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Report by the Task Force on Commissions and Committees
In April, 1975, the Board of Supervisors approved the Economy and Efficiency Commission's report on the Committee on Emergency Medical Care. That report contained recommendations covering the role, responsibilities, principles of operation and composition of the committee.
We also addressed the question whether the Paramedic Committee should be consolidated with the Committee on Emergency Medical Care. We concluded that it should not be, primarily because the functions of the two committees are incompatible. We also recognized that there are substantive issues related to the operation of the Paramedic Committee. We, therefore, stated that in a subsequent report we planned to examine the composition and functions of the Paramedic Committee. Our findings and recommendations are contained in this report.
In conducting the study we have reviewed committee
minutes and files and other documents associated with the
operation of paramedic programs. We have also conducted
over 70 interviews with members of the Paramedic Committee,
County officials, and other participants and authorities in
the paramedic field, including fire chiefs, ambulance
operators, hospital administrators, and community college
officials. (See Appendix A for a list of persons
interviewed.) We thank them for their suggestions and
assistance in the preparation of this report. The
conclusions and recommendations, however, are solely the
responsibility of the task force.
This section summarizes the task force findings and
presents its recommendations. Later sections of the report
explain our reasoning in greater detail.
Development of Paramedic Programs
In 1967, the primary method of treating emergency patients in Los Angeles was to deliver them to hospitals as quickly as possible, with little or no care at the scene or during transport. There were no paramedics. Public safety and ambulance personnel were not trained to dispense definitive care or to describe patient condition and act on physicians' orders. The public was not generally aware of the probability that timely care of many heart patients, accident victims, and other emergency cases could save lives.
Now, in 1975, emergency patients in Los Angeles County are treated at the scene by medical technicians - called mobile intensive care paramedics - trained to describe the condition of patients by radio or telephone to a physician or nurse at a base station hospital and to act on the doctor or nurse's orders. The program extends over nearly all of Los Angeles County and is expected to be available throughout the entire County by January, 1976.
The County Fire Department provides paramedic services to 37 cities and the unincorporated area. Twenty-six other cities, including Los Angeles, provide their own services. There are now in the County nearly 800 paramedics manning 102 rescue squads. They are supported by 25 base station hospitals and respond to approximately 8000 calls per month.
The Board of Supervisors, particularly Supervisor Hahn, provided the leadership and the resources to accelerate the development and expansion of pre-hospital medical service throughout the County.
In 1970, following State legislation enabling Counties
to provide paramedic services, the Board, on motion of
Supervisor Hahn, established the Paramedic Committee to
provide the County guidance and support in the development
of training programs designed to assure a high level of
quality. Under the leadership of Dr. Walter Graf, who has
been chairman of the committee since its inception, the
committee has provided a significant level of guidance and
support in the development of paramedic programs. Paramedic
services have saved countless lives and have markedly
improved the prognosis for thousands of patients.
Need for the Paramedic Committee
Despite these truly remarkable accomplishments, problems and controversy remain unresolved. The existence of problems does not reflect adversely on County officials and others whose creative efforts have been responsible for the immense improvement in the delivery of emergency medical care. Rather, such problems are inevitable when innovative programs experience such rapid growth. This is particularly true in the complex and fragmented jurisdictional environment of Los Angeles County.
We believe the problems and controversy can be resolved. In order to understand the role we recommend for the Paramedic Committee in the resolution of these problems, it is necessary to understand the nature of the issues which confront the County, the Paramedic Committee, and other public and private agencies involved in paramedic programs.
The Control Problem - The programs have developed so rapidly and proliferated so extensively that effective management and control of the system has not kept up with its growth. There are 27 separate paramedic programs provided by various jurisdictions in Los Angeles County. Each has its own management structure, policies and procedures. The Department of Health services is making progress in developing more effective standardization and quality control. However, the programs are still expanding. There is urgent need for the department to complete development of an equitable and comprehensive control system.
County Conflict of Interest - State law assigns to counties the responsibility for establishing standards and controlling paramedic programs by certifying paramedics and training programs and contracting with hospitals. (The Wedworth-Townsend Act of 1970, as amended. See Appendix B.) Los Angeles County also provides services and training through the Fire Department, the Sheriff, and the Department of Health Services. A number of authorities whom we interviewed stated that the County has adopted arbitrary and piecemeal standards that are advantageous to the County as a provider but interfere unfairly with the ability of municipalities, community colleges, and ambulance companies to provide services or training.
Our findings indicate that in some instances the department and the Paramedic Committee have adopted standards on a judgmental basis in the absence of performance data and without sufficient public review and debate. In the period of rapid expansion of the programs, it was necessary to adopt standards. It is true, as we have indicated, that they are piecemeal. In addition, like any judgmental standards they may be criticized as arbitrary. In some cases, there is cause also to question whether they are free of bias toward large governmental providers.
We have found no evidence, however, of improper motivation in these actions. Under the circumstances, the concern of the department and the committee wag to maintain quality treatment and adequate safeguards to protect lives.
Regardless of the merits of these criticisms, the significant point is that the County lacks credibility, when as the provider of services, it adopts standards and controls which regulate the ability of others to provide similar services. Thus the County of necessity has a conflict of interest when it acts as both a provider and controller of services.
Public vs. Private Interests - A controversy has developed over the appropriate roles of the public and private sectors in providing paramedic services. One debate centers on the question whether fire department paramedics should transport patients to the hospital after treatment in the field or continue - as many do now - to call on private ambulance companies for transportation. A related debate centers on the question whether private ambulance companies should participate at all.
In the past, the combined circumstances of rapid expansion of programs and the absence of solid scientific data forced everyone involved, including the County and the Paramedic Committee, to make decisions or take positions based on untested assumptions. At present the department is making progress in acquiring and analyzing the appropriate data. Nevertheless, the controversy is growing.
Essentially, the origin of these issues is the fragmented management of emergency medical services. Paramedic programs, which constitute a segment of these services, are particularly weak in this area. The law governing paramedic services does not provide for management; it merely enables counties to provide services and to exercise some control. The problem is further aggravated by the hybrid nature of paramedic services which involve both rescue and health care. Rescue traditionally has been a public safety function, provided in Los Angeles County by a host of municipalities and private firms as well as County government. Health care, to the extent that it is a governmental function, is provided principally by the County.
Some authorities contend that until some structure for centralized management of emergency medical services is established, there is little hope of resolving current problems. We question this conclusion. While centralized management would bring uniformity and standardization to the system, it is difficult to predict when and how it may be accomplished, in view of the current maze of public and private agencies involved.
The problems, however, are current and the need for solution is urgent. In the absence of centralized management what is needed to resolve them is a comprehensive system of standards and quality control based upon systematic study and research. As we have indicated, the Department of Health Services is engaged in developing such a system.
This control system will not be effective unless it gains a high degree of acceptance from those affected, including cities, fire departments, training institutions, ambulance companies, paramedics, nurses, hospitals, patients, and the patients' physicians. Such acceptance can only be achieved if all these elements of the community are assured that standards, methods and procedures for which the County is responsible will not be unilaterally imposed without an opportunity for public review and discussion.
It is urgent, therefore, at this time that the County take action to establish a mechanism for such public review. The urgency of this need is demonstrated by the history of the Paramedic Committee in recent years. Since 1973 those involved and concerned with paramedic programs have brought a number of issues to the committee for public review and resolution. The committee has advised the Director of Health Services on these issues, even though it has no legal jurisdiction to do so. The ordinance on the committee specifies only that it will advise the Director of Health Services "on matters relating to the training and certification of Mobile Intensive Care Paramedics." (See Appendix C.)
We conclude that the Paramedic Committee should be
reorganized into a new Paramedic Commission to provide a
properly constituted legal body to meet this need.
Function of the Proposed Paramedic Committee
The new commission will serve as a public review and arbitration board to insure that anyone having an interest in paramedic programs has the opportunity to debate or appeal controversial County decisions and policies. We do not mean that the commission should assume the responsibility of the Department of Health Services to develop and enforce a control system. To do so would destroy the ability of the Board of Supervisors to hold the department accountable for its actions. We do mean that the commission should act for the Board of Supervisors to hear and arbitrate matters in which others concerned with paramedic programs differ strongly with the department.
The task force recommends that the commission report directly to the Board of Supervisors. It would be inappropriate for the new commission to report to the Director of Health Services. The commission would lack credibility if It reported to the official whose decisions it was reviewing.
This change in the reporting structure will not make the commission's decisions 1ega11y binding on the Director of Health Services. As we have noted, present State law specifies that the County Health Officer is the certifying authority for paramedic training programs and paramedic candidates. The County Counsel advises us that under the provisions of the current law (Appendix B) the County cannot legally establish a commission whose decisions are binding on the Certifying Officer. In addition, the County Counsel informs us that the Board of Supervisors itself has no authority to direct the Health Officer in making a decision on certification or to overrule a decision once made, since the law does not mention the Board.
