PRESENT: Steve Bennett, Gary Blitz, Paul Card, Rick Churches, Don DuVall, Patti Gressel, Dr. Huffner, Bernadette Josbeno-Oakes, Bill Kennedy, Ron Kintz, Al Lewis, JR Miller, Bob Rajsky, Mike Smith, Mike Sprague, Dick Sullivan, Maryann Sweely, Teri Symonds
STAFF: Judy Blair, Melanie Wood
GUESTS: Mary Perham, Shirley Churches, Jim Kintz
ABSENT: K. Brimmer, J. Chrabaszcz, F. Crist, R. Kimball, K. Lunney, S. Manganaro, M. Teeter

CHAIR RAJSKY: Let's call the meeting to order of the Southern Tier Regional Medical Services Council for September 2004. Welcome to everyone. Introduction of any guests that people would like to do? Seeing none --

DR. HUFFNER: I think it's appropriate to introduce for her first meeting of the Council, Melanie Wood is a staff member from STREMS/EMSTAR Inc. to my left.

MIKE SMITH: What's an EMSTAR Inc.?

CHAIR RAJSKY: We will discuss that. Correspondence and announcements. Under correspondence, the first in your packet I guess correspondence from myself there is a new mailing address for Southern Tier Regional EMS Council, and you should have a card. So any council business, that's the mailing address for that. So Southern Tier Regional EMS Council, PO Box 3492, Elmira, New York 14905.
     Also received correspondence from Mr. Alan Lewis. You should have that correspondence actually in front of you, it's quite a green sheet, lime green. And I wish to read that letter into the meeting tonight. It's addressed to me as chairman. It's dated August 31, 2004.
     "Vote of ‘no confidence' for REMAC Leadership when instituting new Cardiac Protocol.
     "Dear Bob: As a Charter member of the Regional Medical Services Council and the Steuben County representative, I am writing to share my displeasure with the recent operational impact and analysis of implementing the new ALS protocol for patients exhibiting symptoms of a cardiac event and accompanying ST Segment Elevation illustrated by 12 lead EKG in the prehospital setting.
     "While I cannot argue the clinical benefits of the new cardiac protocol, I must stand in opposition and argue the process in which it was implemented and the alienation it has created throughout the county leadership and EMS agencies in the Steuben County. Our three county EMS system is one to be proud of and I believe patients in Steuben, Chemung and Schuyler County have received quality services by all providers including volunteer, commercial and municipal.
     "Speaking for the largest EMS provider in Steuben County, we are a strong proponent of a three county EMS system as it is representative of our healthcare communities primary clinical referral area which benefits patients in many ways including ambulance transfers from one facility to another for specialized care.
      "We would be opposed to a separation from the STREMS Council as much has been accomplished since the formation over two decades ago. Since the mid '70s we have worked together to identify and strengthen our EMS priorities and one by one have addressed them with great success. Withdrawing from STREMS Council will not be in the best interest of quality patient care as it will lead to fragmentation of our patient care delivery system in our three counties. In my opinion, it is my opinion that we need to fix the problems with our relationships and stay united as a team of qualified, quality health care advocates to continually understand and appreciate rural and urban challenges we face every day.
      "We have come a long way from the horizontal taxi and thousands of lives have been saved due to the STREMS Council and the Regional Emergency Medical Advisory Council members interest in quality patient care. But now due to excessive financial and volunteer recruiting pressures, we must regroup before the entire system collapses resulting in patients not having EMS availability in three, in the three respective communities and the strong advocacy team concerned about their outcomes after experiencing a life-threatening event.
      "We all must admit each of our three counties are different, Chemung has less issues with EMS than does Steuben and Schuyler. Steuben and Schuyler have many more ambulance agencies than Chemung and Steuben with the greatest number is more severely geographically challenged than both Chemung and Schuyler.
      "I believe the REMAC, which operates independent of the STREMS Council, has every patient's best interest in mind when a protocol is approved. I don't believe for one minute most members totally understand what impact a new Cardiac protocol has on the EMS system and every ambulance agency's day-to-day operation. I also don't believe the REMAC chair has exhibited due sensitivity for the associated costs of training and capital purchases of very expensive equipment for the agencies to purchase and phase in a protocol as existing equipment is replaced.
      "I fully and totally support providing the very best care we can to all patients needing our services, but reality tells me we need to plan better going forward. If a new protocol will make a clinical outcome difference and can only be accomplished with new equipment, the REMAC and Council must help identify where funds will come from to fulfill the staffing and capital costs for the necessary equipment. I firmly believe if we cannot experience a more positive approach with all protocols and incentives from this point forward, the system will collapse and all three counties may withdraw from the STREMS Council participation.
      Additionally, as I read a letter dated August 16, 2004 from County Administrator Mark Alger pertaining to the county's formal protest of how the protocol process has been implemented, he discusses STREMS Council plan takeover of EMS services by the big paid provider. I can tell you from Rural/Metro's position, we are not advocating for additional territory expansion in Steuben County. Rural/Metro provides general ambulance service to the same municipalities it has for the past 51 years. We support all volunteer services throughout Southeastern Steuben County with ALS and will continue to do so as their individual corp transport volumes do not generate and sustain the necessary revenues for our company to entertain expansion in to those territories.
      "Remembering Steuben County will turn on E911 in a few months. I believe we need to pay particular attention to the inherent issues other counties have experienced with emergency services response and be prepared to adjust our county 911 system to assure everyone receives quality timely EMS services, as they have grown accustomed to expect over the past several years.
      "In closing I will add that it has been known for I believe four years our regional ALS agencies must provide 12 Lead EKG capabilities in the field setting. It has been no secret of the transition as STREMS Council members have been aware of this at many different meetings. Further, I am very concerned that the STREMS Council is being unfairly targeted for mandating new protocols and their implementation as the REMAC actually developed and is implementing them with statutory authority as is occurring in all other regions across the state.
      "Lastly, and most importantly, I sincerely believe we need to reflect on our three county accomplishments, realize our strengths and weaknesses, and not place demands on our fragile EMS system just to be the first in New York State to implement a new program. Our focus must be the constant revision of timely Basic Life Support for every resident and Advanced Life Support everywhere possible with new patient care modalities implemented only when every provider signs off that they are capable of making the financial and staffing and training commitments necessary to fulfill the newly developed protocol.
      "As always, if you have any questions or comments pertaining to the contents of my letter, please feel free to contact me. Respectfully Alan D. Lewis, Sr., general manager of Rural/Metro of the Southern Tier."
      That's that correspondence. The other correspondence is back I believe, Mike Smith had asked -- I am sorry when Dr. Huffner introduced Melanie from the office, in an attempt to separate the different agencies within EMS and the three counties, we have, we had the physician group so we have STREMAC, Southern Tier Regional Medical Advisory Committee, we have this council, STREMS Council, and we have the program agency which staffs and carries out really those other two agencies' functions.
      What has happened though is that the corporation who provides the monetary support through county funding, through state funding, through hospital funding, has taken whacks for decisions that are made by the Council and by STREMAC. And unfortunately that directly hurts patient care. For instance many of you, most of you know Vanessa Jewett who we have paid for years to come every 90 days to recertify the automatic defibrillators in the three counties. And as a result of some of this, the controversy surrounding the 12 lead program, we have seen, and over the past year, we have seen drastic cuts in our funding, and unfortunately that's a direct relationship, a direct problem for, for us to provide what is needed. So by them cutting funds it causes like the corporation to not be able to do what the mission has been. So to try to help with that, we, the Board members came up with a plan of let's just call it something different so we can separate Council, the physician group and EMSTAR which is now Emergency Medical Services Training, Administration and Resources. And by doing that we can maybe avoid some of the conflict which unfortunately that, the corporation has encountered over the last year or two. M

MIKE SMITH: So are you dissolving the STREMS Inc. and reincorporating?

CHAIR RAJSKY: Actually EMSTAR is doing business as, so all of the correspondence, regional correspondence, day-to-day operations will be EMSTAR, and the parent, if you will, the parent corporation is STREMS Incorporated. Unless you looked at our tax forms, you won't see that anywhere.

TERI SYMONDS: Still when you pick up and call the phone, I called the other day and hung up because I thought I had the wrong number, like EMSTAR, oh wrong number.

CHAIR RAJSKY: Right.

TERI SYMONDS: Is a flyer going out to notify people?

CHAIR RAJSKY: Yes. It certainly will. Actually we are going to change that message as well, EMSTAR and then spell it, Emergency Medical Services Training Administration and Resources. Several people have commented on that they call expecting STREMS, hang up and then call back and say oops still got the wrong number. That will go out.

MIKE SPRAGUE: Isn't the program agency created or there to support the Council?

CHAIR RAJSKY: Absolutely. That's, that is one function, yeah.

MIKE SPRAGUE: I guess I am not sure what the distancing itself from the Council is going to accomplish.

CHAIR RAJSKY: It's distancing it only in name.

MIKE SMITH: Well Bob, who, if you have experienced cuts in funding, and I take it that the cuts in funding have been from the political agencies that support this organization.

CHAIR RAJSKY: Yes. Certainly not the Council, the Council funds, the corporation through New York State. So the funding the, you are correct, has been.

MIKE SMITH: You have lost revenue from the three counties.

CHAIR RAJSKY: From one of the three.

MIKE SMITH: Okay.

CHAIR RAJSKY: Significant.

MIKE SMITH: I have to say I find it somewhat odd that you would think changing the name is going to in some way change the perception of this interlocking organization.

CHAIR RAJSKY: Because I guess what you will hear is STREMS has done this to us again, that will be a common phrase. Well I think it's going to be harder to say EMSTAR has done it to us again when we're funding, we're doing the funding, we're doing the training.

MIKE SMITH: With all respect, Bob, if I go to my county executive and tell him I need money for EMSTAR, he is going to say what in the world is EMSTAR; and I am going to say it's STREMS, and I suspect that my colleagues will do the same. You know, I certainly don't wish to criticize the decision, but I think it's rather odd that you would think that that's going to somehow insulate or isolate the incorporated entity from what's going on here. We're all in this boat together.

CHAIR RAJSKY: Yes.

RON KINTZ: I think maybe you, the right thing to say would be, it's not trying to change the name for funding, that's something that's, that is a by-product. But really many of our members I think and the people outside our membership, they think STREMS Council and STREMS Inc. is the same group of people and it's really two organizations. And this decision many months ago to change the name was to avoid confusion, not avoid any money or payment of money or you know anything of that. We thought that by having the same name and putting the Inc. on the end of it, we're really confusing a lot of people. So that was really our purpose for changing. It's coincidental that it happens at this time. We have been probably bringing up the problems of having the same name for both the organizations many months. But we just last few months got around to someone came up with the name, the new name.

