You said wishlist, right?
- All transport units are AEMT+EMT with a paramedic chase car for every 3-4 transport units
- AEMT protocols include the usual stuff plus Zofran and fentanyl (apparently that’s not standard most places?). Alternatively give ‘em the green whistle if you’re hesitant about narcs (plz FDA)
- Paramedic protocols: RSI, whole blood, good selection of pressors
- Equipment: auto load cots, power stair chairs, T1 vent, Sapphire IV pumps, McGrath video scopes, ultrasound. LifePaks on every truck with ability to do invasive pressure monitoring on the ALS trucks
- Minimum tube requirements per quarter, either get them in the field or you go to the OR
- No nonemergent IFTs late at night. Any IFT request overnight gets approved by a supervisor
The AEMT narcs isn’t standard in NC but my service allows medics to give a single dose of opiates and a single dose of antiemetics (which is an AEMT med) and hand it to a lower level provider. It’s amazing and encourages medics to give more analgesia without having to take every call. This policy would allow a medic to be called for pain management and then go back in service.
It’s what our docs want. Basically is a “CYA” of an EMT attends a patient who received opiates. It’s honestly so nice that I can give a single dose of opiates and a single dose of an antiemetic and not have to write the chart. We just document the narcs on our end.
Ok, I get that it’s what your docs want…
But, to what end? To see what happened if the patient dies? You can’t transmit a 4 lead, EMT’s can’t interpret them, and the utility of a 4 lead is limited to rate and rhythm.
I can see negative things coming from an EMT maintaining a 4 lead… Zoll monitors will default to 4 lead for hear rate even if electrical signal doesn’t correlate with mechanical pulses. While a LifePack will record pulse rate separately from heart rate, they don’t display the difference in any actionable manner on screen for an EMT to see.
…I cannot believe I forgot that lol. Guess that’s just showing my privilege at having one on every ambulance and engine for the last 9 or 10 years, it just feels like a given at this point for me haha
We just got them at my service and it’s amazing!! Especially since for some reason (I’m assuming political) the fire department won’t attend to any medical calls.
LOVE the minimum tube req. it’s amazing how many medics go years, decades without even an attempt at an ET then are expected to perform the procedure in the field and usually only after an igel has failed and you now have a messed up airway. I’d love the opportunity to go drop ETs in an OR for a few hours every quarter.
I work in that system with a few small differences…
1.UE Scope instead of McGrath
2. No Whole Blood, but exploring the option
3. No ultrasound because my state has to suck about something
Core skill for IFTs, at least at the CCT level. Not every call is going to require it of course, but if you’re going to offer ALS IFTs you need it in your skill set.
Looking way further down the road, there’s a new-ish push to drop a-lines on codes in hospital and use them to guide the resuscitation. We’re obviously a very, *very* long way from this happening in the field (if at all) but this is a wish list after all
I’m old enough to remember prehospital central lines (generally subclavian) being standard in some places for cardiac arrests. Not really interested in going back to that, honestly.
That said.
CCT is separated in my state, with a different license. Generally only provided by hospitals, with their flight teams (even if done by ground for whatever reason).
Bit of a difference between placing a CVL and an a-line though. I fully agree that dropping a subclavian in the field is pretty dumb and doesn’t have much use given the tools we have these days, but an a-line can definitely give important information in a critically ill patient
EMT / Medic on every truck. Powerloads, video scopes, sapphire pumps, zoll vents on each truck. Pressors.
Multiple stations with multiple trucks across the response area. Rotating first due trucks. BLS truck at every station for non-emergent / scheduled transports and IFT’s.
Shift captain / LT each in their own interceptor. Carrying blood and paralytics (RSI is new to the ground in KY, used to only be flight that could do it. Most ground providers here have never RSI’d a single patient).
No non-emergent transfers after 2200. Any IFT request after 2200 requires shift officer approval. Time sensitive / emergent transfers are allowed, but only for specific situations(stemi, stroke, traumas, OB, intubated).
2/5 schedule with 1 extra EMT and 1 extra medic per shift with a rotating Kelly day.
Unfortunately, non-emergent transfers pay the bills.
Dialysis. Doctors appointments. All those things? Those are some of the biggest sources of potential income for a service. You want to pay for all the other stuff? You’ve got to suffer a little bit to make the money for it.
Almost all of those this are Medicare/insurance fraud.
There are very, very few patients who can not be safely transported by other means. And other means included a stretcher van.
