# Seattle/King County Fire and EMS politics.



## U2623 (Jan 19, 2013)

This may be a hot button topic, but it has bothered me enough to come out of hiding and post about it. I'm really hoping that there are some King Co EMT's and FF's here who can shed light on this.

I am currently an ER technician but am seriously considering going back out into the field. I miss the rigs like crazy, and only took my current job cause everyone was in a hiring freeze when I moved up here in 09. Anyways, the topic of this post is the relationship that FD has with EMS.

Here in King Co., for those unfamiliar, the FD is first on scene and relies on private company EMS for BLS transportation to the hospital. The two companies operating in King County with 911 contracts are AMR and Tri-Med. For as long as I have been around both of them (3yrs now) in the ED, there has been one common thread that is universally accepted...Fire hates EMS and EMS hates Fire.

Granted, there are exceptions with certain crews who have gotten in good with a particular engine company etc etc., but literally daily I always hear one complaining about the other. Fire complains that EMS is worthless and incompetent, and EMS complains the same about Fire. In fact, I have a personal anecdote about how they interact. I was a good Samaritan bystander on a trauma that happened outside of a grocery store. Some crackhead hauled off on a woman with a ceramic coffee mug and beat the heck out of her from the waist up. I was assisting Fire with the workup when EMS (Tri-Med) arrived (as I said before, they are second due). I called out to one of the EMT's for a sling and swath, and the Fire Lt stopped me saying, "This is our patient, they're just transport. We do the patient care. We'll use our gear." I was stunned. I came out of a SoCal EMS operation where FD would refuse to attend social events unless we were invited as well. On this particular call, EMS literally _did not say a single word until the patient was on their gurney in the back of the ambulance_. 

I knew this particular crew from seeing them come to my ED and they were both competent EMT's who provided outstanding patient care. All of my coworkers enjoyed seeing them roll through the door. I asked them about what happened and they said that they were told on hire that if they spoke on scene they could be fired. I know for a fact multiple EMT's that lost their jobs for questioning FD's authority. I also know that several FD's have begun using this particular company for their BLS transport because they were tired of AMR "taking too long on scene after we give them a patient to take to the hospital. Tri-Med doesn't ask questions."

Now let me say this, American Medical Response in King County employs EMT's that are excellent, but they are far more hated by FD than is TriMed. I have experience in EMS operations from SoCal to the mid-west to the northwest, and these EMT's bring us extremely sick patients (ALS turfs to BLS the majority of the time due to low ALS numbers) and provide amazing patient care. I don't know what this AMR operation does, but they seem to get it right. Their reports are thorough, their assessments are nearly always flawless and their patient care is aggressive and bold. When I asked several AMR employees about what they do on scene compared to this other company, they tell me that they run their own full assessment whether FD likes it or not. They also admit that FD either gets livid on scene and cusses them out, or FD will leave the instant AMR shows up. Another source of irritation for FD is that AMR will put their foot down and demand a medic-eval of the pt before they accept them for transport (ALS is usually second due as well). 

I will also say this, I have had FD bring patients in (very rarely, but it does happen) and I have had them put a patient on the bed and walk out without giving a report. I have asked them for a report and they have not asked the patient a SAMPLE hx, or even a HAM hx. We get a lot of patients sent to us that have not had a medic eval that clearly need it. We even got a pediatric respiratory distress (that arrested the second Tri-Med sprinted through our door) that FD had refused to call ALS for. I don't mean to bag on FD, but this is a shared opinion of FD among my coworkers and the EMS community. I can't tell you how often I hear, "Thank God AMR is bringing this guy in."

We have several volly's that work in the ED as techs, and they hate EMS, always talking behind their backs, calling them idiots and pains-in-the-@$$.

I know that this is kind of a rant, but honestly it's very discouraging. I absolutely loved my FD brothers, we were a family. Even though we didn't have stations we would always end up at the fire house sharing meals, chores and football games. The only difference between here and there is that in SoCal we were dispatched simultaneously. 

Does anyone have any insight as to why this is? Any tips on what my interaction will need to be on scene? Maybe I'm reading too much into things, and yes, this is just MY observations from a view that originated INSIDE the hospital and not out in the field. But so far it's enough to make me dread going back on the rig, I don't want to have to have a showdown every time a patient is transferred to my care. I also want to be considered a viable provider in the King County EMS system. The whole feud makes the first-responder world a bit of a laughingstock in the hospital. Most of the non-responder employees shake their heads. Any enlightenment would be awesome, I'm very interested to know what you guys think!


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## DrParasite (Jan 19, 2013)

From what I have been told about Seattle, any and all EMS calls get a paramedic (fire medic 1) ambulance response.  if it's an ALS patient, the paramedic ambulance will transport.  if following an assessment, they determine that no ALS interventions are needed, they call the private BLS ambulance (AMR, now Trimed too?) to transport the patient to the hospital.

Do I have that right?



> I asked them about what happened and they said that they were told on hire that if they spoke on scene they could be fired. I know for a fact multiple EMT's that lost their jobs for questioning FD's authority.


EMS in Seattle is run by the SFD.  in theory, a Paramedic crew has already assessed the patient, so why is the BLS crew questioning the ALS crew's authority?

That being said, the BLS crew should do their own assessment.  If the crew doesn't want to wait on scene for fear of reprisal, load the patient, drive around the corner  and do their assessment.  Or even better, can you do your assessment enroute?  after all, in theory the paramedics have already checked out the patient, and he is stable.

I guess in Seattle, FD does all EMS, private companies are just there to act as the horizontal taxi.  Don't like it?  than don't work for a private company in Seattle, or get your paramedic and apply to work for Medic 1


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## U2623 (Jan 19, 2013)

Actually no. In all of King County BLS FD runs first. In reality ALS is called the minority of the time, and transports even less than that. ALS is almost always second-in. This isn't about BLS questioning ALS, it's about BLS (EMS) questioning fellow BLS (FD) about the often incorrect determination that ALS does not need to be responded.

It's also extremely difficult to get your paramedic in King County unless you work for one of the five FD's that actually have medics. The stand-alone King County Medic One hires 1-2 medics every few years. They have medics who immigrated from Europe just to work for them, and several have a masters or PHd.


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## DrParasite (Jan 19, 2013)

I stand corrected, apparently I was misinformed.  it would appear then that there is an issue about which department has a larger set of genitals.  in this case, it appears to be the FD, and they know it. 

I bet the majority of the AMR and Trimed guys would kill for a position with SFD.

Sounds like a reason not to work for AMR or Trimed (one of the reasons why I will never work for a private company ever again)


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## Aidey (Jan 19, 2013)

Really? You're going to blame the private companies because the KCM1 program has turned ALS into a bunch of egotistical jerks? 

I work with a couple of people who used to live in Seattle. Their stories line up exactly with the OPs. If you aren't in cardiac or respiratory arrest ALS wants nothing to do with you. KCM1 has become so infatuated with their own save rate they have sacrificed everything else to keep it up. I don't know who my co workers worked for, but they also have said they weren't supposed to talk or ask questions and could get written up by fire if they did anything that fire didn't like. 

I've heard stories of ALS showing up, starting a line, giving drugs and then pulling the line and sending the pt with BLS.  Pts coding en route to the hospital while with BLS because ALS refused to respond and they learned it was faster to just drive like hell then try and argue on scene. 

That whole system is screwed up. KCM1 does a few things right, and has used those things to convince the country they are the best of the best. The only explanation I can come up with is that they must have one hell of a PR person.


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## DrParasite (Jan 19, 2013)

Aidey said:


> Really? You're going to blame the private companies because the KCM1 program has turned ALS into a bunch of egotistical jerks?


Apparently it's not the KCM1, at least according to the OP





U2623 said:


> Actually no. In all of King County BLS FD runs first. In reality ALS is called the minority of the time, and transports even less than that. ALS is almost always second-in. This isn't about BLS questioning ALS, it's about BLS (EMS) questioning fellow BLS (FD) about the often incorrect determination that ALS does not need to be responded.


And yes, I absolutely blame the private companies for not backing their people.





Aidey said:


> but they also have said they weren't supposed to talk or ask questions and could get written up by fire if they did anything that fire didn't like.


so yeah, I place the blame solely on the management of the private companies.  If they had any balls, they wouldn't let this type of crap happen.  But as often happens with private, they are more interested in making their contracts happy than backing their people when their people are doing their job and not doing anything wrong


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## Aidey (Jan 19, 2013)

If they are in the city limits of Seattle they are dealing with Seattle fire and Seattle Medic One. If they are outside of the city limits, but still inside King County they are dealing with whatever FD and KCM1. The Medic One programs have a direct influence over the BLS departments and their attitudes towards the private companies. I haven't heard as many bad stories about Settle M1 as I have KCM1, but they do exist. From what I've heard the KCM1 guys will yell at the BLS FD guys just as much as they yell at the private EMS responders. 

If Tri-Med and AMR don't play by the contract rules someone else will. The company management isn't responsible for the attitude issues within the FD and M1 programs. You are basically blaming the victim for the KCM1 paramedics being bullies.


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## RocketMedic (Jan 19, 2013)

It sounds like King County's FDs totally suck. Were one of my FDs to do that, I would smash them.


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## Shishkabob (Jan 19, 2013)

Hose jockeys defensive of their territory, what's new?  They realize that if someone else 'encroaches' on 'their' job, they may well have to prove their necessity.


It's the tone of the area and what the brass has allowed to develop, and private company's don't want to stand up for their employees for fear of losing the contract.  



(Exceptions, good/bad crews, etc etc blah blah)


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## NomadicMedic (Jan 19, 2013)

Linuss said:


> It's the tone of the area and what the brass has allowed to develop, and private company's don't want to stand up for their employees for fear of losing the contract.



Nutshell.

And that's really all I should say.


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## leoemt (Jan 20, 2013)

U2623 said:


> This may be a hot button topic, but it has bothered me enough to come out of hiding and post about it. I'm really hoping that there are some King Co EMT's and FF's here who can shed light on this.
> 
> I am currently an ER technician but am seriously considering going back out into the field. I miss the rigs like crazy, and only took my current job cause everyone was in a hiring freeze when I moved up here in 09. Anyways, the topic of this post is the relationship that FD has with EMS.
> 
> ...



I work in this system so I am going to be careful how I respond to this. 

Seattle Fire, like any other agency, has its good and its bad. Most will work with us and treat us with respect. The "bad apples" are far and few, however they will stick in your mind more than the good ones. Grumpiness doesn't bother me. We bring on fresh crews every 12 hours. Fire is there for 24. There are some that don't get to sleep because of call volume. So getting mad at fire because they are "grumpy" is pointless. Let it roll off. 

Once you touch my cot you become my patient. There have been several times I have taken over care and redone or changed the treatment started by fire. The issue so much is they don't want anyone doing patient care. Rather its they don't want to be embarrassed. I am sure every EMS provider has rolled into an ER only to have their treatment questioned by some nurse or doctor having a bad day. It is embarrassing. I wont do that to fire. We have a mutual respect and I will try to be respectful to them when I am treating my patient. 

That said, patient care comes first. I won't sacrifice patient care to make a fire fighter happy. I am sure I have stepped on some toes and I probably will again. It happens. Most of the fire crews I work with understand I am an EMS professional. They are Fire professionals. I don't tell them how to fight fires and they don't tell me how to do EMS. 

I have spent my career in public safety though. I know how to talk to them. I am also older than many of my co workers so I am probably not looked at as a young know-it-all. I do find that a lot of firefighters will ignore my partner and come up and talk to me, especially if I am working with a female. Even Medics will do that, really bad when it is a female medic who is ignoring my female partner to give me the Short when she should be giving it to my partner. Even when my partners speak up they are still ignored. 

I have had my partners questioned but when I do treatment I am not questioned. Maybe its body language? Maybe its my age? I don't know. Bottom line is SFD has always been respectful. 

