Why is it never discussed that EMS take over fire?

Did I get your attention yet?

This quote from Collier County, FL Medical Director Bob Tober (in reference to fire absorbing EMS) sure got my attention:

“Somehow, providing BLS and the initial ALS (which is all they are really trained to do) is not enough for them because of 1) control, 2) power, 3) influence, 4) some revenue from transport, 5) justification of their existence,” Tober wrote. “Do not forget that 90 percent of what fire (rescue) does is medical. Since EMS is the medical specialist job description in our county, why is it never discussed that EMS take over fire?”

Wow.

Read the rest here.

NAEMSE/Massimo part 2

Several days have passed since my initial post about the NAEMSE/Masimo issue. I have certainly had quite a few phone calls and many more emails. One of the most interesting and appropriate calls described Masimo's marketing activities as similar to Invasion of the Body Snatchers.

Picture it. You are one of the few people that hasn't been infected by the Masimo virus. You act like you have...always worrying that one of the Masimo people will see that you haven't been infected...and then eat your head or something.

I made my previous post at 9:02am EST. By 12:00 noon on the same day I had 4 hits on my blog from Masimo in East Irvine, CA. To date there have been 7.

Lets look at what Masimo has done to market (aka push, shove down our throats) their CO-oximetry product.

They developed curricula for EMS providers and distributed it through NAEMSE. NAEMSE sent a letter to its membership recommending CO screening and the educational products developed under a grant by Masimo. Masimo then sent out a mondo press release which was picked up on hundreds of web sites from CNBC, Reuters and market watch to industry news sites.

They developed curricula for firefighters and distributed it through IAFF. I am in the process of obtaining the CD and accompanying paperwork from this mailing. I'll report back on this.

They have a supplement to JEMS this month touting a "Standardized Curriculum on Carbon Monoxide Poisoning." How did this become "standardized?"

They are the only listed sponsor of firerehab.com. Note the dramatic scrolling list of news with a bent towards CO poisoning incidents.

The are behind firegrantshelp.com because the sponsor of this site is firerehab.com (sponsored by Masimo) Check out their sponsors page. Grants for CO-oximetry anyone?

They have sponsored most current research on CO-oximetry. They also regularly sponsor sessions at conferences which relate to their products.

They have giant booths at EMS and fire shows. They give away big things. I got a nice duffel to carry my dirty laundry home from JEMS.

While not a smoking gun, it is interesting to note that some links to materials on CO-oximetry are dead links including a link to an IAFF PDF on firerescue1.com and the Masimo Carbon Monoxide Training Center at the National Paramedic Institute

Enough already. While companies have the right to push FDA approved devices as much as they want (and make as much money as they want) this borders on exploitative and manipulative. How about taking the money you plan to spend on your next round of pointing out just how necessary and important your product is and REDUCE THE $4,000 PRICE TAG so it can do some of the good you claim it does?

Masimo stock, in its IPO on 8/7/07, was offered at $17.00. At last close it was $40.25 (a 136.8% return in just over 4 months). Despite all the good Masimo may claim to be doing through its lectures, curriculum development and web site sponsoring, let's face it, it is about making money for the corporation.

And back to NAEMSE, the letter was wrong. Period. NAEMSE needs to disclose to its members how much it accepted from Masimo on what dates, who wrote that letter and offer an apology to its membership for this ethical lapse--whether intentional, by oversight or appearance.

Am I ungrateful? No. Practical? Likely. Skeptical? Definitely.

Beware of anyone who takes such lengths to tell us what we need. If it was this important wouldn't it be obvious? Maybe the need to spend $4000.00 isn't as obvious as some would like us to think.

Has NAEMSE gone too far?

