Pis vous vous demandez
� quoi bon les docs
Si il y'a des param�diques ! ?
Assurer vous que vous ayez un directeur m�dical avec du respect, des
couilles et des ressources
... et ind�pendant du service
J'ai vus d'excelletns t'bib
Totalement �mascul� par un service d'incendies, une compagnie, une Un
syndicat, ou juste l'immensit� de la tache de g�rer un service qui
couvre des millions d'habitants...
Bonne lecture...
Charles Brault EMT-P
Doctor in charge rarely call the shots
By Robert Davis, USA TODAY
By Robert Hanashiro, USA TODAY
Marc Ekstein, medical director of the Los Angeles Fire Department,
often battles with fire officials over changes in medical responses.
LOS ANGELES � Marc Eckstein, medical director for the Los Angeles
Fire Department, arrives at the scene of a cardiac arrest just as the
fading light is turning the white stucco nursing home a bright gold.
Emergency crew members are carrying a patient into their rig. The
woman's heart is still. In lay terms, she has "flat-lined." Because
she has not responded to resuscitation efforts on the scene, the same
efforts that would take place in the hospital, Eckstein knows the
woman will not survive.
For months, Eckstein has been trying to get medics to stop
transporting such patients to the hospital. Rushing flat-line
patients to the hospital with lights and sirens risks lives on the
road, wastes limited health dollars and raises false hopes, he says.
It also means those paramedics are not available for emergencies
where they really might make a difference.
But Los Angeles paramedics don't always listen to their medical
director. They don't have to. The emergency crews whose medical
performance he is supposed to oversee actually work for the fire
chief, and Eckstein's role is little more than an advisory one. When
he attempts to discuss the decision to transport the woman with
lights and sirens, thefire captain on the scene is polite but
dismissive. This, Eckstein says, is not uncommon.
Many big-city medical directors are in similar situations, USA TODAY
found in an investigation of the emergency medical systems in the
nation's 50 largest cities. Few cities have given real authority to
the doctors they hired to oversee emergency care, even though that
authority has been proved to save lives. The cities that have sharply
improved their emergency survival rates have had strong oversight
from medical directors with the power to make changes.
Houston has a solution
Houston is one example. The best measure of an emergency medical
system's performance is its survival rate in cases of sudden cardiac
arrest. A 1993 study reported in the journal Critical Care Medicine
found that Houston improved its survival rate when it made its
medical director a full-time physician with the power to train,
supervise and monitor the fire department's paramedics and make
changes.
Houston's survival rate rose from zero in 1983 to 20% in 1988. Today,
the rate is 21%. Other cities where strong medical directors have
helped improve the survival rate include Seattle, 45%; Boston, 40%;
Oklahoma City, 27%; Milwaukee, 27%; and Tulsa, 26%. Los Angeles does
not know its survival rate; it doesn't measure precisely. And
Eckstein doesn't have the kind of power Houston gaveits medical
director. Trying to change the habits of Los Angeles' 522 paramedics
and 2,228 emergency medical technicians "is like trying to stop a
snowball rolling down a mountain," he says.
Los Angeles is such a large system and is so fragmented that even
different parts of the city have responded differently to Eckstein's
requests for change. In some neighborhoods, more than 40% of
flat-line rescue attempts are halted on the scene, as he recommends.
In other areas, it's close to zero, he says.
Often it depends on whom the paramedics call for medical advice. In
New York, where Eckstein used to work, paramedics call one central
medical command center where a doctor is standing by, around the
clock. In Los Angeles, the paramedics call the closest hospital and
talk to a nurse, a medical resident or a doctor.
"I've got 26 base stations with dozens of people on each radio,"
Eckstein says. For a system to work efficiently, he says, "you have
to have centralized medical control where only a handful of
physicians who know EMS and know the system are called on to make
these decisions."
Which city is best?
By Jack Gruber, USA TODAY
In Seattle: Fire department medical director Michael Copass,
foreground, monitors emergency response at Harborview Medical Center.
