46Young

The Fairfax County FD in Va employs three PA's, an NP, and one BSN FT M-F to teach our continuing ED, alphabet card recerts, and to run the ALS internship process for our new recruits. They also run our studies. I worked for Charleston County EMS for a little while, and while I was there, one of the two FT OMD's would run the CEU Sessions. Nowhere, to my knowledge, employed PA's in EMS; it would be cost prohibitive. How about get a FT PA position at one of the hospitals, and then get per diem position at CCEMS or somewhere else? SC is a right-to-work state, so the salaries in EMS are substandard. Nurses make 50% more in NYC as a comparison, and I suppose the same would be true for PA's. Look at the Mt. Pleasant FD. Their FF/medics make maybe 30-33k to start. It's not much more up in Myrtle Beach/Horry county. I was making more than double that right out of the academy in FFX. Less than an hour out of the county, the housing wasn't much higher than SC either. Maybe PM TomB, a member here. He's a Lt at Hilton Head, I believe. I've heard good things about their dept. Keep trying to get in a NOVA FD if supporting your family is your primary concern. Down in SC it's a real, right-to-work good 'ole boy, our way or the highway type of environment. If you rub one person the wrong way, or if a superior sees you as a threat, they'll start positioning themselves to get you out. These systems are typically one-sided in favor of management, so expect undesireable working conditions. If you have to move down there, only do EMS PT if you can. If they own you, you'll be miserable, and probably never see your family due to all the 12-24 hour holdovers, recalls, lousy leave policies, etc.

I worked for the North Shore LIJ Center for EMS for nearly five years. Their HQ is on Jericho Tpke, next to Syosset Hospital, right near you. I liked it there. The people there are more serious about their jobs/careers than what you'll find at the average private employer. They're infinitely expanding. They were getting into Staten Island when I left in 2007, they run out of Lenox Hill now, I believe, as well. They've been acquiring numerous MD's office contracts throughout Brooklyn, Queens, Nassau and Suffolk Counties, so their IFT has a consistent 911 "flavor" to it. They also have three NYC 911 buses, and six or seven BLS, IIRC. They need medics and EMT's. Just e aware that it's not like the vollies; it's oftentimes just you and your partner that are humping the pt on a stair chair down 3-4 stories, taking the equipment with you. You may be removing a pt that passed out in the bathtub, or one that is wedged between the bed and the wall in a cluttered room where moving the bed isn't an option. If you feel you're up to the task, then go for it. Just be sure to get out of the bus and do some stretching and mobility exercises now and then, since you'll spend your downtime sitting in the bus on the street corner. In 2003, a 52 y/o lady was hired along with me. She was a multi trauma MVA victim, and wanted to become an EMT after retiring as a teacher as a way to give back. She did well, but quit after 7-8 months due to the pressure and fast pace of working NYC 911. We also had one of the Health System's BOS ride as an EMT now and again because he enjoyed it. He was in his 50's or 60's, I can't remember. There are people who join FD's in their 40's; there are people who retire from police, fire, or EMS, and join another dept in their 50's, and work into their 60's. Try out NS-LIJ and see if you like it. That's the only way you'll know for sure. I'd avoid the private companies in the city and on the island.

Did the pt's presentation change at all from when the SPO2 was 96%? You didn't mention how the pt was sitting upon arrival. What were her L/S? Did she exhibit any exertional dyspnea? Could she speak full sentences w/o having to catch her breath? Is it possible the pulse ox probe wasn't on correctly? How was the SPO2 waveform? I'd personally have given the pt a few liters via NC if their sat went down, but you have to remeber to treat the pt, not the monitor.

My understanding is that the PFD has been doing rolling brownouts. Does this include ambulances? I don't know. That would help explain the extended response to the airport. Maybe this event can be used as an example to campaign for an upgrade in staffing and deployment. Also, Philly and Camden just reached an agreement that Philly will send aid in the event of a major catastrophe. Does this include ambulances? I don't know.

