UMSTUDENT

You're sort-of right. Providers must only consult for Category C (mainly mechanism) and D (High-Risk Populations). Category A (Screwed-up) and B (Not necessarily dying, but debilitating injuries) can still be flown without consultation. Maryland's system utilizes the basic criterion developed from the American College of Surgeons based on what I belive is ISS (Injury Severity Scores) and relative morbidity and mortality associated with these scores. The system isn't as Mickey Mouse as people would like to believe. The biggest problem in Maryland involves these Category C and D traumas that are often flown. This often isn't necessarily because of "whackers," but mainly because there are really only 3-4 great trauma centers in the state. The rest are a joke. One of the things that has not happened in our state is a true effort to increase the reliability and effectiveness of the centers who receive these designations from the state. It's important to note that Shock Trauma (Level 0), Hopkins, and Washington Hospital Center (Level I) are all within Beltways. Next you must realize that Maryland's biggest tax base (the blue and white collar, suburban middle class) live almost entirely within satellite communities either in the immediate Metropolitan Counties (Baltimore County, Montgomery, or PG) or within the further Satellite counties (Frederick, Howard, Anne Arundel, Washington, Charles). For the most part, these areas lack effective trauma centers. Even if you lived what would appear to be 15 minutes from say Washington Hospital Center, you are more like 25-30 minutes given traffic and sprawling urban development. In response to this a lot of communities have developed community Level II and III trauma centers. While some of these centers are excellent, others have a reputation for being less than stellar...even within their own communities. In more rural areas (Frederick, Washington, etc) the community will actually request to avoid these hospitals. Lack of competition has made this problem even worse. So...what is far more common is for providers who know this to seek helicopter transport to the urban centers knowing their patients will actually receive the attention they need. This has died off in recent years as it seems MSP has made an effort (observationally) to divvy up business among the local centers. The problem is that these are the real issues within the state and no one seems to address them. The state seems to let these things slip as part of the hospital's responsibility to provide good care. Instead the state could use their power to designate these hospitals and provide benchmarks and incentives to improve them. If you don't meet criteria A, B, C we axe your designation and you loose business. Providers in rural areas have for years advocated allowing providers to send active MIs, strokes, and other time sensitive patients via air to hospitals equipped to handle them. Instead, Maryland has allowed some of these rural hospitals to become cath labs that lack cardiothoracic support or the volume to really reach true profecienccy. The saving grace appears to be that these hospitals must contract with larger centers to provide experienced interventional cardiologist. Yes, I know that the answer isn't neccesarily more helicopter transports, but hey, if you can fly tons of rule-out trauma then why not offer the service to medical patients who might actually benefit from it?

Essentially Dust is entirely correct. The career departments within the metropolitan regions have essentially drained the rural areas of much of their talent because of their ability to pay decent salaries. However, there are places within the state (rural) that utilize third-service EMS and who provide a better quality of service...at least clinically. What is astounding is that these places are still mostly volunteer with supplemental career services. The people who have stuck around are there for the right reasons and could definitely benefit from more progressive protocols. This is purely because of the quality of the provider...

Maryland has almost 6 million residents (19th among 50 states). It's 5th by population density and 1st according to median household income. It has the lowest poverty rate in the nation at 7.8% (even with Baltimore City). Essentially, no, state wide protocols are not necessary. Maryland is one of the most geographically and demographically unique states in the union ("America in Miniature"). Tax payers are widely different depending on the area of the state you visit. For instance, the western portion is separated by several mountain ranges (Blue Ridges) and therefore has a fairly unique culture almost independent from the rest of the state. The types of EMS and the quality of EMS provided to these people, in different regions, definitely would allow for unique county/regional protocols. It is true that 90% or more of the population lives in the Baltimore-Washington Metropolitan area (the Interstate 95 corridor).

Very true. MIEMSS can't be entirely blaimed for the situation in MD. Fire-based institutions run every major EMS jurisdiction within the state. I myself almost left Maryland for greener pastures. A good salary and a fiance' kept me here.

