Peoria's Medical Mafia

[drjohn]

This is the first post on www.peoriasmedicalmafia.com.

Synopsis of Emergency Medical Services in Peoria

Peoria’s Medical Mafia documents thoughts regarding Emergency Medical Services (EMS) in Peoria, Illinois. There are approximately 65 posts on this web log, many of them regarding EMS.

Peoria has a population of 113,000. The Peoria Fire Department (PFD) is non transport and provides service at Basic-D level with basic medication. Several years ago the PFD purchased a very nice ambulance using the Foreign Fire Fund. The PFD applied to the Peoria Project Medical Director for permission to outfit this vehicle, their only ambulance, with various basic and advanced life support materials and equipment. This request was denied by the Project Medical Director. The PFD then sold this ambulance because it was not being used.

Peoria has an advanced life support company, Advanced Medical Transport (AMT), which transports patients and gives the only paramedic care in Peoria. It is considered a not-for- profit entity but grosses over 7 million dollars per year. AMT is supported by all three of Peoria’s hospitals. OSF-SFMC, the largest medical center in downstate Illinois, is considered the “resource hospital” for the Peoria Area EMS. All three medical centers have administrators that sit on the AMT Board of Directors. AMT suffered significant legal troubles several years ago when the federal government investigated it for Medicare fraud based on coding and charging. AMT was fined over 2 million dollars by the federal government.

The OSF-SFMC Emergency Department Director is also the Corporate Medical Director for AMT. He was the Project Medical Director for many years in the Peoria area and was salaried by both AMT and OSF-SFMC for his services. Numerous people in the area believe this arrangement constitutes conflict of interest. The PFD also believe that many obstacles have been created over the years to keep them at a basic non transport level so AMT can continue as the only paramedic and transport agency in Peoria.

I believe that Peorians have suffered and died in the pre hospital setting and continue to do so because of the paramedic/transport monopoly. Incredibly, the PFD has paramedics that cannot use their life saving abilities at the scene when they work as firefighters; however, when they “moonlight” for AMT, they are able to use their advanced life support skills.

Similar business arrangements as described above probably occur in other locations around the nation. But just because banks are robbed in many cities, does not mean it is right to rob banks in Peoria.

I hope this web site is informative. Some day Peoria will change for the better regarding EMS and pre hospital care. The system took a while to become this ill and it will take a while to recover.

John A. Carroll, MD
drjohn@mtco.com

[medicmaster]

As I replied to your other post....

A couple of things here...

1. What exactly is the point of all of this?

2. Illinois' entire EMS system is f***ed beyond belief and is so full of bueracracy and red tape its a wonder that anyone in the state receives the care they deserve.

3. AMT from what I have heard has an excellent reputation as an advanced level provider. Aside from being a non-profit agency that "grosses over $7 million a year" (which there are non-profit hospitals that bring 100 times that amount in annually...it's all in how it is spent) and the fact that they had some trouble with CMS a few years ago, you offer nothing to state that they provide a low level of care. However, I do agree that they could stand to pay their staff a little more. (My fiancee considered doing a residency in EM at OSF, I looked into working for AMT...she has since decided on Family Practice instead.)

4. In my personal opinion, fire-based EMS (at the advanced transport level) is flawed. What evidence do you have to support the notion that PFD can provide better service.

Just my $0.02 anyways....

[F18Wub]

As I replied to your other post....

A couple of things here...

1. What exactly is the point of all of this?

2. Illinois' entire EMS system is f***ed beyond belief and is so full of bueracracy and red tape its a wonder that anyone in the state receives the care they deserve.

3. AMT from what I have heard has an excellent reputation as an advanced level provider. Aside from being a non-profit agency that "grosses over $7 million a year" (which there are non-profit hospitals that bring 100 times that amount in annually...it's all in how it is spent) and the fact that they had some trouble with CMS a few years ago, you offer nothing to state that they provide a low level of care. However, I do agree that they could stand to pay their staff a little more. (My fiancee considered doing a residency in EM at OSF, I looked into working for AMT...she has since decided on Family Practice instead.)

4. In my personal opinion, fire-based EMS (at the advanced transport level) is flawed. What evidence do you have to support the notion that PFD can provide better service.

Just my $0.02 anyways....

While I am not going to touch the "medical mafia", I am curious why you say that fire based EMS is flawed? My experience is just the opposite. I have worked at a private, a fire department that provided first response to the private, and fire based ems. The first response to the private's ALS was so filled with red tape and bias it was a joke, and I worked at the private at the time. I have full belief that Peoria can provide as good of level of care if not better than AMT, but that's all I am going to say about that.

[MIKEYLIKESIT]

Sorry 'Master" but you are flawed. My department began ALS Transport service in 1973. Why? Because the privates couldnt do the job. That was 33 years ago. The Fire Department is still here. How many private ambulance services have come and gone, went belly up etc. since then?

[jaybird210]

Sorry 'Master" but you are flawed. My department began ALS Transport service in 1973. Why? Because the privates couldnt do the job. That was 33 years ago. The Fire Department is still here. How many private ambulance services have come and gone, went belly up etc. since then?

He is right on point #2, though.

[MIKEYLIKESIT]

Maybe at the IDPH Jay. But which state had a medical team in place and working in Louisiana within days of Katrina? Our system (South Cook) has been wonderful to me since I started paramedic school...20 years ago.

