# Progressive EMS systems?



## maineiacmedic (Apr 7, 2020)

I'm a brand new Paramedic from New England looking for a change of scenery. I'm wondering if anyone has some insight on EMS systems/departments with high call volumes and aggressive/progressive protocols (RSI, more meds, evidence based, ultrasound, vents, department participates in studies/trials, etc.)? 

Preferably, I'd like to find an urban system in the eastern half of the US. A place that will allow me to practice good medicine as well as help me learn and grow clinically as a new medic. I've applied to Austin Travis County, TX, Wake County, NC, and New Orleans, LA so far. I like the rescue/special ops opportunities that those departments have as well.

If you have some suggestions I'd appreciate it!


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## NPO (Apr 7, 2020)

maineiacmedic said:


> I'm a brand new Paramedic from New England looking for a change of scenery. I'm wondering if anyone has some insight on EMS systems/departments with high call volumes and aggressive/progressive protocols (RSI, more meds, evidence based, ultrasound, vents, department participates in studies/trials, etc.)?
> 
> Preferably, I'd like to find an urban system in the eastern half of the US. A place that will allow me to practice good medicine as well as help me learn and grow clinically as a new medic. I've applied to Austin Travis County, TX, Wake County, NC, and New Orleans, LA so far. I like the rescue/special ops opportunities that those departments have as well.
> 
> If you have some suggestions I'd appreciate it!



My agency is progressive, but isn't a metro area. We are a mix of rural and urban. We get busy in the summer from tourism, then slow way down in the winter. 

We have 6 ALS trucks on during the day and 4 at night. That is augmented by up to 5 ALS fly cars. No BLS ambulances. ALS units are a mix of BLS/Medic and Medic/Medic. Everyone from our Chief down is a working paramedic.

We have evidence based protocols that are updated at least every year. We get a lot of our changes from the Eagles Conference every year. 

We RSI, we have vents on every truck, Lucas on every truck, ultra sound, and unique treatment protocols like Esmolol for refractory VF, a "no medication" traumatic cardiac arrest protocol, IV nitro for CHF, and carry everyone's favorite drug, Ketamine (push dose and drip protocols). Only 1 or 2 of our medications require medial control.

All but one fire department are volunteer, and are mostly EMR level meaning you're medic in charge always. Our supervisors go on many calls to help, but never take scene control from the transporting medic. We often send 2 ambulances to support difficult calls, like cardiac arrest, maternity with imminent delivery, or lift assists. 

We do some small rescue stuff, like low angle ropes. We carry extrication clothing as we are expected to be involved in extrication and patient care on scene of MVAs, not sidelined waiting for a patient.

Our paramedics are the highest paid public safety personnel in the county, we have the best benefits, and we are the only full-time county-wide agency. This puts us in a unique position where other agencies call upon us for help, not the other way around.


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## maineiacmedic (Apr 7, 2020)

NPO said:


> My agency is progressive, but isn't a metro area. We are a mix of rural and urban. We get busy in the summer from tourism, then slow way down in the winter.
> 
> We have 6 ALS trucks on during the day and 4 at night. That is augmented by up to 5 ALS fly cars. No BLS ambulances. ALS units are a mix of BLS/Medic and Medic/Medic. Everyone from our Chief down is a working paramedic.
> 
> ...


You have piqued my interest. What department is this?


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## NPO (Apr 7, 2020)

maineiacmedic said:


> You have piqued my interest. What department is this?


Taney County Ambulance District in Missouri. We are a tax-based third service.


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## maineiacmedic (Apr 7, 2020)

NPO said:


> Taney County Ambulance District in Missouri. We are a tax-based third service.


can you send me a PM I can't figure out how to send one to you 😂


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## DrParasite (Apr 7, 2020)

maineiacmedic said:


> I like the rescue/special ops opportunities that those departments have as well.


If you like EMS based Rescue services, check out Pittsburgh EMS.  And Newark EMS.  and Baldwin EMS (outside of Pittsburgh). And Humboldt General Hospital EMS in Nevada

I have no idea how progressive these agencies are when it comes to EMS, but they all run EMS-based rescues.

And if you do a search, there are several other decent EMS agencies in NC besides wake


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## NPO (Apr 7, 2020)

I would avoid HGH for now. Theyre having some significant leadership changes because of some poor decisions by their management, and morale and everything kinda sucks there right now.