Regarding ETCO2, of course I would rely primarily on L/S. If I heard some wheezing but the pt was moving a decent amount of air, I would hold off on a neb and see if I could help the pt with CPAP and nitrates. The ETCO2 capnography could help me monitor how they're moving air, not to mention their capnometry, which will assist me (along with other aspects of my ongoing assessment) in deciding if my therapies are not working, and intubation will be necessary Episodes of CHF/APE can have a concurrent COPD exacerbation. When I said we don't treat CHF, I meant that the prehospital goal is not to address their peripheral edema; we're treating rales and maybe wheezing presumed to be caused by a weak left ventricle. Are they having an MI? Did their BP spike, causing a 100% occlusion somewhere in the coronary vasculature? Is the afterload too much to effectively overcome due to a rise in BP? Do they need a bolus to increase preload if they're in cardiogenic shock from inaqdequate output from the RV? What I meant is that if the pt has significant peripheral edema, it's not a prehospital goal(at least not here) to treat that directly with a diuretic. There are other treatments that are far more effective. We can give lasix, but that's at the bottom of my list of considerations. If the pt had a BP of 80 or less, I wouldn't be thinking about lasix, and not because renal perfusion shunts away at around that pressure. I would be addressing their cardiogenic shock at that point. Maybe a fluid bolus for the rt, or pressors for the left, generally speaking, among other things. I'm not going to be going renal doses of dopamine, I'll probably be running it at 10-20 mcg/kg/min. I've been using CPAP since 2005, when we got them to use for a trial in NYC (only been a bucket head since 2008). My bad, I forgot about rural EMS, which can txp upwards of an hour, easy.

I had a co-worker at North Shore that worked per diem as a medic at JFK. I don't recall LaGuardia having any txp EMS of their own. On 46E and 46Y, I ran La Guardia now and again. I've also had jobs at JFK once in a blue when I worked 51V. Without any delays, I could make a bathroom near the terminal in either airport in maybe 8-10 minutes. The PA cops were always there to escort us w/o any hassle. If we had to get to someone on a plane, however, we were looking at upwards of 15 minutes from dispatch to pt contact. If things are similar in Philly, that means there was no unit put on the job for at least 20 minutes? The big shots for these EMS depts, no matter what the type, need to realize that running with the bare minimum from day to day is eventually going to lead to disaster.

If Timmonsville is in SC , I would suggest applying to Charleston County EMS. You can be working in a month. I know, because they have a lot of turnover, and hire often. You just need a pulse and a patch, and be able to pass their entrance exam. I didn't care for their mandatory OT policies, their leave policy, and the place is clicky. You should get some good experience there, though. They RSI, and they have every type of environment from rural (McClellanville/Awendaw), suburban (Mt. Pleasant, James Island), t urban (Charleston City). I would also apply to MUSC and Roper hospitals at the same time, on a per diem basis. You'll get good IFT experience. A firend of mine at Roper moved up to the admin position of EMS Liason at Roper last year. If you find CCEMS to not be your cup of tea, you can drop down to per diem after making crew chief, and then go FT at one of the hospitals. If you have to do IFT, you generally get treated much better, with superior working conditions, benefits, etc. than you will see in the privates. There's no comparison. If you're a little more adventurous, apply to Alexandria Fire and EMS in VA. They're hiring single role medics this Oct. Their schedule is 24/48/24/96. You only work two days out of every eight! FD quality benefits. You can live several hours away from there if you want, since you commute less than twice a week.

That's soooo 2005 (maybe years earlier for the more progressive depts). Our medical director actually went so far as to place lasix for APE as an OLMC option. Once we got CPAP, and double dosing of ntg for severe cases, and now nasal ETCO2 to help decide if a neb is appropriate for concrrent broncoconstriction, we started saving a lot of pts from getting tubed. Lasix just screws up their K+, and makes it that much more difficult for the hospital to correct. Really, most protocols call for 40 mg of lasix, or maybe 40 above their single dose (not daily total), up to 120 mg. The problem is, these are arbitrary amounts, given w/o knowledge of the pt's labs. How fast is a lasix going to work, anyway? Nowhere near as fast as aggressive ntg and CPAP, if appropriate. How effective is lasix in prehospital tx of APE? Not very, says numerous studies. Remember, we're not treating CHF. We're treating pulmonary edema with a cardiac etiology. What we need to do as far as prehospital treatment for the pt (maybe 15-45 minutes), and what the hospital does for the next 12, 24 hours or more are not necessarily the same.

