# L.A. County EMS Laws



## elnemt (Oct 15, 2009)

Regarding Los Angeles County EMS and its rules, codes, laws and regulations.

1. When both EMT's (EMT-I, EMT-P) are licensed ambulance drivers and transporting a patient BLS (non-emergency, non-ALS), can the Paramedic drive while the EMT-I (in LA County an EMT-I is basically an EMT-B not to be confused with EMT-I's in other counties where most EMT-I procedures are ALS criteria in LA County) attends to the patient? While I and most of us will have no issues with it in LA County, what does the law say concerning such practice in Los Angeles County?

2. Do most EMS, Ambulance companies (911 and/or IFT/non-911) allow scanners in their ambulances? The current LA County law states:

*7.16.100 Ambulance operator--Prohibited acts.*

D. Use a scanner or radio monitoring device for the purposes of responding to an emergency call when not authorized or requested to respond to that call by the appropriate public safety agency​
If the operators of a 911-emergency ambulance have a scanner can they use the scanner as a supplement to the radio transmission of the city and/or fire department they are servicing? What are common laws and or rules regarding said practice with most, if not all, 911-emergency ambulance operators?


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## exodus (Oct 15, 2009)

Why would you have a scanner when you have a RADIO with your frequencies that you can respond in your district to?  You already have the channels and you won't be hearing anything less, if not *more* on your radio then you would on a scanner...


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## elnemt (Oct 15, 2009)

*Point Missed*

If you would have read the thread carefully you would have noticed that I never mentioned "I" had one. The question is general knowledge regarding things that "Ricky Rescues" and/or "Timmy Traumas" usually carry onto the rig. 
Other similar questions would be regarding: knifes, and/or other equipment not usually supplied by the employer and/or not clarified in local protocols.

Please read carefully before drawing judgement.


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## exodus (Oct 15, 2009)

Please read my post too! How exactly would the scanner supplement you! While you are on duty, while you are working?!  It won't!


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## JPINFV (Oct 15, 2009)

elnemt said:


> Regarding Los Angeles County EMS and its rules, codes, laws and regulations.
> 
> 1. When both EMT's (EMT-I, EMT-P) are licensed ambulance drivers and transporting a patient BLS (non-emergency, non-ALS), can the Paramedic drive while the EMT-I (in LA County an EMT-I is basically an EMT-B not to be confused with EMT-I's in other counties where most EMT-I procedures are ALS criteria in LA County) attends to the patient? While I and most of us will have no issues with it in LA County, what does the law say concerning such practice in Los Angeles County?


Actually, the "I" in EMT-I stands for the roman numeral 1 and is a state wide thing. County adherence to using EMT-I vs EMT-B in day to day operations varies, but the proper legal term for an EMT-B in California is "EMT-I." The EMT-Intermediate level in California is restricted to areas that can't provide paramedics and is known as an EMT-II (2).




> 2. Do most EMS, Ambulance companies (911 and/or IFT/non-911) allow scanners in their ambulances? The current LA County law states:
> 
> *7.16.100 Ambulance operator--Prohibited acts.*
> 
> ...



Why would you need a scanner when you have a radio? Also, even if the 911 ambulance can't specifically communicate with a central 911 dispatcher, the time saved 'predispatching' yourself would be minimal since most times the private company ambulance responds non-emergently while the fire department units respond emergently.


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## mycrofft (Oct 15, 2009)

*I can address the last question about scanners.*

If you are Dispatch, you do not want your units self-dispatching or "getting the jump". What a dispatcher might want his units to have instead of a scanner is a GPS tracking device to see where they are and how fast they are going etc. Whether a company has a specific rule about scanners, there are only two basic uses for them: entertainment/morbid fascination, or freelancing/self-dispatch, including sort of moseying to where the action is so one could get the dispatch. Neither is something a company wants you doing on company time. 

As to the LA County law, no idea; it would seem that if the P (as the clinical superior) decides the pt is not needing her/his special skills, then the P could drive.

Someone trying to settle a bar bet here or what?


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## elnemt (Oct 15, 2009)

True on the EMT-1,I,B vs EMT-II, however, the question wasn't semantics.

Both questions go unanswered. 

"_mycrofft_" understood the question and answered it directly as being a question regarding "laws" and not whether or not it would be cool to carry a scanner while on duty as an EMT at any level in areas where radio communication has already been established and in good working order.

For those of us that are having a hard time dissecting the question, an employee (EMT-P) for a company "I" work for carry's a scanner with them at all times. What does any, if not all, company state as a rule, regulation, law, etc. regarding scanners in ambulances?

The law doesn't not say that it shouldn't be "heard" but should not be used as a tool to respond to emergencies that have not been dispatched to the unit in question.

As to the first question, What does county protocol or "law" say about having a Paramedic drive while the EMT-I, B attends to the patient on a BLS call/run in Los Angeles County?

 Different scenarios may be:

1. ER Runs
2. IFT's
3. Discharges
4. 911 runs with local city/county Paramedic on board with patient.
And if so, what is your company's regulation/rules regarding said practice (if in fact performed)?


	:deadhorse:


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## atropine (Oct 15, 2009)

elnemt said:


> Regarding Los Angeles County EMS and its rules, codes, laws and regulations.
> 
> 1. When both EMT's (EMT-I, EMT-P) are licensed ambulance drivers and transporting a patient BLS (non-emergency, non-ALS), can the Paramedic drive while the EMT-I (in LA County an EMT-I is basically an EMT-B not to be confused with EMT-I's in other counties where most EMT-I procedures are ALS criteria in LA County) attends to the patient? While I and most of us will have no issues with it in LA County, what does the law say concerning such practice in Los Angeles County?
> 
> ...



Why do you have the paramedic seal if you just a basic?^_^


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## atropine (Oct 15, 2009)

you can't respond unless requested by that agency. Even if you roll up on an accident you must still notify that city or county's 911 provider, I know LA County does not hand off any calls its part of there policy, but smaller departments like Compton, or Downey might let another ALS private company transport.


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## elnemt (Oct 15, 2009)

It got your attention didn't it? If you see my title is EMT-Basic. Not making myself out to be someone I'm not.


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## John E (Oct 15, 2009)

*Just a thought...*

have you gone to the Los Angeles County DHS website and looked up any of the rules you're asking about?

Seems like one could either get the accurate information straight from the source or rely on the opinions of folks in a web forum.


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## atropine (Oct 15, 2009)

nice reply John seems like this guy needs a silver seal as well


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## mycrofft (Oct 15, 2009)

*"Got our attention"? Our attention is easily "got" (>>*

How does this all apply to education and training?As I always say, "cut to the chase" and follow John E's suggestion.


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## elnemt (Oct 15, 2009)

Reference No. 517: 

Transport Modalities 
B. ALS Transport​
Unit is staffed with two paramedics unless the ambulance provider has
been given approval by the EMS Agency to staff ALS IFT units with one
paramedic and one EMT-I.

So... according to John Telmos @ L.A. County EMS Ambulance Licensing

Most ALS companies participating in this program (1 on 1 Staffing) have L.A. County approved training manuals. He also mentioned that while it isn't in the protocols, common sense would dictate that the medic should _always _be in the back in case the patient's VS deteriorate. He also mentioned that the jury will almost always side with the plaintiff.

So, I appologize for the run around and yes, I did look at the L.A. County EMS website and nothing concrete just the above reference. 

If I can help anyone research this type of stuff i'll see what I can do that way you don't get a silver seal from someone that finds it amusing (but couldn't give the answer).

Thanks everyone!


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## Akulahawk (Oct 15, 2009)

Sacramento has a similar policy in place. While this county does have ALS permitted ambulances that are held to the same educational and staffing standards as the 911 system units, they do not want non-911 units responding to 911 system calls without prior authorization. That being said, if a non-system unit is flagged down or sees an emergency on their own, they're to report it and may provide full care, including transport, under the 911 system protocols... however, they're encouraged to wait for a system unit to arrive and turn-over care to the 911 unit, if the patient meets transfer of care criteria. 

It's not illegal to have a scanner on-board, however, using it to "poach" system calls is very much against the rules and can result in loss of the operating permit. A company (that no longer operates here) began poaching calls when they first started operating here. They did the same in another county as well... in both cases, the 911 system quickly realized what they were up to and that company came VERY close to losing their operating permits in both counties.