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## akflightmedic (Apr 7, 2020)

If you are in Maine...just jump a few states south or head west....anywhere but there. LOL Nothing like being 20+ years behind the EMS world.


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## maineiacmedic (Apr 7, 2020)

akflightmedic said:


> If you are in Maine...just jump a few states south or head west....anywhere but there. LOL Nothing like being 20+ years behind the EMS world.


Dude, you're telling me! I'm trying hard to get out of there after rona season is over 😂😂


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## SandpitMedic (Apr 7, 2020)

Check Vegas. Not East but very good spot.
No state income tax either.


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## PotatoMedic (Apr 7, 2020)

NPO said:


> I would avoid HGH for now. Theyre having some significant leadership changes because of some poor decisions by their management, and morale and everything kinda sucks there right now.


Good to know.  I've been tempted to apply.


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## NomadicMedic (Apr 7, 2020)

involved in research? king county medic one.


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## Tigger (Apr 7, 2020)

akflightmedic said:


> If you are in Maine...just jump a few states south or head west....anywhere but there. LOL Nothing like being 20+ years behind the EMS world.


Maine's that bad huh?

My parents live in Portland and I spent tons of time on the coast growing up. I could see myself moving there at some point but at the current juncture I kinda like doing fun paramedic things too. 

To the OP: I started my career in MA and still sort of keep tabs on the "scene" and while there are some pretty good smaller services, I imagine it's a battle to get on with them. There's some hospital based services in New Hampshire and Connecticut as well with good reps but again, I imagine an uphill battle. Also hear good things about New Britain EMS in CT which @medichopeful can chime in on I believe.


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## NomadicMedic (Apr 8, 2020)

After doing this for a while, things like RSI and progressive medicine have become less important. I’m far more interested in a great culture, work schedule that allows for work/life balance, promotional opportunity, decent retirement and a fair compensation package. Doing good medicine is important, but being paid well for it is also valuable.

I still recommend Sussex County Delaware as a stand out for all of the above.


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## maineiacmedic (Apr 8, 2020)

NomadicMedic said:


> After doing this for a while, things like RSI and progressive medicine have become less important. I’m far more interested in a great culture, work schedule that allows for work/life balance, promotional opportunity, decent retirement and a fair compensation package. Doing good medicine is important, but being paid well for it is also valuable.
> 
> I still recommend Sussex County Delaware as a stand out for all of the above.


I 100% agree with you, but I also would think I need a good 3-5 years of high call volume experience before Sussex county would even look at my application? I've looked into them and I would LOVE to work there but I'm a BRAND new medic (just licensed in January)


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## maineiacmedic (Apr 8, 2020)

Tigger said:


> Maine's that bad huh?
> 
> My parents live in Portland and I spent tons of time on the coast growing up. I could see myself moving there at some point but at the current juncture I kinda like doing fun paramedic things too.
> 
> To the OP: I started my career in MA and still sort of keep tabs on the "scene" and while there are some pretty good smaller services, I imagine it's a battle to get on with them. There's some hospital based services in New Hampshire and Connecticut as well with good reps but again, I imagine an uphill battle. Also hear good things about New Britain EMS in CT which @medichopeful can chime in on I believe.


Maine is rough, we only have 27 medications available including the basics and most need direct medical oversight, the protocols are very strict and conservative. Mechanical CPR devices are just getting looked at to be "approved." 

I actually grew up in Connecticut and took my EMTB course through NBEMS academy! I've applied to NBEMS three times over the past 4-5 years, never got a call back. I commute to work 48's at a smaller third service in Tolland county just to get some actual experience while I apply around and just got medical control clearance. I would stay in MA or CT but its just way too expensive, and I want to know what a winter is like not worrying about waking up extra early to clean 2 feet of snow off my car 😂


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## NomadicMedic (Apr 8, 2020)

maineiacmedic said:


> I 100% agree with you, but I also would think I need a good 3-5 years of high call volume experience before Sussex county would even look at my application? I've looked into them and I would LOVE to work there but I'm a BRAND new medic (just licensed in January)



Nope. They'd rather you don't have a lot of experience. They want to teach you their way. I'd apply. One of my biggest regrets is leaving.

