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CBEMT, do me a favor, explain to me how those FDNY EMT's in that other thread who drove off with out allowing ALS to enter didn't do EXACTLY what you are suggesting. Now, as I said before I am not exactly sure of the facts of that case, but basically, if you were in the back, and they said "Oh, those ALS providers will halt CPR on a procedure they're not good enough at in adults, let alone kids, and as we already know, no CPR = no chance," you would be in complete agreement with them. Explain to me how that is the right thing to do. Please. I'm all ears.

Okay, well, maybe five years, paroled in less than that. My point is that as horrible as this crime is, it is not as open and shut case as you might think. As emotional as we get for the loss of the victim, I just think you might be a little off in expecting more than what will probably happen. I see people who have committed crimes like this walking around all the time. The guy has no previous record (I assume.) He's a former police officer. Its a registered weapon. There was alcohol involved and the conflict was two way. This means there is a very good chance a judge and a DA will plea it to manslaughter, and the guy will be out in time to complain about the next presidential election.

I've seen the horrors of paramedics focused too much on getting an intubation, indeed, but I have also seen plenty of providers refuse to administer appropriate care simply because they are either not confident enough in themselves or afraid to perform the appropriate intervention, particularly when it comes to pediatrics. Of course, the first priority in a pediatric patient should be rapid transport to an appropriate facility. However, given the high incidence of respiratory problems in the critical pediatric patient, coupled with their compensatory mechanisms, if a pediatric patient needs to be intubated, they should be intubated immediately, not after we call telemetry, not after BLS has its say, not after we wait and see if they get better. A pediatric that needs intubating should have it performed ASAP, and there are few very good excuses why it should not take place in the field, when it is warranted.

Some simple math for you. Alcohol + 8th grade machismo + handcannon = death. If there was no gun involved, this would have been another escalation and maybe some slap happiness. However, add a gun and its point-click-die. Which is why I'm much for morons who have nothing better to do than worry about kids being in his yard not be able to access anything larger than a slingshot. Oh, and the cop in this case? He's going to walk. Registered piece, on his own property. Slap on the wrist at the most. He might lose his job as a police officer due to the bad publicity, but other than that, if he gets more than a misdemeanor, I'll be surprised. We had a similar case in Long Island, a guy blew a 17 year old's face all over his front lawn after the teen decided to play Long-Island-Italian tough guy at his front door. The guy got a year, and that was mostly due to the gun being illegal. My condolences to the firefighter's family.

I delivered a baby the other day. Where's my news story? And it was during EMS week too! Maybe next time I'll call for the firemen so it'll get some publicity. "Cental, send me suppression for good PR value..." Ha ha.

This is the same Cleveland EMS that when the news media did a story about BS calls, the director stated "Well, we're really a social work service and these calls need to be done." Apparently by a paramedic on a fire engine. Its all about the green, folks.

JW, I'm never sure exactly what your docs (or mine, for that matter) have in mind when they write the protocols, but here's my best stab at it. Consider a person having an infarction. At first they call you and you treat under the Chest pain protocol. You give them nitroglycerin and there BP falls below 90, and you follow the rest of the protocol. Now say that person didn't call you right away. Their infarction has been going on for long enough that their heart is damaged or otherwise unable to function properly and their blood pressure is low because of it. Their signs and symptoms are the same, chest pain, cool, pale, diaphoretic, low BP, but the pathologies are different and need to be treated accordingly. Being able to recognize the disease process and accurately describe what is occuring and what is necessary is the true hallmark of a quality paramedic, and goes far beyond saying this sign + that symptom = this diagnosis + this medication. Usually the most clear sign of someone being in cardiogenic shock is the presence of rales. This doesn't mean that someone who is cool, pale, and diaphoretic and has a low BP but no rales is NOT in cardiogenic shock, but someone who has all of these things plus an fitting history and description of onset of symptoms almost certainly is. Hope this helps.

