PRESENT: Steve Bennett, Mary Buth, Jim Chrabaszcz, Keener Cortright, Mark Cowan, Fred Crist, Dave Crowley, Don Duvall, Patti Gressel, Dr. Huffner, Art Jones, Chris Oakes (for B. Oakes), Rick Kimball, Deb Kline, Ron Kintz, Dave Dowdle (for A. Lewis), Bob Rajsky, Dr. Seaman, Mike Smith, Tammy Holbrook (for M. Sprague), Maryann Sweely, Teri Symonds, Mary Ann Teeter. STAFF PRESENT: Judy Blair, Nancy Bush.
ABSENT: A. Davis, M. Colegrove, Dr. Manganaro, D. Sullivan.
GUESTS: Dr. Roger Schenone, Dr. Dominic Romeo, Jim Larson, Elmer Storch, Vanessa Jewett, Gary Lannoye, Patrick Bermingham, Greg Dunn, Ray Colwell, Dan Baker, John May, Ken Sterling.

CHAIRPERSON RAJSKY: All right. I would like to call the Southern Tier Regional Emergency Medical Services council meeting for September to order. Welcome back to all members and our many guests that are with us tonight. In way of agenda items we will go through the agenda. I guess the first thing I would like to do is take a moment of silence for those, all those victims whether alive or perished in the tragic events of September 11th. If we could take a minute to reflect that just for a minute.
     (MOMENT OF SILENCE.)
CHAIRPERSON RAJSKY: Thank you.
     Correspondence: as we have in the past, I need to read in to the minutes the memorandums from the State of New York Department of Health on to those people that have violated state code, those persons or agencies that have violated state code. So they are in our minutes. That's a requirement of us by New York State. So the first is Ray Tennant from Mannsville, New York, a voluntary surrender of his certification from New York State on June of 2001. John Bassani, Jr., from West Sand Lake, New York, surrendered his certification for two years effective April 3 of 2001 through April 3 of 2003. Sean Moogan of Far Rockaway, New York had his certification suspended effective June 14 of 2001. Saratoga Performing Arts Center of Saratoga Springs, New York was assessed a civil penalty of $23,000, they are in violation of Part 18 Code, they didn't file the proper paperwork and have the, they had way more people than their permit allowed. Nicole Dixon of New Rochelle, New York suspended for one year, May of 2001 through May 21 of 2002, was both placed on probation for five years ending May of 2006 and served a civil penalty of $2,000. Joseph Losquadro of Lakegrove, New York, had certification suspended June 1 of 01 through June 1, 2002, and was fined a civil penalty of $4,000. And the last one Vincent Pease of Shokan, New York, had his certification suspended for six months effective May 21 of 2001 through 11/21/2001 and placed on probation for five years which will end May 21, 2006. That's the correspondence from New York State.
     Approval of minutes, they were disseminated from our last meeting in June and I would certainly entertain a motion to approve those minutes.

RON KINTZ: So moved.

PATTI GRESSEL: Second.

CHAIRPERSON RAJSKY: Discussion, any changes? Seeing none, all those in favor signify by saying aye. Opposed? Abstentions? Carried. Thank you.
     Committee reports, Systems Committee was set to meet on September 12 the day after the attacks on the U.S. and they did not meet. STREMAC however did and Dr. Huffner?

DR. HUFFNER: I will handle the SEMAC report first because the SEMAC was scheduled to meet also on the Tuesday of the terrorist activity and that meeting was canceled, so I don't have a SEMAC or a state council report because neither of those bodies met. The STREMAC did meet however on August 14, and you have a copy of the minutes in your packets. It's the longest set of minutes you will probably ever get from the STREMAC, mostly because there are documentations of the revisions made at the meeting to the Regional Protocols that were approved at that meeting.
     You will recall that the REMAC by Article 30 is given the authority to approve transportation, triage and treatment protocols independent of this Council, but it has been our convention, our tradition that all the treatment protocols always come here for final approval. I took it upon myself to provide you with copies of the protocols as they have been corrected and revised. And that was also sent out in your packet. They are organized by color, white being ALS, pink being pediatrics, green having to do with BLS on all levels and the blue are specific to emergency medical dispatch. And I guess I would make the motion that the Council approve the protocols as they have been submitted by the STREMAC, as they have been approved by the STREMAC and submitted to the Council. I make that motion.

CHAIRPERSON RAJSKY: Motion is on the floor to approve the ALS revision.

DR. HUFFNER: Not ALS. There is revision to many protocols.

CHAIRPERSON RAJSKY: Just clarify again for me please.

DR. HUFFNER: All the protocols that have been approved by the STREMAC, I make the motion that we approve them by the Council as well, as a package.

CHAIRPERSON RAJSKY: Motion on the floor.

FRED CRIST: Bob, this was received from Bunny, she wasn't able to be here tonight about the protocols.

CHAIRPERSON RAJSKY: Okay. Motion is on the floor to approve the STREMAC protocol, motion on the floor.

DON DUVALL: Second.

CHAIRPERSON RAJSKY: Discussion?

DAVE CROWLEY: Yes, could I move to vote on these individually, each protocol change?

CHAIRPERSON RAJSKY: You certainly can, you can make that form of a motion.

JUDY BLAIR: Not while there is another motion on the floor.

CHAIRPERSON RAJSKY: You would have to rescind the first motion, defeat the first one -- rescind.

JUDY BLAIR: Unless Dr. Huffner is willing to accept.

DR. HUFFNER: No.

CHAIRPERSON RAJSKY: So you don't want to rescind?

DR. HUFFNER: No.

CHAIRPERSON RAJSKY: Motion on the floor. It was seconded. So we have to vote on that motion that's on the floor and then we can do another motion after that.

DAVE CROWLEY: We're still on discussion?

CHAIRPERSON RAJSKY: On discussion.

DAVE CROWLEY: Okay. On the EMD issue, I have heard a tremendous amount of discussion from a number of different fire departments in Chemung County that are not, don't understand the revisions thoroughly. And I know some of the departments have gone to STREMS to check on the revisions which you know they were asked to do, and they did. And still there are many questions out there that I have heard as far as the revisions go.
     And are the revisions in the best interest of people who need EMS help. And I have one question on the EMD revision that I would like to ask the doctor is to what advantage to anyone who summons for help, EMS help, is a 10 minute delay, potential 10 minute delay when there could be people there as soon as between two and 3 minutes?

