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The Good and the Bad – Continuing Day 2

I left off soon after our first job on the car which had me wanting to see the versatility of Swalwell 405, our Rapid Response Car.   I was beginning to wonder if I had built it up into more than it was when the universe stepped in and answered my questions, as always.

A school child was ill with a unique condition that was familiar to the child’s brother at the school as well as the mother who had arrived on the scene before us in the car.   When Mark had determined the non-emergent condition of the 10-18 year old (not a little one is the point) the ambulance was canceled.   There it was, the front loaded model in action.   A trained set of eyes able to determine no need for a two person gurney transport, so the unit is canceled ASAP.   Should transport be needed or requested (which it never was, save once over there) the patient was appropriate to sit in a car, seat belted, and driven to the A&E or clinic.

Through the course of the evaluation Mark and I both asked a variety of questions trying to get to the center of what the unique condition was doing to our patient.   In the end, Mom decided she would follow up with their Doctor later that day and she will let the child rest at home, something that usually helps when the child feels this way.   Mark offered to follow Mom back to their house just 5 minutes away just in case something happened.   Not sure exactly what that might be I was even more excited when he said, “Or I can just take her in the car and follow you home.   Would that make you feel better?”

The mother smiled, blushed and sighed. “Would you?”   Mark smiled and assured her it was no problem at all and we escorted our patient to the car and drove her home.   There was never a point where this patient needed a hospital, let alone an ambulance based on the mother’s description of the unique condition and other factors revealed at the scene.   In San Francisco I would have had to transport the child or send them home with Mom.   In my experience both parents are often working and unavailable to respond to the school, and that’s IF they even answer the phone number given on the emergency contact card.

5 minutes and a car made a huge difference for resources in the area.   I was sold on it right there and then and a number of other calls re-enforced the benefits of the RRC.   The old man with the hurt wrist who we gave a ride to the clinic, leaving the ambulance available.   The baby with a cough who we gave a ride, strapped in her seat with Mom along for the ride.   None of them needed an ambulance but had no other way of getting evaluated for their chief complaint.   In San Francisco a 4 person ALS engine and 2 person ALS ambulance, 6 people and$600,000 worth of apparatus to do the job of 1 man and a ford station wagon.   It was reading through the real estate section looking for a house to buy that a call came in that would change my mind about the current NEAS system.   A certain resource issue that is.

This is the section Mark has been waiting for.   All through our experiences he has been wondering what my real opinions were/are/will be and I kept telling him, “I already told you.”   But I have to share with all of you or else this is all for nothing, right?

The ambulances currently used by the NEAS are inefficient when it comes to treating a patient enroute or dealing with more than 1 patient.   I use the term carefully since when a rider is placed in Mark’s ambulance and a patient is in the cot, half of his kit is inaccessible.   The large gurneys load into the open space in the rear of the ambulance and latch into a sliding platform that can move the gurney from the wall to the center of the floor for the simple reason of accessing the patient’s left side.   This removes space for a bench seat and moves the patient a good deal away from a practitioner in the back.   I had difficulty imagining Mark working a proper patient, rolling blues to the hospital and being able to access anything quickly and safely.   This photo is from Swalwell Vehicle 214, which we worked on later in the week, but show the head of the cot and the fold down seat for a family member or rider.   the cabinets slide out of the wall so when they are closed they are secure and not accessible.   More on that when I discuss working in these Vehicles.

That being said, I did like being able to almost stand up completely and have all the light and vent controls in an overhead consul instead of buried back in the corner near the shelf near the captain’s chair like in many type IIIs here in the US.

Working a motor vehicle collision with more than one patient opened my eyes to the benefit of multiple hands on the scene.   We arrived soon after the police and began assessment.   An ambulance had already been dispatched and when they arrived I had my first glance into one.   Whoa.

The crew opened the doors and a large lift was raised and the gurney loaded onto it.   Then it was lowered to the ground and removed to our location.   In all less than 2 minutes, but still seemed like a long time.   I’m an immediate satisfaction type of guy.