MIKE SMITH: I would suggest to you that there is a great deal of confusion among the members of this Council concerning STREMS Inc. or EMSTAR or whatever the name of the thing is. I will tell you that as a Council member for the past 13 years, I have very little idea who the members of STREMS Incorporated are or what that organization does. And I think that we had that conversation recently. You know, I understand what Mr. Kintz has said but I have to say that I think if you polled this room you are not going to find too many people who are seated at this table who has the slightest prayer of who the people are at STREMS Inc., who they are, where the money comes from, other than the fact that three counties have provided financial assistance over these many years. Beyond that I don't think there is too many folks in this room who have a clue what's going on.

AL LEWIS: Interestingly enough the folks you are looking at in this room are STREMS Inc. and STREMS. The executive board of directors of STREMS Inc. sits right here in this room today, the majority of us. So we really felt that there is a lot of confusion, and we have talked about this for a year and a half, two years. Maybe more.

DICK SULLIVAN: Longer than that.

AL LEWIS: We really thought it's time to differentiate for the confusion issue more than dollars, has little to do with dollars. I believe it has more to do with trying to simplify and differentiate which is which here. And you know Maryann, Bunny, Bob, Dr. Huffner, Ronnie, myself, Dick Sullivan, we're all board members of STREMS Inc., we're all the same. But we just feel that there is so much confusion that we really needed to make a name change and do a d/b/a. I think if you give us a little time, I think it will work very effectively.

DICK SULLIVAN: However when a Council member picks up the phone to call and they hear EMSTAR, they don't know what it's about or what it entails.

AL LEWIS: Maybe we should have done a better job --

RON KINTZ: That should only happen once now per Council member okay.

JUDY BLAIR: It's a phase in kind of thing, we have changed the phones, I am working on the website. It is going to be at least another week before that's done. It is going to be another month before we can change the name on the website just because of the way web name registrations work. So it's going to be over a gradual period of time that we will see more and more things from the corporation that say EMSTAR, it's going to be just little things as we build up.

MIKE SPRAGUE: I guess the question and it's still Mike's point is well taken, you know it's going to be, it's going to be difficult for us to go back and talk to our respective people and say now this is a separate group of people, it has nothing to do with this group over here, although it's the same people, in a different suit of clothes. I mean essentially what you just said is a lot of the same people from this room are actually sitting on EMSTAR as a separate group. Maybe it needs to be separate people rather than the same people on different groups.

RON KINTZ: Some of our members aren't a member of this Council.

AL LEWIS: There are three or four members, they are members at large.

RON KINTZ: The thing is it's been confusing the way we have done it for years. I really think this may be less confusing. True, some people are going to be confused no matter what you do. Maybe you will be able to get a hold of your people and explain it so they understand it. Everything is the same as it was. The only thing that's changed is the name. Instead of two organizations having STREMS as its name, we now have one organization, one name, one organization. We both do the same thing we did a year ago.

AL LEWIS: I have to wonder if changing the phone, answering the phone should not have been the last thing you did instead of the first thing you did so that it would eliminate the confusion upfront.

TERI SYMONDS: I don't think changing the name is going to change anything. I mean people are still going to affiliate STREMS with EMSTAR, with STREMS, with Council.

MIKE SMITH: Is STREMS Incorporated, is the corporation as a not-for-profit?

CHAIR RAJSKY: Yes.

AL LEWIS: File 1C3.

CHAIR RAJSKY: The phone system actually will be changed to, if you are calling, the Council will have its own telephone number, when that rings it will be answered as STREMS Council, it will have its own separate line.

RON KINTZ: We're hoping press for one will be able to in time tell the difference who they want to complain to, is it STREMS doing something or is it EMSTAR and when we both got the same name that gives us always a bad name. The Council gets a bad name because many times when we complain it's for the EMSTAR that they should be complaining about. But we have the same name. Now I hope that will be --

CHAIR RAJSKY:I think the other way around. With due respect, I would say it's usually not EMSTAR because we support what the Council and the REMAC does.

RON KINTZ: That's the problem, we support it.

DON DUVALL: I guess the problem is, and I got to admit that I don't understand, nor do I plan to understand the relationship between the two entities, we have had a number of discussions actually trying to figure it out and trying to understand who does what, what the relationship is between the two. So that when someone asks me, I can give them a little bit better answer. And after all these years I got to confess I still don't understand the relationship between STREMS Incorporated and the EMS Council. And you know, I got to, the timing if nothing else seems pretty odd for changing the name. I mean if I can't understand exactly what the two entities do, to me it's still the same. You can put any label you want on it, but it's still the same.

CHAIR RAJSKY: What I am going to do at the next Council meeting, we will reserve 15 minutes and I will do presentations outlining out the Department of Health, just the structure of each and what their function is and whose on those. I can do that, if that's helpful for everybody I would certainly be willing to do that.

DR. HUFFNER: It also might be helpful if we all went back and read a little bit of Article 30. EMSTAR is a program agency, STREMS Council is a Regional Emergency Medical Services Council, STREMAC is a Regional Emergency Medical Advisory Committee. Three very, sounds like we're talking about the trinity, three very different persons, all pretty much with the same mission though. EMSTAR is a program agency, STREMS Council is a regional Council, STREMAC is a regional emergency medical advisory committee. Those are the simple, that's the simple recipe.

DICK SULLIVAN: Bob, I think you ought to do an article from the Health Department right down through.

TERI SYMONDS: It might be a good idea to mail it out to volunteer agencies.

CHAIR RAJSKY: Sure. Be happy to do that.

DICK SULLIVAN: Have a flow chart of it.

MIKE SPRAGUE: Bob, this is kind of a symptom of some of what I perceive as some of the problems. It is not necessarily rolled out in the proper method but lots of times we seem to always end up in that spot where we're not rolling it out in the proper method. I was going to save this for later. I have some correspondence I would like to provide to the Council tonight that really kind of addresses this whole issue. If you would let me do it at this point rather than under new business.

CHAIR RAJSKY: Is that okay for everyone?

AL LEWIS: Why not?

MIKE SPRAGUE: I won't read the whole thing but I would like to go through the body itself. In a recent letter I was basically accused of not speaking my mind and not advising people of what I thought. And I guess I am going to do that. And it really kind of fits to this whole thing. I'm proud of being a member of this organization. I have been told that I think that the county should pull out of it. I have specifically done steps to try to keep that from happening. However things keep going that direction which I cannot seem to stop. But essentially: The events of the past two months have placed this organization in the public's eye regarding delivery of advance medical care within this region. Unfortunately there have been things said and reporting that paints the delivery of Emergency Medical Services in a light of confrontation and dispute. As you are aware volunteer personnel provide the delivery of the majority of the EMS services within my county. I have had the question asked of me why would this issue, why would these issues affect the volunteers? The key to a good volunteer base is a healthy morale for the people that the services are dependent on. Someone who will get out of bed, leave the family functions, spend the hours necessary to do the training, the in-services, the QI and the fund raisers that the system is dependent on.
      I have included several attachments to highlight some of the issues that I see as only part of the problem that this council needs to be aware of and needs to get under control. I have attached a copy of the diagram that was presented to my legislators describing the functions of STREMS. Which is attached about three pages down. It was portrayed that the Council is made up of representation throughout the region and essentially the center of all activities. The surrounding committees review and answer to the Council regarding all EMS related activities. I submit to you, as a member of the Council, there are many things that happen within and for STREMS that we do not have any knowledge of. The members of this Council and I know many of you personally, are on this board to make the delivery of EMS the best possible. We will do anything to work with our EMS personnel and instructors to enable them to deliver the care that is needed. I do not believe that we signed on to this to be the police agency of the EMS providers. I know I did not. However, this appears to be the message being delivered by this organization. Not by us, but by those representing this organization. There are others who have been trying to repair the damages, mend the fence and counteract the damage that has been created. Again this is being done without the knowledge of this body. We all need to take a role in this by establishing a clear direction and sticking with it. You may say that my tone is a bit harsh. However I would like to cite three examples.
     One, I do not believe this Council is aware that there was a provider that was summarily suspend from practicing in this region. He was suspended from a PCR, sent a letter that he was suspended and not given any opportunity to any sort of due process.His corps was not notified, his medical director was not notified. The individual was an advance EMT and enrolled in paramedic course at Corning Community College. He was available often during the daytime and would run with several local corps when they could not turn a crew. His situation was reviewed by State EMS and cleared.However the REMAC still has not returned his earlier status and has attempted to appeal. The REMAC chair has not answered his calls as to what his recourse is. There has never been any attempt to work with this individual to correct the wrong that he has been accused of or any chance to plead his case to the group. Most of us do not know that this event has even occurred. He has dropped out of the paramedic class and at this point has lost his motivation to continue. There are letters backing that up on the next several pages down.
     Secondly, I bring to your attention a situation with Wayne Ambulance. They have been on review for poor PCR documentation. They were placed on probation as an ILS provider approximately January 2003. Their situation was reviewed in February of this year and their extremely poor performance, as documented in the STREMAC minutes was discussed at length. They were subsequently notified that their continued probation and advised that their Intermediate Level designation was in jeopardy. The letter was sent to the agency's medical director as well. The medical director contacted the chair of the QI committee and their discussion was that it would be the recommendation of the chair that some remedial PCR training would be a good idea. And e-mails to that effect are attached. I was contacted regarding setting up the training and whole heartedly endorsed the idea. The next day the idea was overridden by the STREMAC chair as unnecessary. The only problem is their lack of documentation regarding the use of ALS. I asked the State to review the PCRs when they were inspected and they were unable to find a significant problem. I believe that the reason this corps is on probation was not clearly identified, and a course of remediation should have been started a year ago to solve the problem. I am also confused and concerned that the QA/QI process that is in place locally has not identified the previous two issues if they are as bad as the "enforcement" has indicated.
     Third, the much-discussed 12 lead requirement and the MI protocol. I have read the SEMAC and SEMSCo minutes regarding the whole issue, it has been become apparent that this region is on the "bleeding edge" of this issue. We are implementing the very issues that the State EMS and the Cardiac Advisory Committee are attempting to answer in order to implement three pilots across the state. I have included minutes where Dr. Huffner clarifies the issue of bing able to proceed with the implementation in the region and is specifically told that as long as it is voluntary and the community is coming together and saying this is something we want to do. I do not believe that this issue, even given the two year lead time, should be subject to enforcement by suspension or revocation. I also noted the very short lead time for the mandatory training that lead to initiation of an appeal with the SEMAC/SEMSCo. In our offices we know we have to get information out there at least a month ahead of time. We as a group, whether we can control REMAC and its chair or not, have to recognize that what is portrayed by this collective group, STREMS, needs to convey what we as a Council believe. I have heard it said that we cannot control the REMAC. If that is the case then we should change the way this organization is portrayed and show us as answering to the REMAC. There is much too much talk of suspension and enforcement of deadlines. We do not give ample lead time to our mandatory training/in-services. We do not work with our people in the field if we identify a problem and work together to solve it. These people, the volunteer EMS providers do talk amongst themselves and do know, more than we do as Council members, what is going on between STREMS and the providers.
     I was once told that perception is reality. We need, we have to change this perception or we're wasting our collective time as an organization. The motivation of our providers depends on us providing a positive working environment with the Emergency Medical Services. I have highlighted for this group the crisis we are facing in Steuben County maintaining sufficient personnel to provide the services necessary to make this system work. On August 23, two days after the issues broke out in the papers, we had an elderly woman down, not breathing call in Steuben County during the late morning hours. It took three ambulance services and 40 minutes before an ambulance and a full crew could be found to transport this person to the hospital. ALS and a Sheriff's Deputy also assisted and an AED was utilized. I can tell you of several other calls that have occurred with the same problem. We need to address the issue of service delivery and volunteer recruitment and the morale of our providers before we attempt to enhance the care we are able to provide. The standards can be raised as high as you want, but without the personnel to deliver them, we have no system.
      As we turn on 911, it is going to be crystal clear that we're going to be turning the calls around as fast as possible. We're trying to shave seconds off with 911 and we're talking minutes, we're talking in half an hour time frames, the ambulance response. It's going to be very clear, media is going to be watching the turn on. When that turn on occurs and the ambulance and the equipment don't show up, they are going to be asking why. And at some point that's going to be the finger is going to be pointed at the corps which I don't think is fair to them, it is going to be pointed to us. So I understand what you are trying to do with EMSTAR, but I guess, my point is, that perception is reality and the people out there perceive this organization, this group is the problem, we need to change that. Somehow, some way, whether it's controlling our efforts to enforce and get out there and do more, efforts to actually work with the people, do some remediation, I don't care how you do it but you got to get out there and work with them or we won't have anybody left.