DR. HUFFNER: Is that for me or for?

CHAIRPERSON RAJSKY: Yes.

DR. HUFFNER: Certainly not. It would be best if we could get the emergency physician, the emergency nurse, cardiologist and a transplant surgeon also to respond to their door. That's not the issue. The issue is what is in the best interest of the system. The system is composed of providers as well as patients. And we're not without limited resources. And by limited resources I am not talking about money, dollars or anything like that. I am talking about the most important resource which is our providers.
     We must give attention to the efficient use of our EMS providers. When they are not needed, there is no reason to tone them out, get them out of bed in the middle of the night to rush and put our communities at risk by rushing around with lights and sirens and ambulances when they're truly not needed.
     And the emergency medical dispatch protocols, each one makes an assessment, that assessment was done by physicians, emergency medical dispatch providers and fire chiefs, an assessment was made of each one of those possible presentations, knowing what each level of service brings to the potential patient, knowing what that potential, that patient's potential diagnosis is, and then coming to a rational decision about what's needed. Some of those weren't exactly cut and dry. Some of those a judgment was made saying that yes this patient is critical, there is no question that everybody comes. There is some patients that there is no question they probably could be best served by being handed a voucher to take a taxi to the hospital. But there is also another class of patient, that it's okay, in the judgment of that group of people, it's okay for a time factor to be factored in. And that's a judgment of those people that came up with those protocols.

DAVE CROWLEY: I do know that a number of providers do not agree with that position. And I would ask this Council to make every attempt to get these providers more fully informed about these changes before it is approved.

CHAIRPERSON RAJSKY: Dr. Huffner, would you describe the process in which protocols --

DR. HUFFNER: Certainly. This is germane to the entire discussion. We followed the State Emergency Medical Advisory Committee's procedure for protocol, regional protocol approval which means that the protocols are developed and drafted, they are sent out, return receipt requested to the area hospitals' CEOs, the president of their medical staff, the emergency department nurse managers, the emergency department medical directors.
     In addition because these protocols affected all levels of service from emergency medical dispatch all the way through ALS level, each EMS service in the region, whether they are ALS first response, BLS, BLS ambulances, ALS ambulances, they all received a copy of those protocols. Comments were received -- excuse me. They were sent out and they were given, we're required of the 30 day waiting period. Our protocols were mailed out June 20, and with a deadline for comment of August 1 which is more than the required 30 days. And those comments were received, collated and considered by the STREMAC when we made those decisions.

CHAIRPERSON RAJSKY: Okay. Further discussion?

MARK COWAN: I have some concerns about the ALS protocols with regard to suspected acute myocardial infarction. I know there has been some concern among the medical community, in particular the cardiologist specialists with regard to the issue of emergency angioplasty, its availability and the impact that this protocol change may have on the ability of EMTs to, as it says here, EMTs are to assess whether patient has a large anterior infarct, for example, whether that's really something that can be done in the field by an EMT. I know we have some doctors here tonight who have some questions and concerns. Bob, how will these physicians comment?

CHAIRPERSON RAJSKY: I guess they can, I would allow comment. The problem is that these are approved protocols from STREMAC, we, the Council has always done it as a courtesy to adopt, have on record adoption of the protocols. We're unique in this area that we have included the physicians in our council as a committee of the council. Most areas it's separate. And really operations were told this is the way it's going to be and that's it. So here we kind of had the luxury of having the physician's input, develop the protocols, send it to all the parties that are, that we feel are, the ones that have a vested interest in how to, how to best practice the emergency medicine.

MARK COWAN: Was it sent to the cardiologists in the communities?

DR. HUFFNER: As I said it was sent to the presidents of the medical staff, the CEOs of the hospitals, the emergency department directors and the nurse managers as well as the other people I listed.
     But let's be very clear about that protocol, Mark, I hope you have it in front of you, it's page nine of the white sheets, suspect acute myocardial infarction. And physicians here should know this, there is a big box in the middle that says Medical Control. Many may not know what that means. Essentially everything above that box is performed by the EMS provider independent of direct supervision by a physician online, real time via radio. That's part of offline Medical Control, that's part of what the protocols are.
     Everything below that box and all the providers know this, everything below Medical Control is a decision process that involves a physician. That means a physician must be contacted to make that decision to consider transport to an angioplasty center. That decision is not made independent of a physician's order. Which means that when a prehospital provider encounters a patient like this, before they can -- no, not before, the decision to consider transport to an angioplasty center is one made by Medical Control, by the emergency physician in the department who is responsible for the care of that patient. Which means that, and we know that Medical Control emanates from the five area hospitals in our region, Ira Davenport, Corning, Schuyler, St. James, Arnot, and St. Joe's, that emergency physician is the one who actually considers transport to an angioplasty center if any of those bullets are present. That decision is not made independent of physician direction and guidance.

TERI SYMONDS: Then it should say that, it should say it's the ER physician's.

DR. SEAMAN: That's what Medical Control means.

TERI SYMONDS: It doesn't say it's the ER physician's decision.

DR. SEAMAN: That's who Medical Control is.

DR. HUFFNER: Medical Control comes from nowhere but the emergency department physician.

DR. SEAMAN: That's what that means and what it's always been.

TERI SYMONDS: But it doesn't say.

DR. SEAMAN: It says everything it needs to say.

DR. HUFFNER: Okay. But the key thing here is remember, Teri, that this is part of the adult ALS protocols and that is explained in the beginning of the ALS protocols what Medical Control means. All the providers around the table of course know what that means. Independent people who have never seen them may not know that, you are absolutely correct. Absolutely.

TERI SYMONDS: I am just thinking of EMS agencies in my area, they are not.

DR. HUFFNER: They know what Medical Control is.

TERI SYMONDS: Right but if it's in black and white, you need to contact Medical Control, you know or the physician to make that decision, they are going to do it. But if they say, contact Medical Control, they are just going to say well I think this guy needs an angio.

DR. HUFFNER: Then they would be violating the protocol.

TERI SYMONDS: Right.

DR. HUFFNER: And that's what's clear. If they don't contact Medical Control, that's a violation of protocol.

CHAIRPERSON RAJSKY: Go ahead, Fred.

FRED CRIST: Okay, where we're at a lot of times we can't use radios, we can't use the telephones.

DR. HUFFNER: That's right.

FRED CRIST: We're dead either way, what do we do in that point?

