p3medic

Fire here doesn't go to shootings, stabbings, asthma, childbirth, diabetics, or lower priortity calls unless accident, fire or extrication needed. They do go to chest pain, sob, cardiac arrest, unconscious calls. It seems that the lower acuity calls are what is tying up EMS resources there, perhaps instead of a non-transport ALS capable fire truck they should send fire to all minor illness calls, ass aches, nausea/vomiting, psych's, minor injuries etc, and they can provide basic first aid until a transport unit becomes available, leaving the medics clear for the higher priority calls, assuming increasing EMS staffing isn't going to happen. After all, if fire really wants to help, this would be a step in the right direction.

Not pinpoint pupils from a pon's bleed if he's CAOX3.

Interesting. Send a $250,000 piece of apparatus, with 4 top paid firefighters to a medical to do the job of 2 medics in a $100,000 abulance. Good plan. :roll:

Applying pacer pads is quicker than starting an IV in most cases, however most people find TCP to be fairly uncomfortable, so sedation should be given when possible. The patient with depressed LOC and a heart rate of 20 probably needs immediate pacing, however the dizzy, diaphoretic bradycardia might well wait for the IV sedation, and if your going to place an IV before initiating TCP, a trial of atropine might be warranted.

1. Pediatric age group—due to difficulty with smaller patients cricothyroidotomy should not be undertaken in children under ten unless absolutely necessary, and should not be undertaken at all in children under five. In this latter age group, emergent tracheostomy, orotracheal intubation with in-line cervical stabilization (even if cervical spine injury is suspected), or needle cricothyroidotomy may be preferred. Spenac, this is a direct quote from the article you sited. In this 4 yo child, the best course of action would have been a large bore needle, 14-10g. You can ventilate adequately longer than you think through that. Dwayne, if the obstruction is at the glottis then a needle placed through the cricothyroid membrane would be below the obstruction, allowing for oxygenation as the ball be obstructing most airflow above. Ventilation would take a bit longer, and the rate would need to be low to allow time for passive exhalation. CO2 would rise, however the body can do just fine for a long time with hypercapnia, not so much with hypoxia.

The kid was 4, a large bore needle for the 10 minute ride would have been more than adequate. Attempting an open surgical cric on a 4 year old would have been a waste of time in my opinion.

The mechanism here is unlikely to involve c-spine injury, and I agree with the much more likely posible of closed head injury as Dust stated. As for the pediatric spine being more forgiving than that of the adult, I would agree, however the acronym SCIWORA should not be forgoten. Serious Cord Injury Without Radiological Abnormality. Although they are less likely to fx, they are not immune to serious cord injuries, if the mechanism warrants, immobliize.

Depends on the Island. Oahu 911 was City and County of Honolulu EMS, third service provider. Pay is not bad, although cost of living is high. Paramedics are 2 year degree MICT's. at least thats the way it was if I recall. They cover the whole island, from very urban Waikiki to the badlands of Wainae. There website would certainly give more info than I can, good luck!

I seem to remember reading in Annals a few years back about a 20% unrecognized esophageal intubation rate in Orlando, a medic on every red truck is NOT the answer to providing top notch health care, well educated, well trained EMS providers are. LA has a medic on every street corner too, and there numbers suck worse.

Why not do law enforcement too? A sick CHF patient, a structure fire and a bank robbery are all completely different jobs. The reason fire departments want to do EMS is for the sake of fire fighter jobs, nothing more. Cities like New York and Chicago wanted nothing to do with ems 30 years ago, its been in the past decade or so with the steady decline of fires and a bloated budget and workforce that cities across the nation began gobbling up third service and private ems agencies as a job saving tool, nothing more. The IAFF have made it their mission to take over ALL EMS across the nation. I respect your passion for EMS, and that of your fellow dedicated dual role medics, but the two jobs should be totally seperate IMHO.

Strong work.

I don't get why an emt-b ff gets paid more than a medic. Doesn't make much sense to me. Sounds like a bunch of emt/ff's would rather not ride the box, and by staffing it with 2 lesser paid medics(?) you would save money and spend all your time on an engine or ladder. For some reason I thought you were a dual role dept, i.e medics and emt's were all ff's, apparently not. Seperate agencies might be a move in the right direction. Just an opinion, take it for what its worth.

Our current numbers to date are a median door to balloon time of 62 minutes, with 89% under 90. I know a week ago we had one under 20, and I think it will continue to improve.

This is why systems with medic over-saturation have such an abysmal intubation success rate, and for that matter cardiac arrest survival to discharge. Take a system like LA, with an over abundance of medics and compare to another system like Seattle. Fewer medics, with excellent oversite and frequent exposure to the sickest of patients = better patient outcomes. RSI is a great tool, however without strong physician oversite and frequent exposure to patients requiring urgent airway management is a recipe for disaster. If the system in question is a very low volume one, then ED/OR intubations should be an absolute requirement. Intubation manequins are NO substitute for the real thing in my opinion.