As far as calling a Medic, it is true that we get a lot of ALS calls turfed to us. I have never had SFD question my wanting a Medic. I will rarely call for Medics though. I am usually closer to the ER than the Medic is to me. Medics have always been good to me when I deal with them and if time allows will usually explain things like an EKG strip to me. I am slowly training them that when you turf an ALS patient to me I want a strip. 

We are a private business and need to make money. Other ambulance companies are our competition. That said, we do work well with them and many of us have friends and acquaintences with other companies. People will like AMR, others will hate them. Its true with any company. 

Can improvements be made? Sure. Is the system good? Yes it is. Ultimately we need teamwork to achieve best possible care for the patient. Remembering that you wont have an issue. The scene is SFD, enroute to the ER is our domain. I hope this helps.


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## chaz90 (Jan 21, 2013)

Like many, when I first got involved in EMS I desperately wanted to be a part of the Medic One system. I love the Seattle area, and their hype completely hooked me. The more I learn about EMS and that system in particular though, the happier I am that I just accepted a new job thousands of miles away.


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## RocketMedic (Jan 21, 2013)

I wouldnt last a day in KCM1.


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## NomadicMedic (Jan 22, 2013)

chaz90 said:


> Like many, when I first got involved in EMS I desperately wanted to be a part of the Medic One system. I love the Seattle area, and their hype completely hooked me. The more I learn about EMS and that system in particular though, the happier I am that I just accepted a new job thousands of miles away.



I was the exact same way. After learning more about it and working BLS, I realized it was not a system for me. However, if I ever suffered a VF arrest, I'd want it to happen in Seattle. 

But, if I was just sick, I'd find a way to drag myself out of the county.


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## KingCountyMedic (Jan 22, 2013)

Our system is far from perfect. FAR, FAR, from perfect! I will admit that in a heartbeat. In the State of Washington there has been a Public vs. Private war that has raged for decades, not just in King County but all across the State. There were no ALS fire departments in the western half of the state until really the late 80's early 90's. EMS was delivered by many private companies, many run out of funeral homes. Outside of Seattle King County the first fire paramedics were all trained by the private guys as far as ride time etc. You might train a guy and then a few months later he would be telling you to get your cot or shut up and wait outside and so on. This kind of thing has gone on for years. Many people in the private sector got fire jobs or medic jobs and within a few years or less, forget where they came from and start treating private guys like :censored::censored::censored::censored:. It still goes on to this day and it's embarrassing to say the least. As far as what you experience in the ED between Private EMS and Fire I don't have any brilliant answer for you. In all 3 divisions (fire, private and M1) you have people that really care and try to do a good job and a few that don't give a :censored::censored::censored::censored:. The really bad employees are the ones that really stand out. This is where the stories come from. I would encourage you to be an advocate for the patient. If you have an issue that can't be resolved by talking directly to the crew you contact their Supervisor or MSO or Bat Chief. I know at KCM1 any complaint from the hospital, fire department or ambulance crew against us is aggressively investigated. Don't let these types of issues discourage you from pursuing a job here. We need people like you to come make it a better place.


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## BH11MEDIC (Jan 31, 2013)

....


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## the_negro_puppy (Jan 31, 2013)

Not being allowed to speak on scene?









EMS in America is in a far, far more dire position than I first thought


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## RocketMedic (Jan 31, 2013)

Yeah...I actually sucked a firefighter going through Paramedic school into a diabetic wakeup a few hours ago and lrt him run the call. for the most part, we have a good relationship with our firefighters here in Oklahoma City.


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## sweetpete (Jan 31, 2013)

Linuss said:


> Hose jockeys defensive of their territory, what's new?  They realize that if someone else 'encroaches' on 'their' job, they may well have to prove their necessity.



Comments like this simply causes you to lose credibility in any further posts you make. Uggghhhh.. The anti-fire sentiment in these rooms is sometimes nauseating.

I'd prefer just trying to be a "team" and work together for the benefit of the patient. Just a thought.


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## Aidey (Jan 31, 2013)

Whether you like it or not, it can be true. The problems between the FD, Medic One and private companies in Seattle are well known. It is possible for the FD and the ambulance to not get along. Pointing that out shouldn't cause anyone to lose credibility.


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## 46Young (Jan 31, 2013)

Aidey said:


> Whether you like it or not, it can be true. The problems between the FD, Medic One and private companies in Seattle are well known. It is possible for the FD and the ambulance to not get along. Pointing that out shouldn't cause anyone to lose credibility.



"Hose jockeys defensive of their territory, what's new?" is a generalization, which includes everyone else in the fire service. This type of comment can alienate the fire based EMS providers on this forum. That's what sweetpete was getting at.


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## NYMedic828 (Jan 31, 2013)

Linuss said:


> Hose jockeys defensive of their territory, what's new?  They realize that if someone else 'encroaches' on 'their' job, they may well have to prove their necessity.



Hey now, don't exclude the bucket fairies...


And don't be jealous that the firemen have bigger hoses.


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## NomadicMedic (Jan 31, 2013)

It's not hose jockeys trying to defend their territory, it's much bigger than that. Kind of hard to explain if you haven't worked in the system. Let me just say there is a big disconnect between ALS and basic life support. There is a huge rift between fire department EMTs and private ambulance EMTs. 

I understand it's a great place to work as a paramedic. The training is amazing. The pay is great. It is an absolutely horrific place to work as a BLS provider. Especially if you're on a private ambulance.


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## KingCountyMedic (Jan 31, 2013)

n7lxi said:


> It's not hose jockeys trying to defend their territory, it's much bigger than that. Kind of hard to explain if you haven't worked in the system. Let me just say there is a big disconnect between ALS and basic life support. There is a huge rift between fire department EMTs and private ambulance EMTs.
> 
> I understand it's a great place to work as a paramedic. The training is amazing. The pay is great. It is an absolutely horrific place to work as a BLS provider. Especially if you're on a private ambulance.



I have to disagree with this. I have spent 25+ years in Washington State EMS with over half of that time working Private EMS in Pierce, Thurston, and King. It is what you make it here. We have Tri-Med and AMR crews come to our stations for meals, especially around the Holidays. The majority of KCM1 Medics come from the private sector, many of our best people are former Tri Med and AMR guys & gals. In the last 10-15 years we have added more Medics and the culture has changed. Many of the old school "less than friendly" folks have retired. The majority of fire departments now have their training done by KCM1 Paramedics. Our Medical Directors are also getting very much involved in the BLS programs as well now. I'm not denying that you may have some horror stories and you may have experienced bad things when working here, I too can look back on stuff in King County from my Private days that was bad at times but all in all this place is not as bad as many people on here would make it out to be. Again, anyone can come ride with us any time, we welcome it.


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## NomadicMedic (Jan 31, 2013)

You can disagree with whatever you choose. That's the nice thing about the Internet, we can all have opinions.

As I mentioned, working as a paramedic in King County is probably a great job. You have excellent training, outstanding oversight on the ALS medicine, you make great money… If I never worked BLS in King County, I wouldn't know any better and I probably would have applied for a job there.

However, after working BLS there, I was disgusted and decided that there was no way I would ever consider working for that system. So, perhaps it's based on perspective. And please, don't tell me that a ride along would get to see any of the dreck that occurs on a daily basis. Everyone would be on their very best behavior, hey… It happens here too. For a ride along to really experience the interaction between BLS fire, private ambulance and ALS, a paramedic candidate should probably put on a white EMT shirt and ride BLS with TriMed or AMR for a couple of weeks and then see if they want to put themselves in that position.


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## usalsfyre (Jan 31, 2013)

46Young said:


> "Hose jockeys defensive of their territory, what's new?" is a generalization, which includes everyone else in the fire service. This type of comment can alienate the fire based EMS providers on this forum. That's what sweetpete was getting at.



The above poster has also been known to make broad, sweeping generalizations about how privates are "fake 911", run down their abilities compared to fire medics (which in this area is laughable depending on the department), call them "woodchucks", tell them to "get over my opinion, and many other derogatory comments. Glass houses and such...

Broad, generalizations are (as a broad generalization) stupid. Every place has their turds.

The fire-based hate is often hurled around in response to the arrogance that seems to go hand in hand with scoring higher on a high-school level civil service exam than everyone else.


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## usalsfyre (Jan 31, 2013)

To clarify, it's not 46young I'm speaking of...


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## NomadicMedic (Jan 31, 2013)

usalsfyre said:


> To clarify, it's not 46young I'm speaking of...



Who, exactly, are you speaking of?


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## usalsfyre (Jan 31, 2013)

n7lxi said:


> Who, exactly, are you speaking of?



Sweetpete, a post history reveals some very pointed accusations towards private EMS.


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## ffemt8978 (Jan 31, 2013)




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## PotatoMedic (Feb 1, 2013)

I must say I do like your little star sheriff!


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## leoemt (Feb 1, 2013)

n7lxi said:


> You can disagree with whatever you choose. That's the nice thing about the Internet, we can all have opinions.
> 
> As I mentioned, working as a paramedic in King County is probably a great job. You have excellent training, outstanding oversight on the ALS medicine, you make great money… If I never worked BLS in King County, I wouldn't know any better and I probably would have applied for a job there.
> 
> However, after working BLS there, I was disgusted and decided that there was no way I would ever consider working for that system. So, perhaps it's based on perspective. And please, don't tell me that a ride along would get to see any of the dreck that occurs on a daily basis. Everyone would be on their very best behavior, hey… It happens here too. For a ride along to really experience the interaction between BLS fire, private ambulance and ALS, a paramedic candidate should probably put on a white EMT shirt and ride BLS with TriMed or AMR for a couple of weeks and then see if they want to put themselves in that position.




I don't know how long ago you worked here in King County, but it is not as bad as you make it sound. Sure, there are some engine crews that couldn't give a rats a** about us. That happens in every system. I have worked with almost every station in the city and can say that Seattle Fire and Medics have treated me with respect and been respectful of my company. 

Ever think that maybe it was you that had the conflict? Some people don't fit in. I agree with KingCountyMedic. I have been invited to the stations for meals and to hang out. Both Seattle and King County Medics have BS'd with me at Harborview. In fact it is their encouragement that has made me want to pursue EKG education. 

Our system is unique yes. The relationship between fire and private is good. That doesn't mean that everyone gets along. Just because some crews may have personality issues doesn't mean the system is flawed. I would assume that in every system there are those that have conflicts. Besides, its not like FF's never have a bad day. 

I enjoy working for AMR in Seattle and I enjoy my interactions with Seattle Fire and Police. If you can't hack our system then get out. Not everyone will fit in and be accepted.


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## sir.shocksalot (Feb 1, 2013)

I'm surprised that not every patient sees a paramedic in Seattle. Not that every patient needs a paramedic but it makes me wonder if some patients in pain or nauseated or whatever go without comfort measures because they aren't "sick" enough.

Sounds like a hit and miss thing with personalities though. I know personally that I don't ever have a problem getting along with fire or LE on scene, but there is still the occasional guy that has some deep internal desire to be a feminine hygiene product. I think individuals can have totally different perceptions of peoples behavior though. There was one FD paramedic at a place I worked who most people didn't like running calls with because he was "bossy", I never had a problem with him because I interpreted it as simply giving instructions. There was another guy I hated because I constantly thought he was mocking me, when everyone else thought he was funny. Different strokes for different folks.

Seattle sounds like a system that is set up to have problems between FD and EMS, as is almost every system where two separate agencies with the same training wind up on the same scene.


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## sir.shocksalot (Feb 1, 2013)

leoemt said:


> If you can't hack our system then get out.


I don't like it when people say this. It never exactly fosters an environment where learning and growth can happen. I've watched some good people get kicked to the curb who weren't exactly given the best guidance to succeed in this work.
Nothing personal and not saying an individual might not be a good fit in EMS, I just see that saying thrown around a lot in this business without any regard to why that person can't "hack it". In my personal experience, 50% of the time that is said to someone it's simply the person saying it can't be bothered to train or guide the non-"hacking it" guy.