DR. HUFFNER: It's very clear, you know what you are supposed to do. Not go any farther.

FRED CRIST: Right. Where it says Medical Control.

DR. HUFFNER: You don't go any farther.

FRED CRIST: Hopefully you have an after burner on the ambulance.

DR. HUFFNER: You don't go any farther, so if a communications failure in our region, and this is not consistent across the state, you are not allowed to proceed below where it says Medical Control.

CHAIRPERSON RAJSKY: In that clarification too, Medical Control, what Medical Control facility would be contacted?

DR. HUFFNER: Let's ask, well I know what the answer to that is, whatever the patient identifies as where they want to go. If they want to go to St. James, that's the Medical Control facility that they will contact. It's patient preference that identifies Medical Control.

DR. SEAMAN: Or in the absence of that, the one you can reach, which plays a role throughout our region.

DR. HUFFNER: In the hinterlands.

DR. SEAMAN: As you may or may not be able to reach the place that you want.

DR. HUFFNER: And we have some unique situations in Steuben County where Medical Control emanates from a hospital that's quite a distance from where, but that's a good thing, it's not a bad thing.

CHAIRPERSON RAJSKY: Any other discussion?

ART JONES: Question, for obtaining the 12-lead EKG, in protocols in the past when we have had a new method of care, new piece of equipment required, there has been an implementation time. I see it's not, if available, on this.

DR. HUFFNER: That's correct. The American Heart Association has determined that 12-lead prehospital EKGs are class I recommendation. The REMAC struggled with that issue because it is going to cause a financial hardship.

ART JONES: $20,000 a unit.

DR. HUFFNER: That we would not back down from that, that that would be required. And the implementation dates for all of these protocols has not been set. Because not only because of that but because of other issues as well, in terms of in-servicing, but certainly the cost implication of requiring 12 lead EKG and the reliability of being able to transmit them and all those issues still has to be worked out. But you are absolutely correct.

FRED CRIST: So this is going to be a class I recommendation?

DR. HUFFNER: It is a class I recommendation, use of prehospital.

FRED CRIST: But we're not going to implement it until we have some way of --

DR. HUFFNER: A recipe of how long it is going to take until we can get this done, some kind of a plan.

FRED CRIST: Okay. And that's still on hold then.

DR. HUFFNER: Absolutely.

FRED CRIST: Good.

MARK COWAN: I guess that would be my question, is not all areas have the capability of 12-lead EKG and so on and we have a protocol here, does that become kind of confusing, but are we approving something that will not be implemented until all these things are in place.

DR. HUFFNER: That's correct.

MARK COWAN: Why are we passing on a protocol at this point when we really haven't, rushing to do that when we really haven't looked at all the issues in terms of for example the availability of emergency angioplasty within the area, we haven't talked with the practitioners who perform it or the hospitals who provide the service.

DR. HUFFNER: That's not true.

DR. SEAMAN: That actually isn't true.

DR. HUFFNER: We have talked to the provider of angioplasty in our community. But I don't know if that's the real issue. The issue of 12 leads is we realize there needs to be a phase-in time to allow the services that don't have this. But it's not going to be an open-ended date that they have until 2005 to get a 12 lead. We will take the necessary steps to bring in the services that don't have it. And at the same time frankly do everything we can to assist them in getting that and arrive at a reasonable date for implementation.
     The emergency physicians did not take lightly the issue of the angioplasty center, there were discussions with Dr. Kahn, there were lots of discussion about the issue of using the word consider as opposed to transport, because the American Heart Association also lists transport to an angioplasty center with those bullets as a class I recommendation. You certainly could read that and make an assessment that that certainly isn't of the same flavor that we have taken when we're talking about other class I recommendations i.e. requiring that that occurs. We also are very cognizant of the fact that we don't operate in shall we say the friendliest of situations in at least Chemung County when it applies to this. And we're not about to take the stance that we as the REMAC were going to take, if you will, the flack associated with making that decision. Know that some emergency physicians at that meeting wanted very strongly to have the transport to an angioplasty center in the same flavor as other class I recommendations i.e. you shall do this so that they are removed from having to make that decision, i.e. on the radio given someone who is aged under 75 and in cardiogenic shock, they are going to have to make the call, do you come here or do you go to the angioplasty center. Some physicians seemed to think it would be better to say not consider, but you shall do that if that exists. But that would have created even more conflict we believe in Chemung County.

CHAIRPERSON RAJSKY: Any other discussion?

MARK COWAN: In terms of the application of that, are there certain time frame recommendations of how long it should be before you go to or how you should get there in terms of maybe if you are in far reaches of Steuben County, should you be looking at some other kind of transport? Such as helicopter or something like that? I mean how far does this go? That's the question. Or is this something that only applies to a limited geographical area in proximity to an angioplasty center?

DR. SEAMAN: I think it is going to be very different throughout the region, because our region is so very different when you go from northern Steuben in to Chemung. And Chemung you have the relative luxury of several hospitals in a geographically close proximity. Northern Steuben you have no such luxury. I think the way this will become most useful is through the application of 12 lead in the field, which we do support. And it will have to be formed in over time with the improvement of cellular function in the area. And that is happening. The cost of the units for transmission is coming down. Rick recently quoted me some prices that still make you choke, but not what they used to be. We can now buy equipment for much much less than we did in the past. But I think the, this becomes, the onus rests on Medical Control to try to help make these decisions based on some objective information, based on the history from the EMS system, from the paramedic on the scene, you put that together and you try to make your best decision. So I can't give you a black and white marching order on that.

MARK COWAN: I guess the reason I raise the question about time is that in Chemung County we have two hospitals that are pretty close together, and currently if a patient comes in to St. Joseph's Hospital and it is determined that they do need angioplasty, they are transported to Arnot Ogden and by the time they are ready to have the emergency angioplasty then the cardiologist is available. And that availability does change from time to time depending on the availability of the cardiologists, what they're involved with and so on. And I guess my question in terms of the time issue is whether that really makes a difference in time, whether you go to St. Joe's Hospital or go to Arnot in terms of emergency angioplasty.

DR. SEAMAN: That becomes more of an institutional factor, doesn't it.

MARK COWAN: Well that's why I am saying I think we need to involve the institutions and the services in the discussions so they understand what the parameters are.

