Emergency Medical Services
in the
United States of America
An Australian Perspective
May 2014
Hi, welcome to my first blog - and hopefully, the first of many!
My name's Levi and I recently completed my Bachelor of Paramedics at Flinders University in South Australia. My studies concluded at the end of 2013, and in May of 2014 I visited the United States where I was fortunate enough to have been able to undertake clinical placement with two ambulance providers. These providers were Longwood Fire Company (Pennsylvania) and the Fire Department of New York. I decided to write this blog to detail my experience and to give my friends back home a picture of how ambulance care is provided in America and how it contrasts from Australia.
I'll break this blog into I suppose three sections. We'll begin with an overview of the service model, then I'll discuss my experience at the two services. I'll also share some photos intermittently to break up my rambling. Here's one of the engine bay at Longwood Fire Co in Pennsylvania.
Hi, welcome to my first blog - and hopefully, the first of many!
My name's Levi and I recently completed my Bachelor of Paramedics at Flinders University in South Australia. My studies concluded at the end of 2013, and in May of 2014 I visited the United States where I was fortunate enough to have been able to undertake clinical placement with two ambulance providers. These providers were Longwood Fire Company (Pennsylvania) and the Fire Department of New York. I decided to write this blog to detail my experience and to give my friends back home a picture of how ambulance care is provided in America and how it contrasts from Australia.
I'll break this blog into I suppose three sections. We'll begin with an overview of the service model, then I'll discuss my experience at the two services. I'll also share some photos intermittently to break up my rambling. Here's one of the engine bay at Longwood Fire Co in Pennsylvania.
I expect the majority who read this blog will be Australians, so bear with me if you're not Aussie as I take a moment to explain some of the unique components of the American ambulance service to those back home. These components contrast somewhat between the American EMS model, and the Australian model. "EMS" of course being the acronym for Emergency Medical Services (we don't often use this acronym in Australia).
Structurally, the provision of emergency ambulances to American citizens within each state is provided by a number of services, rather than just by a single state service as occurs in Australia (ie SA Ambulance, Ambulance Victoria, Queensland Ambulance are the sole providers of emergency ambulance in their respective states within Australia). The American states on the other hand have privatised their provision of emergency ambulance care, and this has has lead to a three-pronged model of service delivery which includes a state service, regional county based services (the word 'county' correlates to what Australians know as councils. ie imagine a Salsibury Fire Department or a Yarra Fire Department), and also private providers (not unlike the privatisation of non-emergency ambulance care in some Australian states). There are also hospital-based ambulances, however I am under the impression that they only provide hospital transfers.
So, in the case of a 911 call, a dispatcher responds the ambulance most suitable to the location of the call given consideration to distance and jurisdiction. Therefore it may be that the ambulance which attends is not actually the closest to the incident, say for instance if the caller's location is outside of any county jurisdiction, then it falls within the jurisdiction of the state service - which may need to bypass counties to respond!
Another point of interest is that, similar to Australian paramedics, American paramedics also lack any form of national registration and consequently each paramedic works under the clinical authority (and protocols) devised by their service's own Medical Director/s. This is not unfamiliar to Australian paramedics, whose state services have a board of directors which provide ATP (authority to practice) and clinical guidelines. So the Medical Director is responsible for everything from deciding which drugs stocked are stocked, to accepting infield consultations etc. So while I've just stated that this model of governance compares similarly with Australia, I do need to emphasise the point that given the huge number of ambulance providers in each American state, each working under different directors, American citizens can expect significant differences in the care provided to them depending on their location within the state. As you would expect, each service also markets itself with different uniforms/service badges. I wish I'd thought to take a photo to exemplify this point, but try imagine arriving in a chaotic city hospital ED and seeing a rainbow of different coloured ambulance uniforms - and then remember that each crew is working under a different system of governance.
This photo was taken outside the Alfred DuPont Hospital (children's hospital) in Pennsylvania. You might have already noticed from this photo - and those above -that the American ambulance is almost square-shaped compared to the Australian ambulance. A little further on I discuss the vehicles in more detail.