CHAIR RAJSKY: Comments?

AL LEWIS: I guess I was unaware of Mr. Sprague's packet. But there is a lot of similarities in our letters that were written separately but have a lot to say about the perceptions of the system in Steuben County. There is no doubt that the leadership of Steuben County is extremely upset and dismayed by this organization. And it, most of it is being based by the, first of all by the credential thing that occurred that was unfairly received and second of all by the Cardiac protocol that just has been instituted. Regardless of what has occurred looking back, I think we got to look ahead, and we have a legacy of bad feelings, we need to eliminate those by getting to these people and saying look, we really want to maintain a three county system. I must tell you if we were to try to, if somebody were to try to break this system apart, I think they would be unsuccessful to begin with. I think the state would look extremely unfavorably at that. That's not the answer. Our patients flow through our three county system. We need to have collaboration, communication and work together on training and issues that better improve the quality of care for our patients. We need to set aside all this bullshit and move on with the positive attitude to bring this Council together. We really need to. I mean it's in all of our best interests to work as a team in these three counties.RON KINTZ: I agree with somewhat of Al says and we got to work together and I don't, I won't even try to give the right answers to Mike on this letter here because evidently you put a lot of work into it. And I speak only for myself. I need more time to look at it and justify it. I do say this, I don't believe we can hold back medical care for patients in three counties, because one they're either can't or don't want to do it.
      Now, do we want to write two programs, the standard level care and the substandard, no, we don't want that. And no one would like to be in that area of substandard. What we need to do is to see what we have done right or wrong, and that's what's being charged here, and then either the blame will be on Steuben County and this membership or not. And if it's on us, we should make some changes. But I got to ask you when we have so many members from Steuben County that goes home to their county, how come they are not telling the mayor and the county, Mr. Algers and other people what's going on. It seemed like the leadership is in the dark, maybe the members know what's going on, but they don't know. They go home with the idea they are supposed to be telling them what's going on here.

MIKE SMITH: Ronnie, I would address the issue why the county leadership doesn't know what's going on. I don't say this with any disrespect. They typically are not interested in this until it becomes a problem. And when it becomes a problem, it is because there has been such a horrific mess of some description that it, that people involved have decided the only recourse they have is to go and complain to their political leadership. Then the milk is spilled and it's too late. I would say to you that part of the problem that I see is, it's just like this EMSTAR thing, if you are going to roll something like that out, then you need a, got to do some marketing, there has got to be a marketing plan to do that, there needs to be an announcement. And I think that as members of the Council, I will, it would be rather important that all of us be notified of this great news. We have got a new name, here it is, here's the announcement. Everybody on the Council, everybody on the REMAC, everybody in the Inc. gets told at the same time that we have made this grand new change and here's why we did it. If you call, this is what you are going to hear on the phone. It seems very strange that we're going to make, which appears to be a fairly significant change and that we find out about it in piecemeal. Teri calls and doesn't know who she reached, she hangs up. I hear it by accident by Dr. Huffner and wonder what it is. That hardly seems an appropriate way to deal with the membership of this group.
     Perhaps the whole issue is in marketing and how we portray ourselves, and how we bring forward these new products, if you will, because everytime a new protocol comes out, that's a product that's coming out of this organization. And Ronnie, I think that I would dispute one thing that you said. I don't think that, I don't believe we have people in Steuben County who are unwilling to provide quality care. I don't think that's the issue at all. However I think that this organization has to be cognizant of the capabilities that the volunteer service has, the training, response, fund raising, maintenance and operation of their equipment, the operation of their organizations. I think that there is a chance that many of us who come from an area like Chemung County where we're really blessed, we got an ALS paid ambulance service, and I am not plagued with these problems, I have a problem getting volunteer First Response people in the fire departments, but I don't generally have to worry about an ambulance coming in a prompt manner. I don't have to page and page and page to get an ambulance on the road to respond to something like this cardiac call that's mentioned in here. I don't deal with that. Thank God, I don't have to. But I think we need to recognize what's driving the volunteer service in Steuben County and we need to be trying to support that base. Now I don't say that the development of new protocols is bad. But I think as they are developed, we got to figure out how we're going to be able to implement these new protocols. You know what's going to be the marketing strategy, maybe that's what we missed. Maybe we got to be better salesmen here and when we have a policy or procedure, there has got to be plan for its implementation, it's clearly understood by all of us so that it can be clearly described to those people who are going to be affected by it. Maybe that's where we have fallen down. I don't know the answers, I certainly don't portray myself as any expert on this. But I can tell you that when it gets so bad that the county administrator in Steuben is writing to the county executive in Chemung and to the county legislative chair in Schuyler about this issue, we have got a real big problem here. And we better do something about it quickly to get ourselves back on track. You know you talk about loss of funding, you could lose a good deal more funding, if we don't find a way to address these issues.

TERI SYMONDS: Needs to be addressed other than through the newspaper. I mean this whole cardiac protocol thing, people were calling and saying so if I have chest pain I can't call you guys, I mean they are totally confused on about what to do and how to do it. Nobody made any clarifications through the paper, I don't know whether it should have been STREMS or if it should have been the hospital, who should have made some clarification. But people reading that in the Hornell paper and they were totally confused. They have no idea. And that's where the bottom line is is patient care and it just seems like all this other stuff is piled on top of it.

RON KINTZ: I hate to set precedent, you are the person I agree with, this is wrong. I don't normally agree with three people. But what bothers me is when the articles in the newspaper, they're erroneous, no one's telling them they have to take patients to Rochester or Elmira. Their protocol says your doctor is the one, not us, not the ambulance people.

TERI SYMONDS: That's not what the paper said.

RON KINTZ: I know. Who told the paper and who took the effort to correct it?

MIKE SMITH: Unfortunately the problem you have with the print media is this issue is too complex for first of all them to understand, because you are not dealing with the sharpest knives in the drawer there at the newspaper, nor do they wish to devote the print space necessary to make the full explanation so it would be understandable. It is not an issue that would be solved in the news media, they don't have the time for it.

TERI SYMONDS: It's pretty pathetic. People calling from Woodhull saying the next time I have chest pain what do I do.

MIKE SPRAGUE: It goes right back to the symptom of the problem. We rolled out EMSTAR but we really didn't give sufficient thought. My own personal feeling, we didn't give sufficient thought to make sure all of us as a Council know it's happening first. I would give money for the number of times I go back from a Council meeting and find out something from someone else that the Council, that STREMS somehow has sent out or scheduled or something, that I knew nothing about. That as Council member makes me look like I am in the dark number one. But secondly we need to have a plan for rolling out something like this so that it comes out in an organized fashion as opposed to just plopping out on the telephone.

CHAIR RAJSKY: I have to take exception to that. You do not have any authority to say anything over EMSTAR, you are not on that board. So you do not have any authority to tell us how to do that. That's number one. Volunteers were not affected by 12 lead EKGs, there is four agencies in the region, Rural/Metro, Hornell Ambulance, Schuyler Ambulance and Erway Ambulance. Those are the four agencies that were affected by that protocol. So to say volunteers are affected and are leaving because of 12 lead EKGs is absolutely 100 percent wrong.

MIKE SMITH: No, it's not Bob. I would take exception to that, because I am going to tell you and just as Mike said in his letter the perception of this is that if my volunteer ambulance goes to this call and we'll say that Rural/Metro brings their ALS 12 lead EKG machine in, who is transporting? The volunteer ambulance, if I tie those volunteers up for four or five hours because they are going into Rochester or Elmira, then I absolutely have affected the volunteer service. I agree further with you that we don't have anything to say about EMSTAR or STREMS Inc.. But I think as a matter of courtesy to the members of this organization, it would have been very nice had we been notified that this has happened. I don't think we should have anything to say in what STREMS Incorporated does. But I think it is at least important that we do have the courtesy of notification that this change has been made and why. So that if one of our volunteer service members calls over there and then calls us and says what's going on with that, we don't have to say gees, I don't know what you are talking about. I don't know anything about it. It's strictly an issue of notification, information sharing, getting that stuff out there, so that we avoid these stumbles and bumbles and looking like the people on the Council don't know what's the program. It's embarrassing for us.

