If EMT-B education was better, 1 ALS per 20,000 might be OK. But until then, I'd prefer to have more, not less, ALS. I've seen too many basics make absurd mistakes to think otherwise.
Seattle/King County Fire and EMS politics.
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If EMT-B education was better, 1 ALS per 20,000 might be OK. But until then, I'd prefer to have more, not less, ALS. I've seen too many basics make absurd mistakes to think otherwise.
the_negro_puppy
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Bullets
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That about the ratio for my entire county! 6-7 ALS trucks covering 620k living across 600sq miles. We also have a Physician roaming the county
abckidsmom
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You have to know what you're talking about though. Average time on task, transport time, response times, drop times, interval between clear from the hospital and in service in the district.
Our county of 35k over 500 sq mi is at times woefully underserved with 3 medic units and a spare couple of BLS units here and there. It's scary to think that an accident on the interstate with the report of 3 people injured dumps the entire county's resources.
We can laude the ROSC rate in Seattle all day long, but it is not the sole measure of an EMS system, nor can every system be held up to that standard.
NYMedic828
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The NYC-FDNY EMS system usually has 300-400 ambulances patrolling the city. 1/5 of those are probably ALS units. We have a population over 8,000,000. In many areas they have quite a bit of down time. We also run dual medic exclusively though and only send ALS units to calls triaged for them by dispatch.
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Boston EMS runs 5 medics at daytime staffing for a city with a daytime population of over 900 so it's certainly possible. That said, I don't know what the hospital situation is in Seattle, but here we have a Level 1 accessible in under 15 minutes from anywhere. The city BLS units (19 on in the daytime) are also much better trained than average. They have a three month didactic orientation followed by three months of FTO time before being released.
Do patients with significant pain or nausea/vomiting go untreated to the ED frequently? Yes. And I am sure that even sicker patients are taken by BLS by system necessity. I'd still say the system still does ok considering transport times and the ability of BLS to recognize when it's time to go to the hospital immediately. I get the idea that this doesn't happen everywhere, but in Boston BLS is certainly prompt.
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There is only one level one hospital, and the only way it can be reached in 15 minutes is if you are within 10-30 blocks, depending upon time of day. There are a plethora of level two hospital scattered about, though.
KingCountyMedic
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Okay, I'll respond a bit better for you. MY posts are sometimes a bit vague in proper explanations. My fault, sorry.
As far as treating SVT with Adensosine and leaving them home I should have said it is something we do, all though it is VERY rare. If we have a patient that has a history of SVT, has been treated with adensosine and converted by M1 previously and WANTS to stay home and follow up with their cardiologist and they are stable we will have them sign AMA and we will contact Medical control and their cardiologist if possible. If we have never seen the patient before we take them in.
As far as responding to your insults I won't.
As far as this hang up so many of you have with pain and nausea management. We are not going to double or triple the ammount of medics just to treat simple injuries or a bit of nausea. Any good EMT can tell you that GOOD splinting will take care of pain quite a bit. As far as nausea, yes it sucks to be nauseated. If you are at the point that you can't stop puking and your BP is low and you will get a visit from a Medic unit and you will get fluid and zofran or promethazine and whatever else you may need but if you have stable vital signs and you are not having other serious issues you need to go see the ED or clinic. If you look at all the recent studies where you have a group of Doctors saying Paramedics should not intubate, should not have RSI, should not perform central lines in the field you will see that the majority of these areas have a paramedic on every rig, every street corner and very little training or experience. We believe in having a limited ammount of ALS providers seeing a lot of sick people. Our training program is longer than most, we are in the field on day 3 of Paramedic school and we are starting IV's learing to intubate and place central lines in the first 2 weeks of school. I'm not trashing any of your programs, I'm not trying to brag about mine but I am proud of where I work and I love my job. We do have amazing save rates, I am a piece of that but a small one. We have more citizens trained in CPR than pretty much anyplace in the country. We have a ton of cops and they all have defibs and PD is dispatched to all CPR's. We have public defibs all over the place. We send multiple units to CPR calls, we try to shoot for continuous chest compressions, we do not stop compressions during intubation. That is why we have the save rates, it's not because I'm some para god. I have great help every place I turn. We have very tight dispatch criteria, designed by Doctors and Paramedics so the people that need to get seen by ALS do get seen. It's not always perfect and there is always room for improvement.
VFlutter
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You place central lines in the field? <_< Subclavian or Femoral? Do you use ultrasound? I am guessing it is limited to cardiac arrests.