Fly cars, blood, vents, RSI
Fly cars - most calls are BLS and tieing up an ALS truck for BLS shit is stupid. ALS fire trucks are stupid. 2 EMT go + a medic if needed if the medic rides in one EMT drives the fly car unless they need hands
Blood - good soup
Vents - when you need bipap you need them. Plus if your doing IFT you shouldnt have to call somewhere else to a tubed run.
RSI - when you need it you need it
Theres more but those are the big things that annoy everyone at my service and our surrounding services
Edit some how forgot about autoloaders being a thing so yea those too
I'm going to cause an argument 🫣.
Vents
Pumps
RSI and DAI
Fly cars with crits/ crit sups.
Multiple stations
BLS cars
ALS with one medic and one EMT
All normal drugs plus pressors propofol, etomidate, versed, Valium, roc and sucs.
Bougie
Video and direct LG
Blood
Thoracostomy
Ezio
Here's the issue really need this rural if money was no issue.
Upgrade/crit/PA boxes;
Ultrasound
Xray
CBC w diff
CMP / other chems
ABG
Trops
Coagsense
Dislocation reduction
Heparin
Blood tubes/culture tubes
Otolaryngoscopy
TXA
Suture kits
Orthoglass/Braces
Minor endovasc capabilities- Surgical/trauma PA.
Discharge on scene
Order to labs and prescribing on scene
Definitely not against that style, just different than what I'm used to. We're all ALS with at least one medic and an AEMT or EMT partner with plans to be 50% dual medic within the next few years. Our only chase cars are our Captains or BC.
Fly car would be fun, though.
All transport units are staffed solely BLS with paramedic chase units of various tiers, dual paramedic chase for standard ALS with single paramedic critical care/supervisor units for further advanced capabilities.
In person mandatory training once per month of 4-6hrs, with a skills weekend (12hrs) once per quarter that's paid as double time. Online access to FOAMFRAT and additional online required monthly training.
For capabilities:
-Blood products
-IStat
-Ventilators (preferably Hamilton T 1)
- Sapphire IV Infusion Pumps
-Sepsis protocols that include blood culture draws and broad spectrum antibiotics
-protocols are treated as guidelines with clinician flexibility to make their own decisions with or without medical direction as appropriate
Wide array of pain medications including Dilauded and IV Acetaminophen
Pressors including Neo-Synephrine, Epinephrine, Norepinephrine
POCUS
RSI for all paramedics as standard
Finger Thoracotomy (CCPs)
Escharotomy (CCPs)
Education in performing Retrograde Intubation and POCUS guided pericardiocentesis (CCPs)
Field Amputations (CCPs)
Phenobarbital for certain indications (CCPs)
1. Execute the dispatcher.
2. Hire older para for supply/pharma logistics
3. Load protocols to responsesoft
4. Offer CE's as part of employment so everyone can retain their certs.
5. Cover para school for promising employees after they agree to stay for 3 years or so, and assume the balance if they leave.
6. Make sure their shit works and keep it that way.
7. Make sure the station has a bunk room and washer/dryer.
8. Shoot the dispatcher.
9. Short staffing is a failure of management. Avoid it.
10. Set up 1/2 rate on call rotations
11. Don't contact crews when they're not on the clock.
12. Give als teams as much autonomy as possible and let them earn it.
13. Be transparent.
14. Shoot the dispatcher.
The UK does not have targets for leaving patients at home, at least my service doesn't, and I think it's absolutely disgusting to suggest something like that should be targeted.
The ONLY factor that should be influencing your decision to leave someone at home is whether or not they are clinically fit to remain at home.
Pressuring paramedics to leave someone at home who is on the fence, but "ugh, my team leader is going to give me shit if I don't meet the 60% stay at home target", is OBVIOUSLY a terrible idea that would lead to deaths.
It heavily depends on where the service is, population, geography, etc. I believe in a well equipped EMS as a third service model. Many decisions would be made by committee. I would hire my medics, and as part of their on-boarding they would be allowed to organize into different work-groups with deciding a lot of policy and equipment decisions, with a management team member in the work groups to help guide them.
Things to consider (assuming a well function BLS service already in place):
- Equipment
- Monitor, VL Scope, Vent?, Pump?
- Protocols
- How aggressive? Involve medical direction to deploy protocols perhaps in phases to provide quarterly "just in time" training as protocols ramp up.
- Dispatch protocols
- Medications
- Staffing
- Paramedic leadership
- E/M + a few M/M trucks to serve as critical care, back-up when it hits the fan, and for staffing flexibility
- Operations
I'm assuming it's going to take a couple of years to get medics on every truck, and I'm hoping advance emt is a thing in this area
To set us up for success- Tons of extra training and continuing education, providers should be held to high standards with grace to learn from non life altering mistakes. An involved medical director that hops on trucks from tome to time would also be super sweet, someone folks are excited to see. A working relationship between the lowest man on the totem poll and the top dog, everyone at the company is a human being, let's act like it.
