# Dallas Fire Department EMS Care - Quality



## foreverbound (Dec 5, 2012)

I just wanted to open this thread to generate some conversation on something I haven't been able to get off my mind. Just a quick intro...I'm a FF/EMT-LP for a small department here in Texas. We run what most would consider an advanced EMS system (aggressive anaglesia, RSI, field hypothermia, etc). The culture at our department is very pro-EMS and puts quality care as a primary goal and focus. 

I recently had the misfo...err...opportunity to ride with a friend who works at Dallas Fire Department for 12 hours on one of their Rescue Ambulances. 

Wow.

I know this is going to sound like a rant for a while, and especially considering this is my first post, I'm sure it'll go well. 

---I seriously left my ride along pissed. Pissed at what I saw. While one ride out and one crew isn't representative of the whole department...the level and quality of care I saw was horrible, unprofessional, and honestly embarrassing.

When was it okay to show up with an unprofessional uniform with laces untied, shirt hanging out, and "sporty" mostly black tennis shoes?

When was it okay to try to convince people that need to go to the hospital that they were "fine"? 

When did it become okay to not provide analgesia to a pt with an obvious fracture who has no contraindications to pain management?

...and if that wasn't enough...

WHEN in the WORLD did it become acceptable to have MVC patients climb into an ambulance and lay on a LSB? SERIOUSLY!?:angry::angry::angry::angry:

Seriously, I was shocked and embarrassed at what I saw. I saw care that was just simply horrible and minimal. I looked at some previous threads about DFD and couldn't agree more about some of the things I read. They shouldn't even be considered an "ALS" department by any means...heck, they shouldn't even be considered "BLS" for that matter. 


Can somebody enlighten me? Did I just have a bad experience or did I really witness what I've heard from many...that EMS in Dallas is really that bad? Maybe for those who enter the DFD EMS system with no prior EMS experience, they see nothing wrong...but...it's my hope that as EMS professionals, we have better standards. 

Thoughts, comments, and opinions are welcome. I just couldn't get this experience out of my head.


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## Aidey (Dec 5, 2012)

I have zero first hand knowledge of DFD, so I can't comment on their overall quality. 



foreverbound said:


> When was it okay to show up with an unprofessional uniform with laces untied, shirt hanging out, and "sporty" mostly black tennis shoes?



Show up? Perfectly fine. You just have to tuck in your shirt before you go out on the amb. We also allow all black athletic shoes as long as they do not have colored logos. So no big Nike swish.




foreverbound said:


> When was it okay to try to convince people that need to go to the hospital that they were "fine"?



It depends on what the pt is complaining of and how they are presenting. People are going to disagree on who needs to go to the hospital by amb. 



foreverbound said:


> When did it become okay to not provide analgesia to a pt with an obvious fracture who has no contraindications to pain management?



This is the only thing you've mentioned that is an obvious issue. 



foreverbound said:


> ...and if that wasn't enough...
> 
> WHEN in the WORLD did it become acceptable to have MVC patients climb into an ambulance and lay on a LSB? SERIOUSLY!?:angry::angry::angry::angry:



Since around the time we discovered that LSBs are utterly useless. However, we still have to use them because the protocols haven't gotten around to acknowledging just how useless they are yet. I agree it is a bit unorthodox, but I personally wouldn't get worked up about it.


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## foreverbound (Dec 5, 2012)

Aidey, the uniform issues were during patient contact. I agree with solid black shoes are no problem and arguably more comfortable than some boots. These were shoes with logos and colors on them. 

There were some pts that clearly needed to be evaluated at the hospital...but..the vibe I got was they wanted to clear up and go available as soon as possible and did not like transporting. This one, I agree with you, could be discussed for a while.

As for analgesia, people have told me DFD rarely rarely ever uses pain meds (believe fentanyl is the only thing they carry). Maybe somebody with more insight about DFD could comment on this part. 

Yes, LSBs for the most part are completely useless. Unfortunately, DFD doesn't have selective backboarding protocols. I agree with the fact that we can (arguably) do more harm by using LSBs. However, there are still some patients that need the whole package. Having pts who are weak/dizzy and/or short of breath climb into ambulances is just wrong.

Thanks for your fast reply, Aidey.


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## RichLew (Dec 6, 2012)

I haven't heard anything positive about them actually. It's actually my understanding that they'll hire you with zero certification, send you through a 3 month EMS program and then you're out there running calls.


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## STXmedic (Dec 6, 2012)

RichLew said:


> I haven't heard anything positive about them actually. It's actually my understanding that they'll hire you with zero certification, send you through a 3 month EMS program and then you're out there running calls.



That's pretty standard for many larger cities. They hire off a civil service exam with zero experience required. They then put you through a 6ish month fire academy that includes a 5ish week EMT school. After that, you're put into your probationary period in the field. Some cities will have an accelerated academy for people who already have their certifications (usually 2-3 months). Very common and not surprising at all.


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## NYMedic828 (Dec 6, 2012)

PoeticInjustice said:


> That's pretty standard for many larger cities. They hire off a civil service exam with zero experience required. They then put you through a 6ish month fire academy that includes a 5ish week EMT school. After that, you're put into your probationary period in the field. Some cities will have an accelerated academy for people who already have their certifications (usually 2-3 months). Very common and not surprising at all.



Exactly how FDNY does it.

Must be EMT or medic to get hired.

3 month academy.


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## terrible one (Dec 6, 2012)

If you want to witness stellar EMS than feel free to visit any one of the fire departments in SoCal. The energy and enthusiasm to provide quality EMS care is palpable.
Enter sarcasm wherever you'd like.


