EMS and ladder trucks

[GMCmedic]

A few nights ago we had a juvenile on acid, running around on the roof of a local high school. Most of my details are from the medic or firefighters on scene so I have no idea how to police got onto the roof. What I do know is this juvenile fought with police and was ultimately tazed 7 times and was still fighting. The fire department was called and set up their ladder with 1 section deployed at a 20 degree angle. The medic on scene was asked to climb onto the roof to sedate the patient, she refused because of a fear of heights. Everyone understood and they instead shackled and restrained the patient in a stokes basket with multiple straps and sheets.

Our director has since gotten involved and flat out refused to allow us to ever climb a fire department apparatus. While i would agree with him to an extent, I feel that a ladder with one section deployed at 20 degrees and the entire 137' ladder deployed at 60 degrees are two different worlds. (Ive climbed the entire 137' in full gear with an air pack at 60 degrees so i can attest to that)

It is my personal opinion that liberal sedation is the safest way this person could be transported. I also feel that there are several scenarios besides this where a ladder truck may come into play and a blanket no is the wrong approach. I.e. electrecution, crush injuries, fall with fracture etc

Another option would have been to call my department as two of us from my service that are paramedics are also on that department. If were on a call with fire and the medic on scene needs us to perform ALS, we are allowed to clock in. He has gone as far to say we cant climb the ladder as a firefighter and clock in on the roof to sedate the patient.

Im normally very pro fire does fire stuff but as ive said, i can see many scenarios, though rare, that a patient could benefit from ALS care.

Has this ever come up anywhere else and how does your service approach it?

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[NomadicMedic]

We had a couple of medics ride out to a cargo ship in a fire launch and climb an external staircase on the side of the ship to reach a head injury patient.

SOP was immediately ammended to prevent this from happening again.

Recently had an entrapped patient and the volunteer FD was unable to disentangle the vehicle from around the patient. A medic on scene, a former firefighter, took the tool from the volunteers and performed the extrication.

SOP was immediately ammended to prevent this from happening again.

Non fire paramedics should not be on or using fire department apparatus or equipment. The liability is HUGE and should never be assumed by any reasonable command officer.

I would have also refused to climb a ladder to sedate a violent patient.

 

[CWATT]

@the OP, prior to entering EMS I was unaware of dual-service departments. I had the opportunity to complete my clinical with one and was truly amazed at the quality of patient care they are able to provide. Your situation highlights one of an infinite possibilities where a disconnected EMS / Fire situation failed this patient and policy trumped prodecrue. There was an opportunity to chemically restrain this patient for their safety and that of the first responders. However, the safety concerns are valid here. I've never been trained to climb an aireal apparatus and I'm sure I'd do it incorrectly and ultimately unsafely despite my best intentions. I feel like the EMS policy effectively protected the employee, albeit at the possible expense of patient care.

If I were to take this situation as an opportunity to wax first-responder philosophic, I would suggest in cities where EMS and Fire are separate entities, there exist the option to provide specialized EMS units. Many cities have tactical medics who operate in a sprint vehicle then respond to Police situations and are cross-trained to do so. From the show Nightwatch, there is a similar sprint vehicle with an EMS provider trained in underwater patient rescue. I think this is another excellent opportunity to cross-train an EMS responder in 'advanced patient rescue' where they are cross-trained with the local Fire/Rescue service to render medical care in situations exactly as these (or confined-space, low oxygen, high-angle, etc.). I recently read of a large metro Fire service being issued bullet-proof vests for situations assisting Police (although I struggle to understand the rationale here because that same city already has tactical medics).

 

[Carlos Danger]

Interesting situation. I'll spare you guys the war story (even though it is a pretty good one) but probably the most memorable call of my career involved an unusual and fairly risky situation (though I was perfectly comfortable with it, as was my partner) that didn't require any specialized training, just some good balance and some fitness, that also turned into a debate about whether we should be doing that type of stuff and whether our insurance covered it.

Anyway, I guess my feeling is that as public safety professionals, any EMT or Paramedic who does 911 should be able to climb a ladder or a fire escape with their equipment, walk down a narrow trail with a cliff on one side, breach a door when a patient is clearly in need, and approach a patient trapped in a MVC even before fire arrives. Not talking about stuff that requires any special "tactical" or "rescue" training, just some basic awareness and agility and physical fitness, as well as equipment that is packaged in a way so as to be portable and packable, as well as uniforms that are functional and conducive to exertion.

