UMSTUDENT

I think as a profession that we often forget about some of the truly great jobs there are in EMS, especially for the amount of work you do. Think about it. Where I'm from, a person can join one of the several county-based EMS/Fire systems and go through an 18-20 week academy. During this time they will be trained as a firefighter, rescue technician, and basic EMT. They will start at around 34 to 37 thousand dollars a year while in the academy and make a significant jump after finishing...maybe 40,000 dollars a year. Then, if they choose, the county will pay them to take a 10 month paramedic-cook-book class through that same academy and their pay will jump to almost 49-52,000 dollars a year. Language proficiency? Add a couple thousand a year. This is all BEFORE overtime. This is an IAFF, union supported job with a 20-25 year retirement, great health benefits, sick-days with procurement, vacation time, Kelly days, and 24-48, or 24-72 hour shifts! One local jurisdiction works 24 hours on, 48 off, then 24 hours on and then 92 hours off! Some of the paramedics (those that have no lives) are clearing triple digits a year with overtime. Moderate overtime consumption can bring you into the 75,000 dollar range with a decent amount of time for family and fun. This is all out of high school with practically, IMHO, little real educational requirements. Someone with a degree in EMS, or anything for that matter, starts in the same place...at the same relative salary. Only recently have some of the jurisdictions given advancement preference to college educated individuals. How many other jobs out there let you do what we do, with such a decent salary? I know this isn't common throughout all of the country, but think about what we could really make if we all would prescribe to higher education standards.

I know of several volunteer fire departments that allow their members, specifically "live-ins," to consume alcohol on premises. They may only do this when they are entirely off the schedule and NOT on duty. Many of these departments have separate living quarters attached to the station and provide rent-free living arrangements for volunteers who meet certain hourly/duty commitments throughout the week. At the same time, however, there are definitely limits as to the amount and kind of alcohol that these people are allowed to keep, maintain, and exactly where and when it may be consumed. I believe most of them have the general .00 level alcohol rule. You may have absolutely NO alcohol in your system when riding on any piece of apparatus or assisting any individual in the capacity of a firefighter/EMT. Doing otherwise will lead to immediate disciplinary action and even legal consequences. At the same time, most of these stations do routine drug testing for illegal substances. Do I condone this? Not really. Does it usually work? Yes. Have there been abuses? Probably.

I don't see where this is so ground shattering. I'd say most of the larger counties in Maryland already provide full county funded fire and emergency medical services in a similar capacity. Many of them don't bill and simply provide it as an "essential public service." In some counties, EMS has been integrated in exactly the same way as NJ. As we speak in my county, a regionalized EMS system is being implemented. 9 paramedics were just hired to function as intermediary, roaming paramedics to plug shortfalls in the system. Also during this phase (currently phase 1), the county will begin assuming most of the routine maintenance cost for existing volunteer stations. During phase 2, more paramedics will be hired to begin being stationed at volunteer stations that voluntarily secede to county control. The idea is to eventually have the original 9 paramedics serve as supervisors, while the others function in house. This seems to be working so far, surprisingly. Like the NJ plan, percentages of billing will be taken from those stations that secede and used to pay for the services they no longer can maintain on their own. Of course, general county funds will cover billing shortfalls. This is almost 20 years behind the better funded, more metropolitan counties in the DC/Baltimore area. Props to NJ though!

I had an exposure to a patient of about the same age. My issue was sheer stupidity and a combination of being dazed and confused from lack of sleep. The call came out as a medical/diabetic emergency. Upon arrival, we found a lady down (supine) outside of a church. A towel had been placed under her head, which I of course thought was placed purely for comfort. Initially bystanders reported that she had fallen from ground level and the paramedic asked me to grab her head for c-spine precautions until he could assess further. I put my hand, with open cuts, directly into a pool of warm blood and tissue. The occipital region of the patient's scalp was bleeding profusely. Apparently it was later discovered, from the patient, that her internal defibrillator had fired causing her enough surprise to fall backwards and strike her head on the corner of the sidewalk. Upon reaching the hospital I requested to be seen under our infection control protocol. The patient was unconscious, but the physician went ahead and preformed a rapid ELISE test. She came back negative. My physician “officially” advised me to begin taking the HIV cocktail, but “personally” advised me that given the test results and the patient’s age that taking it might not be the best thing to do. He explained some of the negative consequences of the cocktail. I declined. A month later, a follow-up visit revealed that the patient tested negative for Hep-C, B, and HIV. I was also negative. Protocol stated that I should have received follow-up testing every couple weeks up to six months. I never followed up, but for your own comfort I would suggest doing so given your situation. In my case, everything was totally covered by worker's compensation as should yours. Take advantage of the free care. Honestly, I think only a thorough understanding of the virus can help you make an informed decision about your choices, but given the limited time you have to decide, I would probably start the cocktail. At least until her results are returned. Your exposure was a needle stick, which may be more serious than my open cuts.