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## RichLew (Dec 6, 2012)

I personally don't feel that's long enough to confidently provide quality medical care, especially in the prehospital setting when it can hit the fan rapidly


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## NYMedic828 (Dec 6, 2012)

RichLew said:


> I personally don't feel that's long enough to confidently provide quality medical care, especially in the prehospital setting when it can hit the fan rapidly



Nor is a 150 hour EMT program. Or 1400 hour medic program.

None of the standards in EMS are acceptable.


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## STXmedic (Dec 6, 2012)

RichLew said:


> I personally don't feel that's long enough to confidently provide quality medical care, especially in the prehospital setting when it can hit the fan rapidly



Long enough? It's the same class everybody else takes; they just go Monday through Friday 8-5. They have the exact same curriculum. They take the exact same national registry. What is it you feel you learn in a 1-2 day per week class that they don't? The selectivity of the entrance exam tends to naturally bring on people who are fairly intelligent, and we have a near 100% first time pass rate for EMT (100% total pass rate). I tend to be quite tough on my judgement of EMS providers; I find our basics to be excellent, even fresh out of the academy. Now our paramedics are a different story... :glare:


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## usalsfyre (Dec 6, 2012)

RichLew said:


> I personally don't feel that's long enough to confidently provide quality medical care, especially in the prehospital setting when it can hit the fan rapidly


It is short, but the school (through UTSW) isn't the biggest issue. DFRs biggest issue is a culture of mediocrity.


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## NYMedic828 (Dec 6, 2012)

The issue that seems to be widespread with municipalities is not getting acquiring good employees, it's getting rid of the bad ones.

FDNY for example has many great providers but at the same time we have a good few awful ones. The problem is it takes an act of god to lose your job. The only real way to get fired is payroll fraud, drug use, DUI, losing your cert or drivers license.

There's people who have basically killed patients but didnt lose their cert so they still have a job...


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## Christopher (Dec 6, 2012)

foreverbound said:


> WHEN in the WORLD did it become acceptable to have MVC patients climb into an ambulance and lay on a LSB? SERIOUSLY!?:angry::angry::angry::angry:



That's actually more in tune with the literature than boarding and collaring the patient in the vehicle or a standing takedown.

True story.

If they left off the LSB and just put a collar on and walked them to the truck and lay them down on the stretcher they'd be among the most progressive forward thinking departments in the country. No sarcasm here either.


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## rescue1 (Dec 6, 2012)

Christopher said:


> That's actually more in tune with the literature than boarding and collaring the patient in the vehicle or a standing takedown.
> 
> True story.
> 
> If they left off the LSB and just put a collar on and walked them to the truck and lay them down on the stretcher they'd be among the most progressive forward thinking departments in the country. No sarcasm here either.



To be fair to the OP though, accidentally being a progressive service due to laziness is not quite the same as being a progressive service. Though I share your skepticism towards the effectiveness of spinal immobilization.


As to the issue, I have no experience with Texas EMS at all, but it is my experience that in any profession, if management does not expect excellence, then the service provided will not be excellent.


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## Christopher (Dec 6, 2012)

rescue1 said:


> To be fair to the OP though, accidentally being a progressive service due to laziness is not quite the same as being a progressive service. Though I share your skepticism towards the effectiveness of spinal immobilization.



We have procainamide available at my service, not because we're in tune with the literature, but because a broken clock is right twice a day...


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## Fish (Dec 6, 2012)

terrible one said:


> If you want to witness stellar EMS than feel free to visit any one of the fire departments in SoCal. The energy and enthusiasm to provide quality EMS care is palpable.
> Enter sarcasm wherever you'd like.



Ha exactly,

I used to get wide eyed while watching the news in San Diego and behind the News reporter you'd see SDFD and Rural Metro pointing patients to Back Boards lying on the ground and having patient's walking around with c-collars on to the board and having them lay down on them.


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## Fish (Dec 6, 2012)

Aidey said:


> Since around the time we discovered that LSBs are utterly useless. However, we still have to use them because the protocols haven't gotten around to acknowledging just how useless they are yet. I agree it is a bit unorthodox, but I personally wouldn't get worked up about it.



While no one disagrees that SMR is over done and serves no purpose in a lot of cases. I think everyone agrees that if your going to do a skill, do it right and not half-assed.


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## Tigger (Dec 6, 2012)

Fish said:


> While no one disagrees that SMR is over done and serves no purpose in a lot of cases. I think everyone agrees that if your going to do a skill, do it right and not half-assed.



This is how I feel. It does not seem likely that such a large department would have instituted such a policy (letting a patient walk into the ambulance to the board) and then none of us would have ever heard of it. That would be considered a pretty big deal in the EMS world.

While I agree that the board is horribly overused, I'm not going to give them any credit for being lazy and accidentally ending up with something that's acceptable.

For those of us that think that SMR is really overrated and have the protocols in place to limit it's use, would you ever walk a patient into the truck and onto a board? That just seems pointless.


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## Fish (Dec 6, 2012)

Tigger said:


> This is how I feel. It does not seem likely that such a large department would have instituted such a policy (letting a patient walk into the ambulance to the board) and then none of us would have ever heard of it. That would be considered a pretty big deal in the EMS world.
> 
> While I agree that the board is horribly overused, I'm not going to give them any credit for being lazy and accidentally ending up with something that's acceptable.
> 
> For those of us that think that SMR is really overrated and have the protocols in place to limit it's use, would you ever walk a patient into the truck and onto a board? That just seems pointless.



We rule out cspine a lot, if we are cspine-ing, it is for a reason or a "potential" and for that reason I will always do it correctly. Including standing take downs on ambulatory patients


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## NYMedic828 (Dec 6, 2012)

If a patient has been walking around an MVA seen for 10 minutes, and claim spinal injury they can't attribute that damage to you not performing a standing takedown.

I've had patients walk to the stretcher and lay down as well as walking into the ambulance.