DR. SEAMAN: They originally were. Director of the cath lab came and spoke to us at length, an entire meetings' length, and his comments were sent back to us at our request in his own verbiage before any of these decisions were adopted to adopt AHA Guidelines 2000, which you can see are pretty onerous, huge changes.

MARK COWAN: I guess within the Elmira medical community there is a lot of concern among the cardiologists whether this is something that is really an issue.

DR. HUFFNER: We haven't heard any of that, Mark. We had a 30 day waiting period, didn't get any input from any cardiologist. We had Dr. Kahn participate in.

MARK COWAN: Was he invited specifically?

DR. HUFFNER: Yes, he was.

DR. SEAMAN: As the director.

MARK COWAN: I guess the issue being I think at the timing when you put protocols out in the middle of the summer, that sort of thing, a lot of people I think don't see them. And a lot of people that might, and I think whenever you are looking at a protocol that involves some kind of service like this, that you really, we would be advised I think probably to involve and make every effort to involve the physician community who is more acutely involved with the process.

CHAIRPERSON RAJSKY: Again, I want to make it clear and I still don't know if it is, that the medical staff, the medical directors for each institution of the six hospitals in the Southern Tier were given a copy of this and were told to comment along with the CEOs of each hospital and the others that were outlined by Dr. Huffner. Dr. Seaman or Dr. Huffner, maybe it's appropriate to kind of outline what REMAC is and how we come to, how do they come to the decision, who is on that, I don't know if we discussed that.

DR. SEAMAN: Well it's basically whoever volunteers which probably lowers the participants' IQ by at least 20 percent. So there we sit, you know doing this work, trying to figure out what's best for our region, tailored to our region, every region being different. Who is that? As I said anybody who will volunteer, right now physician representatives from throughout the region, Warren Klick serves Schuyler, myself serving Schuyler and Corning, Dr. Huffner with in-depth knowledge of Chemung County, Dr. Manganaro, St. Joe's, and Dr. Robshaw from Hornell, Naber, and Dr. Chipman, lest I forget. And Dr. Bernett is our newest member who has not yet joined the group. So that's the group that has to make the decisions.
     When these were turned out, when they went out in the mail for comment, the only people who really commented were, the most were the people on the committee. I was really surprised. I really expected letters with plastique and other accoutrements coming. But we really didn't hear much. If our timing was bad, we worked through the summer to do it because we felt it was pressure of time and an important issue. And we found that when we delay something, a meeting, it usually reflects, ends up with a six month delay in process or thereabouts. Dr. Huffner shares that view, but we can lose six months in a heartbeat it seems. My understanding having attended these state updates for 2000 was that these really, the goal was to have these in process by June of this year. So we were behind by the time we had sent out our --

MARK COWAN: When you say in process, you mean being reviewed.

DR. SEAMAN: AHA's ideal was to have Guidelines 2000 written into your protocols by June.

DR. HUFFNER: Operational.

DR. SEAMAN: Operational by June.

MARK COWAN: Are you aware of any other regions that have them in operation at this point?

DR. SEAMAN: I think Monroe.

DR. HUFFNER: Several of them across the state.

MARK COWAN: When I called around I haven't found any that has.

DR. HUFFNER: No EMS regions that have enacted changes of AHA 2000?

MARK COWAN: No.

DR. HUFFNER: There are many. There are many.

MARK COWAN: Or maybe as indicated there are many areas that don't have 12 lead capabilities.

DR. SEAMAN: That's a wide-spread problem with finding the technical means to communicate well, and with any reliability.

CHAIRPERSON RAJSKY: Great. Further discussion?

DR. SEAMAN: In closing let me just answer finally that the fact that we accept these tonight or not, it's an ongoing process. We with pain meet each other every year to look at another section of the protocols. It will be pediatrics, followed by adult by -- and it's a never ending loop. It's kind of like being in a terminal code, patient never dies and you never die, so you keep going on. That's the process which we go through. And this, since it is, we knew it was a hot issue when it went out. We certainly felt it was not going to make everybody happy, Lincoln would have been correct on this one. We expected feedback. But we really expected it in the mail prior to this meeting. We're open to your feedback any time. I think that as we have experience with these, we're going to find out what works and what doesn't. My own personal feeling is that when these were designed they really had a large city in mind. It just smacks of that when you, you say well, who in their right mind would transport to the angioplasty center if you were in Dundee. Well you know, Donny, who?

DON DUVALL: In actuality, as I looked at the protocols, I was kind of excited because there have been patients over my experience who couldn't have thrombolytics for one reason or another. And the AHA Guideline is to the cath lab within an hour, we can make that from Dundee, and if that's what a patient truly needs and our medical director agrees to that, then.

DR. SEAMAN: But this opens the door -- I guess I didn't pick some place far enough away. This opens the door to what you said, Mark, was how is it going to play into transport. What transport system do we use, Donny has somebody in Dundee, maybe flight is the best methodology. Maybe, you know rather that same patient who would have stopped at Schuyler or the person, you know midway between Noyes and Ira Davenport who might have stopped at IDM, maybe they get flown to reduce time, because they are clinically unstable, but is that going to be improved by stopping at a hospital without angioplastic capability? That's what we have yet to learn.

MARK COWAN: That's why when you look at something that maybe is potentially as you know beginning to pick up patient and take them by air ambulance is a pretty serious change. And I think that's why it really, something like this takes a lot of thought and a lot more communication with the service providers at all levels. It's not, I don't think it's a simple, although it's I know you think you appreciate that, it's not simple.

DR. SEAMAN: When you see it in black and white.

MARK COWAN: I tend to be one of the one who likes to see things, figured out a little bit more upfront than, you know, I mean there is obviously a lot of things that got to be figured out before it can be implemented. Even in Chemung County.

RON KINTZ: The doctor back here?

CHAIRPERSON RAJSKY: Members first then.

RON KINTZ: I probably should keep my mouth shut but I am confused now that Donny said, if a patient has got a cardiac condition, and they want to go to a certain hospital, regardless of what hospital that is, if the decision is made to go to the other one, maybe more distance away, it's got to be by the ER doctor, right?

CHAIRPERSON RAJSKY: Correct.

RON KINTZ: So no one is really saying here as I understand it, that for example Mark, if patients wanted to come to St. Joe's, they are going to come to St. Joe's, they are going to bring them to you. It is going to be your doctor in ER that says don't do it if that's the case.

DR. HUFFNER: That's absolutely correct.

RON KINTZ: I am confused.