If you have a strong educational foundation, you'll be a good fit. Trying to BS your way through is a recipe for disaster.


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## maineiacmedic (Apr 8, 2020)

NomadicMedic said:


> Nope. They'd rather you don't have a lot of experience. They want to teach you their way. I'd apply. One of my biggest regrets is leaving.
> 
> If you have a strong educational foundation, you'll be a good fit. Trying to BS your way through is a recipe for disaster.


well shoot, I'll throw my application in. Thanks for the tip! Why'd you leave? Whats their initial training program like?


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## Barsa (Apr 8, 2020)

I saw HGH EMS and felt I needed to reply to shed a little bit of light on our current situation.  Long time lurker, first time poster and what follows is of course under the usual "These are my views and not those of my agency" disclaimer.  

What @NPO said is accurate, to a point.  Currently, only two of the seven command staff that were here in November are still working for us and they are serving as the Interim Director and #2.  I was in the new hire process when the leadership change happened back in November.  The agency was very transparent and notified me that the changes had occurred almost as soon as they did.  From speaking with some of the other medics, some of the changes were needed changes, but they just happened extremely suddenly and relatively unexpectedly.  Right now we are "short" I think I heard 5 Paramedic positions, but we only have one shift line actually open, because two of the positions would be to staff a unit about 45 minutes north of town, but that hasn't been staffed since the change and isn't a "required" unit.  The other two would be filling office positions, which are currently secondary duties of two of the Medics.  We also have what are called "Casual Call" employees, which is essentially our verbiage for per diem positions, and we are almost always hiring for those.

I haven't noticed the morale actually feeling down, if anything I think the changes in leadership have strengthened the organization, because much of the workload has been shared between everyone, rather than one or two people as it historically was.  It also feels like the initial shock has worn off since and we are just about back to operation as normal.  If you are interested, I would absolutely apply, just knowing that the process may take some time.  

The "cliff notes" version (in case it hasn't been updated) of the agency is that we run approximately 3000 calls a year between 911, IFT between two hospitals, vehicle extrication, Haz-Mat, and Rope rescue.  We cover an area of approximately 10,000 square miles and roughly 20,000 people, currently with two full time crews and a supervisor, with most of the staff living in town with call back ability if needed.  We have 3 primary 911 ambulances, a "Rescue Ambulance," a heavy rescue, and a dual stretcher transfer rig as well as 8 or 9 additional semi- or unstocked rigs we use for Burning Man or if we had a significant MCI.  

We just switched to a 2 on, 5 off schedule (previously 1 on, 1 off, 1 on, 4 off) and are still feeling it out, since an average transfer is about a 6 to 7 hour round trip to Reno and seem to like to start around 9 pm.  I came from Fire based systems in Colorado and REMSA previous to that and absolutely love it here.  We have very open ended Clinical Guidelines, and usually do some type of training every day, with a lot of focus on airway and ventilator management.  We do have RSI and TXA on standing orders, as well as vents, IV pumps, and KingVision VL on every truck.  It is by far the most open scope I've had as a Paramedic, and we are encouraged to look beyond the 911 setting and actually about the long term patient outcome and course on each call.   I actually feel supported by the leadership in all contexts of the job, and the channels of communication are very open between field crews and the Interim Director.

Hopefully this helps out a little bit.  Feel free to PM me if you have some other questions.


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## E tank (Apr 8, 2020)

Got nothing to contribute...just so gratified to see something other than dumb Covid stuff....😷


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## NomadicMedic (Apr 8, 2020)

maineiacmedic said:


> well shoot, I'll throw my application in. Thanks for the tip! Why'd you leave? Whats their initial training program like?



I left because a mentor of mine got me back into my previous field. It was a bad mistake. But, what doesn't kill us makes us stronger. 

The hire process has changed a bit, I've heard. It used to be scenario and panel questions from FTOs and leadership. I hear they added a written test to weed out the zeroes. 

The clearance process is long and involved. It's basically the FTEP process, all competency based. It used to be very difficult to complete successfully, but I think they washed out too many candidates. It can take anywhere from 6 weeks to 6 months, depending on your skill level and how well you learn their systems. 

It's a great place. It has downsides,like anywhere... But if I were just a medic,looking to start a career with an agency,I'd go back in a heartbeat. Unfortunately they don't hire for anything other than medics, so someone with lots of experience still starts brand, new at the bottom. And the promotional process takes seniority into account. 

