1. #26
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    Quote Originally Posted by emt161 View Post
    The only items with documentation to support improved patient outcomes by arriving at the patient's side before the ambulance is CPR-trained individuals and an AED. Sorry.

    Because I'm a nice guy, I'll spot you a BVM, O2, ASA, and an Epi-Pen.

    If we want to be treated like the medial professionals we think we are, we need to stop spending time and resources on things that have no basis in medical evidence. If firefighters don't care about being medical professionals because it doesn't fit their business model, well.... that's another issue entirely.
    With all due respect please do not post unless you actually have a clue about what your talking about because it is obvious you don't. There are MANY situations where my ALS engine has started ALS care that directly improved the Pt's outcome. The ambo out of my station runs on average 10 EMS runs a shift...leaving a lot of time for them to be at the hospital, or on a call in another's stations district. For instance I have given atropine and paced a very severe bradycardic Pt., turned around 2 anaphylaxis Pt's with Epi, fluids, and Benadryl , worked a hand full of full arrests before an ambos arrival where we had a IO, ET tube, and a round of meds before the ambos arrival, delivered a baby, and have controlled major bleeding, and given fluid bolus for a Pt. who was in shock after cutting his arm off with a table saw....And not to mention like I stated before, if an ALS engine can do a 12 lead, pre-hospital stroke scale, get medications on board, or even get a Pt. hx prior to the ambos arrival that decreases scene times and improves Pt. outcomes. Also I know when I am on the ambo I love having the ALS engine on every EMS call with me. It is nice to have an extra medic or 2 from the engine because it takes a huge load off the two medic on the ambo. And for the issue of cost...the EMS system supplies us with everything except for a few things such as the cardiac mointers which I believe grants paid for all those. And as far as firefighters not wanting to be paramedics, it is a requirement to be a paramedic to receive an application. If the candidate does not want to be a paramedic, well that's his own fault no one forced him to take the job and there is plenty of guys behind him that would love to have it.
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  2. #27
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    Quote Originally Posted by emt161 View Post
    The only items with documentation to support improved patient outcomes by arriving at the patient's side before the ambulance is CPR-trained individuals and an AED. Sorry.

    Because I'm a nice guy, I'll spot you a BVM, O2, ASA, and an Epi-Pen.
    And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

    While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.
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    Quote Originally Posted by TruckSixFF View Post
    With all due respect please do not post unless you actually have a clue about what your talking about because it is obvious you don't. There are MANY situations where my ALS engine has started ALS care that directly improved the Pt's outcome.
    Anecdotes are not evidence. Time to join the rest of medicine.

    And as far as firefighters not wanting to be paramedics, it is a requirement to be a paramedic to receive an application.
    So basically you're encouraging people to take the fastest, cheapest, easiest medic school they can possibly find so they get the patch and ride the BRT like they actually want. You're doing nothing but contributing to skill dilution and medical care provided by people who don't actually want to be doing it.

    In Seattle and Boston, being a paramedic is a promotion that not everyone gets, whether they have it at time of hire or not. Their save rates regularly hover in the mid 40's, their care is consistently on the cutting edge, and research on what's next in EMS happens on their trucks all the time. You don't get that in departments where everybody and the janitor is a paramedic. You can't, because the same quality just isn't there.

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    Quote Originally Posted by BoxAlarm187 View Post
    And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

    While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.
    Jury is still out on pre-hospital cooling in general- I highly doubt a couple minutes sooner than the ambulance will make a difference if the ambulance's initiation of treatment hasn't made any. Engine 12-leads is a maybe. In the urban department near me that most recently went to ALS engines, there hasn't been a manual BP taken since the monitors hit the trucks. $25,000 vital sign machines. RSI- no way in hell. How are the medics staying current if every idiot with a patch can do it? How many tubes is each medic getting per month? If the medical director doesn't know the first name of every RSI-qualified paramedic, they shouldn't be doing it. Cardiac meds will expire in the box before you use most of them- doesn't sound like a great idea to me. The guys in Florida couldn't even pass a written test they had notice for on what they were carrying on the engine. Sounds like a great idea!

    Again, it's all about skill maintenance, QI, evidence-based medicine, etc. ALS engines either detract from or don't meet the findings of pretty much all of them.

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    Quote Originally Posted by emt161 View Post
    Engine 12-leads is a maybe. In the urban department near me that most recently went to ALS engines, there hasn't been a manual BP taken since the monitors hit the trucks. $25,000 vital sign machines.
    Our 911-to-Balloon time is averaging 55 to 65 minutes. We're alerting the ER that we're bringing them a STEMI before the ambulance has even arrived. With an expecation of a 12-lead application within 7 minutes of the arrival of the first unit, there's no way we'd give up a monitor on the engine. And if there are departments using them as a matter of convenience, shame on them.

