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DOH policy statement 10 - 01 January 2010. Epi and AEDs were required to be on NY ambulances as of May 01 2010. Great job. Putnam Valley had the same experience back in 2001. We put epi on the rigs even though we had ALS back up. A woman presented with a hornet sting an hour old, having no reaction. The medic kicked it back to BLS and half way to the hospital she had a massive reaction. What seemed like a lot of money for something ALS could do for us turned out to be an excellent investment. It is wonderful to see BLS step up and have such a positive outcome. Well done.

For more information, see Circulation vol 122, issue 18, supp 3. http://circ.ahajournals.org/ [The white and red box, right side of page.] The long version is a must read for professional providers. If I might respectfully rephrase what Seth says, I see paramedicine as craft built on science. At our best, we bring both in equal measure to the patient.

"Expedite" is just a word. What one does with it is entirely up to the responder. It doesn't affect how I drive, but it does get me thinking about what I'm going to be walking into when I get there. "Expedite" actually tells me a lot. It means the scene is not under control and the person "in charge' is wetting themselves. That said, "Expedite" sounds a whole lot better than "I want my mommy!!!!" Let's come up with something better. Ideas? "35 Medic 1....'Clean up Aisle 5.'"

Who does and who should may be different questions. Keeping this post within the context of AHA guidelines: " A different rule may be useful when the additional diagnostic and therapeutic capabilities of an advanced life support EMS response are available to the victim. The National Association of EMS Physicians (NAEMSP) suggested that resuscitative efforts could be terminated in patients who do not respond to at least 20 minutes of ALS care.32 " An ALS termination of resuscitation rule was derived from a diverse population of rural and urban EMS settings.33 This rule recommends considering terminating resuscitation when ALL of the following criteria apply before moving to the ambulance for transport (see Figure 2): (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. This rule has been retrospectively externally validated for adult patients in several regions in the US, Canada, and Europe,25,27–29 and it is reasonable to employ this rule in all ALS services (Class IIa,). "

The overarching concept seems to be early and absolutely uninterrupted chest compressions for the duration of the resuscitation attempt. Intubation, if it is to be performed at all comes later and with only a 10 second pause. All therapies are secondary to compressions and defibrillation. Blind airways that do not require a pause for insertion are given more weight in the new guidelines. I think a patient that does not have ROSC prior to transfer to the ambulance is assumed to be beyond resuscitation. Primary skills/therapies have to be performed in situ if they are to be successful. As for doing CPR through defibrillation...... It got you all talking about the new guidelines, now didn't it? If you were fish, you'd be dinner.

From the journal Circulation as referenced in the 2010 AHA ACLS guidelines, Part 7 CPR techniques and devices. "Over the past 25 years a variety of alternatives to conventional manual CPR have been developed in an effort to enhance perfusion during attempted resuscitation from cardiac arrest and to improve survival. Compared with conventional CPR, these techniques and devices typically require more personnel, training, and equipment, or they apply to a specific setting. Application of these devices has the potential to delay or interrupt CPR, so rescuers should be trained to minimize any interruption of chest compressions or defibrillation and should be retrained as needed. Efficacy for some techniques and devices has been reported in selected settings and patient conditions; however, no alternative technique or device in routine use has consistently been shown to be superior to conventional CPR for out-of-hospital basic life support." [emphasis mine} As for the rescue pod a.k.a. ITD the same section states": " The ITD also has been used during conventional CPR with an endotracheal tube or with a face mask, if a tight seal is maintained.77,80,81 During conventional CPR with and without the ITD, 1 randomized trial80 reported no difference in overall survival; however, 1 prospective cohort study82 reported improved survival to emergency department (ED) admission with the use of the ITD. One meta-analysis of pooled data from both conventional CPR and ACD-CPR randomized trials83 demonstrated improved ROSC and short-term survival associated with the use of an ITD in the management of adult out-of-hospital cardiac arrest patients but no significant improvement in either survival to hospital discharge or neurologically intact survival to discharge." [emphasis mine] Thanks for the literature, here's back at you. I'm going to have to go with the AHA guidelines, however.

And yet, devices are not improving outcomes.... and the real concern is that setting up devices may be taking time away from useful CPR. Energy seeks the path of least resistance, which is pad to pad. Locked hands, even on a bare chest, are unlikely to offer a better path to ground. General [ and perhaps unreasonable] fear of electricity should not be influencing patient care. If safety were the only issue, then find another line of work than EMS, which has many opportunities to be unsafe. What we are looking for as EMS providers is maximum effect with minimum risk. As the case becomes more compelling for continuous CPR, I'll ask again.... how long are we taking away from CPR to shock and is it necessary?