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## NomadicMedic (Feb 1, 2013)

The first post, from the guy that works in the hospital, clearly shows it's "just me". Nice try, thanks for playing. 

I've seen some amazing King County paramedics. I've worked on scene with some. I've also seen some amazing fire department EMTs. However, KingCountyMedics post shows that even he is aware of issues between the various factions. He tried to gloss over them, but he knows they're there. I appreciate the fact that he addressed them and advised EMTs that have issues to be patient advocates and to talk to the battalion chief. However, if you do that at a private ambulance company, the chance of you getting fired is very high. 

And LEOEMT, let me give you a piece of advice. The fire guys cooking you dinner aren't doing anything but buying your continued complacency. As long as you dont question anyone, show up quickly in the big white Taxi and believe that transporting hypoglycemics and anaphylaxis patients without ALS is a good idea, you just feed the machine.

King County EMS is a different animal... some think it works great others think it works poorly. Again, it's perception. Somebody said to me once, "King County Medic One writes great press releases. The problem is, they believe them." 

Anyone who comes from a system where ALS and BLS are tightly integrated would find the King County disconnect to be disconcerting. I'm giving you a pass, simply because you are new and you don't know what you don't know. I'm sure as long as you keep drinking that Kool-Aid you'll continue to be an excellent employee.


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## Luno (Feb 1, 2013)

*Wow...*



leoemt said:


> I don't know how long ago you worked here in King County, but it is not as bad as you make it sound. Sure, there are some engine crews that couldn't give a rats a** about us. That happens in every system. I have worked with almost every station in the city and can say that Seattle Fire and Medics have treated me with respect and been respectful of my company.
> 
> Ever think that maybe it was you that had the conflict? Some people don't fit in. I agree with KingCountyMedic. I have been invited to the stations for meals and to hang out. Both Seattle and King County Medics have BS'd with me at Harborview. In fact it is their encouragement that has made me want to pursue EKG education.
> 
> ...



Hmmmm.... I guess could weigh in here, but there isn't really much to say, it seems like everyone is pretty well entrenched.  But I guess I'd like to address things in my perspective.  I have been involved with King County EMS for a decade, starting with TriMed in '03.  I am also a WA State EMS evaluator and King County CBT evaluator.  In my experience, there are definite personality conflicts that lead to very poor working relationships, and unfortunately those faces get tied to the AMB company, so sooner rather than later, the poor experience is associated not with the crew, but with the sign on the side of the ambulance.  Guess what, then the next (insert name here) AMB shows up, all they remember was the poor experience that they had.  From that point on, it becomes an accumulation of bad experience blamed on the company, and good experiences credited to the crew.  There are crews that have been running together for a significant amount of time, and they work well with the FD crews.  They do community events together, superbowl, fill the boot stuff, etc...  Kind of like an extended family, which in an ideal world is how things should be.  They recognize that each has a specific role, and make very sure to fulfill their role to the best of their ability.  I was lucky, I guess.  

There are bad crews though, both on the FD side and on the AMB side.  The outcome of that is never pretty.  We'll use AMB crews for instance, crews that are regularly late, lost, argue onscene with FD are probably not going to make friends.  It's never really about what you know, but how you present it, especially if you try to help someone instead of coming off as a know it all.  Unfortunately, new EMTs are usually in that boat, they don't understand the system that they are working in, and they are just trying to show how much they know.  They also have a poor ability to think outside of the box, and ultimately what is best for their patient.  (guess what, sometimes it's faster for the patient to get them to a hospital then to argue about medics)  My personal issue with EMTs is those who don't know their protocols.  Now on to the bad FD crews, the ones that don't have any interest in EMS are really easy to pick out, and provide the most cookie cutter service (when it's convenient) and are most likely to turf without any patient care/evaluation or even a med/hx.  The bad FD crews are also the least likely to have any clue about protocols, and perpetuate the "this is the way it's done" attitude.  The upside with the bad FD crews is that if you've worked with them and they trust you, it becomes your call.  They step back because they don't want to be up at 3a in some stinky apartment trying to figure out what cookie cutter approach will work, and they know that you do the "medical" stuff and really want to help the patient.  The hard part is earning their trust, and getting to that point.  Once you've hit that point, you can not only run your scene, but help your FD co-workers learn the medical side better.  I don't like fire or extrication, but they like to explain how things happen, that is usually how medical works, just inverse.  Now bad Medics, well, I do have to give them their due, most of the KCM1 medics that I have worked with have been far easier to discuss the patient in detail as well as the plan, and answer questions regarding the hows/whys.  There are definitely calls that you know you're going to take (depending on the crew and dinner time, etc...) but those are the exception, generally not the rule, and it's usually based on the probability of the patient tanking in the 10min to get to the ER.  Some of the most valuable lessons that have helped me in my career (tactical/disaster/remote and military medic) were taught to me in my first year on a rig by KCM1 medics, alot of them from Lee and Michael.

 LEOEMT, I can empathize with your position, as I'm assuming from your posts that you primarily work Seattle, however alot of this focus is at S. King.  Also there are alot of jaded responses particularly from TriMed.  AMR has the benefit/detriment of being a union organization.  (I'm not going to get into the benefit/detriment argument here)  TriMed is not union.  For me, personally I liked it, but it does bring a certain amount of uncertainty about the future.  It is a well known fact that for most employees that if a FF calls the company with a complaint, there is a high probability that you need a new job.  This causes animosity from the begining especially when someone dictates a questionable course of action and you feel stuck between what you feel is substandard care and your ability to provide an income.  This also causes the feeling that "you can't talk on scene."  FDs in S. King are guard their reputation very jealously, and if you’re going to make them look stupid, be prepared to pay the piper.   From my personal experience, I have never been quiet on scene, and between dumb luck and what I'd hope is skill, but probably more dumb luck, I was never fired.

I guess that I would summarize South King County EMS as a work in progress, but it has improved for the basic level transport EMT significantly since I first became involved with the system.  From my perspective there are a lot of personalities, they don’t always agree, and they can't always behave like adults.  It is a progressive system that is trying to drag along some very cookbook minded individuals and departments (FDs and AMBs) into the future.  Are there some issues that I think could be handled differently?  Absolutely, but they are being considered and adjusted according to the vision of the Medical Director, and his vision is different than mine, but he’s got a whole lot more education, insurance, a license and several thousand prehospital providers at stake, and I’ve got an opinion.  Having met with him though, he is very open to new ideas, provided they are properly thought through, have data to back them, and a concrete educational plan.  I think that there are various issues which cloud the water, including EMS/FD funding based on municipalities instead of county, companies’ strategies, as well as education at the basic provider level.  
Well, that’s my two cents, and it’s worth all you paid for it.


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## leoemt (Feb 1, 2013)

n7lxi said:


> The first post, from the guy that works in the hospital, clearly shows it's "just me". Nice try, thanks for playing.
> 
> I've seen some amazing King County paramedics. I've worked on scene with some. I've also seen some amazing fire department EMTs. However, KingCountyMedics post shows that even he is aware of issues between the various factions. He tried to gloss over them, but he knows they're there. I appreciate the fact that he addressed them and advised EMTs that have issues to be patient advocates and to talk to the battalion chief. However, if you do that at a private ambulance company, the chance of you getting fired is very high.
> 
> ...



I will no longer comment in this thread as I feel it is leaning more to the non-informative. I will conclude my participation with this: The system is what it is. It works for us. Some of us work well with fire and others don't. I would assume this is true nationwide. I enjoy my job, I enjoy my relationship with Seattle Fire and Medic One and I enjoy the respect that I am shown by them. Maybe I am unique in that. I have tremendous respect for them and for our system. 

Is our system perfect? No it is not. I have my own ideas as to how it can be improved as I am sure others do as well. That said, I am fortunate enough to work with some of the best in the business. Some people like it others don't. We all have our own opinions and you are entitled. But, unless you have worked here recently you don't really know. 

I will leave with this thought: I am here for the patient. Regardless of what interventions have been started, if you are given to me I will do for you what is in your best interest. 

With that said, I conclude my involvement in this topic.


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## Shishkabob (Feb 1, 2013)

sweetpete said:


> Comments like this simply causes you to lose credibility in any further posts you make. Uggghhhh.. The anti-fire sentiment in these rooms is sometimes nauseating.
> .



My view of getting FD out of medicine, where it doesn't belong, is no secret and I don't try to hide it to make friends.  Fire departments should not do medicine.    Fire departments do medicine to boost their budget. 


Generalizations?  Sure.  But generalizations backed up by the fact that darn near every single world renowned EMS agency is NOT run through a fire department but is infact, separate of them, despite that fact that 1/3 of EMS agencies in this country are fire-based.


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## Aidey (Feb 1, 2013)

leoemt said:


> I will no longer comment in this thread as I feel it is leaning more to the non-informative. I will conclude my participation with this: The system is what it is. It works for us. Some of us work well with fire and others don't. I would assume this is true nationwide. I enjoy my job, I enjoy my relationship with Seattle Fire and Medic One and I enjoy the respect that I am shown by them. Maybe I am unique in that. I have tremendous respect for them and for our system.
> 
> Is our system perfect? No it is not. I have my own ideas as to how it can be improved as I am sure others do as well. That said, I am fortunate enough to work with some of the best in the business. Some people like it others don't. We all have our own opinions and you are entitled. But, unless you have worked here recently you don't really know.
> 
> ...




"Works" is a _very _subjective term. 

And if any interventions have been started, there is an excellent chance the best thing to do for your patient is refuse to accept care and make the medic do their freaking job.


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## waaaemt (Feb 1, 2013)

sir.shocksalot said:


> I'm surprised that not every patient sees a paramedic in Seattle. Not that every patient needs a paramedic but it makes me wonder if some patients in pain or nauseated or whatever go without comfort measures because they aren't "sick" enough.



Well there are only 7 Medic units available in all of Seattle, and we're a prettyyyy big city, so if every Pt was to see a medic... you can see how that just wouldn't work.


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## usalsfyre (Feb 1, 2013)

oogemsquagger said:


> Well there are only 7 Medic units available in all of Seattle, and we're a prettyyyy big city, so if every Pt was to see a medic... you can see how that just wouldn't work.



A novel idea would be adding medic units....


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## Aidey (Feb 1, 2013)

oogemsquagger said:


> Well there are only 7 Medic units available in all of Seattle, and we're a prettyyyy big city, so if every Pt was to see a medic... you can see how that just wouldn't work.



I know the concept of supply and demand is hard to grasp, but I have a hunch that demand is outpacing supply significantly.


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## NomadicMedic (Feb 1, 2013)

They strongly oppose adding additional medics as they believe it will lead to dilution of the call volume of acute calls for the medics and degradation of skills.


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## Aidey (Feb 1, 2013)

1. Maybe if they deflated their egos a bit they would be able to fit more medic units in the city without it being a big game of bumper cars.

2. One would think that a program that has such great access to Harborview would be able to come up with a way to keep their medic's skills up.

3. Someone might want to advise them that acute call does not always equal cardiac arrest. 

4. Someone might also want to advise them that the job stopped being about life and death calls a long time ago.


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## usalsfyre (Feb 1, 2013)

n7lxi said:


> They strongly oppose adding additional medics as they believe it will lead to dilution of the call volume of acute calls for the medics and degradation of skills.



So tier it. Medics that can handle the majority if calls on all trucks and a few advanced level medics to run high acuity calls. Like the rest of the world does....


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## NomadicMedic (Feb 1, 2013)

I have always though that King County would be a perfect place for the AEMT to practice. COPD exacerbation that needs a neb would get one. Opiate ODs would get Narcan. Hypoglycemics would get Dextrose.  If King County want to save the medics for the "bad ones", let EMS providers that can start immediate treatment get things moving. 

Now, that would be a progressive move. Have a tiered system with first line providers able to make a definitive difference rather than just provide "the stare of life". 

However, I think we'd quickly see the shine fade from the Medic One system if the paramedics aren't doing anything but RSI and Arrests.