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## atropine (Oct 16, 2009)

I think it's a great policy too may Ricks out there, and the privates just really don't seem to know what their doing.


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## John E (Oct 16, 2009)

*I get it now...*

it's a game to see if folks are paying attention...

You need to dig a little deeper at the L.A. County EMS website. 

Thanks for playing...


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## daedalus (Oct 16, 2009)

atropine said:


> I think it's a great policy too may Ricks out there, and the privates just really don't seem to know what their doing.



I would not trust most of the private folks in LA with my dog's life. However, I would say the same thing about the fire folks as well. It is just a terrible area.


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## atropine (Oct 16, 2009)

What's so terrible about it?, yeah I guess its really bad if you want to make 100k plus a year.


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## daedalus (Oct 16, 2009)

atropine said:


> What's so terrible about it?, yeah I guess its really bad if you want to make 100k plus a year.



Terrible area for patient care. I do not care what the fire guys make, in fact, I heard a rumor that LA City Fire is laying off over 100 firefighters within the year.

Are you even a firefighter?


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## John E (Oct 16, 2009)

*I'd be very curious...*

to know on what basis you're making the claim of terrible patient care in the Los Angeles area.

Can you point to something other than your personal feelings to validate that claim?


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## daedalus (Oct 17, 2009)

John E said:


> to know on what basis you're making the claim of terrible patient care in the Los Angeles area.
> 
> Can you point to something other than your personal feelings to validate that claim?



I prefer to work and live in a county where Paramedics do not have to call for orders from a nurse to do anything more than a set of standing orders that fits on half a page of paper (check Procedures Prior to Base Contact) (doctors do not even bother answering radios in LA, next time you are in a ER in the county ask why). 

Yes, I can point to the fact that becoming a paramedic in Los Angeles does not require college anatomy and physiology. Becoming a paramedic in Los Angeles does not require any college education at all or let alone a AS degree (most places do not but where I work now you are looked down on for doing the bare minimum of education). I can point to the fact that many fire department paramedics are not happy preforming their duties on the rescues or squads and are just biding time until they get on an engine, and then the paramedic cert gets dropped. Does patient care thrive in such an environment?

One has to look no further than the fact that paramedics in Los Angeles are not allowed to read 12 leads, not allowed to intubate pediatric patients, not allowed to treat patients based on their field diagnosis, and have to call nursing control (one cannot call it medical control because no doctors answer the other end) to get permission for their third round of drugs in a code (hint no one else has to do this). It seems like year there is another bulletin from EMS talking about new cuts to the paramedic scope of practice.

Can I provide studies to demonstrate poor outcomes? No. I wish I could and I would bet a pretty penny that most other systems in California would far surpass the Los Angeles and Orange County systems. However, based on my work history as an IFT, and then 911, and after that a CCT unit EMT in the county, I have seen the results of the care provided to patients before, during, and after 911 calls. I have transported patients on CCT who were nearly killed by fire paramedics. I have worked with paramedics who BLSd me intracranial bleeds (a very bad thing to do). I have a friend who was given a STEMI patient by an LA County Fire medic while they went back to the station. The doctor in the receiving ER actually drove to the fire station to have a words with that crew, who threw him out of the station. I know what an LA county Paramedic patient assessment looks like, and they are pretty poor. Day in and day out I saw things that made me question my place in EMS and in medicine in general if these things I saw was how emergency medicine was practiced everywhere. To regain my sanity I moved to a system north of Los Angeles, and it is night and day up here. We are accountable to physicians for our actions. We are expected to provide quality care, unlike in Los Angeles where the RN feels like she has a good paramedic if they bothered to start a line (when needed). We can think independently and have protocols on par with that. The paramedics value education. 

I am someone who values quality patient care. I chose to leave Los Angeles county because of poor patient care. I have a better paying job now, with more respect from other medical professions. We are seen as professionals in their eyes, this is something i have never felt in Los Angeles.


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## daedalus (Oct 17, 2009)

Oh, and I find it funny that local malls and gyms can provide a higher level of care to cardiac patients than EMTs in Los Angeles who do not work for one of the three-four ambulance companies (out of around 90) who carry AEDs.


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## JPINFV (Oct 17, 2009)

daedalus said:


> One has to look no further than the fact that paramedics in Los Angeles are not allowed to read 12 leads, not allowed to intubate pediatric patients, not allowed to treat patients based on their field diagnosis, and have to call nursing control (one cannot call it medical control because no doctors answer the other end) to get permission for their third round of drugs in a code (hint no one else has to do this). It seems like year there is another bulletin from EMS talking about new cuts to the paramedic scope of practice.



That's not 100% accurate. I used to volunteer at a base hospital in Orange County and there was an RN and physician assigned to the radio. While the RN handled all of the radio communication and could issue most of the base hospital orders by themselves, they were linked via a Nextel to the designated physician. In 6 months, I think I observed the radio RN discuss something with the physician once. The vast majority of the calls to medical control were calls because they were forced to based on protocol.

Edit: Base hospital contact and transportation guideline: http://ems.dhs.lacounty.gov/policies/Ref800/808-1.pdf


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## atropine (Oct 17, 2009)

daedalus said:


> I prefer to work and live in a county where Paramedics do not have to call for orders from a nurse to do anything more than a set of standing orders that fits on half a page of paper (check Procedures Prior to Base Contact) (doctors do not even bother answering radios in LA, next time you are in a ER in the county ask why).
> 
> Yes, I can point to the fact that becoming a paramedic in Los Angeles does not require college anatomy and physiology. Becoming a paramedic in Los Angeles does not require any college education at all or let alone a AS degree (most places do not but where I work now you are looked down on for doing the bare minimum of education). I can point to the fact that many fire department paramedics are not happy preforming their duties on the rescues or squads and are just biding time until they get on an engine, and then the paramedic cert gets dropped. Does patient care thrive in such an environment?
> 
> ...



Iam glad someone values patient care, but patient care isn't going to pay my bills, bla bla bla, if the system is so bad why doesn't anyone fic, must not be broken Iam sure all the medical directors in LA Ciunty would jump on improvement, but wait we still have operate under a Dr. I guess up north in Ventura they don't do that? I guess there are no fire medics up north just private heros that operate on there own agenda, man I got to go there and be a cowboy.


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## JPINFV (Oct 17, 2009)

Nice false dichotomy there by saying that all fire medics are heroes and all private medics are cowboys. 

Now, my question is, "Why do counties that don't use fire medics for the majority of EMS (like, say, Riverside County outside of a few areas) have more progressive (ok. You got me. "progressive" and "California EMS" doesn't belong in the same sentence, but still...) and liberal treatment protocols than LA and Orange County?" Again, I'll note that in Orange County, if you're working as a paramedic, you work for the fire department.


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## Shishkabob (Oct 17, 2009)

atropine said:


> Iam glad someone values patient care, but patient care isn't going to pay my bills, bla bla bla, if the system is so bad why doesn't anyone fic,



Because people like you advocate less education, less responsibility, and in general don't care about being a medic.  You'd rather put blue on red then handle medic calls, which ironically enough, is more than 70% of your call volume.


And you're telling me there is nothing wrong with that picture?


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## EMSLaw (Oct 17, 2009)

atropine said:


> Iam glad someone values patient care, but patient care isn't going to pay my bills, bla bla bla, if the system is so bad why doesn't anyone fic, must not be broken Iam sure all the medical directors in LA Ciunty would jump on improvement, but wait we still have operate under a Dr. I guess up north in Ventura they don't do that? I guess there are no fire medics up north just private heros that operate on there own agenda, man I got to go there and be a cowboy.



Wow.  You do realize that in this one paragraph, you validated everything that Daedalus said about fire-based EMS in your area, right?  And everyone else that has posted here over the years saying that for firefighters, it's all about getting a bump in pay and a patch, and not much about making sure that sick people live.    

So, patient care doesn't matter, as long as you get paid well?  I'm glad to know what your priorities are.  I'll take the cowboy who actually gives a crap and keeps his skills up to date.