CHAIR RAJSKY: It won't be tomorrow that's for -- let's get back to the demands of the 12 EKGs on the volunteers, absolutely operationally. But in letters of correspondence, it was training issues, that were brought up in that as well. Members of this Council are on the Ambulance Association of Steuben County. Certainly I sit on that. I have been over this past two years, also sitting on the Rural Health Committee for Steuben County. The credentialing issue was dropped. There was outcry, it went out to everyone that was my decision to send it to everyone up front. There was outcry, it wasn't going to work in the format in which it was, which was general framework you could cross out and we didn't do it. The only credentialing process that's actually going to be presented tonight is for EMS physicians so that was dropped. So the Council listened to that. I am thinking so we don't have a credentialing process so, I think we were sensitive to those issues and it was dropped.
     I certainly ask for monetary support to Steuben County, certainly thousands and thousands of dollars have gone into the volunteers for their automatic external defibrillators when that became an issue and squads had very little money to do anything with. STREMS Incorporated in support of the Council came up with thousands of dollars to buy them AEDs. I had done a presentation recently to the legislature of Steuben County citing that there was accusations that because of the STREMS stumbling blocks or credentialing process, all the requirements we put on the folks in the region, that response times are going up and up and up. And in fact we did that, we crunched numbers from 1999, before we had standards, before New York State had standards. And we looked at the first quarter of 2004, lo and behold today 2004, the response times, average response times in Steuben County, we looked specifically at Steuben County, were 50 percent less. So that means response times in '99, if they were 10 minutes, were five minutes now. And that doesn't have anything to do with our standards, we didn't say you had to have an EMT on every ambulance, that every ambulance had to be certified. But we stepped up to the plate when New York State said that, we said that and said how can we help you and Vanessa was under ambulances in Steuben County when one ambulance service bought an ambulance that didn't have any numbers on it. And she crawled under to find the ID number.
      And for years we have been going through, doing the AEDs to the tune of just about $18,000 a year to have Vanessa and her husband travel to all parts of the region and provide service. There is no funding for that. We have come up with that through the counties, through the hospitals. So I guess to hear, certainly the disaster trailers is another issue. So to say we haven't done anything, that STREMS Incorporated, the Council hasn't done good. I take very big exception to that. Do we have ways to go to do our public relation, maybe we do. But I am not going to sit here and take that. We haven't done anything in our organization that is not good because I truly don't believe that.

MIKE SMITH: I didn't hear anybody say that.

CHAIR RAJSKY:I am hearing it. I am seeing it. Every day.

MIKE SPRAGUE: Bob, I agree with you a hundred percent. There has been a lot of things done. But I will go back to the perception is reality thing. A lot of people perceive this organization as an enforcement arm. And that is not a good thing. If we're trying to get out there and try to make sure things work. Programs you talk about certainly are not enforcement, but they don't catch the lime light and stuff like some other things. I.e. perception is reality is what I was told when Steuben County's 911 system was overbudget by six million dollars. Reality was we hadn't spent a nickel and we were not overbudget. Over I got assaulted with that. We can't walk out and say that's not true, and just walk away. Because of perception is reality. We need somehow to get it so that when we decide to do something, we can get it out there in a reasonable timely fashion so that everybody understands what's going on as it happens. And that is one of those things, the thing that Gary was referencing, this organization ought to have a public information officer. Somebody specifically who would be the one who addresses all the media when the concerns came up, as opposed to this shot here and this one here and this one over there. Let's get our act together and let's do it in an organized fashion so that we come out as a unified organization and actually talk with the press with the proper spin. They are always going to write the wrong thing. They are always going to misquote something, that is a part of being part of public life and talking to the media. If I could find one that I was quoted perfectly in the whole thing, I would give them an award. But for the most part you have to manage that. And the only way to manage that is to get somebody who's good at it, and put them out there and let them talk. And that would help a long ways to going to addressing the stuff that Teri just talked about. I mean as an organization we should have something like that. And really this was not, this whole thing is to talk about the reputation of the organization. Right now we got a bad name. I don't think we should have one, but we need to change that somehow. Maybe we should settle up our, right here and now, with all the other stuff Al said and go forward, figure out how we are going to fix it.

TERI SYMONDS: Speaking as a volunteer, changing the name is not going to fix anything. That's just going to confuse more people. It's confused me. And I am part of it. And I don't think that volunteer agencies are looking for you to buy them things. I mean you had mentioned an AED and all that. When we bought an AED, I didn't come knocking at STREMS' door and say need a new AED. I think they are looking for support with you guys, this case with this EMT with the -- I know very well. For somebody to slap him on his hand, this went all over the counties, and said oh you did this wrong, we can't fix you, you know. And the guy's washed out. And it just filtered through the whole county that way. Nobody said, you know STREMS is going to help me, any of that. When Woodhull applied for the ALS, ILS I realize the circumstances behind it and I understand all of that. But nobody else understood why we didn't get the ALS permit. First time we came through everybody in that meeting said after the meeting we'll help you, we'll help. When it came to the meeting, set in stone, see you later. I understood it but nobody else understood it. And it's just so hard to make everybody understand what's happening and why. I mean it's just very confusing for everybody.

MARYANN SWEELY: I agree we need communication, I agree we need more verbal interaction and information for all of us. I wasn't aware of a lot of these things that occurred here until I read them now. But I hate to hear somebody say policing, to me it's Quality Improvement. It's education. And if this body doesn't do it, who is going to do it? Don't tell me the fire chiefs or the ambulance manager or somebody else. They don't have the time. This group has taken the initiative to follow the PCRs, to improve the quality. I can remember doing that QI in-service way back when when we first started it. My God there was an uproar, I thought I was going to get hung in the Lodge on the Green here. We're not going to do that, we don't have time to do that. But they see it's a means of improvement.
     There is a lot of things here tonight, I agree with. I agree, the Board, the worst thing, my biggest pet peeve's is when somebody comes to me as a manager or administrator and asks me something, or a member of this body, and I don't know the answer, but my co-workers here that don't even sit on Council do as I heard you say, that bothers me. And I agree with you there. But I think we need to all come together, we need to, we know that one of the big issues is communication. I think it always has been.
     There has been a pocket of people that seem to do the things, and thank God for them because they are the workers, they are there, the worker rise and they take the initiative. But that information has to be disseminated to the rest of us so that we can share it and it can trickle it down. You know and I don't think this is going to be a band-aid thing that's going to be cured overnight. But I think a lot of good points were brought up this evening that you need to just work at. Patti said it simply is the phone message, this is EMSTAR -- I agree we should have been informed on that first. But the phone message, this is EMSTAR currently known as STREMS Incorporated. Something as simple as that after the information had been disseminated to all of us. Now we have a lot of hills and bumps in the road. But I think if we stick together as a team, try to take care of these problems that we have identified, with education, with patience, with team work rather than anger, I think we're all be better off.

TERI SYMONDS: That's we need to look at ways of improving what they're doing. And the STREMS in-services, that's a positive thing. They want to do their best. But for some reason all the training, all of that seems to be --

AL LEWIS: I have to wonder, Bob, as I said in my letter, I think specifically Steuben County, our EMS system is fragile. And I have to wonder if there is some fingerpointing just because it's fragile.Now, you know maybe STREMS isn't the big bad guy. Everybody is really suffering in their corps and they are just looking for somebody to blame. And probably STREMS is probably the easiest one to blame. I have been in this business 43 years. And I have never seen a system in our county as bad as it is right now. It's not bad because of the people providing bad care, it's bad because we don't have the people to provide the care. There is some damn good EMTs and paramedics in this county like there are in the other counties. But wow we can't get people out and Mike is right when you get two or three ambulances requested for one patient, you wait until 911 turns on. You think this is going to, I think it is going to be a blood bath for the EMS system in Steuben County once that program is turned on. I think they are going to be calling six and seven different companies, because of the time lines that are going to be built in to that system just to protect the liability of such a litigious situation in Steuben County. I think we need to reach out and see if there is anything we can do with Tim Wixon and Mike and his people as a three county program, say okay you are going to turn it on, but how can we help here. Mike has had some experience with this as has Schuyler County. I am real concerned about it. I think we need to back up look at our basics and make sure our system is strong and in place. I don't think any of us have bad interests in mind here, I think we're all in, have, we're advocates for quality patient care. I just think the system is so fragile that we have, I would think, if you call it infighting because we're concerned for it. Let's get together here and let's make it happen. I got to tell you, rolling out EMSTAR by putting it on the phone is the wrong damn thing to do. This Council should have been the first to know. We're a team. We're altogether on this thinking, I'm shocked that it's on the phone already. It should have been here tonight to the legislatures, to all of the EMS systems that are out there. And the last thing that should be done is put it on the phone. I don't understand how it happened.

MIKE SPRAGUE: My county administration told me about it.

RON KINTZ: Well, I am sort of glad, Bob, that we did, or whoever did, put it on the phone. Because it gives us something to pick on tonight. It was wrong and I agree with them. We should do it in a different way. But what will we pick on if we didn't have EMSTAR tonight. But I do say this. When we talk about PR and communications, everyone here tonight is a carrier of this information. You should leave here and know what the hell is going on. Listen to the reports, he has a report of what REMAC does at every meeting, listen to it, ask questions, then you are supposed to go back and tell somebody, not go to sleep. So part of this PR problem starts right there, right with each one of us that don't take it home. Maybe we got to do more. I think we do. But starts with us. So when you point your finger starting, start with us.

AL LEWIS: Can we move on to an agenda.

CHAIR RAJSKY: Okay. We got through correspondence.

RON KINTZ: Did we?

CHAIR RAJSKY: Thank you. Approval of the previous minutes? You all should have received those via e-mail. And I would entertain a motion to approve.

AL LEWIS: So moved.

MARYANN SWEELY: Second.

CHAIR RAJSKY:Motion made. Changes, additions, deletions? Seeing none all those in favor signify by saying aye.Opposed? Abstentions? (MOTION CARRIED, Unanimous.)

CHAIR RAJSKY: Carried. We move on the committee reports. SEMAC/STREMAC and State EMS reports.