Also, EMS and fire have to interface well. It is completely dysfunctional to have EMS and fire unable to work together when the situation becomes a little unusual.

 

[E tank]

What do you used to "sedate" a teenager on acid that has been tazed fighting with cops? Have to say I've never had to do that before but thinking about it, I'd think "sedation" isn't the right word...."just give 'em something, doc," are five of the most dangerous words ever uttered.

 

[NomadicMedic]

I agree that a paramedic should be able to gain reasonable access to a patient as a normal course of on duty action

However, using equipment that the medics haven't trained on or have the proper PPE to operate seems like a big no no to me.

I know a medic who used a maintenance department scissor lift to access a patient. He was disciplined because he wasn't trained to operate the equipment, the fire department was on the way with specialized rescue equipment and the patient wasn't in immediate danger. Was discipline the right decision? I think so. The union didn't. It quickly turned very ugly. The medics at that service were prohibited from entering the "action circle" of any active incident. Ended badly for everyone because a medic made a bad decision.

Take it for what it's worth, but if you want to climb ladders and perform swift water/confined space/high angle rescue, work for a combo department where you're crosstrained.

 

[GMCmedic]

What do you used to "sedate" a teenager on acid that has been tazed fighting with cops? Have to say I've never had to do that before but thinking about it, I'd think "sedation" isn't the right word...."just give 'em something, doc," are five of the most dangerous words ever uttered.

From what I was told they ultimately went with 15mg of Haldol IM.

I would have went with IM Versed or Ketamine.

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[GMCmedic]

I agree that a paramedic should be able to gain reasonable access to a patient as a normal course of on duty action

However, using equipment that the medics haven't trained on or have the proper PPE to operate seems like a big no no to me.

I know a medic who used a maintenance department scissor lift to access a patient. He was disciplined because he wasn't trained to operate the equipment, the fire department was on the way with specialized rescue equipment and the patient wasn't in immediate danger. Was discipline the right decision? I think so. The union didn't. It quickly turned very ugly. The medics at that service were prohibited from entering the "action circle" of any active incident. Ended badly for everyone because a medic made a bad decision.

Take it for what it's worth, but if you want to climb ladders and perform swift water/confined space/high angle rescue, work for a combo department where you're crosstrained.

I dont disagree. I can think of at least 4 of us right now that are trained to use that equipment, and as I said earlier have been given the go ahead to switch roles from fire to Paramedic(at the request of the medic in charge of patient care) in all other cases but this one.

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[NomadicMedic]

What do you used to "sedate" a teenager on acid that has been tazed fighting with cops? Have to say I've never had to do that before but thinking about it, I'd think "sedation" isn't the right word...."just give 'em something, doc," are five of the most dangerous words ever uttered.

I have limited choices. I don't think a B52 is the right one, although that was the one back in the day. And it worked pretty well.

Ketamine would be my first choice. 5 mg of snout delivered Versed would be #2.

After that?

 

[DrParasite]

Training is one thing, in the job description is another. Also does your job provide you with the proper PPE to do your job? what about the job of others?

I might be a trained law enforcement officer, but when I'm working my part time job on the ambulance, should I be handcuffing the violent patient to the cot?

Similar situation, if you are a paramedic, should you be crawling into the back of a car during a bad MVA, if you don't have the proper PPE, which OSHA requires your agency to provide for you (if its in your job description)? And think of it this way, if you get hurt, should your agency's workman's comp cover you because you were acting outside of your job description?

 

[GMCmedic]

We regularly crawl into cars, whether or not were supposed to I dont know but fire supplies us with appropriate PPE. As far as PPE for a climbing a ladder truck, i dont know what OSHA says but our uniforms are appropriate PPE for a 20 degree climb per the department standards.

On that note, OSHA requires a fall arrest system for any fixed ladder 24 feet or higher. Does that mean nobody should climb a 24 foot fixed ladder to access a patient on a roof?