I have a saying too. Its called one person CPR, in the back of the ambulance, is almost completely ineffective, and serves only to increase risk of injury to the providers and give false hope to the family.

VC, I feel for you, man. I'm sorry to hear the state of LA County EMS, but from the way you describe it, it makes my system seem not so bad. We may have problems with our FF's, but I don't think we've gotten to fistfights. My old partner once threatened to stab a Fire lieutenant in the face with an intubation blade, but that was a rarity and the guy really deserved it. Anyway, as I said, I feel for you. I'm at a period in my career where I'm not sure how much more I can take, I'm at the point where I am not so much regretting my decision to become a paramedic and get into EMS, but just wondering if I could not have spent the time far more productively. The worse thing is that all in all I've had a pretty good career in EMS. I've been at the worst terrorist attack in US history, I brought an 18 year old girl back to life, I've done aviation accidents and been on security details with senators and dignitaries. I've done just about every single procedure and protocol we have written, and I am still at a point where I am starting to dread going into work in the morning and my (legal) pharmacological intake has increased dramatically. I think any large city with Fire involvement in EMS has the same problems you and I face. Single role providers are regulated to playing ghetto-clinic-shuttle for the Medicaid dough while Fire gets to swoop in, pose for some pictures, and go back to their cute little houses when people need help. It is this situation that sets you and I up for a field where our profession becomes second class citizens to people universally recognized as heroes. Its not a good feeling and its not a good position to be in. I guess all I can really say is that if you get out of LA County, sure, maybe things will be better, but IMHO, not exceptionally so. You'll always have assholes on scene, always, I mean, seriously, I think the major requirement sometimes for being a cop or a fireman is being a major league asshole, and no matter where you go, if you work the 911 system, you will have them on scene. Also, in case you haven't noticed, EMT's and paramedics can be a bunch of assholes as well. If you want to be a fireman, all I can say is honestly, the need for firemen in the world is small and rapidly dwindling. Its like steam locomotive engineers, it would be a great job, but the need for them ain't so much anymore. You'll be lucky to find the position, it will take you a long time, a lot of energy, and there is the distinct possibility you will be working with a bunch of assholes who have tattoos of Warner Brother's cartoons on them and wear their sunglasses indoors. If you are one of those rare souls who really like working EMS, your job prospects are better, but still, the chance of you finding a meaningful, rewarding position in EMS are very slim. You'll also find that especially at the paramedic level, the risk starts to outweigh the reward really, really rapidly. Its one thing to pull off procedures that would have an ER attending doing a Hail Mary before attempting, its another to do it in the back of a van with a guy who's last job was working at Dairy Queen and who has less training than a forklift operator. Given the risk of infection, lawsuit, and just plain getting injured, you have to ask yourself, is it really worth it? I hope this helps and I wish you the best of luck in whatever you decide. Stay strong, and, well, FDNY EMS is always hiring.

ccmedoc, thank you for your response. It was very well thought out and articulate. I'm not saying I don't take other people's opinions under advisement. I always do. In the case of the hypoglycemic, it wasn't so much the possibility of a stroke that we disagreed on, but rather the necessity to intubate. Luckily for me, I had a good student with me, who might disagree, and want to be more aggressive, but took my word on the matter an continued accordingly. I have had many people, and unfortunately, usually the less knowledgeable they are the more persistent they are, who would sit there, and argue, and insist, and make comments to the other providers about my care and, and so on and so forth. The bottom line is that while teamwork is important the bottom line is that we are there to do a job and follow orders. Sometimes, when the shit hits the fan, we all have to just shut up and do our jobs, including myself, and I really don't think the notion of medical authority is emphasized as much as it should be.