When the first patient had been boarded and was being loaded I saw Mark reach to his radio and request another ambulance.   I stopped, looked around the crew loading the first patient in and that is when I saw there is no bench.   No place to put a second patient on a board.   Neither of the patients needed critical care interventions, just C-spine precaution, routine medical care and assessment, something I’ve done to 2 LSB folks often.

It was an awkward wait in the middle of the highway for that second ambulance.   During that wait, on the other side of the highway went a fire engine.   In service, staffed, yet not dispatched to the motor vehicle accident on the highway.   The first emotion was confusion as in, “Why can’t they respond to assist?” which gave way to frustration, “Lazy brigade won’t even hang a u-turn and check on us?” then reality sank in, “They couldn’t help right now if they wanted to.”   No fluid leaks, no fire hazard, the road was already safely blocked by the highway department and all we needed was a place to put a patient on a backboard.

My plans to move over were put on hold.   For all the benefits there were indeed drawbacks.   Of course there would be.   But so far, the only thing missing was that ability to take a second backboarded patient and have access to all the equipment in case of a proper patient.   Especially since Mark spoke of having to do CPR and push drugs alone in some cases.

But what is the answer?   The NEAS used a Chevy type III years ago and it didn’t work out.   From what I’ve been told I think it was a combination of politics and underpowered motors, not necessarily the patient care compartment.   That conclusion is drawn from a number of conversations with a number of NEAS folks.

It was made clear to me when I brought up my observations to Mark that the governing bodies mandate the secured nature of all the equipment in the ambulance and that repositioning it would not only take a completely new vehicle, but changes in rules and regulations country wide.   So the work is cut out there. However, to be fair, Mark took one look into the back of medic 99 and nearly passed out.   Nothing secured, supplies behind flimsy plastic doors, no cot lift, it was a recipe for injury in his mind and the mind of his regulators.

Is there a middle ground?   Wheeled Coach, Medstar, there are so many different manufacturers just here in the US, what are they using as the basis for their designs?   And what about Mark’s ambulance manufacturer?   Are they deciding what is best for us or are we?   I have yet to work in an ambulance where I thought to myself, “This is perfect!”

See Mark, all things I told you when I was there.   We even discussed it in a video report later in the trip.

A few more jobs and we were back to the station for end of shift.

The spot on swooning British nurse impression Mark does was not actually spoken, but he was told repeatedly that I looked “nice” in my station uniform.   Funniest thing was, I was cold and wearing my coat most of the time and he had me remove it before going in.   I think he’s angling for a different style of uniform.

The end of my first day on the RRC brought smiles from me and from Mark and a look forward to another wonderful evening with my extended UK family.   Tea with Margaret, Sandra and the Boys was my family time.   Had I had the time to bring Mark the hour home with me each night here in SF, I think he would have had a much better experience and I now regret not being able to share that time with him.

Back to the hotel and a warm shower and inviting bed.   Tomorrow would be another big day on the car and an afternoon of local heritage, discussing Event EMS and an explanation of this photo:

Steph Frolin? Is that you?

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0 Comments

  1. Tim January 8, 2010 5:06 am

    I understand the whole immediate satisfaction thing, but I see the benefits of a tail-lift in the ambo. Even with a power gurney made for bariatrics, there’s still a lot of potential for injury.

    • the Happy Medic January 8, 2010 5:52 am

      Tim, the less we use our backs the more at risk for injury we are. Our guys spend plenty of time lifting and carrying without major injuries. I see the inconvenience of it breaking down as more of an issue than a well conditioned work force. We are taught to “lift with our legs” so our backs never develop. We should “lift with our core” to stay healthy. But i am still an immediate satisfaction kind of guy.
      And one quick thing, is there really a benefit to holding a cot as a motor pulls the trolly up? Can’t my partner do that quicker or, like ours, it collapses in on itself?