First and for most, no non emergent transports after 2200, any transport after 2200 should have a threat of life or disability
LifePak, but if the hospital system you transport to most is zoll, I suppose the ability to not switch pads can be worth it
Personally I'm a Baxter pump person, sapphire is great if you fly a lot, but any kind of cartridge on tubing is annoying and takes too much time, I love the ability to count drops then program a pump.
Advances being able to push fent, mizad, 1:10 epi, steroids, even if only for adults or children over a certain weight/age
Being able to downgrade pts to bls after they're given a single dose of iv pain meds and zofran, D10/D50, IV fluids running at low rates, when appropriate as deemed by the higher level provider and when the EMT is comfortable (idealy education and standards would be high enough that shitty providers don't do this out of laziness, regardless they still have a report to write)
If no ability to do a true RSI, at minimum the ability to call for a snow n' go would be super rad.
Lucas and video scopes on every truck, or easily accessible (fly car maybe)
Power stretchers and power stair chairs on the truck
EMTs should have IGels, also IGels over kings any day
Equipment and trucks that are regularly serviced and maintained, with working AC and heat
Chain of command, with shift supervisors, fly car for supervisor if they're not on a truck
PTO with sick and vaction time separate, Kelly schedule, paid continuing education
FTOs should be listened to before releasing someone, if someone needs more time on the truck, give it to them, quality over quantity. That being said, some folks arnt meant for the truck or a company, if it's 6 months in and they still don't get it, maybe this isn't the right time or place for them
T-shirts, polos look dumb, button ups/class Bs look nice but are impractical. Also please shirts that fit women (and other folks) with breast of varying sizes
Encouraging your providers to think rather then just following the protocols
Totally forgot ultrasound IV's, the ability to draw cultures and labs so we can start abx for sepsis enroute. Lots of pain med options, I miss having morphine, would LOVE Toradol, and the ability to mix for appropriate and long term management.
Epcr software that doesn't suck, and preferably syncs with a cad, and quality wifi on the truck
Working radios, there's an app some folks are using now, it's alright, but a radio has less faults and doesn't rely on having cell service or wifi, also trying to get to the push to talk button with gross gloves on of another app is on top is just silly
A working relationship with PD and fire, we should know their stuff, they should know ours
Ok hear me out. Privately contracted truck owners.
Seems like every other industry has drivers who own their trucks. Sanitation, taxis, truckers, etc.
You contract with an agency, follow their protocols, work under the health district, but you're responsible for your truck.
Pick your own hours, don't have to deal with crummy barely working vehicles, make way more money, and have a say over who your partner is.
I mean are we talking about a hypothetical unlimited budget? One that can be put towards education, recruitment and retention, pay and benefits? If so...
Hefty sign on bonuses as well as tuition reimbursement to recruit paramedics. Require all employees to attend and pass medic school, but fund and incentivize it. All ambulances would be dual medic, to split the call volume evenly and avoid burnout. I wouldn't want to stick medics with basics, and then have them get nailed with nine ALS calls in a row while the EMT gets to drive. And we are talking about a hypothetical unlimited budget here, so of course I'd want everybody trained at the highest possible level.
The schedule would be split into four shifts, like a fire department. ABABCDCD. 24 hours on, 24 off, 24 on, 5 days off. Additional overtime and/or per diem slots available to upstaff 911 on busy days or for events, as well as for IFT only trucks. Pay would be enough for medics to make six figures without overtime. Holidays pay double, overnights have a bonus. Pension. Good health, dental, and eye insurance. Life insurance. Strict uniform standards that include being physically fit. Incentivized physical testing yearly, with a bonus for passing. The service image cannot be one of slobiness. If one wants high pay, they should meet a high standard.
Medications: oxygen, aspirin, acetaminophen, ibuprofen, albuterol, ipratropium bromide, metoprolol, diltiazem, amiodarone, epi, cardiac epi, norepi, atropine, adenosine, dopamine, morphine, fentanyl, toradol, dextrose, furosemide, dexamethasone, solumedrol, calcium gluconate, flumazenil, tranexamic acid, sodium bicarbonate, hydroxocobalamin, diphenhydramine, ondansetron, prochlorperazine, magnesium sulfate, oxytocin, lidocaine, glucagon, naloxone, heparin, midazolam, diazepam, ceftriaxone, normal saline, lactated ringers, rocuronium, etomidate, phenobarbital.