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## NYMedic828 (Feb 1, 2013)

Linuss said:


> My view of getting FD out of medicine, where it doesn't belong, is no secret and I don't try to hide it to make friends.  Fire departments should not do medicine.    Fire departments do medicine to boost their budget.
> 
> 
> Generalizations?  Sure.  But generalizations backed up by the fact that darn near every single world renowned EMS agency is NOT run through a fire department but is infact, separate of them, despite that fact that 1/3 of EMS agencies in this country are fire-based.



Municipalities that run EMS often lose money vs gain it. FDNY EMS actually costs NYC around 200,000,000 a year to keep in service. (its really 400,000,000 but we usually generate half back in transports. Meanwhile 90% of the service is convinced they make bags of money for the city left and right)

Mind you firefighters do not generate revenues outside of inspection violations they can issue and the RARE parking ticket they write but you can't exactly not have a fire department whereas EMS is easily privatized and generally profits when it is vs costing massive amounts.


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## Shishkabob (Feb 1, 2013)

NYMedic828 said:


> Mind you firefighters do not generate revenues outside of inspection violations they can issue and the RARE parking ticket they write but you can't exactly not have a fire department whereas EMS is easily privatized and generally profits when it is vs costing massive amounts.



You can EASILY have a much smaller funded FD, while providing much better funding to EMS.


Sole FD required calls (fire, HAZMAT, etc) account for less than 5% of 911 calls (more like 3%), however FD OFTEN get the lions share of a budget compared to PD, and even more compared to EMS.  That make no sense in any way shape or form FDs try to spin it.  Hell, include EMS calls to FDs volume, and fire calls account for 15% of their volume, but the majority of their budget and training.  Again, makes no sense, but they defend it like it's a necessity.  

If you're not willing to put the majority of your budget, training and time in the portion of your job you do most (medicine) then you don't need to be doing medicine.  Period.  




Small auxiliary FD with skeleton crews on duty, supplemented by volunteers, is what the vast majority of cities / towns can get away with, without any detrimental outcome.


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## Veneficus (Feb 1, 2013)

n7lxi said:


> They strongly oppose adding additional medics as they believe it will lead to dilution of the call volume of acute calls for the medics and degradation of skills.



But since BLS and not ALS is the proven life saver, ACLS aside from defib and cpr is BS, what exactly do they even have medcs for if nobody sees them?

To prove they can intubate dead people?


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## Veneficus (Feb 1, 2013)

Linuss said:


> Small auxiliary FD with skeleton crews on duty, supplemented by volunteers, is what the vast majority of cities / towns can get away with, without any detrimental outcome.



While I generally agree, I don't think NYC is one of those cities.
Old and densely packed cities need effective fire coverage to do aggressive operations to save lives and property. 

Suburbs and more modern cities do not.


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## waaaemt (Feb 1, 2013)

n7lxi said:


> I have always though that King County would be a perfect place for the AEMT to practice. COPD exacerbation that needs a neb would get one. Opiate ODs would get Narcan. Hypoglycemics would get Dextrose.  If King County want to save the medics for the "bad ones", let EMS providers that can start immediate treatment get things moving.
> 
> Now, that would be a progressive move. Have a tiered system with first line providers able to make a definitive difference rather than just provide "the stare of life".
> 
> However, I think we'd quickly see the shine fade from the Medic One system if the paramedics aren't doing anything but RSI and Arrests.



amen to that! I kind of think AEMT should just be the base level. I know in Canada that's pretty much how it is, and it would be way more practical for everyone.


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## KingCountyMedic (Feb 1, 2013)

You guys are killing me :deadhorse:

I haven't intubated a dead person in over a month! I only had 4 tubes in Jan. All elective intubations, everyone lived. Also none of my patients have ever died in an ambulance. Let me think, I have put patients in the back of a BLS unit after giving: Dextrose, Narcan, Zofran, combivent nebs, and Adenosine. I have also left many patients home after giving those same meds. I was in contact with Medical Control Doctors on every single patient that I treat and they agreed with my treatment and transport decisions every time. I treat my Private Ambulance folks like GOLD because I was one and it's the right thing to do. I often will take an AMB crew with me to the hospital so they can experience sick patients and get a break from running transfers and posting. We do not bill for transports. The majority of ALS providers in our state, both public and private bill so they end up starting IV's on everyone because that is how they make $$$. As I have said before, we aren't perfect but we do a pretty great job overall. I realize some of you have experience working here and if it was negative let me be the first to apologize. Others here just seem to like to be arm chair QB's and trash talk everything on a constant basis. I got nothing for you. Enjoy your selves, regardless of what you say about me or King County EMS I'm going to go to work, have fun, see sick people, be nice to others and get paid very well. PEACE!


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## medicsb (Feb 1, 2013)

Aidey said:


> I know the concept of supply and demand is hard to grasp, but I have a hunch that demand is outpacing supply significantly.



What demand?  Some places such as Seattle/KC target paramedics to "sick" patients, like they were originally envisioned.  Is there ANY evidence that there are more sick EMS patients?  As far as I can tell, there are probably fewer (likely in almost every EMS system in the US), so why would they add more?  

Why would ANY place add more?


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## Veneficus (Feb 1, 2013)

KingCountyMedic said:


> You guys are killing me :deadhorse:
> 
> I haven't intubated a dead person in over a month! I only had 4 tubes in Jan. All elective intubations, everyone lived. Also none of my patients have ever died in an ambulance. Let me think, I have put patients in the back of a BLS unit after giving: Dextrose, Narcan, Zofran, combivent nebs, and Adenosine. I have also left many patients home after giving those same meds. I was in contact with Medical Control Doctors on every single patient that I treat and they agreed with my treatment and transport decisions every time. I treat my Private Ambulance folks like GOLD because I was one and it's the right thing to do. I often will take an AMB crew with me to the hospital so they can experience sick patients and get a break from running transfers and posting. We do not bill for transports. The majority of ALS providers in our state, both public and private bill so they end up starting IV's on everyone because that is how they make $$$. As I have said before, we aren't perfect but we do a pretty great job overall. I realize some of you have experience working here and if it was negative let me be the first to apologize. Others here just seem to like to be arm chair QB's and trash talk everything on a constant basis. I got nothing for you. Enjoy your selves, regardless of what you say about me or King County EMS I'm going to go to work, have fun, see sick people, be nice to others and get paid very well. PEACE!



I am not trash talking I have legit questions.

I want to know what is going on there in order to justify having such service.

Since i know most EMS treatments are not definitive and pain management is a reasonable expectation for patients in 2013, I want to know how you address that?

All I ever hear about King County is their "outstanding" cardiac arrest survival, which I know is not from ALS measures, because nobody's is.

Maybe the FD treats non FD members bad, that is no different than 99% of the services I encountered. I don't care about that at all. 

I am not a fan of kool-aid, tell me what you got.


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## Aidey (Feb 1, 2013)

medicsb said:


> What demand?  Some places such as Seattle/KC target paramedics to "sick" patients, like they were originally envisioned.  Is there ANY evidence that there are more sick EMS patients?  As far as I can tell, there are probably fewer (likely in almost every EMS system in the US), so why would they add more?
> 
> Why would ANY place add more?




Because the definition of sick does not equal dead. Most of the rest of the developed world recognizes that there are a variety of ALS interventions and medications that can either improve patient outcomes or ease suffering. Heaven forbid paramedics are wasted giving pain control for broken hips or CPAP and nitro for CHF or fluids in the septic patient.


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## medicsb (Feb 1, 2013)

Aidey said:


> Because the definition of sick does not equal dead. Most of the rest of the developed world recognizes that there are a variety of ALS interventions and medications that can either improve patient outcomes or ease suffering. Heaven forbid paramedics are wasted giving pain control for broken hips or CPAP and nitro for CHF or fluids in the septic patient.



Where did I say that sick equals dead?  The incidence of MI, stroke, hospitalization for asthma, etc. have been declining for some time.  While true emergencies and sick patients exist, they're not as frequent as they were in the past.  There is pretty much no need anywhere to increase the number of medics.  If anything, they should be decreasing the number.  And you don't need a paramedic to give pain meds, it could easily be done by an AEMT.


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## Aidey (Feb 1, 2013)

I'm talking about their definition. The greater Seattle area is so obsessed with their intubation and ROSC rate they save their medics for those calls. We're talking about *7 medic units for 620k people*. That isn't enough medics to run 12 leads on all the legit chest pain calls, let alone address any of the other ALS calls that come out. 

No one is saying floor the system with 200 medics, but 7 is beyond insane.


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## usalsfyre (Feb 1, 2013)

At this point I'm not 100% sure you're not trolling....I want to focus on some highlights of this masterpiece....


KingCountyMedic said:


> Also none of my patients have ever died in an ambulance.


Then you are either a)deluding yourself b)brand new (which would explain a lot) or c)working in such an urban area they don't have a chance to crump. 



KingCountyMedic said:


> Let me think, I have put patients in the back of a BLS unit after giving: (edit) Adenosine. I have also left many patients home after giving those same meds.


I can't even begin to describe the fail involved here. Try not buying a couple of hours of monitoring or even a 23 hour obs stay after adenosine in a hospital. From a clinical supervision and medicolegal standpoint the thought of leaving an SVT patient at home without a serious, serious AMA conversation leaves me....I'm not even sure how to articulate it.   



KingCountyMedic said:


> We do not bill for transports. The majority of ALS providers in our state, both public and private bill so they end up starting IV's on everyone because that is how they make $$$.


Perhaps the rest of the state has realized that relieving pain and suffering is a worthwhile enterprise....



KingCountyMedic said:


> As I have said before, we aren't perfect but we do a pretty great job overall.


Based on what? It's pretty easy to say "we're doing a great job" when you're the one building the criteria.  



KingCountyMedic said:


> Enjoy your selves, regardless of what you say about me or King County EMS I'm going to go to work, have fun, see sick people, be nice to others and get paid very well. PEACE!


The "haters gonna hate" attitude is not fooling anyone. You've yet to directly answer anyone's questions, starting with how you "KNOW" everyone who trash talks KCM1 was rejected from there.


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## KingCountyMedic (Feb 1, 2013)

I won't respond anymore on any of these threads. PM me if you want to have a polite conversation and ask me anything you want and I will be honest and open. I am not trolling at all.


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## medicsb (Feb 1, 2013)

Aidey said:


> I'm talking about their definition. The greater Seattle area is so obsessed with their intubation and ROSC rate they save their medics for those calls. We're talking about *7 medic units for 620k people*. That isn't enough medics to run 12 leads on all the legit chest pain calls, let alone address any of the other ALS calls that come out.



I think that is how you define it for them.  The thing is, and I've said this before, their system is quite transparent (unlike most places).  Do some googling (or pubmed searches) and you'll see that it is obvious that they treat many many patients not in cardiac arrest.  

Anyhow, 1 medic unit per 80-100,000 is ideal in my opinion.  There are some places that have 1 medic unit per 20,000 - that is triple super duper ridiculous insane.


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## rescue1 (Feb 1, 2013)

medicsb said:


> I think that is how you define it for them.  The thing is, and I've said this before, their system is quite transparent (unlike most places).  Do some googling (or pubmed searches) and you'll see that it is obvious that they treat many many patients not in cardiac arrest.
> 
> Anyhow, 1 medic unit per 80-100,000 is ideal in my opinion.  There are some places that have 1 medic unit per 20,000 - that is triple super duper ridiculous insane.



If EMT-B education was better, 1 ALS per 20,000 might be OK. But until then, I'd prefer to have more, not less, ALS. I've seen too many basics make absurd mistakes to think otherwise.


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## the_negro_puppy (Feb 1, 2013)

usalsfyre said:


> At this point I'm not 100% sure you're not trolling....I want to focus on some highlights of this masterpiece....
> 
> Then you are either a)deluding yourself b)brand new (which would explain a lot) or c)working in such an urban area they don't have a chance to crump.
> 
> ...