I've been reading the back papers to the recomendations, and it's interesting. While lidocaine has an effect on VF, overall mortality increases with it. Amiodarone, in limited studies, shows no improvement at low doses and is harmeful at high doses. Short version is antiarrythmics are Class III, not recommended.... to quote: "Following an episode of VF, there is no conclusive data to support the use of lidocaine or any particular strategy for preventing VF recurrence. Further management of ventricular rhythm disturbances is discussed in Part 8.2: "Management of Cardiac Arrest" and Part 8.3: "Management of Symptomatic Bradycardia and Tachycardia." [Circulation Nov 2010 Part 10 Managemenrt of Arrythmias] But that's not why I posted.....And this is a 'charged' question..... More and more evidence is mounting that ANY interruption of compressions is harmful with longer interruptions being worse. And yet there still is this block of time where we do not do compressions while defibrillating. Why? While I would not ask a fellow rescuer to continue compressions with a shock imminent, I've started doing them myself and through gloves, I'm just not feeling it. Are we missing an opportunity to improve outcomes when we hold off on compressions during active defibrillation? Anybody out there have experience they could share?

Dawn was one of the tigers of EMS. She was dedicated, a tireless worker, and always there when she was needed. Long after weaker souls might have stopped, she made EMS a part of her life and EMS was richer for it. It was an honor to have worked beside her. Thank you, Dawn.

Ah, another 'grasshopper'... What I would say is that 'shorter time to patient' is always better. That said, if this is THE goal, then there are many ways to achieve it. Every 'way' has a 'cost' associated with it. Cost/benefit is a decision that gets made long before we get dispatched to a call in the form of staffing and system management. The greater determinant in how long it takes to get help to a patient is how far away from the patient the help is, not how fast you drive. Almost invariably, it is trained bystanders whose instantaneous help keeps a patient viable until EMS gets there that make the larger difference in outcome. And yet basic emergency tactics aren't even taught in schools. One can get a driver's license and not know what to do at an auto accident. Minutes also carry different values. If time from injury to arrival of useful EMS is under 8 minutes AND it is a critical call, then shaving time here might make sense. If time from injury to EMS arrival is going to be 15 to 20 minutes, then shaving a minute or two here doesn't have nearly as much value. As for RLS versus reckless, half of all drivers are below average. One need not be reckless to meet up with an inattentive driver who completely isn't prepared to stop or take evasive action. Whether RLS has value needs to be evaluated case by case. I think the wise responder does this starting from the position that RLS is not worth it and then tries to build a case that it is,not the other way around. These are good questions. If at 20, one does not have the 'fire in the belly' then one shouldn't be in emergency services. If one still has it at 50, then they also shouldn't be in emergency services. Remembering one of the great quotes on why a driver didn't go all that fast..."If the fire's any good it will still be going when I get there."

First, one of the things I love about sites like this is that anyone of any age or background can get us up and talking about stuff. I think this is great and this is not a bad question. We should all be able to answer it. To rephrase it a bit, why put them on in the first place ? Any call for aid probably trumps what the majority of citizens are out doing in their cars on a given morning. The ability to cross the yellow line, to use the oncoming lane, to not wait for 6 cars waiting for a light to change and then turn left,.....well, lights or sirens help us do that. Abiding by every traffic control device and waiting for every driver in front of us is using a lot of time that most drivers will gladly give us if they know we have someplace to go. Lights and sirens let other drivers know a vehicle may not be where they expect it to be and that that vehicle would like a little courtesy. Lights and sirens are like any other tool, useful if used wisely and for an intended purpose. Light functions in a straight line. It is very useful for signaling oncoming traffic and moderately useful for signaling same direction traffic ahead [if the driver is using his rear view mirror for more than hanging fuzzy dice]. Lights have no effect on traffic that is not direct line of sight. Sound MAY--and that's a huge 'may'--- signal drivers not in line of sight. Physics here is key and I will skip the details unless people really want me to dig it up, but given sight lines in intersections, sound proofing in cars, reaction time of sober adults, and speed through intersections------- 10 to 15 miles an hour is as fast as a vehicle RLS can enter an intersection against a stop sign or red light. And that is if no one is texting. So for me, lights [and much less often, sirens] is a way to say, "Excuse me." and move to the head of the line , but it doesn't mean one has to significantly increase speed. And if one does increase speed to the point that one outruns the usefulness of the lights and sirens, then that person is begging to have a collision for which that person will be responsible,and which will significantly increase response time for that call. So, yes light and sirens are an essential part of the conversation that emergency vehicles have with other vehicles out on the road. But that conversation is a dialogue, not a monologue. Lights and sirens in no way give us the right to be aggressive with or disrespectful to other drivers.