Absolutely that is the case. Certain obvious things dictate caution; for instance ECG changes indicating an inferior MI would indicate judicious use of nitroglycerin instead of blind implementation. The basics of med administration still apply. For instance, an allergy to a drug would obviously contraindicate its use. Otherwise, the protocol is clear. There is a gray area with this patient, since he was under 35. Another protocol would indicate he is a BLS patient. The interpretation gets fuzzy because most jurisdictions here indicate that once an ECG is performed, a solely diagnostic procedure, the patient is now ALS. Stupid, but true. Sorry to tell you.

I'd like to add to this discussion by noting a phenomenon that I've been seeing ever since I recently became registered. I live and work in a fairly conservative state, from a protocol perspective that is. The state, probably in the best interest of its citizens, generally tends to develop its protocols based on the proficiency of the lowest educated, least skilled ALS provider. Basically, this state develops all of its protocols around the EMT-I and certificate level, protocol monkey paramedics. What is totally sad about this is that in most cases it works…in safe, sorta mitigating way. Patients get to the hospital relatively intact with some level of palliative or supportive care. I recently got in an argument with a paramedic I highly respect. He works for a private flight service and generally knows his sh*t. We went to the workplace of a 26 y/o male patient who was experiencing a sudden onset of chest pain. The guy didn't describe it as substernal, but more of an encompassing "pain-like" sensation. He stated that he had recently been referred to a cardiologist who had diagnosed him with panic disorder. I started a 12-Lead on scene to see what was going on. The 12-Lead came out and low and behold...nothing. The guy had an otherwise nondiagnostic, normal 12-lead ECG. I, as a fairly new ALS provider, handed it to this veteran and told him my findings. The guy's only cardiac mitigating history was that he recently quit smoking and had been unintentionally abusing his nicotine patches. The guy was in a normal sinus ECG w/o ectopy or other notable abnormalities. Perfect vitals, not diaphoretic, not in any obvious distress. My impression was that he was having a panic related event and needed to be treated accordingly. In our state, with the initiation of ALS, all patients complaining of chest pain get ASA and at least one nitro. So regardless of what you think is wrong, the protocol clearly states that you must perform this procedure. The difference is that this paramedic looked up at this guy and said, "You know bud, I think I see something that concerns me, so I'm going to work you up. I don't exclude people based on history." To this I said, "Ugh, what do you see?" He said, "I see something in V1 that is concerning, plus he has poor R-wave progression and some elevation in V2 and V3." I said, "His QRS duration in V1 is normal, I doubt he's got RVH, and the elevation is 1-2 mm and nonspecific." "Oh, and I don't see a delta wave either." Now I also realize that there are a billion criteria for every interpretation of a 12-lead, but this guy didn't fit the bill. To me these were just normal variants, or as I like to say, fingerprints of a unique individual's ECG. No bundle, no benign WPW. Age, history, and simple probability don’t lend themselves to cardiomyopathy. Ischemia? There is chance he could have some. It does happen occasionally after all. Preventive ASA and nitro wouldn’t hurt the guy. A clear presentation to a consulting physician at bedside, with the ECG in hand would be an absolute. We got in an argument later about the merits of using a patient's history in determining the level of care that would be provided. This paramedic believes that the results of an ECG are final in the interpretation of possible cardiac events 100% of the time. We didn't disagree on treatment, especially since the protocol clearly states what to do every time. I argued that he did more harm to this guy. IMHO, this guy was suffering from a psychological issue that was diagnosed by a physician and met all of the clinical manifestations of a panic related event. Telling him that something is wrong with him will only make him not believe his doctor and NOT seek help for his problem, which itself can be severely debilitating. I explained that the most appropriate thing to do was to treat him and let his doctors, with more definitive test, make that decision in a less stressful situation. Presenting the nitro and ASA as a preventive, “just-in-case” measure that is afforded to everyone presenting with similar ailments would have been a much more appropriate way to present the treatment. Besides, he opted for no oxygen! Now the point of this story is that because of these protocols our treatments, regardless of the clinical interpretation we each had, would be the same. The difference between the two of us is the tact and presentation we would have made to the patient. Sure, would I be cautious and give the guy some aspirin? Sure. Would I have given him a shot of nitro? Maybe. Would I have told him that he has a potentially life threatening cardiac complication? Absolutely not. The evidence simply wasn’t there to get this guy worried about his heart exploding. Now you may be asking, if you actually read this essay-long post, what is the different between the two of you? Well education for one. I had a fairly well-rounded education from a psychology stand point. I also have some experience writing on anxiety related conditions. Lastly, I had a very good, intense, well-rounded patient assessment class. My hunches are based on statistical information, common and uncommon presentations, good history taking skills, and a fairly thorough understanding of the human body. Not to say the other guy doesn’t, but I believe it’s more founded in experience and less in formal instruction. The difference between an educated and uneducated paramedic may seem like nothing on the surface, especially in an environment (state) like I work in. If you were to look at this case from a QA standpoint, knowing nothing of the interactions between the paramedic and the patient, you would say he did his job. The difference is in the realization that being a professional, well-rounded paramedic isn’t just about performing skills. It’s about treating the whole patient, not just a perceived emergency. It’s about remembering that your interactions with that person will follow them long after they leave the ambulance. So to the person who says that skills must be commiserate with education, you’re flat wrong. Until more paramedics can thoroughly understand the basics of patient care and the basics of treating the complex, amazing machine that is a human being, then skills should probably remain see-do.

