health". Obviously this would require very high levels of education, Bachelors Degree is a good place to start but Post Grad Dip or a Masters degree is more appropriate here. Now this model may be easier to implement here or in other nations e.g. Australia and the UK because we have nationalised healthcare including a nationalised health information system (the National Health Index) but I think it would be a struggle in the US. /End fantasy

You are pretty much dead on; the key term here is a SHIFT of fluid and a mismatch between the intravascular and interstitial fluid. That which is in the vasculature of the pulmonic circulation is not being ejected into the systemic circurt by the heart hence the osmotic presssure increases and ... suprise, simple fluid dynamics tells us that the fluid will take the path of least resistance in this case straight into the lungs.

I agree, I bet you Fire will have more revenue with less work and EMS will be the opposite. That's how it works here.

You do make a good point Dust but I think its somewhat utopian to say that we can move to a single level system just like that (snaps fingers). Any system is going to have to adjust and even the best sysems in the world have more than one level, at the very least they have two; either Technician/Paramedic (UK) or Paramedic/Intensive Care or Advanced Care/Intensive Care. Nursing has public health nurses, coronary care, emergency, renal, operating theatre, mental health etc. Fire has firefighters, engineer/operators, station officers, captains, cheifs etc. There are really differnt levels of specalities within each profession just as there are to many types of professions; a pilot might fly a 737, a helicopter, a twin Cessna or an Airbus but he is still called a pilot. A "Paramedic" might be a Paramedic but she might specialise in (well, hopefully in my truck but failing that .....) neonatal care, community care, intensive care, critical care etc. They all have the word "Paramedic" in them. Get rid of this Technician crap and just call every ambo a Paramedic. I know this is a departure from some of my rant on other topics but I do really feel that it's a good thing. You might realistically have ... Intensive Care Paramedic (ALS) Critical Care Paramedic (CCT) Community Care Paramedic (ECP) Neontal Care Paramedic etc

I was referring to Primary, Advanced, and Intensive Care Paramedic but since you had to bring it up sure, Stanley my big grey pet elephant needs somebody to bring him peanuts and take him for a walk. Also very true

So what titles do you suggest we use instead, I have mine above but what do you all think?

Sorry mate, but you're bullshit. Your poor spelling and atrotious grammar are just wrong. ALS is not "hard" maybe because you don't need any actual education in the United States to practice as an ALS level Officer you find it difficult. Look at why frusemide is being pulled off trucks, why standing orders in Los Angeles are two pages and why you still have "medical command" and practice piss poor remote control medicine in your part of the world. You can write down on ONE SIDE of A4 what you need to do for a cardiac arrest; ask the resuscitation council they have done it. Doesn't mean it's "easy" it takes "skill" but very little "knowledge". Now, try to write down on ONE SIDE of A4 the treatment and management flow-chart for a patient who presents with undifferentiated abdominal pain. Sorry to say, acute stuff like cardiac arrests and intubation is easy, it takes SKILL but very little KNOWLEDGE. Less acute patients which lets be honest, is 90% of the workload, well, my workload anyway, are HARD they take high levels of KNOWLEDGE and little skill.

Welcome aboard, transit northbound approved at or below one thousand approved new QNH is one zero two four millibars, there is VFR traffic operating just to the north of you at or below 500 he is outside the CTA but he does have you in sight

Welcome my friend, welcome to the other side. Now, I know I'm going to be preaching to some of the converted here but still: If it is one thing that annoys me the most about EMS it's this American attitude of "BLS vs ALS" and its like you blokes think they are somehow an actual procedure to be carried out like splinting a broken arm "oh I gave this patient BLS" mmmm yes .... Because this patient is stable he is a "BLS" patient even tho he's been shanked in the stomach but only has a teeny-weeny hole despite the fact he is gonna crash ten minutes into his "BLS" transport. All patients to not require "life support" and I think this is an outdated term, as you said they require care. Most care is very simple and carried out by all levels of Ambulance Officer be they a "BLS" level Technician or an ALS level "Intensive Care" officer. Included are the essential primary elements of practice like communication, safety, history taking, vital signs, physical assessment etc and does not vary between practice levels except maybe for 12 lead ECG monitoring, you can also include fundamental patient care like splinting and transporting, oxygen, salbutamol etc. This is one of the reasons I am really pleased with the way Ontario has structured its education program for Pirmary Care Paramedic; it's two years and includes the in-depth education in A&P, patho etc so that they can go in and conduct a good, detailed assessment and differential diagnosis of a patient and begin to hone and develop thier skills and knowledge rather than just a two page four hour class on how to take a few vitals and ask SAMPLE questions, for example. Australia with it's Advanced Care Paramedic (ILS) internship and post-graduate qualification for Intensive Care Paramedic (ALS) also offers a good comparison to draw here as they should offer simmilar outcomes. Ask your basic EMT to tell you how to differentiate between say indigestion and .... a gallbaldder attack for example. Some care that ambo's offer patients is quite invasive and advanced; such as rapid sequence intubation, thrombolysis and chest decompression. These advanced skills require a solid grounding in bioscience and extensive experience, competency and overall a high level of confidence which is inherently linked back to the other competencies I outlined. It takes four to five years to become an Advanced Care (Canada) or Intensive Care Paramedic (Australia/NZ). Contrast this with some dude who has 700 hours of education over 14 weeks at the Houston Fire Department's Paramedic-R-Us patch factory. You mentioned fundamental skills like bag mask and this is often a problem I see with people. They bag the snot out of patients and don't understand the reasons why they shouldn't. Try to explain to them about hyperoxemia, hypocapenia or dynamic hyperinflation and they just give you a glazed over look. Ask any ambo how GTN works and they'll tell you "dialates blood vessels" and no more. So who does which? Which what? Well if we want to refer to "life support" my argument is that ambo's don't really do that and I am sure a lot of intensivits and ICU RNs will agree with me. My spin is that "care" is provided. Therefore we should do away with this "life support" nonsense and embrace what Canada has done; term everybody some level of "Care" (ehem, Alberta and Manitoba excluded, whacky Albertobaians...) because that's what 99% of my jobs have been .... providing CARE and not "life support". Two level systems (US) Primary Care (old BLS) Intensive Care (old ALS) Three level systems (US) Primary Care (old BLS) Advanced Care (old ILS) Intensive Care (old ALS) Everywhere else in the world smart enough to not have a "BLS" level Advanced Care (old entry to practice) Intensive Care (old ALS) Until you guys fix that whole BLS vs ALS crap it'll continue to be what makes your system a joke.