croaker260

Dwayne, The only thing I can tell you is that while preceptorship should be tough, very tough, it should be tough academically and medically, not due to hazing and bias. Some of the horror stories you mentioned would not be tolerated at my service. Our FTO program is based on a law enforcement model with stringent standards. While we do some things that some might consider unreasonable (the preceptee often techs every patient and writes every chart until he is down several), the Preceptee often has homework assigned, or tests at work...we consider that FTO descretion and part of the learning process. The other stuff your mentioned is a liability to learning, to the FTO program, to the FTO, and to the service, and is not tolerated here. It also sounds like to me you have heard all the bad things about some rather unsupervised FTO programs, and nothing good. Not all FTO programs are created equal, or even similar in structure. In fact, many are not structured at all, you are just paired with someon who someone else thought would do an OK job. Our FTO program emphasizes the learning as well as the evaluation experience. I dont know of any time a preceptee/trainee ever had an FTO put his hands on him unless it was for his or a patients safety. Ever. Dont sweat it until you get there, dont get a chip on your shoulder before you even start, you will enjoy yourself a lot more that way. Dont get me wrong...it should, and must be tough, but that doesnt mean it cant be fun.

Sassafras, It was directed to my comment about DC fire and EMS, wich was more rhetorical than serious. Do some reading about DC fire/EMS, and you will see why.

It is known as hillbilly heroin because it first erupted in eastern KY , were prescription opiate abuse is a new level recreational drug use in the mid to late 90s. It has been currently replaced by methadone as the DEA cracks down on Oxy. So methadone ODs coming to am ambulance near you! Two comments, this drug used to be known, and sometimes still called, "Robo" or "Robot", for two reasons. 1 it is the primary recreational drug in robotussin. Two, it sometimes produces a dis-association with motor functions that results in a "robot" like walks called the "robo-walk". If you are not familier with this drug, this is one of the fasted growing drugs int he high school and middle school crowd out there. And yes I know its been around for years. Also, it is known as "tripple C" or "Contac" because major form of its abuse is OTC cough meds liek "Coricedin Cough Caps" (Hince the CCC). I cant second this enough. While a pro drug site, this is the single best clearinghouse of diverse drug information on the net.

The 25 year retirement that someone mentioned at 18k/year doesn't sound that hot. Here we are rule of 80 (years in service plus age must equal 80) so we work longer (example I will retire at 54) but will get the average salary of my 5 highest years... so at least I will be able to live....It would be nice making 5-7k/month in retirement and still be reasonably young enough to enjoy it.

So let me get this straight, both EMS and fire fall under FDNY, but FF have better retirement than EMS??Am I wrong but isnt 19/hour crappy pay for NYC?? Another reason for well qualified medics to come out to boise. At least we have good retirement and as good or better benies here as at the fire departments. www.adaparamedics.org

How does it compare to DC Fire and EMS???

We have it in our protocols

Just an update, our hiring test has been set for June. www.adaparamedics.org

SHort and sweet: I would also recommend my service, third service county based, very very nice protocols. Definitely a completely different medical and operational experience than most other places. General discussion from the time of our last hiring here, discusses schedule and pay (although check out our website for latest): http://forums.firehouse.com/showthread.php...unty+paramedics Next hiring prob this summer or next fall, don't know for sure. Keep checking your web site: www.adaparamedics.org and our SWO's: http://www.adaweb.net/departments/paramedics/swo2006.asp Please feel free to ask any questions you want, here or in PM or via Email colemedic@hotmail.com. 'Nuff said!

Where in Idaho are you from? And being from both TN and now Idaho, I second that.

Our complete protocols at: http://www.adaweb.net/departments/paramedics/swo2006.asp Acetylsalicylic Acid Adenosine Albuterol Sulfate Amyl Nitrite (Not carried, at industrial sites) Atropine Sulfate Bretylium Tosylate Calcium Chloride Dextrose 50% in Water Diazepam Diltiazem Diphenhydramine Hydrochloride Dopamine Hydrochloride Epinephrine IV , Drip, and Nebulized Etomidate Fentanyl Citrate Furosemide Glucagon Haloperidol Ipratropium Bromide Lidocaine Hydrochloride Lorazepam Magnesium Sulfate Meperidine Hydrochloride Methylprednisolone Midazolam Morphine Sulfate Naloxone Nitroglycerin Oral Glucose Oxytocin Phenylephrine Procainamide Promethazine Sodium Bicarbonate Sodium Nitrate (Not carried, at industrial sites) Sodium Thiosulfate (Not carried, at industrial sites) Succinylcholine Chloride Terbutaline Vecuronium

BTW: In most drug circles, "hot shot" means an especially powerful, often fatal overdose of medication, not just that it was IV. The biggist problem is , of course, if you have an untoward effect of the medication, then a key component of treating that effect (IV access) does not exist. Not that you have it when you IM medications, but some situations call for a little common sense, and sometimes IM or IN is a better route if no IV access is available than Main line-ing something. This was a key factor in the idea of mainlining narcan going bye bye..although i heardof this being done in the new england area (wont mention where mind you) as late as 1995, with at least one incident resulted in a cardiac arrest...and with no IV access...bad news and MAJOR loss of kewl points. The proper use of narcan with and with out IV access is another adventure and discussion altogether.