I feel that the difference is evident anytime you encounter an uneducated paramedic. I will qualify this statement with another statement: educated doesn't necessarily ALWAYS mean someone with a formal college/university education. Unfortunately for the patient, most of the time it does. I see this all of the time in my encounters. I routinely run with paramedics with rudimentary reading and writing skills. Most can't form a proper sentence. I'd say more than half of them have absolutely no idea what is going on in the world on any given day; more than half couldn't tell you how many senators there are in the United States Senate. 3/4 work on old or outdated principles in performing their care. I'd say over 80% could not effectively read a published, peer-reviewed study. We can sit and talk all day about how education makes you a "well-rounded individual." I would have to agree 100% with this statement, but the real problem is that uneducated paramedics = bad care. I think too much of our profession is totally ignoring this fact. If you've made no effort to educate yourself on the issues that directly affect your job and you make a bad decision because you didn't know or understand, then you have absolutely no excuse for your actions. When we start making this an absolute expectation within our ranks, we’ll start moving forward.

I'm interested in what path many of you took to a career in EMS. I was recently sitting at my station, of which is a mixed volunteer/career department, and observed and overheard many of the younger members discussing their aspirations to become a paramedic. It got me thinking about how I chose EMS as a career and why. I also started realizing how very different many of the people coming into the department are, especially from a values stand point. So my question is this: How did you get started in EMS and why? Do you regret it? And finally, do you observe any differences in the current generation of students coming out of school with their license?

Thanks VentMedic. I took this information to our county medical director, and after much of the same conversation and a demonstration, he also came to the conclusion that the OXY-PEEP is not true CPAP. The discussion started with much of what you're explaining now, but more in line with Bernoulli's principle. Where the confusion seems to be is that the OXY-PEEP does not utilize any mechanism, say a restrictive valve or even progressively smaller tubing, to simulate an inspiratory pressure. The device works essentially as a nonrebreather mask with a PEEP blow-off valve attached. The FiO2 adjustment device in no way controls the flow. All you're getting is a standard flow of 15 LPM of oxygen, because as you exhale against the PEEP the oxygen being delivered is simply blown off too. There is no subsequent build-up of inspiratory pressure. I'm going to look over some of these studies. Thanks again!