So, in the case of a 911 call, a dispatcher responds the ambulance most suitable to the location of the call given consideration to distance and jurisdiction. Therefore it may be that the ambulance which attends is not actually the closest to the incident, say for instance if the caller's location is outside of any county jurisdiction, then it falls within the jurisdiction of the state service - which may need to bypass counties to respond!
Another point of interest is that, similar to Australian paramedics, American paramedics also lack any form of national registration and consequently each paramedic works under the clinical authority (and protocols) devised by their service's own Medical Director/s. This is not unfamiliar to Australian paramedics, whose state services have a board of directors which provide ATP (authority to practice) and clinical guidelines. So the Medical Director is responsible for everything from deciding which drugs stocked are stocked, to accepting infield consultations etc. So while I've just stated that this model of governance compares similarly with Australia, I do need to emphasise the point that given the huge number of ambulance providers in each American state, each working under different directors, American citizens can expect significant differences in the care provided to them depending on their location within the state. As you would expect, each service also markets itself with different uniforms/service badges. I wish I'd thought to take a photo to exemplify this point, but try imagine arriving in a chaotic city hospital ED and seeing a rainbow of different coloured ambulance uniforms - and then remember that each crew is working under a different system of governance.
This photo was taken outside the Alfred DuPont Hospital (children's hospital) in Pennsylvania. You might have already noticed from this photo - and those above -that the American ambulance is almost square-shaped compared to the Australian ambulance. A little further on I discuss the vehicles in more detail.
Another significant difference between Australian and American ambulance provision is that in America, ambulance exists under the banner of 'Fire & Rescue'.
State services like FDNY (responsible for both fire and ambulance response as I've just explained) maintain separate ambulance and fire stations, however your typical county-based services run amalgamated stations - with ambulance and fire appliances running from under the same roof.
Which leads nicely into a point I'll make about the fire services themselves: as occurs in some Australian states, fire fighters in America are heavily involved in medical response. They respond to a majority of 911 medical calls , providing BLS (basic life support) backup or else simply first response to incidents.
State services like FDNY (responsible for both fire and ambulance response as I've just explained) maintain separate ambulance and fire stations, however your typical county-based services run amalgamated stations - with ambulance and fire appliances running from under the same roof.
Which leads nicely into a point I'll make about the fire services themselves: as occurs in some Australian states, fire fighters in America are heavily involved in medical response. They respond to a majority of 911 medical calls , providing BLS (basic life support) backup or else simply first response to incidents.
Now earlier in this blog I referred to Medical Directors. Medical Directors or 'MDs' is not a term used in Australia, but certainly not unfamiliar to us given what we see on TV. MDs are American doctors (physicians), and as I mentioned, each EMS service is overseen by an MD (or a panel of MDs). The reason I'm explaining this is that my excursion to Pennsylvania was actually thanks to Dr David Neubert, the MD of Longwood Fire Company. Dave is an emergency department physician in Philly who leads a busy life. Additionally to his role as a full-time ED doc AND the MD for Longwood, Dave also directs an extensive list of other fire companies. One of the small perks of taking on the director position of a fire company is qualifying for emergency beacons on your personal vehicle (the picture to the right is Dave's Porsche). There's actually a story to why I took this photo. Dave was driving me out to Longwood Fire Company and we encountered some significant flooding. The flood water was actually overflow from a river which should have existed 300 metres off in the distance! Pennsylvania was experiencing some rare weather extremes during my stay, and caused us to take a number of long detours.
Now you would think Dave would have his hands full from what I've told you about him already, right? Full-time ED physician and the MD of various fire companies?Yet Dave is also founder of a company called Tac-Med LLC. If you don't already follow Tac-Med LLC on Facebook, minimize this window right now, open up Facebook and follow this page. Dave and his colleagues often write up and share interactive clinical case-studies through this page and these will boggle your mind. Tac-Med LLC itself is a unique company which provides tactical medicine training courses for Fire & EMS services, incorporating training in everything from trauma and disaster medicine, to law enforcement. What's more, the company brags a really cool car (above). If you didn't watch TV as a kid and you don't recognise this, this is an retired highway patrol car complete with operational lights and sirens!
