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BCC Minutes 12/08/2008 W (Fire & EMS) December 8, 2008 MINUTES OF THE MEETING OF THE COLLIER COUNTY BOARD OF COLLIER COUNTY COMMISSIONERS, THE ALS-ENGINE, EMERGENCY MEDICAL SERVICES AND FIRE DISTRICTS WORKSHOP Naples, Florida, December 8, 2008 LET IT BE REMEMBERED that the Board of Collier County Commissioners and the ALS-ENGINE, EMERGENCY MEDICAL SERVICES, and FIRE DISTRICTS having conducted business herein, met in a WORKSHOP SESSION on this date at 9:00 AM in the Administration Building "F," 3rd Floor, Collier County Government Complex, Naples, Florida with the following members present: CHAIRMAN: Commissioner Tom Henning Commissioner Jim Coletta Commissioner Fred Coyle Commissioner Donna Fiala Commissioner Frank Halas ALSO PRESENT: Jim Mudd, County Manager Jeff Klatzkow, County Attorney Sue Filson, Executive Manager, BCC Office Dan Summers, Director, Bureau of Emergency Services ei' , f " -,-~~~ AGENDA December 8, 2008 9:00 a.m. BCC ALS Engine Workshop 3'. Floor Boardroom W. Harmon Turner Building Tom Henning, Chairman, District 3 Donna Fiala, Vice-Chairman, District 1 Frank Halas, Commissioner, District 2 Fred W. Coyle, Commissioner, District 4 Jim Coletta, Commissioner, District 5 NOTICE: ALL PERSONS WISHING TO SPEAK ON ANY AGENDA ITEM MUST REGISTER PRIOR TO SPEAKING. SPEAKERS MUST REGISTER WITH THE COUNTY MANAGER PRIOR TO THE PRESENTATION OF THE AGENDA ITEM TO BE ADDRESSED. ALL REGISTERED PUBLIC SPEAKERS WILL RECEIVE UP TO THREE (3) MINUTES UNLESS THE TIME IS ADJUSTED BY THE CHAIRMAN. COLLIER COUNTY ORDINANCE NO. 2004-05, AS AMENDED, REQUIRES THAT ALL LOBBYISTS SHALL, BEFORE ENGAGING IN ANY LOBBYING ACTIVITIES (INCLUDING, BUT NOT LIMITED TO, ADDRESSING THE BOARD OF COUNTY COMMISSIONERS), REGISTER WITH THE CLERK TO THE BOARD AT THE BOARD MINUTES AND RECORDS DEPARTMENT. IF YOU ARE A PERSON WITH A DISABILITY WHO NEEDS ANY ACCOMMODATION IN ORDER TO PARTICIPATE IN THIS PROCEEDING, YOU ARE ENTITLED, AT NO COST TO YOU, TO THE PROVISION OF CERTAIN ASSISTANCE. PLEASE CONTACT THE COLLIER COUNTY FACILITIES MANAGEMENT DEPARTMENT LOCATED AT 3301 EAST TAMIAMI TRAIL, NAPLES, FLORIDA, 34112, (239) 252-8380; ASSISTED LISTENING DEVICES FOR THE HEARING IMPAIRED ARE AVAILABLE IN THE COUNTY COMMISSIONERS' OFFICE. 1. Call to order - Chairman Henning 2. Pledge of Allegiance 3. Welcome, Self Introductions and Opening Remarks 4. Overview of ALS Engine Agreements and Medical Director's Responsibilities - Jeff Klatzkow, County Attorney 5. ALS Engine Discussion with Participating Partners 6. Brief Power Point Presentation Entitled "Med Com" - Dr. Robert Tober 7. Public Comments 8. Summation and Final Comments 9. Adjourn INQUIRIES CONCERNING CHANGES TO THE BOARD'S AGENDA SHOULD BE MADE TO THE COUNTY MANAGER'S OFFICE AT 252-8383. December 8, 2008 1. Call to Order -Chairman Tom Henning The Workshop was called to order at 9:00 AM. 2. The Pledge of Allegiance was recited. Chairman Henning stated it was his understanding the reason for the Workshop was due to the Inter-Local Agreements but he noticed the topic was not included on the Agenda. He mentioned the Workshop was scheduled in response to a letter from Fire Commissioner Lombardo, North Naples Fire District, to the Board of County Commissioners. 3. Welcome, Self Introductions and Opening Remarks Chairman Henning welcomed the participants. Thefollowing Introductions were made: Dr. Robert Tober, Collier County Medical Director; Dr. Douglas Lee, Collier County Assistant Medical Director; Jeff Page, Chief-EMS; Mike Brown, Fire Chief-North Naples Fire District; Chris Lombardo, Commissioner-North Naples Fire District; Doug Dyer, Chief, East Naples Fire District; Tom Cannon, Chairman-East Naples Fire District, Jim McEvoy, Chief-City of Naples Fire Department; Rod Rodriguez, Fire Chief-Isle of Capri; Joseph Langkawel, Isle of Capri Advisory Board; Mike Murphy, Chief-Marco Island Fire District; and Frank Recker, Vice Chair-Marco Island City Council Chairman Henning stated he received a copy of the Board's Minutes confirming the subject matter for the Workshop was the Inter-Local Agreements as well as the Advanced Life Support ("ALS") service provided by the Fire Departments. 