Collier County, FL; The battle is on

[VentMedic]

http://www.nbc-2.com/articles/readarticle....=22588&z=13

Video included.

Battle between firefighters, medical director heating up

Originally posted on: Tuesday, October 28, 2008 by Kara Kenney

Last updated on: 10/28/2008 6:35:21 PM

COLLIER COUNTY: The war of words between firefighters in Collier County and their medical director got nastier. Both sides are locked in a heated battle over how many life-saving medications should be allowed on the fire trucks.

The battle heated up with what some call a scathing letter from Collier County Medical Director, Bob Tober, to county commissioners.

Dr. Tober is saying firefighters should be less involved with saving lives - a notion that has firefighters fired up.

Firefighters no longer just fight fires. These days, they're also ready to give you medicines that could save your life.

But the letter sent to commissioners could change how firefighters do their jobs.

Collier's medical director told the county commissioners to, "Cease and desist any further attempts to put advanced life support in the hands of fire departments."

That has firefighters like Deputy Chief Jorge Aguilera furious.

"I think he just said we don't do anything of value when it comes to providing first response medicine," said Aguilera. "I don't know which graphs he's looking at, but he's sure not looking at the graphs we are."

Aguilera says arming firefighters with advanced life-saving drugs improves response times and allows for more people than can save your life.

"You want more or less?" asked Aguilera.

NBC2 asked Tober if he thought it would make more sense to have more people and more drugs out there to save lives.

He answered, "Actually, that's not the case. Do you want the surgeon that did your operation five years ago or five times last week?"

A month ago, firefighters had more than 20 medications on their trucks. At Dr. Tober's request, they knocked that down to 15 and if he gets his way it will go down to just four drugs.

"The more drugs they carry, the greater the opportunity there is to not only help, but harm somebody if the drug is misused," Tober said.

Dr. Tober wouldn't say if he's planning to cut advanced life support from fire departments altogether, but says firefighters should stick with firefighting and basic life support.

Collier Commissioner Tom Henning says the long standing feud needs a break.

"I'm disappointed he took the stance he did," said Henning. "But cooler heads need to prevail here. We just need to cool down for a while and regroup and solve this problem."

The North Naples Fire Department is hoping to have a public workshop with commissioners and Dr. Tober to sort through some of the issues in the letter.

http://www.nbc-2.com/articles/readarticle....=22588&z=13

[VentMedic]

http://www.nbc-2.com/Newslinks/CCEMS-Fire%...02008%20(2).doc

The Scathing Letter

October 26, 2008

Dear Commissioners of Collier County and County Manager,

I find myself compelled to write to you reference the newly created Office of The Medical Director and its role in formulating a safe and responsible oversight of pre-hospital clinical activities by Police, Fire and EMS. I find myself continually challenged by fire administration in the clinical activities that I permit their fire medics to engage in and/or the training and experience mandates that I demand in exchange for those privileges.

The current road we are heading down increasingly is becoming a battle ground of what privileges we are going to grant to fire-based paramedics and, based on those privileges, what training they must receive. This is a critical and potentially high-risk area because these fire-based medics are just never going to receive the clinical experience of a CCEMS-based medic. Of even greater haunting relevance is my conviction that if the fire departments did only basic life support (BLS) with the addition of epinephrine, benadryl, atropine and amiodarone as preliminary advanced life support (ALS) drugs, the community would be served equally well and probably with a safer level of oversight. I have plans, one day, to arm the police with epinephrine and benadryl for acute allergic reactions because these are such time-sensitive, life-threatening events.

You have all witnessed the raging politics associated with any attempts on my part to responsibly adjust medications on fire-based apparatus based on evidence and my own medical experience as well as that of Dr. Douglas Lee. These arguments are 100% political and have nothing to do with prudent prehospital medical care. None of the contested drugs were ever used by the engines and, of the 15 drug dosages actually administered last year, one of these was administered inappropriately. (Note: in the same time period, CCMES administered 7547 dosages of drugs)

I recently copied your commission on training and ride-time guidelines for the fire departments to achieve Intermediate or ALS Engine Certification Status. I am already hearing that these guidelines are too expensive and too time-consuming for them to comply with. Instead, they want me to form yet more committee’s to “discuss” these demands and negotiate something that is easier for the fire departments to live with. Such negotiations are not only time consuming, but are again heading down political roads that put risk ahead of responsible medical judgment.