If the Board of Supervisors wishes to invest itself and the Paramedic Commission with binding authority, the County Counsel states that it will be necessary to amend the Wedworth - Townsend Act. We do not recommend that the Board seek such an amendment at this time. The current Act expires in July, 1976. Work is already under way throughout the State for a comprehensive revision. Any amendment proposed by Los Angeles County should take other proposed changes into consideration. Therefore, legislation to clarify the authority of the Board of Supervisors should be deferred until the 1976 revision. In the interim, the Board, the commission, and the department should determine from experience whether the change is necessary.
At present, our conclusion is that the omission in the law will not impair the ability of the Paramedic Commission to act as an effective arbitration and hearing board. The necessity for public review and debate and the desire of all providers of paramedic services, including the County for such an agency will inevitably give strong authority to the commission's findings. In addition, the change in reporting structure will enhance the commission's credibility and effectiveness. Commission effectiveness, however, will also require that County officials inform those disagreeing with a County decision that they can appeal to the commission.
It is important to note that although the commission will report to the Board of Supervisors, it will communicate its decisions to the Director of Health Services and other responsible County officials. We would expect that the department would normally concur with the findings of the commission. In the event that a decision of the commission conflicts with a decision of the Director of Health Services, the Director may choose either to concur with the commission or to confer with the Board of Supervisors for final resolution.
We would anticipate little discord between the
Department of Health Services and the commission. As we
have emphasized, it is much to the advantage of the
department to have its decisions reviewed in public in
controversial cases.
We recommend that the Board of Supervisors amend the present ordinance (Article IXX of the Administrative Code) to dissolve the Paramedic Committee and establish by ordinance a Paramedic Commission. The new ordinance should contain provisions providing for the following:
Objective of the Commission
To promote, within a framework of fair treatment of all sectors of the community having an interest in providing paramedic training or services, uniform, high quality paramedic care to the people of Los Angeles County.
The Board of Supervisors will appoint the Paramedic Commission and it will report directly to the Board. To meet its objective, the Paramedic Commission will perform the following functions:
1. To provide public review on any issue involving paramedic services and training when requested by a County department, other sectors of the community, or on its own initiative.
2. To arbitrate, in the field of paramedic services and training, differences between the Department of Health Services and other sectors of the community, including but not limited to municipalities, public safety agencies, community colleges, hospitals, private companies and physicians.
3. To hear appeals of decisions made by the
Department of Health Services on the following
4. To hear appeals of certification decisions by the Department of Health Services and the certifying officer.
5. To review and advise the Board of Supervisors on County action to propose1 support or oppose State legislation and regulations affecting paramedic programs.
In performing the above duties, the commission's review authority will cover standards and controls governing the following subject matter:
The commission shall have 10 members as follows:
Appointment and Term of Office
The Board of Supervisors will appoint commission members for two-year terms upon nomination of two by each Supervisor. The Board should determine which of the following methods it prefers to use in assigning positions for nomination by individual Supervisors.
With either method the Board could elect to assign one physician to each Supervisor.
Qualifications of Members
Public Members
Membership Limitations
This section expands on the problems and controversy discussed in Section I.
Proliferation of Paramedic Programs - The Control Problem
Paramedics are field medical technicians, who operate outside of the clinical and institutional environment which usually supports other medical technicians as well as nurses and physicians. The concept of systematic medical intervention in the field although well developed for military applications, is less than a decade old for civilian populations.
As we indicated in Section I, paramedic services have developed from an experimental base established in 1969 to nearly full coverage of Los Angeles County in 1975. At present there are 27 separate paramedic programs provided by various jurisdictions in the County. Each has its own management structure and method of operation. For example, some cities train firefighters to be paramedics, others contract with ambulance companies; some transport patients, others contract with an ambulance company for transportation.
The programs have developed and are operating in the absence of a comprehensive system of quality control or standards. There are historical reasons for this situation. In contrast to several other newly developed medical technologies, there was no professional tradition to provide conceptual support to paramedic development, as for example the tradition of registered nursing provided for licensed vocational nursing. Systematic development was also hindered by opposition to the entire concept. There were in the beginning many medical professionals who were opposed to the provision of medical services in the field by non-physicians. To some extent such opposition still exists.
According to the basic legislation allowing public operation of paramedic programs (see Appendix B), County government is responsible for establishing standards and controlling paramedic programs operated from County hospitals or hospitals with County contracts.
The County has two major methods of controlling paramedic services. The first is the certification process. Without certification no individual can practice as a paramedic. To be certified he or she must successfully complete a training program which also must be certified. The legislation specifies that the County Health Officer is the certifying authority. Therefore, the County controls both the labor supply and the training for all paramedic programs.
The second County control is the system of Emergency Aid Program contracts - contracts with hospitals and ambulance companies that insure that the County will pay for emergency aid for indigent patients. Through these contracts, the County controls, at least partly, the organizations which will provide paramedic services.
With the proliferation of programs, a much more structured and comprehensive system of control based upon systematic study and research is clearly needed. The County, as we have stated, has now established an Emergency Systems Division. While it therefore is developing the resources needed to establish a comprehensive system of controls, its efforts to do so have been and will continue to be highly controversial. Its decisions influence the costs and effectiveness of programs operated by independent political jurisdictions and private firms. The decisions also will directly affect the careers of the people involved and the lives of patients.
The control problem was highlighted in 1973 when Pasadena City College applied for certification of a new training program for paramedics. The college viewed its proposed program a8 a natural extension of the health occupation training it already offered.
The program, however, differed in major respects from that conducted by the County, and some County officials were strongly opposed to it. Their opposition was not based on evidence that the proposal failed to measure up to a standardized curriculum incorporating performance objectives. No such curriculum existed. Rather the opposition of County officials was based primarily on their opinion that community colleges lacked teaching resources equivalent to those in the County. Pasadena City College was able to implement its program at that time only because it had the opportunity to review its proposal in public with the Paramedic Committee.
The Emergency Systems Division of the Department of Health Services is now developing a standardized curriculum which will serve as a rational and objective yardstick for selecting proposed paramedic training programs and evaluating existing ones. Standardization and control is similarly needed other elements of the paramedic program. The Emergency Systems Division is also working to develop a system to apply to these elements.
The Pasadena City College case demonstrated the need for public review in the absence of a standardized system of controls. As we have stated, however, the system itself is bound to be controversial and will require public review for acceptance.
The Paramedic Committee has to some extent been performing this review function. The problem is that it is not legally authorized to do so.
County Conflict of Interest
Through its control of the certification process, the County can:
The County not only controls but also provides paramedic services and training. In unincorporated territory and in contract cities, County fire-fighters are the paramedics. The Sheriff also employs paramedics for search and rescue operations. The County's major teaching hospitals, Harbor General Hospital and the County USC Medical Center, offer paramedic training.
Thus, other potential providers of service, such as municipalities, community colleges, proprietary hospitals, and ambulance companies, have found that to begin to provide service, they must obtain the approval of an organization that competes with them - Los Angeles County government.
As we noted in Section I, in this situation the County of necessity has c conflict of interest. The potential is high that the other providers of service will allege that the standards adopted by the County are arbitrary and ar4e designed merely to obstruct the provision of services and training by others. We have, in fact, during the course of our study heard such allegations. Two standards adopted and enforced in the past illustrate this point.
For example, the County has established the requirement that before an individual can be admitted to a paramedic training program he or she must be employed by a sponsoring ambulance company or fire department. One may ask the question - why paramedics? There are no comparable governmental standard8 restricting any person's freedom to undertake training'a8 a physician, nurse, respiratory therapist, radiological technician, or similar vocation. While there may be valid reasons to justify the County policy, such as the limited capacity of existing training programs, it seems clear that the possibility of the policy favoring large tax-funded organizations like the County, makes imperative public debate and review of such policies.
Even when a standard has been accepted as fair and practical, it may still be susceptible to abuse and manipulation. The County, for example, requires that each paramedic complete an internship of twenty shifts of twenty- four hours with a working paramedic rescue squad prior to certification.
The primary purpose of internship is to give the trainees some basic field experience before they assume operating responsibility. The problem is that the number and types of rescue calls encountered in twenty shifts is strongly dependent upon the service area of the unit to which the trainee is assigned. Consequently, those who centrally administer the assignments control the quality and effectiveness of internships.
While we can cite no evidence that the County has abused its authority to assign internships, the possibility that it could do so clearly reflects the need for impartial review of assignment methods and resolution of disputes if they arise.
These are two examples of standards which the County has been enforcing and which some authorities allege are unfair. Others could be cited.
