Seattle/King County Fire and EMS politics.

[VFlutter]

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.

Actually, most the medics responding to this thread are truly impressive and very intelligent as are the non-medics who also take issue with some of the practices of KCM1.

As Vene stated if you claim to be the best then you must except scrutiny. You should be able to respond to criticism without getting defensive.

From what I have read in this thread I would not consider any of it "bashing" but rather legitimate concerns about questionable policies and practices.

 

[RocketMedic]

KCM's statements are pretty much exactly why EMS in the US is what it is.

Also, EMSA-OKC, MedStar Fort Worth, and Wake County do post some significantly higher-than-expected "cardiac arrest save rates", as do many other flagship systems. I think it's a combination of having the bandages of Lazarus woven into our monitor pads and potentially the widespread adoption of BLS-centered CPR with a lot of people really close by to compress/ventilate.

Here is a pointed question though: is it "less sexy" to take an old lady with chest pain (c/o falling to dispatch, btw), provide analgesia for a painful but non-life-threatening injury, or start CPAP/nitro on a patient with dispatched leg pain because their CHF exacerbation is objectively more of a problem than their massively overswollen leg? Of course they're not as sexy as Massive Traumatic/Cardiac/Respiratory arrest, since in any system other than EMSA, it doesn't involve flashing lights and sirens on the return trip (yes, here, the chest pain mostly managed with nitro and the CPAP were automatic emergent returns per protocol). In all three cases, I showed up to sick or injured people who were also scared. I applied what knowledge I have and the skills/tools at my disposal to give these patients a subjectively "better" outcome. None of them would have died in the 10-20 minutes it would take any EMS crew, regardless of level, to extricate, package and transport them to a hospital. However, in my case, at least two of these patients would probably not have even received ALS, despite benefiting considerably from ALS interventions. That bothers me.

KCM1 must have some amazingly cavalier paramedics, some fantastic and often worried EMTs, and some really really amazing hospitals quite adept at doing our jobs for us.

Even if you don't document anything more than gloveside and never transport, realistically, I can't see a medic helping more than 2 people an hour. That's 24 in a technician-only setting with minimal assessment time and a drugs/shock/tube-only scenario. Since KCM1 doesn't do this and doesn't have a lot of people, I think we can all agree that patients who get ALS in other systems don't get it in King County.

I think it's quite telling that defenders of KCM1 use lots of skill names, capitalized words and the Kool-Aid/Starcare approach to defend the system, whereas its critics use logic, reason and pointed questions.

(For what it's worth, I wish that EMSA would chase MedStar so I could be more like Linuss, not KCM1)

 

[NomadicMedic]

Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.

 

[mrg86]

Just asked a buddy of mine that is in Harborview's medic school, he says Seattle and South King still do not have CPAP.

 

[KingCountyMedic]

Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.

CPAP and transport vents are an ongoing discussion, prob moving to those in the near future. CHF is still nitro, more nitro, followed by nitro. Lasix not so much, and we have a huge lasix shortage right now. We have also placed the EZ IO and I-Gel airway on the truck. We are carrying versed and ativan now. We just got the new LP15 with the ability to send 12 leads to the hospital. The LP15 has all the time voice and data recording and we are required to download every CPR for review and study. Oh and we are getting new trucks this year, we are going with International TerraStar trucks.

 

[KingCountyMedic]

From what I have read in this thread I would not consider any of it "bashing" but rather legitimate concerns about questionable policies and practices.

I wasn't talking about just this thread, I found a trend of what I felt to be bashing in searching multiple threads. If you have questions by all means ask away but please don't just read what others post on the web about us and take that for the gospel truth.

 

[sir.shocksalot]

I think a lot of "great systems" are really only great because they are big city EMS systems. Under scrutiny I think many, maybe even most, EMS systems would have multiple areas in need of drastic improvement.

Regarding my question about comfort measures, in KCM1's defense, I think it's far worse to have a provider on scene who can give pain control but chooses not to than to have one not show up at all. How many systems can say that they are very aggressive with pain control? I know of several systems, even well respected ones, locally where multiple providers able to give pain control are on scene and the patient still goes without. Why? "They don't need it." "Too much paperwork." "They're faking it." "They're a seeker." "I'm not here to make you comfortable, I'm here to save lives."

So the real question is, what yard stick are we using to say any system is "awesome", "progressive"? I know that most of my coworkers and friends will think a system is awesome simply because they run a lot of "cool calls". The more cardiac arrests, shootings, stabbings, and other "cool things" are what tend to make systems "awesome" and "progressive".