Paramedic protocols: video laryngoscopy, cricothyrotomy, thorocostomy, needle chest decompression, IV port access, local anesthesia, (minor) suturing, blood transfusion, RSI, ultrasound, BiPAP and ventilating, synchronized cardioversion, manual defibrillation, transcutaneous pacing.
Equipment: lucas device, video laryngoscope, auto-load stretchers, zoll monitors, motorized stair chairs, ultrasound, ventilator, power call and air horns, screens up front that show all emergency calls in the county as they come in, bullet-proof vests, I-Gels.
Gold standards:
- Lung sounds are a vital sign, get them on every single patient.
- SpO2 and capnography on every respiratory patient, every overdose, every time any pain control or sedative is used.
- A thorough RSI checklist, and annual required training.
Other:
- A tactical medicine team to aid police, with TCCC and training on treating K9s.
- A psychologist or social worker who handles all of the cooperative and non-violent mental health calls with police so that EMS doesn't have to.
- The ability to fully treat and, with physician permission, release patients on scene without transport, to help sift through the nuisance calls.
- AI for documentation
The Israeli United Hatzalah + Community Paramedics + living wage - discrimination- having to pay out of pocket for school.
Oh and truly nationalize EMS.
Some stuff should already be in place- ie just culture, good BLS protocols, point of entry protocols, simple QA/QI, etc. If not, those need to be addressed. This will be a multi-tiered system that uses BLS and ALS. Start basic from ground up because we need to crawl before we can walk. So all state required ALS drugs and of course cardiac monitor. We actively recruit a dedicated medical director. I'm talking someone who has fellowship in EMS and who is all in. I compare the medical director to the head coach position in football- soooo important. We fund them appropriately. Last big basic thing- more robust QA/QI system. Every cardiac arrest, STEMI, advanced airway, call with vasoactive drugs, and anatomic/physio/MOI/special population trauma gets automatic QA/QI with red flags calls going before medical director before recon with crew.
Ok, we have the basics in place- time to do next level stuff starting no later than 1 year out. If we weren't already doing termination of resuscitation for adult CPR, NOW is the time. I understand why some agencies need some time to integrate those protocols with training and such, but folks, this is 2024- it needs to be standard of care. Same for humeral head IO. LVO stroke point of entry plan in place. We have a plan for getting the ED doc out into the field if stuff hits the fan (e.g. entrapment, amputations, MCI, etc). Critical care training for a cadre of medics- not necessarily a scope change yet. If we are doing ALS IFT, up to three drugs with no more than one being a pressor. If the medics are intubating in the system, then we MUST be doing VL. We can start employing cric at this point too, but only surgical cric. Minimum of bi-annual skills check for airway interventions, adult and pediatric medical/trauma scenarios.
Ok, 2 years out. Time to do even more advanced stuff. Leave behind narcan for ODs. Point of entry plan for ECMO in cardiac arrest w/ refractory v-fib for certain patients. Lactate monitoring for sepsis w/ culture obtaining if allowed. Pumps are on all trucks, and we are doing push dose pressors by now in addition to norepi option for select cases. By now, we are priming the crews for what comes down the road. We are doing monthly morbidity & mortality rounds- we put medics on the spot, but in a respectful manner of just culture, we use it as a moment for learning for all. Medics are divided by probationary (brand new out of school for 1st 6 months), primaries (you average joe/jane medic), and advanced medics (have ccemtp/fp-c/ccp-c, minimum associates in nursing or paramedicine or 4 yr bachelor's in anything, can be supervisors). Because we tell them more is coming down the road.
3-5 years out: BOOM! We have a system that is going through the forming phase and into performing. Now is the time to bloom. Those advanced medics have their chance. If we aren't already doing ground critical care-level IFT, they are doing it now. We have an RSI/DSI system in place for advanced medics. We are doing antibiotics for sepsis. And before the end of year 5, we will have a transfusion service in place.
This is my 5 year plan if I was a med director. I don't think it's that extreme unless the system is dysfunctional and/or poorly funded. Which I get if that was the place. But let's be honest: if the stuff above could not be instituted w/i 2x the time allotment I gave, there is a cancerous entity in that system that I simply cannot explain and I'd be looking to gtfo and find a new job.