My trusty Timex. Everything else I an flush down the toilet and still do okay. Without my watch I fall apart.

ccmedoc, I understand your points, but I really am at a loss to understand your reasoning. Maybe you can explain it to me. You stated that "just because someone is of higher medical authority doesn't mean that other ideas should be squashed" or something to that effect. But the notion I don't understand is that of the "idea". What type of "ideas" are we talking about, and in what context should those "ideas" be weighted? My most common experiences is that of either an EMT-B, paramedic student, or very new paramedic coming up with the "zebra diagnosis" when in actuality it is almost always something more mundane. For instance, a paramedic student I was working with recently thought very strongly that our patient was having a stroke and needed to be intubated, while my ultimately correct diagnosis and treatment was that of hypoglycemia. Was I supposed to have a discussion with them on scene as to why they were wrong? What if our BLS was also convinced it was a stroke too? Was I suppose to let democracy rule and the patient receive the wrong and possibly harmful treatment? Now my question is, exactly how much time and effort should be spent trying to entertain their ideas and creativity before we get to work and treat the patient? Am I suppose to hold a mini-CME lecture onscene until I have everybody at my level of understanding? How exactly is it supposed to play out? Please, I am really interested in what you have to say.

Laura Anne, I can see it from both sides of the fence. First, if I was the PA AND I had full rights to declare death (and given that PA's are physician extenders I don't see why they can't with or without an OK from an online/telephone physician), and I called it, declared death, and 911 still showed up demanding access to the patient and their medical history, I might get snippy too, the same way I might get snippy if I had pronounced and the firefighters insisted on checking a pulse. The PA was probably having a bad night. Also, its stressful declaring people dead. Unfortunately, due to some of the less well trained and professional people in our service, many health care professionals have had poor experiences with EMS. It happens.

Quit the course and put the time and effort into getting your paramedic. Do it. Right now. Thank me later.

Don't you think its a little demeaning to fireman to extend heartfelt congratulations at holding legs AND talking at the same time? You guys must have a really low opinion of firemen. For shame. What's next, you want me to say good job for chewing gum and walking at the same time too?

Gaelic, that was a very intelligent, well thought out post. However, I think you're missing a few things. The Army and the Marines analogy isn't a bad one, I often use an analogy of the Air Force and the Marines to describe EMS and Fire's relationship in the FDNY, but the only way the analogy would hold is if the Army and the Marines were directly funded by the tax payers and people would go around describing the Army as "those guys with the guns" and the Marines as "heros". Fire services have absolutely no problem in sucking up all the credit the media will lay on them, whether they deserve it or not. We all know it. I would suggest you share one of my experiences, sitting in a bar with some friends after working 16 hours in the sweltering heat of Hell's Kitchen in August, cardiac arrests, asthmas, traumas, all of it in one day, only to watch NY1 with the piece about how the firemen saved the choking infant. Its hard to see others get patted on back for what you do every day you go to work. That's all.

Unless its a Ph.D. in something cool like particle physics, or anthropology, usually Dr. without the MD or DO to go with it equals touchy-feely-pass-the-talking-stick-crap. The worst thing about this mythos of teamwork being the most important end all and be all is that it overlooks the fact that the patient's well being is supposed to come FIRST. It comes BEFORE me trying to assist a struggling team member, and it comes before who is having a fun time on the scene. Or at least its a supposed to. These are the same a--holes who told us not to keep score in the little league game, I tells ya. Patient care is not a matter of opinion. It is not based on the democracy of the group or the urgings of the majority. It is based on rules, evidence, and fact that is written down and handed to us by our medical director. If somebody is not doing what we are supposed to be doing, they are wrong, and should be removed, end of story. By the way, the hospital analogy doesn't work. The lowest team member in the ER may be (hopefully) nurse or specific technician. They all have lots of standards, training, and education. The lowest person on the prehospital care team may be Jimbo the vollie fireman or the homeless guy who is helping me lift the stretcher in. Big difference.

EMS gets the work, firemen get the glory. Its division of labor. If EMS was out getting their pictures snapped for the paper every time we successfully put our boots on, we'd have no time to respond to emergencies.

Heh, heh, I like the response of the doc. I get stuff like that all the time, mostly from bystanders. My favorite is "Are you going to take him to the hospital?" I usually respond with a deadpan "Well, we thought too..."