4. Overview of ALS Engine Agreements and Medical Director's Responsibilities - Jeff Klatzkow, County Attorney . Under Florida Statutes, anyone engaged in emergency medical transport must be licensed by the State of Florida Department of Health . In order to obtain the license, a County must first issue a Certificate of Public Convenience and Necessity . Collier County issued one Certificate to itself as the sole operating entity . Under Florida Statutes, anyone who operates a life support transportation service must employ a Medical Director who is personally responsible for supervising and assuming direct responsibility for the medical performance of the entire EMS system . The County entered into Inter-Local Agreements with the Marco Island, the North Naples Fire Control and Rescue District, the East Naples Fire Control and Rescue District, and the City of Naples . The purpose of the Inter-Local Agreements is: - to provide quality and cost-effective fire rescue and emergency medical services to residents; - the recognition and utilization of existing and future personnel skills, qualifications, and resources in the best interests of all agencies and the public served 2 December 8, 2008 5. ALS Engine Discussion with Participating Partners Chief Brown, North Naples Fire District, stated Fire Commissioner Lombardo sent a letter to the Board concerning the Inter-Local Agreement between the County and North Naples. The Agreement cited a level of training which North Naples achieved and was to maintain throughout the contractual agreement as well as how training would be performed, and how the Matrix (i.e., procedures and drugs used in the field) was developed. He stated as a result ofletters from the Medical Director, North Naples' service was down- graded which violates the Inter-Local Agreement. Due to the resources available within its District, North Naples wants to provide a level of service that gives its residents the best possible care. He further stated he believed the ALS Agreement remains in place and North Naples can operate in accordance with the Agreement. Chief Dyer, East Naples Fire District, stated the training Matrix has not been resolved. One issue is centralized training at the EMS Training Office on Horseshoe Drive. While East Naples is close, most of the other Districts find it difficult to attend training sessions. He stated he met with Dr. Tober who expressed interest in investigating distributive learning capabilities through the use of closed-circuit television. Dr. Tober also stated there were specific topics which he would personally teach. (Dr. Joseph Nelson, State of Florida EMS Medical Director, arrived at 9: 15 AM and was introduced to the Board.) Chief Murphy, Marco Island Fire District, stated seven years ago there were 80 state- certified Firefighter/ Paramedics working in Collier County. He stated the driving force behind the ALS Engine Agreement is to maximize utilization ofresources existing within the County. There are 102 Paramedics currently working for the Fire Rescue Departments. He stated it is a disservice to the public to not utilize the Paramedics to the maximum capacity of their abilities. Training is an important issue and should be on-going. Commissioner Coyle stated the BCC received letters from the Fire Districts expressing concerns regarding a directive from Dr. Tober and the possibility of violating their Inter- Local Agreements. The Office of the Medical Director reports directly to the Board of County Commissioners because nothing else relates more specifically to the health, safety and welfare responsibilities of the Commissioners than Emergency Medical Services. A procedure should be established to communicate the policies to everyone involved. The problem revolves around policy issued without consultation and/or review by the Stakeholders and without certification by the Board of County Commissioners. He stated the goal of the Workshop should be the involvement of all Stakeholders in the review and implementation of the best possible medical policy for Collier County. 3 December 8, 2008 Chief Brown, North Naples Fire District, stated North Naples met with Dr. Nelson, the State of Florida EMS Medical Director, on December 5, 2008 to discuss the Office ofthe Medical Director and the participation of the Stakeholders in the process. After the Office of the Medical Director was enacted, requests were made to participate in the Office but were refused. The Stakeholders requested a "place at the table" to deal with the day-to-day issues that arise and the responsibility Office of the Medical Director to provide an opportunity to vet issues. Dr. Tober stated the primary continuing issue has been the vocal dissatisfaction of the Fire Departments over his to decision to not authorize placement of a virtual smorgasbord of drugs on all engines carrying ALS Fire/Medics. He confirmed he would not allow specific medications on certain units until they were "in line." He is in the process of developing new protocols concerning body cooling of cardiac arrest patients to increase survival rates, and work cooperatively with the two hospitals able to receive pre-cooled