Saturday, June 30

Overheard in the Risk Manager's Office

The phone rings while I'm immersed in discussion with one of the field Captains.  A man is asking for help with an elevator.  I get all manner of complaint calls, so this one is a welcome change.

Medical Expert (ME) - "Sure I can help you"

Stair Phobic (SP) - "Yes, I need a copy of your stair ordinance that says how tall a building has to be before it gets an elevator."

ME - "Well, that sounds more like a building code question, have you been to City hall?"

SP - "Yes, but specifically I need to know where it says that you have to have an elevator for the paramedics."

ME - "That would be a lovely addition to the building code, but currently no such statute exists.  Why do you ask?"

SP - "Our elevator has been out of service for weeks and the building owner is taking too long getting it fixed, so I thought I'd remind him that the Paramedics will need it if anyone gets hurt."

ME - "If you're on the 30th floor and get hurt and the elevator is broken, we'll get to you and get you out if we need to, elevator or no."

SP - "But where does it say that?"

ME - "That's just what we do."

SP - "Do you train your people that?"

ME - "Of course."

Wednesday, June 27

Special Call Mobile Surgery 1, Mobile Surgery 2, EMS Surgeon 1...

A nice resource to have if your system is innundated by, oh I don't know, the shaking of the earth until everything falls down.  Especially in a City with water on 3 sides and only 4 trauma


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Saturday, June 23

9 Letters away from a solution - An EMS 2.0 update from San Francisco

I've been going about it all wrong.


Here I was scouring the laws, policies, regulations and statutes looking for a way to get alternate transport vehicles, like vans, SUVs and cars classified as ambulances.

Turns out all levels of regulation are quite clear on what an ambulance (the 9 letters, in case you're wondering) is.

It starts at the State level defining an ambulance (I'm paraphrasing these) as a vehicle modified to accommodate a stretcher and staffed by 2 people, at least one of them an EMT-1 and that meets all local standards for an ambulance.  So that kicks the details to the local EMS agencies.  I'm OK with that, let the communities decide what specifics they need.  Oh, but there is the 2 person standard and the stretcher part I need to change.

The California Highway Patrol has standards for a vehicle to be LABELED ambulance and allowed to violate certain aspects of the vehicle code by using red lights, siren and blocking the right of way etc.  It requires a forward facing red light, distinctive paint, a cot and 2 people.

Dang it.

Then the County Health Code breaks down an ambulance and a routine medical transport vehicle, both requiring cots and 2 people.  This is looking bad.  So far I have to change a state law, a vehicle code and a County Health Code.

The local EMS Agency is specific on the staffing requirements of a BLS and ALS ambulance, equipment for first response vehicles (do all ALS first response vehicles really need a long spine board?) and are also charged with certifying that all ambulances in the system comply to the standards.

I have a huge uphill battle if I want to start transporting people in something other than a 2 person ambulance.

Or do I?

What is surprisingly lacking in all the statutes I'm reading are 2 things:  The definition of a patient, and a definition of what a patient uses to get to the hospital.

It appears the automatic default is that a patient will go via an ambulance and vehicles carrying those 9 letters are well regulated, and for good reason.  But what about when we let folks refuse transport, then they climb in a car and go to a hospital anyways?  Is that drier violating the state law, vehicle code, County Health Code and local ambulance ordinance? Of course not, silly, it's not an ambulance.

It's not an ambulance.

I've been going about this all wrong.  A complete 180 is in order.  Instead of trying to wiggle my solution into a decades old understanding of 9 letters, we could simply exist without them.

This theory applies only to my pilot project of course, the 9 lettered certified ambulances are still meeting all local, state and applicable laws, but now imagine being able to call the company taxi and send the person who meets criteria in something not labeled ambulance and they get the care they need.

Won't someone think about the billers?!

Oh, I forgot to mention 1 little law that does go against my idea: Medicare part B.

Medicare part B is the legislation that looks retroactively and decides if the ambulance was really necessary and reimburses accordingly.  This is the main reason so many systems tell their practitioners not to walk patients to the ambulance like I do.  They're likely not going to pay you for that trip.

So why are we still making the trip in the most expensive, regulated manner possible?

Because of 9 little letters.

Medicare has strict definitions as to what makes a BLS and ALS ambulance and gives subscribers guidelines as to what is and is not covered for reimbursement, even being as specific as to where you are when we declare you dead.  Another reason some agencies transport all cardiac arrest patients.

Turns out the folks who would meet criteria for a retriage to alternate transport wouldn't be eligible to have Medicare cover the bill anyways.  So why not arrange for alternate transportation at far less cost?  It's a cost more likely to be recovered and freeing up the ALS ambulance to find another paying customer patient in need.


I was always told there was a big law somewhere telling us we had to do things a certain way.  And there is, if you want to keep doing things the same way.