Great cardiac arrest outcomes come from great public CPR and AED programs. Great trauma outcomes come from great trauma systems in hospitals, I'd argue that EMS involvement actually worsens outcomes. So instead of pointing the finger at any particular service like KCM1 and saying "they aren't as progressive as they claimed to be" I'd ask "who said they were? and why?". At least for my colleagues, they are the text book agency of progressive because they do "cool stuff lots". I think many of peoples problems with KCM1 really come down to problems that are prevalent throughout EMS. As much as I think their system has issues, as the saying goes, those who live in glass houses...

 

[ffemt8978]

Okay, this is everyone's last warning on the matter.

Knock off the personal attacks, direct and indirect, or this thread will become my personal pet project.

 

[DrParasite]

Interesting, when I left WA, KCM1 units did not have CPAP and still were using Lasix, along with NTG as a front line for CHF. Curious if that's changed.

If Im not mistaken, NTG is currently trending as the best first line med for CHF, then administer CPAP (got to dialate the vessels so the fluid can go somewhere). Lasix is really a long term solution.

Personally, I don't have a problem with what I have read about KCM1 (although some of the treat and release and treat and RMA/AMA is really sketchy). And if you give an ALS intervention, at least transport instead of turffing to the BLS.

I happen to think that you can pick any EMS system in the US, and find 5 things wrong with it, and 5 things that they aren't doing right (at least in your opinion, which isn't always right.). And people in glass houses shouldn't throw stones (except when it comes to fire departments, they should get out of EMS and let EMS handle EMS).

 

[VFlutter]

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

You still suture central lines? Take a look at StatLocks. They are awesome

 

[Brandon O]

CPAP and transport vents are an ongoing discussion, prob moving to those in the near future. CHF is still nitro, more nitro, followed by nitro..

Notwithstanding the rest of this thread, I find this extremely surprising. Is there a reason that a system with such obvious interest and ability for progressive, evidence-based EMS has deemphasized the adoption of CPAP?

 

[Shishkabob]

For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.


If they don't want to go, they don't have to go. I had a supervisor show up as a second Paramedic witnessing, but it is what it is and I'm not going to lose sleep over someone elses educated refusal.

 

[ExpatMedic0]

For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.

:lol: HAHA awesome

 

[Trashtruck]

For the record, I AMAd someone yesterday after giving them Adenosine for SVT at 190.


If they don't want to go, they don't have to go. I had a supervisor show up as a second Paramedic witnessing, but it is what it is and I'm not going to lose sleep over someone elses educated refusal.

Precisely.
I'm not here to make choices for people. If they don't want to go, fine. Here's what's up and here's what may happen. Sign this. See ya. If you're an idiot, that's none of my business, Mr. Alert-and-oriented-enough-to-make-your-own-decisions. Thank you for using XYZ for all your medical needs. Have a glorious rest of your day.

 

[Rialaigh]

I have read most of this thread but I am sure I missed many things and I apologize if this has already been said or anything.

First off - On the issue of ALS medications and skills not being used on patients that are not life threatening. It brings up a good point, are we as EMS charged with using ALS skills (when available) to better serve every patient that calls 9-1-1. Or would you say we are charged with using ALS skills to better the medical care for those who's medical condition at ER arrival would differ if brought in by BLS. For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome.

Second on the issue of AMA's - If the person is of right mind, and has not broken the law or stated they are going to break the law (threatening suicide..etc..) then I have no issue with an AMA regardless of medical condition. I am not hauling granny in, in handcuffs with police because she doesn't want her SVT treated at the hospital. Same goes for trauma patients, if it is that bad they will get altered mental status while we are on scene and we can justify taking them in restrained, if it is not that bad then we can leave and they can call back when they do need us. Not a perfect system by any means but I have a much harder time justifying to myself placing a perfectly rational person in handcuffs to drag them to the hospital because they are not as educated as us in medical opinions.

 

[Veneficus]

I have read most of this thread but I am sure I missed many things and I apologize if this has already been said or anything.

First off - On the issue of ALS medications and skills not being used on patients that are not life threatening. It brings up a good point, are we as EMS charged with using ALS skills (when available) to better serve every patient that calls 9-1-1. Or would you say we are charged with using ALS skills to better the medical care for those who's medical condition at ER arrival would differ if brought in by BLS. For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome.

Second on the issue of AMA's - If the person is of right mind, and has not broken the law or stated they are going to break the law (threatening suicide..etc..) then I have no issue with an AMA regardless of medical condition. I am not hauling granny in, in handcuffs with police because she doesn't want her SVT treated at the hospital. Same goes for trauma patients, if it is that bad they will get altered mental status while we are on scene and we can justify taking them in restrained, if it is not that bad then we can leave and they can call back when they do need us. Not a perfect system by any means but I have a much harder time justifying to myself placing a perfectly rational person in handcuffs to drag them to the hospital because they are not as educated as us in medical opinions.