Actually, they do have problems getting in. The unfortunate thing about medical schools in the United States these days is that a lot of stuff outside of your academic ability plays into your chances of being accepted. Race, gender, income, family status, etc are all taken into account when admitting competitive individuals. On face value this isn't how its portrayed, but they do have their unique role. Obviously, people who are not competitive get the toss initially, but what it really comes down to in the end is "who deserves it more?" Am I going to take Johnny Tambourine who has a 3.7 GPA, 34 MCAT, Paramedic, from an upper-class family? OR Bobby Tambourine who has a 3.6 GPA, 30 MCAT, research assistant, who grew-up in a lower class family? Outside of social class these kids are relatively on the same playing field. Hell, they're probably both great kids! The issue, at least from what I've seen at my university, is that the average middle-class American is at a severe disadvantage for ever making it to medical school. You're not rich enough to afford an Ivy education or the connections to buy yourself into competitive research programs and you're not poor enough to qualify for the tons of programs that baby-step “disadvantaged” kid through the med school process. You have to be absolutely stellar, have perfect grades, tons of volunteer experience, and go out and fight for these research opportunities on your own with minimal assistance from anyone. For example, I met a girl recently who is trying to apply to a very competitive MPH program that I myself am interested in. On paper, she and I are both good students. We've taken roughly the same classes. From our conversations, it seems I've performed better in many of them. I also have an EMS and healthcare background, significant volunteer experience, teaching background, and a small publication credit. However; she has one HUGE advantage over me. She's from an upper middle-class family and her father is a researcher for the government. He provided her with a research assistant position in his lab and she was able to get her name on a published paper. I'm sure she worked hard for it, but the problem is simply that. I probably would have had to compete in a competitive selection process to get that same research position instead of utilizing nepotism. These examples are everywhere. Another example, A student of mine was in an EMT class because he wanted to improve his resume for medical school. He was a graduate of an Ivy League university with a degree in Bioengineering, an MCAT score of 32, a 3.6 GPA, and was a research assistant with a local university study. He applied to 18 allopathic medical schools in the United States. He was accepted at none, and wait-listed at 2. He was working on his second application cycle and needed to spend another 2,000 dollars on application fees, AMCAS fees, etc. The doesn't even include the fees to fly to interviews I asked him what he thought kept him at a disadvantage and he explained it like this, "I got into my undergraduate school on scholarship and hard work. My family is upper middle-class, but they could have never paid my education by themselves. So on paper, I look like a stuck-up Ivy Leaguer, white kid with every advantage in the world...but I don't. I have no connections and little money to spend on fluffing my education like a lot of my peers. This is really my last ditch effort." The kid was an amazing student and really had a passion to do it. Maybe he interviews horribly or writes crappy personal statements, but does that make him a bad applicant? The problem with medical school admissions is that they don't seem to have an insight on the true story. On paper they're using an objective set of criteria to admit students into their programs, but what they fail to realize is that some of that criteria is easier for certain people to accomplish. This has just been my observation. I think the difference for many people is that you just have to get over it and try your best, or seriously reconsider doing it at all. Play other cards in your deck and try again later. The traditional route to medical school isn't neccesarily for every applicant. When you do make it, make sure you have a say in changing the process.

VentMedic do you know any literature that compares PEEP only devices like the OXY-PEEP to devices like the WhisperFlow and CPAPos that deliver inspiratory pressure? Specifically on the effectiveness of these two devices when compared to the other?

Sorry Dust, that is a typo on my part. It should read "expiration", not respiration. My bad. I noticed it as soon as you pointed it out. So for the benefit of Dr. Bledsoe, the correct quote is as follows, "CPAP is often confused with positive end-expiratory pressure (PEEP). The difference is that PEEP is applied only during expiration, whereas CPAP is applied during the entire respiratory cyle. For this reason, CPAP is the preferred modality for CHF." It still supports what I was saying, minus my brain fart while copying it from the book.

I agree completely. Of my courses that focus on EMS education, there is one thing that is consistently mentioned throughout the course. Most EMS providers are not educated at the collegiate level and many of them, sadly, have not had the very basics of education (proper high school education) to properly engage in analytical thought. Now I'm no specialist in EMS education, but it seems to be that most of it can be summarized like this: Teaching EMS providers is much like teaching most adults, except that they are extraordinarily stubborn, pompous, and have EXTREMELY short attention spans. They are often unable to incorporate new or different learning styles that may not be immediately familiar to them. This basically is like teaching special education kids and can be very frustrating. That’s what I took away from my introductory classes.