DR. HUFFNER: You have, that means with grandma with her esophagitis complaining of chest pain wants to go to St. Joe's, that's where she is going. Now if grandma has a 12, having chest pain and she has a 12 lead EKG that shows a huge anterior infarct and she is in cardiogenic shock and she is ineligible for fibroid therapy and her systolic blood pressure is less than a hundred and her heart rate is more than a hundred and she has got rales one third of the way up, they are still going to call St. Joe's, if the St. Joe's ER doctor wants to take that patient, that patient goes to St. Joe's. That's what the protocol says.

RON KINTZ: Thank you.

CHAIRPERSON RAJSKY: Art.

ART JONES: Thinking back to the springtime, one of the STREMAC meetings we talked about maybe trying to identify the number of patients that would fall in to that category. Were we ever able to pursue that?

DR. HUFFNER: No, we did not.

SPEAKER: Is it okay to kill a few or let a few pass away, the numbers don't factor in all that much.

ART JONES: To identify how many patients fall in to this criteria of cardiogenic shock, talking about trying to capture that.

DR. HUFFNER: The numbers actually don't make a difference though, whether it's one patient or a hundred patients. The protocol still should stand, it still should apply.

ART JONES: Would it also give us an idea of the impact on us as a system, I think that was the discussion.

DR. HUFFNER: That impact shouldn't affect the medical decision making process. Unless, well except if the numbers were such that they would overwhelm the capabilities I suppose of the angioplasty center. We may find that out after this gets enacted and we start doing this.

DR. SEAMAN: The fail safe here, not to intrude, Bill, the fail safe here is the Medical Control. And the fact that the paramedic is accessing Medical Control, maybe because of their own concerns, maybe because it's dictated. If either are uncomfortable with the patient's stability and ability to go on, the process stops, and you go to closest facility. I mean that's, that is I think the implicit understanding, the tacit understanding, the written understanding; if it is not the understanding then it needs to be the understanding that if all parties aren't comfortable with the move then they come to you. And that is the part we're going to have to learn about over time from feedback from our cardiology colleagues when they get a patient, he should have been there sooner, they review the case, say you could have done this differently, well listen. But I think it will be a slow start. We're not going to jump into this feet first and say everybody goes, everybody must go immediately. It is going to have considerable judgment interposed in the system by the emergency docs, which is why we're issuing 3 new clean sets of underwear to every Medical Control physician because they are going to need them.

TERI SYMONDS: Can we have a list of those hospitals that offer this? I mean if you have a rent-a-doc at St. James from Rochester, they are not going to know where you are closest to.

DR. SEAMAN: I am sorry I didn't understand that question.

TERI SYMONDS: I just want a list of the agencies that provide angioplasty. I am saying if you have a rent-a-doc in the ER, they are not going to know what agency, where to take the patient, which is closer.

DR. SEAMAN: Yeah they will.

TERI SYMONDS: Okay.

DR. SEAMAN: And if they don't that's a real problem on the part of that hospital. That's part of your initial introduction to hospital A, B or C is who is where, who the consultants are.

TERI SYMONDS: It still would be nice to have a list of agencies of who provides, at least for the providers if nobody else.

DR. SEAMAN: That's really an indoctrination question for each incoming emergency physician. In this area we're fairly lucky because we have a fairly stable cadre of ER docs that are familiar with that.

FRED CRIST: Right now the way it is set up. Hopefully it is going to change, it is either 60 miles to Rochester or it is 60 miles to Elmira, take your pick.

DR. SEAMAN: That's what we mean about regional difference, logistical differences within the region, because we're such a large region. I don't think there is anything in this verbiage that says that the angioplasty center of choice becomes the one that's in your region, if it's equal distance to the other that's not in your region.

CHAIRPERSON RAJSKY: Dr. Romeo you had a comment.

DR. ROMEO: I think the physicians that are here tonight primarily practice at one specific hospital in the Elmira area, and our concerns really have been answered by Bill. We were concerned about safeguarding the wishes of our patients that wanted to come to the hospital we primarily practice in. And if Medical Control is going to be the final choice in making that decision, then that's the way it is going to be, we really I think our concerns have been answered. We didn't come here to debate the merits of primary angioplasty or your protocols which are fine, we just wanted to safeguard the wishes of our patients, and that's why we had this turn out. Because there was some concern that that might not be the case.

DR. HUFFNER: Who gave you that concern Dominic? It fascinates me, how did you.

DR. ROMEO: I think that's a perception that has pervaded through this community since I have been here. Now whether it exists or doesn't exist, I don't know. That's just a situation that's existed and you know it's black and white, you know whatever you want to call it. It just, it exists here in this community. Two opposing forces that hit heads all the time. And it's unfortunate that occurs, nobody wants it to occur. And that's what happens. And we're just concerned about that. It's a perception and sometimes patients of ours wind up at the other hospital against their wills and that's, for whatever reason, and that further promotes that perception. But I can't give you anything specific.

DR. HUFFNER: Okay. Thanks.

RON KINTZ: I agree with you, Dr. Romeo, I am in the middle of that every day. And these patients wind up, end up at the wrong hospital, honestly I think if I can know about these cases within the 3 months of them happening, we could probably, you know get the history of why it happened. There are state rules and regulations that make our paramedics make certain decisions. But I can guarantee all of you that we make no decisions to favor or disfavor a hospital, we don't do that. If, I am in the middle of this all the time, you got to forgive me for saying that but I am. I just want to say if you know something I don't know, please tell me right a way. Because I would like to know it. If we got somebody doing something wrong, we will change it. But really we do have some state laws that we have to obey. Maybe we don't like them, and I am sure sometimes your people don't like them and my people don't like them, but we got to do it.

CHAIRPERSON RAJSKY: Any further discussion on the motion that's on the floor?

JIM CHRABASZCZ: Call the question please.

CHAIRPERSON RAJSKY: Call the question. All those in favor of calling question signify by saying aye. Opposed? All right. So the question has been called. The motion on the floor, can we have it restated?

DR. HUFFNER: The motion is to approve the protocols as approved by the STREMAC and submitted to the council in the packet that includes adult, pediatric and basic and emergency medical dispatch protocols.

CHAIRPERSON RAJSKY: Great. Thank you. All those in favor signify by saying aye. Opposed?

CHAIRPERSON RAJSKY: If you can raise your hands. All those in favor signify --

DR. HUFFNER: Mr. Chairman, I will request roll call vote.