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[Tigger]

We're facing a similar issue with backcountry rescues and what constitutes uncovered risk. We carry ATV helmets and whatnot on the ambulance to protect our people when they get rides in on ATVs/dirtbikes. This I feel is reasonable. We do not operate ATVs nor are we trained to.

We do not do rope rescue. But if the fire department provides us with PPE and builds/controls the system to allow us to access the patient, is that undue risk? I don't know. What about helicopter insertions into the backcountry to lessen hiking? It's a non-technical discipline, but there is certainly an increased risk. Where is the line?

 

[DesertMedic66]

I would have probably gone up without any issue. Grab my helmet and a pair of gloves (that's all that fire usually has during training operations for ladders).

As for the TC/MVA as far as I know we do not have a policy. I have been inside the vehicle multiple times before fire gets on scene and after they are on scene. Our supervisors have been on scene and done the same with nothing being said.

If we call in for an airship and the only one available is the highway patrol that is sometimes staffed with an EMT then our policy actually allows us to fly in with that patient.

We hike in on calls for injured parties and either treat and walk them out or treat and have SAR hoist them out.

We have had medics picked up by airships and flown to the patient location.

I've had to make several forced entries and jump fences/walls to get to patients before.

I have loaded all my gear into the back of a 4x4 SUV that was owned by a citizen (who volunteered) and he drove us to the patient location.

Out in our way far East end we have had medics hop on boats to get to patients.

For my company it pretty much seems like as long as you feel comfortable/safe doing it then you are free to do so.

 

[Jim37F]

All the paramedics here are firefighters in the fire department so there's really no issue with them climbing the ladder or going into a wrecked car or whatever, as of course they have all the proper PPE and training on that equipment (Now a confined space rescue or HAZMAT requiring additional special training/equipment is a different story, but I would be hardly surprised at all if the USAR truck has a guy who is a medic that can initiate some sort of ALS care whilst extracting, situation dependent....but those decisions are well above my pay grade ha). Of course, the flip side of the coin is that us private BLS guys get to stand back with the gurney until extrication is completed. We will regularly help out with minor wrecks....we have helmets and brush coats, and anything not requiring tools to get into is fair game though.

As far as ladder trucks go, yeah, that ladder can be highly dangerous. Just look at the FDNY FF who died recently when he fell 10 stories when something went tragically wrong and he fell while moving from the ladder's bucket to the roof.....On the other hand, those same ladders are used to rescue untrained (and likely panicked) civilians, so it stands to reason that with some training, a single role medic could safely climb one to the roof of a 2 story building.....though the department(s) (and insurance companies I guess) would then have to decide a) What's the minimum required training to be allowed to climb the ladder? b) how often refresher training is required, c) how far is too far? The roof of a 2 story is OK, but not a 3 story? What if the truck has to park further away, does the extra total distance factor in as well? And so on.

Single role medics based out of the same station on the same schedule as the suppression guys would obviously have the best chances to attend the drills the ladder truck guys do to maintain currency to safely use the ladder......but if you're a medic for a private company that responds with lots of different FD's (or there's more than one private that responds with that FD) and you don't have a set station (SSM anyone?) on a different schedule (I'm spitballing here, say your schedule is M-W-F eo Sat 1400-0200......I find it much less likely to maintain a regular recert training cycle on that ladder...unless the FD agrees to one one day specifically for those EMTs/Medics and they're expected to come in off shift

So yeah, is it doable to be trained to safely use a ladder truck's ladder or other FD tools without being a dual role FF/EMT or FF/PM...sure, though there's plenty of obstacles as well that would prevent a great many medics from doing so as well.

 

[GMCmedic]

All good points guys, I cant say that I disagree with anyone here. I really dont know the best answer to the problem, probably may never know. Im just hoping for some middle ground to keep firefighters and patients safe.

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[EpiEMS]

Wasn't able to find any research, but I bet somebody could use some of the NEMSIS data to get a sense for how often scene considerations like this impact patient care & outcomes (maybe using the scene delay field).

Anybody have any quantitative info on this?

 

[NomadicMedic]

This post is the stuff that policies are made of.

It's all okay until it's NOT okay. First time a medic falls off an ATV, falls out of a pickup truck, gets injured making a forced entry or on the airship... it's all over. Trust me.