I think if you are an ALS agency, providing "better care" is all you can hope to do.

If you are talking about outcome based care, ALS has almost no place in it. People talk about allegery attacks and epi, etc, but in they are a very small minority of cases. People with such allergies who do not have their own, access to epi pens, etc are an even smaller minority.

A hypoglycemic patient, while benefitting from ALS, will probably survive a few more minutes with a BLS ride to the hospital. With more or less deficit dependant on the case.

The only likely exceptions to this are in the rural environments, which makes urban and suburban ALS completely irrelevent.

If you consider glucometry, states where BLS is permitted to start an IV or admin a neb, it is far more economical and practical to supply these BLS providers with a few simple things like an epi pen, albuterol, dextrose in water, and protocols to administer them with or without medical control contact.

You would save millions of dollars, if not hundreds of millions of dollars, each year providing "ALS."

With CPR and an AED, you just equipped a BLS ambulance with a handful of things that would completely and totally mitigate the need for ALS.

As was stated here, starting central lines and intubating people while demanding high levels of education and compensation is just a needless drain. Even if you only have 7 of these rigs running around a major city.

It has been a while, but I will restate, ALS is a want, not a need. Nobody "needs" ALS.

So if you are going strictly off of want, ALS providers may want to provide better care. If their rank and file value their jobs and have any brains, they would demand it.

 

[systemet]

For example, if you have someone with a forearm fracture, slightly deformed, and clearly in pain but not crying screaming, is it our responsibility to dispatch ALS to medicate this patient. Because while the patient's experience might be better, the utilization of ALS on this call will not change (barring extreme circumstances) the medical condition or the medical outcome of the patient. Same goes for mild nausea, does a medic giving Zofran change the medical outcome of this patient, probably not. The argument here is whether medics should be used to provide "better care" or "improved medical outcomes". Because those two things are not the same, and very often providing better care does nothing to improve the outcome.

This depends on how you define "outcome". If you define it in terms of mortality or long-term disability, then I agree, you're unlikely to impact it in these patients. If you define outcome in terms of pain reduction, then, sure ALS can improve the outcome for the patient with the long bone fracture. If you consider that many cancer patients rate their nausea as more problematic than their pain, then perhaps there might be even more benefit to being able to provide a po / IM or IV antiemetic to patient #2.

At some point each system needs to decide what EMS care is. Is it:

(1) Lifesaving or potentially lifesaving interventions delivered outside of the hospital to reduce mortality. This seems to be the King Co. model.

(2) Providing general medical care outside of the community, as well as the life-threatening stuff, e.g. pain control, antiemetics, etc.

Or is it:

(3) Generating an opportunity for the patients first point of entry into the healthcare system to be provided outside of the hospital?

I would argue for (3), that EMS is not public safety, it's not simply transport, but that calling 911 should result into seamless transition into the healthcare system.

 

[systemet]

I think if you are an ALS agency, providing "better care" is all you can hope to do.

It seems like this is what we should be doing everywhere in healthcare. For some reason there's a segment of the EMS population that seems to think that providing non-acute care is beneath them.

If you are talking about outcome based care, ALS has almost no place in it. People talk about allegery attacks and epi, etc, but in they are a very small minority of cases. People with such allergies who do not have their own, access to epi pens, etc are an even smaller minority.

However, one could argue rationally that the patients with a first anaphylaxis event, or those who have had a severe enough prior reaction to require an epi-pen prescription but don't have access to it, represent a high-risk group. I realise this is rational conjecture versus anything evidence-based.

I agree that this represents quite a small percentage of EMS patients.

A hypoglycemic patient, while benefitting from ALS, will probably survive a few more minutes with a BLS ride to the hospital. With more or less deficit dependant on the case.

True, but for a healthcare system what's a better utilisation of resources -- sending an ambulance with a provider with 3 years of education, costing around $1,000, and perhaps directing this patient to a nonurgent family MD consult at a later point, or, using a provider with a year of education, costing about $1,000, transferring that patient to a hospital, and then having them assessed by an attending, a bunch of RNs, lab techs, etc., trying up scarce resources, and then getting a nonurgent family medicine referral.

I think that if we look at this from a systems perspective, there's some value to throwing a paramedic on an ambulance. The incremental cost isn't that high when you start looking at other healthcare system costs.

If you consider glucometry, states where BLS is permitted to start an IV or admin a neb, it is far more economical and practical to supply these BLS providers with a few simple things like an epi pen, albuterol, dextrose in water, and protocols to administer them with or without medical control contact.

It's cheaper, for sure. In my region, around $10/hr cheaper, with a lower capital cost for equipment. But it's not really that much cheaper, is it?