patients. He stated there has not been one incident of deficit in pre-hospital care, to date, with regard to the amount of drugs and clinical privileges given to the Fire/Medics. The deficit of care in Collier County is that Basic Life Support cannot be provided to every individual within a response time of five minutes. The one single action that will save the largest number of lives is to determine how to shorten the response time from 9 minutes to 5 minutes. He further stated he has been repeatedly questioned concerning why he has not allowed more ALS capability. Data has shown that in 99+% of Fire Departments' runs, only Basic Life Support was administered in emergency situations. The drugs removed from the fire engines had not been used in the past 12 months and, when used, were specifically used by EMS Paramedics when transporting patients. The protocols used were designed to keep patients alive for a 60-mile trip due to the size of Collier County. The EMS Paramedics are equipped with the drugs needed and used for emergency treatment during transportation. He suggested the community should examine its resources to determine a way to redistribute them to ensure Basic Life Support for each resident within a response time of 5 minutes. Commissioner Halas stated if drugs placed on the ALS Engines are not utilized, it is a waste of taxpayers , money. Dr. Tober stated evidence indicated only 17 drugs were consistently utilized. He suggested another option was to place a limited amount of drugs for use by the Sheriffs Department officers who encounter time-dependent situations, such as bee stings. In response to a question concerning medical responsibility and legal liability, Dr. Joseph Nelson stated the responsibility for EMS falls directly on the shoulders of the Medical Director. The Medical Director is required by law to write protocols, perform Qualify Assurance, and other activities to ensure proper patient care and safety. Chris Lombardo, Commissioner - North Naples Fire District, stated the focus should not be on who can be sued but how to provide the best service and protection for the citizens of Collier County. The Fire/Medics should have the maximum amount of ability (drugs) since they are state-certified and usually arrive first at the scene. 4 December 8, 2008 He confirmed North Naples' goal is to achieve a balanced and a cooperative relationship with the Office of the Medical Director, and is committed to training and hiring the best and brightest candidates. Chairman Henning asked if any of the Districts have failed to adhere to the terms of the Inter-Local Agreements. Dr. Tober stated the degree of understanding of the Agreements varies from District to District. The training component of the Agreements is a process that is evolving. There is a significant difference between the services provided for Basic Life Support ("BLS") versus Advanced Life Support ("ALS") services. The majority of procedures provided by North Naples were BLS services. He stated the issue was how many drugs and how much training should be given to the 105 Fire/Medics who 99% of the time did not need all of the requested drugs for clinical procedures. The risk is in placing drugs in the hands of individuals who do not routinely use them. There are 120 EMS Paramedics who struggle to keep their training current. Five Paramedics are loaned to the Fire Departments on a daily basis. If they remain on a fire engine for more than one month, their skill levels decrease because a different segment of care is provided by the engine companies. The Paramedics are rotated out of service to the Fire Department in order to keep from becoming "stale." The drug utilization records indicate that, over the course of a one-year period, four departments administered only 15 doses of drugs by Fire/Medics while, during that same period, EMS Paramedics administered 7,500 doses of drugs. He stated the Fire/Medics are also firefighting/extrication experts who must spend a good deal oftime training for those disciplines. He stressed the focus of the Workshop should be on how to deliver BLS to a resident within five minutes. Chairman Henning asked if the Inter-Local Agreements should be abolished or, if there are problems with the Agreements, can the problems be repaired. Chief Brown stated the original issue was whether or not the County broke the Inter-Local Agreements. He suggested that, under the new Office of the Medical Directors, all the Stakeholders should meet on a regular basis to discuss Quality Assurance and Quality Control issues, the protocols, and the training Matrix in order to foster dialogue and achieve resolution of the issues. Commissioner Fiala asked if the Fire Department and EMS should be consolidated and how would a consolidated unit affect the concerns regarding ALS/BLS. Dr. Tober stated consolidation would not change the structure of any of the emergency response procedures currently in place. What would change is who would be in charge, who would determine how many Paramedics to hire, and who would decide how to implement the manpower. 