CHAIRPERSON RAJSKY: Okay. Motion made for roll call vote, everybody in favor of that?

DR. HUFFNER: I don't think you have to vote on that. If someone asks you got to do it.

JUDY BLAIR: Okay. For roll call vote I will read through the list and call your name. You can accept the motion, you can reject the motion or if you chose not to vote you simply say present. Your other option is to pass and I will come back to you later. Okay.

DR. SEAMAN: Can you restate the motion?

DR. HUFFNER: No, we have done it several times, twice is enough.

JUDY BLAIR: Also if you are an alternate, if I call a name and you are that alternate, state your name first then your vote so I know. Steve Bennett.

STEVEN BENNETT: Accept.

JUDY BLAIR: Mary Buth.

MARY BUTH: Reject.

JUDY BLAIR: Paul Card. Not here and didn't send an alternate. Jim Chrabaszcz?

JIM CHRABASZCZ: Accept.

JUDY BLAIR: Mark Cowan?

MARK COWAN: Reject.

JUDY BLAIR: Fred Crist?

FRED CRIST: Accept.

JUDY BLAIR: Dave Crowley?

DAVE CROWLEY: Reject.

JUDY BLAIR: Allen Davis? No alternate. Okay. Don Duvall?

DON DUVALL: Pass.

JUDY BLAIR: Patti Gressel?

PATTI GRESSEL: Accept.

JUDY BLAIR: Dr. Huffner?

DR. HUFFNER: Accept.

JUDY BLAIR: Art Jones?

ART JONES: Accept.

JUDY BLAIR: Rick Kimball?

RICK KIMBALL: Accept.

JUDY BLAIR: Ron Kintz?

RON KINTZ: Accept.

JUDY BLAIR: Al Lewis?

DAVE DOWDLE: Dave Dowdle for Al Lewis, accept.

JUDY BLAIR: Kathy Lunney? Absent. Dr. Manganaro, I know he is not here. Is there an alternate? Okay. Bernadette Oakes?

CHRIS OAKES: Chris Oakes and deny.

JUDY BLAIR: Bob Rajsky, I will come back to you, chairperson can't vote right now. Dr. Seaman?

DR. SEAMAN: Accept.

JUDY BLAIR: Wendy Shutter? No alternate? Mike Smith?

MIKE SMITH: Accept.

JUDY BLAIR: Mike Sprague?

TAMMY HOLBROOK: Tammy Holbrook for Mike Sprague, accept.

JUDY BLAIR: Dick Sullivan? Maryann Sweely?

MARYANN SWEELY: Accept.

JUDY BLAIR: Teri Symonds?

TERI SYMONDS: Accept.

JUDY BLAIR: Mary Ann Teeter?

MARY ANN TEETER: Accept.

JUDY BLAIR: Don Duvall?

DON DUVALL: Accept.

JUDY BLAIR: Okay. Mr. Chairperson, you don't need to vote. I have 16 accept and four reject.

CHAIRPERSON RAJSKY: The motion carries. Thank you. Further business, Dr. Huffner?

DR. HUFFNER: The only other thing that I wanted to mention in my report has to do with the minutes of the STREMAC meeting. The state requires that the New York State Emergency Medical Advisory Committee requires that all ALS protocols have formulary, formulary is essentially a document that lists all the medications that we use in our region, and a, if you will, a copying of certain amount of information taken right out of the PDR. We're in the process of doing that now and compiling that. That will actually be a, hopefully approved at the next STREMAC meeting scheduled for October. And that also will come back here. It's more of a teaching document. It will be included with both the pediatric and ALS protocols. But I should at least make you aware of that.
     The key issues associated with protocol implementation, I think we talked about this. There are a number of issues associated with when these protocols are going to actually be put in to effect. Again, a financial impact of requiring new and different pieces of equipment, all the way down to the political ramifications of changing the emergency medical dispatch protocols, all will be factored in. The hope is that we will be able to do a one big fell swoop type of an update in the region, and again picking multiple venues, hopefully multiple nights so that we can acquaint all the regions with all the different protocols, because they apply to all the different levels. So that the hope is we would be able to have an evening where at least probably likely for an hour to two hours we would be doing an update, an in-service on all these protocols including apprising the region about the changes in emergency medical dispatch. Even though Schuyler and -- Schuyler's not done yet, that may have to be, if you will, teased out and redone, because obviously Steuben doesn't have it. But there has been enough I think I would say there has been enough paper written about the issues that I am sure that people, we don't present them formally we would at least need to talk about them and what they mean in terms of EMS.
     The only other issue that I did want to mention to the Council is that we have added yet another physician who is willing to volunteer and Dr. Bernett has volunteered to become a member of the STREMAC. As you recall we do have preserved rules of governance and operation and we're also a fulfilling body and we're now going to add another member to our roster. And Dr. Bernett hopefully will be joining us at the next meeting.

CHAIRPERSON RAJSKY: Thanks. Questions for Dr. Huffner? Seeing none, we will move on to executive committee, actually training. I am sorry. Training, Maryann?

MARYANN SWEELY: We met this evening, the last minutes from training committee was from May 10, 2001, they were approved with no changes. We had no courses to approve. We did discuss current classes and most of them are all full. There are, there is a paramedic refresher coming up October 24 and will run until December 5. Corning is in the process of running EMT, original EMT refresh, CFR original and refresher. And those four classes are all full. Hornell is in the process of running a basic EMT and a CC course, as is Patti from Arnot. Instructor approvals we had none this month, course evaluations we had none, we'll be doing those the next time we meet. We didn't have any courses throughout the summer.
     One of the goals that this particular committee set up was following through with the coaching the emergency vehicle operator course for which we had 3 of our CICs go to Albany and become trained in this. One was Don Duvall, Tina Goodwin and Bruce Erway. That's really been in a holding pattern since DOH seems to have a few other directions at this time. And we need to wait to hear in them before we can proceed with offering that course in this area. But it will be held here as soon as we get the green light.
     Other business we had a Schuyler sponsorship renewal on the table. There were a few questions that need to be answered. The vote for approval was delayed pending this further information is sent to the committee. Don Duvall gave us a report, if you could give us a brief report please from the Albany meeting regarding critical care courses I would appreciate it.