There's still a lot of research required and permissions to get, but the biggest blockade to my desire to introduce alternate transport options is gone.

Just leave out those 9 magic letters.

Wednesday, June 20

Patch me through to the patient please

In one of the opening scenes of the disliked NBC series TRAUMA, the medics responding are wearing their headsets and suddenly begin speaking to the 911 caller.

"Oh, yeah...right..." was my first response too.

But think about it.  Imagine being finally able to put the caller in touch with someone other than the call taker.  What if the Paramedic or EMT responding was able to apply their education and experience to decide how the system will react to this patient.

It might become more efficient.

The call is received, the unit assigned, then the caller transferred to the practitioner assigned to respond.  They begin assembling facts that the little boxes of the priority dispatch and the untrained ears of the call taken can't identify.

"OK, so you have asthma, but this doesn't feel like an asthma attack, you just want some albuterol?" There is no code for that other than an asthma attack, but now we can downgrade the call and possibly save a life and time.  Who's life?  Not the caller's they're fine.  But the responders now travelling with traffic reduces the risk of accident.  The call that may come in with CPR in progress can be triaged ahead now that we have a more accurate idea of what's happening at the first call.

We've spent so much time designing systems to categorize, prioritize and automate dispatches we forgot to upgrade the callers and the call takers.  Instead of staffing dispatch with practitioners, why not just let me talk to the patient you're about to hang up on anyway to meet your target time.

I can begin to establish if that little code even matches what's going on, gage my response based on what the caller is telling me and save time in patient care for being ready for exactly what's going on.


We could ditch the codes and just dispatch based on their chief complaint.

Tuesday, June 19

Overheard on the radio

"Control to Engine 40..."

"Engine 40 go."

"Engine 40 be advised there is a reported blockage, we're upgrading this to a haz mat, stand by..."

"Units dispatched, Engine 36 on Haz Mat 1, Rescue Squad 1, Rescue Squad 2, Engine 19, Engine 40, Truck 19, Battalion 8, RC2, Medic 99, Medic 77, Medic 54 for the Haz Mat...units stand by..."

"Control, this is Engine 40, we're on scene you can cancel that haz mat response."

"Units responding to the haz mat, cancel..."

"Control, Engine 40, we have a woman reporting a long line at the checkout stand at the grocery store.  That's your blockage.  Cancel this and send me PD please."

"Copy Engine 40, do you need them code 3?"



I'm guessing not.

Sunday, June 17

What is a "First Responder?"

I was asked this question by a rather influential law maker recently and my answer surprised me.

Being someone who used to hate the term "First Responder" thinking it dumbed us down, I realized we had to be dumbed down for the general public to grasp what we did day in and day out.  The term is not accurate, but then again, when has the TV and radio ever been given the opportunity to learn why we are so secretive about what we do?  Be it HIPAA or a desire not to owe steaks or ice cream, we avoid the press like the plague, then reprimand them for not knowing what we're doing.

So there I was, being asked what a "First Responder" was.

"A neighbor coming to another's aide," I started, "A father seeing signs of distress in a friend's child, a teacher noting the early signs of an allergic reaction in a student, a college professor noting a suspicious package, today, we're all first responders."

I gulped, thinking I had just sold a generation of actual "responders" down the river, discounting them to be equals with a school teacher who deploys an Ei-pen.

But we're not, are we?

In a community that looks out for one another, we are not needed.  We are a footnote in the history books of when people used to need emergency care via tiny mobile hospitals.  EMS becomes a truly unneeded service, except for the rare true emergency.  Not unlike the Fire Service has found themselves, all full of budget and not sure what to do with it.  How did they become so successful at putting themselves out of business?


It is my goal to put EMS out of business.  It should be every Paramedic and EMTs goal to do the same.  We may have the occasional emergency, sure, but the day to day BS we deal with needs to go away.

And perhaps if neighbor started helping neighbor, friend started helping friend and we all realized the sweeping epidemics of obesity, diabetes, heart disease and cancer and did something about it maybe, just maybe, we could actually see our call volume start to drop.  See our stress levels start to decline, and see the eventual funeral not for another neighbor, friend or family member, but for EMS as we know it.

Get involved in your own community.  Be a first responder to those you meet by chance, not by dispatch, and become a positive force for change in your own community.

If Uncle John is able to lose weight and exercise, maybe he won't need Medicare so soon.  If your neighbor recognizes his need for asthma care and to quit smoking, he lives another 20 years to contribute to the community.

We can make a difference in our communities, EMTs or Paramedics or just regular folken.

Get involved, be the force for positive change you're waiting for.

It doesn't take a badge, look below it.  It takes heart.



Thursday, June 14

You Make the Call - Bit - Part II

Let's recap:

We're miles from the nearest ambulance, 35-45 minutes from the arrival of the first response unit and a now rapidly swelling index finger from a snake bite.