Dust, As someone living and working MD, I'd like to respectively clarify some common misconceptions. First, Cowley readily admitted that the term the "Golden Hour" was pretty much a marketing scheme. There was no "set" time that the body had before shock was irreversible, but try explaining that to the general public while you're simultaneously trying to establish a state funded trauma system. It was just rather unfortunate that generations of EMS textbooks started using this nonsense... Second, there is some anecdotal evidence to suggest that the MSP helicopter system was an elaborately ingenious "referral" system designed to keep paying/interesting customers coming to Shock Trauma. As anyone knows who has done any amount of clinical training in the Baltimore/Metropolitan region can tell you, there isn't a lot of "insurance card carrying" trauma victims within city limits. Add to the fact that you would see an awful lot of small arms fire related trauma...Take some time and watch "The Wire" for a fairly realistic view of Baltimore/Murdaland/Charm City/Little Beirut. To this day, Shock Trauma really is an amazing place to go watch. Dr. Scalea is an amazing doctor still running Cowley's dream of a world class institution. Trauma victims who come into the TRU (Trauma Resuscitation Unit) are generally met with no less than 5-10 specialist physicians/residents. Hell, the unit has CAT Scan machines that were specially developed for the center that are capable of completing a high quality, full-body scan in less than 60 seconds. The technology was modified from imaging systems in use in Africa to check diamond mine worker's body cavities for stolen merchandise. ExpressCare, the university's private fleet of ambulances and one helicopter, transports in patient's from the Mid-Atlantic Region who are deemed "interesting" or who require the speciality services of the unit. I mean the overall system is a great thing. Unfortunately, while Shock Trauma has stayed on the cutting edge, our EMS protocols have been stagnate in progress under the direction of some rather intrenched leadership. State-wide protocols are just not the best thing...

Dr. Bledsoe doesn't really seem to like Maryland. He's written articles against more things that have originated (or found their home) here than anything else. I've read through parts of his critical care book and CCEMTP isn't mentioned once (if I remember correctly). I think that this is unfortunately due to a clash of egos. A lot of people outside of the academic community are probably not aware of the galactic clash of minds that has occurred on things like SSM, PUM, Maryland's flight system, and CISM. I've actually learned a lot from articles on both sides, and yes, to some extent Bledsoe has always raised interesting points regarding all of these practices. Unfortunately, I feel as though he fails to recognize the important place some of these practices have in our field. PUM for instance may be impractical for the responding paramedic, but embraces principles that if used correctly can really equate to a quality EMS service.

I think I can clarify some of the problems here, especially since I sat in the same building as the people who run the CCEMT-P program almost every day for 4 years. That program kept the lights on in the very classrooms where I completed my undergraduate education. First, CCEMT-P is a continuing education course the same as many others you may encounter in your profession. UMBC does not license individuals to practice these skills, but simply provides the vessel by which the education is provided. This course would be somewhat equivalent to taking a 2 week, 8-hour-a-day, ACLS course. The course is meant to bridge that gap between prehospital, emergency medicine ("street EMS") and prehospital transport EMS. Sadly, most paramedic programs don't spend nearly enough time on the pharmacology and other dynamic aspects of the hospital world. From my understanding, the UMBC program covers things like indwelling catheters, vents, ventilation mechanics, pumps, LVADs, advanced airway management, etc. Second, the course it taught around the country via cooperative agreements with UMBC. From what I've gathered, institutions become accredited to teach the material as provided by UMBC. The institution probably pays a fee for this and has to submit that their instructors and classroom settings meet some level of standard. Rid is correct. Medicare does recognize a level of transport above that of your typical interfacility transport. He is also correct in calling this a "Speciality Care Transport." Maryland, as a state, recently began recognizing approved transport programs to participate (and thusly start billing) in these types of services. They also now accredit/license individuals as Speciality Care Paramedics. Part of this process requires having taken UMBC's course. This has no applicability to the 9-1-1 setting. Simply putting a speciality care paramedic on your ambulance will not allow you to bill Medicare for this service. A) The level of service provided would have to be more technical/difficult AND SCT requires a nurse to be part of the team, which is not common in the 9-1-1 setting. Personally I would probably not place "CCEMTP" behind my name. It is not a board certification/registration in the same way that being a NREMT-P is. It would be more akin to a emergency physician in a trauma center placing ATLS (advanced trauma life support) behind his name. Postnominals are generally limited to the most advanced degree you hold and any relevant board/registrations. I feel that the registry should move as soon as possible to establishing a level of criteria for certification of such paramedics, but feel that there is greater need in studying the efficacy of an advanced-level paramedic practitioner.