DON DUVALL: The State Department of Health has rolled out new intermediate and critical care curricula which are due to take effect for all classes starting after January '02, and for any classes testing after June of '02.
     Some of the major changes are that the curricula has been brought in line with national standard curricula, the critical care program is directly linked or closely associated with the national standard of intermediate. And now appears that the New York intermediate is kind of the odd class. It's done in module format, the intermediate program in New York will be the first four modules of the critical care program minus the pharmacology section. And lots of new skills added to the state curriculum, on tubes and interosseus -- so forth. But the other big change is in clinical experience and field internship. And that's due to be competency based rather than hour based. So it looks like a new change.

MARYANN SWEELY: Any questions to Don? Thank you, Don. Certainly in part of the training committee is to assure continued quality assurance within our educational ranks here. And an issue was brought up by Vanessa who travels around as you very well know for the defib classes within the tri-county area. There seems to be a variance in information that's being given, possibly by some of the instructors. She is running in to some questions from students saying that no we haven't learned this way. So to try to improve this and assure quality assurance, we're going to be developing a system where Vanessa will document the issues that the students have directed to her, those in turn will be handed over to STREMS and the sponsor, the sponsor will then again, including the medical director, a team, a circle communication, if you would, and the instructor will be involved here, again so that we can make sure that the information, the education that is being provided to our EMS personnel is consistent and correct. That was it.

CHAIRPERSON RAJSKY: Great. Thanks. Questions for Maryann? Seeing none we will move on to executive committee. Executive committee actually met twice since our last meeting. We met on September 7th with the CEOs or representative of the CEOs of the six Southern Tier regional hospitals. And the purpose of that meeting was to outline the current issue of restocking. Where it has been, where it currently is and how we can work together in the future to make this an operational deal.
     A meeting prior to that, the council executive committee charged me with 3 things, one meeting with the CEOs or their representatives regarding this issue, and then two writing to the Health and Human Services Office of Inspector General's for their interpretation of what we currently do, currently do and have them make a ruling on that. And the third thing, oh is to keep the county, local and county governments officials apprised of the issue of restocking. So those are the 3.
     So the first obviously has been done. We did meet with them on September 7. Good informational meeting, it lasted about an hour and a half. And at that meeting the hospitals asked that before we send for an official opinion from the OIG that we would give them the documentation that we're going to send so the hospitals could have some input, so if they had additional questions and wanted to ask them we would include that so we would get a one shot deal from the OIG. Which makes a whole lot of sense. That actually is in your packet, it's labeled policy for Southern Tier regional hospitals, policy for ambulance restocking by hospitals. That's the packet, that's our final draft that we're going to send to the six CEOs of our hospitals for their input. Any changes, additions that they would like to do we're going to send that out to them tomorrow.

MARY BUTH: Can I ask a question. I notice on the standard list of restock items, there is a lot of generic things. Several pages back there is a more specific restocking form with a lot more detail on them which is fine. But the standard list of restock items doesn't for instance, at least I don't see it anywhere, I don't see meds, there are some other items on this form that aren't on the list. So I'm just not sure whether the list needs to be, the list needs to be expanded just a little bit?

TERI SYMONDS: I was thinking of blood draw kits.

CHAIRPERSON RAJSKY: Yeah I think the last line, pharmaceuticals and other standard contents of a standard drug box are listed in the -- yeah that should be included. That should be included and it virtually is, that is the last page of that. We certainly can clarify that, Mary.

MARY BUTH: Yeah if that's meaning this. I was just concerned that there were things on this that weren't on your list, that's what I was saying.

CHAIRPERSON RAJSKY: The last page is absolutely an inclusive list.

MARY BUTH: That was my question. My question was is it okay that there are things on that list that aren't on one two 3 four items on here. If it's not a big deal that's fine.

CHAIRPERSON RAJSKY: They really should be the same list. Good. If there is anything else that people see in the next day or so let me know.

DR. HUFFNER: Bob, make sure that this list is updated with the new protocols, lactated ringers isn't included in here, there is a couple, I am not exactly sure, the formulary list, Judy has the current formulary list, just make sure they are all in there.

CHAIRPERSON RAJSKY: I will do that before that goes out tomorrow. Those lists should match so we will make sure. Thanks. Okay. So that was the executive committee on 9/7. We met just, also just met just prior to this meeting tonight. And looked at membership. There are four members who will be asking for clarification, whether they want to come back. One has been on leave of absence for six months. We're going to find out the status of that person. So the four that are up we're going to ask their desires for another term, is Mary Ann Teeter, Alan Lewis, Morgan Colegrove and Jim Chrabaszcz, so you will be getting correspondence from us shortly regarding your wishes. And that's the executive committee report. As Dr. Huffner says, State Council was canceled. Quality Improvement, does anyone have a report for Quality Improvement? We met in August?

NANCY BUSH: The minutes were not in the packet.

CHAIRPERSON RAJSKY: We will have to defer that, Bunny is not here for that report. Tri-County Critical Incident Stress Management?

MARYANN SWEELY: This report is inclusive of May 1, 2001 through August 31. In that time frame we did 21 debriefings and eight educational offerings. We went as far away as Buffalo this time. Year to date we have 57 debriefings, eight defusings, and 38 educational programs for a total team activity of 103.
      I will be reporting the next time, every other month I report, but I would let you know, due to this World Trade Center horrific tragedy, we're, our team is on standby with the international critical incidents stress. But in the interim we have been doing a lot of pocket debriefings within our own area, because no matter who you talk to it seems to have affected a friend, an acquaintance, a loved one. And I have been doing them over the Internet which is something really unusual. I have had 3 people been referred to me via the Internet. And I have stayed connected that way. So process seems to be working. So we're here if any of you need us.
     And along those notes I am going to do this now. This came across, we get tons of, those of you who have computers, there is probably not too many in the room that don't. This was the souls of the firemen, I just wanted to be sure that each and every one of you did see this, because it certainly touched my heart, for those of you, all of us here in the EMS field and my way of saying thank you for being there for all of us.

CHAIRPERSON RAJSKY: Great, questions for Maryann? I think our region, it will seem trivial to some of the things, I don't mean that in a negative way, but the size of the problems that we have here are not going to be even conceptualized by the problems in Washington and New York, just the vast amount of human resources, I can't imagine what's going to take for debriefing teams to recover from that.

MARYANN SWEELY: I think a lot of us fear, I would like to note, like a dispatcher, you are there, you can't be on the scene, you can't be actively involved, what can we do, the feeling of I am really not doing anything to help. But if you can stay connected with your colleagues and nice hug or a touch or a kind word, that is helpful.