It has also been brought to my attention that IF all fire departments and EMS were consolidated, “things would be different”. That also is quite untrue. If all departments were consolidated under medical direction, the BEST medics would be matched to the toughest calls; the next best to the daily grind of challenging medical calls and the least experienced medics (most of whom ride on fire engines) would be our BLS safety net along with the police. This is close to what we have today and I am working towards improving this and, we are far from consolidated. I lost some of my best and most experienced medics to the fire departments a few years ago. These medics would be offered re-training and re-assignment to the first or second category of rescue medics (should they volunteer for reassignment), once their clinical skills were refreshed and re-challenged.

Regardless of whether or not the fire departments consolidate among themselves as ONE FIRE DEPARTMENT alongside ONE EMS DEPARMENT, or consolidate with EMS under ONE EMS/FIRE DEPARTMENT, or each entity closes ranks under the county’s watch or the sheriff’s department, medical reality and commons sense must still prevail without the intrusion of turf, power, money and politics. Regardless of the formula of consolidation or its continued absence, medical skills, competence and evidence-based medicine must guide our decisions as a community.

The Office of The Medical Director will eventually require a bit more form and structure to function effectively. It will require an expert medical training department (which I already have a good foundation) and enough administrative personnel to accomplish its tasks of overseeing medical care in the streets prior to hospital delivery of patients by all agencies concerned. I am happy to have input from fire and police, but this is first and last a physician-determined and directed program. This is not up for debate as far as I or the medical community at large is concerned.

In the meantime, I must ask for direction from your commission about continuing down a road that has little basis in fact, experience, evidence or medical common sense. These are not just my opinions; they are standard of care issues that must be fulfilled to protect my license and our county and county commission from excess liability. I can not comfortably continue to make compromises or acquiesce to demands that run counter to my intuition or sound medical judgment and that is exactly what I am doing at this time. It is about the right time to ask for the following:

1. Cease and desist with any further attempts to put ALS in the hands of the fire departments. It is the wrong direction and puts my license and the county at much higher risk. The past 12-15 months have not supported this direction.

2. Reassign primary BLS responsibilities to the fire departments with the addition of 4 additional drugs named above. I need unequivocal support from you to do this.

3. Continue to work towards an enhancement of prehospital medical care thru a structured first-aid course for the police departments.

4. Provide the Office of Medical Direction with a statement of public support that preempts any further debate over what the fire departments will and will not carry on their engines. We have ample evidence that they do essentially nothing beyond BLS and a few rudimentary ALS procedures over more than an entire year.

5. I have, like it or not, been given the responsibility of 4 additional fire departments and 102 paramedics that work for them. I am asking for an additional $48,000 per year to pay an assistant medical director in the name of Dr. Douglas Lee, M.D., FAAEM. An alternative to this would be to employ both myself and Dr. Lee directly under the county. Although this will be of little benefit to me, Dr. Lee is a much younger man and could benefit from the retirement etc. afforded by being a county employee.

I reiterate to all of you that the above is heart-felt and my conviction. I also have the unanimous support of the Collier County Medical Society and Collier County Dental Society comprised of physicians and oral surgeons who recognize the obvious standard of care issues alluded to here. . None of these medical issues and principles is up for debate or negotiation. They are fundamental rules followed by people who provide medical care to a wide variety of people and must prevail in the most difficult environment of prehospital care.

Sincerely,

Robert Boyd Tober, M.D., FACEP

Medical Director CCEMS

Medical Director NCH Healthcare Wound Healing Centers

Medical Director Neighborhood Health Clinic

http://www.nbc-2.com/Newslinks/CCEMS-Fire%...02008%20(2).doc

[firedoc5]

Didn't Mr. Tober ever watch Johnny & Roy, or is he too young for that?