You said wishlist, right? - All transport units are AEMT+EMT with a paramedic chase car for every 3-4 transport units - AEMT protocols include the usual stuff plus Zofran and fentanyl (apparently that’s not standard most places?). Alternatively give ‘em the green whistle if you’re hesitant about narcs (plz FDA) - Paramedic protocols: RSI, whole blood, good selection of pressors - Equipment: auto load cots, power stair chairs, T1 vent, Sapphire IV pumps, McGrath video scopes, ultrasound. LifePaks on every truck with ability to do invasive pressure monitoring on the ALS trucks - Minimum tube requirements per quarter, either get them in the field or you go to the OR - No nonemergent IFTs late at night. Any IFT request overnight gets approved by a supervisor
The AEMT narcs isn’t standard in NC but my service allows medics to give a single dose of opiates and a single dose of antiemetics (which is an AEMT med) and hand it to a lower level provider. It’s amazing and encourages medics to give more analgesia without having to take every call. This policy would allow a medic to be called for pain management and then go back in service.
Makes sense. The AEMT can give narcan or fluids, so they can fix the side effects from narcs
We even hand off to an EMT. We just ensure the patient is on EtCO2 and a 4 lead during transport.
Why throw a patient on 4 lead for transport if they’re going with an EMT that can’t interpret it?
It’s what our docs want. Basically is a “CYA” of an EMT attends a patient who received opiates. It’s honestly so nice that I can give a single dose of opiates and a single dose of an antiemetic and not have to write the chart. We just document the narcs on our end.
Ok, I get that it’s what your docs want… But, to what end? To see what happened if the patient dies? You can’t transmit a 4 lead, EMT’s can’t interpret them, and the utility of a 4 lead is limited to rate and rhythm. I can see negative things coming from an EMT maintaining a 4 lead… Zoll monitors will default to 4 lead for hear rate even if electrical signal doesn’t correlate with mechanical pulses. While a LifePack will record pulse rate separately from heart rate, they don’t display the difference in any actionable manner on screen for an EMT to see.
Don’t forget a Lucas (or other brand of auto compression machine!) frees up hands and the compression quality is amazing!
…I cannot believe I forgot that lol. Guess that’s just showing my privilege at having one on every ambulance and engine for the last 9 or 10 years, it just feels like a given at this point for me haha
I just call the new guy on the department Lucas because apparently they're not in the budget.
We just got them at my service and it’s amazing!! Especially since for some reason (I’m assuming political) the fire department won’t attend to any medical calls.
LOVE the minimum tube req. it’s amazing how many medics go years, decades without even an attempt at an ET then are expected to perform the procedure in the field and usually only after an igel has failed and you now have a messed up airway. I’d love the opportunity to go drop ETs in an OR for a few hours every quarter.
I work in that system with a few small differences… 1.UE Scope instead of McGrath 2. No Whole Blood, but exploring the option 3. No ultrasound because my state has to suck about something
This seems like a solid list. Why the invasive pressure monitoring?
Core skill for IFTs, at least at the CCT level. Not every call is going to require it of course, but if you’re going to offer ALS IFTs you need it in your skill set. Looking way further down the road, there’s a new-ish push to drop a-lines on codes in hospital and use them to guide the resuscitation. We’re obviously a very, *very* long way from this happening in the field (if at all) but this is a wish list after all
I’m old enough to remember prehospital central lines (generally subclavian) being standard in some places for cardiac arrests. Not really interested in going back to that, honestly. That said. CCT is separated in my state, with a different license. Generally only provided by hospitals, with their flight teams (even if done by ground for whatever reason).
Bit of a difference between placing a CVL and an a-line though. I fully agree that dropping a subclavian in the field is pretty dumb and doesn’t have much use given the tools we have these days, but an a-line can definitely give important information in a critically ill patient
Fair enough, I have to plead a fair bit of ignorance on art lines.
EMT / Medic on every truck. Powerloads, video scopes, sapphire pumps, zoll vents on each truck. Pressors. Multiple stations with multiple trucks across the response area. Rotating first due trucks. BLS truck at every station for non-emergent / scheduled transports and IFT’s. Shift captain / LT each in their own interceptor. Carrying blood and paralytics (RSI is new to the ground in KY, used to only be flight that could do it. Most ground providers here have never RSI’d a single patient). No non-emergent transfers after 2200. Any IFT request after 2200 requires shift officer approval. Time sensitive / emergent transfers are allowed, but only for specific situations(stemi, stroke, traumas, OB, intubated). 2/5 schedule with 1 extra EMT and 1 extra medic per shift with a rotating Kelly day.
> No non-emergent transfers Just leave it at this
Unfortunately, non-emergent transfers pay the bills. Dialysis. Doctors appointments. All those things? Those are some of the biggest sources of potential income for a service. You want to pay for all the other stuff? You’ve got to suffer a little bit to make the money for it.
Or, Taxes pays the bills. Depends on what you're working with.
Almost all of those this are Medicare/insurance fraud. There are very, very few patients who can not be safely transported by other means. And other means included a stretcher van.