DR. HUFFNER: SEMAC and SEMSCo met Tuesday and Wednesday of this week. The traditional summary that I usually pass out is not available. But it will be forthcoming, I will make sure it's in your folders at the next meeting.
      National EMS Corps Content and National Scope of Practice documents are available for comment. And all are encouraged to take a look at those, they are available on the NHTSA website NHTSA.com. But also at HTTP://EMSscope of practice.org./. They're interesting documents. The proposals for four levels of care -- four to five levels of care nationally. All are encouraged to send comment in the appropriate direction.
      You should know that stroke centers are the next facilities that are going to be anointed and appointed by the Department of Health. Hospitals across the state have received applications from the Department of Health. There are requirements, you have a copy of that of that document in the office if anyone is interested in seeing it. I did not make copies because again it's an in-hospital type of procedure. It's the expectation that stroke centers will be identified and anointed some time in less than eight to 12 months.
      There has been a BLS protocol proposed. The BLS proposal does include a time sensitive nature. I can tell you this is a very very contentious issue on the state level. And then it's going to be worked on. That BLS policy will obviously have ramifications in our region in terms of the triage and transportation of these class of patients. It also will have ramifications for our own ALS protocol. Currently we do not in our ALS protocol identify any issue of time as being a consideration for determination of where the patient might go. I can tell you that the medical science certainly varies on this. One school of thought is for consideration of TPA, peripherally, another school of thought involves provision of TPA intraarterially. And the time frames associated with those modalities as well as for consideration of operative intervention for non-hemorrhagic stroke also factors into this. So it's going to be a very complicated discussion at the next SEMAC meeting.
      The Cardiac Advisory group of which I have been a member of has met several times over the summer. And Mr. Wronski did give a report on the progress made with that group. Mr. Wronski also set out a letter to REMACs across the state and one specifically addressed to myself and Mr. Rajsky saying that no REMACs, REMACs are asked not to implement any new programs that would systemically, by system transport triage patients with ST elevation MIs to angioplasty centers. Existing programs however can continue, that includes ours. Our program can continue to exist because it does involve very close contact with medical control, and any contact, any decision for transport to an angioplasty center must be confirmed by a medical control physician. It's a medical control decision.
      Fentanil has been used in the prehospital settings in some parts of the state. You should know that it's not allowed according to state regulation at this time.
      We did receive a presentation about regional perinatal centers and the need to cooperate with regional perinatal centers was brought up in light of the EMS system. The indication is that regional perinatal centers are going to have what they're billing as perinatal forums to which REMACs will be invited to, the intent I believe is to make an attempt to identify classes of patients that will be selectively transported directly to a perinatal center. Nassau County Hazmat protocol was approved and is suggested as a model for statewide use for local hazmats. The Suffolk County ALS protocols were also approved.
      The SEMAC is also working on a selective C-spine immobilization protocol which is also generating a great deal of discussion. And it is clear that there are at least two schools of thought on this. One is a clearance type protocol that would identify a class of patient that need not have C-spine immobilization placed. The other school of thought is that we don't need that type of protocol. That type of protocol has been in place in Maine now I think for about four years. They have not had any bad outcomes with it. The other school of thought is that we don't need that type of a protocol, rather we need a more elaborate and extensive educational piece that can be used to educate providers at all levels about which class of patient needs C-spine immobilization.
      There was significant discussion about EMS certification extension for military personnel returning home from active duty. And that there were several, if you will, loop holes that needed to be filled, and every attempt is going to be made on that to ensure that returning service persons can come back and enjoy some type of time until they can get recertified or refreshed. And those are being worked on.
      Learned that AEDs are required in health clubs with memberships greater than 500.
      The State EMS plan which was last worked on I believe in 1999 or 1998 is being revised. I believe that plan is also available on the State's website. A document entitled Addressing Issues Associated with Municipal CONs was approved. We do have that in the office, I did not get a chance to duplicate that. But that certainly will be available in the office for your review. That does constitute my report on the SEMAC and SEMSCo meeting that was held Tuesday and Wednesday of this week. I ask Mr. Lewis if there was anything I missed?

AL LEWIS: Well I guess on the lighter side, Dr. Huffner and I sat next to each other in Albany at the SEMSCo meeting, and we looked at each other on several different occasions, and I have been on that Council for 20 years, Bill a shorter time than that, but we said ‘we didn't know that.' I'll bet 10 times we said ‘that hasn't happened yet.' So I guess I share that with you in jest, because the same damn thing is happening at the state level that we seem to think is happening here. So I guess we are all in it together. One thing we did learn and I will share with you, and Bill and I looked at each other and said ‘that's in our county? We don't know that.' We were told that there are CDC chem-packs in our county today, nerve agent antidotes for a thousand patients, they have been delivered to 71 hospitals, 20 EMS services and 72 physicians' offices. And we're told that the county EMOs have these packets. You guys are aware of this?

MIKE SMITH: It's a secret. I am not being flip here.

AL LEWIS: It was in the New York Times. It was mentioned that it isn't something that's for public information and the media, but you need a protocol to be able to do these things, and the protocol has to come out of the REMACs, and the REMACs sat around that table, all those docs said ‘we didn't know that.' So I mean it's just an example of these things. This thing has just been rolled out by CDC and DOH to SEMO, to EMOs, and you can't use it if you don't have protocols anyway. So we need to get together I think and kind of put a protocol on the table from this group, passed I guess through this group.

MIKE SMITH: What's the protocol to do?

MIKE SMITH: No. My only question is though this is a pharmaceutical stockpile, what protocol would be necessary to use pharmaceuticals?

DR. HUFFNER: Can we go off the record for a moment?

AL LEWIS: No, stay on the record.

BERNADETTE J-OAKES: Leave it on the record.

DR. HUFFNER: My intention was to discuss this with the EMOs at a different time. Because we were told this was supposed to be a very sensitive issue.

MIKE SMITH: It is a super secret.

AL LEWIS: Not any more.

DR. HUFFNER: And it was to be not made public. We were told that should the occasion for the use of these stockpiles be indicated, that there needed to be some type of a protocol for the administration of these drugs. And --

AL LEWIS: By paramedics.

DR. HUFFNER: And that REMAC would be responsible for that. Now that, that's nothing new. I had heard about that, in fact we have had a lot of discussions about the pediatric dosing of the MARK-1 items. I was relatively confident saying well, I don't have to worry about that, we don't have any of these in my county, counties. I don't know specifically what the protocols were, other than sitting at a table being told REMAC shall do this. And I thought that on the side we would get together and do it in a manner that would be appropriate and if you will respective of the nature of what these are supposed to be, which is secret.

AL LEWIS: I did too, but when they told us it was in the New York Times, it's no damn secret any more. It's out there.

DR. HUFFNER: We still don't know officially where they are, so that's one thing.

BERNADETTE J-OAKES: So we should applaud the EMOs in our two counties for managing to pull that off. I would applaud them.

DR. HUFFNER: I know where they are.

RON KINTZ: I don't want to know.

AL LEWIS: But it sounds like there will be prehospital care professionals helping to possibly administer this stuff and there is supposed to be a protocol for that. That's what they said at State level.

MIKE SMITH: Well I would really point out that this is one more example of the New York State Department of Health operating outside of the group that has been trying to manage all of these issues related to our response to potential terrorist acts. And we had this discussion yesterday with the State Emergency Management Office, that somebody needs to identify at DOH who the puppeteer is who is sending edicts and demands on both hospitals and public health departments to try to bring them to heel, if you will. They need to get into the group. This running outside of everything that everybody else is doing is counterproductive and leads to issues such as this. Before that crap ever hit town, these things should have been decided. I mean this is nonsense.

AL LEWIS: Absolutely.

DR. HUFFNER: Again I'm not saying we have to have protocols. I am saying that as a REMAC chair, I sat around saying, I heard that that was one of my responsibilities. I didn't know that it was. I didn't even know they were in my county. So up until that point, counties, I should say.

MIKE SMITH: It's in one of your counties.

DR. HUFFNER: No.

MIKE SMITH: At least I think so.

AL LEWIS: No. I think they are all sworn to secrecy.

DR. HUFFNER: I think it's in secrecy.

AL LEWIS: One more quick thing. We didn't hear anything that was said in the last 20 minutes. At the state museum, help is here, there is a new EMS display for the first time ever right next to the fire service display. There will be a horse drawn ambulance from years ago that I wasn't on, trust me. I haven't been on that long. There is old ambulance that some of our companies around the state own. And I encourage you to go there. We're hoping to get many people to see that exhibit, and something that I think has been needed for many many years, for EMS to finally get in some sort of a limelight for all the things we do and all the people we help. Maybe you ought to put this in the minutes so everybody has a copy of it.

PATTI GRESSEL: Is there any way that that can be forwarded to the newspapers locally?

AL LEWIS: Sure can.

DR. HUFFNER: I don't think the exhibit opens until --

AL LEWIS: It's not open until November 1st. It's in there. We will pass it around.

DR. HUFFNER: I think that's when the appropriate time would be. It would also be appropriate to visit that and go over and see the EMS memorial at the same time. Thank you, Mr. Lewis.
      You have in your packet the STREMAC meeting minutes. We haven't met as a Council since May, so you actually have three sets of minutes. And I am going to go from the back forward. The June 8 STREMAC meeting minutes are the last two pages. And I have a couple things that I wanted to point out. One concerns the use of TraumaDex and other topical traumatic coagulants. The STREMAC decided that those agents did not have a place in our moratorium at this time. They are outside of BLS protocol and therefore would not be considered for use in the region. Dr. William Sheperd was also elected to membership on the STREMAC. His nomination had been previously approved by this body.
      The August 10 meeting of the STREMAC meeting is also, and those are the next two pages of the document. You should know that Schuyler County Volunteer ALS renewal application and a Schuyler County Volunteer Ambulance AED renewal applications we reviewed and approved and permits were issued. You recall that issuance of renewals only require STREMAC action. Bretylium has finally come to be a problem in our region. And that's on the next page. Bretylium use in the region is to continue. And a letter was written notifying the ALS services that they could, they should continue to carry and utilize Bretylium as it is available. However the inability to purchase and/or carry Bretylium will not constitute compliance with the ALS service requirements of the regional protocols or formulary. And again, the services are continued to encouraged to maintain the Bretylium supply as much as possible. The bottom line is there is no, the stuff that they make it out of is just running out. There is not going to be any more Bretylium for use.
      You have in your packet the credentialing of on line medical control physician, it is a yellow document. It comes to you from the STREMAC. The STREMAC I believe has listened very closely to issues associated with credentialing in the region, and has decided to move I guess fairly slowly and step wise and has decided to, if you will, enact what's good for the goose is good for the gander. And the STREMAC seeks the approval of this Council for the initiation of the credentialing of on line medical control physicians. This policy has been around for four years, it was drafted and redrafted by the STREMAC. And was approved at the August 10 meeting. You will notice that the last page, page five is a declarations document. And the STREMAC does request approval of the regional EMS Council in its endeavor.

DON DUVALL: Move to approve.

MIKE SMITH: Second.

CHAIR RAJSKY: Motion made and seconded. Further discussion?

DR. HUFFNER: I would be happy to answer any questions, if anyone has any.

AL LEWIS: I have a question. So every physician that we hear at the other end of the radio from the field is going to have to eventually have this credential in order to be able to talk to the paramedics and the paramedics in the field? Is that what I am hearing, is that correct?