I hope they yank them out as soon as you roll into the ER. I would love to see your complication and CLABSI rates.
NomadicMedic
I know a guy who knows a guy.
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Unless things changed in the last year or two, KCM1 doesn't place IOs, they place subclavian central lines.
Not commenting on King County specifically, but multiple agencies performed central lines in the field prior to the popularity of IO.
As you know from the history of cardiac arrest survival, it seems likely that anybody gave much thought to the complications probably because nobody lived long enough to get an infection.
Ultrasound guidance is not required to place a central line. Most of the people I know can and commonly place those lines without ultrasound guidance all the time.
Substituting technology for skill is not safer, it just costs more.
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I still shudder to think about the consequences if this goes wrong.
I don't recall ever insulting you. I do recall making some rather pointed statements. Tough.
This seems to be a system driven decision rather than a patient driven one. Meaning the accusations of KCM1 leadership caring more about save rates and intubation success start to sound a bit truer.
Then why is the in-hospital standard to control pain prior to splinting? Not doing so is considered cruel. My goal is to bring the ED to the patient to the best of my ability, not the other way around. Pain control by splinting is just a way to justify a poor level of care.
Why exactly is servicing this population such an issue for you and KCM1 as a whole? Because its not cool and exciting? Because press releases don't get written about controlling nausea? Provide me with a real explanation and I'll let it be.
First off, considering EDs and ICUs in most of the country are moving away from placing central lines emergently in favor of IOs so bragging about that might not be the best idea...
The rest of the world, and even some systems in the US (one the next city over from me) manage to put a provider who can do things like pain and nausea management, EKGs, ect on all calls and still have a limited number of skilled and experienced paramedics and/or physicians on hyperacute calls. So why can't KCM1? Other than arrogance and the thought that being a KCM1 paramedic "means something". Again, if you can change my mind with evidence do so. Until then MedStar in Fort Worth makes KCM1 look like they can't manage a system.
Why can't the people who need get seen by someone who can actually help them rather than someone who can provide a taxi? Why is KCM1 so against this?
What I see from your description is an agency that has completely lost patient focus, cares more about skills and numbers than taking care to the patient and is secure in knowing they won't be removed or sued due to built in government protections. Prove me wrong, but its going to take evidence.
KingCountyMedic
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We place IJ, subclavian, and Fem central lines. We use the Trauma Arrow Kit with sterile drape and sterile procedure and suture them in place. We are required to fill out Central line forms for every line placed in the field, same as we fill out airway form for every tube placed. A central line is to be placed only when we have a patient that has no other peri access available. We have recently started using the EZ IO as well and that has cut down on central line use a bit but we still do quite a few. We place them in cardiac arrest patients, trauma patients, anyone that needs one gets one. We are required to perform at least two a year for recert. Our complication rate is very low, as is our infection rate. We are trained in placing central lines with sterile technique by trauma surgeons at Harborview Medical Center. All lines in King County are yanked if the patient is admitted, especially central lines started in the field unless there is no other line to be had. We are required to document everything we do, every IV, central line and ET tube placed is reviewed that week by our medical director. If you screw up you will hear about it usually in less than 24 hours. I have placed many central lines in awake patients, local lidocaine prep and sterile tech used of course. We do a lot of stuff here that isn't done in a lot of places. The single biggest thing about our program is the intense Physician involvement in our training. We have our Medical Directors ride with us on a regular basis. We have monthly Doctors meetings with required attendance and we are usually doing 3-4 big medical studies at all times. It is a great place to be a Medic.
A patient who's not about to die on the other hand....
I am sorry you feel this way. While I agree splinting can substantially reduce pain in many instances, it is basically a partial treatment.
Your system has thus made the decision it does not care about all of its patients, just the headline grabbing populations.
That is unfortunate.
Taken together with your above statement, I can only conclude that while your system provides very good care in all aspects of the sudden cardiac arrest population, it does not seem to much of anything else.
If this were the 1980s your system might be enviable, but it seems considerably behind the times as far as medicine.
I would like to know what you spend so much education time on if you are only providing medical care to a very small protion of your calls?
This seems to me like your system is set up to defend the ability of paramedics to use a variety of ALS skills, not to provide the best care. That is not a reflection of you or any single provider, but it does great discredit to your leadership.
As we are seeing more and more, these advanced skills do not improve survival, in hospital or out. Recent advances in resuscitative medicine call into doubt the need for aggressive airway maagement in a variety of populations, most notably your system specialty of cardiac arrest.