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## daedalus (Oct 17, 2009)

JPINFV said:


> That's not 100% accurate. I used to volunteer at a base hospital in Orange County and there was an RN and physician assigned to the radio. While the RN handled all of the radio communication and could issue most of the base hospital orders by themselves, they were linked via a Nextel to the designated physician. In 6 months, I think I observed the radio RN discuss something with the physician once. The vast majority of the calls to medical control were calls because they were forced to based on protocol.
> 
> Edit: Base hospital contact and transportation guideline: http://ems.dhs.lacounty.gov/policies/Ref800/808-1.pdf



I am referring to Los Angeles County. Most docs I became friendly with would laugh at the prospect of listening to a paramedic's report. That is sad. RNs with the MICN training answer the radios here and the paramedics never call for consultation or for potential creative solutions to problems, just for orders to continue down a pre-established protocol they cannot even follow without permission. (note, this is a complicated are for LA County. There are two fire departments in the whole county that are allowed to follow very limited protocols, but all others must call for orders for very basic things. Look into SFTPs for more info)

**atropine. I never said I worked in Ventura. I live here, and I might work here, or I might work in Kern or Santa Barbara or San Luis.***


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## atropine (Oct 17, 2009)

Linuss said:


> Because people like you advocate less education, less responsibility, and in general don't care about being a medic.  You'd rather put blue on red then handle medic calls, which ironically enough, is more than 70% of your call volume.
> 
> 
> And you're telling me there is nothing wrong with that picture?



Hey man chill out I am just saying that I enjoy my money thats all, I can't pay my bills with protocols thats all Iam saying, and yes again if it's so broken why haven't any of the medical directors try to fix it?, valid question I think. The reality is we have to get paid and why not make the best of it, if you want to make $13.00 an hour as a private medic with progressive protocols although you still have to do what an MD tells you to do then thats your right I guess. Hey man just saying I like the money thats all people will live and people will die, not my problem.


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## VentMedic (Oct 17, 2009)

atropine said:


> Hey man chill out I am just saying that I enjoy my money thats all, I can't pay my bills with protocols thats all Iam saying, and yes again if it's so broken why haven't any of the medical directors try to fix it?, valid question I think. The reality is we have to get paid and why not make the best of it, if you want to make $13.00 an hour as a private medic with progressive protocols although you still have to do what an *MD tells you to do then* thats your right I guess. Hey man just saying I like the money thats all people will live and people will die, not my problem.


 
The medical directors are limited because there are too many that should not be Paramedics but unfortunately somehow got the job as a FF and many of them should not be doing that. When medical directors are presented with those who have the attitudes about education and patient care such as you they have little choice but to have a nurse give you permission to do a protocol or if necessary have them read the protocol to you. Quite possibly if there wasn't a union protecting you for doing so little or nothing at all but show up, the medical director could do something about improving the system. 

In other systems the medical director writes the protocols and allows the Paramedics to think for themselves what protocol to do. The nurse or doctor doesn't have to read the protocol to the Paramedic on each call.


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## triemal04 (Oct 17, 2009)

Not to defend anything to do with Southern California EMS (or California EMS period) or what atropine has said, but a couple of things said by daedulus do need to be addressed as he is, in essence, saying that terrible patient care is the standard throughout the country.


> Yes, I can point to the fact that becoming a paramedic in Los Angeles does not require college anatomy and physiology. Becoming a paramedic in Los Angeles does not require any college education at all or let alone a AS degree


The vast majority of paramedic programs don't require college level A&P or a degree of any sort.  I guess that means that everyone from those places performs terrible patient care.


> I can point to the fact that many fire department paramedics are not happy preforming their duties on the rescues or squads and are just biding time until they get on an engine, and then the paramedic cert gets dropped. Does patient care thrive in such an environment?


I can point to the fact that many private, hospital based and third-service paramedics are not happy performing their duties and are just bidding their time until they retire or move on to something else.  Does patient care thrive in such an environment?  Once again by this reasoning, apparently lot's of places perform terrible patient care.


> Can I provide studies to demonstrate poor outcomes? No.


Huh.  So it's all anecdotal evidence that you, someone admittedly biased against the fire service and EMS in So. California are providing.  While you may be right, don't you think that this creates just a small problem with your credibility?

Again, I'm not saying that EMS in that area ISN'T horrible, just that grandstanding claims and baseless rhetoric don't do anyone a lot of good.  You want change...this isn't how to do it.  Get your facts and arguments straight, and then present them.  The more you go based off emotion the worse off you will be.


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## VentMedic (Oct 17, 2009)

triemal04,

Tell us all now, have you even been to Californa or more specially the Southern part? Do you know anything at all about these FDs? Have you even taken the time to research CA's statutes or the LA protocols? Probably not. You are just spouting emotional stuff again about something you have no knowledge of just to look like a tough fire fighter which you probably aren't one either but would like to be. 

There are reasons why RNs do the majority of CCT and flight in that state as well as giving the Fire Paramedics permission to do their protocols. 

Educate yourself before attacking another forum member's credibility.


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## 46Young (Oct 17, 2009)

Daedalus, the last time I checked, the NREMT didn't require a degree to test, let alone just A&P or pharm. Anyone from any state can go through a mill, get their state card, get the registry, and work at any agency in the country whose state recognizes the NREMT-P for reciprocity. 

The vast majority of medics in NYC that I've come across hold no degree whatsoever. NREMT-P isn't required to be employed, either. Having NYC 911 experience on one's resume will definitely raise an eyebrow most places you go (for 911).


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## reaper (Oct 17, 2009)

No, most decent systems are looking for medics that advanced their education. If I look at a resume, I could care less if it has NYCEMS listed on it. I will go off the persons abilities and education first!


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## 46Young (Oct 17, 2009)

reaper said:


> No, most decent systems are looking for medics that advanced their education. If I look at a resume, I could care less if it has NYCEMS listed on it. I will go off the persons abilities and education first!



You MUST be kidding. I know plenty of people who have left NY for other places. Easily hired. Let's face it, regarding 911, where else do you have medic units that are required to always be double medic, only get dispatched to ALS call types, and have a high call volume (high acuity as well, worth mentioning) at that? 

Everyone knows that working in NYC gives you a steep learning curve relative to time in service. Your job types for the shift are diff breather, asthma critical, cardiac condition, arrest, AMS, multi trauma, unconscious, OB out, etc. etc. You may not see every call type each shift, but you'll get your fill of legit jobs throughout the course of the week. Some nights that's actually what I've run. Compare that to the resume of someone who works out in the sticks. Actually, compare that to someone who works in a busy system, who is subject to mostly BLS, with good, legit ALS jobs being few and far between (maybe even a 911/IFT hybrid). They're doing sick calls, minor injuries, EDP's, BS MVA's while the NY medic is spending that same time learning from higher acuity and critical pts. The NY 911 experience speaks for itself, no one can deny that.

Really, how many medics out there actually have degrees anyway? One in 10? One in 20? One in 100? How many of those actually stick around in EMS for their entire career? More likely if they're applying to flight or CC, but we're talking about 911 prehospital medicine here. We all know that the industry has a high turnover as it is. Many agencies, even quality ones, go through medic shortages from time to time. Most places only look for the NREMT-P card or state. I've never been asked where I went to medic school, and neither has anyone else I've spoken to. That's because no one cares. If you've got the card, you're good. What DOES count is experience. Most places will give you a general knowledge exam prior to hire, maybe a scenario/protocol based oral board, maybe some skills stations before release to internship on the street. That's it.


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## DrParasite (Oct 18, 2009)

46Young said:


> You MUST be kidding. I know plenty of people who have left NY for other places. Easily hired. Let's face it, regarding 911, where else do you have medic units that are required to always be double medic, only get dispatched to ALS call types, and have a high call volume (high acuity as well, worth mentioning) at that?


using that logic, being a medic in NJ would be just as valuable as NYC experience, since all NJ medics work in the exact same system that you just described. and for some reason, we have many NY & PA medics that come to jersey (probably has something to do with the better pay with less BS)


46Young said:


> Everyone knows that working in NYC gives you a steep learning curve relative to time in service. Your job types for the shift are diff breather, asthma critical, cardiac condition, arrest, AMS, multi trauma, unconscious, OB out, etc. etc. You may not see every call type each shift, but you'll get your fill of legit jobs throughout the course of the week. Some nights that's actually what I've run.


actually i know medics in NJ that can run all those calls in a single shift (except for OB, those are BLS calls), plus a GSW or stabbing.

one thing to remember about NYC EMS: you have a hospital every 7 blocks.  your transport times are often super short, and how much ALS can you do in under 15 minutes?  or to clarrify, how many interventions can you perform, see the changes, and then perform additional ones for?  

don't knock the rural guys, when you have a sick patient, treating them for 20-45 minutes is a lot more difficult that treating a sick patient for a 3 minute transport.