My agency can knock me for doing it improperly, but in a court of law you can't prove negligence on that basis.


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## Fish (Dec 7, 2012)

NYMedic828 said:


> If a patient has been walking around an MVA seen for 10 minutes, and claim spinal injury they can't attribute that damage to you not performing a standing takedown.
> 
> I've had patients walk to the stretcher and lay down as well as walking into the ambulance.
> 
> My agency can knock me for doing it improperly, but in a court of law you can't prove negligence on that basis.



An Attorney will find a way to prove anything, just because you have been walking around with no deficits does not mean there is no damage to the vertabre, the chord? Different story. Have loose or jagged ends of the broken vertabre cause damage after asking the patient to do some type of extensive bending manuver like lying down and I would say yes you are at fault.


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## Christopher (Dec 7, 2012)

Fish said:


> An Attorney will find a way to prove anything, just because you have been walking around with no deficits does not mean there is no damage to the vertabre, the chord? Different story. Have loose or jagged ends of the broken vertabre cause damage after asking the patient to do some type of extensive bending manuver like lying down and I would say yes you are at fault.



Except it doesn't happen like that in reality...external motion does not correlate well to internal motion against the cord. Besides, if what you're saying is true then you're negligent by placing them on a spine board as forces will be directed into the cord by virtue of lying on a rigid board.

I do agree that you'll be gigged in the courts, as they are probably 20 years behind reality (you should see what we deal with in software engineering). You'll be faulted for not forcibly manipulating the person onto a rigid spinal non-immobilization device with a cervical-doesn't-actually-provide-immobilization device.

We need to find an enterprising lawyer who will work to sue EMS and Fire departments when their protocols are awful; e.g. placing people on backboards or using lasix for CHF or for stopping at 3 sprays of NTG with pulmonary edema...


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## NYMedic828 (Dec 7, 2012)

Fish said:


> An Attorney will find a way to prove anything, just because you have been walking around with no deficits does not mean there is no damage to the vertabre, the chord? Different story. Have loose or jagged ends of the broken vertabre cause damage after asking the patient to do some type of extensive bending manuver like lying down and I would say yes you are at fault.



Find me a case where its happened and find me a way to prove that it was the sole fault of EMS that permanent damage was caused.

Its very difficult to win a negligence lawsuit against EMS. It isn't worth going after most EMS agencies to begin with because we don't have malpractice insurance and furthermore that whole "If he moves he could be paralyzed for life" never happens. You also have no ones word but yours, your partner and the patient most times. Its not a very good weight on either side and it just gets dismissed more often than not.

The fact is when you go to court, the lawsuit is ruled based on findings of not providing the standard of care. Backboards aren't the standard of care in actual medicine. Its nearly impossible to prove you did harm on the sole basis of not doing some ridiculous maneuver to lay a patient down who got out of his vehicle prior to arrival on his own free-will and has been roaming 
around on scene for 10 minutes.

While I respect following procedure, I also respect doing what is ACTUALLY right for my patient. If the protocol could potentially hurt them, it isn't happening. As far as im concerned a backboard at a minimum causes discomfort. Thats a minor form of harming my patient. If I actually backboard someone, its rare and its basically because everything listed in the protocol is met.


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## Fish (Dec 7, 2012)

NYMedic828 said:


> Find me a case where its happened and find me a way to prove that it was the sole fault of EMS that permanent damage was caused.
> 
> Its very difficult to win a negligence lawsuit against EMS. It isn't worth going after most EMS agencies to begin with because we don't have malpractice insurance and furthermore that whole "If he moves he could be paralyzed for life" never happens. You also have no ones word but yours, your partner and the patient most times. Its not a very good weight on either side and it just gets dismissed more often than not.
> 
> ...


San Diego Rural Metro had this happen, did not ever end up in court because it was not the MES crews fault, it happened while the guy was walking up the beach towards them and bent over to grab his things. I know it is a rare occurance, very rare. And I hope I don't come off as the uber back boarder, cause I am very much the opposite


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## NYMedic828 (Dec 7, 2012)

Fish said:


> San Diego Rural Metro had this happen, did not ever end up in court because it was not the MES crews fault, it happened while the guy was walking up the beach towards them and bent over to grab his things. I know it is a rare occurance, very rare. And I hope I don't come off as the uber back boarder, cause I am very much the opposite



I'm not saying it never happened.

But if it did it can't be proven to be the sole fault of the EMS crew.


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## Fish (Dec 7, 2012)

NYMedic828 said:


> I'm not saying it never happened.
> 
> But if it did it can't be proven to be the sole fault of the EMS crew.



On the same page now, agreed


And the chances are most likely cervical than any, not to mention it is more of an old schoool thought that has been going away with time. Which is good, if we want to get to the point of not backboarding everyone who says they have neck and back pain, or a mechanism that can potentially cause it


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## sir.shocksalot (Dec 7, 2012)

I think you can be sued for anything in this day and age, even walking someone to a back board. That being said I still do it too.

I can't say I have any first hand experience with DFD but I have heard horrid things too, I still remember Vene siting their paramedic program as one of the great big problems with EMS. I think every agency has problem people there, and I think every state has numerous examples of horrid EMS systems with inadequate analgesia, out dated treatment plans (like lasix for CHF), or other problems. If I had a dollar for every time I saw a paramedic put high flow oxygen on patients with an indication of "patient looks sick", or heck just putting oxygen on everyone because they got into an ambulance (on that note do I need oxygen too then?) I'd be stinking rich. There are highly respected EMS agencies that still do somethings backwards or "old school", I think it's actually a profession wide problem of which DFD might just be an extreme example. Until we do something to standardize care and expectations across the country and have real CEs not "refreshers" (where old material is rehashed), there will always be others (or more) like DFD.