Regardless of the merits of these allegations, the County lacks credibility, when,
as a provider of services, it adopts standards and controls which restrict the ability of others to provide similar services. Again, we conclude there is a
compelling need for public debate and review before some agency which is free of conflict of interest and can objectively arbitrate differences and disputes when they occur.
Public vs. Private Interests
Although paramedic programs to date have been widely acclaimed and have received a broad base of public support, a controversy has developed over the appropriate roles of the public and private sectors in the provision of services.
As we noted in Section I, the debate centers on the use of private ambulance companies. In particular, the controversy involves the establishment of standards for determining when an ambulance company qualifies to enter the field, and if it does, the manner in which it should share responsibility with governmental units. Some companies allege that present County standards create a bias toward approving governmental programs which utilize firefighters in a dual role as paramedics and ambulance companies only in the role of transportation.
There is some evidence that County standards have had a preferential effect, if not intent. At present, 24 of 26 cities providing their own paramedics use firefighters, and two, Los Angeles and Pasadena, use civilians employed in the fire department. Only four use an ambulance company for first response service. In addition, County firefighters serve 37 other cities as members of the Consolidated Fire Protection District.
The County requires an ambulance company applying for certification of its service to limit the service of a unit to a contiguous geographic area containing a specified number of people and not covered by a fire department unit. In addition, before a company can operate a paramedic unit for emergency medical response, the County requires the company to have commitments that the city governments of the area it serves will use the service. To meet such standards, a company may have to forego any consideration of achieving economies of scale because of the limitation of geographic boundaries.
To date, public provision of service through local fire departments has seemed highly advantageous. However, a number of local jurisdictions have recently begun to compare the costs of public and private services for similar levels of quality. Some are finding that the use of private providers may have a cost advantage. Others, such as Los Angeles City, have chosen to provide their own service using civilians.
It is not our intention here to argue the pros and cons of public vs. private provision of paramedic services. Our concern rather is that in the controversy over this issue there is little factual evidence to support standards and controls adopted in the past. The result has been that everyone involved, including the County and the Paramedic Committee, have been forced to make decisions and take positions based upon questionable assumptions.
For example, it is not necessarily true, as widely believed, that use of firefighters as paramedics is a cost free use of idle labor. First, fire departments can be penalized by the insurance grading process when firefighting manpower is used for paramedic rescue work. Second, labor is needed in the station for routine overhaul and maintenance activities. If the incidence of rescue calls is high, this labor must be replaced. For these reasons, a number of fire authorities reported to us that they will require a subsidy from the County to continue providing paramedic services. Thus, a number of cities are considering a change to contracting with ambulance companies for basic emergency service.
Again what is needed is a comprehensive system of controls and standards subject
to public debate and impartial review.
The responsibility for which the Paramedic Committee was established - to advise
the Director of Health Services on matters relating to paramedic training and certification
- has not been a principal function of the committee for the past several years Our
conclusion, as presented in Section I, is that a new Paramedic Commission should be
created. We are recommending the change from "committee" to "commission" to
emphasize that the role and scope of the new commission differ substantially from those
of the present committee.
Objective and Responsibilities
The objective and responsibilities of the new commission are designed specifically to meet the need for a mechanism to insure public review of quality control decisions for paramedic programs. As we pointed out in previous sections, the demand for public review of County decisions has been so strong that the current Paramedic Committee has acted to meet the need without explicit legal authority in the absence of any other agency authorized to do so.
In contrast to the original committee, the new commission will not make certification recommendations to the department. We believe that as the responsible legal authority, the Department of Health Services should be held accountable for certification of paramedic candidates and training programs. To be certified, paramedic candidates will be required to pass standardized examinations. Proposed training programs will be required to satisfy criteria incorporated in a standardized curriculum. Similar standardization will need to be established for continuing education, recertification, and decertification.
Thus, under our proposal the department will be fully accountable for certification decisions. As we have emphasized, what is needed is an appropriate avenue of appeal for those who dispute these decisions. This is the role we assign to the new Paramedic Commission. Since it will be acting as a review board when those involved appeal decisions, it would not be appropriate for it to participate in the original decision-making.
The control system will also incorporate performance standards to regulate the quality of such other elements of paramedic programs as drugs, equipment, and supplies. For these elements too the commission will serve as an avenue for arbitration and appeal.
We should point out that the Wedworth-Townsend Act will expire in July, 1976, and is now being reviewed for revision at that time. Consequently, paramedic programs are now undergoing evaluation throughout the State. Whatever the outcome, it is reasonable to assume that the roles of the State, counties, and other providers of service will be clarified by new legislation. We have not, therefore, delineated in detail the subject matter of the control system which the County may be required to develop and operate.
Under present legislation, the County has required deployment of two paramedics per unit. It is not certain under future legislation to what extent counties will be responsible for standards of operation which specify resource allocation and personnel deployment involving the management of programs by municipalities, fire departments, and other providers. We believe that whatever the role of the County becomes, it should be administered by the Department of Health Services, with the Paramedic Commission acting as an appeals board.
Clearly the responsibility we propose for the commission is substantial. But, as we have emphasized repeatedly, the Department of Health Services, because of its conflict position as both a provider and a regulator of paramedic 8ervices, should not make these decisions without giving those affected an opportunity for public debate, arbitration and appeal.
We should also note that the hearing process of the commission is not a passive one. In the course of a review of some decision or set of standards, the commission may wish to recommend alternatives to the County 's proposals.
The functions of arbitration of differences and hearing appeals which we-recommend for the Paramedic Commission could not appropriately be performed by the Committee on Emergency Medical Care. The Committee on Emergency Medical Care has two principal functions. The first is to advise the County in the establishment of policies, programs and standards for emergency medical care services, including paramedic services. The second is to evaluate the system and its impact as the County develops it. Consequently, this committee could not act as an objective and credible hearing board for arbitration and appeals, since it is a principal participant in the development of the County's system.
The task force concludes that the Committee on Emergency Medical Care cannot
properly perform the responsibilities we recommend for the Paramedic Commission.
Scope of Commission Responsibilities
Paramedic programs are only one part of a complex and far-reaching system of emergency medical care. Many people and agencies, in addition to the paramedics at the scene, are directly involved: the doctors and nurses at the base hospital who instruct the paramedics over the radio; the doctors and nurses at the receiving hospitals who prepare for patient admission; the police, firefighters, and ambulance attendants at the scene. Many others are involved in the care of the patient, but with less impact on paramedic performance before hospital admission: the staff of the emergency room in the receiving hospital; the staff of the critical or intensive care units to which the patient may be taken; the patient's physician and family.
The system of emergency medical care will in the future involve certain technicians other than those now designated paramedics. Today's paramedics are trained to a level of proficiency beyond advanced first aid. The advanced first aid level has been designated EMT-I (Emergency Medical Technician I); paramedics have been designated EMT-II. State and other agencies are developing criteria for the training of EMT-III's and EMT-IV's. The concept is that EMT-III's will provide more advanced field treatment and assist in emergency rooms, while EMT-IV's will act as physician's assistants in emergencies.
Criteria for doctors and nurses involved in emergency care are also being developed.
There is a question, then, of where the responsibility for local quality control in these fields should reside. Thus it is important to delineate the scope of the new commission's responsibilities in order to determine what decisions made by the Department of Health Services come within the province of the commission. (See Section I, p. 9.)
Since a system of standards and controls will be needed to insure quality of service in all areas of emergency medical care, it is reasonable to consider defining the scope of the commission's responsibilities to include these areas. However, it is not clear that the County would find itself in a similar conflict position in regulating these other areas. Moreover, the concepts in many of these other areas are not at present well developed. Consequently, it is difficult to determine what role, if any, the commission should have in their regulation.
If in the future it is determined that there is a need for a hearing board in other
areas of emergency medical care, the County should consider expanding the scope of the
Paramedic Commission, rather than creating separate commissions. We would caution
the Board of Supervisors, however, that the amount of work that will be required of the
Paramedic Commission in the paramedic area alone is bound to be substantial for the
next several years. We think it wise, therefore, to limit the scope of the commission at
this time to areas which have a direct impact on the quality of paramedic services.
The primary purpose of the Paramedic Commission is to act as an arbitration and appeals board in order to insure both high quality paramedic services and fair treatment of all sectors of the community having an interest in providing these services. The commission, therefore, should be structured to incorporate the expertise required to understand, analyze and judge the issues coming before it. At the same time, if the commission is to have credibility as an impartial hearing body, its members must be as free as possible from conflict of interest.
To some extent these two criteria are conflicting. That is anyone who possesses experience and expertise in paramedic training and procedures is almost bound to have an interest which presumably at some time could impair his or her objectivity.
Our purpose in determining the membership for the commission was to balance as
much as possible expertise and freedom from conflict. The recommended composition is
designed to provide a balance of points of view, broad representation of the community,
and the skills or expertise which will contribute to the decision-making functions of the
commission. (See Section I, pp. 9-10.)