At first blush it sounds as if you've made up mind. If the question is 'What is the absolute least I have to do to re-certify?' then that is different from asking 'How do I improve my skills and enhance my education?' I would suggest you find instructors who energize you and take what they have to offer be it CME or standard format. One can attend CME's and conferences of interest if basic training seems lacking. What I like about CME's is the opportunity to hear different perspectives on patent care. I also like the ability to go on line if I feel I need refreshing or better information on a topic, learn something and then use that towards re-certifying. EMT certification is mostly just a license to teach yourself the craft.

Insurance data is valuable, but far from a full picture. Homeowner's insurance data does not reflect response to auto accidents, wild fires, searches, wires down, ice storms. In fact, structure fires is a small percentage of what we do. I am aware of no studies on the subject, but 4 fire fighters will have a hard time handling a running brush fire 1/2 mile from the road or a search for a lost person..... and heaven help the person who actually needs someone to fight fire if they are the second call in district. No one has made the case that towns are poorly protected if some manpower and apparatus is out of district. As a rule, a team of 4 or 5 individuals who are well trained can handle initial responses. I think the balance of departments can manage that and a parade. Is there evidence to the contrary? Dare I say it, silence is deafening....

A good question deserves a good answer. My volunteer department has over 100 active members, lots of associates. Some serve out of family traditions, some are adrenaline junkies, some believe in community service. There are even a few souls who come for the food, and my heart goes out to them. Yes, some people love to parade and those people go to parades. The last time I was at a meeting, which is a while ago, there was grousing from the parade people that so few people were turning out, it was a always the same few. Long after one has put on a scott pack for the last time, one can don a uniform and shiny shoes to go marching for the cause. For every hour out at a parade, dozens of hours are spent in house, polishing, gear checking, maintaining equipment. Towns are extremely well protected when everyone is in house on a detail. I even remember a mutual aid call where not only did we make filthy the parade truck and the parade rack, we could have won best dressed department to a running brush fire. It is hard to prove a negative. I can say without reservation that in my 20 years as a volunteer, my department never put parading above fire fighting. I cannot think of a time where service suffered when a truck was out of town, be it maintenance or a parade and I can think of many times a designated crew on stand by cut response time. I can remember the dozens of times that I was asked to stay home and stay frosty. I can remember the day of a department golf outing we handled back to back structure fires with over 40 members at scene. I can remember the night of the 2000 New Year's Eve gala when, party notwithstanding, we mounted an outstanding attack on a propane fueled house fire with easily 50 members at scene. A volunteer fire department is a social enterprize. It is also a large and dedicated fire fighting organization. What we lack in paid performance is more often than not made up in brute size. If for 4 hours on a Saturday afternoon we are down 10 deputy chiefs with a combined age of 750 and one truck.... we still have 7 trucks and 80 members home cutting grass. Parades aren't on held on weekdays. Here is a pair of questions for our paid brothers: How many fire fighters does a paid truck get to the scene.... 4 or 5? Can our paid brothers point out times when participation at a parade has actually resulted in a negative outcome for a community served by volunteers?

A good question deserves a good answer. My volunteer department has over 100 active members, lots of associates. Some serve out of family traditions, some are adrenaline junkies, some believe in community service. There are even a few souls who come for the food, and my heart goes out to them. Yes, some people love to parade and those people go to parades. The last time I was at a meeting, which is a while ago, there was grousing from the parade people that so few people were turning out, it was a always the same few. Long after one has put on a scott pack for the last time, one can don a uniform and shiny shoes to go marching for the cause. For every hour out at a parade, dozens of hours are spent in house, polishing, gear checking, maintaining equipment. Towns are extremely well protected when everyone is in house on a detail. I even remember a mutual aid call where not only did we make filthy the parade truck and the parade rack, we could have won best dressed department to a running brush fire. It is hard to prove a negative. I can say without reservation that in my 20 years as a volunteer, my department never put parading above fire fighting. I cannot think of a time where service suffered when a truck was out of town, be it maintenance or a parade and I can think of many times a designated crew on stand by cut response time. I can remember the dozens of times that I was asked to stay home and stay frosty. I can remember the day of a department golf outing we handled back to back structure fires with over 40 members at scene. I can remember the night of the 2000 New Year's Eve gala when, party notwithstanding, we mounted an outstanding attack on a propane fueled house fire with easily 50 members at scene. A volunteer fire department is a social enterprize. It is also a large and dedicated fire fighting organization. What we lack in paid performance is more often than not made up in brute size. If for 4 hours on a Saturday afternoon we are down 10 deputy chiefs with a combined age of 750 and one truck.... we still have 7 trucks and 80 members home cutting grass. Parades aren't on held on weekdays. Here is a pair of questions for our paid brothers: How many fire fighters does a paid truck get to the scene.... 4 or 5? Can our paid brothers point out times when participation at a parade has actually resulted in a negative outcome for a community served by volunteers?