RON KINTZ: I would just like to say secondhand that this article reminds me of, some people around already been to New York City and come back, and everything I have heard, fortunately I didn't go, because it would take 3 people to take care of me. But for the ones that did go they said the New York City Fire Department really had their act together and really did a hell of a good job. And are still doing a good job. But there has been no, Bob, you were there, there was no bad comments about them. They just did a great job.

CHAIRPERSON RAJSKY: Tremendous. I will take the privilege of the floor.

DAVE CROWLEY: Bob, just to let you know on that, anyone who hasn't seen that already, Elmira Fire Department is a collection point for funds and contributions to go to the New York City widows and orphans fund.

JUDY BLAIR: So is STREMS.

DAVE CROWLEY: However you make the checks out. They can be put in to that.

JUDY BLAIR: STREMS is also collecting for the EMS people who died while trying to help others.

RON KINTZ: May I just say one other thing, certainly the fire department took an awful big hit in New York with the hundreds of people, but I just want to mention because sometimes numbers speak but there has been four or five EMTs that have now died in New York that weren't firemen, they were a member of various ambulance services throughout the state. So it hits everybody. And doesn't matter if you lose one or what, it hurts. Bad bad thing.

CHAIRPERSON RAJSKY: I don't know if it's an announcement or not. On the vote that was taken earlier, it was unfortunate two of the newest members, Keener Cortright and Debbie Kline unfortunately were missed in that roll call vote. So I would ask that their votes be added to our roll call vote.

JUDY BLAIR: Mr. Cortright?

KEENER CORTRIGHT: Accept.

JUDY BLAIR: And Ms. Kline?

DEB KLINE: Accept.

JUDY BLAIR: Thank you.

CHAIRPERSON RAJSKY: Thank you. I apologize for that. What else to come before council this evening?

ART JONES: Just some information for Steuben County squads. The Rural Health Community Systems Rural Health Network working with Mike Sprague and Steuben County MO have been holding meetings to try to improve the communication among squads in Steuben County, emergency medical services in Steuben County. There is another meeting scheduled on Thursday September 27 at 7:00 at the Civil Defense building. Some flyers have gone out with the attempt, for the purpose of the meeting is to try to get an association going countywide. Tammy, have you attended any of the other meetings?

TAMMY HOLBROOK: Yes, I have been to all of them.

ART JONES: Been informal and trying to develop in to a countywide association to improve communication among the EMS.

DR. HUFFNER: I would like the, the regional medical director would enjoy being invited to that sometime when you are up and running to maybe just show up and have everyone take a pot shot or something.

ART JONES: Dr. Huffner, you always have a standing invitation to anything in Steuben County.

DR. HUFFNER: But seriously some time if they would like me to come out there I would like to talk to people, let them see my face, talk to people, about issues.

ART JONES: We would like to have you out in the rural countryside.

CHAIRPERSON RAJSKY: Other comments, concerns for tonight? Anything? Do you have a 911 report, Mr. Smith.

MIKE SMITH: I would just tell you our office has been inundated over this past week and two days with calls from across the United States, some of them have been terrifically bizarre, some have been truly unbelievable.
     Christine took a call Friday from Sunoco, they donated a million dollars in cash and offered to pay for all the fuel that's being used at the World Trade Center site. And Christine said gee I will get you a number in Albany, the fellow said I already talked to Albany and they said well send a check, thanks a lot and hung up on me. So we got him reconnected so that they could accept that donation.
     Microsoft has donated five million dollars in cash and five million in goods and services, the services being employee time to come in and help set up new computer systems and to try to restart the computer operations of the various companies that have been damaged in this. So certainly some of the things that we have seen are just unbelievable.

CHAIRPERSON RAJSKY: And if there is good to come out of a tragedy like this, the people of this country have really come together doing its ordinary, unbelievable the reception we had from city fire, city police and the citizens of New York City, just incredible camaraderie, and it was one team.

JUDY BLAIR: On Tuesday, the Department of Health called us from Albany and said they were setting up a number for people to call for, if they wanted to volunteer, so I went and put it up on our website. We got a note from somebody in Wisconsin who wanted to come, I think Nancy talked to somebody they said there were four hundred doctors at a conference in Denver, they said if you could get us there, you know, we're volunteering.

NANCY BUSH: I had an EMT from California call and volunteer. I also had an e-mail from an emergency department physician in Uruguay, South America anyhow, who has volunteered himself and 10 emergency department physicians and nurses and any supplies or equipment that may be needed. That was sent on to Albany.

CHAIRPERSON RAJSKY: Anything else to come before council tonight? Don?

DON DUVALL: Dr. Seaman asked earlier for a design or prototype for portable decontamination shower unit. We have done that as a joint effort between Schuyler ambulance and Schuyler Hospital's EMS program. And the intention originally was to put it together some place in a meeting room tonight. But we, we opted for plan B and basically to see what your pleasure is. If anybody would like to take a look. And also we're open to suggestions. The prototype seems to work pretty well. From my understanding Dr. Seaman's hope is that we can produce a number of these to be distributed throughout the region. We really don't want to get in to customizing them for each individual agency that would like one. But if somebody has a suggestion that maybe hasn't occurred to us, we would be happy to play with that a little bit. Design we came up with is pretty easy and will go up in about five minutes and will come down in about the same. And most anybody should be able to put it together. So if you would like once the meeting is adjourned, if you would like to see that out in the parking lot.

CHAIRPERSON RAJSKY: Thanks, Don. Anybody that wants to do that see, Donny.

MARY ANN TEETER: This is an adjunct to what you are just saying. The staff spoke earlier to Dr. Seaman, with regard to the domestic terrorism preparedness course, it's been an ongoing course that STREMS has been providing, Dr. Seaman said he is checking the schedule and probably mid November would be the next one. And I will post the date when it is available.

MARYANN SWEELY: There is also going to be one in Pittsburgh, Pennsylvania on national critical incident stress foundation, through the, January the 13th, 2002. These are planned a year and a half before.

CHAIRPERSON RAJSKY: Great. Anything else to come before council this evening?

DR. HUFFNER: Move to adjourn.

STEVEN BENNETT: Second.

CHAIRPERSON RAJSKY: All those in favor? Adjourned. (MEETING ADJOURNED.)