5 December 8, 2008 In response to Chairman Henning's question, he stated the continued controversy indicates something about the Inter-Local Agreements is not working or is not clearly understood by all parties. Chairman Henning stated the Inter-Local Agreements should be better defined. Frank Recker, Vice Chairman - Marco Island City Council, stated the issue should be whether or not, on a particular date, place and time, the treatment administered conformed to the specific standard of care. State certification indicates a certain level of mentality and competency has been attained, whether it is used on a daily basis or not. Commissioner Coletta asked about the differences in arrival times between the ALS engines and the EMS. He stated the County is not served equally by either the EMS or the Fire Departments. Consolidation would develop a network of services throughout the County that would be all-inclusive. Millions of dollars are spent and wasted on redundant services. Dr. Tober stated a consolidated system would minimize the duplication of equipment responding to an emergency situation. He further stated he considered his primary responsibility to the County is to serve as a Risk Manager Officer to provide the safest and most expert medical care to residents. He stated each fire department has been given enough drugs necessary to save lives. Frank Recker stated Marco Island is participating in a pilot program in which call screening determines the type of engine to be sent to a scene allowing evaluation and treatment of a patient. The unit would decide whether or not the patient required transportation to a medical facility by another unit. He stated the Levels of Service should be brought up to ensure the best utilization of resources. He suggested a solution would be to create a committee to review information and determine how to distribute resources in the best interest of the public. Dr. Nelson stated there is a difference between "certification" versus "credentialing." The State certifies, through its testing process, that a paramedic holds a minimum base line of knowledge. At the EMS level, the Medical Director can set a "credentialing" level to perform additional procedures which is achieved through training and expertise. He stated the meeting held on December sth indicated the goal of the participants was to find common ground to improve communication and the EMS system. Florida Statutes mandates that specific quality assurance cases are to be discussed under a separate Emergency Medical Review Committee. When he suggested formation of an Advisory Committee to the Office of the Medical Director to discuss training issues, use of resources, and quality assurance in generic terms, Dr. Tober and the Stakeholders were receptive to the suggestion. 6 December 8, 2008 Chris Lombardo stated there is a concern about the same Levels of Service not being provided throughout the County. The answer to problem solving will be achieved through communication among the parties. Commissioner Coyle stated the problem has been that the Board allowed policy concerning health, safety and welfare issues to be determined at the Stafflevel rather than by the Board itself. He further stated a comprehensive process must be developed to routinely accept the recommendations of the Medical Director and to obtain input and discuss ramifications in order to make whatever decisions are necessary. There will be public review of the policy making process. He suggested creating either a Subcommittee under EMSAC ("Emergency Medical Services Advisory Committee") or a separate ALS/BLS Advisory Committee ifEMSAC does not possess the skills necessary to review the issues discussed during the Workshop. There was further discussion concerning how to achieve an impartial, balanced Committee; whether or not one individual from each agency should sit on the committee, the size of the Committee, and public representation. Dr. Nelson stated creating a separate Advisory Committee to the Office of the Medical Examiner and an EMS Advisory Committee has been done by other Counties. Chief Page, EMS, stated EMSAC currently consists of 14 members: . the Fire Chieffrom the City of Naples . the Fire Chief from the City of Marco Island . a representative from the Fire