  2. tim January 8, 2010 1:06 am

    I understand the whole immediate satisfaction thing, but I see the benefits of a tail-lift in the ambo. Even with a power gurney made for bariatrics, there's still a lot of potential for injury.

  3. Tim January 8, 2010 6:24 am

    Touche. But I highly doubt the fire service will embrace pilates. 🙂

    • the Happy Medic January 8, 2010 4:42 pm

      But we aren’t throwing our backs out loading gurneys because we lift them all the time. We have problems carrying people down the stairs when they reach out and grab something, twisting the chair and our knees. We get hurt doing that more than anything else. Introducing a motor or device that can fail when man power can perform the same task seems silly to me. the lifts may help “reduce” injuries, but each time the lift or motor fails, that is an “injury” and the unit is out of service.
      This is the same reasoning I have behind electronically controlled fire pumps on the engines. Don’t take me out of the loop and leave me powerless to correct when the machine fails.
      Thanks for reading and even more for commenting. What does your ultimate ambulance have in it Tim?

  4. the Happy Medic January 8, 2010 1:52 am

    Tim, the less we use our backs the more at risk for injury we are. Our guys spend plenty of time lifting and carrying without major injuries. I see the inconvenience of it breaking down as more of an issue than a well conditioned work force. We are taught to “lift with our legs” so our backs never develop. We should “lift with our core” to stay healthy. But i am still an immediate satisfaction kind of guy.
    And one quick thing, is there really a benefit to holding a cot as a motor pulls the trolly up? Can't my partner do that quicker or, like ours, it collapses in on itself?

  5. tim January 8, 2010 2:24 am

    Touche. But I highly doubt the fire service will embrace pilates. 🙂

  6. dcimedic January 8, 2010 5:38 am

    I second the lift being a hassle. The bench seat as far as I'm concerned can take a long walk off of a short pier. Having suffered through 2 ambulance accidents, one in which I caught my partner with my face after he was thrown from said bench seat. The other accident I was being a good little medic and actually had my seat belt on while sitting on the bench. We were T boned on the bench seat side and without a shoulder belt I was folded in half by the impact and hit my head on the side rail of the litter. I'm not sure if being thrown against the cabinets would have been a better option though. Now having said that some way must exist to have both no bench seat and carry 2 patients at the same time, if we can go to the moon this should not be a big deal.

  7. Anonymous January 8, 2010 1:38 pm

    I second the lift being a hassle. The bench seat as far as I’m concerned can take a long walk off of a short pier. Having suffered through 2 ambulance accidents, one in which I caught my partner with my face after he was thrown from said bench seat. The other accident I was being a good little medic and actually had my seat belt on while sitting on the bench. We were T boned on the bench seat side and without a shoulder belt I was folded in half by the impact and hit my head on the side rail of the litter. I’m not sure if being thrown against the cabinets would have been a better option though. Now having said that some way must exist to have both no bench seat and carry 2 patients at the same time, if we can go to the moon this should not be a big deal.

    • the Happy Medic January 8, 2010 4:38 pm

      If no bench seat, where would you have been sitting when the accident happened? A three point harness is nice, but does not allow you to tend to the patient. We have a tough spot in having to be free to move, yet be stationary and secured to be “safe.” I have been contacted by 2 ambulance manufacturers about this post asking me what a solution is. I plan to tell them, as soon as i find it. unfortunately, since accidents is the number 1 killer of EMS providers, we need to slow down and be better drivers, especially when using the lights and sirens. until that day, perhaps a complete redesign of the patient compartment is needed. I smell a post coming on.

      • Anonymous January 8, 2010 6:40 pm

        “A three point harness is nice, but does not allow you to tend to the patient.”

        I’ve seen at least one ad from a major manufacturer showing two providers in 3-point harnesses close enough to do anything they need to the patient. A critical care truck near me as a picture of Nadine Levick in their airway seat, secured in a FIVE-point harness, managing their training mannequin’s airway. (They’ve also got 4 other seats in the back with identical harnesses.)