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## 46Young (Oct 18, 2009)

DrParasite said:


> using that logic, being a medic in NJ would be just as valuable as NYC experience, since all NJ medics work in the exact same system that you just described. and for some reason, we have many NY & PA medics that come to jersey (probably has something to do with the better pay with less BS)
> actually i know medics in NJ that can run all those calls in a single shift (except for OB, those are BLS calls), plus a GSW or stabbing.
> 
> one thing to remember about NYC EMS: you have a hospital every 7 blocks.  your transport times are often super short, and how much ALS can you do in under 15 minutes?  or to clarrify, how many interventions can you perform, see the changes, and then perform additional ones for?
> ...



NYC is better known across the country (world), although NJ medics may be just as qualified. 

I know that the pay and working conditions suck in NY. That's why I left, as have many others. 

We do plenty onscene if we're up a few flights and we have reservations as to whether the pt will remain stable for the trip down to the bus. The city's goal is 20 mins onscene, otherwise they start calling for updates. If you've got two good medics, they can assess and bang out most of the interventions onscene, and complete the rest enroute to the hospital. I would keep a mental picture of how much time I have when enroute to the hospital to get stuff done. I'll do the rest onscene with my partner. sometimes we can't get to everything, but often we do. We're not held back by having to call the receiving hosp while enroute to the ED either. The driver gives a quick note to the dispatcher (age, sex, CC, ETA, ALS established) freeing the medics to work. 

A hospital every seven blocks is a gross overexaggeration. My txp times averaged between 4-10 minutes, sometimes longer depending where we're coming from. You can't fly down city streets, either, with all the potholes and such. In Queens alone I've seen St. Joe's (Union Tpke), St. John's (Queens Blvd), and Mary Immaculate close. That leaves Mt. Sinai of Queens, Elmhurst, Jamaica, Flushing, Forest Hills, NYHQ, LIJ and NSUH Manhasset (actually 3-5 minutes into Nassau County) for the entire borough of Queens. 

As far as the rural guys, how many of these critical pts are they actually transporting on a daily (monthly, yearly) basis? I had a taste of that in Charleston County, in McClellanville, John's Island, and similar places. They have RSI, they have medevac available weather dependant, but the typical practice there is to quickly load up and literally do everything enroute to the ED. So, in NY we treat onscene for 15-20 minutes, plus another 5-10 enroute to the ED. The rural crew spends five minutes onscene, and transports for 20-30 minutes, with a medevac option usually available for a critical pt. 20-30 minutes average for the urban crew, vs 25-35 minutes for the rural crew. Not much difference. The only drawback is that you may be the only medic there. Even still, I don't see a rural area running constant high acuity pts for long distances. Certainly not enough to surpass the urban medic's general proficiency.


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## daedalus (Oct 18, 2009)

Say what you want, but I actually worked in LA. I can only offer you the truth from my eyes, the way I saw things, and I recognize that my truth may be blasphemy at another's ears. Like I said, I got the opportunity to see the results of prehospital care on emergent CCT transports. I got the opportunity to deal with patients being discharged as well. And than I got to work with the paramedics themselves on a LA BLS 911 car. I got to see many facets of the system and I got to learn from many different RNs, RTs, Paramedics, and doctors (we sometimes took residents and even attendings on our transports). I tell you what I can based on the sum of this experience. I do not have goal of knocking down fire departments. My aim is to increase the quality of my own care to patients. 

You are trying to disprove my subjective experience. I am not offering any proof, just personal observations. I went into my job not aware of the problems facing EMS and got to learn about them myself. I had the gift of a broad view of medicine before even starting in EMS and I got to work around some very passionate people in public health and family medicine. I found the very opposite to be true in Los Angeles and am still sick to my stomach remembering the nights I spent second guessing my place in health care. I have regained sanity and focus where I am now, and it is people like the ones in this thread that drive me to continue towards my goal of becoming a medical director to restore the medicine to EMS. 

Please don't belittle my experiences and observations in a busy EMS system without first spending some time here yourself. And like I and Vent have said, just look at what they allow paramedics to do (or rather, not to do) in LA. You will see that they are not trusted to do much at all.


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## atropine (Oct 18, 2009)

daedalus said:


> Say what you want, but I actually worked in LA. I can only offer you the truth from my eyes, the way I saw things, and I recognize that my truth may be blasphemy at another's ears. Like I said, I got the opportunity to see the results of prehospital care on emergent CCT transports. I got the opportunity to deal with patients being discharged as well. And than I got to work with the paramedics themselves on a LA BLS 911 car. I got to see many facets of the system and I got to learn from many different RNs, RTs, Paramedics, and doctors (we sometimes took residents and even attendings on our transports). I tell you what I can based on the sum of this experience. I do not have goal of knocking down fire departments. My aim is to increase the quality of my own care to patients.
> 
> You are trying to disprove my subjective experience. I am not offering any proof, just personal observations. I went into my job not aware of the problems facing EMS and got to learn about them myself. I had the gift of a broad view of medicine before even starting in EMS and I got to work around some very passionate people in public health and family medicine. I found the very opposite to be true in Los Angeles and am still sick to my stomach remembering the nights I spent second guessing my place in health care. I have regained sanity and focus where I am now, and it is people like the ones in this thread that drive me to continue towards my goal of becoming a medical director to restore the medicine to EMS.
> 
> Please don't belittle my experiences and observations in a busy EMS system without first spending some time here yourself. And like I and Vent have said, just look at what they allow paramedics to do (or rather, not to do) in LA. You will see that they are not trusted to do much at all.



Really what do plan to restore in ems?. I only ask because there are several medical directors in the LA county area and things have been working just fine for the past 30 plus years. Again if people want to work for peanuts and go else where more power to them, I worked in Tulsa Oklahoma and it sucked money wise, but the calls and protocols were decent, but I don't mind calling the micn. I get to support my family and toys so I am cool with that, this talk about change and standard well I believe it when ems gets rid of system status.


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## reaper (Oct 18, 2009)

atropine said:


> Really what do plan to restore in ems?. I only ask because there are several medical directors in the LA county area and things have been working just fine for the past 30 plus years. Again if people want to work for peanuts and go else where more power to them, I worked in Tulsa Oklahoma and it sucked money wise, but the calls and protocols were decent, but I don't mind calling the micn. I get to support my family and toys so I am cool with that, this talk about change and standard well I believe it when ems gets rid of system status.



You do realize that a good portion of Med directors are Doc in the box types? They get paid a decent salary to sign their name on what ever the systems want. They will not change the way things are done.

Good Md's challenge the system and stand up for better pt care and hold those under them responsible. That is the system that works! If all you care about is the money, then stay where your at. But, be ready to here how crappy your system has been for the last 30 years. Most prefer progressive systems that advance, for the better care of their Pt's!


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## thegreypilgrim (Oct 18, 2009)

I'm going to go ahead and throw in my own comments for good measure. My experience and personal observations are actually consistent with what daedalus has reported. I started out as an EMT working for a private ambulance service that operated in both LA and OC, so I got to see how both counties operated. I did both BLS IFT's and 911 response with fire medics with this company, and what I saw happen daily was hard for me to fathom. I saw so much negligence that after a while it was no longer a mystery to me why the medics here are on such short leashes. I got BLS'd patients with chest pain, shortness of breath, altered LOC, even trauma criteria patients on a near daily basis by both LA and OC fire medics. Shocking that this occurs without fail every day and little to nothing is done about it.