The Paramedic Committee was originally composed entirely of physicians. We think physician expertise will continue to be essential to the operation of the Paramedic Commission, since its primary objective is quality control of paramedic programs. Physicians have the most to contribute in this area. They also represent the major interest group because it is their patients who are involved.
However, in contrast to our recommendation regarding the Committee on Emergency Medical Care, the primary consideration in selecting physician members should be their institutional affiliations rather than their specialties.
The commission will be making decisions and resolving disputes involving the effects of quality control standards on the costs of public and private providers of service. The outlook of physicians from the large public hospital, the community-based private hospital9 and the teaching hospital will contribute a necessary balance of the private and public sectors. The viewpoint of a physician in a paramedic base station and that of a practicing physician with no particular institutional affiliation should further enhance the balance on the commission.
We recommend that one member be a lawyer. The purpose of the lawyer on the commission is not to replace County Counsel. The advice of the County Counsel will always be available to the commission, and would take precedence on any point of law. Nevertheless, the commission will be responsible for providing an impartial forum for hearing the divergent views of various sectors of the health services community. A lawyer's training and experience should contribute substantially to the commission's effectiveness in insuring equitable and balanced debate.
We recommend that one member be an educator. The commission will be considering highly technical educational questions requiring an understanding of the best current educational practice involving curricula, testing, course structures, and training programs.
We recommend that one member be a registered nurse with mobile intensive care experience employed by a paramedic base station hospital. The direct experience of such nurses with paramedics acquaints them with the strengths and weakness of paramedic training. In addition, their insight into the ways that paramedic services complement nursing and its responsibilities will assist the commission in its deliberations, especially with regard to the opposition of nursing groups to the paramedic concept.
We recommend that two members be public members, who are not medical or
health services professionals or providers of such services. Public members contribute to
specialized commissions of this type in two ways. First, they bring the perspective of
detached but potentially affected people to the commission. Second, they tend to
question the tacit assumptions of the professionals on the commission. Thug, they should
further strengthen the commission's impartiality.
Excluded Alternatives
We have elected to recommend a composition which does not include members suggested by some authorities: The most important of these are a fire chief, an ambulance company operator, a working paramedic, and a hospital administrator. There are several reasons for each of these omissions. In general, we have tried to avoid recommending representation which 1) would unnecessarily increase the size of the commission or upset its balance, and 2) would create a potential conflict of interest.
For example, the recommended composition does not include the County Forester and Fire Warden, a member of the current Paramedic Committee. Including the Forester and Fire Warden would require, for balanced representation of both public and private operations, adding representatives of a large city fire department, a small city fire department, and private ambulance companies. All of these, like the Forester and Fire Warden, are providers of paramedic services. In addition, a representative of the Sheriff would have to be considered, since he employs paramedics for his search and rescue operations. The resulting addition of four or five more non-physician members would upset the overall balance of the commission.
Moreover, each of these members would have a potential conflict, since each has a direct interest in the provision of pre-hospital care and the costs associated with the level of quality to be considered by the commission. For these reasons the task force concludes that none of these providers of paramedic services should serve on the commission.
Some of the authorities we interviewed have said that including a working paramedic would enhance the commission's effectiveness by adding the point of view of those whose performance, training, and careers will be directly affected by its actions. As others have pointed out, however, a working paramedic on the commission is likely to have conflicts which will impair his or her objectivity. First, decisions will be considered that will have a personal impact on the paramedic, thus weakening the impartiality with which the commission should operate. Second, the commission will consider matters on which the paramedic's superiors may have strong positions. Whatever the point of view of the paramedic, he or she would be in a difficult position to express it without obtaining the approval of a superior.
The absence of a hospital administrator from our recommendation is based primarily on the scope of commission operation. The commission will be primarily concerned with pre-hospital care. It will be concerned with hospitals only to the extent that their activities have a direct impact on paramedic operations in the field.
With respect to all such alternatives, we should emphasize that it is neither
necessary nor desirable for a commission to include within its membership people with
all the various skills that may possibly contribute to its work. Excluding some types of expertise does not preclude the Commission from 8eeking
advice from such experts, nor will it preclude anyone from requesting a hearing or giving
Membership Limitations
The Paramedic Commission will be considering highly controversial issues that have an impact on the lives of patients and on the careers of medical technicians. Its work will be a part of the decision-making process of County government. Therefore, not only its expertise, but also its credibility and prestige in the community are important to its success. All of the constraints on membership are based, in particular, on the need for credibility. Consequently, we have recommended strong restrictions in the general area of conflict of interest. (See Section I, pp. 11-12.)
The problem with such restrictions, as we noted in the introduction to this section,
is that they can limit the range of the Board's search for expert members. Too strong a
limitation - for example, excluding anyone with a professional or financial interest -
would result in excluding all necessary expertise. The limitations on membership
therefore are designed to exclude only those individuals who would clearly encounter a
conflict of interest, that is, those with a major career, professional or financial interest that
is likely to be affected by commission decisions.
Method of Appointment
The commission will hold hearings on issues which otherwise would require public debate before the Board of Supervisors. It should be structured therefore to effectively represent the Board.
In contrast to the Committee on Emergency Medical care, which has the highly technical job of systems evaluation, the Paramedic Commission will function primarily as an arbitration and appeals board. Therefore, we have proposed that the Board of Supervisors select members of the Paramedic Commission directly, rather than through nominations by organizations that are in a position to locate the expertise needed for technical evaluation of the system.
As the ordinance provision which we recommend states (see Section I, p. 10), each Supervisor will nominate two members for appointment by the Board. We have not specified a method by which the Board should determine which positions are assigned for nomination to individual Supervisors. We have suggested, however, that it could be done either through assignment by the Chairman of the Board or by lot. In either case the Board could elect to assign one physician to each Supervisor.
Whatever the method, we urge the Board to give consideration to the expertise
which current members of the Paramedic Committee possess in this area based on their
years of experience serving on the committee. We would also suggest that Board
members consult with each other regarding the nomination of physicians to insure a
balance of specialty fields, such as emergency medicine, cardiology, traumatology and
surgical specialties.
The ordinance we recommend specifies that the commission shall adopt its own internal operating policies and procedures consistent with the provision8 of the ordinance. (See Section I, p. 12.) The rules should cover time and place of meetings, selection of officers, terms of office, obligations of commission members, structure of sub-committees or advisory councils, if any, and the general conduct of commission business.
The chairman of the current Paramedic Committee, Dr. Walter Graf, was appointed to the chair by the Board of Supervisors when the committee was established in 1970. The new Paramedic Commission may choose to continue this practice or adopt some other method of selecting its officers.
The ordinance also specifies that the commission will appoint its own staff as authorized by the Board of Supervisors. Experience can only determine what staff positions and classifications will be required.
Daniel Freeman Hospital is now furnishing administrative and clerical support to
the present Paramedic Committee free of charge. Since most of the information required
by the new commission to perform its duties will be presented to it in public hearings,
and since the present committee is already functioning in a similar manner, we would
conclude that additional staff requirements will be minimal.