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## Fish (Dec 7, 2012)

sir.shocksalot said:


> I respectfully disagree. While I think you are spot on about the ridiculousness of the procedure, and how much more likely it is to cause harm with a LSB than to actually prevent harm as was intended, I think you can still get sued by walking a patient to a board.
> 
> You are correct, the standard of care in medicine is to remove LSB as soon as possible and generally the patient is left in a collar (at least around these parts). The problem is that doing standing take downs and whatever to back board people is the standard of "care" for EMS, it's how we were trained, and that is the expectation. All a lawyer needs to do is find an educator or clinical director or whatever backwards thinking dumdum we have rampart in our profession to say "It is expected that paramedics back-board patients in this manner", and then find a neurologist to say "I suppose it's _possible_ that the patient walking/climbing to the back-board exasperated his spinal injury". No matter how false or exaggerated any of this stuff is, that alone would likely be enough to sue you. Not to mention if you don't have "selective" spinal immobilization protocols you could really be screwed. Plus there are cases of paramedics getting sued for not back-boarding someone, or not administering oxygen fast enough. All it takes is a smart lawyer and a dumb jury.
> 
> ...



What it comes down to for me is "not allowed to" we do not do half cspines, or walk people to the board, if we do cspine we do it the way taught in school and we do it 100%. Walking a patient to the stretcher to be boarded would raise eyebrows for us, and might get you a trip to explain yourself at Clinical.


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## TomP (Dec 7, 2012)

People who c-spine just to CYA is one of my biggest pet pives, we are supposed to be pt advocates and do whats best for our pt's and strapping someone on an uncomfortable board when they don't need it is horrible practice.


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## jgmedic (Dec 7, 2012)

TomP said:


> People who c-spine just to CYA is one of my biggest pet pives, we are supposed to be pt advocates and do whats best for our pt's and strapping someone on an uncomfortable board when they don't need it is horrible practice.



Quoted for truth!


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## Sublime (Dec 7, 2012)

I heard that back in the day DFD used to have their medications catagorized in boxes by colors. 

If you had a cardiac pt. with chest pain you opened the red box and gave those drugs. 

Respiratory patients got the blue box with those meds.

They didn't actually know what they were giving just gave the colors that corresponded with the complaint. 

They stopped when one medication was labeled the wrong color (I believe it was lidocaine) and was given improperly and killed someone.


This is just what I heard from multiple people, not sure if it's actually true lol.


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## medic417 (Dec 7, 2012)

Sublime said:


> I heard that back in the day DFD used to have their medications catagorized in boxes by colors.
> 
> If you had a cardiac pt. with chest pain you opened the red box and gave those drugs.
> 
> ...




Actually the colored boxes you mentioned were used in many places across the nation.


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## medicsb (Dec 7, 2012)

medic417 said:


> Actually the colored boxes you mentioned were used in many places across the nation.



Was gonna say the same.


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## TomP (Dec 7, 2012)

It is true and it is stupid. In medic school we were taught to learn the colors of boxes of meds, but just like you said what happens if the colors change or a different manufacture uses a different color, then what? Lawsuit!


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## Medic Tim (Dec 7, 2012)

TomP said:


> It is true and it is stupid. In medic school we were taught to learn the colors of boxes of meds, but just like you said what happens if the colors change or a different manufacture uses a different color, then what? Lawsuit!


they teach you to give the colour? Or teach you about the drug but know it is usually in this coloured box so you can find it easier?


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## Shishkabob (Dec 7, 2012)

Pretty standard for DFD, actually.


Actually a bit surprised to hear you say they have Fent, last I heard they had no narcotic analgesics (granted this was a while ago).  But they also don't intubate but rely on supraglotic airways.


It's well known in this area (DFW) that Dallas will all but tell you that you don't need an ambulance most of the time.  Now, I'd argue they are right most of the time, the people they do it to and the tact they use are... not.



Go through my previous posts on here, I'm sure I've posted several times that if I'm involved in an MVC on the east side of DFW (especially Dallas)  I'm crawling my butt to Baylor or Parkland as I stand a better chance.


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## medicsb (Dec 7, 2012)

Linuss said:


> But they also don't intubate but rely on supraglotic airways.
> .



That would actually be progressive, really, but Biotel has ETI in their protocols.


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## Fish (Dec 8, 2012)

medicsb said:


> That would actually be progressive, really, but Biotel has ETI in their protocols.



They do it due to incompetence, not progressive-ness


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## foreverbound (Dec 8, 2012)

Successful intubation with DFD? :rofl: 

DFD will use, from what I've heard, a King (no Combitubes carried) for nearly all airways. Although arguments could be made that this is "progressive"...I think it's clear and evident that ETI is still the way to go for most cases...including arrests. We routinely place ET tubes while compressions are going. I won't get on a soapbox here...but...our EMS system is considering passive ventilation (OPA and NPA with NC and NRB at 15lpm). Yes, a nasal cannula with 15 LPM. 

As for the colors, I think they use the "standard" color boxes just like nearly every EMS system although it does sound like nit he past they were taught to give "the red box" to "X patient" not because it was easier, but because they saw no need to teach the real function/effect of the medications. 

I was told that DFD rarely ever gives narcotics. I believe the "biggest" drug they use is midazolam and it's almost exclusively for seizures.

I *absolutely* agree with the education crisis in EMS. Education has, is, and will continue to be the *foundation* for better, more aggressive, and more professional EMS care. Until we increase EMS education requirements to better standards. Like I read in another post, and sadly agree with...everything's bigger in Texas

...except EMS education. 

Thank you for everyone's comments.