Now that I'm a paramedic and working in LA this system has me tearing my hair out over how upside-down & backwards it is. FD medics here for the most part do not _*care*_ about the thing which basically justifies the fire service's existence & budget, which is EMS. What a bizarre mentality, that it's considered such a burden to the service. Like daedalus said earlier, most guys get their medic license just as a vehicle to get on a department; and, once they do they just bide their time on the rescue or squad until they can move to the engine or truck at which point they let their license lapse. Many people here who are involved with EMS/Fire will look at you like you've got three arms growing out of your head if you state an interest in being a medic for any other reason than to become a firefighter. Why on earth would someone want to do such a thing? It's no wonder then, that paramedics in LA/OC operate on what is likely to be the most restricted scope of practice in the entire country. No interpretation of 12-leads, no pediatric intubation, no needle cricothyrotomy, no needle thoracostomy (Orange County), a med box that consists of about 14 medications, and a list of procedures that may be performed prior to base contact that fits on a single piece of paper (OC medics, for example cannot even give repeat doses of albuterol without an order). Speaking of base contact, like daedalus said, when you call base you speak to a MICN who gives you his/her blessing to continue down the remainder of a pre-established protocol that is very basic yet you can't complete it without this permission. MICN's become very nervous when you request some sort of variance, and usually you'll just get the, "Hmmm, you said you're 5 min. out, just hold off on that and bring them here" line. Also, when you make base contact it doesn't consist of a patient's age, chief complaint, and your ETA. No, in the LA/OC little slice of paramedic heaven base contact consists of a long, drawn-out, detailed report of everything you've found in your assessment, what you've done so far, and what you'd like to do. It's basically a way for the MICN to play 20 questions with you to make sure you haven't killed your patient. There is such a lack of trust afforded to paramedics by hospitals due to terrible performance that this is what the system has come to. It's so bad that many ED's don't even utilize the IV line that the paramedic started in the field - they start a new one once the patient is in the ED and they might use the field line to draw labs or sometimes they even just remove it.

It's true that every year it seems that some other procedure or something is set to be pulled from the field. Sometimes, however, there are these shocking instances of trust extended to medics from medical directors that defy explanation and are subsequently ruined by field personnel. For example, Orange County paramedics used to carry streptokinase (a potent thrombolytic synthesized from streptococcus bacteria). So, despite all of the above OC medics were - for a short time - engaged in pre-hospital thrombolytic therapy. A few years ago, however, this was pulled from the field but not for the reasons one would expect. Medics weren't using it on hemorrhagic stroke patients or administering it horribly incorrectly or otherwise misusing it in any way. So, why did it get pulled from the field? Because they _weren't using it *at all*_. It was drastically underutilized in the field. Here they were, engaging in some seriously progressive prehospital medicine, and they just sat on it. All this streptokinase just sat in med boxes collecting dust until its expiration date. So, the county was tired of paying for this med when it wasn't being used, and now it doesn't exist in OC protocols any longer. Nice work everyone.

Unfortunately, it isn't just the prehospital aspect of our EMS system that is messed up. The ED's have their own bizarre antics as well. For the most part, if you're prehospital personnel, the only way a nurse will give you the time of day is if you wear yellow pants (that is, you're an FF/PM). Private ambulance paramedics are looked upon by ED nurses and other staff as slightly above the guy who's there to fix the HVAC system, but still more of a nuisance. Since I've only ever worked for private ambulance, I can say that I have never felt like I've been acknowledged as a fellow medical professional in this area. Never. The idea that any hospital staff personnel would listen attentively to what I have to say, trust me to make clinical decisions, and treat my like a professional is a foreign concept to me. Many of my friends have left the LA/OC microcosm to be paramedics in other parts of the state, and from what they all say it's like night and day. It took me a long time to accept the sorry state of EMS in this region, and this realization has often caused me considerable anxiety and doubt about my role in EMS. It has also made me seriously consider leaving the field for a different role in medicine (PA school, specifically). Furthermore, I am absolutely 100% certain that I will not take a job in EMS in LA or OC (even if it is for a FD); pretty confident about leaving the state; and, even desiring to leave the country.

It's such a shame that this is the way it is here, because southern California is such a great place to live and work, and there is an excellent variety of calls. It could be such a progressive system, but I can't really see things ever changing for the better. Anyway, I've already said too much as it is so I'll put a sock in it for now.


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## John E (Oct 18, 2009)

*For those making claims about quality of care...*

I would urge those who think that simply giving Paramedics permission to do more in-field procedures and increasing ALS protocols read the article in EMS Responder magazine about the OPALS study, which documents the results of increased ALS procedures done in a pre-hospital setting. The abstract/summary was written by the Medical Director of, surprise surprise...Ventura/Santa Barbara Counties. 

I'm done, thanks for playing everyone.

P.S. the fifth and seventh paragraphs are the best ones...


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## reaper (Oct 18, 2009)

Here's a hint. Go talk with trauma Dr's and see what they think of the OPALS study. Don't stand to close, They may spit on you, from all the laughter!


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## daedalus (Oct 18, 2009)

John E said:


> I would urge those who think that simply giving Paramedics permission to do more in-field procedures and increasing ALS protocols read the article in EMS Responder magazine about the OPALS study, which documents the results of increased ALS procedures done in a pre-hospital setting. The abstract/summary was written by the Medical Director of, surprise surprise...Ventura/Santa Barbara Counties.
> 
> I'm done, thanks for playing everyone.
> 
> P.S. the fifth and seventh paragraphs are the best ones...



You would have thought you just dropped a nuke on some of us or something? OPALS? I think you are the one who needs to re-read OPALS. Dropping a name like OPALS and then saying "I am done" suggests to me you do not know a lot about what you are trying to say. You should re read OPALS, investigate the systems it studied and compared, and then ask some intelligent people what they think about it. 

Also, the efficacy of advanced prehospital care was not even an angle of what myself and Pilgram where speaking of. Speaking for myself, I was talking about just caring for your patients the way they deserve to be cared for. It just is not done that way in Los Angeles based on what I have seen (which seems to be seconded by many others who care about the field).

Also, there is the little fact that Dr. Salvucci in Santa Barbara and Ventura still lets his paramedics use clinical judgement while LA, the RN gets to do that.


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## VentMedic (Oct 18, 2009)

John E said:


> I would urge those who think that simply giving Paramedics permission to do more in-field procedures and increasing ALS protocols read the article in EMS Responder magazine about the OPALS study, which documents the results of increased ALS procedures done in a pre-hospital setting.


 

If you had read OPALS, you would have discovered that the "BLS" the Canadians referred to had more hours of education than the U.S. Paramedic.


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## daedalus (Oct 18, 2009)

*by the way...*



> *The addition of a specific regimen of out-of-hospital advanced life support interventions to an existing EMS system that provides basic life support was associated with a decrease in the rate of death of 1.9 percentage points among patients with respiratory distress.*
> 
> This is good evidence that the prompt and correct treatment of patients with respiratory distress results in better immediate (greater prehospital improvement, lower incidence of ED intubation) and long-term (reduced mortality, better overall cerebral function) outcome. These are important results that identify a group of patients prehospital ALS treatment is likely to help.
> 
> ...



- Angelo Salvucci MD (director Santa Barbara and Ventura counties)


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## John E (Oct 18, 2009)

*You seem to be harboring...*

the illusion that I care about what you think. I don't. You don't make policies, you don't set standards, and truly nothing personal meant but from your own avatar and signature you're not even a Paramedic in the system that you insist on touting at every opportunity. You don't like the way things are done in Los Angeles county, I get that. I just don't particularly agree with you or care about what you think. If and when you can post some data to go with your feelings please do, I'm sure some interested party will read it.

Not dropping any bombs, just pointing out some actual data as opposed to your opinions. Again, feel free to post data that contradicts what the OPALS research shows, send a copy to your medical director while you're at it.

If you can't make the connection between what you've been yammering about and the results of that study, it's your problem, not mine. If your medical director allows his paramedics, are they his personally or does he share them with the community?, but I digress, if he allows them to continue to do procedures that he knows by his own analysis of the OPALS study don't work, again, that's your problem, not mine. I would be curious to know how a doctor reconciles writing that using advanced ALS procedures in the field don't increase patient survival rates but advocates his own people using them but that's an question I'd post to him, not to you. 
Giving paramedics autonomy to continue to perform procedures that don't increase patient survival seems like a pretty hollow victory to me but if getting to interpret that 12 lead makes you feel better about doing your job, have at it.