DR. HUFFNER: No. The locum tenens physicians will be handled at the discretion of the emergency department chair.

AL LEWIS: So if the rent-a-docs may not be trained, may not be credentialed.

DR. HUFFNER: The locum tenens physicians will be handled at the discretion of the emergency department chair. I am going to be very clear in what I say.

CHAIR RAJSKY:Further discussion on the motion? Seeing none, all those in favor signify by saying? Opposed? Abstentions? Carried. (MOTION CARRIED, UNANIMOUS.)

DR. HUFFNER: Thank you. Also of note, one of the significant issues that has been around the region for quite some time has to do with the issue of interfacility transport, development and consideration of protocols thereof. There was a lengthy discussion at the August meeting and a technical advisory group was appointed consisting of Mr. Duvall, Mrs. Lunney, Mr. Kintz, Dr. Seaman and Mr. Rajsky. They are charged with further developing a STREMS Regional Interfacility Transport Protocol. And have six specific tasks that were identified by the STREMAC, and they were charged with doing that. The first is to develop written agreements between services and hospitals. The second is to develop a drug formulary and procedure list that would result in the creation of a regional, imagine this, Emergency Medical Technician-Interfacility Transport Paramedic. Develop an Emergency Medical Transport-Interfacility Transport Paramedic scope of practice document that would be added to the Regional scope of practice documents that already exist. This group is to develop and delineate appropriate educational activities, policies and procedures, insuring that the STREMS Council Education and Training Committee is involved. They are to identify and clarify the administrative and credentialing issues associated with the Regional EMT-IFT-P, and develop necessary policies and procedures. And they are to appoint a TAG chair responsible for the document and report generation. This is by no means a simple task.
      The last set of minutes that you have for your review are from a, the STREMAC meeting of September 7, at which time a great deal of time and energy was spent addressing the issues associated with articles in the Hornell Evening Tribune, the Corning Leader, letters sent and received from Mr. Wronski, the Department of Health, letter received from Mr. Alger, Mr. Lewis, Dr. Weiner is actually the medical director of the Angioplasty Center at the Arnot Ogden Medical Center, and Dr. Gacieck is the director of the Cardiology Group at Rochester General. The following unanimous motions were made: Dr. Robshaw will advocate for the use of 12-lead electrocardiograms by Hornell ALS Ambulance, and Dr. Huffner and the STREMAC will assist Hornell ALS Ambulance in any way possible to implement the use of ECGs consistent with the ALS protocol. A letter was sent to Mr. Wronski dated August 30, that letter indicated that the expectation was that the STREMAC would continue the, its already implemented program, that was the gist of that letter. A letter was sent to Mr. Alger, reaffirming the facts that the STREMAC suspected MI protocol does not bypass any hospital without on line medical control input, and that any destination decision requires on line local medical control confirmation. That letter actually to Mr. Alger has not been sent yet.
      Number five. Most importantly and I think this dovetails very nicely into what Mr. Sprague spoke with. The STREMAC respectfully requests the assistance of the STREMS Council's Public Relations committee in improving the public perception of not only the STREMAC, but the STREMS Council and the entire Southern Tier Regional EMS system. This is, we have that request and are sure going to act appropriately. At the STREMAC I did apologize for not having the sense and wherewithal to stay away from the press. I wrote out information for the press, and it was still misquoted. I provided information and it was still not correctly reported. I will not make public response part of my job. Frankly I am not very good at it. I made an attempt and failed. And I won't go to the press in response to, no matter what is written in the newspaper, because it's clear to me from my own experience, I don't believe they're interested in reporting the facts. I think that the press, anyways the two press people that I was involved with are more interested in reporting material that might sell newspapers. And I think they did much much more harm to the process than any good that might have come out of it. I can tell you that I did meet directly and face to face with Mayor Sean Hogan and Chief Vincent Kelly of the Hornell Fire Department and I believe we had a very positive meeting. I believe that we are going to endeavor to move forward, move beyond the maelstrom that was created, and that the people of western Steuben serviced by Hornell ALS Ambulance will have 12-lead care as soon as possible. I believe that is what Mayor Hogan wants, what Chief Kelly wants, and it is certainly what the STREMAC wants. And I would be happy to answer any questions if you have them. Hearing none, that's the end of my report.

CHAIR RAJSKY: Great. Thank you, Dr. Huffner. Maryann Sweely had to leave but training committee report will be given by Ms. Oakes.

BERNADETTE J-OAKES: Training committee met this evening prior to the Council meeting. And we had not met in quite a while so there is a fair amount of business to conduct. The minutes from the May 13 meeting were accepted as written. There being no old business, there was a review of course evaluation and grades, four were reviewed from St. James, sponsors from St. James, two classes, Arnot Ogden and Hammondsport. And they were very positive, Maryann wanted to make sure we gave accolades to Greg Learned and Vanessa Jewett and to Barb Fletcher. All three of them had classes that got 100 percent in their course grades. The course sponsorships that were renewed were Hammondsport, Basic and EMT Advanced at St. James. And they were started for the 2004, 2005 years. There were corrections made though on the EMS course outlines that were distributed. In addition to the Arnot Ogden sponsorship, there is a CFR original at the high school that is being conducted, it is a closed course, it is a high school course only. There was also a correction, when you get an opportunity to look at it on the third page, the EMT Basic Original offered by St. James, Teri Symonds made a correction that the course did not indeed start on the 20th of September but was started on September 27. So those were just corrections. There was recommendation for changes to the EMS course sponsorship sheet for the use of the training committee, primarily to add after each course boxes to know whether the grades were submitted, evaluations were submitted and that they were reviewed. So that we will be able to better track that we are looking at all the courses in fairness to the instructors and students, that they have a fair time to do that.
      We talked some about the upcoming conference in October. Patti Gressel has forwarded that information to STREMAC. Just so that you know the conference is October 16, if you haven't registered, I don't know if Judy brought any registration forms, we recommend that you do that. I think you said you had about 50 registered so far. It's a day long course and there has been a lot of work and effort put into that. I think that is pretty much it. We did review course applications, there were 16 course applications reviewed and out of those, four of them did not list that they were teaching weapons of mass destruction on the course schedule, which is required. We believe the materials were taught, although it is not documented, it's not done. So we are going to follow-up with that to make sure that that gets in to the documentation. And one thing that I did forget when we reviewed the course evals, there was one course that had a low pass rate, there were only six students in the class, and we felt considering the conditions that the class was presented under, that we're going to track that to the next semester to see where that instructor stands. And that was the end of our report. Any questions? Thank you.

CHAIR RAJSKY: Great. We do have to vote on St. James Mercy's course sponsorship as well as Hammondsport Ambulance sponsorship. I will take individually or together, I will entertain that.

MIKE SPRAGUE: Motion.

STEVE BENNETT: I will second.

CHAIR RAJSKY: Motion made and seconded. Voting on St. James Mercy to continue and Hammondsport Ambulance to continue their course sponsorships with the Health Department. Any further discussion? All those in favor. Opposed? Abstentions? Carried. (MOTION CARRIED, UNANIMOUS.)

BILL KENNEDY: I was just curious about our course sponsor. It was sent way back in June, the Health Department has been out, inspected us, they didn't offer an evaluation, I didn't hear anything, for Schuyler.

BERNADETTE J-OAKES: We didn't have anything at the meeting so we will have to check.

JUDY BLAIR: I will add that to my to do list.

CHAIR RAJSKY:So noted. Quality Improvement?

BERNADETTE J-OAKES: Quality improvement. Regional Quality Improvement committee met August 10 at the STREMS office. We reviewed second quarter reports for that period of time. There was some problem with some of the area coordinators receiving reports, most of them were able to have meetings, but there were a few reports that were missing at the time of our meeting. So it does not accurately reflect all the PCRs that were presented during that time period. There was an issue recognized that throughout the region that there, some of the numbers that may be affecting what we're looking at is that there appeared to have been some confusion between county patients who were treated for chest pain into cardiac arrest numbers. So we're looking to get that corrected. Because the numbers were extremely high for the time period. Also MVCs as opposed to major trauma. Apparently we don't know where that confusion came in. Maybe new people looking at the PCRs, they were all grouped together maybe. The numbers were extremely high. We will look at that. When I report again, we will try to go back and report on this quarter because it really, we were short significant numbers of agencies reports for the time that we met back in August. The GCS less than 15, we're noticing that there is, has been a trend and fallout for that and the lack of glucose collection on patients. And we're, we will look at that in this next quarter and then may make request to STREMAC to look at that or to make recommendations for what we can do to improve on that. There were some attendance issues and those agencies will receive letters.
      The pediatric education program we basically reviewed, although the tests had been completed. If you remember this was from back last winter. It is still available, as far as I know it was on the website. If anybody wants to go in and look at the pediatric program. It has been a good review for peds. So I recommend if you still want to look at it, it is still available.
      First Responder QI, we had decided to look at that. We have not reviewed the report for that. There was a letter that did go out, we talk about communicating, a letter went out ahead of time to the First Response agencies to advise them that we would be reviewing their PCRs for the months of May, June, July. Staff is going to complete that and it has not yet been completed. It should be by the time we meet again in November.
      QI review based on July, August and September studied the QI process. It was indicated some cases were reviewed differently. And this was back from September 2003. There was a survey done on the reporting process and how numbers compared to area coordinators to how it was, to how the staff at the office reviewed some of those PCRs. We tried to identify areas that we might be able to offer educational opportunities to make sure that we're being consistent in a QI program, where we have the number of people involving with the information. There were some minor discrepancies. And we will be able to make more specifics in our next meeting and I will get back to you with those. There wasn't anything outstanding. For the most part it really reveals that everybody, I think is very dedicated to the QI program. I am quite proud of it. I have been involved with it for quite awhile. I do think it is a positive, as Teri said, approach to the area. We really aren't out to police or to look at trying to point fingers. We are trying to identify issues that we can create something such as pediatric program, to make it a positive kind of circle of quality as we refer to it. And we will meet again on November 9 at the STREMS office. That's the end of the QI report.

CHAIR RAJSKY: Thank you. Questions for Ms. Oakes. Seeing none, we will move on to public relations. Unfortunately Maryann Teeter could not be here today due to illness. Their main focus and thrust has been the conference which is coming up in October. To date we have 50 people signed up for that. You can get information about that certainly on-line, everyone should have received the flyer in the mail, every agency did. Melanie, do you want to add anything about that?