That's pretty much the gist of it. In your dept, the medics probably know why certain meds will be used only for asthma, and not COPD. The problem is, in other systems, the medics don't know any better than to follow the cookbook. They think that if they don't give everything in the protocol, they'll get in trouble. We had providers that actually pushed epi and started a mag drip on a COPD exacerbation.

Pillow splint and pain management sounds good to me. I use either a SAM sling or the KED for pelvic fractures. not hip fractures. Like you said, a suspected hip fx may really be a proximal femur fx. You're not going to pull traction for anything other than an obvious midshaft femur fx, so you wouldn't have done anything wrong on that account.

Thanks for the observation. I honestly never checked into it. My protocols say racemic epi, and say to admin. as I said in the above post. Is racemic epi in a different suspension then IV epi? What is true racemic epi? I've recently caught nasal epi in one of our drug bags, so I sent out an e-mail to EMS admin. Several other units also had 30ml vials of nasal adrenalin 1:1000. Apparently the pharmacy dropped the ball on that one, along with the field providers that didn't bother reading the label, either.

From emedicine.medscape.com: <LI>Magnesium: Though controversial, administration of magnesium is thought to produce bronchodilation through the counteraction of calcium-mediated smooth muscle constriction. The addition of intravenous magnesium is now considered to have class B evidence supporting its use in difficult and life-threatening exacerbations. I've seen mag work really well with tight asthmatics. You'll like it to, I think. Do you have a combined protocol for reactive airway disease? That's what it sounds like you're describing. We had a blanket protocol ourselves until 2009, where we split asthma and COPD into their own protocols. For us, the COPD exac. gets only 5 mg albuterol/5mg atrovent, a repeat of one/one, and 125 mg of solu-medrol. The asthmatics can get nebs, solu-medrol, mag, and epi. We also have racemic epi, 5 mg epi 1:1000 undiluted via neb on S.O. for peds croup/epiglottitis.

My dept has protocols to induce post arrest hypothermia, but without any invasive therapies. Just soaked sheets, A/C, etc. Also, not every hospital is onboard with post arrest hypothermia. Only certain hospitals will utilize this therapy.

I'm beginning to see the paradigm shift towards degrees in the fire service. The older members are complaining that you need a degree to place high enough on the promotional list to get made. They're getting left behind by the more educated. On the EMS side, more and more of our newer ALS hires either have EMS degrees already, or are obtaining an EMS AAS or RN as a means of maxing out their educational component of their promotional score. We also have more and more medics here that are fed up with admin's ineffective and convoluted EMS policies. We need to lose these old timers to attrition, and get some forward thinkers in positions of power. There are quite a few medics in positions of power in my dept, but these are individuals that got their cert in 1985 or so, and haven't seen the inside of an ambulance in 10-15 years. The only thing at the moment that would stop the fire service's assimilation of EMS at the present is at least an EMS AAS required to cert as a medic. The ironic thing is that the fire service nowadays is trending towards giving increasing weight towards education (in general) for hiring and promotion, which is something I'm seeing little of from the third services, privates, and hospitals. The hospitals at least will structure your work hours to not conflict with school, but this is usually for a medic program, or for a degree that will result in another career within their health system, not a promotion per se. Welcome to the FDNY EMS website. Click here for the latest rants and cartoons....

+1 on the above. As far as mimickers of ST elevation, I recently asked my medical director if there was a way to diagnose STEMI with a PPM. He said there was, and that it also works for LBBB. He explained T-wave discordance. It prompted me to start this thread; it's a good read: http://www.emtlife.com/showthread.php?t=21542&highlight=lead Tom B. provided this link on the third page: http://ems12lead.com/2010/12/29/excessive-discordance-as-a-marker-of-acute-stemi-in-lbbb/