Unfortunately, I believe there are many groups who are directly responsible for the disabled state of the American healthcare system. EMS isn't one of those organizations. First, the future of health care, IMHO, is in the patient's home. This has many connotations. A) General wellness on the part of the patient. Proper diet, education on disease prevention, and a national effort to stop these diseases at the door before they occur. Bringing preventive medicine and basic health care maintenance to the home of those populations most at risk and who most directly impact the health care system financially. Maintenance of diabetes, COPD, basic cardiac conditions...these can be done by mid-level practitioners (PA, NP, or a Master's Prepared Paramedic equivalent). Advances in diagnostic technology in the next 10 years will only advance the possibilities. I believe EMS is the solution to these problems. I also believe that the eventual socialization of medicine, with its advantages and disadvantages, will probably pave-the-way for this development. The fragmented economy which is the current U.S. Health Care system allows for too many players to be involved in the purchasing of services. When Uncle Sam has to foot the bill AND be the primary entity responsible for this bill, I think you'll see bureaucrats scramble for a quick, efficient solution to expensive hospital bills and money sucking EDs. There will be multiple solutions, but I think we make one of the best. The problem lies in the 48 million Americans who are uninsured. Add in those over 65 and anyone else who decides to take advantage of the system and you have a heavy financial burden to bare. Too many things are already happening: a shortage of residents entering family practice specialties and overcrowded EDs. 48+ million people need to get access somehow... We need to be vigilant in our push for higher education standards while simultaneously engaging our leaders in the front lines of this public health issue.

In my mind this question has many answers. I'll touch on one. I recently visited a friend of mine who works at a very respected flight service in the VA area. While I was there we had a discussion about the type of safety measures they utilize before going into the air. Unlike many HEMS services, this program utilizes true resource management . ANY member has the right to deny a flight for any reason. No questions, no banter from management. The sky could be completely blue. At his company all pilots are IFR certified and capable of utilizing their instruments in inclement weather. Both the pilot and crew have access to military night vision technology. Safety seems to be their biggest virtue and is constantly on everyone's mind. I don't believe this is the case in ground EMS at all (and some flight services). How many times have all of us walked onto an ambulance at the beginning of our shift and simply believed that our ambulance is structurally stable? If our fluids are adequate? Can you guarantee exactly how many 7.0 endotracheal tubes are in your intubation kit? Why are there no simulators in ambulance training? Why don't we simulate catastrophic events? We need to start adequately training our providers for the types of situations they will deal with on a daily basis. There seems to be too much "on-the-job training" and improvisation instead of hard, preparatory education and training.

I agree, the chief of our department ordered the recognition software turned off almost two years ago. It was his way of showing the powers at be that he believed his paramedics to be well-trained and capable. Plus, it forced the few that were not properly reading their 12-Leads to learn it or leave. Unfortunately, I have to agree with Dust that these little "alerts" do serve to tip you off to things you may not have immediately noticed before. Plus, I've found the Phillips software relatively good at arrhythmia recognition. I don't know about others using the Phillips MRx, but I find it to have a fairly crappy baseline and very non-intuitive gain amplification. Subtle A-Fib (not obviously irregularly irregular) often gets pushed aside by our providers as simply a sinus rhythm with a crappy baseline (instead of 'f' waves). For some reason though, the software seems to fairly regularly look through and properly differentiate.