[medicmaster]

Mikey,

For one, Chicagoland is a whole different ballgame compared to the rest of Illinois...things seem to run much smoother there.

I will agree that there are fire based EMS systems that do a fantastic job. However, my point was not to break it down into fire based and privates. There are many county and muncipal based third services who do much better jobs than privates.

I agree that most privatised EMS systems do not do a good job at providing service (although there are some that do.) From what I know about AMT, they are a good private provider.

My point is though, and this is just my personal opinion, that the world of emergency services has come to be very specialized, and I think that fire protection would be better served by firefighters who train only to be top notch fire fighters without being bogged down by running a dozen EMS calls, and then fighting a structure fire at 3am. EMS would be better served by having highly trained paramedics who are focused on patient care.

I recently began working for a city where EMS and Fire are separate city departments. Although the stations are shared, and there is an excellent working relationship between our two agencies, we have separate department heads, and the medics are very high quality. The firefighters are also very high quality, and when we all need to play together, things go smoothly.

Our city is only one of three in the nation to have all three public safety agencies nationally accredited, and I can definately say that our EMS department is one of the highest respected systems in the state.

With that said, I'm not saying that I don't think that PFD can provide better service than AMT, I was simply making a point that this doctor presents no evidence to say that they can.

[drjohn]

Dear Medicmaster,

I appreciate your comments above.

When patients were brought into the ED my most important conversation was with the paramedics or EMT's that brought in the patient. How the patient looked at the scene and enroute was very important and my respect for Peoria's paramedics and all levels of prehospital level providers was and is great. They are not the problem.

As www.peoriasmedicalmafia.com documents, evidence in Peoria is lacking, or I would provide it for you. EMS everywhere needs to be transparent. The one statistic that we seem to know, as verified by a consulting firm several years ago, the PFD responded to life threatening emergencies two minutes faster than did AMT. Is that clinically important? Maybe, especially when chest pain and breathing problems are involved, according to the medical literature that looks at response times. When I spoke with the Peoria Area EMS office several years ago, I was told that there is no aggregate data to look at regarding clinical outcomes. I do not know if that is true, but the data is not "out there" to find easily. I tried IDPH also to obtain this data, and got nowhere.

My point is not to provide data, for reasons described above, that the PFD can provide better service than AMT, even though I think they could with the proper director and level of training. My point with the web log is to say that the first arriving best trained provider should be allowed to provide his or her services for the benefit of the patient. When PFD paramedics have to stand around and wait for AMT to arrive to give ALS, that seems wrong. I know there are alot of rules regarding how departments respond, but the situation in Peoria needs to be scrutinized carefully. When the patient needs an endotracheal tube, and the PFD firefighter cannot place one unless asked to do so by AMT, that seems to be problematic, doesn't it? What if AMT is not on scene to ask for help with the tube?

Not all conflict of interest is bad. If conflict of interest is acted upon in a negative way, that is not good. George Hevesy, MD is the ED Director at OSF and was the PMD for the Peoria area for many years. OSF is the main supporter of AMT. Hevesy was and is the Corporate Medical Director for AMT and paid by AMT for his services. He is also Director of Region 2 for IDPH. The general public doesn't understand what any of this means, but EMS providers do.

I have talked to municipal fire departments all over the United States. When they are designated to provide service at a certain lower level, many departments have options that allow some of their firefighters who are paramedics to function as paramedics even though the department is not "paramedic". Please advise me how this takes place. This seems to make sense. The PFD should be able to use this option, shouldn't it?

Thanks.

John Carroll, MD

[medicmaster]

As www.peoriasmedicalmafia.com documents, evidence in Peoria is lacking, or I would provide it for you. EMS everywhere needs to be transparent. The one statistic that we seem to know, as verified by a consulting firm several years ago, the PFD responded to life threatening emergencies two minutes faster than did AMT. Is that clinically important? Maybe, especially when chest pain and breathing problems are involved, according to the medical literature that looks at response times. When I spoke with the Peoria Area EMS office several years ago, I was told that there is no aggregate data to look at regarding clinical outcomes. I do not know if that is true, but the data is not "out there" to find easily. I tried IDPH also to obtain this data, and got nowhere.

My point is not to provide data, for reasons described above, that the PFD can provide better service than AMT, even though I think they could with the proper director and level of training. My point with the web log is to say that the first arriving best trained provider should be allowed to provide his or her services for the benefit of the patient. When PFD paramedics have to stand around and wait for AMT to arrive to give ALS, that seems wrong. I know there are alot of rules regarding how departments respond, but the situation in Peoria needs to be scrutinized carefully. When the patient needs an endotracheal tube, and the PFD firefighter cannot place one unless asked to do so by AMT, that seems to be problematic, doesn't it? What if AMT is not on scene to ask for help with the tube?

In a tiered system, such as the one that exists in Peoria, first response (in this case the FD) is supposed to arrive several minutes before the ambulance. Fire stations are (should) be built in areas that allow an engine company's response to a scene as quick as possible. In most cities where the ambulance is not housed at the fire stations (such as with many private or third service providers), they are placed to provide coverage wherever needed to an entire city based on volume, versus an engine company whose primary objective is rapid response within its first due district. If the ambulance routinely beats the engine company, or they routinely arrive at the same time, then tiered response is a waste of resources.

Those two extra minutes give the engine company the oppurtunity to initialize BLS maneuvers and perform a patient assessment to pass along to the EMS crew when they arrive.