Well said Doc!

Interesting. I suppose if I were in that situation I'd transport, give the hospital a heads up that we were coming in with a patient that arrested in our ambulance with a valid DNR, and need a room out of the way. I couldn't imagine bringing a corpse back into a home, but thats just me, and I wasn't there. As far as state law is concerned, not particularly worried about it, I took a burned 5yo to the morgue once a long time ago, was brought out of a house fire at 3 am, non viable, we put it on the bench in the truck, ME didn't show up after waiting a couple of hrs, and then a decision was made to bring the kid to them. No one seemed to mind.

I believe the Lawrence system on the north shore of MA does as well. The lack of education is a huge problem, however the art of intubation cannot be learned in a classroom. It is a manual skill that takes lots of repetition and lots of experience in different anatomy, i.e. fat people, skinny people, kids, neonates, teens with downs syndrome, traumatic airways, burned airways etc.... No University education on the planet can teach intubation better than actually doing it. Now, the pharm, patho, etc needs to be well understood, and I have no idea weather that was the case with the S.D. medics, but I do know that if you take the number of medics out there with the number of live intubations they do in a year, you will see they average about 2. You can have all the education in the world, but if you see 2 tubes a year, your gonna suck, plain and simple.

Actually its the posterior pituitary, just saying. AZ makes many good points as usual.

Bet their response time to "structure fire" is way better than cardiac arrest....just a guess.

I try to avoid the whole needle thing and go with the nasal atomizer.

I know there is a pay chart around here somewere, but for the life of me I can't find it. Ball park figures, BLS start around 17/hr while in the academy, and top out around 25, medics start around 27, tops out around 34/hr, not including the other built ins, i.e hazard duty, longevity, diff's etc...

Good points. Learning how to drive and speak properly will come....with time.

It is true, they play at special events and the annual award ceremony.

All new hires for Boston EMS are hired as EMT-B's, regardless of experience or certification level. The EMS academy is approximately 12 weeks of didactic/clinicals, and another 9-12 weeks of field preceptorship. After completing and passing all portions the new hire is a probationary employee for 1 year. In order to sit for a paramedic promotional exam you need a minimum of 1 year continuous employment with BEMS, so in actuality you may only work BLS for about 6 months. The promotional process consists of a written, practical and oral exam, very competitive. The usually promote in groups of 6-10, with many more applicants than available positions. If you get into the ALS internship, its another month of clinicals/classroom, and a 9-12 week field internship. At the end of that there is an "exit" interview, pass/fail, although recently they have extended field internships on a case by case basis. All new hires are required to be city residents within 6 months of hire, after 10 years you are exempt from the residency requirement. There are creative ways to live elsewere, but officially you are required to live within the city limits, and the cost of living is relatively high. The pay is good, enough to afford to live here anyway. EMT's make the same here as a medic in the "privates". There are step raises, one every year for five years. Hazard pay, longevity pay, shift differential is built into the weekly paycheck. There is also an anual uniform allotment, 15 paid holidays, and you earn 15 paid sick days a year. You start with 2 weeks of paid vacation, 3 at 5yrs, 4 at 10, 5 at 15 and 6 at 20. You are vested in the city retirement system, health insurance, dental, with weekly contributions, city pays the majority, but I'm unsure of the exact breakdown. We are represented by the Boston Police Patrolmans Association-EMS division. The negotiate contracts with the city, and represent the membership for contract/labor management issues. We have an active training department, all con-ed is either done on re-assignment from your regular shift, or on overtime. We operate under state-wide treatment protocols, and several "special project waivers" that are unique to BEMS. BEMS is a tiered-system, BLS and ALS trucks, staffed with either 2 EMT's or 2 Medics. ALS calls get an ALS, BLS, and sometimes a fire dept first response, i.e cardiac arrest, unconscious. Paramedics can refer patients to BLS units for transport after an ALS assesment, with the Medical director or one of the Associate Medical directors reviewing 100% ALS charts. We are a relatively small department, 300 EMT's and 50 medics. The medical director knows evey paramedic on a first name basis, and if your not pulling your weight everyone will know it. Your peers will expect you to continue swimming up-stream, and you should expect the same from them. The educational process never ends, and if you would like to clock in and clock out without ever having to continue learning you will not like working here. It is not all roses, there are plenty of things to gripe about as in any job, and the way we function is very different than how things are done on the left coast. I am certainly biased, so take it with a grain of salt. If there are any specifics I can help you with, feel free to ask or fire off a PM. Good luck!

20$/wk.