Members of the Paramedic Committee Gail V. Anderson, M.D. Professor and Chairman, Department of Emergency Medicine, County-USC Medical Center J. Michael Criley, M.D. Chief, Division of Cardiology, Harbor General Hospital Sister Frances Ellen, R.N. Nursing Administrator, Queen of the Valley Hospital Walter S. Graf, M.D. Chairman Clinical Professor of Medicine, University of Southern California and Loma Linda University Julius W. Hill, M.D. Professor of Surgery, Charles R. Drew School and Martin Luther King Hospital David B. Homer, M.D. Associate Clinical Professor of Medicine, University of Southern California Richard H. Houts Forester and Fire Warden and Chief Engineer, Los Angeles County John W. H. Sleeter, M.D. Director, Emergency Department, Santa Teresita Hospital Paul A. Teslow Administrator, Northridge Hospital County Employees - (Not members of the Committee) John E. Affeldt, M.D. Medical Director, Department of Health Services Gaylord E. Ailshie Director, Paramedic Services, Division of Emergency Medical Systems, Department of Health Services Richard B. Baird Division Chief, Program and Budget Division, Chief Administrative Office Morrison E. Chamberlin Chief Deputy Director, Department of Health Services Robert Eskanos Principal Administrative Analyst, Management Audit Division, Chief Administrative Office R. T. Freeman Inspector, Sheriff's Department John Gelfuso Firefighter Paramedic, Station 3, Consolidated Fire Protection District Stanley Grant Administrator, Division of Emergency Medical Systems, Department of Health Services David L. Lemm Captain, Station 3, Consolidated Fire Protection District Ben E. Matthews Chief, Operations Division, Department of Forester and Fire Warden Daniel D. Mikesell, Jr. Deputy County Counsel John P. O'Connor Deputy Director, Contracts and Community Services, Department of Health Services Jess Perez Firefighter Paramedic, Station 3, Consolidated Fire Protection District Ronald Pierce Firefighter Specialist, Station 3 Consolidated Fire Protection District Nino F. Polito Division Assistant Chief, Operations Division, Department of Forester and Fire Warden Elliot Salenger, M.D., M.P.H. Medical Director, Division of Emergency Medical Systems, Department of Health Services Paul P. Schneider Division Assistant Chief, Operations Division, Department of Forester and Fire Warden Richard S. Scott, M.D. Director of Special Projects, Department of Emergency Medicine, County-USC Medical Center Paul G. Seehusen Deputy County Counsel Ronald D. Stewart, M.D. Director, Paramedic Training, Division of Emergency Medical Systems, Department of Health Services Gerald Surfus Chief, Risk Management, Program Evaluation Division,Chief Administrative Office Liston A. Witherill Director, Department of Health Services Others Brian G. Adlington President, Verdugo Hills Hospital Robert B. Andrews, Ph.D. Professor, Graduate School of Management, UCLA Mrs. Colly Bakeman, R. N. Past Coordinator-Instructor, EMT and Paramedic Program, Department of Nursing, Pasadena City College Joseph N. Baker City Manager, City of Burbank Harry C. Bigglestone Chief Protection Engineer, Pacific Region, Insurance Services Office Rand Brooks Owner, Professional Ambulance Company Inice Chirco, R.N., M.A., M.S. Chairman, Department of Allied Health, Rio Hondo College Frank Clark Director of Professional Affairs, Los Angeles County Medical Association Mrs. Joan M. Davidson, R.N. Chairman, Department of Nursing, Pasadena City College Joseph M. Dolphin President, Los Angeles County Ambulance Association Charles Dovey Los Angeles MICU Paramedic, MEDEVAC Paramedic Ambulance Inc. Raymond L. Eden Executive Director, American Heart Association, Greater Los Angeles Affiliate Walter Edwards, M.D. President, American College of Emergency Physicians and Director, Emergency Room Daniel Freeman Hospital Ida L. Frisbee Chairperson, Department of Human Services, Compton College Winnie Hobbs Paramedic Coordinator, Education Department, Daniel Freeman Hospital Dennis Jorgensen Vice President, Newhall Ambulance Inc. George W. Kahl Fire Chief, City of Monrovia Glenn A. Langer, M.D. President, American Heart Association, Greater Los Angeles Affiliate Kenneth Long Chief Engineer, Fire Department, City of Los Angeles John R. MacFaden Executive Vice President, Los Angeles County Ambulance Association John H. Mahaffey President, ANVAL Enterprises Inc. John W. Mahaffey Secretary-Treasurer, ANVAL Enterprises Inc. Gene Mahoney Chief, Fire Department, City of Arcadia George D. Morgan Captain, Paramedic Co-Ordinator, Department of Fire, City of Long Beach Muriel M. Morse General Manager, Personnel Department, City of Los Angeles Gail Pleasance, R.N Instructor, Education Department, Daniel Freeman Hospital J. Walter Schaeffer President, Schaeffer's Ambulance Service Inc. Edward L. Schindler Assistant Director for Emergency and Disaster Services, Hospital Council of Southern California Joe G. Smith Chief, Fire Department, City of Inglewood Leslie R. Smith Executive Director, San Pedro and Peninsula Hospital John F. Sturges Chief, Fire Department, City of Santa Monica Mrs. Mary Taylor, Jr. Chairman of the Board, American Heart Association, Greater Los Angeles Affiliate William Trautman Los Angeles MICU Paramedic, MEDEVAC Paramedic Ambulance Inc. Robert B. White San Fernando Valley Area Representative, Los Angeles County Federation of Labor, AFL-CIO Robert F. Woehrmann Owner, AIDS Ambulance and Medical Service Mrs. Betty Wright, R.N. Coordinator-Instructor, EMT and Paramedic ProgramDepartment of Nursing, Pasadena City College Howard Zuck Assistant General Manager, Personnel Department, City of Los Angeles
1480. Pilot program
Any general acute care hospital operated by, or contracting with, a county may
conduct a pilot program which provides services utilizing mobile intensive care
paramedics for the delivery of emergency medical care to the sick and injured at the scene
of an emergency, during transport to a general acute care hospital, while in the emergency
department of the general acute care hospital until care responsibility is assumed by the
regular staff of the general acute care hospital, and during training within the facilities of
the sponsoring general acute care hospital.
1480.1 Pilot program
The training of mobile intensive care paramedics may only be conducted by a community college, college, university, or hospital that has a certificate of approval for its curriculum and training program from the county health officer of the county in which it is located.
1481. Definitions
As used in this article:
(a) "Mobile intensive care paramedics" means personnel who have been
trained in the provision of emergency cardiac and noncardiac care in a training program
certified by the county health officer of the county giving certification or a certified
training program in another county that has been evaluated and approved by the county
health officer of the county giving certification, and who pass the performance and
written examinations required for certification by the officer as qua1ifed to render the
services enumerated in this article in the county giving such certification.
(b) "Mobile intensive care nurse" means a registered nurse who has been
certified by a county health officer as qualified in the provision of emergency cardiac care
and noncardiac care and thc' issuance of emergency instruction to mobile intensive care
(c) "Mobile intensive care units" means any emergency vehicles staffed by mobile intensive care paramedics or mobile intensive care nurses and equipped to provide remote intensive care or cardiac care to the sick or injured at the scene of medical emergencies or during transport to general acute care hospitals.
(d) "Emergency department" means any department or separate area within a
general acute care hospital which is staffed and equipped to provide emergency medical
care to the sick or injured.
1481.1 Minimum training; experience
The training program for mobile intensive care paramedics shall consist of a
minimum of 200 hours of didactic training, a minimum of 100 hours of clinical
experience, and a field internship of at least 200 hours.
However, all or any portion of the required training program for a mobile
intensive care paramedic may be waived by the county health officer of the county giving
certification if the applicant passes the performance and written examinations required for
certification or the appropriate portion of the performance examination.
1481.2 Program evaluation report
Each county conducting a pilot program pursuant to this article shall submit an
annual report to the Legislature and to the State Department of Health, not later than
January 31 of each calendar year, evaluating any such pilot program conducted at any
general acute care hospital operated by the county or under contract with the county. The
report shall include an evaluation of the competency and effectiveness of the performance
by the mobile intensive care paramedics in their duties in staffing rescue units and in the
rendering of medical and nursing care pursuant to this article. The report may include
recommendations relating to the extension or modification of the provisions of this
1481.3 Courses of instruction and training; certification; fees; reimbursement by federal
Any county conduct a pilot program under this article may provide courses of instruction and training leading to certification as a mobile intensive care paramedic. Where such instruction and training is provided to public employees other than employees of the county or employees of the fire protection district within the county, a fee may be charged sufficient to defray the cost of such instruction and training. Where such instruction and training is provided to any other persons such fee shall be charged. However, such fee may be reduced to the extent of any federal funds obtained by the county for the purpose of providing such instruction and training.
1482. Duties
Notwithstanding any other provision of law mobile intensive care paramedics may do any of the following:
(l) Render rescue, first aid and resuscitation services.
(2) Perform cardiopulmonary resuscitation and defibrillation.
(3) During training and while caring for patients in the sponsor general acute care hospital under the direct supervision of a physician or registered nurse, or while at the scene of a medical emergency where voice contact or a telemetered electrocardiogram is monitored by a physician or a certified mobile intensive care nurse where authorized by a physician, and where direct communication is maintained, upon order of such physician or such nurse:
(a) Administer intravenous saline, glucose or volume expanding agents or solutions.
(b) Perform gastric suction by intubation.
(c) Perform pulmonary ventilation by use of esophageal airway.
(d) Obtain blood for laboratory analysis.
(e) Apply rotating tourniquets.
(f) Administer parenterally, orally or topically any of the following classes of drugs or solutions:
(i) Antiarrhythmic agents.
(ii) Vagolytic agents.
(iii) Chronotropic agents.
(iv) Analgesic agents.
(v) Alkalinizing agents.
(vi) Vasopressor agents.
(vii) Narcotic antagonists.
(viii) Diuretics.
(ix) Anticonvulsants.
(x) Ophthalmic agents.
(xi) Oxytocic agents.
(xii) Antihistaminics.
(xiii) Bronchodilators.
(xiv) Emetics.
g. Assist in childbirth
1483. Liability for instructions given paramedics
No physician or nurse, who in good faith gives emergency instructions to a paramedic at the scene of an emergency, shall be liable for any civil damages as a result of issuing the instructions.
1484. Duration of article
(a) This article shall remain in effect only until July 1, 1976, and shall have no force or effect after that date.