Oh, please. The greatest cop show of all time? Due South.

And yet a life is just as precious in the boondocks. Why is it acceptable to have a different standard for rural service and demand one service standard for urban/suburban? As a matter of semantics, population density makes a huge difference, not in what level of service [a.k.a. response times] is acceptable, but in what level of service is possible. Consider White Plains. With a resident population of about 60K and a daytime population of 250K, this is an urban example where a lot of people are in a small area that might expect to have multiple ambulances and with that, short response times. In a bedroom community that feeds WP, a resident population of 10,000 becomes 5,000 during the day. In that situation one might even argue that all ambulances should be in WP and none in the suburbs. A 4 minute response time for 250K and 15 minute response time for 5K might be a good use of resources. Which by the way is exactly what happens when there is paid service. Units are placed where they will do the most good. High density areas see better response times than less populated areas ... at least they do if someone is managing the system properly. All of which speaks to the need for some minimum level/standard of service. I would expect that in urban situations that standard might be exceeded by a significant amount.

Ooh, ooh I can answer that. Call volume, population density, square miles per agency, and length of roads. My volunteer corps answers about 700 calls a year, serves just over 10,000 residents, covers 43 square miles. Rostered in station and driving like a bat out of hell, it takes 15 minutes to get from the station to our farthest population center. To meet 4 minutes BLS and 9/90 ALS transport, we would need two more stations and another medic unit. And I don't think it would improve outcome.

Bnechis makes an excellent point about annual reports. QA/QI should also have QR-- quality of response. If we quantify the problem we can better address it. Towns have an obligation to their taxpayers to ask agencies what level of response they are getting for their money. At one time the Putnam County EMS Council was providing data from dispatch on response times at their monthly meetings, which is tantamount to public disclosure. The point about standards is flawed. The AHA standard is based on responses to cardiac arrest compared to survival rates. The research is good, but one should not confuse ideal response times for cardiac arrest in an urban setting with 'reasonable' response times for EMS overall. 4 minutes BLS and 9/90 ALS transport was studied in an urban setting. Staffing to that level would be cost prohibitive in almost all suburban settings. Even in the weakest EMS systems 'CPR in progress' or 'PIAA, blood running in the streets.' usually gets a rapid response. If one were to poll taxpayers, asking if they wanted an ambulance at their door in 4 minutes I have no doubt the answer would be 'Yes'. If at the same time one asked them to fund an additional $250,000 a year to pay for it, I also have no doubt the answer would be 'No'.

That's it..... breathe......let the anger out. I am reminded of the joke about the woman who when asked if she would sleep with the town drunk for a million dollars said, 'I guess so.' and at 50 dollars showed outrage saying, 'What do you think I am?' The reply was "We have established what you are m'am, we were trying to determine the degree." Compensation is relative. Whether we do it for $10-$25 an hour or all you can eat shrimp once a year..... we are all underpaid and perhaps we can agree that probably makes us all idiots, just a matter of degree. I meant no disrespect to paid service, [which I am 60 hrs a week], and if you found it in my post I apologize sincerely. I never said nor meant to imply that paid service lacks compassion. Some days I do not sense the enthusiasm, which you quite adequately addressed in your first paragraph. In life, in EMS, it is not only where the path takes you, but how you choose to walk it.