I was doing my daily search of EMS news recently and found a press release on EMS1.com from Masimo touting how the the National Association of EMS Educators made a critical medical announcement:

NAEMSE Letter to Members Warns of Critical and Fatal Implications of Missing the Diagnosis of Carbon Monoxide Poisoning

IRVINE, CA - Masimo (NASDAQ: MASI), the inventor of Pulse CO-Oximetry and Read-Through Motion and Low Perfusion pulse oximetry, today announced the National Association of EMS Educators (NAEMSE) has issued guidance to all its members advocating carbon monoxide screenings for patients presenting with any of the signs and symptoms of carbon monoxide poisoning or suspected exposure. In addition, the organization is advocating enhanced carbon monoxide training programs for all EMS professionals to help improve outcomes and save lives.

In a letter to its membership issued earlier this month, NAEMSE said failing to diagnose carbon monoxide (CO) poisoning during the emergency response efforts may lead to poor pre-hospital decisions, including failure to transport, failure to transport to an appropriate facility, failure to properly treat and failure of the emergency department to diagnose. The consequence of misdiagnosis can often result in returning the patient to a poisoned environment, possibly leading to a fatal outcome. Recognizing that CO poisoning-the most common form of poisoning in the United States-is notoriously difficult to detect, NAEMSE said improved screening and implementation of proper carbon monoxide EMS training programs "can no doubt lead to improved outcomes for patients and potentially save many lives."

Too often, even the most skilled first responders can miss the chance to treat carbon monoxide poisoning early because until now there hasn't been a fast, accurate and noninvasive way to detect elevated levels of CO in the blood. However, with the Masimo Rainbow SET Rad-57 Pulse CO-Oximeter, EMS professionals can easily detect carbon monoxide poisoning on the spot in just seconds with the push of a button, allowing for prompt and possibly life-saving treatment. In addition, Rad-57 can also limit the likelihood of long-term cardiac and neurological damage that can result from non-fatal exposures.

"We see first hand the overwhelming and immediate need for carbon monoxide screening during the first response stage and the importance of standardized carbon monoxide training protocols for EMS professionals as a matter of public safety," said NAEMSE President Angel Burba.

NAEMSE will soon have a new online training program available to all its members, free of charge, on their website www.naemse.org. The program-consisting of four carbon monoxide modules developed by Dr. Bryan Bledsoe and approved by top EMS physicians and professionals-covers the physiological dangers of CO poisoning, its signs and symptoms, as well as noninvasive methods for on-scene detection of CO in the blood. The modules include downloadable student workbooks, instructor manuals and PowerPoint slides for classroom presentation. Dr. Bryan Bledsoe is an emergency physician, highly regarded as one of the premier educators in the EMS field, and the leading author of numerous EMS textbooks.

Joe E. Kiani, Chairman and CEO of Masimo stated, "NAEMSE's recommendations for proper EMS training and field screening of carbon monoxide poisoning represents an important milestone in the establishment of new protocols for emergency responsiveness and improved public safety. If implemented nationwide, these recommendations will help reduce morbidity and mortality from unsuspected cases of carbon monoxide poisoning."

Coincidentally, NAEMSE's website welcomes Masimo as a new platinum corporate sponsor. Does anyone smell a pay-off? Can you guess who funded the development of the educational materials on the NAEMSE site? Does anyone actually think that someone at NAEMSE wrote that letter? It smells of being written by Masimo and copied onto NAEMSE letterhead--letterhead quoted on sites like firerehab.com (sponsored by Masimo) and healthcare purchasing.com as shameless Masimo ads.

Perhaps most disturbing is the between the lines implication that CO-oximetry may have a routine use to catch those sneaky non-diagnosed cases of CO poisoning.

Remember when we were all incensed when the AHA pushed Amiodarone after the manufacturer built them a new auditorium? How is this any different? And why would MASIMO do this with NAEMSE? Couldn't they get any clinical associations (e.g. NAEMSP, ACEP) to jump on with this sales pitch?

As a matter of fact, letters in Annals of Emergency Medicine are clearly divided on carbon monoxide poisoning and the role of these devices and act as a good representation of the fact that more research and technology improvement is needed.