MELANIE WOOD: There has been periodical notices sent out. There was a post card way back and the flyers themselves. And then for specific agencies everytime there is a PCR summary, there was another notice sent out including one yesterday. The deadline for registration is September 24, so we're trying to get the word out. So any help with that would be appreciated.

CHAIR RAJSKY: Good line up of folks presenting. Systems committee, Mr. Duvall.

DON DUVALL: Systems committee met tonight prior to Council meeting. Hadn't met since summer recess. So a lot of things got accomplished. As you recall we have been working on a radio project as a carry-on from the radio study that we had done a couple years ago. There is nothing new to report there.
      MCI trailers, there has been an ongoing issue with a shortage of equipment. We have identified exactly what it is that we're missing from the trailers, and actually are asking STREMS Incorporated or EMSTAR to provide for replacement equipment. When that's done, there is going to be a detailed inventory for each trailer so that agencies who are keeping the trailers can sign for, an itemized list rather than for the trailer as a whole. Along that line, a couple of trailers are missing MCI kits. The state is in the process now of sending new MCI triage kits to agencies across New York State. There will be one triage kit for each ambulance in the state. And a command pack, one per agency across the state. These command packs are available on state bid, and the committee decided to also ask STREMS Incorporated or EMSTAR to purchase four of these MCI command packs for placement in the trailers to replace the old New York State disaster kits. The purpose of this would be so that the MCI supplies in the trailers are compatible with what's being provided to all the agencies across the state. So we will look to them for that.
      Purchasing program that we had been exploring to provide for better pricing on EMS supplies for ambulances in our region was revisited tonight. We sent out a survey in the spring asking all of the agencies within the region if they were interested in a purchasing program, if they were interested in participating. We only received about three surveys back. So Systems has decided that since there doesn't seem to be any interest in coordinating group purchasing, that issue will be dropped.
      There are four PAD applications pending, however those are all missing some form of documentation, missing some of the components that they need. Letters have been sent back to the agencies to try to assist them in completing their applications.
      Credentialing was discussed. And the Systems Committee decided to invite the ALS providers in our region, Erway, Schuyler, Rural/Metro and Hornell Fire to sit down and look at the programs that each agency has in-house. And see if we can't get this working group to try and pick the best parts of each system and work at putting together what they perceived to be a good credentialing system. At least to move in that direction. It's going to be strictly for critical care and paramedic level providers. We decided that at this time it would be appropriate to work on one level, finish it, make it right, make sure it works. And then talk about expanding it after the fact.
      Lastly we discussed the change in meeting time and date, and need to speak to a couple committee members yet. If that change is made that information will be forthcoming to the Systems Committee. Any questions?

AL LEWIS: Just a comment, you certainly can be assured we'll participate. I think that's the right way to do it.

CHAIR RAJSKY:Thank you. Critical Incidents and Stress Management.

BERNADETTE J-OAKES: Yes, the summary of activity for our team, and this is from May 1st until August 31, 2004. There were a total of 13 debriefings, one defusing and three educational offerings. Year to date that has been 34 debriefings, one defusing and 9 educational programs. In total team activities of 17 total, administrative time 58 hours. And year to date that brings it to 130. The total team member education hours that have been our own people taking courses is 30. Year to date that brings that to 38. Maryann actually reaches the compilement for us. We are still out there and active, if they need us.

CHAIR RAJSKY: Anything else?

BERNADETTE J-OAKES: That's all for right now.

CHAIR RAJSKY: Thank you. Executive Committee met just prior to this meeting. We discussed a few items. The first was to approve for Teri Symonds and that would be to add Steve Foster to her list, I would entertain a motion for that.Motion made and seconded. All those in favor signify by saying aye? Opposed, abstentions?(MOTION CARRIED, UNANIMOUS.)

CHAIR RAJSKY: The other items were membership applications, there were two vacancies, are two vacancies in Schuyler County, and we had two applications. Heidi Wilmott who is representative from Schuyler Hospital, she currently serves on the Regional QI committee, her application was here. And Earl Molyno from Tyrone Fire Department and Ambulance service also both were recommended from the executive committee. So I would --

AL LEWIS: So moved.

STEVE BENNETT: Second.

CHAIR RAJSKY:Discussion? Seeing none. All those in favor signify by saying aye. Opposed? Abstentions? Carried. (MOTION CARRIED, UNANIMOUS.)

CHAIR RAJSKY: Steuben County, there were three vacancies, the first Tim Wixom came up as Steuben County E911 director. Unfortunately we didn't receive his application, he lives currently outside the region. And it's clear that by state statute he is ineligible. The next one was Bill Hawk from Bath Ambulance. And he was approved at the executive committee, I will entertain a motion.

PAUL CARD: Motion.

GARY BLITZ: Second.

CHAIR RAJSKY: Great. Discussion? Seeing none. All those in favor signify by saying aye.Opposed? Abstentions? Carried. (MOTION CARRIED, UNANIMOUS.)

CHAIR RAJSKY: And the last person we have an application for is Dave Dowdle. And the committee tabled his application until next time. And that was the executive committee report. Other business before Council this evening?

DR. HUFFNER: I would like to speak at this time to one of the issues that Mrs. Sweely brought up and the issue is of, concept I guess of policing. And I need, going to, if you can bear with me, I am going to actually use the materials that Mr. Sprague handed out to us.
      The STREMAC is often in a very and delicate position of actually seemingly acting like the policeman of the region. And in fact I think that's probably a fairly accurate description at times. We are not filling in potholes or painting road signs. We are doing patient care. Mr. Sprague uses the issue of the only prehospital provider ever to be sanctioned by this REMAC as an example of inappropriate due process, inappropriate policing. This is a very very difficult case, and you should know that the REMAC was very very concerned about it. They are also very frustrated by the fact that the curriculum for intubation, ventilation sequencing states that a missed intubation should be optimally ventilated. American Heart Association requires ventilation for missed intubation.
      In discussions with the Department of Health as Mr. Sprague points out, the Department of Health initially cleared that this was an acceptable form of care. There is a conflict, the physicians feel that it's unacceptable. Mr. Zastrow, who is not a physician, feels it is. I can tell you that this matter is being discussed. It's at the state level now. What does ‘optimally' mean, that's what the crux of the question is. Because people, some people will say that you can ignore the American Heart Association recommendation, we aren't bound by them, they don't license us, they don't, they are not in statute. And they are correct. Optimally to the REMAC means do it. Well, there is a conflict.
      You should know that this situation is an unfortunate one, however the REMAC is well aware that there is an issue that has to be resolved. Does that mean Mr., that the provider involved should be restored? We don't know the answer to the question yet. How can we as a REMAC restore someone when we aren't sure a hundred percent what the state position is on ventilation sequencing. You should know that if, and correct me if I am wrong, educators, but if you attempt to ventilate on a test, and do it incorrectly and don't reventilate, you flunk. Well if it's good on a test, why wouldn't it be good in a field. In looking at this, I would say that that is the job of the STREMAC, to ensure the quality of care; and at times it would appear that they act like policeman.
      The second issue that I think we need to talk about is that the unfortunate one involving an ambulance service, and their ILS permit. Several cases were brought anecdotally to the STREMAC. One by another physician who said that there is a problem in this corps. The corps was sent letters indicated that they were going to be reviewed prospectively. Here's the physician group saying to a corps, listen we believe there might be some problems based on some misadventures, we are going to look at you forward. We are going to collect a hundred cases because it wouldn't be inappropriate to collect two or three. It took a lot longer than we expected. We had no idea how long it was going to take. We collected 46 cases. Now mind you, remember that this corps knew that the REMAC was, if you will, looking at them, policing them, or doing what may be seen as an inappropriate action; I don't think so. But of those 46 cases and this comes again from Mr. Sprague's information, 22 of those cases fell out for either poor documentation or failure of vital sign assessment documentation every 15 minutes. 15 PCRs fell out for significant patient care issues including failure to follow regional treatment protocols, and/or regional policies concerning ALS interface.
      The REMAC subsequently rewrote to the, and this was in May 3 of this year, wrote back to this ambulance company and said that okay, we are going to continue to collect the other 54 cases because we said we would collect a hundred. But it's clear that this doesn't look like positive progress. Is it inappropriate for a REMAC to do things like that? I would say no. I would say that's their job. Someone has to be responsible, some organization, some entity has to be responsible ultimately for the quality of care that we give to our patient. I think these are two examples of unfortunate situations which are public relations nightmares, they do not create warm fuzzies, good feelings. But I also think that they have to be addressed and taken care of. It may seem very sterile, it may seem somewhat uncaring, the REMAC has the responsibility to do their job in a sterile, unbiased approach. And to do it any other way I think would be counterproductive to the Regional Quality Improvement system and also counterproductive to what's in the best interest of patient care. It's unfortunate but part of the job of the REMAC is going to be seen as big brother looking over your shoulder, policing if you want to use that. We could use Quality Improvement activities, we could use quality enhancement activities, but that's what it is, it is assuring, making sure that what we say we're supposed to do, what we know we're supposed to do is done. And there is not a very good way to paint that any other way.
      I certainly may be as the REMAC chair need to be a little bit more sensitive as to how the pictures are painted. But I don't know in those two instances how they could be painted any differently. Certainly in the first case involving that individual provider, it's an unfortunate situation. I don't think it happens very often that the REMAC and the Department of Health investigator disagree. But in fact we do. And in fact this very issue was addressed again at the State Council with -- not at the state Council, at the SEMAC with the State EMS Medical Advisory, and he does have to pass judgment. What does optimally mean. Well if we had the patient on a pulse oximeter in the back of the ambulance, and his PO2 was above 90, Dr. Huffner do you think we should necessarily have to hyperventilate that person prior to attempt to reintubation. Well I don't know what his desaturation curve is and where he is exactly, because I don't have a blood gas on him. But I might say no. But certainly in the back of an ambulance, with a missed intubation with someone who is in extremis, and this patient was, it would seem to me that proper ventilation is key. And that's really what this comes down to. It comes down to patient care. I am not apologizing, I guess I am trying to explain at least part of the job of the REMAC and how it isn't always going to have a positive spin. It needs help with public relations. But those activities can't stop. I don't think any of us around this table want those activities to stop. That's all, thank you.

TERI SYMONDS: Did anybody make an attempt to go up and talk to the ambulance corps, sit down face to face, and say this is the letter. This is the issue. If they have a letter, yeah maybe somebody signs for it but how do you know who that is going to. I get letters in my box all the time that aren't addressed to me. They can be addressed to the fire department. I am not the fire chief. But I am allowed to sign for them. So how do you know for sure if the right person received that letter? If somebody sat down with Wayne Ambulance corps and said look it this is the issue, with volunteers you can't just send a letter, here you go have it. You need to sit down.