Dust, thanks for the welcome. I definitely understand your concern regarding the overall quality of our paramedics. You're right, personally, I consider myself one of the top 10% in the county. Granted, I only have a year of experience as an ALS provider, and I'm definitely not as "skills" competent as some of the more salty guys, but I know that on a consistent basis I recognize things more often than my counterparts. I've had colleagues tell stories that make my head spin... Still, I was educated in metropolitan Baltimore. I completed hundreds of hours of clinical time with incompetent providers that I had to baby sit all the time. Granted, I had many good preceptors, but also many poor ones. Even the worst providers in my county (more rural area) are light years beyond the idiots riding around down there. Still, the hospitals in-and-around Baltimore extend medics a type of reverence that I've never seen elsewhere. In some regards, their incompetence is perpetuated by hospital personnels' making excuses for them (ex: "Oh, well we don't know what its like out 'there.'" ) A lot of this, in my opinion, is MIEMSS' need to pump PR trauma BS up every nurse's a$$ whose within reach of their home office. If you hear it enough, eventually you'll really believe that these guys are excellent. Still... Medicine is interesting. The attitudes and egos that are found in a hospital are amazing. I try on a daily basis to extend some level of respect to everyone I meet. The bias that I experience as an educated paramedic is astounding. The other day I brought a nurse a patient with a weird AMS presentation. With a 25 minute transport and an extensive interview, I was able to determine that the patient had a history of hypertensive crisis, Stage IV Non-Hodgkins Lymphoma (in remission), and a recent diagnosis of diabetes. The patient was experiencing weird neurologic symptoms that seemed to indicate several different etiologies (the most simple being heat exhaustion). She seemed stunned that I was able to lead a conversation with her about these conditions, my treatments, and my thoughts on his problem. This should be the rule, not the exception.

Hey Everyone, Done school and very bored. A bit of a thought provoking issue I've encountered in my early career: The service I'm currently working for is comprised of multiple independent agencies that provide ALS service for multiple regions within our county. EMS oversight is provided by a county medical director, "EMS coordinator," and a committee of individuals from each county organization. This committee is usually comprised of a representative from each station (who may or may not be ALS), our EMS coordinator, medical director, and one of two EMS "representatives" from the county's largest hospital. I'm allowed to sit-in on these meetings, but have very few speaking privileges. Recently, the hospital decided to develop and staff a emergency PCI center for treatment of AMI. It appears to be pretty rinky-dink and is nowhere near the size of some of the larger metropolitan cath-labs (it isn't a teaching hospital and I believe there are only a few interventionist). The hospital's representatives came to the meeting and requested that each EMS company purchase software and equipment to wirelessly transmit all 12-Lead ECGs performed in the field to the hospital. They stated that until we, as EMS providers, begin doing such the hospital will refuse to activate the cath-lab or prepare for cardiac intervention. They seemed to indicate that they have had a "few" instances where 12-Leads were misinterpreted to be MIs when they actually were not. Of course, most of the committee responded in outrage for several reasons, but most importantly (in their eyes) they thought it was ridiculous that the hospital would institute a "unfunded mandate" that would negatively affect their patient's outcome. Furthermore, many providers thought their ultimatum was childish and irresponsible. Myself, and a select few other ALS providers, raised objection to being required to "transmit" all 12-Leads. Most of us believe ourselves to be extremely proficient in our interpretations. I believe it to be a professional slap-in-the-face. Many of us saw this coming. The hospital had begun becoming less and less responsive to consultations regarding ST elevation. When we arrived, anything short of 4-5 mm of elevation was regarded as uninteresting. Many of us observed patients being heavily medicated for pain and then languishing for up to an hour or more until proper cardiac enzymes were drawn, analyzed, and results posted for the physician. Then, suddenly, there would be a quite rush to transfer the patients to larger centers for PCI. We'd come back to find the patient mysteriously missing and new patients being moved to their room. Follow-ups would often reveal our suspicions. What would you guys do? Specifically to our roaming physicians: is this behavior acceptable? What really takes so long? Why do we as EMS providers seem to place a larger importance on early recognition and treatment?