USA TODAY asked big-city medical directors to name the cities they
thought had the best emergency medical service in the nation and to
explain why. Not surprisingly, the cities that save the most lives
were high on the list. Boston, Milwaukee, Houston and San Francisco
were named as fine systems. "Strong medical direction" was a primary
reason cited.
The city most often named No. 1 was Seattle, which is widely viewed
by medical directors as a model. Its survival rate for "most
saveable" victims, 45%, is the highest among the largest cities.
In Seattle, the medical oversight is completely different from Los
Angeles'. Seattle's system was created with strong medical direction
as one of its cornerstones more than 30 years ago, and strong medical
oversight remains today.
Paramedics and firefighters dare not ignore Michael Copass, the
medical director for Seattle's fire department. He's all over his
medics all the time. He listens to their medical reports in the
middle of the night on radios in his car and inside his house. He
listens to their findings in the emergency room. He reads every
report written by every one of his 76 paramedics � a total of 23,086
calls last year.
In the "radio room" inside Harborview Medical Center's ER, a closet
full of phones and radios and computers that serves as the
paramedics' umbilical cord to their medical advisers, Copass pores
over a stack of run reports each day, looking for good decisions and
bad. When he spots a mistake, he fires off a "see me." The dreaded
note arrives in the medic's mail.
The feedback keeps the medics on their toes on every scene.
During one drug-overdose call, a medic had been considering a lucid
man's request to be left alone � until the medic's partner whispered
in his ear, "Don't forget the Copass rule on overdoses."
That rule � that overdoses always get worse as the drugs take hold �
means that leaving the patient could be a fatal mistake. The medics
took him into the emergency room for a closer look.
The concept of medical oversight filters down in the system.
Paramedics give feedback to the less trained workers in the fire
department, the emergency medical technicians, or EMTs.
Seattle firefighter EMTs can get a bad report from paramedics on what
they call a "blue sheet" if they have not done their job as well as
they could have.
On a shooting, for example, in which a person is critically wounded,
if the EMTs do not have the patient ready to load into the ambulance
when the paramedics arrive, they could get marked down on the blue
sheet.
This accountability is key because both the EMTs and the paramedics
must explain to Copass why they broke his "triple seven" rule: seven
minutes to get there, seven minutes on scene, seven minutes to get to
the hospital.
This simple equation gives surgeons more to work with in the
operating room, where shooting or other trauma victims will get the
care they need to survive.
Leonard Cobb, one of the founders of the Seattle system, says
constant oversight of the medical care saves more lives. "If we are
practicing medicine out in the streets," he says, "we ought to do it
as well as we can."
That accountability is absent in Los Angeles. The problem is the
system, Eckstein says, not the emergency crews themselves. "Our
strength lies in our people. Where the rubber hits the road, our EMTs
and paramedics provide the best care they can. My challenge is to
take that pride and work ethic and channel it to provide the cutting
edge pre-hospital care."
After the sun goes down, the bullets begin to fly. At the scene of a
drive-by shooting, with a reporter looking on, Eckstein finds that
paramedics are still there more than eight minutes after the man with
bullet holes in his chest went into cardiac arrest. The key to
survival in severe trauma is surgery. The longer paramedics work with
a trauma victim, the lower the chances of survival.
Worse, when Eckstein climbs into the back of the rig, he sees that
the patient still has no intravenous line sending fluid to his veins
to replace lost blood. And the paramedic is only beginning to try to
snake a tube toward the lungs.
The paramedic's first attempt fails. The driver shouts to the back,
"Ready to go?"
Not yet, the medic says. Wait.
A second attempt fails as the driver waits to put the rig in drive
and race toward the trauma center.
On the third attempt, the tube is in place, the medic yells "Go!" and
the rig is rolling.
Later, Eckstein tells the paramedic he did a good job but suggests
the tube might have been too big, causing it to bend on the first two
attempts.
The firefighter walks away without acknowledging the doctor's
observation.
http://www.usatoday.com/news/nation/ems-day2-directors.htm
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