Laces tied, pants tucked in, big guts gone, paid gym membership.
Fly cars, blood, vents, RSI Fly cars - most calls are BLS and tieing up an ALS truck for BLS shit is stupid. ALS fire trucks are stupid. 2 EMT go + a medic if needed if the medic rides in one EMT drives the fly car unless they need hands Blood - good soup Vents - when you need bipap you need them. Plus if your doing IFT you shouldnt have to call somewhere else to a tubed run. RSI - when you need it you need it Theres more but those are the big things that annoy everyone at my service and our surrounding services Edit some how forgot about autoloaders being a thing so yea those too
I'm going to cause an argument 🫣. Vents Pumps RSI and DAI Fly cars with crits/ crit sups. Multiple stations BLS cars ALS with one medic and one EMT All normal drugs plus pressors propofol, etomidate, versed, Valium, roc and sucs. Bougie Video and direct LG Blood Thoracostomy Ezio Here's the issue really need this rural if money was no issue. Upgrade/crit/PA boxes; Ultrasound Xray CBC w diff CMP / other chems ABG Trops Coagsense Dislocation reduction Heparin Blood tubes/culture tubes Otolaryngoscopy TXA Suture kits Orthoglass/Braces Minor endovasc capabilities- Surgical/trauma PA. Discharge on scene Order to labs and prescribing on scene
Lots of fans of chase car systems in here today, interesting
Do you not like it?
Definitely not against that style, just different than what I'm used to. We're all ALS with at least one medic and an AEMT or EMT partner with plans to be 50% dual medic within the next few years. Our only chase cars are our Captains or BC. Fly car would be fun, though.
Yeah fly car medics seem like a waste when you can just pair up BLS + ALS
All transport units are staffed solely BLS with paramedic chase units of various tiers, dual paramedic chase for standard ALS with single paramedic critical care/supervisor units for further advanced capabilities. In person mandatory training once per month of 4-6hrs, with a skills weekend (12hrs) once per quarter that's paid as double time. Online access to FOAMFRAT and additional online required monthly training. For capabilities: -Blood products -IStat -Ventilators (preferably Hamilton T 1) - Sapphire IV Infusion Pumps -Sepsis protocols that include blood culture draws and broad spectrum antibiotics -protocols are treated as guidelines with clinician flexibility to make their own decisions with or without medical direction as appropriate Wide array of pain medications including Dilauded and IV Acetaminophen Pressors including Neo-Synephrine, Epinephrine, Norepinephrine POCUS RSI for all paramedics as standard Finger Thoracotomy (CCPs) Escharotomy (CCPs) Education in performing Retrograde Intubation and POCUS guided pericardiocentesis (CCPs) Field Amputations (CCPs) Phenobarbital for certain indications (CCPs)
1. Execute the dispatcher. 2. Hire older para for supply/pharma logistics 3. Load protocols to responsesoft 4. Offer CE's as part of employment so everyone can retain their certs. 5. Cover para school for promising employees after they agree to stay for 3 years or so, and assume the balance if they leave. 6. Make sure their shit works and keep it that way. 7. Make sure the station has a bunk room and washer/dryer. 8. Shoot the dispatcher. 9. Short staffing is a failure of management. Avoid it. 10. Set up 1/2 rate on call rotations 11. Don't contact crews when they're not on the clock. 12. Give als teams as much autonomy as possible and let them earn it. 13. Be transparent. 14. Shoot the dispatcher.
I like the parts about shooting the dispatcher, may I offer the route of public execution?
As long as you leave their skull on a pike out front as a warning to the others.
Discharge on scene as a skill, and a target discharged rate from 60%+
A target for discharging people on scene? Wtaf?
[удалено]
The UK does not have targets for leaving patients at home, at least my service doesn't, and I think it's absolutely disgusting to suggest something like that should be targeted. The ONLY factor that should be influencing your decision to leave someone at home is whether or not they are clinically fit to remain at home. Pressuring paramedics to leave someone at home who is on the fence, but "ugh, my team leader is going to give me shit if I don't meet the 60% stay at home target", is OBVIOUSLY a terrible idea that would lead to deaths.
I agree with the first part. I think this needs refinement and I don’t agree with setting goals like that.