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## Bullets (Feb 1, 2013)

Aidey said:


> I'm talking about their definition. The greater Seattle area is so obsessed with their intubation and ROSC rate they save their medics for those calls. We're talking about *7 medic units for 620k people*. That isn't enough medics to run 12 leads on all the legit chest pain calls, let alone address any of the other ALS calls that come out.
> 
> No one is saying floor the system with 200 medics, but 7 is beyond insane.



That about the ratio for my entire county! 6-7 ALS trucks covering 620k living across 600sq miles. We also have a Physician roaming the county


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## abckidsmom (Feb 1, 2013)

medicsb said:


> I think that is how you define it for them.  The thing is, and I've said this before, their system is quite transparent (unlike most places).  Do some googling (or pubmed searches) and you'll see that it is obvious that they treat many many patients not in cardiac arrest.
> 
> Anyhow, 1 medic unit per 80-100,000 is ideal in my opinion.  There are some places that have 1 medic unit per 20,000 - that is triple super duper ridiculous insane.



You have to know what you're talking about though.  Average time on task, transport time, response times, drop times, interval between clear from the hospital and in service in the district.

Our county of 35k over 500 sq mi is at times woefully underserved with 3 medic units and a spare couple of BLS units here and there.  It's scary to think that an accident on the interstate with the report of 3 people injured dumps the entire county's resources.  

We can laude the ROSC rate in Seattle all day long, but it is not the sole measure of an EMS system, nor can every system be held up to that standard.


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## NYMedic828 (Feb 1, 2013)

medicsb said:


> I think that is how you define it for them.  The thing is, and I've said this before, their system is quite transparent (unlike most places).  Do some googling (or pubmed searches) and you'll see that it is obvious that they treat many many patients not in cardiac arrest.
> 
> Anyhow, 1 medic unit per 80-100,000 is ideal in my opinion.  There are some places that have 1 medic unit per 20,000 - that is triple super duper ridiculous insane.



The NYC-FDNY EMS system usually has 300-400 ambulances patrolling the city. 1/5 of those are probably ALS units. We have a population over 8,000,000. In many areas they have quite a bit of down time. We also run dual medic exclusively though and only send ALS units to calls triaged for them by dispatch.


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## Tigger (Feb 2, 2013)

Aidey said:


> I'm talking about their definition. The greater Seattle area is so obsessed with their intubation and ROSC rate they save their medics for those calls. We're talking about *7 medic units for 620k people*. That isn't enough medics to run 12 leads on all the legit chest pain calls, let alone address any of the other ALS calls that come out.
> 
> No one is saying floor the system with 200 medics, but 7 is beyond insane.



Boston EMS runs 5 medics at daytime staffing for a city with a daytime population of over 900 so it's certainly possible. That said, I don't know what the hospital situation is in Seattle, but here we have a Level 1 accessible in under 15 minutes from anywhere. The city BLS units (19 on in the daytime) are also much better trained than average. They have a three month didactic orientation followed by three months of FTO time before being released. 

Do patients with significant pain or nausea/vomiting go untreated to the ED frequently? Yes. And I am sure that even sicker patients are taken by BLS by system necessity. I'd still say the system still does ok considering transport times and the ability of BLS to recognize when it's time to go to the hospital immediately. I get the idea that this doesn't happen everywhere, but in Boston BLS is certainly prompt.


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## ffemt8978 (Feb 2, 2013)

There is only one level one hospital, and the only way it can be reached in 15 minutes is if you are within 10-30 blocks, depending upon time of day.  There are a plethora of level two hospital scattered about, though.


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## KingCountyMedic (Feb 2, 2013)

usalsfyre said:


> At this point I'm not 100% sure you're not trolling....I want to focus on some highlights of this masterpiece....
> 
> Then you are either a)deluding yourself b)brand new (which would explain a lot) or c)working in such an urban area they don't have a chance to crump.
> 
> ...



Okay, I'll respond a bit better for you. MY posts are sometimes a bit vague in proper explanations. My fault, sorry.

As far as treating SVT with Adensosine and leaving them home I should have said it is something we do, all though it is VERY rare. If we have a patient that has a history of SVT, has been treated with adensosine and converted by M1 previously and WANTS to stay home and follow up with their cardiologist and they are stable we will have them sign AMA and we will contact Medical control and their cardiologist if possible. If we have never seen the patient before we take them in.

As far as responding to your insults I won't.

As far as this hang up so many of you have with pain and nausea management. We are not going to double or triple the ammount of medics just to treat simple injuries or a bit of nausea. Any good EMT can tell you that GOOD splinting will take care of pain quite a bit. As far as nausea, yes it sucks to be nauseated. If you are at the point that you can't stop puking and your BP is low and you will get a visit from a Medic unit and you will get fluid and zofran or promethazine and whatever else you may need but if you have stable vital signs and you are not having other serious issues you need to go see the ED or clinic. If you look at all the recent studies where you have a group of Doctors saying Paramedics should not intubate, should not have RSI, should not perform central lines in the field you will see that the majority of these areas have a paramedic on every rig, every street corner and very little training or experience. We believe in having a limited ammount of ALS providers seeing a lot of sick people. Our training program is longer than most, we are in the field on day 3 of Paramedic school and we are starting IV's learing to intubate and place central lines in the first 2 weeks of school. I'm not trashing any of your programs, I'm not trying to brag about mine but I am proud of where I work and I love my job. We do have amazing save rates, I am a piece of that but a small one. We have more citizens trained in CPR than pretty much anyplace in the country. We have a ton of cops and they all have defibs and PD is dispatched to all CPR's. We have public defibs all over the place. We send multiple units to CPR calls, we try to shoot for continuous chest compressions, we do not stop compressions during intubation. That is why we have the save rates, it's not because I'm some para god. I have great help every place I turn. We have very tight dispatch criteria, designed by Doctors and Paramedics so the people that need to get seen by ALS do get seen. It's not always perfect and there is always room for improvement.


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## VFlutter (Feb 2, 2013)

KingCountyMedic said:


> we are starting IV's learing to intubate and place central lines in the first 2 weeks of school.



You place central lines in the field? <_< Subclavian or Femoral? Do you use ultrasound? I am guessing it is limited to cardiac arrests. 

I hope they yank them out as soon as you roll into the ER. I would love to see your complication and CLABSI rates.


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## NomadicMedic (Feb 2, 2013)

Unless things changed in the last year or two, KCM1 doesn't place IOs, they place subclavian central lines.


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## Veneficus (Feb 2, 2013)

Chase said:


> You place central lines in the field? <_< Subclavian or Femoral? Do you use ultrasound? I am guessing it is limited to cardiac arrests.
> 
> I hope they yank them out as soon as you roll into the ER. I would love to see your complication and CLABSI rates.



Not commenting on King County specifically, but multiple agencies performed central lines in the field prior to the popularity of IO. 

As you know from the history of cardiac arrest survival, it seems likely that anybody gave much thought to the complications probably because nobody lived long enough to get an infection.

Ultrasound guidance is not required to place a central line. Most of the people I know can and commonly place those lines without ultrasound guidance all the time. 

Substituting technology for skill is not safer, it just costs more.


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## usalsfyre (Feb 2, 2013)

KingCountyMedic said:


> As far as treating SVT with Adensosine and leaving them home I should have said it is something we do, all though it is VERY rare. If we have a patient that has a history of SVT, has been treated with adensosine and converted by M1 previously and WANTS to stay home and follow up with their cardiologist and they are stable we will have them sign AMA and we will contact Medical control and their cardiologist if possible. If we have never seen the patient before we take them in.


I still shudder to think about the consequences if this goes wrong. 



KingCountyMedic said:


> As far as responding to your insults I won't.


I don't recall ever insulting you. I do recall making some rather pointed statements. Tough. 



KingCountyMedic said:


> As far as this hang up so many of you have with pain and nausea management. We are not going to double or triple the amount of medics just to treat simple injuries or a bit of nausea.


This seems to be a system driven decision rather than a patient driven one. Meaning the accusations of KCM1 leadership caring more about save rates and intubation success start to sound a bit truer. 



KingCountyMedic said:


> Any good EMT can tell you that GOOD splinting will take care of pain quite a bit.


Then why is the in-hospital standard to control pain prior to splinting? Not doing so is considered cruel. My goal is to bring the ED to the patient to the best of my ability, not the other way around. Pain control by splinting is just a way to justify a poor level of care.  



KingCountyMedic said:


> As far as nausea, yes it sucks to be nauseated. If you are at the point that you can't stop puking and your BP is low and you will get a visit from a Medic unit and you will get fluid and zofran or promethazine and whatever else you may need but if you have stable vital signs and you are not having other serious issues you need to go see the ED or clinic.


Why exactly is servicing this population such an issue for you and KCM1 as a whole? Because its not cool and exciting? Because press releases don't get written about controlling nausea? Provide me with a real explanation and I'll let it be.   



KingCountyMedic said:


> If you look at all the recent studies where you have a group of Doctors saying Paramedics should not intubate, should not have RSI, should not perform central lines in the field you will see that the majority of these areas have a paramedic on every rig, every street corner and very little training or experience. We believe in having a limited ammount of ALS providers seeing a lot of sick people. Our training program is longer than most, we are in the field on day 3 of Paramedic school and we are starting IV's learing to intubate and place central lines in the first 2 weeks of school.


First off, considering EDs and ICUs in most of the country are moving away from placing central lines emergently in favor of IOs so bragging about that might not be the best idea...

The rest of the world, and even some systems in the US (one the next city over from me) manage to put a provider who can do things like pain and nausea management, EKGs, ect on all calls and still have a limited number of skilled and experienced paramedics and/or physicians on hyperacute calls. So why can't KCM1? Other than arrogance and the thought that being a KCM1 paramedic "means something". Again, if you can change my mind with evidence do so. Until then MedStar in Fort Worth makes KCM1 look like they can't manage a system. 



KingCountyMedic said:


> I'm not trashing any of your programs, I'm not trying to brag about mine but I am proud of where I work and I love my job. We do have amazing save rates, I am a piece of that but a small one. We have more citizens trained in CPR than pretty much anyplace in the country. We have a ton of cops and they all have defibs and PD is dispatched to all CPR's. We have public defibs all over the place. We send multiple units to CPR calls, we try to shoot for continuous chest compressions, we do not stop compressions during intubation. That is why we have the save rates, it's not because I'm some para god. I have great help every place I turn. We have very tight dispatch criteria, designed by Doctors and Paramedics so the people that need to get seen by ALS do get seen. It's not always perfect and there is always room for improvement.


Why can't the people who need get seen by someone who can actually help them rather than someone who can provide a taxi? Why is KCM1 so against this? 

What I see from your description is an agency that has completely lost patient focus, cares more about skills and numbers than taking care to the patient and is secure in knowing they won't be removed or sued due to built in government protections. Prove me wrong, but its going to take evidence.


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## KingCountyMedic (Feb 2, 2013)

Chase said:


> You place central lines in the field? <_< Subclavian or Femoral? Do you use ultrasound? I am guessing it is limited to cardiac arrests.
> 
> I hope they yank them out as soon as you roll into the ER. I would love to see your complication and CLABSI rates.



We place IJ, subclavian, and Fem central lines. We use the Trauma Arrow Kit with sterile drape and sterile procedure and suture them in place. We are required to fill out Central line forms for every line placed in the field, same as we fill out airway form for every tube placed. A central line is to be placed only when we have a patient that has no other peri access available. We have recently started using the EZ IO as well and that has cut down on central line use a bit but we still do quite a few. We place them in cardiac arrest patients, trauma patients, anyone that needs one gets one. We are required to perform at least two a year for recert. Our complication rate is very low, as is our infection rate. We are trained in placing central lines with sterile technique by trauma surgeons at Harborview Medical Center. All lines in King County are yanked if the patient is admitted, especially central lines started in the field unless there is no other line to be had. We are required to document everything we do, every IV, central line and ET tube placed is reviewed that week by our medical director. If you screw up you will hear about it usually in less than 24 hours. I have placed many central lines in awake patients, local lidocaine prep and sterile tech used of course. We do a lot of stuff here that isn't done in a lot of places. The single biggest thing about our program is the intense Physician involvement in our training. We have our Medical Directors ride with us on a regular basis. We have monthly Doctors meetings with required attendance and we are usually doing 3-4 big medical studies at all times. It is a great place to be a Medic.