        If it’s two patients you’re worried about, there’s at least one ambulance in NJ I know of that can hold two patients on two stretchers, and neither stretcher needs to be removed to get to the other one.

        It IS possible.

  8. dcimedic January 8, 2010 9:38 am

    I second the lift being a hassle. The bench seat as far as I'm concerned can take a long walk off of a short pier. Having suffered through 2 ambulance accidents, one in which I caught my partner with my face after he was thrown from said bench seat. The other accident I was being a good little medic and actually had my seat belt on while sitting on the bench. We were T boned on the bench seat side and without a shoulder belt I was folded in half by the impact and hit my head on the side rail of the litter. I'm not sure if being thrown against the cabinets would have been a better option though. Now having said that some way must exist to have both no bench seat and carry 2 patients at the same time, if we can go to the moon this should not be a big deal.

  9. the Happy Medic January 8, 2010 12:38 pm

    If no bench seat, where would you have been sitting when the accident happened? A three point harness is nice, but does not allow you to tend to the patient. We have a tough spot in having to be free to move, yet be stationary and secured to be “safe.” I have been contacted by 2 ambulance manufacturers about this post asking me what a solution is. I plan to tell them, as soon as i find it. unfortunately, since accidents is the number 1 killer of EMS providers, we need to slow down and be better drivers, especially when using the lights and sirens. until that day, perhaps a complete redesign of the patient compartment is needed. I smell a post coming on.

  10. the Happy Medic January 8, 2010 12:42 pm

    But we aren't throwing our backs out loading gurneys because we lift them all the time. We have problems carrying people down the stairs when they reach out and grab something, twisting the chair and our knees. We get hurt doing that more than anything else. Introducing a motor or device that can fail when man power can perform the same task seems silly to me. the lifts may help “reduce” injuries, but each time the lift or motor fails, that is an “injury” and the unit is out of service.
    This is the same reasoning I have behind electronically controlled fire pumps on the engines. Don't take me out of the loop and leave me powerless to correct when the machine fails.
    Thanks for reading and even more for commenting. What does your ultimate ambulance have in it Tim?

  11. Anonymous January 8, 2010 7:31 pm

    Currently I am a flight medic on a both a EC 135 and a BK117. I do the vast majority of my treatment secured in my seat with a shoulder harness and belt, very occasionally you may need to unbelt to reach something but not very often. The ground critical care units at my service do not have a bench seat now and have chairs that slide forward and back in place of the bench seat. Most of the supplies you may need during transport including suction and oxygen are close at hand in drawers with no need to get out of the seat. I can also reach the monitor that is secured with the same system that I think Marks service uses. I will agree that the placement of the supplies in the pictures you posted are not the solution. I have no problem accessing my patients for the vast majority of treatments in the ground trucks. Times will occur that you need to be unbelted to do something i:e move to another seat or grab a unusual pice of equipment but the point is to minimize the time you are out of the seat. As for the second patient pre-haps we need to look at some of the technology that the military uses to transform cargo aircraft into flying ambulances? As a side note to my previous post lights and sirens were being used for only one of the accidents. The T bone was a old guy that ran a stop sign onto a major street and the second the person crossed the yellow lines and hit us head on in our lane. I agree that improvement in driver training and the judicious use of L&S or blue’s & two’s but that does not keep you safe from the other nuts on the road. The sad truth is that the current KKK specs for ambulance design are not safe and need to be revised and crash tested.

    • Anonymous January 8, 2010 7:41 pm

      Sorry about the additional post but you should look up Dr.Nadine Levick (http://www.objectivesafety.net/) about this subject. She is the Pro from Dover on the subject and is very familiar with both US, Australia, and European ambulance design.

  12. CBEMT January 8, 2010 2:40 pm

    “A three point harness is nice, but does not allow you to tend to the patient.”