As for being done, I was referring to being done arguing with people and reading some of the nonsense posted in this thread. Sorry I wasn't clearer about that.

Now I'm done.


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## VentMedic (Oct 18, 2009)

John E said:


> the illusion that I care about what you think. I don't. You don't make policies, you don't set standards, and truly nothing personal meant but from your own avatar and signature you're not even a Paramedic in the system that you insist on touting at every opportunity. You don't like the way things are done in Los Angeles county, I get that. I just don't particularly agree with you or care about what you think. If and when you can post some data to go with your feelings please do, I'm sure some interested party will read it.
> 
> Not dropping any bombs, just pointing out some actual data as opposed to your opinions. Again, feel free to post data that contradicts what the OPALS research shows, send a copy to your medical director while you're at it.
> 
> ...


 

I can't believe I am reading such a comment in the year 2009.

You really should pull up the OPALS for both cardiac and trauma. Read the full articles.

You also need to educate yourself for the Canadian education requirements.


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## daedalus (Oct 18, 2009)

> I just don't particularly agree with you or care about what you think.


I am allowed to post my opinions here just the same as you are, correct? Civil debate is better than dragging someone through the mud. 

You are right, I am not a paramedic. I am an EMT. I also do not make policy. I am however a member of our national advocacy organization, and frequently write letters to politicians who probably ignore them, all to improve patient care in our state. I also plan on making EMS policy one day. 

It seems to me you are a standby EMT for film and other events. Have you worked with the firefighters on a 911 BLS car? Have you transported patients from the emergency department after they have been brought into the ER by the fire departments? How can you stand to defend them?

And, it is not a hollow victory for me and my paramedic partners to be greeted by emergency room staff as professionals, and to be recognized as independent thinkers and have our opinions listened to and respected.


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## VentMedic (Oct 18, 2009)

VentMedic said:


> I can't believe I am reading such a comment in the year 2009.
> 
> You really should pull up the OPALS for both cardiac and trauma. Read the full articles.
> 
> You also need to educate yourself for the Canadian education requirements.


 
Just for clarification, the O in OPALS stands for Ontario which is in Canada.


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## John E (Oct 18, 2009)

*Now we're learning geography...*

thanks for the geographical information. The summary I referred to dealt with ALS interventions, not with BLS interventions. The fact that Canada has different BLS educational standards is so far from the point of what I referred to as to be a totally different topic. 

Other than having only one road, Canada is very nice place to be from...even Ontario. 

P.S. The people who live and work in Ontario, California might take exception to your statement that Ontario is in Canada...

John E


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## daedalus (Oct 18, 2009)

John E said:


> thanks for the geographical information. The summary I referred to dealt with ALS interventions, not with BLS interventions. The fact that Canada has different BLS educational standards is so far from the point of what I referred to as to be a totally different topic.
> 
> Other than having only one road, Canada is very nice place to be from...even Ontario.
> 
> ...



Not far from the point at all. You brought up OPALS. The O in OPALS stands for Ontario (In canada). OPALS compared BLS and ALS. In Canada, BLS is close to what we call ALS in the United States.

You are now being belligerent. Are you even aware of the qualifications of the people you are arguing with? Compared to your own?


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## JPINFV (Oct 18, 2009)

John E said:


> thanks for the geographical information. The summary I referred to dealt with ALS interventions, not with BLS interventions. The fact that Canada has different BLS educational standards is so far from the point of what I referred to as to be a totally different topic.


When the definitions of "BLS education," "ALS education," "BLS treatment," and "ALS treatment" varies the amount that they do between the US definition and the Ontario, Canada definition, you can't apply studies about Canada BLS treatments to American BLS treatments. It's like saying that a NP can treat condition X as well as a physician. Well, the NP is a nurse, therefore an RN can provide the same level of care. 




> P.S. The people who live and work in Ontario, California might take exception to your statement that Ontario is in Canada...




1. The "Ontario" in "Ontario Prehospital Advance Life Support" is not Ontario, CA.

2. Canada can have Ontario as far as I'm concerned. They can take Pomona too as long as the region bordered by 1st St, 3rd St, Town, and Gibbs stays in California.


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## JPINFV (Oct 18, 2009)

John E said:


> the illusion that I care about what you think. I don't. You don't make policies, you don't set standards, and truly nothing personal meant but from your own avatar and signature you're not even a Paramedic in the system that you insist on touting at every opportunity. You don't like the way things are done in Los Angeles county, I get that. I just don't particularly agree with you or care about what you think. If and when you can post some data to go with your feelings please do, I'm sure some interested party will read it..


To be fair, you aren't a paramedic either in the system you're touting.


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## VentMedic (Oct 18, 2009)

John E said:


> thanks for the geographical information. The summary I referred to dealt with ALS interventions, not with BLS interventions. The fact that Canada has different BLS educational standards is so far from the point of what I referred to as to be a totally different topic.
> 
> Other than having only one road, Canada is very nice place to be from...even Ontario.
> 
> ...


 
I can't believe you think OPALS is about Ontario, California.


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## John E (Oct 18, 2009)

*And I can't believe...*

that you believe that I actually believe that I was referring to Ontario, California either but you've shown to unable to understand other things that other people have written in the past so who knows what you think.

Now ask me if I care what you believe?

Just don't it via private messages, I've got enough of those from you already.

John E


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## JPINFV (Oct 18, 2009)

To be fair, I can't believe that you believe that Canadian "BLS" is comparable to American "BLS." So I guess we're even.  Now go sit in the... comfy chair...


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## John E (Oct 18, 2009)

*Not really...*



JPINFV said:


> To be fair, you aren't a paramedic either in the system you're touting.



Well to be fair, I haven't actually touted any system, nor have I ever claimed to be a Paramedic, I simply asked for the person who was denigrating the Los Angeles County EMS system to provide some actual data other than their personal feelings. Personally, I haven't heard of, read of, been told of, or seen an EMS system that couldn't stand improvement but that's my OPINION.

I'm well aware that L.A. has it's problems, I live and work here full time, have done so for the last 30 years now. (Not working in EMS all that time).

It's simple, if I state that the school you're attending is crap and anyone who goes there is an idiot I should either be able to offer up some evidence or admit that I'm only offering my personal opinion. To state that your school is crap and attempt to offer as proof that I didn't like it when I attended it isn't proof of anything other than that I had a bad experience. There are a large number of people on this forum who think that offering up their opinion means that it should be accepted as fact and I call bull:censored::censored::censored::censored: on that.

In the interest of full disclosure, I once lived in Pomona, have driven by your school but have never set foot in it or attended classes therein so my opinion that it's crap was only meant as an illustration...;^) Is it crap? Never mind...

And for what it's worth, my comments about daedalus not being a Paramedic yet wasn't an attempt to put him/or her down, it really wasn't. I was simply making the observation that he/she isn't working as a Paramedic in the Ventura County EMS service yet and until that happens, no one really knows what he/she will think of things. I would also add that anyone attending Paramedic school should be enthusiastic, I'd be worried if they weren't. Time has a way of  tempering that enthusiasm into reality.

John E


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## John E (Oct 18, 2009)

*Thought I was finished...*

turns out I wasn't.

As someone else wrote, just for clarification, I don't believe, think, or know that what we call BLS is the same as what our brothers and sisters in Kanuckistan call BLS. I also never wrote, stated, claimed, exclaimed, pontificated, or espoused that belief. As I've written before, if you can find a post in which I did so, please post it. 

My comments about the study which did not take place in or around Pomona or even Ontario, California were very specific, I asked for people interested  to read the summary of the OPALS that was written by the Medical Director of Ventura/Santa Barbara Counties and that was published in EMS Responder magazine, specifically the fifth and seventh paragraphs of the writers conclusions. If one were to do that, one would find that the writer is not comparing Canadian and U.S. BLS practices nor is it comparing Canadian and U.S. BLS practices vs ALS practices. I'm not gonna spoil the fun of it for those who want to go and read the actual words as written but to paraphrase, the author is commenting on the effects of ALS interventions and the survival rates of patients in the study.  Again, I don't want to spoil anything but I was hoping that some of superbly educated among us, and even those with a "mere" Associates Degree would be able to understand the comments made by the Doctor who wrote the summary.