(b) On or before July 1, 1975, the State Department of Health shall submit to the Legislature a comprehensive report on emergency medical services in California. Such report shall include a thorough review and evaluation of the mobile intensive care paramedic pilot program authorized by this article and shall make specific recommendations on the following:
(1) Development of statewide coordination of emergency medical service
systems, including appropriate communications Systems and equipment;
(2) Development of manpower certification standards for all types of emergency
medical service personnel to include specifically the training and scope of practice
requirements for the categories of ambulance personnel (E.M.T. I) and paramedics
(3) Standards for local paramedic programs including location, qualifications for
appropriate teaching institutions, performance standards, and the curriculum necessary for
state accreditation of the local program; and
(4) Standards for the staffing and equipping of hospital emergency rooms.
(c) In developing such report, the department shall solicit the advice and recommendations
of the Advisory Committee on Emergency Medical Services.
1484.1 Duration of article
During the clinical internship portion of the training program specified in Section
1481.1, mobile intensive care paramedic interns shall be supervised continuously by a
physician or registered nurse.
During the field internship portion of the training program specified in Section
1481.1, mobile intensive care paramedic trainees may perform all the services
enumerated in this article, provided that they are supervised and accompanied by a
certified mobile intensive care paramedic, a physician, or a mobile intensive care nurse.
l484.2 Duration of article
The county health officer shall establish criteria necessary to maintain
certification as a mobile intensive care paramedic or a mobile intensive care nurse
including, but not limited to:
1494.3 Duration of article
No agency, public or private, shall advertise or disseminate information to the
public that the agency provides paramedic rescue or paramedic ambulance service unless
that agency does, in fact, provide mobile intensive care units on a continuous
24-hours-per-day basis. If advertising or information regarding the agency's paramedic
rescue or paramedic ambulance service appears on any vehicle it may only appear on
those mobile intensive-care-unit vehicles utilized solely to provide service on a
continuous 24-hours-per-day basis.
1484.4 Duration of article
It shall be a misdemeanor for ambulance personnel to impersonate or refer to
themselves as paramedics unless the person has been certified as a mobile intensive care
paramedic and currently maintains that certification.
1485. Short title
This article shall be known and may be cited as the Wedworth-Townsend
Paramedic Act. It is the intent of this article to respond to the critical shortage of
professionally trained medical and nursing personnel for the fast, efficient medical care of
the sick or injured at the scene of a medical emergency, during transport to a general
acute care hospital, and in the emergency department of the general acute care hospital
until care responsibility is assumed by the regular staff of the general acute care hospital.
Improved emergency medical service is required to reduce the mortality and morbidity
rates during the initial treatment phases of the onset of an acute illness or following an
accident. Within the goals of this act is the provision of the best and most efficient and
economical delivery of emergency medical care.
FOOTNOTE: This has been prepared for your use by the office of State Senator James Q. Wedworth. It is the complete Wedworth-Townsend Paramedic Act effective January 1975, and
includes the original act and subsequent legislation.
ORD. NO. 4099 274 - 10,846 Eff. 3-22-74
(10,846 3-22-74)
Sec. 1651. CREATION. There is hereby created the Los Angeles County Paramedic
Committee, hereinafter referred to in this Article as the "Committee," which shall supersede the Los Angeles County Paramedic Committee heretofore established
pursuant to Board Order.
Sec. 1652. MEMBERSHIP. The Committee shall consist of ten members and one ex
officio member. All members, except the ex officio member, shall be appointed by the
Board. Eight of the members shall be licensed to practice medicine in the State of
California. The five physicians currently serving on the Los Angeles County Paramedic
Committee, heretofore established pursuant to Board Order, shall be deemed members of
the Committee. The ex officio member shall be the County Forester and Fire Warden.
Three additional physicians shall be selected as follows:
(a) One shall be a physician actively engaged in the practice of emergency medicine in a paramedic base hospital in the County of Los Angeles and be a current member of the American Col1ege of Emergency Physicians.
(b) One shall be a physician in charge of the emergency department of a paramedic base hospital in the County of Los Angeles.
(c) One shall be nominated, subject to Board approval, by the Medical Advisory Council of the City of Los Angeles and be currently engaged in practice in a paramedic base hospital in the County of Los Angeles.
The remaining two non-physician members shall be selected as follows:
(d) One shall be nominated by the Hospital Council of Southern California, subject to Board approval, and be currently employed as an Administrator of a paramedic base hospital by the County of Los Angeles, He shall not, however, be from the same hospital as any of the physicians appointed pursuant to sub-paragraphs a, b and c above.
(e) One shall be nominated by the Directors of Nursing Council, subject to Board approval, and be currently employed as a registered nurse in a paramedic base hospital in the County of Los Angeles, whose specialization is emergency care in an emergency setting, such as a trauma center, critical care unit, or intensive care unit.
Sec. 1653. TERMS. Each member or the Committee, except the ex officio member,
shall serve for a term or one year from the date of appointment and until his successor is
appointed and qualifies. For those physicians who are deemed members pursuant to
Section 1652 of this Article, the date of appointment shall be the effective date or this
Article. All appointments are subject to the right of the Board to remove any such
member at any time at its pleasure and also subject to the provisions of Section 39.5 and
all other applicable provisions of this Ordinance. In the case or the death, resignation, or
removal of any member by the Board or pursuant to Section 39.5, or otherwise, his
successor shall serve for the remainder of the unexpired term.
Sec. 1654. COMPENSATION. The compensation of members of the Committee and the
Advisory Council shall be as provided from time to time in the current salary ordinance
of the County of Los Angeles. In the absence of any provision therefor in said current
Salary Ordinance, the members of the Committee and the Advisory Council shall serve
without compensation.
Sec. 1655. SELF-GOVERNMENT. The Committee may prepare and adopt rules for the
conduct of its business and designate the time and place of its meetings.
Sec. 1656. DUTIES. The Committee shall act in an advisory capacity to the Director of
Health Services in matters relating to the training and certification of Mobile Intensive
Care Paramedics.
Sec. 1657. ADVISORY COUNCIL. As a part of the Committee a separate advisory council is hereby created to consist of six members. Pursuant to Section 51 of the Charter of the County the Committee shall appoint the six members as follows:
(a) A representative proposed by the Los Angeles County Ambulance Association.
(b) A representative proposed by the Los Angeles County Heart Association.
(c) A representative proposed by the League of California Cities, said representative to be from a participating city and whose assignment is to supervise a Mobile Intensive Care Unit.
(d) A representative from the Communications Department of the County of Los Angeles.
(e) An educator proposed by the Southern California Association of Community College who is skilled in the area of training of mobile intensive care paramedics.
(f) A practicing Paramedic proposed by the Director of Paramedic Training, County of Los Angeles.
The members of the Advisory Council shall serve for a term of one year from the date of appointment and until their successor is appointed and qualifies, subject, however, to the right of the committee to remove any such member at any time at its pleasure.
The Advisory Council shall act in an advisory capacity to the Committee.
Mr. Burke Roche, Executive Secretary
Los Angeles County Economy &
Efficiency Commission
163 Hall of Administration
500 West Temple Street
Los Angeles, California 90012
Re: Recommendations of Economy and Efficiency Commission Concerning the Organization and Operation of the Paramedic Committee
Dear Mr. Roche:
You have asked that we review the subject recommendations, dated July 2, 1975, to
determine whether there are any legal impediments which would prevent their
implementation. We have completed our review and note that several of the proposals
seem contrary to provisions of the Wedworth-Townsend Paramedic Act, hereinafter
referred to as 'Act" (Health and Safety Code (HSC) Section 1480 et seq.). We refer
specifically to those provisions contained in HSC 551480.1, 1481, 1481.1, and 1484.2.
HSC Sec. 1480.1 provides:
"The training of mobile intensive care paramedics may only be conducted
by a community college, college, university, or hospital that has a certificate of
approval for its curriculum and training program from the county health officer of
the county in which it is located."
HSC Sec. 1481 provides:
"As used in this article:
(a) 'Mobile intensive care paramedics' means personnel who have been
trained in the provision of emergency cardiac and noncardiac care in a training program certified by the county health officer of the county giving certification or a certified training program in another county that has been
evaluated and approved by the county health officer of the county giving certification, and who pass the performance and written examinations required for certification by the officer as qualified to render the services enumerated in this article in the county giving such certification.
(b) 'Mobile intensive care nurse' means a registered nurse who has
been certified by a county health officer as qualified in the provision of emergency
cardiac care and noncardiac care and the issuance of emergency instruction to
mobile intensive care paramedics.
"* * * *"
HSC Sec. 1481.1 provides:
"The training program for mobile intensive care paramedics shall consist
of a minimum of 200 hours of didactic training, a minimum of 100 hours of clinical experience, and a field internship of at least 200 hours.