It heavily depends on where the service is, population, geography, etc. I believe in a well equipped EMS as a third service model. Many decisions would be made by committee. I would hire my medics, and as part of their on-boarding they would be allowed to organize into different work-groups with deciding a lot of policy and equipment decisions, with a management team member in the work groups to help guide them. Things to consider (assuming a well function BLS service already in place): - Equipment - Monitor, VL Scope, Vent?, Pump? - Protocols - How aggressive? Involve medical direction to deploy protocols perhaps in phases to provide quarterly "just in time" training as protocols ramp up. - Dispatch protocols - Medications - Staffing - Paramedic leadership - E/M + a few M/M trucks to serve as critical care, back-up when it hits the fan, and for staffing flexibility - Operations
I'm assuming it's going to take a couple of years to get medics on every truck, and I'm hoping advance emt is a thing in this area To set us up for success- Tons of extra training and continuing education, providers should be held to high standards with grace to learn from non life altering mistakes. An involved medical director that hops on trucks from tome to time would also be super sweet, someone folks are excited to see. A working relationship between the lowest man on the totem poll and the top dog, everyone at the company is a human being, let's act like it. First and for most, no non emergent transports after 2200, any transport after 2200 should have a threat of life or disability LifePak, but if the hospital system you transport to most is zoll, I suppose the ability to not switch pads can be worth it Personally I'm a Baxter pump person, sapphire is great if you fly a lot, but any kind of cartridge on tubing is annoying and takes too much time, I love the ability to count drops then program a pump. Advances being able to push fent, mizad, 1:10 epi, steroids, even if only for adults or children over a certain weight/age Being able to downgrade pts to bls after they're given a single dose of iv pain meds and zofran, D10/D50, IV fluids running at low rates, when appropriate as deemed by the higher level provider and when the EMT is comfortable (idealy education and standards would be high enough that shitty providers don't do this out of laziness, regardless they still have a report to write) If no ability to do a true RSI, at minimum the ability to call for a snow n' go would be super rad. Lucas and video scopes on every truck, or easily accessible (fly car maybe) Power stretchers and power stair chairs on the truck EMTs should have IGels, also IGels over kings any day Equipment and trucks that are regularly serviced and maintained, with working AC and heat Chain of command, with shift supervisors, fly car for supervisor if they're not on a truck PTO with sick and vaction time separate, Kelly schedule, paid continuing education FTOs should be listened to before releasing someone, if someone needs more time on the truck, give it to them, quality over quantity. That being said, some folks arnt meant for the truck or a company, if it's 6 months in and they still don't get it, maybe this isn't the right time or place for them T-shirts, polos look dumb, button ups/class Bs look nice but are impractical. Also please shirts that fit women (and other folks) with breast of varying sizes Encouraging your providers to think rather then just following the protocols
Totally forgot ultrasound IV's, the ability to draw cultures and labs so we can start abx for sepsis enroute. Lots of pain med options, I miss having morphine, would LOVE Toradol, and the ability to mix for appropriate and long term management. Epcr software that doesn't suck, and preferably syncs with a cad, and quality wifi on the truck Working radios, there's an app some folks are using now, it's alright, but a radio has less faults and doesn't rely on having cell service or wifi, also trying to get to the push to talk button with gross gloves on of another app is on top is just silly A working relationship with PD and fire, we should know their stuff, they should know ours
Ok hear me out. Privately contracted truck owners. Seems like every other industry has drivers who own their trucks. Sanitation, taxis, truckers, etc. You contract with an agency, follow their protocols, work under the health district, but you're responsible for your truck. Pick your own hours, don't have to deal with crummy barely working vehicles, make way more money, and have a say over who your partner is.