O'Malley (O’Malley GF. Non-invasive carbon monoxide measurement is not accurate. Ann Emerg Med. 2006;48:477–478) stated:

We prospectively non-invasively measured COhgb on every ED patient. By the end of the second day of the study, we identified 5 false positive pulse co-oximeter readings. Every patient with an elevated COhgb level as described by the pulse co-oximeter had normal serum COhgb as measured with the blood test (100% false positive). The ED staff became distrustful of the pulse co-oximeter and lost interest in recording COhgb readings on every ED patient. We officially stopped the study after recording COhgb non-invasively on 328 patients and identifying 5 false positive COhgb readings

Suner, et.al. (Non-Invasive Screening for Carbon Monoxide Toxicity in the Emergency Department is Valuable Selim Suner , Robert Partridge , Andrew Sucov , Kerlen Chee , Jonathan Valente , Gregory Jay Annals of Emergency Medicine- 2007 May (Vol. 49, Issue 5, Pages 718-719) replied in a subsequent letter:

...To discredit a new technology based on 5 cases in a study which was stopped after 2 days is premature. Screening tests will have false positive results. Although confirming false positive results by performing venous co-oximetry has costs associated with it, identifying occult cases of carbon monoxide toxicity may prevent significant morbidity and mortality. With new technology in the field of medicine, frequently there is initial skepticism and growing pains. Similar complaints were evident when pulse-oximetry was first introduced in health care to measure oxy-hemoglobin concentration. It took months if not years before this technology was accepted. Now it is an indispensable tool in our diagnostic armamentarium and arguably a fifth vital sign. It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

The take-home point in this case isn't in the statistical or research dispute. The issue is clearly stated in the last two sentences of Sumer's letter:

It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

In short, it's not time yet.

In a position paper, "Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning," (October, 2007) the American College of Emergency Physicians states that there were 491 accidental deaths from carbon monoxide poisoning in 1998. Non-fatal poisonings were estimated at 15,000 - 40,000 with an acknowledgment that numbers may be higher because of misdiagnosis.

This post is getting long. Look at the references listed here. Make your own decisions. Here is the Dan Limmer position paper as a conclusion:

1. Masimo appears to have funded every study, education curriculum and press release out there.
2. NAEMSE went too far in issuing the press release and recommendations. I'm OK with the curriculum--generally and as a resource for educators--but am opposed to any statements or veiled implications making CO-oximetry a standard of care at this time. I believe this endorsement timed with platinum sponsorship by Masimo takes credibility away from NAEMSE as a national leadership organization.
3. I question the need for every agency to run out and buy a $4,000 device at this time. It is clearly not a standard of care. The scope of carbon monoxide poisoning cases as noted above does not warrant this designation.
4. In firefighter rehab and suspected carbon monoxide cases it may be useful (duh!) and we didn't need fanfare and press releases to tell us this. Firefighters deserve the best of care. In this area CO-oximetry may be useful and warrant recommendation.
5. The technology is in its infancy and will likely improve to be more reliable. At this time any implication that routine screening of patients is necessary or even suggested is nonsense and may in fact cause unnecessary transport and additional invasive testing.

The end.

Accessories make the man...

According to WBNG 12 news, a Johnson City, NY Fire Chief showed up to work last month wearing only a hat and tie. And I mean ONLY a hat and a tie.

JC Assistant Fire Chief Arraigned After Arriving At Work Naked

Apparently this was planned because his stepfather showed up to take photos. The chief was arrested for exposure of a person. Difficult to deny with photos floating around.

Oh, the jokes that come to mind... Wouldn't it be embarrassing to have the charges dismissed for lack of evidence?

I hope the hat and tie were at least Nomex.

Feel free to add your own.

Thanks to Paul Maniscalco's news emails for this story.

You can lead a horse to water...

Millstone, NJ is having emergency service problems.

Millstone, NJ has a first aid squad. They also have a fire department. According to an article in the Examiner of Allentown, NJ, they don't work together.

It appears that first aid squad members respond from home some of the time. Firefighters sit in the station, able to respond, but can't.

Even more absurdly, it appears that when the Millstone First Aid Squad is on a call, another Monmouth County, NJ mutual aid squad responds to Millstone...while the firefighters still sit in the station.