[WolfmanHarris]

Dr. Tober wrote an excellent, well thought out and reasoned letter there. I have very little to add other than my thumbs up. I hope things go his way down there.

Interesting to note that despite all the previous arguments around here about FD holding back EMS training we have a big example of a department wanting EMS but not being willing to do EMS. The medical director provides them with criteria to run ALS engines under his license and they say its "too expensive and too time-consuming for them to comply with." Case in point. This might not be all the departments out there, but its enough and it really hurts the case of any FD that might be committed to running EMS for the sake of EMS. (They may exist out there somewhere and I'd rather not wait for the exception that disproves the rule)

Other point of discussion, if he's going to give FD drugs for an enhanced BLS response, why not drop amiodarone and atropine, removing a lot of the need for Fire provided ECG interpretation. Put nitro and ASA on the engine instead? I hate second guessing a physician, but aren't these the frontline cardiac meds. Also what about Salbutamol and Glucagon? In other words why these as the drugs that stay over others? BLS here gets nitro, ASA, glucagon, salbutamol and epi.

- Matt

[FormerEMSLT297]

Dr. Tober is a BRAVE man and he cited evidence based EMS to back up his claims and assertions.....

I think that based on the letter he wrote, his decisions are the correct ones, If the FD really wants to do ALS, they will step up and comply with the training directives he laid out... As the Paramedics of CC Co. are operating under his license..... Good for him.... amnd as for the FD,,, their claims of hardship, and training time, simply show one thing,, they are interested in doing EMS for a bigger paycheck and bigger piece of the CC County budget, and are really not interested in the best thing for patients.......

I would be curious to know what the ALS response is for CC Co. and how many responses, the ALS engines go to do not get an ALS ambulance...... I just hope that for the sake of political expeidiency, they do not can Drt. Tober, and replace him with a YES man ....

FDNY Killed the provision of quality Pre-Hospital care in NYC, Do not let the same thing happen in Coolier Co. FLA.....

[pguy280]

How can any Fire Department that only administered drugs 15 times think there doing the county justice. I can't see there arguement or justification for wanting to continue providing ALS engines. This is one situation that I agree with taking the ALS meds off the engines. I see no needs for them to have any meds right now. I am sure they had all meds mention in the article for the time period mention and did not use them but 15 times. Doing EMS half assed is just wrong.

My departments Medical Director here actually responds to calls with us to monitor and provide additional care if needed. He also QA/QI all our calls. He also requires all 17 medics here to attend rounds monthly, be certified in pals and nals and pass his written exam in order to practice as a medic We also have to go through a skills screening once a year with him as well. This is all done on our own time and our expense.

Plain and simple you want to practice do what the medical director wants. Know wonder they call us bucket head and fire monkey with crap like this.

[WolfmanHarris]

Plain and simple you want to practice do what the medical director wants. Know wonder they call us bucket head and fire monkey with crap like this.

Don't forget hose jockey or waterfairies.

I wasn't clear from your post, does your department transport too?

It seems to me that if an FD is providing first response for a transport ambulance, they should only need the first line, time sensitive drugs. If they have time to run all their algorithms for all these different drugs, getting the 12 lead, starting the lines and all that, I'd wonder why a transport unit is taking so long to arrive and take over.

[pguy280]

Don't forget hose jockey or waterfairies. I knew there were more. LOL

Yes we do the transport as well.

[WolfmanHarris]

Okay. I've never understood the areas that have fire based ALS, but not transport.

[Dustdevil]

Okay. I've never understood the areas that have fire based ALS, but not transport.

It all goes back to the prime point being made here, which is that FDs traditionally want all the money and glory that comes with EMS, but don't want to commit fully to it. They only want the sexy patients. They're too good to deal with the routine. They want to scream to the scene, save the day, get on the news, and then be back in their recliner chair before the patient even arrives at the hospital. Typical fire service selfishness. It's never about the patients. It's all about the firemonkeys.

Ironic how the group of people who most often beats the altruism drum in this country has become the most selfish and narcissistic.