Actually, there is information to suggest that most patients are not ALS in nature. Only about 20-30% of 9-1-1 requests require ALS interventions. With that said, there is tons of literature to support EMS systems that are 100% ALS utilizing a flexible production strategy. Whether you agree or disagree with PUM EMS systems, Stout was successful in demonstrating, utilizing real peer-reviewed research, that BLS is basically useless... For example consider: Cone and Wydro, in the Oct-Dec edition of Prehospital Emergency Care showed that 77% of ALS cancellations by BLS providers were inappropriate. 87% of these patients required ALS upon arrival at the ER. 31% were admitted and one died. Schmidt and Atcheson showed in the June 2000 edition of Academic Emergency Medicine that 3-11% of patients determined not to need a ambulance by EMTs had a critical event. Sasser (1998) demonstrated that Paramedics and Doctors disagreed 52% of the time regarding the level of treatment needed. Burstein (1996). Study on paramedic refusals. 199 patients refused service. 48% sought care within a week. 13 patients were admitted and 1 died. The list goes on. I mean I actually have list...this is a hotly debated topic in the world of EMS management and one that gets preached down my throat in lecture after lecture. I think what the data shows is that 9-1-1 is abused and perhaps used inappropriately by some individuals but that paramedics and EMTs are either: A) Uneducated to make adequate determinations of the level of care. OR Paramedics and EMTs lack the diagnostic tools to make these determinations in the field. I choose to believe that A is the main cause of poor choices(B is also important) in clinical work-up in EMS, which is why I am hugely in favor of advancing EMS education and working towards the development of a better prepared, advanced prehospital clinician. I honestly believe there is a lot of room for EMS to make a genuine contribution to public health.

Horrible. My prayers are with Mr. Vazquez and his wife and children. GOD bless his family.

This definitely needs to be investigated furhter. This is something that is central to our health and safety as EMS professionals.

While I understand that as a patient there must be significant fear of infection, I also can understand how devastating it might be for a person with one of these diseases to loose their practice. As for the provider passing one of these diseases, I think we should all worry more about passing MRSA or some other bacteria from person-to-person. When was the last time anyone here took extra special care to practice aseptic technique? I've probably yelled at several providers in the last week about using gloves when they set-up an IV bag. Insuring the line NEVER touches the floor. Properly removing extension lines from wrapping so that a minimum level of exposure is had. Do you all wash your hands after every call? Scrub your ambulance top-to-bottom? Has anyone here seen the studies on the cultures done from the back of ambulances? Many of the diseases mentioned here, minus TB, require direct blood-to-blood contact or saliva-to-blood contact. Even then, some of these diseases require a significant viral load. I understand both sides of the argument, but also know that people fear things- sometimes irrationally. I see few instances where a person with HIV, as a paramedic, can easily pass the disease to their patient. I see our patients bleeding on us more than the other way around. Remember tolerance. It would be a shame to take a very skilled person off the street for fear only. I don't think this is generally a black and white answer.

An instructor I had said he used one of these kits on the way back from a vacation/conference. He said that the one he used was fairly elaborate. Full AED, first-line cardiac, etc. He said that he and another provider consulted with a contracted ground agency physician and performed a good amount of stuff en route. Started a line, hung fluids, etc. I believe it was a patient with chest pains. Needless to say, in Maryland all ALS providers are issued a license on hard card. It is issued by MIEMSS and is required to be carried on your persons at all times while functioning in the capacity of an EMS provider. They are color coded, have a picture of the patch/seal of your licensure and say: State of Maryland Paramedic OR Cardiac Rescue Technician. It clearly in bold states "License" for ALS providers and "Certification" for BLS providers. It also list your affiliated county, company ID, and personnel identification number. Of course name, address, etc are also listed. A barcode is located in the lower right hand corner.