Here are some killer quotes from the article:

Millstone Committeeman Ramin Dilfanian in reference to the First Aid Squad and Fire Department:

"I can lead the horse to water, but I can't make it drink," he said. "I can get the groups together, but I can't make them cooperate and work together."

and in the "I'm glad its not my heart category.."

First aid squad member Tina Mitchell said the first aid squad currently does not need the help of the firefighters and that the squad's response times are in line with the mutual aid system in Monmouth County.

So, Tina, what you are saying is that it could be faster if the FD responded but since we're in line with the county, the extra minutes a loved one spends in cardiac arrest is OK.

No, wait! The First Aid Squad has now decided the fire department can respond to cardiac arrests and unresponsive people.

At the fire commissioners' monthly board meeting June 11, first aid squad Capt. Bob Trifiro attended to discuss the first-responder issue. Trifiro told the firefighters that they could respond to emergency medical calls involving unconscious victims and to calls during which cardiopulmonary resuscitation (CPR) is already in progress.

I'm sorry if that doesn't leave me teary-eyed with the spirit of cooperation. Its not enough.

But what about the breathing difficulty patients, the patients with anaphylaxis, those with chest pain that haven't yet died? At least death finally invokes the First Aid Squad's blessing for the FD to respond.

There is a fable about a dog walking over a bridge with flesh in his mouth. He looks into the water and sees another dog with a bigger piece of flesh. He opens his mouth to grab the other dog's meat and loses his into the water--his greed costs him everything.

If I lived in Millstone, NJ and I had to wait even two extra minutes when EMT trained firefighters were there to respond sooner--or if an out of town squad had to respond in while firefighters were there to respond much sooner I'd be livid. Litigiously livid.

Like the dog with the flesh, some squads turn down help when they need it out of a sense of pride, threat--or greed. This leads to the demise of a squad faster than if they took the help and built the team that best served the citizens.

Plus--it is never wrong to do what is best for the patient.

Glad he's not my boss - part 2

This one goes into the category of "if you think your city administration is bad, you could always work in Ridgeley, WV."

While cruising the Internet for something of interest I hit the jackpot.

I saw an article in the online edition of the Cumberland (MD) Times-News about how the fire department ambulance is in its thirtieth year. Call volume continues to increase but the paper reports the FD is handling it well. The chief was one of the original EMTs. Good for them. This is nice--but not mother of all stories for a blogger.

While looking at the related story links I saw an article that reported the police chief and town clerk of Ridgeley, WV were fired by the mayor--who called in from jail! Hard to believe, but true. The mayor, Mitchell Reeves, was arrested for fraud one month after being arrested for driving without a license.

It could always be worse. You could be in the public safety biz in Ridgeley, West Virginia.

Glad he's not my boss

If you ever thought your job was bad, it could be worse. You could work in East Cleveland, Ohio.

According to an article on cleveland.com, East Cleveland Mayor Eric Brewer wants firefighters there to assist public works crews in cutting lawns and working in parks.

"We have 54 firefighters, and they have a lot of downtime," Mayor Eric Brewer said Thursday. "Instead of sitting around the station, they'll be assisting us as we beautify the city."

Ken Adams, Deputy Safety Director says "The new duties are similar to other non-fire-related tasks performed by firefighters, such as checking hydrants, conducting fire inspections or visiting schools."

Excuse me, Mr. Adams, but these ARE fire-related duties--and more important than cutting grass. As a matter of fact, according to the East Cleveland web site, the fire department also has a free smoke detector program and a child seat safety program.

In my experience, decisions such as this are made from a lack of knowledge of what firefighters do and are often based on the false stereotype that firefighters sit around the station all day and watch television.

The union believes that the lawn mowing duties may prevent them from hearing their radios and decrease response time. I'm not sure that is a strong enough statement. The lawn mowing duties cause a critical distraction away from (call me crazy, now) fighting and preventing fires!