    I've seen at least one ad from a major manufacturer showing two providers in 3-point harnesses close enough to do anything they need to the patient. A critical care truck near me as a picture of Nadine Levick in their airway seat, secured in a FIVE-point harness, managing their training mannequin's airway. (They've also got 4 other seats in the back with identical harnesses.)

    If it's two patients you're worried about, there's at least one ambulance in NJ I know of that can hold two patients on two stretchers, and neither stretcher needs to be removed to get to the other one.

    It IS possible.

  13. dcimedic January 8, 2010 3:31 pm

    Currently I am a flight medic on a both a EC 135 and a BK117. I do the vast majority of my treatment secured in my seat with a shoulder harness and belt, very occasionally you may need to unbelt to reach something but not very often. The ground critical care units at my service do not have a bench seat now and have chairs that slide forward and back in place of the bench seat. Most of the supplies you may need during transport including suction and oxygen are close at hand in drawers with no need to get out of the seat. I can also reach the monitor that is secured with the same system that I think Marks service uses. I will agree that the placement of the supplies in the pictures you posted are not the solution. I have no problem accessing my patients for the vast majority of treatments in the ground trucks. Times will occur that you need to be unbelted to do something i:e move to another seat or grab a unusual pice of equipment but the point is to minimize the time you are out of the seat. As for the second patient pre-haps we need to look at some of the technology that the military uses to transform cargo aircraft into flying ambulances? As a side note to my previous post lights and sirens were being used for only one of the accidents. The T bone was a old guy that ran a stop sign onto a major street and the second the person crossed the yellow lines and hit us head on in our lane. I agree that improvement in driver training and the judicious use of L&S or blue's & two's but that does not keep you safe from the other nuts on the road. The sad truth is that the current KKK specs for ambulance design are not safe and need to be revised and crash tested.

  14. dcimedic January 8, 2010 3:41 pm

    Sorry about the additional post but you should look up Dr.Nadine Levick (http://www.objectivesafety.net/) about this subject. She is the Pro from Dover on the subject and is very familiar with both US, Australia, and European ambulance design.

  15. the Happy Medic January 8, 2010 4:38 pm

    If no bench seat, where would you have been sitting when the accident happened? A three point harness is nice, but does not allow you to tend to the patient. We have a tough spot in having to be free to move, yet be stationary and secured to be “safe.” I have been contacted by 2 ambulance manufacturers about this post asking me what a solution is. I plan to tell them, as soon as i find it. unfortunately, since accidents is the number 1 killer of EMS providers, we need to slow down and be better drivers, especially when using the lights and sirens. until that day, perhaps a complete redesign of the patient compartment is needed. I smell a post coming on.

  16. the Happy Medic January 8, 2010 4:42 pm

    But we aren't throwing our backs out loading gurneys because we lift them all the time. We have problems carrying people down the stairs when they reach out and grab something, twisting the chair and our knees. We get hurt doing that more than anything else. Introducing a motor or device that can fail when man power can perform the same task seems silly to me. the lifts may help “reduce” injuries, but each time the lift or motor fails, that is an “injury” and the unit is out of service.
    This is the same reasoning I have behind electronically controlled fire pumps on the engines. Don't take me out of the loop and leave me powerless to correct when the machine fails.
    Thanks for reading and even more for commenting. What does your ultimate ambulance have in it Tim?

  17. CBEMT January 8, 2010 6:40 pm

    “A three point harness is nice, but does not allow you to tend to the patient.”

    I've seen at least one ad from a major manufacturer showing two providers in 3-point harnesses close enough to do anything they need to the patient. A critical care truck near me as a picture of Nadine Levick in their airway seat, secured in a FIVE-point harness, managing their training mannequin's airway. (They've also got 4 other seats in the back with identical harnesses.)

    If it's two patients you're worried about, there's at least one ambulance in NJ I know of that can hold two patients on two stretchers, and neither stretcher needs to be removed to get to the other one.

    It IS possible.