Not the gospels, but an interesting conclusion written by someone who would appear to know what he's talking about.

I'll leave it to the readers to see if the conclusions reached have any bearing on the idea that having Paramedics that can do more and more procedures in the field, with or without an MD or an RN's supervision is a good idea or not. If I'm completely and totally wrong about what I read, I would love to be shown where and how, with the exception of being told again and incorrectly that I don't know the difference between Canadian BLS and U.S BLS since that was NEVER the point in the first place. And since I do in fact know the difference. I've actually been to Canada, how many of you can say that...?;^)

John E


P.S. Poutine, yet another reason why Canada is an interesting place to be from...


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## triemal04 (Oct 18, 2009)

Daedalus-

Actually I don't really disagree that EMS in Southern Cali is screwed up.  (perhaps you should re-read the post if you didn't get that).  What I disagree with, and was pointing out was that the examples and situations you used to try to get that point across were, for the most part, not valid.  Nobody is trying to to "disprove" anything you may have seen; but anecdotal stories from someone with your bias (even if it's a valid bias in this case) doesn't mean much.  An arguement doesn't really mean much if the claims that are made don't add up.  Clear?

venty....why do you do this to yourself?  Do you actually *read* posts anymore, or just hit the reply button and type whatever random thought is going through your head?


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## thegreypilgrim (Oct 18, 2009)

John E said:


> turns out I wasn't.
> I'll leave it to the readers to see if the conclusions reached have any bearing on the idea that having Paramedics that can do more and more procedures in the field, with or without an MD or an RN's supervision is a good idea or not.


John, I seriously doubt anyone is suggesting that Paramedics' scope of practice should just be arbitrarily increased to allow them to do all sorts of cool crap in the field for no reason. You're creating a straw man. If you just stood back and didn't consider your opponents' posts in isolation you'd see the larger picture. Virtually everyone challenging you here is one who advocates expansion of paramedic _*education*_ first, and _*therefore*_ increasing their general scope of practice and clinical independence. No one is advocating we always do all our ALS interventions on every patient we ever see because that's what we do because we're ALS and so on. You also keep bringing up the OPALS study as some sort of bizarre defense of the restricted scope for LA County EMS. What precisely is your point here? You think the LA County Medical Director read OPALS and said, "Holy *beep* I gotta get my medics in line with current research!" and that's why LA has such a crappy scope? Since when did OPALS become the gold standard for prehospital trauma management anyway? As far as I know most authorities in the U.S. are still trying to figure out how to interpret it and even apply it to the American system. Nor am I aware of organizations like the AMA or ACEP or ACS suddenly revising their standards to make them in accordance with OPALS. Yeah, we all get that penetrating trauma patients fair worse with fluid resuscitation and spending time on scene to intubate them if transport times are short. As far as I can tell no one's trying to challenge that, and this is just so off course from the initial discussion that I don't even understand how we got here.

Daedalus and myself have just offered up our own observations and opinions on the nature of LA EMS after having spent considerable time working in that system. Nothing further has been suggested. Yet, somehow, these observations have been interpreted as an attempt to "prove" something (that's really the wrong word to use in this context too, let's not allow ourselves to be bewitched by language games). I don't really see what your motivation is, nor can I understand how you could have worked in this system as an EMT and think it's "fine" or otherwise no worse off than other systems.


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## JPINFV (Oct 18, 2009)

John E said:


> As someone else wrote, just for clarification, I don't believe, think, or know that what we call BLS is the same as what our brothers and sisters in Kanuckistan call BLS. I also never wrote, stated, claimed, exclaimed, pontificated, or espoused that belief. As I've written before, if you can find a post in which I did so, please post it.
> 
> My comments about the study which did not take place in or around Pomona or even Ontario, California were very specific, I asked for people interested  to read the summary of the OPALS that was written by the Medical Director of Ventura/Santa Barbara Counties and that was published in EMS Responder magazine, specifically the fifth and seventh paragraphs of the writers conclusions. If one were to do that, one would find that the writer is not comparing Canadian and U.S. BLS practices nor is it comparing Canadian and U.S. BLS practices vs ALS practices.


First off, thank you so much for providing a reference. At the very least, a link would have been appropriate, however, here you go.

http://www.emsresponder.com/print/EMS-Magazine/Literature-Review--Advanced-Life-Support-for-Major-Trauma-Patients/1$8060

To take OPALS and apply it to US *is* saying that their BLS and our BLS is the same. Period. There is no discussing this fact. To take a study that, in the words of your article, "compared the outcomes of patients for three years in BLS systems and then for three years after introducing paramedics in ALS systems," and trying to advocate BLS treatments in the US is simply absurd without clarifying and discussing the differences between an EMT-B in the US and a primary care paramedic in Ontario (Canada) makes a critical error in analyzing this study.

Furthermore, you, at no time in the post where you brought this up, specified "trauma." This brings up a few major points. First, I can find articles that showed that it is safer for trauma patients to be transported by private vehicle than to wait for an ambulance. Should we stop sending ambulances to traumas since ambulances are associated with worse outcomes when compared to 'home boy ambulance service?' Second, even your article admits that "For minorly to moderately injured patients, an IV with analgesia is very appropriate." So, what should we do? Send EMT-Bs only to traumas and have them call for paramedics if they aren't going to die in the next 3 minutes? 

Third (and this get's it's own segment), OPALS looks at more than cardiac arrest and trauma. Here's a gem at the end of one part of OPALS* that ties this entire thing together. "A program to administer medications for symptom relief (nebulized salbutamol and sublingual nitroglycerin) was introduced toward the end of the first phase of this study. Although this program was not specifically related to advanced life support, it may have been a factor that influenced the benefit in the second phase of the study." So the introduction of symptom relief might have been a factor, but looky here. It's salbutamol (albuterol) and nitroglycerin. Gee. Those aren't BLS interventions in the US (especially California), but they aren't considered ALS in Canada, but those are considered an important set of treatment interventions.

Does ALS make a difference in Ontario (Canada)? Well, it depends on the complaint. However, applying OPALS to the US would mean comparing paramedics to PAs trained in emergency medicine because Canada calls our paramedics "BLS" and our basics "first responders."


*Since I'm actually trying to make a consistant discussion, I'll actually provide a reference and link. 

Stiell IG, Spaite DW, Field B, et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. _N Engl J Med._ 2007. 356;21 
http://content.nejm.org/cgi/reprint/356/21/2156.pdf


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## VentMedic (Oct 18, 2009)

John E said:


> Now ask me if I care what you believe?
> 
> Just don't it via private messages, I've got enough of those from you already.
> 
> John E


 

You sent the first PM and you continue with the PMs.  Enough already. You are only showing you don't understand anything JPINFV, daedalus or anyone has tried to explain to you. 

You must read a study before you spout off stuff about it.  
You must understand the difference between Ontario, Canada and Ontario, Calfornia. 
You must understand that the OPALS are NOT referring to the 120 hour EMT-Basic in their "BLS" study.

However, I will repeat again, you MUST READ a study and understand it first.


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## fortsmithman (Oct 18, 2009)

John E said:


> P.S. The people who live and work in Ontario, California might take exception to your statement that Ontario is in Canada...
> John E



I'm Canadian and fyi the Province of Ontario is one of our more heavier populated provinces as well as being the province that the national capital Ottawa is located in.


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## John E (Oct 18, 2009)

*I take your point...*

But as I've written before, I'm done with this thread. And this time I mean it.

If people are going to accuse me of not knowing where Canada is, I'm just not going to play.


John E


P.S. I do want to apologize here publicly to daedalus, I used some pretty harsh words in my earlier posts to you and I shouldn't have, for that I'm sorry.


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## John E (Oct 18, 2009)

*I should have been more clear...*

Ontario is not ONLY located in Canada.

Apologies to my brothers and sisters in the land of poutine and Leonard Cohen, long may it wave...

John E

P.S. J, can I call you J? I only referred to 2 paragraphs of the conclusion which you seem to have either overlooked or skipped. They helped prove the point which I was making. Which was again that simply increasing scopes of practice and allowing Paramedics to do more without direct supervision is not a guarantee of better patient care or of increased survival rates. Since I didn't cite the entire study I can't speak to it's accuracy. One would hope that the Medical Director of Ventura/Santa Barbara counties would when he wrote:

 " There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility."