Looking at response numbers on the East Cleveland unofficial web site, the fire department gets its share of jobs--both fire and EMS. It appears that they are working quite diligently for their money.

I spent some time looking at the web site for Mayor Brewer. He has some high hopes for East Cleveland. Sounds like a shaker and mover may be necessary for the City of East Cleveland. On his web site the Mayor says his "main goal is to take East Cleveland from “poverty to prosperity” during his term in office. Beefing up the city’s service and police departments are vital to his plans, along with eliminating waste and mismanagement, and increasing employee productivity."

Well, although I don't agree with the plan, at least he is one politician who keeps his word.

Mayor Brewer was also quoted on cleveland.com as saying (in reference to mowing):
"Actually, that looks like fun," he said. "I might get out there and cut some grass myself."

I hope he keeps his word there, too. And gets the firefighters off lawn mowers and back where they belong.

While I tread on dangerous ground...how about the fire - EMS issue?

This thread began with a post about Senator Allard's really bad day, then lurched into some of the political issues and how EMS is lagging behind its public safety counterparts. Might just as well bring up the whole fire/EMS issue: just where does EMS belong?

It seems the city of Pittsburgh is asking the same question as evidenced in this article in the Pittsburgh Tribune Review.

The EMS union actually has it in their contract that they can't merge with fire unless there is a renegotiation of the contract terms (a smart bargaining team when that contract was negotiated). The fire union president wants EMS and blames the EMS union for holding up a merger.

Dropping back to a local example, the Kennebunk, Maine Police have been talking about merging with other local police forces. The issues, whether in the smaller police merger or the large Pittsburgh situation, generally aren't equipment or stations or budgets--people and cultures will make or break the merger. Issues like seniority, working environment and perception of equality within the ranks are the big issues.

There are a few big cities out there that may be wishing they could turn the clock back pre-merger for just these reasons.

The leaders who will institute the mergers also make a significant difference. How the merger is introduced, instituted and fed to the rank and file sets a foundation. Early, equitable decisions on controversial issues combined with a consistent message and expectation are vital.

I have seen spectacular fire medics that could treat my family any day. I've also seen fire medics treat people like shit because they got pulled from an engine company to work the rescue. Likewise there are some medics in third service agencies who are true clinicians and others who are many years past their prime.

To me, the issue isn't a blanket decision whether fire or EMS is better. It is about the agency which considers it its mission to provide high quality, clinically competent, patient-centered care to the people it serves--be it fire or EMS.

Wouldn't it be a wonderful world if we had two agencies in one municipality whose true mission it was to provide that type of care...but if that were the case mergers wouldn't be an issue after all, would they?

Does a fire chief need a degree?

The position of fire chief is open in St. Paul, MN. The city of St. Paul lists qualifications for the new chief: bachelor's degree required, master's degree preferred. Only one person in the St. Paul FD meets these qualifications.

Does a fire chief need a degree?

The union has asked the city to lower the requirements so the job is in reach for in-house candidates. Currently only 1 is eligible. The city counters that thousands of unqualified people may apply if the bachelor's degree requirement is lifted.



The bigger issue: those in the emergency services need more education. The lack of education comes easily. Not all employers require degrees in their new hires. Some require degrees for promotion. The young person lands a career job. Bennies, retirement. He or she knows a degree is important--but now it is not a priority. Then the lure of overtime and the demands of a family continue the pull away from education. (Note: I speak from experience!)

Until an injury puts a person back on the job market. Or a provider retires at 45 and suddenly has no other skills or education. Or, as is the case in St. Paul, a promotional opportunity comes up. In all these cases its too late to start now.

Yes, emergency service providers have difficult schedules. Employers should step up to the plate with some scheduling concessions to make education easier. But with the quality, legitimately accredited distance education institutions out there, is there really an excuse for not pursuing a degree?

Take a look at:
Excelsior College
Empire State College

Both of these reputable, accredited schools provide distance education and mechanisms for evaluation of training and life experience toward college credit. And almost all local and state schools have some sort of option such as this.