You are actually making my argument for me...I think you are looking at bystander CPR as a different and separate quantity than regular (HCP) CPR. IN THIS ARGUMENT, CPR is CPR, and does not require a paramedic to do it well, in fact many paramedics unfortunately do crappy cpr . FOR THIS ARGUMENT, what is important is that rapid BLS with AED, be it bystander CPR, HCP CPR is far more important that rapid ALS will ever be. If that is lay persons,, great, if it is a 1st response engine with BLS capability , equally great. The King COUNTY system is the very reason why they have such great bystander CPR rates. They didn't do it because it was cool, or good PR...they did it for the scientific and clinical benefit in a sytems approach. The same reason why they push rapid BLS and high end ALS over all ALS model..for the clinical benifit. The two are not separate approaches, they are different sides of the same coin. Simply put the arguments that all ALS is just magically somehow better is hogwash IMHO, and based solely on the thought process that "more is better", and that one paramedic is as good as another. In fact ..only BETTER is BETTER, and as Wang has proven in airway management a bad medic is worse than a good EMT any day, at least in regards to airway management. No one is saying neglect training, training is very important as well. As discussed before the King County System addresses it very agressively. But this is a fact, many KCM1 system (seattle, So KC, etc) medics get over 40 tubes a year (I have it from several first hand sources), you dont find that anywhere else on the ground and not in too many air services either. Therefore given their studied and documented success rate of over 99%, and considering that many other service have success rates less than 70% in some cases FAR less....with and with out RSI...with and with out trainign and QA/QI...we MUST consider that PROPERLY STRUCTURED experience plays a vital role as well. In short training is an important, but not the only, piece of the puzzle. We must address the clinical benefit of managing the experience of the medics..we manage everything else right..training, hiring, EBM and protocols development, the experience of the provider is the LAST piece of the puzzle..again not just quantity but quality...we can only get the most out of this ..and have the greatest impact on patient care...by putting aside preconcived notions of what EMS should be based on political and labor agendas..and make it what it should be..for the patients benifit. The experience component of the equation is best managed when we realize that not every patient, or even most need a medic, so we MANAGE the number of medics, the position of medics, and the training of medics to make sure they are used on calls that need them. This improves the clinical competence of the medics as well as provides better care to the patient and better use of taxpayer dollars (not cheaper, better) Let the EMTs handle the rest. The BLS is the safety net, the other component is a fast, large, efficient BLS response both transport and first response. with both a BLS and ALS ambulance being on scene together a rare thing but almost always a BLS first response, because BLS is far more imprtant than ALS in many cases. The big question is how is this adapted to rural and suburban ALS systems. 1st, perhaps rural systems should have to prove the ability to sustain, not just want, a paramedic response. Otherwise they should have to maintain a more aggressive ILS response instead (which is really what many of these areas really need anyway ) The recent draft scope of practice model actually had a lower level paramedic that would be perfect for this, yet still called a paramedic, removing the stigma of "not having a paramedic" system. of course the IAFF fought the higher trained, higher standard, degreed paramedic concept of the same document, essentially keeping EMS in the dark ages...another argument I know... 2nd, there should be grants and incentive for hospital agencies to support EMS agencies through clinical and educational resources,like OR rotations. 3rd, Laws and regulations that have been used to shut out EMS providers from more active and QUALITY clinical experiences should be amended to allow this, in the interest of public health. Medicare reimbursement should be tied to a hospitals support of the public health system, which as a side note should include EMS, instead of it buried in DOT. Thats my rambling for now.