Longwood Fire Company
The flooding delays meant I only arrived at Longwood Fire Company in time to enjoy 36 hours of 'on call' at the station.
Longwood runs three
ambulance fleets, a sprint car, and a multitude of fire appliances (their website has descriptions of their current apparatus)
Here's a photo of their primary response vehicles (below).
Take a moment to compare the size of their ambulance fleets either side of their sprint car. They're huge, right?
Any guesses how many paramedics you could seat around the patient? Seven! Comfortably and safely seated. This next photo of the interior shows black-padded benches either side of the stretcher. Each bench seats three persons each (plus the airway seat, making seven seats).
Note the electronic stretcher? The service I volunteer for in Australia uses manual lift stretchers, and they really don't compare next to these beauties!
Equipment-wise, the ambulance fleets at Longwood are stocked at an IC (intensive care) level. Some nifty additions carried by Longwood include environmental CO detectors, haemorrhage tourniquets and venepuncture equipment (for prehospital blood draws). Pharmacology-wise I was impressed to see kits stocked with a range of drugs including beta blockers, dopamine and electrolytes (sodium, chloride and potassium).
A quick tour later I was given a Longwood uniform and pager and I joined the other paramedics in the recliners!
This is one of their "MICU" pagers - Mobile Intensive Care Unit
Page alerts are different to what I was used to back home. Dispatch is made verbally rather than by text. The pager is essentially a one way radio in effect. The dispatcher reads out (and repeats) the address of the incident and the major complaint of the patient. The information is then printed on paper from a fax machine at the station as well as displayed on a data terminal in the ambulance.
Now I had been told that Longwood had a rescue boat, and that with the current flooding, the company had been called out more than 10 times in the previous 24 hrs requiring their rescue boat. But disappointingly (for me) I didn't get to see the rescue boat in action during my stay, but here's a photo for your enjoyment.In fact the only good thing to come out of the flooding was this ironic photo of a sign intended to warn commuters of flooding!
My first job at Longwood was a suspected stroke at a nursing home. Sure enough, the patient presented with hemiparesis and AMS (altered mental status) and was managed without delay.
There wasn't a lot to describe in the second job. A young man with persistent nausea & vomiting declined our offer of transport. His horses however were mesmerised by the ambulances and made departure a little challenging!
Things got a little tense when the call came in for a 2 year old with central cyanosis (unspecified aetiology). Thankfully a quick assessment yielded no airway obstruction/oedema, and she was managed with supplemental oxygen and diesel therapy.Our next job took us to the local prison. I have personal views on the penitentiary system which place me quite strongly opposed to the design of the prison model (in Australia and America). I won't belabour the point aside from to say that the experience of being lead through this prison, with its thick metal doors and patrolled by many armed guards made me feel uncomfortable. Our patient had fallen down some stairs and had a severe laceration to the occipital region. My crew treated under suspicion of spinal injury, dressed the head wound and transported to hospital (with a prion guard escort in the ambulance, and another following behind). Our patient was handcuffed and appeared quite disorientated during the journey. At one point he began spontaneously vomiting and I later found out he was diagnosed with a subdural haematoma.
I had an excellent experience at Longwood. The crews were warm, friendly and professional. Thanks to their company directory, Scott (pictured below) for hosting me, and a big thanks to Dave setting up the experience and showing me Philadelphia on his days off!
Fire Department New York
Next stop was New York, and
Manhattan was just like the movies. Fast, busy and full of culture.
The FDNY is no exception.