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## Fish (Dec 8, 2012)

foreverbound said:


> Successful intubation with DFD? :rofl:
> 
> DFD will use, from what I've heard, a King (no Combitubes carried) for nearly all airways. Although arguments could be made that this is "progressive"...I think it's clear and evident that ETI is still the way to go for most cases...including arrests. We routinely place ET tubes while compressions are going. I won't get on a soapbox here...but...our EMS system is considering passive ventilation (OPA and NPA with NC and NRB at 15lpm). Yes, a nasal cannula with 15 LPM.
> 
> ...



First 6 minutes are an OPA and NRB during Cardiac Arrest for us

During RSI, we place a NC at 15lpm, this is discontinued after tube has been secured.


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## foreverbound (Dec 8, 2012)

Interesting, Fish!

How are the survival rates looking?


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## Fish (Dec 8, 2012)

foreverbound said:


> Interesting, Fish!
> 
> How are the survival rates looking?



TO soon to tell, plus not all first responders have been educated on the new protocol yet.


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## TomP (Dec 8, 2012)

Fish, please tell me you meant BVM not NRB on a cardiac arrest


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## rescue1 (Dec 8, 2012)

TomP said:


> Fish, please tell me you meant BVM not NRB on a cardiac arrest



There have been studies involving NRB use as opposed to BVM use. If it wasn't 5am I'd try to dig it up for you... but night shift has been kinda sleepy.


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## Clare (Dec 8, 2012)

Ventilation is not a priority in cardiac arrest, there are only two things that are and these are 1) CPR and 2) defibrillation.

Experience has consistently shown that even very experienced ambos hyperventilate; in cardiac arrest this can lower venous return to the heart by increasing intrathoracic pressure .

Then there is the whole "flooding ischaemic cells with 100% oxygen free radical damage" thing which I don't know a whole lot about, well, that's all I know about it, but apparently its bad?


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## rescue1 (Dec 8, 2012)

Yeah, what she said.


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## TomP (Dec 8, 2012)

I'm a AHA instructor for BLS,  ACLS and PALS and I've never heard of such a thing, you are very right about hyperventilation and intrathoracic pressure, but this is the first I've ever heard of advanced level providers not being told to ventilate. I'm gonna have to do some research on the subject. Thanks


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## Clare (Dec 8, 2012)

rescue1 said:


> Yeah, what she said.



Thank you sir


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## Fish (Dec 8, 2012)

TomP said:


> Fish, please tell me you meant BVM not NRB on a cardiac arrest



No, I ment NRB. For reason that peeps stated below. 

This is NOT something the AHA pushes, but studies have shown it works. It is relatively new however


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## NomadicMedic (Dec 8, 2012)

We're not at the point where we are using an OPA and NRB on arrests, but we are using a nasal cannula with high flow O2 as we RSI. It's part of our protocol that we start with a baseline end-tidal CO2 with nasal prongs, so it just makes sense to flow it at 15.


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## medic417 (Dec 8, 2012)

foreverbound said:


> As for the colors, I think they use the "standard" color boxes just like nearly every EMS system although it does sound like nit he past they were taught to give "the red box" to "X patient" not because it was easier, but because they saw no need to teach the real function/effect of the medications.
> 
> .



No he was talking about a box that was a certain color and contained sometimes several medicines in it.  They would look up protocol and if it said red box they would give all the various meds in the red box.  Required no training or education.  Very bad idea, no telling how many patients were harmed or killed.


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## RocketMedic (Dec 8, 2012)

Christopher said:


> Except it doesn't happen like that in reality...external motion does not correlate well to internal motion against the cord. Besides, if what you're saying is true then you're negligent by placing them on a spine board as forces will be directed into the cord by virtue of lying on a rigid board.
> 
> I do agree that you'll be gigged in the courts, as they are probably 20 years behind reality (you should see what we deal with in software engineering). You'll be faulted for not forcibly manipulating the person onto a rigid spinal non-immobilization device with a cervical-doesn't-actually-provide-immobilization device.
> 
> We need to find an enterprising lawyer who will work to sue EMS and Fire departments when their protocols are awful; e.g. placing people on backboards or using lasix for CHF or for stopping at 3 sprays of NTG with pulmonary edema...



I think I suggested this last month lol.


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## Aidey (Dec 8, 2012)

TomP said:


> I'm a AHA instructor for BLS,  ACLS and PALS and I've never heard of such a thing, you are very right about hyperventilation and intrathoracic pressure, but this is the first I've ever heard of advanced level providers not being told to ventilate. I'm gonna have to do some research on the subject. Thanks



Look up "apneic oxygenation"


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## RocketMedic (Dec 8, 2012)

I think it's a cultural issue myself, I reckon there's departments/services/agencies everywhere that do things this way due to education and "protocols". Education and individual responsibility for patient care (guidelines vs protocols) would go a long way towards improving this.


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## TomP (Dec 8, 2012)

So I've done a lot of reading about apneic oxygenation and I do understand it although it still seems like proper ventilation with a BVM/ETT would benefit the pt more. Almost seems like your medical director doesn't have enough confidence in ems to even let them bag a pt, which is stupid! Not like were RT's, who are the worst at over bagging, mainly because that's all they can do in a code. I'm also curious if using sodium bicarb is a big part of your cardiac arrest protocol to counter act the respiratory acidosis your causing by not bagging the pt.


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## usalsfyre (Dec 8, 2012)

TomP said:


> So I've done a lot of reading about apneic oxygenation and I do understand it although it still seems like proper ventilation with a BVM/ETT would benefit the pt more. Almost seems like your medical director doesn't have enough confidence in ems to even let them bag a pt, which is stupid! Not like were RT's, who are the worst at over bagging, mainly because that's all they can do in a code. I'm also curious if using sodium bicarb is a big part of your cardiac arrest protocol to counter act the respiratory acidosis your causing by not bagging the pt.