Thanks Dust, I understand that both types of device are technically maintaining a continuously positive airway; however, even your friend Dr. Bledsoe's book remarks that they are technically different devices. True CPAP delivers a positive pressure during inspiration, thus decreasing the work of breathing during the normally active phase of respiration. After inquiring with some friends, it seems that these PEEP devices are a cheaper, more cost effective way to "theoretically" provide the same effect. The problem here seems to occur in that expiration is the normally passive portion of the respiratory cycle. When using PEEP without equal or greater IPAP, or inspiratory pressure, you cause the individual to work to breath out and in. This is counter intuitive to the reasoning many proponents of CPAP tout its use for patients with COPD: to decrease the work of breathing. PEEP devices maintain a continuously positive airway, while the device itself is not continuously positive. PEEP keeps the airway primed due to positive expiratory pressure, whereas true CPAP primes the device and the airway regardless of the effort displayed by the patient. Per Bledsoe's Essentials of Paramedic Care 2nd Ed., “CPAP is often confused with positive end-expiratory pressure (PEEP). The difference is that PEEP is applied only during respiration, whereas CPAP is applied during the entire respiratory cycle. For this reason, CPAP is the preferred modality for CHF. “Pg. 1223 And "PEEP uses a restrictive valve on the endotracheal tube or mask of the bag-valve unit. There it resists exhalation, maintaining a positive pressure and keeping the patient's airway open longer during exhalation. CPAP uses special ventilation equipment that increases pressure during both inspiration and expiration. This keeps the airway open during more of the respiratory cycle." Pg. 844 I appreciate the response and agree that this is an effort in semantics to some degree, but I do see an obvious advantage to the device which provides positive inspiratory pressure.

There is no inspiratory pressure, only end-expiratory. Only when the patient attempts to breath out is there any pressure on the device. When inspiring, the device is no different to a normal non-rebreather mask. PEEP. Other CPAP devices I've used deliver pressurized inspiratory oxygen. Your lips and cheeks puff up if you resist against the device. It literally forces a set pressure into your lungs at all times. This device in no way does this.

I'm having a bit of difficulty understanding something. Recently, one of the systems I work in finally decided to implement CPAP in the CHF protocol algorithm; however, they decided on using a device called the OXY-PEEP by Smiths Medical. The device is purely a PEEP mask according to the manufacturer's specifications and from my own observations. It allows you to adjust the end expiratory pressure, but does not deliver continuous pressure during inspiration. This has not been my experience with the Emergent PortO2Vent or other devices that I've used or been trained on in the past. While I understand that PEEP is better than nothing at all, I find it hard to justify calling it CPAP on a patient care report. Am I missing something here? I want to make sure I'm not catching something before I go complaining.

There are degrees in EMS at the graduate level in the United States, they're just very rare and most of them focus on system management and development or education.

This is where Dust is absolutely right. Unfortunately, we have an entire group of cookbook paramedics out there looking for reasons to hand out every piece of candy in their drug box. Working on intuition is one thing, but blatantly handing out drugs is something entirely different and I think you see more and more of this in the EMS community to some extent.

Nope, I was right, just a reading comprehension problem. Abrasive are we not?

University of Maryland, Baltimore County has a Masters of Science Degree in Emergency Health Services with an education track that can be done through distance education. Check it out.

I hope that is sincere, LOL. Adding a comment on the general use of aspirin, while not directly related to the topic at hand, is appropriate. Secondly, I obviously advocate for the proper use of a drugs based on education and training. Unlike some people however, I feel I should not overstate my level of knowledge or rights to practice. While I may have a thorough knowledge of the drug I'm talking about, changing your practice on a universal level based on my statements is not advised. I don't want someone on here telling their medical director they're an idiot because of something I said.

Education. Understanding and knowing the potential effects of a drug given your patient's detailed history and physical assessment goes a long way. Hubris? As a paramedic you would be paralyzed with fear or simply stupid to not be able to predict the reactions your medications will have on that individual, especially in a drug like nitroglycerin. You'd be surprised what you can get out of a patient if you know how to properly question them. For instance, a patient who tells you, "My doctor says my heart only works 30%" is telling you a lot (actual quote). What can we deduce from this statement? The patient is recalling a comment from a physician. If the patient has an otherwise unknown cardiac history we can presume that he is probably referring to his ejection fraction. Even if you take this statement literally, it still translates to a rough estimate of his/her heart's overall working capacity and the result is the same. Nitroglycerin has a potent effect on the end systolic ventricular pressure (afterload). A patient with a relatively floppy, nonfunctioning heart will probably have a more pronounced reaction to the drug. This is what I'm referring to. Even if your patient simply says, "I get dizzy, lightheaded and pass out when I'm given that drug" you've discovered a lot. Prepare a large bore IV and have fluids available just in case. Blind implementation of protocols without any thought on the part of the provider is just asking for danger.