    RSI- no way in hell. How are the medics staying current if every idiot with a patch can do it? How many tubes is each medic getting per month? If the medical director doesn't know the first name of every RSI-qualified paramedic, they shouldn't be doing it.
    As a matter of fact, he does. We have 524 members, 189 of them are ALS, and 47 of them are RSI qualified. Ironically, the RSI medic on my shift completed his 8 hours of RSI CEU's today, which included both classroom review and scenario-based practical sessions. Who leads the program? The medical director himself.

    Cardiac meds will expire in the box before you use most of them- doesn't sound like a great idea to me.
    If you see the box is going to expire, trade it for one of the boxes on the ambulance. It ain't that hard.

    The guys in Florida couldn't even pass a written test they had notice for on what they were carrying on the engine. Sounds like a great idea!
    Sounds like they need more accountability.

    Again, it's all about skill maintenance, QI, evidence-based medicine, etc. ALS engines either detract from or don't meet the findings of pretty much all of them.
    You're talking to a guy that works for a department that employs two full-time QA managers - one for ALS providers, and one for BLS providers. A department that has installed gyrometers in the ambulances to study the effectiveness of CPR in a moving ambulance. We take EMS seriously, and constantly review our depolyment models to ensure that the most effective EMS is being delivered to our taxpayers - and this often times includes ALS engine companies.
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    Quote Originally Posted by DeputyChiefGonzo View Post
    If it weren't for fire based EMS.. many commuinities would not have EMS on either the BLS or ALS level at all...
    While true, and something is generally better than nothing, something is often not the best case scenario, just the best practical scenario.

    A for profit company will not station crews in an area unless they can turn a profit. They may respond from a base station, but that response time could be anywhere between 10 minutes to half an hour.
    There are options besides fire based and private for profit based.

    by the way.. my FD started doing EMS runs in the 1950's when the engines were equipped with the old E&J Resuscitators...
    ...and the city I grew up in has a subscription program that is justified because "Providing emergency medical services is expensive and outside of traditional Fire Department duties." (Questions 6 and 9) (Microsoft Word doc warning). Oh, and since the fire department can't be bothered (again, one of my chief objections is too many fire departments only want to do half of the job) to provide ambulance service, residents are still charged for the ambulance transport regardless of whether the fire medics ride along or not. Remind me again how this is significantly different than profit based EMS companies?

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    Quote Originally Posted by BoxAlarm187 View Post
    And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

    While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.
    May I suggest reviewing the OPALS study? There's also a reason why AHA's Emergency Cardiac Care guidelines has essentially de-emphasized ACLS interventions (to the point of even removing atropine from cardiac arrest guidelines in the 2010 release) over the past 5 years?

    Also, if your fire department cared about EMS, why are they not running enough ambulances to properly meet demand?

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    Quote Originally Posted by BoxAlarm187 View Post
    As a matter of fact, he does. We have 524 members, 189 of them are ALS, and 47 of them are RSI qualified. Ironically, the RSI medic on my shift completed his 8 hours of RSI CEU's today, which included both classroom review and scenario-based practical sessions. Who leads the program? The medical director himself.
    First off, congrats on not requiring everyone to be a paramedic, and even further limiting the number that can utilize RSI. How many intubations does each of the RSI medics get a month? Now how many intubations would it be if all 524 members were paramedics? That, alone, is one of the main issues since too many fire departments require everyone to be a paramedic, thus diluting the number of interventions to the point where competency is non-existent for most medics.

    If you see the box is going to expire, trade it for one of the boxes on the ambulance. It ain't that hard.
    So they expire on the ambulance instead of the engine? Additionally, if paramedic engine first response presents such a significant time saver, wouldn't the stocks of medications on the engine be used more often than the ambulance medications?

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    I may be a little late in the game, but I'm going to interject some thoughts into this conversation.

    First, many fire-based EMS systems will split the medics' time between the BRT and the bus. The plain and simple reason has to do with pay and FLSA. Firefighters can be put on the 28 day cycle while EMS is on a 40-hour week. If you split that time, you can still use the 28 day cycle which results in less OT. Simple economics.