Part of the complexity is that I don't think there are accepted performance standards. Could you reference them if you can find them? Given that the case in point is rural/suburban, standards need to be for that. Another is that an agency providing an essential service can't just up and say 'I give up, we're not making it', nor can an agency spend [taxpayer] money it does not have to hire help. Logistically, paid crews only solve the problem of the first call. Staffing second rigs is prohibitively expensive unless a large region is all using the same provider who can ballast multiple call situations. Towns are paying for EMS. A town can say 'You're not doing a good enough job', put out a contract stipulating level of service required and take bids..... and if memory serves a lot of that happened and towns were unhappy with the result. We are all responsible for our own health care, and that of those we consider family. Consider taking your own good intentions to town board meetings and lobbying your elected officials for more funding or more service. We all need to know the resources available to us and plan accordingly. If your family has special health needs, are they preplanning how to get a family member out of a house, perhaps drive them privately, arrange for a paid service to respond directly? [When we have friends staying with us in the Adirondacks we know it is an entirely different level of service and plan to take action accordingly.] If you are looking for statistics, ask agencies. Most can give you call volume and mutual aid information. Response stats come out of dispatching centers so try there or see if your county has someone in charge of coordinating EMS that can help, it's a lot of data entry that most agencies don't have time to do. And that said, what constitutes a response time is a whole new topic. Get involved with your local EMS council. There is a lot we can all do in addition to posting.

We need to find some common ground here. Volunteers aren't holding anyone back, and speed is relative. Overworked paid systems have long response times as do rural areas.[ In most of the Adirondacks you will almost never get a medic and an ambulance will be coming from 20 miles away to take you to a hospital farther away than that.] And I see in the volunteer EMTs that I work with an enthusiasm and dedication to patient care that is too often lacking in paid services. Volunteers are there because they want to be, and it shows. I just wish they wanted to be there more often. Paid systems are minimally staffed, so when it gets really busy they have extended response times, too. Volunteers, or those managing them need to step up on the hard issues. Sacrifice requires.... sacrifice. Volunteer EMS agencies have to set minimum standards and meet them. That may mean mandatory rostering in station and/or supplementing with paid staffing. A distinction that needs to be made is that individuals VOLUNTEER, agencies by and large do NOT. I believe all agencies [locally] are funded by some combination of municipal funding and billing. Either through taxes or billing a patient is seeing the cost of running an EMS system. The money is there. How is it spent? One view is that spending money on ridiculously expensive ambulances with all the bells and whistles, fancy jackets, awards and steak and shrimp dinners will bring in and keep volunteers. If that is working, great. If it isn't, then consider the agencies that bill and use that money to supplement volunteer availability. Volunteerism is fantastic. We do not need to get rid of volunteers; we need to make it possible for people to volunteer at the same time that we provide consistent, timely, EMS service. Billing was a hard pill to swallow for volunteers, but we got over it. Supplemental staffing or mandatory rostering is just as hard. We need to get over that, too.

And if all you've got is balls, then in my opinion, it's just another pair of fuzzy dice on the rear view mirror.

Stokes baskets....or keep one in your gear... Fashion a loop [or four] of 1 inch webbing that's about 3 feet lying flat [doubled]. Girth hitch one to a handle in each corner of the basket. For confined situations or vertical changes, the straps can be fed forward to other rescuers for stabilization. On a straight carry, throw the strap back over the shoulder, around the neck and down to the outside hand. Now the load can be balanced across the back and give the inside arm a rest. It also lets you pass a basket forward before letting go entirely. Much safer. [cave trick]

Where we are is, well, where we are. The question I think we are sniffing around is... Is where we are good enough? And that's tricky because 'good enough' is a broad term that changes. Enough resources, enough manpower, enough training, soon enough? EMS is changing. What was,in suburban/rural communities, 'neighbor helping neighbor' occasionally and in genuine emergencies is becoming a full service, let us bring the hospital to your door operation. My VAC, Putnam Valley, was the first in Putnam to get certified. That had to be early 90's, when just fielding an EMT on every call made us special. Now almost every call gets a medic with a monitor, a box of drugs and the promise of new and exciting toys and techniques coming every day. It's making a difference. Stabilizing respiratory emergencies, getting trauma to trauma centers, addressing cardiac emergencies is improving length and quality of life. What EMS lacks is consistency and system management. Calls have to be answered. They HAVE to be answered. Mutual Aid cannot be a substitute for primary coverage. If we solve the primary coverage question, the 'how long does it take' question goes away. Somebody has to set a standard for the industry. The same DOH who might put a rig out of service for not having enough oxygen is silent on the subject of not getting a rig there at all. That's a health issue. Town supervisors ought to ask what service does a town need and is their provider delivering it? Putnam Valley is fortunate to be able to cover, usually, two calls at a time straight volunteer. That said, if 3 members are sick/quit/on vacation, then we probably wouldn't be covering calls. And response times can be long. We could improve service by as much as 10 minutes a call by rostering crews in quarters. It's not a popular idea. "It's too much to ask of volunteers." For me, this is at the crux of the debate. EMS has progressed to the point where doing it well and on time may be too much to ask of volunteers. It most likely will be too much to ask within the next 5 years. What service do we need to provide? How do we get there?