Chiefs' Association . a representative from the Sheriffs Office . a representative from the Health Department . representatives from each of the two hospitals . five members from the public representing the five Districts . two "at large" positions Chief Dyer pointed out an EMS System Master Plan was funded by Collier County and contains great deal of useful information. The Plan viewed the function of Fire Districts as an enhancement to the EMS. ALS Engines were especially helpful in the area of concurrent calls. BLS before ALS is paramount, but it makes no sense to request EMS support if the ALS Engine can handle the situation. He further stated the Office of the Medical Examiner should have no allegiance to any particular agency - only to the public and the EMS System in total. Sharing of information between the Districts and the Office of the Medical Examiner is critical. Dr. Tober stated his allegiance is to patient welfare. He stated his decisions, including training decisions, were based on evidence. His training decisions have met with resistance due to claims of expense or logistics. Decisions are based on risk management and concerns for public welfare. 7 December S, 200S Commissioner Coyle stated he supports Dr. Nelson's recommendation to separate medical treatment protocol determinations from EMS policy implementation. He suggested medical policy and training procedures should be formulated by the best medical minds available. Failure to collect accurate data must be corrected. Input from the Fire Districts regarding their concerns will be taken into consideration by the Board which will also review the recommendations of the Advisory Committee regarding the level of training, what equipment should respond, and the types of medication necessary. The Board will make its decisions in a public forum. BREAK: 10:26 AM RECONVENE: 10:42 AM 6. Brief Power Point Presentation, entitled "Med Com" - Dr. Robert Tober (Not presented) There was discussion among the Commissioners concerning several issues: . How to provide the best emergency service . Cost-effective considerations concerning wasted resources, i.e., drugs that are not used but are routinely replenished due to expiration dates . The composition of the Committee ~ should encompass a spirit of communication and cooperation without political allegiance or bias . Why the EMS Master System Plan was not presented to the Board . The conflicting facts and figures presented during the Workshop ~ all data should be presented to the Board . Applicants for membership on the policy advisory committee should be interviewed by the BCC prior to appointment . Dr. Tober should have primary responsibility for recommending members to the medical advisory committee . Whether or not the policy advisory committee should be subordinate to EM SAC . The Productivity Committee that is already in place and might be an alternative to creating another committee Chief Brown stated there have been problems with due process. The Stakeholders have not had access to determine whether or not a process was viable. He suggested the involvement of the Stakeholders will give them a voice at the table. He acknowledged the Medical Director will make the final decision concerning the provision of medical services but with information from the Stakeholders. Chairman Henning requested a decision from the County Attorney's Office regarding whether or not the Florida Statutes could be pre-empted concerning protocols. County Attorney JeffKlatzkow stated the Workshop discussion has focused on determining what is actually necessary and such decisions will be made by Dr. Tober. Commissioner Coyle stated lay-persons should not decide medical treatment protocols. Medical decisions are to be determined by medical professionals. Debate and public input are appropriate when the Board is to make a decision concerning policy. The process of S December S, 200S determining what type of treatment and medication is to be provided will be decided by Dr. Tober who will present his recommendations to the Board. At that time, the EMS and Fire Departments will also provide their input to the Board. If the Board decides to modify or if it fails to adopt a treatment regime recommended by the Medical Director, the Board must be certain the decision is based on careful consideration of all of the facts presented. There was further discussion about the types of Committees in existence throughout the State that could be used as models. It was suggested the individuals who deliver the services, i.e., Fire/Medics, Paramedics and training officers, together with the Emergency Room physicians who receive the transported patients, should be