Saying "well, we've being doing it this way forever, nobody's ever said anything and nobody's gotten hurt" is not an acceptable defense. That's why risk management professionals get paid so much.

I would have probably gone up without any issue. Grab my helmet and a pair of gloves (that's all that fire usually has during training operations for ladders).

As for the TC/MVA as far as I know we do not have a policy. I have been inside the vehicle multiple times before fire gets on scene and after they are on scene. Our supervisors have been on scene and done the same with nothing being said.

If we call in for an airship and the only one available is the highway patrol that is sometimes staffed with an EMT then our policy actually allows us to fly in with that patient.

We hike in on calls for injured parties and either treat and walk them out or treat and have SAR hoist them out.

We have had medics picked up by airships and flown to the patient location.

I've had to make several forced entries and jump fences/walls to get to patients before.

I have loaded all my gear into the back of a 4x4 SUV that was owned by a citizen (who volunteered) and he drove us to the patient location.

Out in our way far East end we have had medics hop on boats to get to patients.

For my company it pretty much seems like as long as you feel comfortable/safe doing it then you are free to do so.

 

[DrParasite]

Our director has since gotten involved and flat out refused to allow us to ever climb a fire department apparatus.

sounds like your director made the call. Why don't you ask him why not? I'm sure he has a reason why he doesn't want his staff on fire apparatus.

It is my personal opinion that liberal sedation is the safest way this person could be transported. I also feel that there are several scenarios besides this where a ladder truck may come into play and a blanket no is the wrong approach. I.e. electrocution, crush injuries, fall with fracture etc

better for who? the patient? or the agency? or the individual provider? so whose safety comes first? Yes, it's best for the patient, but if it puts the provider at more risk, is your director going to go for it? Who is his ultimate responsibility?

For my company it pretty much seems like as long as you feel comfortable/safe doing it then you are free to do so.

until someone gets hurt, and then workman's comp asked why he was doing it. or OSHA comes in, asking for documentation that the provider was trained in helicopter operations. or that civilians SUV has faulty breaks, and crashes into a tree, and you legal department asks why the provider was in a vehicle that he didn't know the status of, with bad equipment, and now declines any workman's comp claim because he should have never gotten into a non-agency owned and maintained vehicle in the first place.

Remember, the insurance agent isn't looking out for the patient's best interest, they are going to try to find a reason to deny the claim, and doing something you aren't supposed to do (as per your job description), aren't trained to, do (according to OSHA standards), and are told not to do (as per your SOPs or supervisors directions) are surefire ways you can end up holding the bag when something bad happens.

 

[EpiEMS]

anything not requiring tools to get into is fair game though.

Curious - is this SOP or is this just generally accepted wisdom?

 

[DesertMedic66]

This post is the stuff that policies are made of.

It's all okay until it's NOT okay. First time a medic falls off an ATV, falls out of a pickup truck, gets injured making a forced entry or on the airship... it's all over. Trust me.

Saying "well, we've being doing it this way forever, nobody's ever said anything and nobody's gotten hurt" is not an acceptable defense. That's why risk management professionals get paid so much.

It would be next to impossible to list or even make policies for things we are not allowed to do. Waiting on scene while I can see a patient who has a broken hip on the other side of a sliding glass door and just doing nothing because the fire department isn't there is poor patient care IMPO. Same with a child locked inside a car on a 125 degree day. There is no policy that says I can or can't break the window but I'm not officially trained in how to break a window so what now? The fire department isn't always right around the corner and can easily take over 30 minutes to respond.

We actually have a written policy for us riding in on the airships that allows us to do so..

I have a boating accident in the river/lake and the only way to access them is by boat. There are other boaters there more than willing to give us a ride over but instead I am going to wait possibly close to an hour before the fire department gets there with their boat..

Same with drownings. The patient is still in the pool but I'm not a lifeguard and not trained in "water rescue" neither is PD or fire. So what do we do? Wait for a lifeguard to get on scene of this privately owned pool? Wait for them to float to the surface and fetch them with the pool net?

I judge the risks vs benefits for these types of situations and go from there. These are not just "what if" scenarios, these are actual calls that have happened. I've had the hip fracture call many many times.