"However, all or any portion of the required training program for a mobile
intensive care paramedic may be waived by the county health officer of the county
giving certification if the applicant passes the performance and written
examinations required for certification or the appropriate portion of the
performance examination.
HSC Sec. 1484.2 provides:
"The county health officer shall establish criteria necessary to maintain
certification as a mobile intensive care paramedic or a mobile intensive care nurse
including, but not limited to:
(a) A formal program of continuing education.
(b) Continuous service as a mobile intensive care paramedic or a
certified mobile intensive care nurse.
(c) Retesting at two-year intervals, which shall include a performance examination and may include written examinations and oral examinations."
These statutory provisions clearly give the county health officer (our Director of
Health Services) exclusive authority (1) to approve mobile intensive care paramedic
training programs providing paramedics for his county (if the minimum standards of HSC
S1481.l are satisfied), (2) to certify all mobile intensive care paramedics and mobile
intensive care nurses providing services in his county, and (3) to establish criteria
necessary to maintain certification as a mobile intensive care paramedic or nurse.
Under the referenced recommendations, it is proposed that a reorganized
Paramedic Committee, whose members would be appointed by the Board of Supervisors,
would be given, among other responsibilities, the following duties:
"A. To arbitrate differences between the Department of Health Services and
other sectors of the community including but not limited to physicians,
private companies, community colleges, municipalities, and hospitals in
the field of paramedic services and training.
B. To hear and decide appeals of decisions made by the Department of Health Services on the following matters:
1. Decisions to establish and enforce policies, procedures, and standards to control the certification of mobile intensive care nurses and paramedics.
2. Decisions to accept or reject proposals of any public or private organization to initiate or modify a program of paramedic services or training.
C. To hear and decide appeals of certification decisions by the Department of
Health Services and the certifying officer."
"* * * *"
Decisions reached by the Paramedic Committee could be appealed to the Board of
The effect of these proposals would be to give the Paramedic Committee, and finally, the
Board of Supervisors, apparent authority to override decisions of the Director of Health
Services concerning matters which, by virtue of the cited Health and Safety Code
provisions, have been vested by the Legislature solely in the Director. It is, of course,
settled that a county possesses only those powers specifically granted by law and those
necessarily implied from the powers expressed. San Vincente Nursery School v. County
of Los Angeles (l956), l41 Cal. App. 2d 79, 85. It is also settled that where the law
prescribes a particular mode by which a county shall exercise a power, that mode must be
followed in order to make it a valid exercise of power. Hilton v. Board of Supervisors
(1970), 7 Cal. App. 3d 708, 714.
As noted, it is the Wedworth-Townsend Act which sets forth the powers of a county in
the paramedic area, and it is the cited provisions of the Act which prescribe the mode by
which paramedic training programs, and paramedics and mobile intensive care nurses, are
certified. That mode does not provide for decisions relative to such certification to be
vested in any public officer other than the county health officer. Accordingly, such
decisions by the Paramedic Committee or the Board of Supervisors would be ultra vires,
would be illegal, and could not be binding upon the Director of Health Services. Cf.
Skidmore v. West (1921), 186 Cal. 212, 217.
Therefore, it will be necessary to amend the Act in order to provide the Paramedic
Committee and Board of Supervisors with the necessary authority to make these
decisions. If you wish, we would be pleased to assist you in drafting an appropriate
Sincerely yours,
County Counsel
Deputy County Counsel


text:
AYER/SHIRLEY -- Ayer-Shirley Youth Drama is bringing celebrity comedian/political satirist Jimmy Tingle ("60 Minutes," Comedy Central, "The Tonight Show") to Ayer-Shirley Regional High School with his "American Dream" tour.
This production will be a fundraiser for the arts in our schools, including enhancements to our forthcoming "new" auditorium that are not covered as part of the state/town renovation project.
Jimmy Tingle's "American Dream" will play at the Ayer-Shirley Regional High School Auditorium on April 26, at 7 p.m. The production is free to Ayer-Shirley students. Special fundraiser tickets for all others are $20 in advance; $25 at the door. Group rates are available. For tickets and information, call 978-772-2545 or email email@example.com. Tickets are also available online via the ASYD website at www.jacneed.com/ASYD/Tickets.htm. This production is family-friendly (rated G), but little ones may get fidgety. Recommended for ages 10 and older.
In Act I of our evening, Jimmy Tingle's "American Dream," an award-winning documentary film and tour-de-force of comedy, commentary and conversation will be presented. Some of America's most iconic personalities and social critics, as well as family, friends and total strangers speak up and speak out on the American Dream, including Howard Zinn, Robert Altman, Mort Sahl, Janeane Garafalo, Sean Hannity, Lewis Black, Margery Eagan, Jim Braude, Bobcat Goldthwaite, Sister Lena Divey, Al Franken, Robert Reich, Colin Quinn, Barry Crimmins, Jimmy's mother Frances and more. The film's score includes music by Willie Nelson; The Mighty, Mighty Bosstones; The Neighborhoods; and Jimmy Tingle himself on harmonica.
ASRHS Principal Brian Haas said, "I think it's great that ASYD is bringing Tingle's 'American Dream' to Ayer. We're very fortunate to have the film and show to use in our curriculum with the students, as well as having a celebrity coming to town to entertain parents and faculty, as well. Mr. Tingle's generosity with his time and talent are truly appreciated, helping to raise funds for our kids' arts endeavors."
In Act II, following a meet and greet during the refreshment-filled intermission, audiences will be treated to a fully audience interactive stand-up performance by Tingle, as he brings his intelligent, timely comedy to ASRHS' auditorium.
"I'm really looking forward raising spirits, funds and awareness for the dramatic arts the Ayer-Shirley schools, says Tingle. "I love that we can use my film 'American Dream,' along with a Q&A, a little comedy and expertise to help other people in the dramatic arts achieve their artistic goals." He continues, "The film is a self-produced and self-financed documentary about my 'dream' of becoming a stand-up comedian, making it onto national television, starting my own theater, and going back to school. I always enjoy the way the audiences get a kick out of the people we interview about what the American Dream means to them -- everyone from a homeless person to my mother, to Oscar winners and other comedians. Our goal on April 26 is to raise a lot of money, and moreso to help inspire the students and attendees to follow their own dreams and aspirations in the arts and beyond."
For information on Tingle, visit www.jimmytingle.com, where you'll also find a direct link to his "American Dream."

subset: commoncrawl


text:
Hey, Dog-whistle RT @mmfa Fox hosts Chuck Norris to discuss his warning of "1,000 years of darkness" if Obama is re... tl.gd/j6voo3—
Keith Olbermann (@KeithOlbermann) September 07, 2012
Well, time for yet another section in the old Handbook of Racial Code Words! Like Clint Eastwood's bit with a chair, Chuck Norris using the phrase "1,000 years of darkness" is also a dog whistle. That only racist leftists can hear.
@KeithOlbermann @mmfa … the dogs of war … 1000 years of darkness ! lmao I think it has 2 do with the darkness of some1's skin sadly—
reddroostermann (@reddroostermann) September 07, 2012
Update: The sane on Twitter swiftly weigh in.
@KeithOlbermann Im not sure if you are a trying to be a comedian or not. You certainly are not a journalist. Only racist here is you. #msnbc—
Brad (@Brad_D80) September 07, 2012
@KeithOlbermann Don't you have a place to be… like a news station or news program to host? oh wait… awkward—
Conservative Hick (@ConservativeHic) September 07, 2012
Aw man. When did @KeithOlbermann lock his Twitter account? Now where am I supposed to get my regular dose of idiocy?—
Meredith Jessup (@MeanwhileinDC) September 07, 2012
@KeithOlbermann Dude, not even MSNBC wanted you. Set sail for fail. @twitchyteam—
Ivan Ivanopoulos (@lvan_lvanovich) September 07, 2012
Hey, @KeithOlbermann, the point of a dog whistle is that only dogs can hear it. You should look in the mirror sometime. If you can stand it.—
Laura Barr (@laurakbarr) September 07, 2012
@KeithOlbermann You still take yourself seriously??? The rest of us don't. It's in your own soul that racism can be found. You should look.—
Mark Waters (@RothenFury) September 07, 2012
Well, at least he took a break from vile misogyny today. For now.