included on the Committee to serve as technical advisors. The goal should be to develop a premiere protocol system to provide quality care from whatever unit is assigned to an emergency. It was acknowledged that Dr. Tober has the authority to oversee the Committee. Chairman Henning read a portion of Florida Statutes: "Each Medical Director shall establish a Quality Assurance Committee to provide a quality assurance review of all Emergency Medical Technicians and Paramedics operating under his supervision. " Dr. Tober stated a Committee has been established and comprised of members from the Training Department and representatives from the various Fire Districts. Chief Brown stated no representative from his District was included on the Committee as was previously requested. Dr. Nelson stated the Statutes refer to the Emergency Medical Review Committee, which is the technical term for a Quality Assurance Committee. The EMRC deals with specific patient care on one or more specific runs. The Committee reviews, in detail, the care provided to the patient. Under normal circumstances, the information reviewed is protected medical information. The confidentiality of the records must be protected. An Advisory Committee to the Office of the Medical Director serves a separate function. The Advisory Committee would review information provided by the Emergency Medical Review Committee concerning disturbing trends or patient care issues. Issues regarding protocol and/or training are topics for the Advisory Committee. Dr. Nelson suggested the members of the Advisory Committee should be position-specific to ensure broad spectrum representation. Commissioner Fiala stated there has been an ongoing power struggle between ALS vs. BLS. The composition of the Advisory Committee should not be involved in the power struggle but concerned with health, safety and welfare of the entire community regardless of which vehicle arrives at an emergency scene. 9 December S, 200S It was suggested to consult the Collier County Medical Society to provide access to individuals in key positions in the hospitals, those involved in Emergency Room procedures, and ER management. Also suggested was inclusion of a representative from the Paramedic units as well as a representative from each of the Fire Districts. Dr. Tober stated protocols have been revised and updated as necessary. He further stated the conflict persists over what is permitted on individual units, i.e., who should be carrying what and on which vehicle. He further stated he will be happy to assemble an Advisory Committee and will call the Medical Directors from adjacent Counties to serve on the Committee. Chief Dyer agreed with Commissioner Coyle's comments and stated if Collier County had adhered to the terms ofthe Inter-Local Agreements, the Workshop would not have been necessary. He stated East Naples has: . Complied with the medical protocol and participated in medical training and quality assurance programs in accordance with the County; . Designated a representative to the County who was approved by the Medical Director as a quality assurance member to participate on the ALS Non-Transport Quality Assurance Committee, although the Committee has not met since November, 2007 East Naples' Fire/Medics and EMTs ("Emergency Medical Technicians") have met the same requirements and have performed the same appropriate medical protocols as defined by the County EMS Medical Director. East Naples has adhered to standard operating procedures, medical quality assurance programs, general orders, and chain of command as employees of the County's EMS Department. Chief McEvoy, City of Naples Fire Department, stated he has been a member of the Emergency Medical Services Advisory Council for the past seven years. Collier County has many highly trained emergency medical professionals who only want to do their jobs. The issue to be settled is what should they be allowed to do - who can practice the protocols and where. The Stakeholders are key to any Committee to be created, as well as the public. 