As an example, the city I work in has four fire stations with a fifth under construction. Two of these stations are staffed 24/7 with career firefighters, the other two are staffed with paid on call firefighters. We staff three ambulances 24/7 at two of the unstaffed stations, and one of the staffed stations. Most of our runs do not require additional manpower, so the squads will respond to EMS assignments unassisted by the engine companies. Exceptions are calls to the firefighter staffed station's district which does not house an ambulance, in which case they do provide first response. Other exceptions are if the squad housed at the other staffed station is out on a call and another truck from another part of the city has to respond. Motor vehicle accidents and unconscious persons will also be an automatic engine company response. Additionally, the EMS crews can request an engine company's assistance if needed. All of the engines are BLS equipped.

Not all conflict of interest is bad. If conflict of interest is acted upon in a negative way, that is not good. George Hevesy, MD is the ED Director at OSF and was the PMD for the Peoria area for many years. OSF is the main supporter of AMT. Hevesy was and is the Corporate Medical Director for AMT and paid by AMT for his services. He is also Director of Region 2 for IDPH. The general public doesn't understand what any of this means, but EMS providers do.

I realize I may be making an assumption here, but from what I saw on your blog, it seems that you questioned this guy's motives and intents and he decided to kick you out of the ER to keep you quiet. While I will sympathize with you in that this clown does not sound like the type of person we need taking EMS and Emergency Medicine into the future, I can't help but wonder if this is because you have an axe to grind with the man. Again, I'm playing deveil's advocate and making an assumption, but it sounds like this physician is the problem, not the EMS system. In fact, to be completely honest, with St. Frances being a very respected EM residency program, it scares me to think about how many ERP's in the midwest will adopt this guy's attitude about things! :eek:

I have talked to municipal fire departments all over the United States. When they are designated to provide service at a certain lower level, many departments have options that allow some of their firefighters who are paramedics to function as paramedics even though the department is not "paramedic". Please advise me how this takes place. This seems to make sense. The PFD should be able to use this option, shouldn't it?

This is true...at least over here in Iowa what it requires is that the transport agency's medical director must approve them to function as an ALS provider in the transport agency's squad, with their equipment.

Having ALS first response is something I'm very undecided about. I began my career with an ALS volunteer first responder service, but due to our rural setting, ambulance response to the scene after we had arrived was often times 10-15 minutes. In those 10-15 minutes, we had most if not all of the ALS stabilizing treatment performed. However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.

By the way....this has turned into a great discussion!

[k3twpfire]

However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.


Please explain how initiating ALS procedures is more of a hinderance when the ALS ambulance is 2 - 3 minutes behind the engine than 10 - 15 minutes.

[F18Wub]

Having ALS first response is something I'm very undecided about. I began my career with an ALS volunteer first responder service, but due to our rural setting, ambulance response to the scene after we had arrived was often times 10-15 minutes. In those 10-15 minutes, we had most if not all of the ALS stabilizing treatment performed. However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.



Where I work, ALS engines are the rule, rather than the exception. I really don't understand how having more ALS providers on scene, providing care can be a hinderance, especially in a situation like Peoria, where, if I recall correctly, single medic ambulances are commonplace. Granted, most calls are not of a critical nature, but when needed, the assistance is of great benefit to the patient. Think about the flow of a scene. BLS engine shows up, assess the patient, begins BLS intervention. Ambo shows up 2-3 minutes later, gets report from engine, then begins to assess the patient, because the usually won't trust the BLS providers impression. (Someone will disagree with me on that, but I have worked in that situation before and that's how it was, even when I was a medic, and they knew me.) Then begins to provide ALS care. That can be quite a bit of time. Now, look at the flip side, and this is how it works in the area I work now. ALS engine shows up. ALS providers begin assessment and intervention. Ambo shows up, gets report, assess for themselves, but care is already ongoing, and uninteruppted.

With that said, I'm not saying that I don't think that PFD can provide better service than AMT, I was simply making a point that this doctor presents no evidence to say that they can.

At face value, this guy is an ER Doc, meaning he sees first hand the level of care that is going on. So, if things were working properly,with the high level of care expected, I doubt we would be having this conversation. But, keep in mind, having worked in the area, a good of medics working at privates did so for one reason. To be hired at a FD. Granted, not all, but a good deal of them.

[medicmaster]

Please explain how initiating ALS procedures is more of a hinderance when the ALS ambulance is 2 - 3 minutes behind the engine than 10 - 15 minutes.

Because with few exceptions, ALS interventions generally are not performed in the first few minutes...those first few minutes are (should) be spent performing an initial exam and assessment of the current condition.

Go down to Florida where they routinely will have an ALS company respond along with an ambulance, those scenes are chaotic when there are anywhere from 6-10 paramedics on a scene. The only instance where that might be valuable is on a cardiac arrest. What percentage of Peoria's calls are arrests?

[medicmaster]

At face value, this guy is an ER Doc, meaning he sees first hand the level of care that is going on. So, if things were working properly,with the high level of care expected, I doubt we would be having this conversation. But, keep in mind, having worked in the area, a good of medics working at privates did so for one reason. To be hired at a FD. Granted, not all, but a good deal of them.


1. He may be an ER doc, but he does not mention anything about poor care that he has seen AMT give. He is primarily against the physician in charge and talks about OSF's monopoly on the EMS system in Peoria by having a conflict of interest and barring PFD from using a transport unit.