As mentioned by chase, there are considerable complications with the use of central lines. So much so even in hospitals it attempts at reducing infection rates are of prime concern all over the world. I would need to be convinced that using this technique in the field environment was anything but hubris.
I also do not believe that you have any more sick people per capita than any place else. Because of the general level of health in that region, you probably have less sick people.
I would amend your statement to say you have ALS providers not seeing many people at all. Again, not something I would be proud of, but it must take a great deal of spin doctoring to turn that into a positive.
If I could just maybe put this into perspective?
With the exception of central lines, you have nothing here that everyone else isn't doing. The use of central lines outside of the hospital is highly questionable.
You have almost triple the education of the average medic program, but are expected to only use this education on an extremely limited population. While I applaud this increase of educaiton, it seems to me that it might be a bit wasteful considering what you actualy do.
There is nothing wrong with being proud of where you work. Here again you detail "save rates" and everything your system does to improve them at the cost of every other aspect of EMS.
I know what it is like to work for agencies considered the best. I know that whether you lay that title on yourself or somebody else does, everybody else puts you under the microscope. A considerable amount of those people want that title for themselves. It is the nature of man. But from what I have learned here, I do not think your system is what it claims to be, and I think that when people point that out, instead of taking a hard look at your system and make changes, your providers try to claim that everyone else is just jealous because they cannot be like you.
It reminds me of a story about the Emperor's New Cloths.
It sounds to me like an N=1 experience or a patient refusal. I cannot believe that any doctor, especially in the US, would approve a treat and release cardioversion.
If as was clarified, a patient refuses medical advice and transport, that is not because of the outstanding work of the medic, it is because the patient is assuming the risk.
I further cannot believe that any highly educated provider, paramedic or otherwise, would meet a patient with a new onset heart arrhythmia, chemically cardiovert it, and be fool enough to think that it could not revert or not acknowledge it may simply be a symptom of a more serious underlying pathology.
But again, no provider in any system can be faulted for a patient refusing AMA.
I think this has been established beyond any doubt. Not only from this post but the history of its claims. (Some of which had to be redacted I might add)
From this post, part of it sounds like economics. It takes an aweful lot to train people 3x as long, pay them a corresponding wage for this, do as little as these ALS providers do, and justify the cost.
At least part of it is the system leadership is so focused (for whatever reason) that they have lost sight of all else. But that is not the fault of the providers.
I must concur, KCM1 does not seem to meet the level of excellence that other nations and the more admirable systems in the US have set.
But nobody wants to say "My system is almost 40 years out of date and does only 1 thing really well." Even personal emotional security dictates providers believe they are doing the best. (or at least the right thing)
I must concur with this assessment, but I am not sure if the reasons they do what they do is sinister or just misguided belief.
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Aidey
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It is actually in their protocols.
It is supposed to apply to patients with a known history of SVT and after medical control consultation.
Still highly questionable.
That is a very diplomatic way to say that.
KingCountyMedic
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Yes it is very rare that it actually happens.
I'm sorry if I haven't made myself more clear. Frankly some of you seem to have a problem with just about anything that anyone posts on here. You are very impressive web medics I'm sure. I didn't start posting here to get into arguments. I was originally just looking around for interesting stuff, maybe try to learn something, swap a story or two but I made a mistake and searched Seattle/King County and discovered all the bashing of my system and felt defensive. I'm sure that I'm not the guy my chief would have chosen to go out and champion our way of life, I'm an old street medic that has been working in some type of ambulance for going on 27 years. I am obviously not good at making a point in a forum or properly explaining how we do things. My bad, all on me. I have seen just enough of this place to know that it is a lot like working EMS. There are a lot of good folks out there but the only ones that you notice and remember are the a-HOLES. So enjoy your forum, sorry if you don't care for me or my system. Take care.
At the risk of diverting this thread in another direction, we do this too, and some of the services in our general region have for > 10 years. We have a written treat & refer protocol for this situation, and it requires that the patient is stable, lacks other acute pathology, is under 65, has a hx of prior adenosine-responsive SVT, has someone responsible who can stay with them for 4 hours, and is able to call 911.
ExpatMedic0
MS, NRP
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Slightly off topic, but the medic 1 system is M.D. taught and 3000 hours in length, most of the students are already certified Paramedics, correct? They also have the highest cardiac arrest survival rates in the nation right?