For a guy who's an ACLS instructor you sure have a limited understanding of both the physiology of and team member roles during resuscitation...


The profound metabolic acidosis caused by an extended amount of time without circulation makes any respiratory issues moot.

RRTs are in my anecdotal experience,
 on average, far better at mask ventilation than EMS. In addition in many places they manage all the airways outside of the ED.


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## medicsb (Dec 8, 2012)

So there seems to be a lot of hear-say... "They don't intubate... I don't think they have X drug..." blah blah blah

Their protocols are online for everyone to see for themselves: http://www.biotel.ws/


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## usalsfyre (Dec 8, 2012)

medicsb said:


> So there seems to be a lot of hear-say... "They don't intubate... I don't think they have X drug..." blah blah blah
> 
> Their protocols are online for everyone to see for themselves: http://www.biotel.ws/


Quick word...the protocols are straight forward, some of that is optional per dept though.

Again, the huge issue is departmental culture. I've been involved in the care of some their patients before, and seen many, many more brought to EDs. Some of the malarkey I've seen is astounding.


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## RocketMedic (Dec 8, 2012)

usalsfyre said:


> Quick word...the protocols are straight forward, some of that is optional per dept though.
> 
> Again, the huge issue is departmental culture. I've been involved in the care of some their patients before, and seen many, many more brought to EDs. Some of the malarkey I've seen is astounding.



Are they using the ambulance as punishment duty or ???


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## triemal04 (Dec 8, 2012)

TomP said:


> I'm a AHA instructor for BLS,  ACLS and PALS and I've never heard of such a thing, you are very right about hyperventilation and intrathoracic pressure, but this is the first I've ever heard of advanced level providers not being told to ventilate. I'm gonna have to do some research on the subject. Thanks


You just finished paramedic school and you're allready an ACLS and PALS instructor?  Were you a nurse before becoming a paramedic?  PA?  Something else?

Cardiocerebral rescucitation (continuos compressions with passive ventilation or no ventilation) was looked at awhile back with fairly promising results.  After the 2005 changes in CPR (which in my personal opinion it helped drive) the differences between CCR and CPR started to decline.  Still think the theory is sound, and things seem to be moving more and more in that direction anyway.


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## rescue1 (Dec 8, 2012)

Clare said:


> Thank you sir



Don't tell anyone my secret...I wait until someone smarter shows up and just agree with them.


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## Clare (Dec 8, 2012)

rescue1 said:


> Don't tell anyone my secret...I wait until someone smarter shows up and just agree with them.



I like where this is going ... for me, not for you


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## rescue1 (Dec 8, 2012)

Clare said:


> I like where this is going ... for me, not for you



...I agree


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## sir.shocksalot (Dec 8, 2012)

TomP said:


> People who c-spine just to CYA is one of my biggest pet pives, we are supposed to be pt advocates and do whats best for our pt's and strapping someone on an uncomfortable board when they don't need it is horrible practice.


The entire procedure of c-spining is an exercise in CYA. There is no, nor was there ever, scientific evidence the procedure actually does anything. Remember when everyone got their tonsils out? Or how about when we used to do blood letting? It's the story of medicine.

I think culture is a huge part of EMS care in some places. The protocols might look pretty good but what is actually being practiced on the ground is a whole different reality. There is a FD in the Denver area who has it in their protocols to intubate but the reality is that all airways are "controlled" with a King-tube. Same FD has protocols for up to 200mcg of Fentanyl, reality is that rarely is 100mcg pushed, usually it's 50mcg or so. Department culture is at least partially responsible for how care is provided, and I think any department really pushes people to drink the kool-aid is really prone to having huge patient care problems. 

Indoctrination really isn't good for any industry, but is especially deleterious to medicine.


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## Shishkabob (Dec 8, 2012)

medicsb said:


> So there seems to be a lot of hear-say... "They don't intubate... I don't think they have X drug..." blah blah blah
> 
> Their protocols are online for everyone to see for themselves: http://www.biotel.ws/



Except the issue:  Biotel is more of a mix and match type of medical control, allowing each department they oversee to choose what protocols they have and to what extent they go.

Example:  Back in 2010 they came out with RSI.  Some FDs adopted full RSI, some adopted only PAI, and some, such as Dallas, were like "Nope, we don't trust our people, don't give us more drugs to play with"


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## Fish (Dec 8, 2012)

All of this aside, I do hear that Dallas has great benefits and pay


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## Trashtruck (Dec 8, 2012)

Hmmm, let me see...
Don't treat anybody, talk them out of needing an ambulance, 'BLS' every call, and enjoy great pay and benefits.
Yep! Sounds like a Fire Dept. to me.


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## Fish (Dec 8, 2012)

Trashtruck said:


> Hmmm, let me see...
> Don't treat anybody, talk them out of needing an ambulance, 'BLS' every call, and enjoy great pay and benefits.
> Yep! Sounds like a Fire Dept. to me.



Ha!


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## Tigger (Dec 9, 2012)

Trashtruck said:


> Hmmm, let me see...
> Don't treat anybody, talk them out of needing an ambulance, 'BLS' every call, and enjoy great pay and benefits.
> Yep! Sounds like a Fire Dept. to me.



Sounds like a substandard EMS provider to me, and pretty much nothing else.


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## Medic2409 (Dec 13, 2012)

Word, rumor, is that DFD is trying to get out of EMS, and has approached a certain green ambulance company about doing so.


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## RocketMedic (Dec 13, 2012)

That would be _epic_. I'd move for it.


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## Fish (Dec 13, 2012)

Medic2409 said:


> Word, rumor, is that DFD is trying to get out of EMS, and has approached a certain green ambulance company about doing so.