2. Yes, medics going to work at privates so they can get hired at a FD is something that happens all over the country. Who wouldn't want to end up in an FD job, the pay is generally better. The problem is that many of them who are good medics with the fire departments become pisspoor medics with the fire department because it is not of interest to them anymore. i.e. they became medics to become firefighters. I certainly realize that not all of them do, but probably the majority. (not just at PFD, but any ALS fire based system).

[k3twpfire]

Because with few exceptions, ALS interventions generally are not performed in the first few minutes...those first few minutes are (should) be spent performing an initial exam and assessment of the current condition.


Suspected Cardiac Patient - In our system, ALS interventions are expected to begin within 2 minutes. Patient with substernal chest pain - exam, history, medications, allergies, BP, 4 Baby Aspirin all can be done in the first 2 minutes. Then IV, followed by Nitro, etc. etc.

Known/Suspected Diabetics - Take a Blood Sugar - its 34.. start IV, D50, etc. etc.

There are many situations where ALS can be done in the first 3 minutes.

[medicmaster]

Suspected Cardiac Patient - In our system, ALS interventions are expected to begin within 2 minutes. Patient with substernal chest pain - exam, history, medications, allergies, BP, 4 Baby Aspirin all can be done in the first 2 minutes. Then IV, followed by Nitro, etc. etc.

Known/Suspected Diabetics - Take a Blood Sugar - its 34.. start IV, D50, etc. etc.

There are many situations where ALS can be done in the first 3 minutes.

With ACS, it has become standard of care to perform a 12-Lead EKG. This should be done with the initial vitals prior to administration of any medications as NTG especially can cause ST segement abnormalities to change or disappear altogether. Again, two minutes is not going to make a difference.

With the diabetic patient, I doubt you could obtain a blood sugar, perform an assessment and establish an IV all in two minutes, and once again, that two minutes is not going to make a difference in patient outcome.

Cardiac Arrest is the only situation where immediate ALS is beneficial.

[drjohn]

I realize I may be making an assumption here, but from what I saw on your blog, it seems that you questioned this guy's motives and intents and he decided to kick you out of the ER to keep you quiet. While I will sympathize with you in that this clown does not sound like the type of person we need taking EMS and Emergency Medicine into the future, I can't help but wonder if this is because you have an axe to grind with the man. Again, I'm playing deveil's advocate and making an assumption, but it sounds like this physician is the problem, not the EMS system. In fact, to be completely honest, with St. Frances being a very respected EM residency program, it scares me to think about how many ERP's in the midwest will adopt this guy's attitude about things! :eek:

Your concerns here are very valid. Ethics in EMS need to be taught to resident physicians in training.

[medicmaster]

Your concerns here are very valid. Ethics in EMS need to be taught to resident physicians in training.

I absolutely agree.

My fiancee is in her fourth year of medical school and will be starting her residency in June 2007. She had considered emergency medicine at St. Frances, but has decided to go into FP instead...I'm glad too, based on what you have said about this doc!

[drjohn]

[QUOTE=medicmaster]1. He may be an ER doc, but he does not mention anything about poor care that he has seen AMT give. He is primarily against the physician in charge and talks about OSF's monopoly on the EMS system in Peoria by having a conflict of interest and barring PFD from using a transport unit.

My point is not to comment on poor care by AMT. The physician who was PMD and is now Director of the ED at OSF, Dr. George Hevesy, is part of the problem, in my opinion. I am not "against the physician in charge", but I don't agree with his draconian policies. He and his colleagues have controlled EMS in the Peoria area for about 15 years as he has accepted a salary from both OSF and AMT. He should know better in this day where "conflict of interest" seems everywhere and especially embedded in the medical community.

The EMS system in the area needs to be changed, so the public, and not profit, becomes the main focus in Peoria.

[drjohn]

My best to your fiancee in FP, but I still think she should go into ER. She will have definite schedules, will see tons of pathology, and get more follow up than she might believe, and have an inside track on EMS ethics.

As you can see, I don't know how to "quote" with this site. Tell me what to do, because I still have some comments and want to use the "quote" the correct way.

[drjohn]

Dear Medicmaster,

You state that "cardiac arrest is the only situation where immediate ALS is beneficial". I think you are correct from the standpoint that defibrillation is the only modality shown to improve outcome. Epinephrine, lidocaine, atropine, etc. have not been "proven" to help survival. But how would someone do a controlled double blinded prospective study to see if witholding these drugs and responding two minutes slower ("the Peoria Protocol") is beneficial to the patient? In other words, if you were the pre hospital patient in full arrest (or one of your family members), would you want these ALS drugs given, and if you wanted them given would you want them given two minutes quicker or two minutes later?

I know your answer already.

Thanks.

Dr. John

[F18Wub]

Well, I can thing of several situations where immediate ALS is benificial, arrests, near arrests, respiratory emergencies and trauma, which Peoria see's it fair share of. Actually, depending who you talk to, you don't even need ALS for trauma. You seem to have your idea's, and I have mine. I am absolutely certain that immediate ALS works, and have seen it do so many times, I know of people who are crawling and walking on this Earth because ALS care was there two minutes earlier than it would have been in Peoria. I know Fire based ALS works where I am, and I got a hunch it would work in Peoria.