    Second, you can't compare systems to each other no matter how you try. The system we have where I work isn't going to work everywhere, nor is the system you work for. We run ALS first response with two ambulance services in the city, one a tax-based district and the other private. It works fine for us, though it's had its moments. While I think fire-based EMS would work for us as well, I don't see that happening in the near future. The primary thing here is that the EMS system, which entails both the FD and the EMS agencies, works for the patient. We all have the same medical director, so that helps, too.

    You can quote whatever study you want, but much like what I just said, you can't necessarily apply that study to every situation. Just because LA does a study doesn't mean that the same result is going to happen in Chicago or vice versa. I've seen a number of these studies throughout the years and none of them apply to every locale.

    My favorite was the one a few years ago that said we're spending too much time on scene trying to intubate. While there's some validity to the result, it's not something that you can blanketly say "no more intubating in the field". In our system, it's not uncommon for our medics to have CPR initiated, patient intubated, IV established and a round of meds in the patient prior to EMS arriving. However, it's also not uncommon to see an ambulance sitting outside a house blocks away from a hospital trying to get all that done. The principle is that you have to take ALL of the information from the study and realize the root problem. In this case, sitting on scene trying to get an IV and a tube instead of doing it en route can be detrimental to the patient. But then again, the same doctors that gripe about us getting tubes in the field are often the ones that spend several minutes in the ER trying to get one as soon as the patient arrives.

    Lastly, the system as a whole is only as good as the people. If you have medics taking VS and leaving, that's a problem with that agency. I could make the argument based on the information I have in our system that the ambulance crews do the same thing. It's not necessarily the agency, it's the medic. Perhaps its time that instead of complaining you should advocate for a true EMS system that involves all the agencies communicating with each other as patient advocates instead of complaining about each other. While ours isn't perfect, we do have regular meetings with representatives from all the players- the fire department, both EMS agencies, and both ER's- in which we discuss what's best for the system as a whole, not just for each individual agency.

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    Quote Originally Posted by Gadfly View Post
    Also, if your fire department cared about EMS, why are they not running enough ambulances to properly meet demand?
    Where in the world did you get that from? We have 20 fire stations, and we staff 14 ALS transport units along with 2 paramedic supervisor captains. We're futhermore supplemented by three 100% volunteer EMS agencies, who supply us with (generally) 2 BLS ambulances and 1 ALS ambulance, along with an ALS chase vehicle.

    Based upon our statistics and staffing, each ambulance is answering an average 5 calls per shift. This is somewhat biased, based on geography and population, as our slowest answers generally 1 per day, and our busiest 8-10.

    It's rare that our first-responder engines are on scene for more than about three minutes prior to the arrival of the ambulance. That's extremely important to our county manager, so BLS and ALS engine company response is here to stay for the foreseeable future. And, keep in mind, he does his own research to validate his desire of fire & EMS delivery - he doesn't simply rely on what we're telling him.

    There's also a reason why AHA's Emergency Cardiac Care guidelines has essentially de-emphasized ACLS interventions (to the point of even removing atropine from cardiac arrest guidelines in the 2010 release) over the past 5 years?
    As dynamic as AHA guidelines are, I wouldn't be shocked to see epi removed and atropine replaced in the next guideline revision. Cardiac guidelines have changed more in the past 20 years than ever before, and as EMS grows out of adolescence, we should expect to see more changes. That being said, I'll hardly hang my hat on the elimination of one drug from a long-stand cardiac arrthymia guideline as a waypoint in the delivery of fire-service EMS.

    First off, congrats on not requiring everyone to be a paramedic, and even further limiting the number that can utilize RSI. How many intubations does each of the RSI medics get a month?
    I've never been a fan of an all-ALS fire suppression model for a number of different reasons.

    I truly don't know how many RSI's we're getting per month countywide, but I'll check with our ALS quality assurance coordinator and find out - she stays abreast of that.

    So they expire on the ambulance instead of the engine? Additionally, if paramedic engine first response presents such a significant time saver, wouldn't the stocks of medications on the engine be used more often than the ambulance medications?
    You're a smart fellow, and I know you can't be simple minded enough to think that we'd allow the box to expire on the medic. You simply exchange between the two units on the 25th of the month, and then when the box is used on the ambulance and re-stocked at the hospital in the next couple of shifts, it's good to go again.

    We have some engine companies in the outlying regions that use their boxes far more often than others. Again, our county's geography is do diverse, it's hard to make comparisons at times.
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    187,

    Congrats on being in probably the top 1% of fire-based systems. I mean it. If you guys worked here, I probably wouldn't bitch so much.

    That said, you're what's known as a statistical outlier, IIRC. You're so far above and beyond the average that using you to make judgements about the whole is almost pointless. And I mean that both literally and metaphorically.

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