7. Public Comments . Juan Campos, a Fire/Medic for the past nine years and a Certified Paramedic for the past eleven years, was one of the Paramedics who approached Dr. Tober with concerns that their skill levels were deteriorating due to a 4-mo.extended service on the Engines necessitated by personnel shortages. He stated his assessment and diagnostic skills were definitely affected. Those skills are developed over time by actual experience. Paramedics greatly respect the Fire/Medics and often utilize their assistance, but not for diagnostic and assessment decisions. . Dr. Fay Biles was a member and past Chair of EM SAC. She stated EMSAC did point out existing problems. Collier County has one of the finest EMS programs in the nation 10 December S, 200S and it won the State and National awards while she was EMSAC's Chairman. But people are sick and tired of the Fire/EMS controversy and it is time for the issue to be resolved. While the topic of consolidation was not the issue ofthe Workshop, it should be carefully considered. . Earle Borman has been a Collier resident for the past 12 years. He stated he was encouraged by the discussion. The parties involved are part of the solution. He urged the Board to maintain the quality system already in place and to ensure its continued improvement. . Duane Billington has been a 33 year resident of Collier County and a congestive heart failure/heart attack survivor. A congestive attack leaves the patient breathless and unable to communicate. There are several drugs that can be used, but the wrong one can cause the heart and lungs to flood with fluid drowning the patient. Collier County has a 37% cardiac save rate which is 4 to 6 times better than the national average. Dr. Tober developed those protocols and should be making all of the medical decisions. . Larry Meltz has been a long-time resident. Collier County offers the most efficient and best life saving treatment available. The objective to achieve a more cost effective solution is admirable. He stated EMS should operate separately under the Office of the Medical Director. He cited Marion/Osceola and Broward County where programs failed and the EMS service is in disarray. He stated the Fire/Medics should be trained to a higher standard. . Bill Hagman stated if the system isn't broken, don't "fix" it. The Naples Daily News has reported the ongoing saga. There has not been any valid criticism of Dr. Tober's management in the past 10 years. While the Fire Departments may merge, the EMS System should remain separate. The primary concern should be saving lives. . Burt Boersma stated politics should not influence the operation of critical services. Even winning awards does not mean that services are perfect. If he were in need of emergency medical assistance, he would not choose someone who did this once in a while in place of someone who performed this function everyday. Firefighters perform a great service by extricating those in danger and putting out fires. They are well trained for this work. He supports Commissioner Coyle's recommendation for a Medical Services Advisory Committee. From his personal experience, 14 members are too many for any Committee. Patient care and safety should be under the supervision of Dr. Tober. . Nancy Lascheid, RN, stated the Master Plan was presented to the BCC by the EMSAC Subcommittee. She was a member of the EMSAC Subcommittee and stated the Report was primarily concerned with the Fire Departments. EMSAC is too big and should be restructured. She suggested appointing only 5 members to the Medical Advisory Committee: a physician, an ER nurse, a hospital administrator, an attorney, and a representative from the business community. She agreed that reinforcement of skills is paramount because drugs can just as easily kill lives, as well as save them. She agreed with Paramedic Campos' concerns. Decision making in the field can only be done with experience. Basic Life Support is critical to saving lives and she urged training in BLS for the police as well as the fire departments. . Dr. James Hampton, a former ER physician, stated he worked under the supervision of Dr. Robert Tober. He stated Dr. Tober was the best ER physician and the most innovative physician he has known. He asked several rhetorical questions of the BCC. He stated Broward County's cardiac resuscitation rate is 1/8th of Collier County's rate. 11 December S, 200S Decisions concerning the Fire Departments should not be made by a physician, and medical decisions should only be made by the Medical Director. . James Cunningham, a representative of the North Naples Fire Control and Rescue District, stated Dr. Tober has referred to himself as the Medical Director of Collier County's EMS and referred to "my EMS staff' several times during the Workshop. The Fire Departments are requesting some ownership and some voice regarding concerns about how they are to proceed. No one questions that the Medical Director has full authority to develop protocols. He also stated the Fire Departments are requesting a voice concerning Quality Assurance, training and compliance issues. The Fire Departments request access to an unbiased Medical Director who will listen to what the Fire Department can "bring to the table" and who will make educated decisions after meeting with all parties. He supported the creation of the Office of the Medical Director to report directly to the Board. He hoped this would alleviate all previous political influence. There should be more structure for the Office. The Medical Director has not received, nor asked for, all of the information and documentation available from the Fire Departments. When the proper tools and equipment is not provided, it is difficult to determine if a service is actually provided. 