Would have to go out to competitive bid, can't just chat and bring in a service without a bid


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## RocketMedic (Dec 13, 2012)

Fish said:


> Would have to go out to competitive bid, can't just chat and bring in a service without a bid



AMR and Acadian, _perhaps_ Rural/Metro or Paramedics Plus. It's home turf for all of them. Perhaps a Medstar expansion?


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## Trashtruck (Dec 13, 2012)

Medic2409 said:


> Word, rumor, is that DFD is trying to get out of EMS, and has approached a certain green ambulance company about doing so.



I'm not familiar with how the DFD runs EMS. Could somebody give me a run down on it? 

What is the proposal to remove EMS from the Dept.? Isn't EMS a financial crutch(or shoring!) for most FD's? This seems counter-intuitive to me.


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## usalsfyre (Dec 13, 2012)

They were talking to a couple of companies about back-up at high volume times only (first to second hand knowledge of this). DFD getting completely out of EMS isn't going to happen.


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## Fish (Dec 14, 2012)

Trashtruck said:


> I'm not familiar with how the DFD runs EMS. Could somebody give me a run down on it?
> 
> What is the proposal to remove EMS from the Dept.? Isn't EMS a financial crutch(or shoring!) for most FD's? This seems counter-intuitive to me.



911 is not a financial gain for anyone


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## Trashtruck (Dec 14, 2012)

I never said it was profitable. EMS within a Fire Dept. brings in more funding and a larger budget for the Dept. 
I'm just wondering why DFD wants OUT? The rest of the country FD's seem to want to take over EMS.


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## Fish (Dec 14, 2012)

Trashtruck said:


> I never said it was profitable. EMS within a Fire Dept. brings in more funding and a larger budget for the Dept.
> I'm just wondering why DFD wants OUT? The rest of the country FD's seem to want to take over EMS.



Gotcha,

What is funny is....... We have Chiefs from Larger Fire Depts that ran EMS getting jobs around here as Chiefs at smaller Depts (4-5-7 station depts) that when asked if they want to takeover EMS reply with "It is a headache, a not profitable headache....." 

It brings in a bigger budget, but the guys on the Floor want nothing to do with it....... In my experience


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## Veneficus (Dec 14, 2012)

Fish said:


> Gotcha,
> 
> What is funny is....... We have Chiefs from Larger Fire Depts that ran EMS getting jobs around here as Chiefs at smaller Depts (4-5-7 station depts) that when asked if they want to takeover EMS reply with "It is a headache, a not profitable headache....."
> 
> It brings in a bigger budget, but the guys on the Floor want nothing to do with it....... In my experience



Nothing has changed...

One of the reasons the guys want nothing to do with it is because fire and EMS attract entirely different and distinct personalities.


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## Fish (Dec 14, 2012)

Veneficus said:


> Nothing has changed...
> 
> One of the reasons the guys want nothing to do with it is because fire and EMS attract entirely different and distinct personalities.



Yes,

Where we work the County is run by a third service EMS agency and all Fire Departmetns are non-transporting BLS, the FDs at the floor level love it this way. And so do we on the Ambulance, we both went into our different careers for different reasons and do not want to mix it


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## foreverbound (Dec 17, 2012)

http://crimeblog.dallasnews.com/2012/12/dallas-fire-rescue-investigates-handling-of-asthma-attack-patient.html/

Friend of mine at nearby department sent this to me. Maybe I didn't have an abnormally bad experience.


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## Fish (Dec 17, 2012)

Sounds like laziness. Of course, it is under investigation and not facts or proof yet.


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## Veneficus (Dec 17, 2012)

a couple of years ago, a doc friend of mine studying out of hospital cardiac arrest survival dug up that of all the departments using the Utstein criteria (which in both of our opinions is highly flawed anyway) Dallas came in at the bottom of all reporting.

Coincidence? I don't think so...


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## foreverbound (Dec 17, 2012)

Veneficus,

Do you have a link to that study by any chance? 

Just curious...what are some concerns about using the Utstein criteria? Isn't this the standard for reporting survival rates?


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## foreverbound (Dec 17, 2012)

...


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## Veneficus (Dec 17, 2012)

foreverbound said:


> Veneficus,
> 
> Do you have a link to that study by any chance?
> 
> Just curious...what are some concerns about using the Utstein criteria? Isn't this the standard for reporting survival rates?



to my knowledge his research on the matter was not published in any journal, it was used primarily for an anti-fire take over of an EMS system so there is no link.

Utstein is a standard, not everyone uses it. 

The major sticking point is some of the criteria is not validated. It is basically opinion or a guess.


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## foreverbound (Dec 17, 2012)

I don't see anything wrong with comparing survival rates amongst different agencies provided they use the same standard.

But yes, you are correct. A quick google on the utstein criteria shows that not all agencies use it. It seems to only apply to a very specific group of patients...witnessed cadiac arrest with a shockable rhythm upon EMS arrival.


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## Veneficus (Dec 17, 2012)

foreverbound said:


> I don't see anything wrong with comparing survival rates amongst different agencies provided they use the same standard..



If the data does not reflect reality, then it is useless because all conclusions drawn from it are flawed.


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## foreverbound (Dec 17, 2012)

"If the data does not reflect reality, then it is useless because all conclusions drawn from it are flawed."

What part of reality doesn't it reflect? The Utstein criteria simply reflects the survival rate for cardiac arrest victims who have a witnessed arrest and present in a shockable rhtyhm.


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## Veneficus (Dec 17, 2012)

foreverbound said:


> "If the data does not reflect reality, then it is useless because all conclusions drawn from it are flawed."
> 
> What part of reality doesn't it reflect? The Utstein criteria simply reflects the survival rate for cardiac arrest victims who have a witnessed arrest and present in a shockable rhtyhm.



It is also used to evaluate the effectiveness of EMS agencies and procedures.