[medicmaster]

Dear Medicmaster,

You state that "cardiac arrest is the only situation where immediate ALS is beneficial". I think you are correct from the standpoint that defibrillation is the only modality shown to improve outcome. Epinephrine, lidocaine, atropine, etc. have not been "proven" to help survival. But how would someone do a controlled double blinded prospective study to see if witholding these drugs and responding two minutes slower ("the Peoria Protocol") is beneficial to the patient? In other words, if you were the pre hospital patient in full arrest (or one of your family members), would you want these ALS drugs given, and if you wanted them given would you want them given two minutes quicker or two minutes later?

I know your answer already.

Thanks.

Dr. John


Under the current system as described, with a BLS engine company arriving a few minutes prior to arrival of ALS, its my belief that if a cardiac arrest victim has any chance of survival, it will be found in the provision of quality BLS with ongoing ALS care.

The new ACLS and BCLS algorithms indicate that 2 minutes of uninterrupted CPR prior to defibrillation has been shown to improve the likelihood of VF being converted with defibrillation due to the theory of "priming the pump" (building up levels of ATP and increasing coronary perfusion pressure).

Emphasis has been taken away from the airway as it is believed that the rate of ventilations should be around 6-10 a minute.

A BLS engine with an AED should be capable of providing this care, which is the same care that an ALS provider will administer in the first few minutes of an arrest.

I think that it is safe to say that in most cases, if perfect BLS is performed in the first few minutes, and the patient is not resuscitated prior to departure from the scene, it is fairly likely the patient will not be resuscitated. This has been my own experience, and this is what recent literature suggests. In other words, the time factor of the medications is negligible (if we are talking about just a few minutes), if good BLS and early defibrillation will not bring them back, all the meds in the world probably won't either.

[medicmaster]

Well, I can thing of several situations where immediate ALS is benificial, arrests, near arrests, respiratory emergencies and trauma, which Peoria see's it fair share of. Actually, depending who you talk to, you don't even need ALS for trauma. You seem to have your idea's, and I have mine. I am absolutely certain that immediate ALS works, and have seen it do so many times, I know of people who are crawling and walking on this Earth because ALS care was there two minutes earlier than it would have been in Peoria. I know Fire based ALS works where I am, and I got a hunch it would work in Peoria.

I guess we will have to agree to disagree. I'm not necessarily against PFD upgrading to ALS first response, but it would be interesting to see if they did how much ALS treatment they would actually render before arrival of a transport unit.

However, unless someone can provide me with evidence that AMT provides subpar patient care, I will stand by my opinion that the fire department should not provide transport.

[drjohn]

Medicmaster,

I completely agree with your comments regarding cardiac arrest, early BLS, then ALS. The literature would substantiate it as well. But as you know, ALS has been shown to be helpful early on with chest pain (not cardiac arrest) and breathing difficulties (not cardiac arrest). The PFD responds to thousands of chest pains and breathing difficulties each year and cannot provide ALS which is proven in the literature to decrease morbidity and mortality. And the verdict is still out with trauma. But as a paramedic I would ask you the same question as before, "Given the choice, if you had penetrating or blunt trauma, would you hope that the paramedics/EMTs would load and go and secure your airway and access your vasculature during transport to the hospital where the surgical suite is going to really save your life? Or would you prefer to wait extra minutes before your thoracotomy or laparotomy was done. (Princess Dianna would probably have preferred the former.)

Last point, if the City Council in Peoria says the city does not have enough funds for transport by the PFD, what would be wrong with a dedicated SUV with a PFD paramedic on board to respond quickly and use ALS if needed, and wait for the private ambulance company to transport the patient? Isn't most money made in transport? AMT could still make the money and the patient would have rapid ALS as needed. Seems reasonable to me, but the PMD, OSF, PAEMSS, and the good ol' boys club need to advocate this approach or a similar approach, or Peoria will continue as is.

Dr. John

[medicmaster]

Medicmaster,

I completely agree with your comments regarding cardiac arrest, early BLS, then ALS. The literature would substantiate it as well. But as you know, ALS has been shown to be helpful early on with chest pain (not cardiac arrest) and breathing difficulties (not cardiac arrest). The PFD responds to thousands of chest pains and breathing difficulties each year and cannot provide ALS which is proven in the literature to decrease morbidity and mortality. And the verdict is still out with trauma. But as a paramedic I would ask you the same question as before, "Given the choice, if you had penetrating or blunt trauma, would you hope that the paramedics/EMTs would load and go and secure your airway and access your vasculature during transport to the hospital where the surgical suite is going to really save your life? Or would you prefer to wait extra minutes before your thoracotomy or laparotomy was done. (Princess Dianna would probably have preferred the former.)

Last point, if the City Council in Peoria says the city does not have enough funds for transport by the PFD, what would be wrong with a dedicated SUV with a PFD paramedic on board to respond quickly and use ALS if needed, and wait for the private ambulance company to transport the patient? Isn't most money made in transport? AMT could still make the money and the patient would have rapid ALS as needed. Seems reasonable to me, but the PMD, OSF, PAEMSS, and the good ol' boys club need to advocate this approach or a similar approach, or Peoria will continue as is.

Dr. John


I wouldn't be against PFD operating a paramedic fly car, if they went about it proactively. I mentioned that in a response to F18Wub above. Too often though, I have seen a number of fire departments who make the move into doing this and it makes the system worse in several cases;

1. Because arrival of the ALS engine/fly car is only a few minutes before arrival of the ambulance, these paramedics generally do not get to perform the skill intensive procedures (IVs, intubation...etc)

2. There are too many ALS providers on the scene and it would be akin to having 7 doctors and 1 nurse in the trauma bay at the ER.