  18. dcimedic January 8, 2010 7:31 pm

    Currently I am a flight medic on a both a EC 135 and a BK117. I do the vast majority of my treatment secured in my seat with a shoulder harness and belt, very occasionally you may need to unbelt to reach something but not very often. The ground critical care units at my service do not have a bench seat now and have chairs that slide forward and back in place of the bench seat. Most of the supplies you may need during transport including suction and oxygen are close at hand in drawers with no need to get out of the seat. I can also reach the monitor that is secured with the same system that I think Marks service uses. I will agree that the placement of the supplies in the pictures you posted are not the solution. I have no problem accessing my patients for the vast majority of treatments in the ground trucks. Times will occur that you need to be unbelted to do something i:e move to another seat or grab a unusual pice of equipment but the point is to minimize the time you are out of the seat. As for the second patient pre-haps we need to look at some of the technology that the military uses to transform cargo aircraft into flying ambulances? As a side note to my previous post lights and sirens were being used for only one of the accidents. The T bone was a old guy that ran a stop sign onto a major street and the second the person crossed the yellow lines and hit us head on in our lane. I agree that improvement in driver training and the judicious use of L&S or blue's & two's but that does not keep you safe from the other nuts on the road. The sad truth is that the current KKK specs for ambulance design are not safe and need to be revised and crash tested.

  19. dcimedic January 8, 2010 7:41 pm

    Sorry about the additional post but you should look up Dr.Nadine Levick (http://www.objectivesafety.net/) about this subject. She is the Pro from Dover on the subject and is very familiar with both US, Australia, and European ambulance design.

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  21. Burnedoutmedic June 11, 2010 4:59 am

    you really do look very dashing in that uniform. it really brings out your eyes. haha.

  22. Scott June 15, 2010 10:06 am

    I am having a great time reading this, Justin! This, along with the talk that you gave to the SFPA that night really paints a great picture of EMS in England. I’ve got a few comments though:1. I agree with the immediate satisfaction point 100%. I think the lifts might be a little bit of overkill. Do they keep the stretcher in the “down” position most of the time?2. If you want to see an ambulance setup that allows movement, is equipped for a second patient, and has a decent amount of safety features, check out the EMS Safety prototype vehicle that AMR and AEV put together. I’ve seen it first hand it has some impressive features.3. There’s one thing that puzzles me about this post though. A lot of the points you’ve made thus far have had to do with how great it is to have the RRC instead of having “6 responders” to the scene with a 4 man ALS Engine, and a 2 man ALS Ambulance, and how you can do this great job without all of those extra hands, yet you seem displeased with the lack of response from the FD on the highway. Lets say they HAD hung a U-Turn and stopped. What purpose would you see them serving on that scene? Also, if you had the exact same scenario on a shift with SFFD what would that Engine have done that the RRC didnt?Thanks, Justin!

  23. Scott June 15, 2010 10:06 am

    I am having a great time reading this, Justin! This, along with the talk that you gave to the SFPA that night really paints a great picture of EMS in England. I've got a few comments though:

    1. I agree with the immediate satisfaction point 100%. I think the lifts might be a little bit of overkill. Do they keep the stretcher in the “down” position most of the time?

    2. If you want to see an ambulance setup that allows movement, is equipped for a second patient, and has a decent amount of safety features, check out the EMS Safety prototype vehicle that AMR and AEV put together. I've seen it first hand it has some impressive features.

    3. There's one thing that puzzles me about this post though. A lot of the points you've made thus far have had to do with how great it is to have the RRC instead of having “6 responders” to the scene with a 4 man ALS Engine, and a 2 man ALS Ambulance, and how you can do this great job without all of those extra hands, yet you seem displeased with the lack of response from the FD on the highway. Lets say they HAD hung a U-Turn and stopped. What purpose would you see them serving on that scene? Also, if you had the exact same scenario on a shift with SFFD what would that Engine have done that the RRC didnt?

    Thanks, Justin!

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