I'm going to weigh in here. I agree medicine is a team sport. However, I also believe that the discipline of a hierarchy is imperative to good quality prehospital care. I don't need someone to help me make the diagnosis. I don't need them to give me tips when intubating. What I need is someone to be able to have the BVM, suction, and oxygen ready so I can focus on correct tube placement. Personally I can't stand this touchy feely Dr. Phil BS that takes the place of professionalism in the work place. I don't come to work to be anyone's friend. I don't come so that everyone has a good time or goes home feeling good. I come to work to do my job, assess, treat, and transport, go home safely and collect a paycheck. Of course I believe that if someone of higher authority is doing something that will grossly endanger a patient they should be called on it. But the cases of that happening versus the far more common phenomenon of some poor overworked paramedic nicely explaining his decisions just so he doesn't have to grow another set of hands out of his ass so the EMT's will do their job are very small. In the cases of a dual medic truck, if the two paramedics disagree, usually either a paramedic supervisor or, even better, the telemetry physician is called in to mediate. When people really need care, it is time for the people in charge to do their job, and the people under them to do theirs. And the bottom line is despite what all of the textbooks, and psychologists, and social workers may say, I do NOT have to respect any body's opinion about my patient care decisions who does not have equal or greater knowledge and experience in regards to the same situation as I do. Just because the patient's family member thinks I should shock the patient doesn't mean I'm going to, and just because the EMT thinks its a stroke and not hypoglycemia will not make a difference in my patient care decision either. If we're talking about what to barbecue, your opinion is just as valid as mine, if we're talking about how to treat the patient, it isn't. If you can't handle that I suggest another line of work where not acting correctly, swiftly, and decisively will not end in death or litigation. I shouldn't have to worry if my persona or my demeanor or my "rep" is enough to "command respect". I should be in a system that teaches enough respect in its subordinates that unless I am doing something grossly inappropriate, people should understand that their JOB is to follow orders, just like mine is. Personally I think we've gone overboard with the teamwork and brotherhood and camaraderie and patting each other on the back crap to the point we've lost sight that we are supposed to be PROFESSIONALS doing a JOB. Professionals don't take canoe trips.

Confirming absence of something, especially in the human body, is always difficult. In this vein, what do you think would happen if the AHA started mandating compressions being initiated in anybody found apneic or with agonal respirations? They've found chest compressions are almost as effective in dislodging an obstruction as abdominal thrusts are. My opinion is that if lay persons and EMT-B's were taught to start CPR whenever a patient apneic, it would do more good than our current system of pulse checks, which this article proves can be inaccurate.

It continues to amaze me the sheer amount of ignorance, even amongst supposed professionals, when it comes to organ harvesting. The big concept that Dr. Quackenbush from SCREWU (Case Western Reserve) can't seem to grasp is the purpose of these ambulances is to PROVIDE RESCUSITATION even after someone is declared brain dead for the purpose of maintaining perfusion to the body. His comments not only are inflammatory but serve to reinforce myths about organ harvesting. But hey, so long as it gets your name in the paper, right? It should tell you something when ABC News can't get a doctor in the city they are reporting about to comment on their story. Way to cost some lives to sell a few commercial spots. I'm going to send a nasty letter to whoever that doctor was from Case Western. What a maroon.

Unless you're military pilots who are routinely alternated on modafinil (Provigil) for "go pills" and zolpidem (Ambien) for "no go pills". Legal drugs can be so much more fun.

Yeah, there's nothing better than standing outside the ER doing compressions and waving at HAL to open the pod bay doors already.

Substance abuse in EMS and health care in general is indeed rampant, although I tend to think "in house" stimulant abuse is perhaps one of the most common. Coffee can only keep you going so long during those endless shifts in the hospital as a resident or even an attending or an RN. While was in paramedic school an RN actually OD'd in the hospital while on duty, as in was given Narcan and revived. No, she didn't keep her job, after she recovered she was led out in cuffs and lost her license.