3. The FD would need to do response time studies and determine, based upon where in the city there are greater variances between engine company arrival and EMS transport arrival, where they will base the paramedic responders at. It is not beneficial or cost effective to do this at every fire station in the city. (Look at Philadelphia as an example) If they really want to do this, they need to talk to fire departments who are doing this and find out what works best. Cedar Rapids and Davenport Iowa are cities of similar population to Peoria that provide ALS engine companies, but transport is handled by private ambulance companies. These systems work well, and perhaps they could talk to their leadership and find out what to do and what not to do.

Again, I would be in agreement with them running ALS engines, but only if the paramedics are willing to dedicate themselves to being good, high quality paramedics who happen to be part of the fire department, versus firefighters who just do EMS "because its required"...which is a prevalent theme in the American fire service.

High quality, competent fire based ALS Transport only seems to work in departments who have always operated the ambulance. Too often, I hear about departments who saw EMS as a bastard step child until they saw the income potential or it provided protection from jobs being cut, at which point they took it over and did a crappy job of providing service...as long as that is not the goal of the PFD, it could work.

[efd824]

Wub how the hell are ya? This situation has been on going for years over here, Politics run wild in this system and i must say that pt. care suffers because of it. I worked with Wub and while we had our problems he can atest that our situation just to the west was far better than crossing that county line. AMT in general is a good service, i know alot of the medics and that are just run in to the ground. They are trying to cover so much area and just don't have enough trucks to cover, I have a good friend on PFD and he has called East Peoria over to transport because AMT doesn't have any trucks avaliable, Engine 15 worked a code for 20 minutes once with no ALS trucks anywhere in the area. I have been a paramedic for 8 yrs. and in EMS for 11 and because of politics i can't run as such in the peoria system, because i won't take a basic meds class so they can teach me how to give asa, ntg, and proventil, if i don't know how to give it now i might as well start a paper route. I think the relationship between PFD and AMT has gotten better, but then again i don't work there. Our relationship with our FD's is most generally pretty good, both the paid FD's we work with are great, We have our share of egos and most of the time it is new medics trying to show everyone they are in charge, and just about everytime the bubble gets burst at one time or another, I wish our FD's were ALS, most of the medics that work for the FD's are part time medics for us anyway, and when we have something bad they are right in there starting a line or pushing a med while i tube or vise versa. And it works both ways, the guys know i am a vollie FD and i help them out at fires, had to catch a hydrant and throw a ladder the other day for Pat and Brian while they were making an attack, i trust them and they trust me. Peoria would truly benefit with ALS engine companies, will it ever happen? know one knows. Not to hijack the thread but Wub where are ya working these days up there? Stop in and see us sometime if your come back. I am wearing a red hat out here now.....scary isn't it :eek:

[F18Wub]

Chick,

Things are good up here. Still working in Barrington, making friends and influenencing people. Red hat huh, heard Pat got a white one. Congrats on that. I don't know when I will get down again, but I will try to look you up. What shift are you working on now?

[MIKEYLIKESIT]

When the hell are we going out drinking?

[efd824]

I am still on the red shift, being #7 on seniority is going to keep me right here, i am the only one left of the good ole RED crew, everyone has retired, Bybee runs Elmwood public works and i work my 2 days off down there for streets and water. Mikey we will get up there sometime, the mrs. is 6 months along and we will be having a boy in Nov. i can't wait because her being prego in this heat has her almost unbearable to be around, i love her to death, but at this point with the heat i would rather be fighting a dairy barn fire and arm wrestling a grizzly, its about like being home...lol..i hope she never scans this stuff or i will be living in my truck :eek:

[F18Wub]

Chick,

Congrats on the kid, don't feel any pressure to name him after me. I had heard about Bybee, how's Davey getting along? I haven't seen him in quite a while. Whats up with the system split in Galesburg. Seems strange to me, but I am only getting bits and pieces.

[1EMTtruth]

Unfortunately I see most of the people commenting on this forum are from areas outside Peoria. As a person living the the Peoria area, allow me to fill you in on some of the facts.
1) The Peoria Fire Department functions at the EMT-Basic level because that is all they have ever asked approval for. In fact, that is all the Peoria City Council wants them to be. If the Peoria City Council would allow the Peoria Fire Department to apply for an advanced level of service they could then work towards that level. The problem is that the City of Peoria doesn't want to fork out the money for training and equipment.
2) John Carroll's interest here is only to beat his drum to the tune of how OSF and AMT are in a conspiracy and have formed a mafia to control the level of care people receive. That is a lie. Here is the truth. John Carroll was fired from the ED at OSF. As a result he has made it his mission to try and discredit the people who fired him. His rantings and ravings in the paper and on this internet have no validity and are nothing more than sour grapes.
3) The tiered response system in Peoria is a model for the nation. It works. People here receive great pre-hospital care. From both the fire department and from AMT. We are lucky to have both.
4) The discussion regarding an average 2 minute difference in response time is ludicrous. Whoever gets there first will start CPR and use their AED or Defibrillator. You can't even get past your initial BLS care with AED in less than 2 minutes. Worrying about who is going to give lidocaine first is fanciful dribble. The patient doesn't need lidocaine, the patient needs shocked and both AMT and Peoria Fire can do this! Non-issue.
What is the issue is that the only discussion John Carroll ever has about response time is when AMT is there 2 minutes or more behind Peoria Fire. What about the times when AMT gets there first! Happens every day. It just depends on where people are stationed in the city and where the call is located. No more, no less. There have been instances where Peoria Fire has engine companies tied up at a working fire and they have been way behind in medical response time due to trucks having to travel from other parts of the city. Guess what, there is nothing wrong with that. That is why we have a tiered response system. Everyone is doing their job. The system works. But creating fantasies about a medical mafia and conspiracies sells more papers.