Half-life and therapeutic effect are often different. Nitroglycerin has an onset of 1-3 minutes with a therapeutic effect of approximately 30 minutes. My point was my point. The risk of building up toxic, potentially harmful levels in individuals who otherwise have no sensitivity to the drug is probably not as high. The body rapidly metabolizes nitro in the liver into two metabolites. The sudden, drastic drop in blood pressure among individuals who are given nitrates is seen is certain populations. Not everyone's pressure is going to bottom out given multiple doses of this medication. This is why ingesting large quantities of nitroglycerin by mouth is often very non life threatening (depending on the form). It succumbs to a tremendous first pass effect! Basically, nitro is a drug whose use must be tailored to the individual receiving it. As I said before, these are drugs that cannot carelessly be given to individuals blindly based on protocol. The "therapeutic effect" will vary widely among individuals who it is given to. The best advice is to know the drug you’re giving and the potential ill-effects of its use.* Secondly, my comments on aspirin are based on some reading of my own. My comments were based more on the tendency of some physicians to place their patients on ASA on a daily regime for a variety of ailments. More research has come out indicating that aspirin may have therapeutic effects beyond its traditional uses. I think I'm referencing a TIME article, but I couldn't begin to cite specifics. Type in "aspirin, cancer" though and you'll get a floury of news articles and stories on the research linking it to cancer prevention, specifically in colon cancer. Hope that helps clarify things. * Not a pharmacist. Consult protocols!

If I remember correctly, Nitro has a very short half-life, somewhere in the range of 1-4 minutes. I think using it during a suspected cardiac event is warranted, so long as you have a thorough understanding of the effects it will have on that individual's unique heart and vasculature system. For instance, I would say a 12-Lead ECG is a good diagnostic tool to implement before just randomly giving nitro. For instance, the presence of an inferior MI may warrant more judicious use of nitro. Aspirin on the other hand is an anti-platelet aggregator. The immediate advantage of giving ASA in the field is probably negligible, although it does have added advantages of keeping the clot from getting larger. Interestingly enough, there is a huge divide in the medical community about the utility of salicylates in certain aspects of medicine. There is some research to suggest it may help with a variety of ailments, while yet other research suggest its dangers when used carelessly. I think we can all agree on its most basic uses. I think the take home point of these drugs is to use them when warranted by clinical signs and symptoms with the proper use of available diagnostic tools. Basically, this means utilizing your brain instead of blindly handing out drugs for every patient meeting only the mildest criteria.

There is no scientific evidence to my knowledge which would point to the helicopter being the reason these people survive. I would be more inclined to believe that it has everything to do with how the system works as a whole; a fluid machine developed over years to deliver rapid and effective trauma care. If you know anything about the topography, population density, and economics of the DC/MD/VA area then you'd at least understand that the helicopters probably do have a great deal to do with the survival rate. Traffic here is horrendous. I've worked in areas around Baltimore and DC where even though you may be 5-7 miles from the nearest trauma center, the transport with lights and sirens may take 30 minutes or more during peak rush hour(s). The western parts of the state have level 3 trauma centers that certainly are not equipped, IMHO, to handle complex trauma issues. Transport to Shock Trauma from there would be over 1 hour by ground on a good day. In every way it appears that the people who fly walk out alive. To the people of Maryland, and to many people around the world, Baltimore may very well be the medical capital of the world. You don't look at every hospital to have the same capabilities as the next. Here, people take into account the skill and atmosphere of the medical community that will be treating them. For instance, we fly these patients too: Hand injuries go to the National Hand Center at Union Memorial Hospital. Pediatric Trauma Patients go to Johns Hopkins Pediatric Trauma Center or Children's Hospital in DC CO poisoning, Nitrogen Narcosis, etc go to Shock Trauma for their multiplace hyperbarics chamber. Burns go to Johns Hopkins Bayview Hospital. Eye Injuries go to the Johns Hopkins Wilmer Eye Institute We don't mess around here sending patients to unqualified doctors. People want specialist and honestly, if it means the difference between a favorable and unfavorable outcome, then the money is worth it.