8. Summation and Final Comments Chairman Henning stated Dr. Tober told the Board his field training officers and medical staff were the core of medical competency. It was the Board's understanding that the training required by the Inter-Local Agreements was to be provided by the medical training staff. He stated the Agreements should be honored. The Medical Director's staff should provide BLS and ALS training. Chief Dyer confirmed the original Agreements stated the Medical Director's staff would train the trainers for each Fire District. The trainers would attend Dr. Tober's in-service, as would the other Paramedics, and they would train the East Naples Fire Department personnel. There has been a great deal of passive resistance in obtaining approval ofrosters and submitting training curriculum. It has been difficult to accomplish the objectives. There was further discussion of the need for field training officers and potential expansion of the program. Dr. Tober stated training from an EMS standpoint involves the critical factor of ongoing experience. Rotation of EMS Paramedics is required in order to maintain skill levels. He has used evidence to determine what drugs should and should not be placed for use by individuals who do not have daily experience with the medications.. He stated the suggested Subcommittee should be limited to a small group to determine what the ALS Engines should and should not carry to support the medical protocol. He agreed an ER nurse should be a member and proposed the appointment of a physician from Lee County with ER experience. Dr. Tober stated ifhe went to work in a Trauma Center tomorrow, he would need to be supervised by Dr. Lee because he lacks recent trauma experience, even though he has three 12 December S, 200S times the medical experience of Dr. Lee. He further stated the crux of the issue is determining what is the safest, most prudent method to distribute tools/drugs to a Fire/Medic who infrequently handles those tools. Chief Brown stated capable trainers are currently available. North Naples offered to finance and provide resources to train Paramedics and will continue to offer that service to Dr. Tober. Chief Dyer referred to the Collier County's cardiac resuscitation rate which was nationally recognized and stated each Collier County Fire Department contributed to achieving the distinction whether they were the "first responder," or provided Basic or Advanced Life Support. He stated Chief Page is not a physician but he was responsible for overseeing the EMS system and, until several months ago, Dr. Tober worked under EMS. The position of "Fire Chief" or "EMS Chief' is a managerial position and does not provide medical direction. The Fire Districts have never challenged Dr. Tober's medical credibility. No one has stated Dr. Tober is not to be respected or trusted. The Medical Director should consider all paramedics as "his" paramedics. Dr. Tober stated his slide presentation underscored the fact that the Fire Departments and the police are an integral part of the EMS system and without the Fire Department and the Police Department, Collier County would not have the same success rates. Tom Cannon, Chairman - East Naples Fire District, stated he has the greatest respect for Dr. Tober and the EMS system. The controversy was not created by the Fire Departments. The Fire Districts have not instigated the stories that appeared in the newspaper. He wrote to all five Fire Commissioners after the first story appeared. The County created the controversy. The independent and dependent fire departments want to provide the best medical care and safety to the community. He asked the Board to remember the independent fire services are each governed by their own Board of Fire Commissioners who determines policy and procedures. He hoped the Fire Services will be included in any future discussions. There being no further business for the good of the County, the Workshop concluded by order of the Chair at 11 :57 A.M. ***** 13 December 8, 2008 ning, Chairman ATTEST: DWIGHT E.~RQCl<;, CLE\U< .....' , bj'.Juul . ~(Z.PA .OC. At(est IS to It · , \ QIIature 0111\ These Minutes w~re approved by the Board/Committee on --1::1 ~ ~ as presented V , or as amended __' 14