DR. HUFFNER: Mr. Day did receive that letter and he is the CEO. The medical director did receive that letter. And we are learning now that letters have to be sent return receipt requested.

TERI SYMONDS: But it might not have been shared with the people doing the care.

MIKE SPRAGUE: Mr. Day shared with me exactly what is their problem. He received the letter but the letter has no specific, other than these are the problems that you found. What exactly is their problem. And I can't answer because I don't know. And I guess that's, that's sort of the direction that I am concerned as you know the provider is caught in a catch-22 with the state and right now the REMAC, no one has talked to him. If he had a problem, if somebody had said you should not ought to do that, and this is what you should have done. We could have kept him in the system. He has been out a year. He does not know there is a debate going on back and forth as to what the proper curriculum is. And he is being held out here because of that. He is a good provider and I think if somebody had sat down and said you know, this is what, this is what we found is the problem. Then let's move forward. Suspending with no further action just leaves him out there. Leaves him stuck and the same thing with Wayne. And I think that's really the gist of this: Is let's be more proactive. Because we don't have enough people to set aside until things are over.

TERI SYMONDS: The problem is identified especially in a volunteer agency.

DR. HUFFNER: The May 3rd letter does identify the fact that 22 PCRs fell out for either poor documentation and/or failure of vital sign assessment and documentation every 15 minutes, 15 PCRs fell out for significant patient care issues including failure to follow regional treatment protocols and/or regional policies concerning ALS interface.

TERI SYMONDS: It may have explained everything in detail. I don't know. But I am saying with volunteer agencies you need to sit down with them and say this is the issue. You can't send a letter. A problem is identified, these people work 40, 50 hours a week, they might go on one ambulance call a month, they may show up for a meeting every other month. But you need to sit down with these guys and say look this is the issue. You can't just send a letter. It just doesn't work.

DON DUVALL: I think you need to step back a little and not look at the issue of whether this ambulance is right or this ambulance is wrong. There is a letter here from the STREMAC that says 22 PCRs out of 46 had documentation problems. And the medical director for this ambulance requests that STREMS offer a training on PCRs, he felt this would add a positive note to things. Then a subsequent e-mail that came from Judy which attributed quotes to Dr. Huffner said I talked to Dr. Huffner, he said that documentation is not a problem, at least not as the REMAC sees it. Well if the medical director is coming and saying you know let's do something about this together, but then all the sudden it's not a problem, well, in your original letter in 22 out of 46 cases documentation was a problem. I think the thing that's getting missed is at least in my own mind, I am not debating whether the REMAC is right or wrong in passing the judgements that they are passing. I think the problem lies in how to fix it. Because you know, I have been attending these meetings, and some of these issues are dragging on forever, without any kind of clear resolution or any kind of step toward something positive. And I am not here saying that you shouldn't take that ambulance service to task for their shortcomings, I am here to say when the medical director comes to you and says they got a new guy here, they are willing to do this, let's get something together, let's do it, somebody needs to get something together and do it. Rather than to say well it's not really the problem. It must be a good part of the problem.

DR. HUFFNER: Certainly would look like that to me.

DON DUVALL: You are quoted here as saying it is not a problem.

DR. HUFFNER: Even though my letter says that it is.

TERI SYMONDS: It is confusion.

DR. HUFFNER: There is some inconsistency there.

RON KINTZ: The point made is good. We must remember it works two ways, if they don't understand, they can call up the company as well as we can. I think we need improvement but let's not make it a one-sided incident. Everyone that has a misunderstanding should come to someone and talk to it.

TERI SYMONDS: Our agencies have a problem, they call Dr. Robshaw. If our agencies don't show up to a QA meeting, he is on the phone, where are you, why aren't you there. I am not sure if all medical directors are like that or not. But we are very fortunate to have Dr. Robshaw, because he is willing to go the extra mile to help the volunteers. If he received a letter like that he would be on the phone fixing it. I guess it just needs to be fixed communication wise.

AL LEWIS: Is there a way to develop some sort of ambassadorship that you and Mike and somebody else from the county that has the problem, you make a visitation, say let's sit down and talk about it. To try and clean up this bad or poor communication. I think it would be appropriate, Bill, for you or Mike Seaman or somebody to make a visit to that corps, sit down and talk with them. I mean we're all talking about patient care here and I don't know that they meant to provide bad patient care. I think they need some remedial instruction it seems. Let's reach out to them. They're struggling to stay in business just like so many others are. I agree that we need to do a better job of that. And I know your time is limited and I appreciate that. DR. HUFFNER: Well you have to remember, Al, that I am a volunteer too.

AL LEWIS: Yes, you are and I appreciate that.

DR. HUFFNER: They also have a service medical director who got the same letter. And to say that the problem is purely documentation, I don't think that's, that that's correct.

DON DUVALL: And I didn't say that either.

AL LEWIS: That's part of the problem.

DR. HUFFNER: Part of the problem. Because we know, I heard in somewhere in Mike's writing that in fact some of the decisions not to cancel ALS was because they were closer to the hospital. That's absolutely correct. If ALS is closer behind bricks and mortar, that's appropriate. That's where ALS needs to be. But the bottom line is their service medical director needs to step up to the plate, I don't know if that's happening or not. I don't know, I don't recall the e-mail stuff that I am quoted as saying. I certainly would say that documentation, PCR documentation program is not going to cure what's wrong there, what the problem is. I find it very difficult to understand a corps that knows that the Regional Medical Advisory Committee is, for lack of a better term, policing them, looking at them, would produce PCRs like that. Unless they didn't know. Maybe they didn't know.

TERI SYMONDS: Right, that's a good possibility. Especially if you have a crew that's all brand new EMTs, maybe they didn't have a clue.

MIKE SPRAGUE: The problem is that is the question. Because I listened to them with more of a keen ear and they don't move without ALS. So you know, maybe there is a documentation issue here that we're not connecting. And that's really what I am saying in this whole thing. I am not saying you are wrong. But I think if you identify something then maybe we ought to go with QI and training and figure out who should talk to these folks. Let's get this thing fixed.Losing that provider is huge hole in my system because he is available and he really had at one point and he is kind of caught in this catch-22. And as far as he knows he is just out there in left field some place and nobody cares. And that is, that's that whole morale issue that's gone right down the tubes. He told me the other day he doesn't care, he is an EMT now and has got to go back through and recertify. He has really lost all interest in EMS. Here was a guy who was studying to be a paramedic. This is wrong.

DR. HUFFNER: And he dropped out of paramedicine because of this whole situation?

MIKE SPRAGUE: He was dropped off because he was told he couldn't practice the skills at the I-level during that. Someone told him that so he dropped out. Whether it was right or wrong it doesn't matter.

TERI SYMONDS: It affects everybody in the area, it affects his corps.

DR. HUFFNER: This is on the record now. He dropped out of paramedic class?

MIKE SPRAGUE: Yeah, Corning Community College.

DR. HUFFNER: Because of this, he was relegated to BLS?

MIKE SPRAGUE: Yeah. Actually he was relegated to nothing until he got reinstated; but yes as a basic.

DR. HUFFNER: Well maybe we'll investigate that. Because the issues associated with this are very very complicated. But they are also very very serious. Because I had direct discussions with this provider. And there was clearly a difference of understanding of what is proper ventilation sequencing in a missed intubation. And there was a difference. And the decision that was presented at the REMAC and that was the decision. You should know that that's only been done once. That is the first and only time that we have ever taken a provider off line.

TERI SYMONDS: Look at the outcome of one provider though. All this for one provider.

DR. HUFFNER: All of what?

TERI SYMONDS: I mean it's gone through his whole ambulance corps. It's a chain reaction, it didn't just affect him. It affected everybody on that end of the county.

MIKE SPRAGUE: And the response times have increased because of it. I guess that's all I am advocating, is you need to do what you need to do. But I think we need to come up with a better solution other than end, no communication after that. Somehow we have to keep that going. I seriously think that if somebody were to sit down and retrain him, I don't think he would go against it. I really don't. Because like he is, he is very willing or was very willing to go further.

DR. HUFFNER: Well the reason I brought those two issues is they were handily there. But they are also important I think examples of what the REMAC still must do. And I guess we need to make the results of the REMAC and how those things are done a little bit more palatable. And certainly try to work on that and hope that public relations can help us with that.

AL LEWIS: You also have a statutory responsibility.

DR. HUFFNER: Well we do.

AL LEWIS: We didn't mention that. We do have a statutory responsibility for this region.

DR. HUFFNER: That's correct.

AL LEWIS: People cannot forget that. Cannot forget that. Okay.

BERNADETTE J-OAKES: Can I add, Mike, I want you to know that QI committee is obviously very interested in this whole. But this lull of information comes from the area coordinators to us, we are certainly filters of information. We don't look, the information is cleansed by the time it gets to us. If there is concerns identified such as -- I am going to use pediatrics because that ended up on a positive thing. That we referred on to STREMAC. We were sort of junior direction, training. We're sort of the middleman, not saying we don't bear any responsibility, that's not what I am saying at all. And I feel bad if this could have been handled differently. It was brought as a concern actually from the area coordinator representing that area. And I myself as you quoted in there spoke directly with him, because their medical director works at St. Joe's. And I had the opportunity.

MIKE SPRAGUE: That was a breath of fresh air. He was looking forward to that.

BERNADETTE J-OAKES: And he made me aware, while there is a lot of concerns that were above my head, he wanted to talk with them on a physician level and wanted more training, so I referred that on. But certainly, you know, keep us in the loop because anything that that committee could do, and that's where we're at is what can we do. We don't want to step on toes, we want to identify and correct issues. That's why we don't step on it first quarter, second, issues. Pediatrics I think we watched over, well over 18 months before we made any recommendations so. But thank you for your input.

MIKE SPRAGUE: Welcome.

CHAIR RAJSKY:Anything else to come before Council tonight ?

AL LEWIS: Just so you know, we did have the press here tonight. It will be interesting to see what's in the paper.

CHAIR RAJSKY:To see what is in the Corning Leader here tomorrow.

AL LEWIS: With that, I will make a motion to adjourn.

STEVE BENNETT:Second.

CHAIR RAJSKY:As we do that we need everyone to have the picture taken for the conference. We said we were going to do individual pictures this year, place them on the board, who you are and who you represent. Motion on the floor, seconded. Thank you.

(MEETING ADJOURNED.)

C E R T I F I C A T I O N I hereby certify that the proceedings and evidence are contained fully and accurately in the notes taken by me on the above cause and that this is a correct transcript of the same to the best of my ability. ELIZABETH R. BRUCIE