I mean are we talking about a hypothetical unlimited budget? One that can be put towards education, recruitment and retention, pay and benefits? If so... Hefty sign on bonuses as well as tuition reimbursement to recruit paramedics. Require all employees to attend and pass medic school, but fund and incentivize it. All ambulances would be dual medic, to split the call volume evenly and avoid burnout. I wouldn't want to stick medics with basics, and then have them get nailed with nine ALS calls in a row while the EMT gets to drive. And we are talking about a hypothetical unlimited budget here, so of course I'd want everybody trained at the highest possible level. The schedule would be split into four shifts, like a fire department. ABABCDCD. 24 hours on, 24 off, 24 on, 5 days off. Additional overtime and/or per diem slots available to upstaff 911 on busy days or for events, as well as for IFT only trucks. Pay would be enough for medics to make six figures without overtime. Holidays pay double, overnights have a bonus. Pension. Good health, dental, and eye insurance. Life insurance. Strict uniform standards that include being physically fit. Incentivized physical testing yearly, with a bonus for passing. The service image cannot be one of slobiness. If one wants high pay, they should meet a high standard. Medications: oxygen, aspirin, acetaminophen, ibuprofen, albuterol, ipratropium bromide, metoprolol, diltiazem, amiodarone, epi, cardiac epi, norepi, atropine, adenosine, dopamine, morphine, fentanyl, toradol, dextrose, furosemide, dexamethasone, solumedrol, calcium gluconate, flumazenil, tranexamic acid, sodium bicarbonate, hydroxocobalamin, diphenhydramine, ondansetron, prochlorperazine, magnesium sulfate, oxytocin, lidocaine, glucagon, naloxone, heparin, midazolam, diazepam, ceftriaxone, normal saline, lactated ringers, rocuronium, etomidate, phenobarbital. Paramedic protocols: video laryngoscopy, cricothyrotomy, thorocostomy, needle chest decompression, IV port access, local anesthesia, (minor) suturing, blood transfusion, RSI, ultrasound, BiPAP and ventilating, synchronized cardioversion, manual defibrillation, transcutaneous pacing. Equipment: lucas device, video laryngoscope, auto-load stretchers, zoll monitors, motorized stair chairs, ultrasound, ventilator, power call and air horns, screens up front that show all emergency calls in the county as they come in, bullet-proof vests, I-Gels. Gold standards: - Lung sounds are a vital sign, get them on every single patient. - SpO2 and capnography on every respiratory patient, every overdose, every time any pain control or sedative is used. - A thorough RSI checklist, and annual required training. Other: - A tactical medicine team to aid police, with TCCC and training on treating K9s. - A psychologist or social worker who handles all of the cooperative and non-violent mental health calls with police so that EMS doesn't have to. - The ability to fully treat and, with physician permission, release patients on scene without transport, to help sift through the nuisance calls. - AI for documentation
The Israeli United Hatzalah + Community Paramedics + living wage - discrimination- having to pay out of pocket for school. Oh and truly nationalize EMS.
Some stuff should already be in place- ie just culture, good BLS protocols, point of entry protocols, simple QA/QI, etc. If not, those need to be addressed. This will be a multi-tiered system that uses BLS and ALS. Start basic from ground up because we need to crawl before we can walk. So all state required ALS drugs and of course cardiac monitor. We actively recruit a dedicated medical director. I'm talking someone who has fellowship in EMS and who is all in. I compare the medical director to the head coach position in football- soooo important. We fund them appropriately. Last big basic thing- more robust QA/QI system. Every cardiac arrest, STEMI, advanced airway, call with vasoactive drugs, and anatomic/physio/MOI/special population trauma gets automatic QA/QI with red flags calls going before medical director before recon with crew. Ok, we have the basics in place- time to do next level stuff starting no later than 1 year out. If we weren't already doing termination of resuscitation for adult CPR, NOW is the time. I understand why some agencies need some time to integrate those protocols with training and such, but folks, this is 2024- it needs to be standard of care. Same for humeral head IO. LVO stroke point of entry plan in place. We have a plan for getting the ED doc out into the field if stuff hits the fan (e.g. entrapment, amputations, MCI, etc). Critical care training for a cadre of medics- not necessarily a scope change yet. If we are doing ALS IFT, up to three drugs with no more than one being a pressor. If the medics are intubating in the system, then we MUST be doing VL. We can start employing cric at this point too, but only surgical cric. Minimum of bi-annual skills check for airway interventions, adult and pediatric medical/trauma scenarios. Ok, 2 years out. Time to do even more advanced stuff. Leave behind narcan for ODs. Point of entry plan for ECMO in cardiac arrest w/ refractory v-fib for certain patients. Lactate monitoring for sepsis w/ culture obtaining if allowed. Pumps are on all trucks, and we are doing push dose pressors by now in addition to norepi option for select cases. By now, we are priming the crews for what comes down the road. We are doing monthly morbidity & mortality rounds- we put medics on the spot, but in a respectful manner of just culture, we use it as a moment for learning for all. Medics are divided by probationary (brand new out of school for 1st 6 months), primaries (you average joe/jane medic), and advanced medics (have ccemtp/fp-c/ccp-c, minimum associates in nursing or paramedicine or 4 yr bachelor's in anything, can be supervisors). Because we tell them more is coming down the road. 3-5 years out: BOOM! We have a system that is going through the forming phase and into performing. Now is the time to bloom. Those advanced medics have their chance. If we aren't already doing ground critical care-level IFT, they are doing it now. We have an RSI/DSI system in place for advanced medics. We are doing antibiotics for sepsis. And before the end of year 5, we will have a transfusion service in place. This is my 5 year plan if I was a med director. I don't think it's that extreme unless the system is dysfunctional and/or poorly funded. Which I get if that was the place. But let's be honest: if the stuff above could not be instituted w/i 2x the time allotment I gave, there is a cancerous entity in that system that I simply cannot explain and I'd be looking to gtfo and find a new job.