The Coleman Brand Snakebite kit is a small package of provodine, a scalpel and a little sucker tube.  More or less useless unless we were hours from help.  We're far, but not nearly THAT far.

One of the moms has the rangers on the phone and they're en route, advising us not to take any action.  They've got a small BLS bag and arrive soon after we heard them running sirens on the mountain road.

The Rangers gather their patient's basics and make a decent attempt to take a blood pressure when I suggest ever so gently that perhaps time is of the essence and an intercept with the responding ambulance would be a good idea.

"We can't transport him."

No, you can, you just can't bill for it, or call your vehicle an ambulance.

"Oh, OK" was what came out of my mouth.

A patient update has been sent and when I realized the decision that had been made only one thing crossed my mind:

I wish Rogue was here to see this.

The helicopter was already circling, less than 10 minutes since the gentleman wandered into camp and at the rate the edema was intensifying even a ground intercept was going to be cutting it close.  The initial edema didn't seem so bad, but now you can almost see it creeping slowly past the second knuckle with no sign of slowing down.

All my breathing coaching is helping a bit, but I was later informed of the reason his pulse rate increased:

He has no insurance.


The landing was fast, they didn't wait for an LZ to be set up, just picked an empty campsite around the corner and did their thing.  One of the rangers drove off to check on them, code 3 of course, and came back moments later.

"Get him in here I'll drive him over to the chopper."

Chopper?  Really?  Oh well.  Suddenly we CAN transport, and I remind the patient to stay calm and let the nurse and medic know about any dizzyness, numbness, trouble breathing, the big stuff and away he went.  Another few moments later we hear the helicopter throttle up and tilt the rotors and away they went.

Now imagine he hears the helicopter and tells you there's no way he's going with them and asks you to drive him to the ambulance.

What would you do? You Make the Call.

Sunday, June 10

You Make the Call - Bit

This weekend was to be the first camping trip of the year.  Staying local, visiting a state park that we had never visited takes the strain of a few hours transit out.  On a clear day you can see most of our region, 60-70 miles in all directions.  Seemed like a fun spot and provisions were secured.

Universe Warning #1: No alcohol allowed in the park.

Now I know how CHL folks feel when they can't take their weapon with them certain places.

Universe Warning #2: Extreme Fire Danger in effect. Only charcoal and gas stoves allowed, no open burning.

How am I supposed to do SMORES over a charcoal built in? We'll make do.


And that was before we even packed the car.  Looking back, the Universe, God, Karma, something was trying to send me the signal NOT to go camping this weekend.  I wasn't listening.

I'm getting to the You Make the me.

Arriving at the park we picked out a shady site with a large enough spot for our tent and the girls to run around and exhaust themselves.

As I open the back of the van to get the gear I hear from commotion from the next site over, "Oh God he got bit by a rattlesnake!"


A 58 year old male walks in from the open space nearby holding his left hand.  He sits at a nearby bench, 1st finger with a single puncture wound, the bleeding has stopped but the site shows initial edema.  He is smacking his lips while speaking in full sentences and is in good spirits considering.

Being the kind camper you are you approach and offer assistance.  A woman is tying a twine tourniquet on the finger which you quickly remove and they raise his hand which you quickly restore to it's natural position and ask if anyone has called the Ranger Station.

Another woman has appeared (It was a Girl Scout outing, moms and girls) with a snake bite kit.

Your situation:

What might pass for a BLS camping kit plus a dose of epi 1:1000 back in your own camp.

New in package Coleman brand Snake Venom Removal Kit.

Campsite is 15 linear miles up a mountain, the drive took you 35 minutes avoiding bikers.

The Ranger Station is maybe 2 miles back down and just a few minutes ago had 2 Ranger vehicles parked there.

The man has no pertinent medical history, is alert and oriented and in the few moments it takes to assess the situation the edema has not changed.  His pulse rate is elevated, 130, but he is anxious as well.


What do you do?

You Make the Call


This will be a 2 part YMTC and will expand on what I did and what happened then.

Wednesday, June 6

Bill me

I got to sit in on a meeting with our billing company the other day and had a nice little discussion about what constitutes an ALS call.

In their non-clinical world only a call where a person performs an ALS skill is an ALS call.

I couldn't disagree more.

I see what they're going for, thinking about justifying our ALS rate for the guy who claimed to be suffering a stroke, but got no treatment.

But WHY did he get no treatment?  Because of a good ALS assessment.  That, to me, makes it an ALS call.  If we get on the scene with a BLS engine and they're able to determine the transport is BLS, great.  Trouble is I have no BLS cars in my fleet, so even if I stick an EMT in the back I still have a Medic driving.  Plus there's the stickler that the regulatory agency requires an ALS assessment on all patients.