And it's Delaware. So, there's that. It's a bit insular and slow. (it's why they call Sussex county "slower lower" Delaware )

Anything else, just ask.


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## DrParasite (Apr 8, 2020)

Barsa said:


> The "cliff notes" version (in case it hasn't been updated) of the agency is that we run approximately 3000 calls a year between 911, IFT between two hospitals, vehicle extrication, Haz-Mat, and Rope rescue.  We cover an area of approximately 10,000 square miles and roughly 20,000 people, currently with two full time crews and a supervisor, with most of the staff living in town with call back ability if needed.  We have 3 primary 911 ambulances, a "Rescue Ambulance," a heavy rescue, and a dual stretcher transfer rig as well as 8 or 9 additional semi- or unstocked rigs we use for Burning Man or if we had a significant MCI.


OK, so you staff 2 911 ambulances and a supervisor.... who staffs the rescue ambulance and the heavy rescue?  off duty staff?  the supervisor takes the rescue wherever it needs to go?  if there is a MVA, does one crew respond in the ambulance, and the other put the 911 truck OOS and take the rescue?  Are most staff paramedics, or a mix of EMT and paramedic?


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## NPO (Apr 8, 2020)

DrParasite said:


> OK, so you staff 2 911 ambulances and a supervisor.... who staffs the rescue ambulance and the heavy rescue? off duty staff? the supervisor takes the rescue wherever it needs to go? if there is a MVA, does one crew respond in the ambulance, and the other put the 911 truck OOS and take the rescue? Are most staff paramedics, or a mix of EMT and paramedic?


The rescue is cross staffed. They have 2 stations, one hasn't been staffed pretty much since it opened other than a fly car sometimes.

Ideally, the rescue ambulance and 2 ambulances are staffed. But that hasn't been the case in a long time.

It's a mix of EMT/EMTA/Medic.


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## Barsa (Apr 8, 2020)

Heavy rescue is call back, almost entirely for Semi crashes or super technical rescues.  The Rescue Ambulance is the primary rescue rig, since it can also transport, and will be staffed by one of the crews.  So, yes, one crew brings a "normal" ambulance and one Rescue.  Each of our 911 ambulances also have a saw-zall and battery powered combi-tool if rescue is committed or delayed to get started. 

Right now, we have most of the full time crews as AEMT and Medic, but there are a few that are basic/medic with the EMT working on completing the written for NR-AEMT.  @NPO is right about the other station, it has not been very busy historically, so the current hospital admin has trouble justifying it.


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## NPO (Apr 8, 2020)

Barsa said:


> Heavy rescue is call back, almost entirely for Semi crashes or super technical rescues. The Rescue Ambulance is the primary rescue rig, since it can also transport, and will be staffed by one of the crews. So, yes, one crew brings a "normal" ambulance and one Rescue. Each of our 911 ambulances also have a saw-zall and battery powered combi-tool if rescue is committed or delayed to get started.
> 
> Right now, we have most of the full time crews as AEMT and Medic, but there are a few that are basic/medic with the EMT working on completing the written for NR-AEMT. @NPO is right about the other station, it has not been very busy historically, so the current hospital admin has trouble justifying it.


Glad to have you on board. You'll have better insight into HGH than I.


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## Barsa (Apr 8, 2020)

I appreciate it!  I have contemplated joining a few times over the years, so much useful knowledge and experience on the boards here!


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## GMCmedic (Apr 8, 2020)

NPO said:


> My agency is progressive, but isn't a metro area. We are a mix of rural and urban. We get busy in the summer from tourism, then slow way down in the winter.
> 
> We have 6 ALS trucks on during the day and 4 at night. That is augmented by up to 5 ALS fly cars. No BLS ambulances. ALS units are a mix of BLS/Medic and Medic/Medic. Everyone from our Chief down is a working paramedic.
> 
> ...



Man, I was pushing hard for IV nitro right before I left my ground gig. Never could get the medical director on board. I did manage to get them finger thoracotomy as a going away present.


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## NPO (Apr 8, 2020)

GMCmedic said:


> Man, I was pushing hard for IV nitro right before I left my ground gig. Never could get the medical director on board. I did manage to get them finger thoracotomy as a going away present.