It has been a while, but I will restate, ALS is a want, not a need. Nobody "needs" ALS.

So if you are going strictly off of want, ALS providers may want to provide better care. If their rank and file value their jobs and have any brains, they would demand it.

This may be what I'm doing here, and I appreciate that you're being deliberately inflammatory. I think there are some areas where ALS has positive impacts:

* Control of pain
* Control of nausea
* Augmenting palliative care resources
* Referring patients away from the hospital, e.g. low-risk hypoglycemia
* CHF treatment (I recognise that much of this is in the process of being downloaded to BLS)
* Respiratory distress (see OPALS subgroup analysis --- I might be cherrypicking)
* STEMI recognition, PCI bypass, field thrombolysis
* CVA identification and stroke center bypass (admittedly, potentially very BLS)
* Psychiatric / Agitated patient transport (rather benzodiazepines than a taser or two and a few broken limbs).
* Seizure control
* Tranexamnic acid in trauma (I know that you don't like CRASH-2 and you're far more educated than me in this area).

Granted there's little evidence (or none) for most of this. But I'd also argue that the cost of ALS care is relatively low. There's already going to be an ambulance -- unless we're going to replace them with a taxi service, which I guess we could. I don't think many people would find that acceptable, but that would be an option. There's already going to be a bunch of equipment on that ambulance, and a couple of providers drawing salary.

Sure, there are cheaper monitors than an LP12/15/X-series that BLS can use -- although the options dwindle if we provide BLS 12-lead, which realistically we should. Some of the disposables, like adenosine, or TNK, are pretty expensive. But it's not that great an incremental cost between running a BLS response and running an ALS response. Is it really that much to ask that when I call 911, the representative of the health care system that arrives has a couple of years of education, and can move someone with a long-bone fracture without a whole ton of unnecessary screaming?

With respect.

 

[Brandon O]

"To cure, seldom; to relieve, often; to comfort, always."

I would add: to organize and direct patients to the most appropriate resources, and vice versa. Because that helps fulfill all of the above.

Nobody would say the triage nurse isn't serving a purpose, but is she really "saving lives"? You'd be missing the point if you asked that, wouldn't you?

 

[Veneficus]

True, but for a healthcare system what's a better utilisation of resources -- sending an ambulance with a provider with 3 years of education, costing around $1,000, and perhaps directing this patient to a nonurgent family MD consult at a later point, or, using a provider with a year of education, costing about $1,000, transferring that patient to a hospital, and then having them assessed by an attending, a bunch of RNs, lab techs, etc., trying up scarce resources, and then getting a nonurgent family medicine referral.

But currently US EMS does not refer to other healthcare resources as a matter of practice.

An acute hypoglycemic really should go to the hospital. I realize they don't regularly want to, and often refuse AMA, but it is AMA, not "let's do this."

I think that if we look at this from a systems perspective, there's some value to throwing a paramedic on an ambulance. The incremental cost isn't that high when you start looking at other healthcare system costs.

It's cheaper, for sure. In my region, around $10/hr cheaper, with a lower capital cost for equipment. But it's not really that much cheaper, is it?

It's cheaper, for sure. In my region, around $10/hr cheaper, with a lower capital cost for equipment. But it's not really that much cheaper, is it?

Medicare ALS 1 and private billing costs and expenses of the ALS provider. ALS comes up with substantial increase over BLS costs system wide.

There are logisitcs (like medication reporting/accountability), con ed, capital equipment expendatures, etc.

I don't think you accounted for the "hidden costs" that few people consider or think about.

This may be what I'm doing here, and I appreciate that you're being deliberately inflammatory. I think there are some areas where ALS has positive impacts:

* Control of pain
* Control of nausea
* Augmenting palliative care resources
* Referring patients away from the hospital, e.g. low-risk hypoglycemia
* CHF treatment (I recognise that much of this is in the process of being downloaded to BLS)
* Respiratory distress (see OPALS subgroup analysis --- I might be cherrypicking)
* STEMI recognition, PCI bypass, field thrombolysis
* CVA identification and stroke center bypass (admittedly, potentially very BLS)
* Psychiatric / Agitated patient transport (rather benzodiazepines than a taser or two and a few broken limbs).
* Seizure control
* Tranexamnic acid in trauma (I know that you don't like CRASH-2 and you're far more educated than me in this area).?

I am not being inflammatory. There is no benefit to a mortality measuring ALS service the way the US commonly practices it.

It is a level of services that is wanted, for the increase in care it brings. Many places in the US do not mandate EMS care, they do mandate fire and police.

There's already going to be a bunch of equipment on that ambulance, and a couple of providers drawing salary.

As above, there is more to ALS cost than equipment and salary.