At school we spent a significant amount of time studying the cluster that is DCFD. The problem stems from a very entrenched political system of deceiving the DC city council. The Rosenbaum family had the opportunity to destroy DCFD. The liability seemed incredible. Instead, being good natured people, they took the death of their loved one and tried to exact change within the department. An investigation was launched by the Inspector General for the District of Columbia. Subsequently a taskforce was formed to make recommendations on how to improve the department. The taskforce made a lot of good recommendations-institute a form of SSM, develop a system to send the closest ambulance, retrain providers, etc. The biggest thing they missed was: A) The medical director is not independent. One improvement was that in the past, DC Fire Chiefs would "shop around" for medical directors. Basically firing anyone with a progressive thought in their head. DC restructured the medical director's position to report solely to the Mayor. Great move, but flawed. He can still be fired and still has the city council as his primary constituency group-not the patient. Instead of finally separating EMS from fire, the fire department saw it as a great opportunity to bring in tons of speakers who advocated combining the department to make it inter operable and "improve morale." In the past many DC paramedics were paid by the fire department, but not considered true members of the fire fighting cadre. The report blamed this lack of hokey togetherness on most of the problems. I think Boston EMS might have been the only third service agency to really have had a chance to speak on the side of an EMS only system. In reality, Mayor Fenty should have kept good on his campaign promises to separate the two agencies.

I agree that it is legal to ban smokers, but I'm sure it is questionable to screen or ask if they smoke during interview. Legally, it is the right of the employee to say no. So long as he/she is not caught they're fine. If they say yes, they must quit. To categorically right that individual off, and not allow them the very rare opportunity to quit the very next day, is probably wrong. I guess in the case of the hospital, the nicotine test acts as the "test." I also noticed that they offer smoking cessation classes. Interesting. Like I said, I'm no expert. Obviously someone else had the same idea before me.

I hate to sound judicious, but it could easily be argued that smoking is indeed a form of addiction. Medical/legal issue. I don't know honestly. I agree that smoking is a bad habit and that it definitely doesn't belong in EMS. I think a better policy would be to just ban it while working and fire the individual on the spot should they get caught.

I'm not sure how many people follow the economy, but I think you should feel lucky if you're: A) Financially stable (good debt to income ratio) You're currently an employed paramedic. Preferably in the public sector, but private too. The way the economy is looking, some people are predicting a longer-than-normal recession. As the housing market tanks and creditors fall behind, people with stable "decent paying" jobs may well prevail through this recession. Paramedics are needed aspect of public safety/public health/health care, so I doubt you'll see dramatic layoffs. Avoid buying unnecessary crap and there may be opportunities for investment at the end of this economic downturn.

This is easy to avoid. Outside of asking about previous EMS experience, your employer has no business knowing about your hobbies or otherwise. More specifically, an employer wanting to avoid a discrimination lawsuit should keep the questions job specific less he/she accidentally use your personal life to form preconceived notions about you. This is why you'll find that most employers avoid asking things like marital status, etc. Granted, being a volunteer firefighter/EMT isn't a protected class, but there are some general pieces of etiquette that apply to most interviews. Generally just answer questions as they're thrown to you. Offer helpful information only. Dust is right, depending on the agency, your volunteer experience may not be something to necessarily brag about. This goes both ways, but you'd be right to be careful about what information you volunteer. Present yourself as a professional EMT/Paramedic who is willing to learn and adapt to the employer's needs. Rock the boat after you get hired and completely processed. Employers (good ones that is) invest significant money in making you a deployable member of their team. In most cases, you have to be a real pain in the a$$ or really stupid to get fired. Again, proceed with caution.

I only have to say one thing... Watch and enjoy.

Objective comes before assessment. I'm familiar with SOAP.

I'm finishing my last year in school and currently we're focusing heavily on documentation. I was wondering how everyone here documents their ALS calls? Specifically, I'd like to see how you do a review of systems within a SOAP (SOAPIE) format. It is something that many people do, but I've never been instructed on. I'm just intersted to see how different ALS providers document. Please feel free to give examples. Thanks.