I elected to have my shifts at Midtown (close to Times Square) and at Harlem, which is referred to (not by me!) as "the ghetto". While I met my crews at these stations, the stations are essentially just garages and crews do not respond from these locations. Instead they clock-on, ensure their ambulances are stocked, and then drive out to pre-allocated stand-by points within the city and wait to be dispatched. No recliners, TV or computer for the FDNY medics!
My first job was a standby at a 7 eleven fire. Nothing much to report on although I found it interesting that FDNY paramedics on standby at a fire are required to don fire fighting PBI gold (the same protective clothing worn by those fighting the fire). The medics I was paired with displayed annoyance at having to stand in the sun wearing overalls and a helmet, and I soon learned that this probably had less to do with the heat and more to do with being referred to as "fire fighters" by passers by! Apparently professional pride is strongly echoed by our American colleagues. Interestingly, having a flick through their service protocols, it seemed that if we had of received a CO asphyxiation patient, FDNY carry a drug helps discourages the CO-haemoglobin affinity. The drug, which I'm not familiar with, is apparently very costly. This drug has since been described by a reader - see the 'comments' section for moreSadly a number of my cases in NY were alcohol and drug-related. One of my first patients was a homeless man who was a frequent-flier to my crew due to his many alcohol-related incidents. The gentleman himself was generally quite pleasant to attend but would become agitated with little excuse.
We later attended an anaphylactic patient where the suspect culprit was thought to be nut remnants on our young patient's deli salad. By the time we arrived at her, she had significant facial oedema and systemic hives. While she was aware of her allergy, she'd never been prescribed an epipen. She got a quick dose of adrenaline ("epinephrine" as it's known in America!) from my crew, accompanied by some steroids.
NY also provided my first exposure to the trending recreational drug PCP (Phencyclidine) which is known on the streets as "angel dust". The drug is actually a retired general anaesthetic that is now used as an elephant tranquilizer! The reason it is no longer used on humans is because of its dissociative effects. Unsurprisingly this patient was difficult to attend to. He didn't seem to be aware of time, person or place. The call of the week went to a mid 30yo tradie who we picked up from his work site after an episode of witnessed syncope. The patient appeared to have vomited prior to our arrival and was amnesic to the events after his collapse. He was given a GCS of 13 (3, 4, 6) however as we were loading him into the ambulance, he became suddenly orientated and opened his eyes.
Language barriers made it hard to establish a history but we were able to determine that he had suffered a recent MI.
His ECG (abbreviated in America to "EKG") was also interesting.
By lucky coincidence, an EMT who backed us up on this job spoke Spanish which helped us immensely as our patient only spoke Portuguese. Thankfully our patient remained stable throughout our care.
On my final night-shift I wrapped up my placement with perhaps the ideal job to finish on. We were called to a 3yo who had reportedly swallowed Mum's pearl earring. You could actually see the earing it in the back of her throat but it wasn't causing her any respiratory distress, and we kept a careful eye on her as we transported her to hospital. The reason I loved finishing on this case is that this young girl was absolutely adorable, and during the trip I was seated opposite her. As the attending paramedic was interviewing her mother, I poked my tongue out at the young girl.
It was the catalyst she had been waiting for, - particularly given how tense the environment had been since our initial arrival. From that moment on, she became a frenzy of tongue-poking and raspberry-blowing. This adorable girl later asked us for hugs, and became distraught when she lost sight of us at the hospital.
After a night of alcohol and drug related cases, it was really pleasant to have attended her, and a reminder of the aspects of this job which I love. Thanks to the welcoming crews who had to put up with me during my shifts! If anyone is interested in undertaking placement with FDNY, feel free to get in contact
To wrap up this blog, the original intent of my trip to the States was my brother's wedding in Kansas, and the third & final stop on my trip. Congratulations Jake, and welcome to the family, Krystal!
Thanks for reading! Please feel free to get in touch- or view my other blogs below:
EMS in Japan - An Australian Perspective (April 2016)
EMS in Europe - An Australian Perspective (September 2016)
EMS in New Zealand - An Australian Perspective (Coming - November 2016)