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## daedalus (Oct 18, 2009)

triemal04 said:


> Daedalus-
> 
> Actually I don't really disagree that EMS in Southern Cali is screwed up.  (perhaps you should re-read the post if you didn't get that).  What I disagree with, and was pointing out was that the examples and situations you used to try to get that point across were, for the most part, not valid.  Nobody is trying to to "disprove" anything you may have seen; but anecdotal stories from someone with your bias (even if it's a valid bias in this case) doesn't mean much.  An arguement doesn't really mean much if the claims that are made don't add up.  Clear?
> 
> venty....why do you do this to yourself?  Do you actually *read* posts anymore, or just hit the reply button and type whatever random thought is going through your head?



I never implied that I had proof or that my experiences were substitutes for proof. In fact, I believe I said that I would not trust EMS folks in LA with my dog's life. That is a far cry from saying "I can prove that prehospital care in LA sucks". However, point taken. 

I stand by my statements. I am in firm belief that the prehospital care in Los Angeles sucks major horse's butt. This is formed from my experiences. I only offer my opinion as the sum of my experience and nothing else. You may decide to disagree with me, however, before accusing me of being wrong I suggest you ride out a few shifts down here. 

John E, I am perplexed. You have insulted people that I am quite fond of here just because they called you out on your posts. Like greypilgrem said, none of the people you are arguing with are advocating increases in the amount of skills paramedics can do. In fact, VentMedic, JPINFV, and myself all have called out paramedics and EMTs who think in the "skills" mentality. You have criticized increasing paramedic education in another thread, and than criticized ALS level interventions in this thread. Taken together, I can only assume you think that paramedics should not increase educational standards and should not do ALS level care because it results in poor outcomes (our logic). Is this a pass at paramedics in general? 

I do not mind people disagreeing with me, I just do not understand your stances on issues facing EMS and what experiences lead you to say the things you have said.


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## daedalus (Oct 18, 2009)

John E said:


> P.S. J, can I call you J? I only referred to 2 paragraphs of the conclusion which you seem to have either overlooked or skipped. They helped prove the point which I was making. Which was again that simply increasing scopes of practice and allowing Paramedics to do more without direct supervision is not a guarantee of better patient care or of increased survival rates. Since I didn't cite the entire study I can't speak to it's accuracy. One would hope that the Medical Director of Ventura/Santa Barbara counties would when he wrote:
> 
> " There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility."



Again, this is for *trauma* only. Dr. Salvucci has also said in reference to the OPALS study:



> The addition of a specific regimen of out-of-hospital advanced life support interventions to an existing EMS system that provides basic life support was associated with a decrease in the rate of death of 1.9 percentage points among patients with respiratory distress



"ALS" level care is superior to BLS level care for medical calls. However, I also argue that ALS level care is superior to BLS care in trauma as well. We have evolved our management of trauma patients in the field thanks to (unfortunately) the wars in Iraq and Afghanistan. We have learned a lot about fluid resuscitation and permissive hypotension. We have learned to limit time on scene, move intubation down on our priorities, use capnograpghy as needed to confirm placement, and to start IVs en route as opposed to on scene. Should you doubt this new line of thinking, check the latest ITLS standards. Paramedics also have a much improved understanding of trauma, anatomy, and the physiology of shock. They should be able to better care for trauma patients than EMTs. Paramedics can also provide "BLS" interventions. Both BLS and ALS are medical care and paramedics are in a better position to provide medical care as they have practiced it more than an EMT in school, and have a greater understanding of the human body and pathology.


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## JPINFV (Oct 18, 2009)

John E said:


> Ontario is not ONLY located in Canada.
> 
> Apologies to my brothers and sisters in the land of poutine and Leonard Cohen, long may it wave...
> 
> ...



Apparently you didn't read my post because I quoted a section of that exact paragraph and have underlined it here. Should we stop sending paramedics to traumas until it's determined that the patient isn't going to die immediately? Furthermore, there's other things to consider than mortality. Denying paramedics (which, with the proper training wouldn't be ****ing around on scene anyways) to patients also denies pain control and other measures. Can I volunteer you to be the patient who gets denied pain control since "BLS" is 'better' for traumas (note: not specifying severity, just trauma in general).

Hell, I'll take this a step further. Transport by POV has at least one study that shows better outcomes than ambulance transport Since ransporting by POV has a lower mortality rate than ambulance transport, can we stop sending ambulances to car accidents and shootings?

"CONCLUSIONS: Patients with severe trauma transported by private means in this setting have better survival than those transported via the EMS system."
-Demetriades D, et al. Paramedic vs private transportation of trauma patients. Effect on outcome. Arch Surg. 1996 Feb;131(2):133-8.
http://www.ncbi.nlm.nih.gov/pubmed/8611068


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## atropine (Oct 18, 2009)

daedalus said:


> I never implied that I had proof or that my experiences were substitutes for proof. In fact, I believe I said that I would not trust EMS folks in LA with my dog's life. That is a far cry from saying "I can prove that prehospital care in LA sucks". However, point taken.
> 
> I stand by my statements. I am in firm belief that the prehospital care in Los Angeles sucks major horse's butt. This is formed from my experiences. I only offer my opinion as the sum of my experience and nothing else. You may decide to disagree with me, however, before accusing me of being wrong I suggest you ride out a few shifts down here.
> 
> ...



You don't have any LA experience in LA buddy, unless you have to wake up in the mornig give drills on equipment study your *** off for your probationary test, and workon the RA, or squad then you can rant about all your experience until then your are just a hater for what ever reason, my point to all this is that people talk crap about this system and don't work in it. Even if your a private medic in the LA ciounty area your not part of any of the 911 system, so I don't get how your points can even be valid, and yes I am all for change but the MD's with the higher uo education feel that nothing is broken so why fight it, can't we just all get along with our cool jobs, great bennies, and suv's.^_^


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## daedalus (Oct 18, 2009)

atropine said:


> You don't have any LA experience in LA buddy, unless you have to wake up in the mornig give drills on equipment study your *** off for your probationary test, and workon the RA, or squad then you can rant about all your experience until then your are just a hater for what ever reason, my point to all this is that people talk crap about this system and don't work in it. Even if your a private medic in the LA ciounty area your not part of any of the 911 system, so I don't get how your points can even be valid, and yes I am all for change but the MD's with the higher uo education feel that nothing is broken so why fight it, can't we just all get along with our cool jobs, great bennies, and suv's.^_^


This is laughable. I was a EMT at a company that provided 911 transport to LAcoFD. I worked with the paramedics. I quit that job and went to an IFT company in LA while I went to school. I then quit that job, and am at my new one somewhere else out of the county. 

I also do not need to do drills in the morning to know what I am talking about, since FD drills have nothing to do with medicine. Perhaps I should have you take organic chemistry before getting into a debate with me?


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## fortsmithman (Oct 19, 2009)

Before I joined my town's ambulance service I thought that fire and EMS went together.  After joining the service and reading posts from EMS personnel in govt third service agencies and private service as well as fire I've come to the conclusion that EMS should be a separate service.  The posts that influenced my views came from the fire medics on this forum.  If we were to be merged with another public safety agency then it would have to be the police service.


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## atropine (Oct 19, 2009)

daedalus said:


> This is laughable. I was a EMT at a company that provided 911 transport to LAcoFD. I worked with the paramedics. I quit that job and went to an IFT company in LA while I went to school. I then quit that job, and am at my new one somewhere else out of the county.
> 
> I also do not need to do drills in the morning to know what I am talking about, since FD drills have nothing to do with medicine. Perhaps I should have you take organic chemistry before getting into a debate with me?



about your 911 transport that really doesn't count now does it, I wouldn't trust the privates to even take a B/P for me, and drill have everything to do with medicine and more again unless your there you can't talk. I have given drill on meds, MCI's IV cathiters, and much more along with the suppression stuff. I not trying to ruffle feathers here, but dual role really deserves all that we get, for obtaining the knowledge we have to use and do on a daily basis.


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## mycrofft (Oct 19, 2009)

*"Oh, YEAH!??"*

You guys still at it?


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