[MIKEYLIKESIT]

Congratulations on the baby ! ;)

[MIKEYLIKESIT]

Sometimes you do not have time to sit around waiting for an ambulance to show up. One of those cases would be a serious trauma. I dont know anything about Peoria but I will ALWAYS advocate fire-based EMS whenever practically possible.

[medicmaster]

Sometimes you do not have time to sit around waiting for an ambulance to show up.

This is true in some very rare cases, but turning the ambulance over to the fire department will not solve anything. I see from the department's website that they have 12 stations. It is not fiscally responsible to have every station staffed with an ambulance...this is the reason for tiered response! An engine company that is close responds first and provides initial care, the ambulance arrives soon after.


I will ALWAYS advocate fire-based EMS whenever practically possible.

I agree with you on this point...however, the key phrase here is "whenever practically possible."

[drjohn]

Unfortunately I see most of the people commenting on this forum are from areas outside Peoria. As a person living the the Peoria area, allow me to fill you in on some of the facts.
1) The Peoria Fire Department functions at the EMT-Basic level because that is all they have ever asked approval for. In fact, that is all the Peoria City Council wants them to be. If the Peoria City Council would allow the Peoria Fire Department to apply for an advanced level of service they could then work towards that level. The problem is that the City of Peoria doesn't want to fork out the money for training and equipment.
2) John Carroll's interest here is only to beat his drum to the tune of how OSF and AMT are in a conspiracy and have formed a mafia to control the level of care people receive. That is a lie. Here is the truth. John Carroll was fired from the ED at OSF. As a result he has made it his mission to try and discredit the people who fired him. His rantings and ravings in the paper and on this internet have no validity and are nothing more than sour grapes.
3) The tiered response system in Peoria is a model for the nation. It works. People here receive great pre-hospital care. From both the fire department and from AMT. We are lucky to have both.
4) The discussion regarding an average 2 minute difference in response time is ludicrous. Whoever gets there first will start CPR and use their AED or Defibrillator. You can't even get past your initial BLS care with AED in less than 2 minutes. Worrying about who is going to give lidocaine first is fanciful dribble. The patient doesn't need lidocaine, the patient needs shocked and both AMT and Peoria Fire can do this! Non-issue.
What is the issue is that the only discussion John Carroll ever has about response time is when AMT is there 2 minutes or more behind Peoria Fire. What about the times when AMT gets there first! Happens every day. It just depends on where people are stationed in the city and where the call is located. No more, no less. There have been instances where Peoria Fire has engine companies tied up at a working fire and they have been way behind in medical response time due to trucks having to travel from other parts of the city. Guess what, there is nothing wrong with that. That is why we have a tiered response system. Everyone is doing their job. The system works. But creating fantasies about a medical mafia and conspiracies sells more papers.

Dear 1EMTtruth,

I read your post with amazement. The idea behind a forum such as this is to provide statewide and national dialogue. Your deliberate spin and incestuous ideas are exposed to everyone with a forum such as this. Peoria's EMS system is also being exposed much to your dislike.

Whenever the PFD attempts to talk about advancing their services, consulting firms are hired. As I am sure you are aware, the last consulting firm several years ago, for which the City of Peoria paid $79,000, had connections with AMT. Surprise, surprise. Where was the Project Medical Director the last 15 years pushing the Peoria City Council to make sure that the PFD provide the best service possible and providing mechanisms where the PFD paramedics can act as paramedics? For example, there are municipal fire departments across the nation that allow their paramedics to act as paramedics even though their department is not considered paramedic. Where was the Peoria PMD when the PFD was not even allowed to give an aspirin for chest pain in the field until several years ago? Have you ever heard of laryngeal mask airways? The PFD has not. Basic fire departments can be taught the use of these airways. Why wasn’t the PFD?

When the PFD bought their one and only ambulance several years ago and was not allowed to stock it or use it as a transport vehicle, do you think they didn’t ask the PMD to allow this? Since the PMD did not allow them to utilize this good vehicle like it should have been used for Peorians, they sold it for a loss. (I actually publicly stated that I would buy the ambulance from the PFD and donate it back to them, if OSF and the PMD would be forthcoming with pre-hospital statistics and allow the vehicle to be used for the citizens of Peoria in emergencies. Seemed like a no brainier to me. Needless to say, they ignored my offer.) AMT was allowed to continue as the only transport and paramedic agency in town. Do you think the tearful PFD/paramedic that was not allowed to intubate a patient who had been in full arrest and then died was happy with the PMD in Peoria? Do you think the patient’s family was happy with the EMS system in Peoria? When the executive director of AMT and the Project Medical Director at OSF advise the Peoria City Council, do you think they are advising them that the PFD should increase their services for the general public or do you think they are protecting the interests of AMT and OSF? Come on 1EMT, we all know the answer. Why do administrators from OSF attend Peoria City Council meetings when EMS issues are discussed? Do they have nothing else to do on Tuesday nights? Do these administrators have a burning interest in coronary artery perfusion pressures or are their interests elsewhere?