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## usalsfyre (Feb 2, 2013)

KingCountyMedic said:


> It is a great place to be a Medic.


A patient who's not about to die on the other hand....


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## Veneficus (Feb 2, 2013)

KingCountyMedic said:


> Any good EMT can tell you that GOOD splinting will take care of pain quite a bit..



I am sorry you feel this way. While I agree splinting can substantially reduce pain in many instances, it is basically a partial treatment. 

Your system has thus made the decision it does not care about all of its patients, just the headline grabbing populations.

That is unfortunate. 



KingCountyMedic said:


> As far as nausea, yes it sucks to be nauseated. If you are at the point that you can't stop puking and your BP is low and you will get a visit from a Medic unit and you will get fluid and zofran or promethazine and whatever else you may need but if you have stable vital signs and you are not having other serious issues you need to go see the ED or clinic..



Taken together with your above statement, I can only conclude that while your system provides very good care in all aspects of the sudden cardiac arrest population, it does not seem to much of anything else.

If this were the 1980s your system might be enviable, but it seems considerably behind the times as far as medicine. 

I would like to know what you spend so much education time on if you are only providing medical care to a very small protion of your calls?



KingCountyMedic said:


> If you look at all the recent studies where you have a group of Doctors saying Paramedics should not intubate, should not have RSI, should not perform central lines in the field you will see that the majority of these areas have a paramedic on every rig, every street corner and very little training or experience. We believe in having a limited ammount of ALS providers seeing a lot of sick people..



This seems to me like your system is set up to defend the ability of paramedics to use a variety of ALS skills, not to provide the best care. That is not a reflection of you or any single provider, but it does great discredit to your leadership.

As we are seeing more and more, these advanced skills do not improve survival, in hospital or out. Recent advances in resuscitative medicine call into doubt the need for aggressive airway maagement in a variety of populations, most notably your system specialty of cardiac arrest. 

As mentioned by chase, there are considerable complications with the use of central lines. So much so even in hospitals it attempts at reducing infection rates are of prime concern all over the world. I would need to be convinced that using this technique in the field environment was anything but hubris. 

I also do not believe that you have any more sick people per capita than any place else. Because of the general level of health in that region, you probably have less sick people.  

I would amend your statement to say you have ALS providers not seeing many people at all. Again, not something I would be proud of, but it must take a great deal of spin doctoring to turn that into a positive. 



KingCountyMedic said:


> Our training program is longer than most, we are in the field on day 3 of Paramedic school and we are starting IV's learing to intubate and place central lines in the first 2 weeks of school.



If I could just maybe put this into perspective?

With the exception of central lines, you have nothing here that everyone else isn't doing. The use of central lines outside of the hospital is highly questionable. 

You have almost triple the education of the average medic program, but are expected to only use this education on an extremely limited population. While I applaud this increase of educaiton, it seems to me that it might be a bit wasteful considering what you actualy do.



KingCountyMedic said:


> I'm not trying to brag about mine but I am proud of where I work and I love my job. We do have amazing save rates, I am a piece of that but a small one. We have more citizens trained in CPR than pretty much anyplace in the country. We have a ton of cops and they all have defibs and PD is dispatched to all CPR's. We have public defibs all over the place. We send multiple units to CPR calls, we try to shoot for continuous chest compressions, we do not stop compressions during intubation. That is why we have the save rates, it's not because I'm some para god. I have great help every place I turn. We have very tight dispatch criteria, designed by Doctors and Paramedics so the people that need to get seen by ALS do get seen. It's not always perfect and there is always room for improvement.



There is nothing wrong with being proud of where you work. Here again you detail "save rates" and everything your system does to improve them at the cost of every other aspect of EMS.

I know what it is like to work for agencies considered the best. I know that whether you lay that title on yourself or somebody else does, everybody else puts you under the microscope. A considerable amount of those people want that title for themselves. It is the nature of man. But from what I have learned here, I do not think your system is what it claims to be, and I think that when people point that out, instead of taking a hard look at your system and make changes, your providers try to claim that everyone else is just jealous because they cannot be like you. 

It reminds me of a story about the Emperor's New Cloths.  



usalsfyre said:


> I still shudder to think about the consequences if this goes wrong..



It sounds to me like an N=1 experience or a patient refusal. I cannot believe that any doctor, especially in the US, would approve a treat and release cardioversion. 

If as was clarified, a patient refuses medical advice and transport, that is not because of the outstanding work of the medic, it is because the patient is assuming the risk. 

I further cannot believe that any highly educated provider, paramedic or otherwise, would meet a patient with a new onset heart arrhythmia, chemically cardiovert it, and be fool enough to think that it could not revert or not acknowledge it may simply be a symptom of a more serious underlying pathology.

But again, no provider in any system can be faulted for a patient refusing AMA.  





usalsfyre said:


> This seems to be a system driven decision rather than a patient driven one. Meaning the accusations of KCM1 leadership caring more about save rates and intubation success start to sound a bit truer..



I think this has been established beyond any doubt. Not only from this post but the history of its claims. (Some of which had to be redacted I might add) 



usalsfyre said:


> Why exactly is servicing this population such an issue for you and KCM1 as a whole? Because its not cool and exciting? Because press releases don't get written about controlling nausea? Provide me with a real explanation and I'll let it be..



From this post, part of it sounds like economics. It takes an aweful lot to train people 3x as long, pay them a corresponding wage for this, do as little as these ALS providers do, and justify the cost. 

At least part of it is the system leadership is so focused (for whatever reason) that they have lost sight of all else. But that is not the fault of the providers. 



usalsfyre said:


> Until then MedStar in Fort Worth makes KCM1 look like they can't manage a system..



I must concur, KCM1 does not seem to meet the level of excellence that other nations and the more admirable systems in the US have set. 

But nobody wants to say "My system is almost 40 years out of date and does only 1 thing really well." Even personal emotional security dictates providers believe they are doing the best. (or at least the right thing)  



usalsfyre said:


> What I see from your description is an agency that has completely lost patient focus, cares more about skills and numbers than taking care to the patient and is secure in knowing they won't be removed or sued due to built in government protections.



I must concur with this assessment, but I am not sure if the reasons they do what they do is sinister or just misguided belief.


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## Aidey (Feb 2, 2013)

Veneficus said:


> It sounds to me like an N=1 experience or a patient refusal. I cannot believe that any doctor, especially in the US, would approve a treat and release cardioversion.
> 
> If as was clarified, a patient refuses medical advice and transport, that is not because of the outstanding work of the medic, it is because the patient is assuming the risk.
> 
> ...



It is actually in their protocols. 

It is supposed to apply to patients with a known history of SVT and after medical control consultation.

Still highly questionable.


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## Veneficus (Feb 2, 2013)

Aidey said:


> It is actually in their protocols.
> 
> It is supposed to apply to patients with a known history of SVT and after medical control consultation.
> 
> *Still highly questionable*.



That is a very diplomatic way to say that.


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## KingCountyMedic (Feb 2, 2013)

Aidey said:


> It is actually in their protocols.
> 
> It is supposed to apply to patients with a known history of SVT and after medical control consultation.
> 
> Still highly questionable.



Yes it is very rare that it actually happens. 

I'm sorry if I haven't made myself more clear. Frankly some of you seem to have a problem with just about anything that anyone posts on here. You are very impressive web medics I'm sure. I didn't start posting here to get into arguments. I was originally just looking around for interesting stuff, maybe try to learn something, swap a story or two but I made a mistake and searched Seattle/King County and discovered all the bashing of my system and felt defensive. I'm sure that I'm not the guy my chief would have chosen to go out and champion our way of life, I'm an old street medic that has been working in some type of ambulance for going on 27 years. I am obviously not good at making a point in a forum or properly explaining how we do things. My bad, all on me. I have seen just enough of this place to know that it is a lot like working EMS. There are a lot of good folks out there but the only ones that you notice and remember are the a-HOLES. So enjoy your forum, sorry if you don't care for me or my system. Take care.


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## systemet (Feb 2, 2013)

KingCountyMedic said:


> As far as treating SVT with Adensosine and leaving them home I should have said it is something we do, all though it is VERY rare. If we have a patient that has a history of SVT, has been treated with adensosine and converted by M1 previously and WANTS to stay home and follow up with their cardiologist and they are stable we will have them sign AMA and we will contact Medical control and their cardiologist if possible. If we have never seen the patient before we take them in.



At the risk of diverting this thread in another direction, we do this too, and some of the services in our general region have for > 10 years.  We have a written treat & refer protocol for this situation, and it requires that the patient is stable, lacks other acute pathology, is under 65, has a hx of prior adenosine-responsive SVT, has someone responsible who can stay with them for 4 hours, and is able to call 911.


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## ExpatMedic0 (Feb 2, 2013)

Slightly off topic, but the medic 1 system is M.D. taught and 3000 hours in length, most of the students are already certified Paramedics, correct? They also have the highest cardiac arrest survival rates in the nation right?


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## VFlutter (Feb 2, 2013)

KingCountyMedic said:


> Frankly some of you seem to have a problem with just about anything that anyone posts on here. You are very impressive web medics I'm sure. I didn't start posting here to get into arguments. I was originally just looking around for interesting stuff, maybe try to learn something, swap a story or two but I made a mistake and searched Seattle/King County and discovered all the bashing of my system and felt defensive.



Actually, most the medics responding to this thread are truly impressive and very intelligent as are the non-medics who also take issue with some of the practices of KCM1. 

As Vene stated if you claim to be the best then you must except scrutiny. You should be able to respond to criticism without getting defensive. 

From what I have read in this thread I would not consider any of it "bashing" but rather legitimate concerns about questionable policies and practices.


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## RocketMedic (Feb 2, 2013)

KCM's statements are pretty much exactly why EMS in the US is what it is.

Also, EMSA-OKC, MedStar Fort Worth, and Wake County _do_ post some significantly higher-than-expected "cardiac arrest save rates", as do many other flagship systems. I think it's a combination of having the bandages of Lazarus woven into our monitor pads and potentially the widespread adoption of BLS-centered CPR with a lot of people really close by to compress/ventilate. 

Here is a pointed question though: is it "less sexy" to take an old lady with chest pain (c/o falling to dispatch, btw), provide analgesia for a painful but non-life-threatening injury, or start CPAP/nitro on a patient with dispatched leg pain because their CHF exacerbation is objectively more of a problem than their massively overswollen leg? Of course they're not as sexy as Massive Traumatic/Cardiac/Respiratory arrest, since in any system other than EMSA, it doesn't involve flashing lights and sirens on the return trip (yes, here, the chest pain mostly managed with nitro and the CPAP were automatic emergent returns per protocol). In all three cases, I showed up to sick or injured people who were also scared. I applied what knowledge I have and the skills/tools at my disposal to give these patients a subjectively "better" outcome. None of them would have died in the 10-20 minutes it would take any EMS crew, regardless of level, to extricate, package and transport them to a hospital. However, in my case, at least two of these patients would probably not have even received ALS, despite benefiting considerably from ALS interventions. That bothers me.

KCM1 must have some amazingly cavalier paramedics, some fantastic and often worried EMTs, and some really really amazing hospitals quite adept at doing our jobs for us.

Even if you don't document anything more than gloveside and never transport, realistically, I can't see a medic helping more than 2 people an hour. That's 24 in a technician-only setting with minimal assessment time and a drugs/shock/tube-only scenario. Since KCM1 doesn't do this and doesn't have a lot of people, I think we can all agree that patients who get ALS in other systems don't get it in King County.

I think it's quite telling that defenders of KCM1 use lots of skill names, capitalized words and the Kool-Aid/Starcare approach to defend the system, whereas its critics use logic, reason and pointed questions.