So there we were, arguing whether or not running an EKG is an automatic ALS transport, him taking the side that it can't be because it didn't show anything and me arguing that that's the entire point.  ALS isn't the tools we carry or the skills we practice, it is our assessment skills.

I can train a cat how to intubate, but I can't train him when not to.


Our assessment skills are what make the difference between a BLS and an ALS patient.  Plenty of ALS patients can be treated with BLS in the short term, sure, let's not get into a BLS vs ALS pissing match, but instead shift our focus from what's in the toolbox to when and WHY to use what's in there.


Discussion finished, and me having lost, I wondered about the inefficiency of an all ALS transport system.  Perhaps I can convince the state and County to open their minds to alternate options.  We already transport to a specific alternate facility, perhaps more research is in order?


Just hope I can bill it at the ALS rate.


Sunday, June 3

The Legend of the Little Dipper

I had completed my surf rescue qualifications only a week ago and had been carrying my gear on the engine along with the helmet, vest and fins.  My name was on the board finally, assigned to Rescue Watercraft 1 under "Swimmer."

It is what I had worked so hard to achieve.  Weeks in the pool at the gym, 8 hour days of water training, swimming in the bay, the finally all paid off.

On this particular day I had wandered over to the store on the corner for an apple and the radio came alive when I had just left.

"Engine 8 on Fireboat 1, Engine 16 on RWC1, Truck 16 on RWC2, Battalion 4, Medic 99 and RC2 respond for the bay rescue..."

The rest was a blur.

I thought dressing for a fire in a hurry was a challenge.  I needed to go from full uniform to wetsuit, then gear up from there on the short drive to the docks.  In the past, before I got my rescue cert I would drive this leg, then help prep the skis.

Not today.

Today my heart is pounding, the wetsuit is on and so are my boots and gloves.  The vest is bulky and makes it hard to sit in the seats, the fins are clipped to my belt that I've made sure isn't looped through my seat belt.

The tourists are photographing the engine as we come to a stop outside the Marina Office and jump out. 3 minutes.  Not bad.

We're at a steady jog around the corner and down the walkway to the docks.  At the end rests the rescue boat and the rescue water craft.  They're uncovered quickly and the operators fire them up and prepare to leave.  We have our possible location of a windsurfer in distress out in the middle of the bay.

My mind swirls with all the training I received.  It's an ebb tide, meaning the water is leaving the bay, probably around 5 knots.  It's a chilly afternoon, mid 60s and the water will be in the 50s.

Hood and goggles in place I climb on the ski just as it's throttling up to make the trip into the windy almost white capped bay.

Why anyone would windsurf in this weather is beyond me.  Clinging to the operator and the hand holds, the rescue board attached behind us looks like a far better place to be but trying to change positions at full speed could prove dangerous, wet and fracking cold.

By the time we arrive at the large passenger ferry who spotted the wind surfer in distress we discover that callers out here are no different than on land.

Our "victim" is a kite surfer who is having trouble getting started back up with the ferry hovering in his wind.

We thank the ferry operator who begins to go back the the three hour tour of the bay and we offer to tow the surfer into a better wind vane.  He climbs on the rescue board and I reach over to grab his board.


Any moderately experienced jet skier will know that you never stand and you especially never lean over when on the water.  I knew that, but in the wind down of adrenaline and finding out I won't be swimming 100 yards against the tide, I got comfortable...and forgetful.

I can only imagine the comments from the crew of the Coast Guard boat now arriving at our location, seeing a Fire Department Jet Ski with only a wind surfer holding onto the back and 2 knuckleheads in the water.

The kite surfer was back on his way and the wetsuit was doing a decent job, but we were cold.

Back at the docks RWC2 is wondering why my operator is all wet.  The swimmer, sure, but the operator?

"What happened to you guys?" The officer asked, tucked warmly in his turnout coat.

Without missing a beat my operator thumbs in my direction and says, "Why don't you ask the Little Dipper back there."


Luckily that name stuck for only a few weeks.  That is, of course, until the Legend of the Big Dipper.

Saturday, June 2

365 Days


BOX 8155

10:44am Thursday, June 2nd, 2011

LODD – Lt Vincent Perez – Engine 26
Perez - Badge

LODD – FF/PM Anthony Valerio – Engine 26

Valerio - Badge

Click HERE to learn more about these brave men

In Remembrance...

Special thanks to the men of OCFA Engine Co 26

Brendan Vaccaro Photography

and a remarkably well raised young man

Friday, June 1


Time for bed. They need to get up early to report for duty in the morning.  The obligatory, half asleep "be safe" may await them.


Tonight they close their eyes.


Tomorrow will be their last sunrise;  Their last cup of coffee with their brothers. the time you read this it may already be too late.


I miss you Tony.  I miss you Vince.