It was on my list of things to push for, but wasn't at the top. Our medical director beat me to it.


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## CANMAN (Apr 9, 2020)

NomadicMedic said:


> After doing this for a while, things like RSI and progressive medicine have become less important. I’m far more interested in a great culture, work schedule that allows for work/life balance, promotional opportunity, decent retirement and a fair compensation package. Doing good medicine is important, but being paid well for it is also valuable.
> 
> I still recommend Sussex County Delaware as a stand out for all of the above.



Couldn't agree more on this point. You really want to find a good balance of total package. Early on I wanted all the high speed things and was willing to (and did) compromise on the pay and work life balance. I ended up working a full-time and two part-time jobs to make the money I wanted to make. After about 5 years I had enough, and although felt like clinically I was on the tip of the spear, that in an of itself wasn't enough to keep me where I was at. As I got older things that were once important to me were now not as important, and supporting & spending time with family rose a bunch of notches. 

With that being said, don't make a move strictly based on finances. I left a program I was overall really happy flying for because of low wages, which factored into the work life balance obviously. For the last 3 years I was flying for a lesser know, lesser quality, and crap culture place, and really regretted my decision to leave my previous job. Thankfully I can report they revamped their entire wage and program structure to include a clinical ladder, and I recently accepted a position to come back as a manager starting next week. 

Moral of the story is don't be guiding or pulled in a direction by one or two items and really evaluated the entire package. Great point Nomadic!


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## Peak (Apr 9, 2020)

I would add that what makes a good progressive system is more than just what advanced protocols or procedures are in place. 

Does the system allow for changes in protocols to be presented/made to the medical director by the line medics, nurses, and RTs? 

What is the process for QA/QI? Does the service have a professional and organized peer review process? How are errors handled, does leadership actually have just culture training?


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## medichopeful (Apr 9, 2020)

Tigger said:


> Also hear good things about New Britain EMS in CT which @medichopeful can chime in on I believe.



I can indeed chime in on them.  Hands down the best EMS service I've ever worked for.  In fact, I'm so happy there that I'm still there part-time even after picking up my full time flight job.

A quick run down of the service:
-Not-for profit, VERY heavily supported by the city (basically, we're a third service in everything but pension and benefits.  Benefits are good from what I understand, I don't have my health insurance through them but they very much take care of you)
-911 only (with the exception of the occasional stand-by for some sporting events and larger events), no posting, very nice base
-All box trucks with the exception of some SUVs (supervisors), a pick-up truck, and a Gator.  Powerlift/Powerloads on the majority of the frontline trucks, the rest are being installed in the near future
-Amazing working relationship with fire, police, and the hospital(s) in the area
-Protective equipment issued for all employees: helmet, extrication gear, and traffic vest.  Ballistic vests are available to check out at the beginning of the shift if you want, or they can help you buy your own
-Management truly cares about us, and they take our well-being and safety extremely seriously.  For example, if there's a tough call, it isn't uncommon for the on-duty supervisor to buy dinner for the entire on-duty staff
-Standing order RSI, vents on every truck, Lucas on every truck, King Vision on every truck, and LP15s which get replaced fairly frequently
-Excellent QA/QI program that is non-punitive with a dedicated QA/QI lieutenant
-Excellent FTO program that is broken up into 4 stages, and can be altered based on past experience.  All FTOs have at least 1 year of experience, and have to interview and test for the position
-When there isn't a pandemic, we have students with us all the time so there's plenty of opportunity to teach, even if you are not an FTO

It's a busy system, but you'll gain a ton of experience.  Unfortunately, it isn't the easiest to get hired because it's one of the top services in the state, but if you're a paramedic you should have a much easier time.



maineiacmedic said:


> I actually grew up in Connecticut and took my EMTB course through NBEMS academy! I've applied to NBEMS three times over the past 4-5 years, never got a call back. I commute to work 48's at a smaller third service in Tolland county just to get some actual experience while I apply around and just got medical control clearance. I would stay in MA or CT but its just way too expensive, and I want to know what a winter is like not worrying about waking up extra early to clean 2 feet of snow off my car 😂



We're currently hiring part-time paramedics, which would be a foot in the door should you decide you wanted to stay in the area and go full-time if a position were to open up.  If you're interested or have any questions just let me know!


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