How do you accurately evaluate agency performance on unsubstantiated benchmarks?


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## foreverbound (Dec 17, 2012)

Cardiac arrest survival rates can be one sign of the quality of care a system provides, provided a system is compared to another system that uses the same reporting criteria.

A system that has a 40% save rate vs a system with a 5% save rate can be concluded that they are more effective, provided both system's survival rate was reported using the same criteria. 

Who said they're not good benchmarks? The Utstein criteria is simply one reporting system that only includes cardiac arrest victims who are witnessed and in a shockable rhythm.

I'll be down to say that it's almost always true that the systems with the best survival rates are the best systems over all.


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## Veneficus (Dec 17, 2012)

here you go.

http://www.youtube.com/watch?v=ad80GcWSJC0


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## medicsb (Dec 17, 2012)

I believe you can see Dallas' Utstein survival rate in a few of the Resuscitation Outcomes Consortium studies.  I can't find an article off hand, but I did find this really quickly: 
	

	
	
		
		

		
			





In case anyone is curious about the most recent recommendation for data collection according to the Utstein template:
http://circ.ahajournals.org/content/110/21/3385.full?sid=18adadb2-a5f2-4991-9d69-82c78c3c8cf8


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## Veneficus (Dec 17, 2012)

foreverbound said:


> Cardiac arrest survival rates can be one sign of the quality of care a system provides, provided a system is compared to another system that uses the same reporting criteria.
> 
> A system that has a 40% save rate vs a system with a 5% save rate can be concluded that they are more effective, provided both system's survival rate was reported using the same criteria.



I've actually had this same argument before.

A system like King County, which has a relatively healthy, middle class, and well educated populous cannot possibly be compared to a system for example in Ohio, NJ, etc that has a destitute, unhealthy, and largely uneducated urban populous. Wouldn't you naturally expect better numbers in the former?

(which is actually another major flaw) comparing systems without the general health of the population. 

In my mind, that makes it a rather poor indicator of system effectiveness.


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## foreverbound (Dec 17, 2012)

Veneficus, 

I'm not really sure where the whole FD based EMS vs non-FD based EMS thing came into play here. I didn't say that FD based EMS systems have higher survival rates. I simply said that systems that have higher survival rates are generally better systems, assuming these systems are compared on an equal level. 

According to that video, yes, non-FD based EMS systems DO have higher survival rates. I'm not surprised DFD ranked amongst the lowest.


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## Veneficus (Dec 17, 2012)

foreverbound said:


> Veneficus,
> 
> I'm not really sure where the whole FD based EMS vs non-FD based EMS thing came into play here. I didn't say that FD based EMS systems have higher survival rates. I simply said that systems that have higher survival rates are generally better systems, assuming these systems are compared on an equal level.
> 
> According to that video, yes, non-FD based EMS systems DO have higher survival rates. I'm not surprised DFD ranked amongst the lowest.



it was a link to the information gathered by my friend regarding the save rates for Dallas. 

You asked for it, I found it.


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## foreverbound (Dec 17, 2012)

Veneficus said:


> I've actually had this same argument before.
> 
> A system like King County, which has a relatively healthy, middle class, and well educated populous cannot possibly be compared to a system for example in Ohio, NJ, etc that has a destitute, unhealthy, and largely uneducated urban populous. Wouldn't you naturally expect better numbers in the former?
> 
> ...



Does it really matter how healthy, how rich, and how educated a population is when comparing arrest saver rates if you're comparing them against another city using the SAME reporting criteria?

Are you saying that in Ohio/NJ, a poorer person who is less educated is going to have a lower chance of surviving a witnessed VF arrest than a rich degree holding citizen in Seattle who also experiences a witnessed VF arrest?

I hope I am understanding what you mean by educated. College, I assume? Or are you talking about educated about CPR? Perhaps that IS one thing that could affect how reliable comparing cities using the Utstein criteria can be. I could see an argument made that using the Utstein criteria for Seattle vs...lets say Dallas...while they're using the same reporting criteria...Seattle might have a better survival rate because of their CPR education and public awareness?


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## foreverbound (Dec 17, 2012)

Veneficus said:


> it was a link to the information gathered by my friend regarding the save rates for Dallas.
> 
> You asked for it, I found it.



Sorry. That makes sense now. Thank you, Veneficus.


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## Fish (Dec 17, 2012)

Veneficus said:


> It is also used to evaluate the effectiveness of EMS agencies and procedures.
> 
> How do you accurately evaluate agency performance on unsubstantiated benchmarks?



i want this data that you and your friend compiled!


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## Veneficus (Dec 17, 2012)

Fish said:


> i want this data that you and your friend compiled!



posted in the link above.

incidentally, it was all him, I can take no credit for it.


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## medicsb (Dec 18, 2012)

Veneficus said:


> I've actually had this same argument before.
> 
> A system like King County, which has a relatively healthy, middle class, and well educated populous cannot possibly be compared to a system for example in Ohio, NJ, etc that has a destitute, unhealthy, and largely uneducated urban populous. Wouldn't you naturally expect better numbers in the former?
> 
> ...



Overall, I agree, but demographic information is not hard to find.  It is not hard to make a comparison despite the fact that the Utstein template does not include demographic variables.  However, considering that the template has been revised twice in the past, it is possible that it would be revised again.  The ROC has published work showing socioeconomic associations with cardiac arrest and outcomes and at least two of the researchers involved with ROC have been coauthors of Utstein documents (Mickey Eisenberg and Graham Nichol).  

While it may not be fair to compare Seattle/King County to Dallas or NYC, etc.  It may be totally appropriate to compare Seattle/King County to Portland/Multnomah or Boston to Denver, etc., etc.

No one would conclude that Utstein is perfect, but it still has its use as a standard for data collection for cardiac arrest.


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