Your point number two is quite pathetic. You seem to be seething with anger…but maybe you should be, because you may have a lot to lose if Peoria got into the EMS business. I give a full description of my firing from OSF at www.peoriasmedicalmafia.com. If you really step out of the box in Peoria with your thinking, bad things can happen to you. People like you can gang up on people like me. Challenging OSF and then subsequently being fired by them was one of the best things I have ever done. I think if my “rantings and ravings” didn’t have validity, you wouldn’t have wasted our time with your post.

Do you think that the fact that the PMD was paid by both AMT and OSF was more than just coincidence? OSF’s CFO Sue Wozniak even told me that it was a relationship to step away from and she sits on the AMT Board of Directors! Do you think that the lawyer for PAEMSS and OSF (and a few years ago, for AMT) is the same person is just a coincidence too? Do you think that the PAEMSS statement that Dr. George Hevesy, the PMD referred to above, that there was not even “the potential for conflict of interest” (that Hevesy was receiving a salary from AMT) was in any way misleading? What do you think about Hevesy’s and IDPH’s relationship? Don’t tell me you know nothing of it. Come on, 1EMT, who is misleading whom?

Your point number three about Peoria’s “tiered response being a model for the nation” is a yawner. You are just repeating OSF’s and AMT’s local banter. On your next post you should use “duplication of services”…that seems to be another phrase used here in Peoria to support AMT and OSF. Please post all the statistics you have to conclude that “people here (Peoria) receive great pre-hospital care”. We will all be anxiously waiting.

Contrary to what you say in point number four, minutes can make a difference if you need ALS. The median response time for life threatening emergencies is two minutes faster for the PFD than for AMT. Also, you are the one talking about lidocaine, not me. If you read the literature, and as I have expressed above, rapid ALS has been proven to help save lives with breathing problems and chest pain. Why are you writing about lidocaine? That’s used for ventricular tachycardia and fibrillation, isn’t it? Please don’t try and confuse the subject. So early effective ALS CAN be an issue. If it were you, 1 EMT, what would you want: earlier or later intervention?

Also, electrical defibrillation was used in the 50’s in Ireland for the pre-hospital patient. In 1992, the AHA stated that all basic units should be electrically defibrillating people. So where was Peoria? The PFD wasn’t shocking people for years later even though AMT was? Why? Who was advising the Peoria City Council on this life saving technique? Do you think that Peoria’s PMD was aggressive enough pushing this issue with the PFD? Did Peoria’s PMD say to the Peoria City Council and the PFD, “You need to purchase AED’s and take thirty minutes to learn how to use them? And if you don’t get AED’s, I’m going public and tell everyone why Peoria needs AED’s”.

1 EMTtruth, you need to change your moniker to “1EMTspinmeister” or something equivalent. Better yet, why don’t you tell us who you really are? Don’t be afraid, because you believe that the mafia stuff is all just “dribble”. (I would like to take the credit for the word “mafia”, but a well known Peoria physician used that word to describe the situation to me.) This is America where you can speak out and not have to stand behind some silly cyberspace name. I bet if you told us who you really are, we would understand your anger and spin much better and realize why your allegiance and irresponsible defense of AMT and OSF is so dogmatic.

Sincerely,

John Carroll, MD
drjohn@mtco.com

[ChiefReason]

And come to think of it, didn't OSF just purchase the helicopters lock, stock and barrel? Two of them.
Geez; even in a little town like Galesburg, the firefighters are paramedics who can do paramedic level delivery of care. GHAS doesn't seem to mind.
You don't suppose this has anything to do with money, do you?
I work in Peoria, where I have seen first hand AMT and PFD responses to emergencies.
What I really wonder is: how does OSF have a lock on pre-hospital care with Methodist and Proctor hospitals fighting for dollars?
And for clarity's sake, OSF is NOT entirely non-profit. They have a for-profit charter as well.
This is some good stuff.
CR

[drjohn]

ChiefReason, you are hitting it all on the head.

JC

[climb2hi]

Dr. Carroll’s argument seems incredibly logical to me. Whoever gets to the scene first should be able to use all of their training to help the victim, whether that happens to be AMT or the fire department. It makes no sense for the firefighters to be restricted from using their skills. If the firefighters are trained in ALS, they should be able to use their training to help the patient. Since a majority of the time the fire department arrives at the scene faster than AMT, according to the Matrix report, the most logical and best thing for the patient would be for the firefighters to begin ALS to save the person’s life. The firefighters shouldn’t have to watch someone die when they could be performing ALS.

[medicmaster]

And come to think of it, didn't OSF just purchase the helicopters lock, stock and barrel? Two of them.
Geez; even in a little town like Galesburg, the firefighters are paramedics who can do paramedic level delivery of care. GHAS doesn't seem to mind.
You don't suppose this has anything to do with money, do you?
I work in Peoria, where I have seen first hand AMT and PFD responses to emergencies.
What I really wonder is: how does OSF have a lock on pre-hospital care with Methodist and Proctor hospitals fighting for dollars?
And for clarity's sake, OSF is NOT entirely non-profit. They have a for-profit charter as well.
This is some good stuff.
CR

I wondered when you would bring the "voice of reason" to this thread...being as it is YOUR neck of the woods! :D