(For what it's worth, I wish that EMSA would chase MedStar so I could be more like Linuss, not KCM1)


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## NomadicMedic (Feb 2, 2013)

Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.


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## mrg86 (Feb 2, 2013)

Just asked a buddy of mine that is in Harborview's medic school, he says Seattle and South King still do not have CPAP.


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## KingCountyMedic (Feb 2, 2013)

n7lxi said:


> Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.



CPAP and transport vents are an ongoing discussion, prob moving to those in the near future. CHF is still nitro, more nitro, followed by nitro. Lasix not so much, and we have a huge lasix shortage right now. We have also placed the EZ IO and I-Gel airway on the truck. We are carrying versed and ativan now. We just got the new LP15 with the ability to send 12 leads to the hospital. The LP15 has all the time voice and data recording and we are required to download every CPR for review and study. Oh and we are getting new trucks this year, we are going with International TerraStar trucks.


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## KingCountyMedic (Feb 2, 2013)

Chase said:


> From what I have read in this thread I would not consider any of it "bashing" but rather legitimate concerns about questionable policies and practices.



I wasn't talking about just this thread, I found a trend of what I felt to be bashing in searching multiple threads. If you have questions by all means ask away but please don't just read what others post on the web about us and take that for the gospel truth.


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## sir.shocksalot (Feb 2, 2013)

I think a lot of "great systems" are really only great because they are big city EMS systems. Under scrutiny I think many, maybe even most, EMS systems would have multiple areas in need of drastic improvement.

Regarding my question about comfort measures, in KCM1's defense, I think it's far worse to have a provider on scene who can give pain control but chooses not to than to have one not show up at all. How many systems can say that they are very aggressive with pain control? I know of several systems, even well respected ones, locally where multiple providers able to give pain control are on scene and the patient still goes without. Why? "They don't need it." "Too much paperwork." "They're faking it." "They're a seeker." "I'm not here to make you comfortable, I'm here to save lives."

So the real question is, what yard stick are we using to say any system is "awesome", "progressive"? I know that most of my coworkers and friends will think a system is awesome simply because they run a lot of "cool calls". The more cardiac arrests, shootings, stabbings, and other "cool things" are what tend to make systems "awesome" and "progressive".

Great cardiac arrest outcomes come from great public CPR and AED programs. Great trauma outcomes come from great trauma systems in hospitals, I'd argue that EMS involvement actually worsens outcomes. So instead of pointing the finger at any particular service like KCM1 and saying "they aren't as progressive as they claimed to be" I'd ask "who said they were? and why?". At least for my colleagues, they are the text book agency of progressive because they do "cool stuff lots". I think many of peoples problems with KCM1 really come down to problems that are prevalent throughout EMS. As much as I think their system has issues, as the saying goes, those who live in glass houses...


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## ffemt8978 (Feb 3, 2013)

Okay, this is everyone's last warning on the matter.

Knock off the personal attacks, direct and indirect, or this thread will become my personal pet project.


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## DrParasite (Feb 4, 2013)

n7lxi said:


> Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.


If Im not mistaken, NTG is currently trending as the best first line med for CHF, then administer CPAP (got to dialate the vessels so the fluid can go somewhere).  Lasix is really a long term solution.

Personally, I don't have a problem with what I have read about KCM1 (although some of the treat and release and treat and RMA/AMA is really sketchy).  And if you give an ALS intervention, at least transport instead of turffing to the BLS.

I happen to think that you can pick any EMS system in the US, and find 5 things wrong with it, and 5 things that they aren't doing right (at least in your opinion, which isn't always right.).  And people in glass houses shouldn't throw stones (except when it comes to fire departments, they should get out of EMS and let EMS handle EMS).


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## VFlutter (Feb 5, 2013)

KingCountyMedic said:


> We place IJ, subclavian, and Fem central lines. We use the Trauma Arrow Kit with sterile drape and sterile procedure and suture them in place



You still suture central lines? Take a look at StatLocks. They are awesome


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## Brandon O (Feb 5, 2013)

KingCountyMedic said:


> CPAP and transport vents are an ongoing discussion, prob moving to those in the near future. CHF is still nitro, more nitro, followed by nitro..



Notwithstanding the rest of this thread, I find this extremely surprising. Is there a reason that a system with such obvious interest and ability for progressive, evidence-based EMS has deemphasized the adoption of CPAP?


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## Shishkabob (Feb 8, 2013)

For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.


If they don't want to go, they don't have to go.  I had a supervisor show up as a second Paramedic witnessing, but it is what it is and I'm not going to lose sleep over someone elses educated refusal.


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## ExpatMedic0 (Feb 8, 2013)

Linuss said:


> For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.



:lol: HAHA awesome


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## Trashtruck (Feb 8, 2013)

Linuss said:


> For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.
> 
> 
> If they don't want to go, they don't have to go.  I had a supervisor show up as a second Paramedic witnessing, but it is what it is and I'm not going to lose sleep over someone elses educated refusal.



Precisely.
I'm not here to make choices for people. If they don't want to go, fine. Here's what's up and here's what may happen. Sign this. See ya. If you're an idiot, that's none of my business, Mr. Alert-and-oriented-enough-to-make-your-own-decisions. Thank you for using XYZ for all your medical needs. Have a glorious rest of your day.


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## Rialaigh (Feb 10, 2013)

I have read most of this thread but I am sure I missed many things and I apologize if this has already been said or anything.

First off - On the issue of ALS medications and skills not being used on patients that are not life threatening. It brings up a good point, are we as EMS charged with using ALS skills (when available) to better serve every patient that calls 9-1-1. Or would you say we are charged with using ALS skills to better the medical care for those who's medical condition at ER arrival would differ if brought in by BLS. For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome. 

Second on the issue of AMA's - If the person is of right mind, and has not broken the law or stated they are going to break the law (threatening suicide..etc..) then I have no issue with an AMA regardless of medical condition. I am not hauling granny in, in handcuffs with police because she doesn't want her SVT treated at the hospital. Same goes for trauma patients, if it is that bad they will get altered mental status while we are on scene and we can justify taking them in restrained, if it is not that bad then we can leave and they can call back when they do need us. Not a perfect system by any means but I have a much harder time justifying to myself placing a perfectly rational person in handcuffs to drag them to the hospital because they are not as educated as us in medical opinions.


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## Veneficus (Feb 10, 2013)

Rialaigh said:


> I have read most of this thread but I am sure I missed many things and I apologize if this has already been said or anything.
> 
> First off - On the issue of ALS medications and skills not being used on patients that are not life threatening. It brings up a good point, are we as EMS charged with using ALS skills (when available) to better serve every patient that calls 9-1-1. Or would you say we are charged with using ALS skills to better the medical care for those who's medical condition at ER arrival would differ if brought in by BLS. For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome.
> 
> Second on the issue of AMA's - If the person is of right mind, and has not broken the law or stated they are going to break the law (threatening suicide..etc..) then I have no issue with an AMA regardless of medical condition. I am not hauling granny in, in handcuffs with police because she doesn't want her SVT treated at the hospital. Same goes for trauma patients, if it is that bad they will get altered mental status while we are on scene and we can justify taking them in restrained, if it is not that bad then we can leave and they can call back when they do need us. Not a perfect system by any means but I have a much harder time justifying to myself placing a perfectly rational person in handcuffs to drag them to the hospital because they are not as educated as us in medical opinions.



I think if you are an ALS agency, providing "better care" is all you can hope to do. 

If you are talking about outcome based care, ALS has almost no place in it. People talk about allegery attacks and epi, etc, but in they are a very small minority of cases. People with such allergies who do not have their own, access to epi pens, etc are an even smaller minority. 

A hypoglycemic patient, while benefitting from ALS, will probably survive a few more minutes with a BLS ride to the hospital. With more or less deficit dependant on the case. 

The only likely exceptions to this are in the rural environments, which makes urban and suburban ALS completely irrelevent. 

If you consider glucometry, states where BLS is permitted to start an IV or admin a neb, it is far more economical and practical to supply these BLS providers with a few simple things like an epi pen, albuterol, dextrose in water, and protocols to administer them with or without medical control contact.

You would save millions of dollars, if not hundreds of millions of dollars, each year providing "ALS." 

With CPR and an AED, you just equipped a BLS ambulance with a handful of things that would completely and totally mitigate the need for ALS. 

As was stated here, starting central lines and intubating people while demanding high levels of education and compensation is just a needless drain. Even if you only have 7 of these rigs running around a major city. 

It has been a while, but I will restate, ALS is a want, not a need. Nobody "needs" ALS. 

So if you are going strictly off of want, ALS providers may _want_ to provide better care. If their rank and file value their jobs and have any brains, they would demand it.


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## systemet (Feb 10, 2013)

Rialaigh said:


> For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome.



This depends on how you define "outcome".  If you define it in terms of mortality or long-term disability, then I agree, you're unlikely to impact it in these patients.  If you define outcome in terms of pain reduction, then, sure ALS can improve the outcome for the patient with the long bone fracture.  If you consider that many cancer patients rate their nausea as more problematic than their pain, then perhaps there might be even more benefit to being able to provide a po / IM or IV antiemetic to patient #2.

At some point each system needs to decide what EMS care is.  Is it:

(1) Lifesaving or potentially lifesaving interventions delivered outside of the hospital to reduce mortality.  This seems to be the King Co. model.

(2) Providing general medical care outside of the community, as well as the life-threatening stuff, e.g. pain control, antiemetics, etc.

Or is it:

(3) Generating an opportunity for the patients first point of entry into the healthcare system to be provided outside of the hospital?

I would argue for (3), that EMS is not public safety, it's not simply transport, but that calling 911 should result into seamless transition into the healthcare system.


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## systemet (Feb 10, 2013)

Veneficus said:


> I think if you are an ALS agency, providing "better care" is all you can hope to do.



It seems like this is what we should be doing everywhere in healthcare.  For some reason there's a segment of the EMS population that seems to think that providing non-acute care is beneath them.



> If you are talking about outcome based care, ALS has almost no place in it. People talk about allegery attacks and epi, etc, but in they are a very small minority of cases. People with such allergies who do not have their own, access to epi pens, etc are an even smaller minority.



However, one could argue rationally that the patients with a first anaphylaxis event, or those who have had a severe enough prior reaction to require an epi-pen prescription but don't have access to it, represent a high-risk group.  I realise this is rational conjecture versus anything evidence-based.

I agree that this represents quite a small percentage of EMS patients.



> A hypoglycemic patient, while benefitting from ALS, will probably survive a few more minutes with a BLS ride to the hospital. With more or less deficit dependant on the case.



True, but for a healthcare system what's a better utilisation of resources -- sending an ambulance with a provider with 3 years of education, costing around $1,000, and perhaps directing this patient to a nonurgent family MD consult at a later point, or, using a provider with a year of education, costing about $1,000, transferring that patient to a hospital, and then having them assessed by an attending, a bunch of RNs, lab techs, etc., trying up scarce resources, and then getting a nonurgent family medicine referral.

I think that if we look at this from a systems perspective, there's some value to throwing a paramedic on an ambulance.  The incremental cost isn't that high when you start looking at other healthcare system costs.



> If you consider glucometry, states where BLS is permitted to start an IV or admin a neb, it is far more economical and practical to supply these BLS providers with a few simple things like an epi pen, albuterol, dextrose in water, and protocols to administer them with or without medical control contact.



It's cheaper, for sure.  In my region, around $10/hr cheaper, with a lower capital cost for equipment.  But it's not really that much cheaper, is it?




> It has been a while, but I will restate, ALS is a want, not a need. Nobody "needs" ALS.
> 
> So if you are going strictly off of want, ALS providers may _want_ to provide better care. If their rank and file value their jobs and have any brains, they would demand it.