For those who don't believe the over saturation argument (Kev Kie and tniuqs), or more importantly, the solution, one has to only look at the success in the King County Medic One system to see this principle is real and the solution WORKS. You have not only the highest cardiac arrest survival rates in the nation (in te 40's for working codes, when most places cant get above 2%), but probably the highest ET success rate in the nation (over 99%), doing RSI and doing a lot of tubes. (this tells me that the principles we are talking about here not only work for intubation, but patient care in general) In addition you can extrapolate the successes of many high end air medical providers compared to many ground services, and the reasons why for those successes, you should get the same conclusions. The are four parts to this solution. They are : - Higher pre-employment and post employment standards (i.e. FTO and credentialing programs) - Better specialist/physician lead continuing training and ongoing clinical education. - (very important) High volume of patient contacts - (And most importantly) High patient acuity in the majority of those same contacts. Its not just about over saturation, its about low patient acuity. In the end you still want the medics you have to stay busy, only you want them busy on high acuity patients. You miss ANY PART of this equation, the whole skill set falls apart. That is why many services (like LA,) fail in the big picture of airway management. And you want a LOT of BLS/ILS units to handle everything else. A lot of them. 3:1 maybe? More even? (no one is saying everyone does not get an ambulance in 8 minutes or less, just that most of the time is doesn't need to be a paramedic) While this philosophy only works in an urban/suburban area due to total tun volume and high acuity run volume, many of the principles can be successfully applied in rural areas. In fact we see some of them in the air medical industry, the difference is their area of response and their ability to get higher acuity patients is larger and more refined. You only get this in a tiered system. Anything else is not sustainable. This is the same reason why you ddon'thave a cardiologist, an oncologist, and a trauma surgeon for every ER bed "just in case". This is why you ddon'thave a truck company in single every fire house, "just in case". And this is why you ddon'tsend a medic, much less 5 of them , on every call, "just in case". One final comment: Regarding the repeated, and often believed comment that any MONKEY can intubate, you are right. Intubation is a SKILL. But airway management is an art. And requires considerably more than sticking a blade in a mannequin to perfect, and it takes more than tubing one dead floppy corpse every six months (if your lucky) to perfect too. And this is what WANG, and others are trying to get us to believe. Wake up people. Just because you bull-shitted your way into a medic patch no longer means you are an airway master. You have to earn that, every day. And the day you stop earning that, it starts to go away. And even if you are competent, in most services, nothing says the dude next to you is. In fact, chances are he doesn't give a crap about patient care, and is waiting for the sweet job on the engine to come in, or his next heroin fix, or the union contract negotiations, or bangin the nurse in the ER, or bangin the 16 year old FIRE/EMS explorer, or anything OTHER than how to MASTER his craft. And with the paramedic mills, the BS hiring standards, the "Pulse and a patch" mentality of many services...this is going to get worse. We need to FIX our approach to airway management, not just intubation, to paramedic deployment, and to hiring, to training, to FTO programs, and our whole profession. We need degrees, we need higher standards, and we need to kick all the scmucks giving people like you and me a bad name to the curb.

We have a HAZ MED team at ada county paramedics, AHLS, COBRA, etc. They have a special ambulance with the extra stuff at a central station they man when there is an incident. Otherwise it sits except for training.It is set up for command and support rather than transport, has the lap top and internet access, etc. Most of their stuff is Meth lab breakdowns but they get some "real" calls everyonce and a while too.

NIMS was never ment to address dispatching procededures. ANd sincer the dispatch code is related to that and not normal communications, it is a gray area. Some agencies, like mine, simply tell you if its an Alpha, etc to help you know if it is a code response. If we want more specific info then the full code is on our MDT information and we can look at it enroute...although most of us never bother. Otherthings to deal with, like mapping, driving, and wathcing for traffic. SO the basic C/C, hazards, safety info is plenty. Other agencies do put out the full EMD code so you can look it up...but most medics I have talked too in those systems dotn bother, concerned with other things like..well...like mapping, driving, and wathcing for traffic. So once again the the basic infor on C/C, hazards, safety info is plenty.

One other thig to consider, something even us Yanks often forget..is that the idea of a "national" anything is not popular politically. In fact it wasnt until after the civil war in the mid 1800's that people in the US even BEGAN to think of themselves as somethign other than Kentuckians, Idahoians, or New Yorkers. In fact, this regional idenidity still persist to this day. I know, we certainly have come a long way from those days in terms of federalism...but the principle still holds. Instead of national health care we have regional medicare/medicaid insurance with no national health system...instead of a national Highway construction we have the DOT giving money to the states to administer it for them...and instead of a FEDERALY mandated national standard for EMS, we have national recomendations that the states can chose to comply or not comply with. The main way the Federal Goverment "enforces" anything is by tying compliance with reimbursement and federal monies, very seldom by mandate. Look at HIPAA, only enforced if you want to receve medicare monies. If you dont recieve medicare monies, then HIPAA doent apply from a legal point of view.

Well, there are no nationally mandated standards, or even state standards, or even local standards ...except what is mandated by contractualo terms with performamnce based contracts. That said there are GOALS. The most commmon goal is to have ALS with in 8 minutes and BLS within 4 minutes for a cardiac arrest, wich is the recomendation ofthe American Heart Assos. and is far from a national regulation in any snese of the word. Several organizations have pushed for more relaistic and comprehensive standards, such as response times for calls that are non cardiac arrest, non ALS and complete BS., but also considering areas with low population density and such. The problem is that there are too many competing interest ijnthe US to allow such standards to be adopted...the Unions, the provates,anmd everyone who doenst want another eye looking over their shoulder (even if they neeed it) speaks out. Then there are the "what if" crowd who want a medic on every street courner with in 4 minutes or less on every fire engine crowd... Does that help at all? Bottom line there are quite a few individuals and small groups who have some very neat ideas on this subject...but a lot of highly funded assholes who want to see the idea die.

You can vagal from any pain response, or from increased ICP from noxious stiluli can decrease HR as well.

The line that someone attributed to mitch was : "You assume to much, how's that, well if you look at it this way It makes an ass out you and me, if you must know ASS_U_ME! "

Actually ..no. Mitch said "It makes an ass out of U...and umption!" I love that movie. especially the "I just sock them in the jaw and yell 'pop goes the weasel!" Here is a qoute for you: "If you can't do something smart, do something right." And: 'Wash' : This landing is gonna get pretty interesting. Mal: Define "interesting". 'Wash' : [deadpan] Oh God, oh God, we're all going to die?