This may be what I'm doing here, and I appreciate that you're being deliberately inflammatory.  I think there are some areas where ALS has positive impacts:

* Control of pain
* Control of nausea
* Augmenting palliative care resources
* Referring patients away from the hospital, e.g. low-risk hypoglycemia
* CHF treatment (I recognise that much of this is in the process of being downloaded to BLS)
* Respiratory distress (see OPALS subgroup analysis --- I might be cherrypicking)
* STEMI recognition, PCI bypass, field thrombolysis
* CVA identification and stroke center bypass (admittedly, potentially very BLS)
* Psychiatric / Agitated patient transport (rather benzodiazepines than a taser or two and a few broken limbs).
* Seizure control
* Tranexamnic acid in trauma (I know that you don't like CRASH-2 and you're far more educated than me in this area).

Granted there's little evidence (or none) for most of this.  But I'd also argue that the cost of ALS care is relatively low.  There's already going to be an ambulance -- unless we're going to replace them with a taxi service, which I guess we could. I don't think many people would find that acceptable, but that would be an option.  There's already going to be a bunch of equipment on that ambulance, and a couple of providers drawing salary.

Sure, there are cheaper monitors than an LP12/15/X-series that BLS can use -- although the options dwindle if we provide BLS 12-lead, which realistically we should.  Some of the disposables, like adenosine, or TNK, are pretty expensive.  But it's not that great an incremental cost between running a BLS response and running an ALS response.  Is it really that much to ask that when I call 911, the representative of the health care system that arrives has a couple of years of education, and can move someone with a long-bone fracture without a whole ton of unnecessary screaming?

With respect.


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## Brandon O (Feb 10, 2013)

"To cure, seldom; to relieve, often; to comfort, always."

I would add: to organize and direct patients to the most appropriate resources, and vice versa. Because that helps fulfill all of the above.

Nobody would say the triage nurse isn't serving a purpose, but is she really "saving lives"? You'd be missing the point if you asked that, wouldn't you?


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## Veneficus (Feb 10, 2013)

systemet said:


> True, but for a healthcare system what's a better utilisation of resources -- sending an ambulance with a provider with 3 years of education, costing around $1,000, and perhaps directing this patient to a nonurgent family MD consult at a later point, or, using a provider with a year of education, costing about $1,000, transferring that patient to a hospital, and then having them assessed by an attending, a bunch of RNs, lab techs, etc., trying up scarce resources, and then getting a nonurgent family medicine referral.



But currently US EMS does not refer to other healthcare resources as a matter of practice.

An acute hypoglycemic really should go to the hospital. I realize they don't regularly want to, and often refuse AMA, but it is AMA, not "let's do this."



systemet said:


> I think that if we look at this from a systems perspective, there's some value to throwing a paramedic on an ambulance.  The incremental cost isn't that high when you start looking at other healthcare system costs.
> 
> It's cheaper, for sure.  In my region, around $10/hr cheaper, with a lower capital cost for equipment.  But it's not really that much cheaper, is it?
> 
> It's cheaper, for sure.  In my region, around $10/hr cheaper, with a lower capital cost for equipment.  But it's not really that much cheaper, is it?



Medicare ALS 1 and private billing costs and expenses of the ALS provider. ALS comes up with substantial increase over BLS costs system wide. 

There are logisitcs (like medication reporting/accountability), con ed, capital equipment expendatures, etc. 

I don't think you accounted for the "hidden costs" that few people consider or think about.



systemet said:


> This may be what I'm doing here, and I appreciate that you're being deliberately inflammatory.  I think there are some areas where ALS has positive impacts:
> 
> * Control of pain
> * Control of nausea
> ...



I am not being inflammatory. There is no benefit to a mortality measuring ALS service the way the US commonly practices it. 

It is a level of services that is wanted, for the increase in care it brings. Many places in the US do not mandate EMS care, they do mandate fire and police. 



systemet said:


> There's already going to be a bunch of equipment on that ambulance, and a couple of providers drawing salary.



As above, there is more to ALS cost than equipment and salary.


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## Rialaigh (Feb 10, 2013)

systemet said:


> It seems like this is what we should be doing everywhere in healthcare.  For some reason there's a segment of the EMS population that seems to think that providing non-acute care is beneath them.




My issue is EMS has already become (not even in the transition stage, we have already transitioned) into a customer service taxi service. I would like to think that non-acute care IS beneath EMS. Because that was not what EMS was created for and utilizing EMS for non-acute care is not efficient.

 For the price of an ambulance ride to the hospital for a non acute issue that could/should be dealt with by a family care physician you could

 - Send a limo to the persons house to pick them up for a Dr. appt on monday and pay for the appt
- Send a Dr. to their house for a house call on Monday thereby eliminating the need to go to the hospital at all or even travel the Dr. office
- etc ..etc...etc..

I personally believe non-acute care is below ER physicians and nurses as well and people that show up with the complain of "tooth pain X 2 weeks" should be glanced at for 60 seconds by a PA or APNR in the triage room and told to follow up with their dentist or family practice doctor. If they don't have one then...tough luck until someone can fix the healthcare system to EFFICIENTLY provide these services to people who cannot pay for them. You cannot efficiently do that in the ER. 

I personally would be okay with adding a hundred clinical hours to an EMT-B curriculum and then putting paramedics only on interfacility critical care transport tucks...

OR

Make paramedicine a 4 year degree that allows the medic to triage, treat, and hand off to BLS for transport to a community medicine center (urgent care) or the hospital, or write a refferal to a Dr. 



However, as long as hospitals will run their own EMS in the same city it is a conflict of interest to allow people to AMA or discourage them from being transported to the ER. Business will dictate that everyone gets transported no matter what the reason because they can then bill for an ER visit too.


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## Veneficus (Feb 10, 2013)

Rialaigh said:


> My issue is EMS has already become (not even in the transition stage, we have already transitioned) into a customer service taxi service. I would like to think that non-acute care IS beneath EMS. Because that was not what EMS was created for and utilizing EMS for non-acute care is not efficient.



You are right, it is not efficent.

I would not say it is beneath them nor would I say customer service driven is bad.

Afterall, medicine is patient driven. Is that not customer service?

If we only had EMSthat responded to life or death, we would only need basics. That cuts down on spots and salary. Does that work fr you?



Rialaigh said:


> For the price of an ambulance ride to the hospital for a non acute issue that could/should be dealt with by a family care physician you could
> 
> - Send a limo to the persons house to pick them up for a Dr. appt on monday and pay for the appt
> - Send a Dr. to their house for a house call on Monday thereby eliminating the need to go to the hospital at all or even travel the Dr. office
> - etc ..etc...etc..



True.

But who will pay for it? Nobody.

Because if somebody did pay for it, there would be no need to call EMS.

That is why the 75/yo lady with CHF goes into crisis and winds up with an ALS ambulance through the ER and into the ICU. 

Because medicare won't pay the taxi cab ride to her doc for a lasix prescription refill that costs a few dollars.

There is also the big problem of primary care physician reimbursement and standard of care.

The former are not paid a livable wage as it is and many are going broke. Many (most)are forced to work in hospitals not only for job security, but also for all of the diagnostics that they would have to supply themselves. Like an x-ray, CT, or lab. 

Customers (aka patients) will not wait 3 days for lab resuls when they could go to the ED and get them in 45 minutes.

Have a 55 y/o guy come to a PCP with a "really bad headache" guess where he is going? To the ED CT. Why pay the PCP middleman? Go direct, pay less.

You really want to see a farce: medical homes.



Rialaigh said:


> I personally believe non-acute care is below ER physicians and nurses as well and people that show up with the complain of "tooth pain X 2 weeks" should be glanced at for 60 seconds by a PA or APNR in the triage room and told to follow up with their dentist or family practice doctor. If they don't have one then...tough luck until someone can fix the healthcare system to EFFICIENTLY provide these services to people who cannot pay for them. You cannot efficiently do that in the ER..



I believe the ED physician is a complete waste. Replace them with IM who could help 99% of the patients in the ED better and have admitting capability.

Give all of acute care back to anesthesia, who are already in the hospital and deal with life and death patients daily. Oh and have the surgeon wander down when required. (which won't be often) Look at that, better care, cheaper, and eliminates the middleman. 



Rialaigh said:


> I personally would be okay with adding a hundred clinical hours to an EMT-B curriculum and then putting paramedics only on interfacility critical care transport tucks....



again, in the name of efficency, have nurses run CCT and have basics do 911. More middleman loss.

OR



Rialaigh said:


> Make paramedicine a 4 year degree that allows the medic to triage, treat, and hand off to BLS for transport to a community medicine center (urgent care) or the hospital, or write a refferal to a Dr.



Exactly, and since the medics are doing it, there is still no need for EM. 



Rialaigh said:


> However, as long as hospitals will run their own EMS in the same city it is a conflict of interest to allow people to AMA or discourage them from being transported to the ER. Business will dictate that everyone gets transported no matter what the reason because they can then bill for an ER visit too.



Misplaced fault.

Medical directors usually work in the ED. They bill those EMS patients. Also EMS in the US is paid for transport, which means, no transport, no money. At current some places bill for showing up, but with a large indigent population in a given area, that would be totally unsustainable.


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## Rialaigh (Feb 10, 2013)

Veneficus said:


> You are right, it is not efficent.
> 
> I would not say it is beneath them nor would I say customer service driven is bad.
> 
> ...





I agree, The only reason I said I would like to think it is "beneath" them is because we were designed to be a service that facilitated field care and transport to a facility while providing life saving interventions in the field. What it has become is what everything has become in the US (with few exceptions) and that is a business. So yes, it is completely customer service oriented now and the 75 year old grandma that is slightly dehydrated doesn't give a rats tail if you give her some fluids or not, she wants to be treated nicely, with respect, and given a ride to the ER. 

My point with the efficiency of transport is that the government pays for it. So if they are willing to pay for the billions of dollars spent on needless transport can't we pay guys 10 bucks an hour, give them a cab or mini van, and have free healthcare transport for everyone in the US. Call the number, cabbie shoes up, present the cabbie with a paper copy of your appointment reminder and an ID, get a free ride there and back, same goes if you want a ride to the ER. Cut the ambulance out of all that completely, sure makes more sense. Allow an individual to use the service up to 10 times a month or something...

Family practice physician salaries is a joke...and a completely different discussion. Most PA's I know make more then the DR. they work under at a family practice.

 I would be all for having a IM doc running the ER and having anesthesia do all emergent procedures (or the surgeon), stuff like intubation, central lines (when needed). Hell give intubation back to respiratory therapist please.. (another pet peeve of mine... and another discussion). 

The only reason I said paramedics run CCT is because around here at least the nurse in a CCT ambulance makes about 20k more than a medic in a CCT ambulance and they can both be taught the same things for transport easily. Hell, just make it a CC-EMT and get rid of EMT-P


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## Rialaigh (Feb 10, 2013)

Also, I apologize for the huge D-Rail...


Back to Seattle and King county. On the topic of so few paramedic trucks. I have no issue with that, make the 7 paramedic trucks supervisors who handle complains and maybe are available for prolonged extrications. When a basic truck transports the medic over that area is aware and if a few trucks in the same area are out on transport the medic can provide backup and run calls in their absence. Frankly I applaud King County for cutting costs in this area if it is something that the citizens do not want to pay for.


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## Summit (Feb 28, 2013)

Veneficus said:


> You are right, it is not efficent.
> 
> I would not say it is beneath them nor would I say customer service driven is bad.
> 
> ...



OK... read the whole thread... and this is my favorite post.


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## RocketMedic (Feb 28, 2013)

Rialaigh said:


> Also, I apologize for the huge D-Rail...
> 
> 
> Back to Seattle and King county. On the topic of so few paramedic trucks. I have no issue with that, make the 7 paramedic trucks supervisors who handle complains and maybe are available for prolonged extrications. When a basic truck transports the medic over that area is aware and if a few trucks in the same area are out on transport the medic can provide backup and run calls in their absence. Frankly I applaud King County for cutting costs in this area if it is something that the citizens do not want to pay for.



It's not a cost that they ever had a chance at paying, and most of the citizens don't know there's alternate options available. That cost cutting = unbalanced service.


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