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campaign prep
The Dr. Who/Tsubasa/Kingdom Hearts-style Campaign
Published by Kat on | 1 Response
Lately I've been kicking around a campaign concept that could be pretty freaking epic if I can manage to pull it off with the right group and the right story and find a time that works for everyone (pretty much impossible, I know). I also blame Gnome Stew/Engine Publishing's Odyssey for getting me excited about […]
Posted in Campaigns, Personal | Tagged campaign, campaign prep, role-playing, settings, systems
November RPG Blog Carnival: Writing the Game
Published by Kat on | 10 Responses
Triple Crit is proud to be hosting the November 2012 Role-playing Game Blog Carnival on a topic well-suited to the blog: Writing in RPGs. National Novel Writing Month is well underway by now, and National Game Design Month will be running alongside it, so writing is seemingly on everyone's mind for the rest of the […]
Posted in For Gamemasters, For Role-Players, For Writers, RPG Blog Carnival | Tagged adventures, blogging, campaign logs, campaign prep, character journals, core books, dungeonmastering, freelance, game design, gamemastering, meta, novel writing, rpg blog carnival, rules, splat books, supplements, writing, writing process


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With the first BCS rankings of the 2011 college football season a mere week away, it's time for the Harris Interactive Poll to gear up. The third major human poll, and one of the two human polls that is part of the BCS formula, the Week 7 Harris Poll (PDF) slates LSU in at No. 1.
The Tigers earned 71 of 115 first-place votes from the Harris Poll's panel of former coaches, players, administrators and current and former media members, and hold a bigger lead over No. 2 Alabama than the Crimson Tide have over No. 3 Oklahoma. Wisconsin and Boise State round out the top five, and are followed by Oklahoma State, Stanford (which received a first-place vote), Clemson, Oregon, and Michigan in the top 10.
Elsewhere, Florida just makes the cut in the Harris Poll at No. 25, making the Gators the lone team from the Sunshine State to be ranked in any of the three major human polls in the college football rankings.
Here's the initial Harris Interactive Poll for the 2011 college football season:


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Tuesday, November 161:00 - 2:00 pm
Student Lounge250 Joralemon StreetBrooklyn
This event is open to all current students.
BLS Con-Law Professors Araiza and Tebbe will discuss recent developments surrounding the "Don't Ask, Don't Tell" policy.
For more information, please contact Shannon Karam. This event is sponsored by the Outlaws student group.
View video of the recent Symposium: Choice of Law in Cross-Border Bankruptcy Cases
"Brooklaw," the BLS Seal, and Logo are service marks of Brooklyn Law School. Contents Copyright © 1995-2013 Brooklyn Law School. All rights reserved.


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This document describes the core collecting objectives of the Southern Historical Collection (SHC) in the Louis Round Wilson Special Collections Library at the University of North Carolina at Chapel Hill. It outlines current collecting focuses, then, as context and background, briefly presents the SHC's mission, collecting rationale, relationships with other repositories, and collecting methods. Note that collecting interests extend to original and unique materials in all archival formats, including handwritten and typed documents, oral histories and other audio recordings, still and moving images, and born-digital materials.[back to top]
Collecting Scope
Geographically, the collecting range of the SHC is the American South and its border states: Alabama, Arkansas, Delaware, District of Columbia, Georgia, Florida, Kentucky, Louisiana, Maryland, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. North Carolina materials often get priority attention, given the SHC's commitment to support the University's mission of teaching, research, and service to the citizens of the state and the development of strong archival programs throughout the South that are able to preserve the history and cultural heritage in their own communities.
Chronologically, the SHC seeks materials dating from the earliest instances of written records relating to the South to the present day. Time period emphases for specific collecting areas are noted below.
The SHC also seeks materials that relate to or expand its existing collections.
Within these frameworks, the SHC emphasizes a number of specific collecting areas. Some areas are built on collecting successes over the years. Others are being actively developed by more recent curatorial initiatives. SHC staff regularly review and modify collecting areas as appropriate. Particular areas may be chosen for special attention for periods of time. Brief collection development statements follow for the subject areas currently in focus.[back to top]
Collecting Areas
Each subject area statement has two parts: a brief review of the history of SHC collecting in that area and a statement of our current collecting interests.[back to top]
Mission of the Southern Historical Collection
The Southern Historical Collection (SHC) encourages the study and appreciation of the history and culture of the American South by collecting, preserving and promoting the use of unique documentary materials of enduring historical value. The SHC does this to enable users to derive meanings from the southern past and to support the University's mission of teaching, research and service.[back to top]
Collecting Rationale
Scholarly research value is the fundamental criterion for collecting primary source documentation in the SHC. In addition, staff may also take into account items' exhibit, outreach, and instructional potential.
Collecting focuses are chosen on the basis of research community needs and SHC collection strengths, as well as knowledge of collections and collecting at other repositories. The SHC seeks to make its contribution to the research community by building on the collection strengths that made it the premier research institution for southern studies, and by carefully choosing new collecting focuses, which are reviewed periodically.
Acquisitions that do not fall into existing collecting areas sometimes are made in anticipation of new emphases.
The SHC acquires materials in a wide variety of formats-handwritten, typed, digital, still and moving images, sound recordings, and print. A strong preference exists for materials that are both original and unique, though associated materials that do not have these two characteristics may be accepted. The SHC is chiefly interested in substantive groups of materials that document an individual, family, or organization. Individual items relating to existing collections or containing exceptional research value will be considered. The SHC supports placement of the entirety of a collection in one repository rather than dispersing parts among repositories. Recognizing that manuscript collections often develop over time, the SHC welcomes donations that are to be placed through multiple additions.[back to top]
Relationship to Other Repositories
The SHC has a strong relationship with other libraries, archives, and cultural heritage institutions in the University of North Carolina system, across the state, and throughout the region.
At the University of North Carolina at Chapel Hill, the SHC works closely with the constituent collections of the Louis Round Wilson Special Collections Library: the Southern Folklife Collection, the North Carolina Collection, University Archives and Records Service, and the Rare Books Collection. As mentioned above, the SHC's collecting efforts are primarily focused on acquiring substantive collections of original and unique primary source materials from southern individuals, families and corporate bodies. Materials not falling under this definition or within the scope of the SHC may be appropriate for partner collections in the Louis Round Wilson Special Collections Library. If possible, staff will make referrals to suitable repositories within and outside the Wilson Library.
The SHC has a strong history of collaboration with other institutions throughout North Carolina and the region. The SHC has worked closely with special collections at Duke University, North Carolina Central University, North Carolina State University, and the North Carolina State Archives in making appropriate collection development decisions within the boundaries of each repository's scope and resources. The SHC will continue to foster relationships with these institutions and will attempt to build new relationships with other libraries and cultural heritage institutions across the state and region.[back to top]
Collecting Methods
Ultimate responsibility for collecting materials for the SHC rests with the Director of the Southern Historical Collection, in consultation with the Director of the Louis Round Wilson Special Collections Library and other staff members, including those in public and technical services. Other SHC staff and members of both Technical Services and Research and Instruction Services departments contribute to the SHC's collection development and collecting initiatives.
Donation is the preferred method of acquisition, and staff solicits gifts of materials from individuals and organizations. Deposits, in which ownership is not and likely will not be transferred, are considered only in exceptional circumstances.
The SHC purchases collections from dealers and auction houses and, rarely, from individuals or organizations. Purchases are funded by endowment income.[back to top]
Policy Overview
Collecting Areas


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Hi. Can you help us? I live in a little village in Scotland UK. We are trying to raise awareness and funding for a childrens hospice. Our hope is to get 7,500 scarves that when sown together will measure the distance from our village to our local Children's hospice in Kinross, 6.6 miles away. The scarves will then be sold and "special" scarves will be auction at a charity ball. The appeal runs from February till September. Details can be found on CHAS (Childrens Hospice Assossiation Scotland ) web site or on Gateside Face book page. You can always e mail me for further information and to let me know I you are willing to help. We are looking forward to seeing where we receive scarves from
Thank you for reading. Sandra
Are there any special dimensions or requirements for the scarves?
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Benton - Local Information, Resources & Photos
Benton - Searchable Map, Aerial Photos & Driving Directions
Benton is an incorporated place (Class Code P1) located in Bossier Parish at latitude 32.6949 and longitude -93.7418. (Benton Panoramio Photos). The elevation is 210 feet. Benton appears on the Benton U.S. Geological Survey Map. Bossier Parish is in the Central time zone (GMT -6). Observes DST? Yes. Current Time. | Benton, LA ZIP Code Maps | Benton local area photos
Photos of the Benton Local Area
Benton had a population of 2,816; a land area of 1.96 sq. miles; a water area of 0 sq. miles; and a population density of 1,440.41 people per sq. mile according to the US Census Bureaue estimate of July 1, 2009. Latest Census Estimates for all incorporated places in Louisiana.
Bossier Parish: Cities & Towns | ZIP Codes | Schools | Features (airports, churches, hospitals, etc.)
Benton Local Resources
Benton Arts & Culture
Benton Community Organizations
Benton Data & Demographics
Benton Entertainment - Movies
Benton Environment & Science
Benton Government
Benton Health & Medical
Benton Newcomer Information
Benton Newspapers, Radio & TV
Benton and Greater Louisiana Parks & Recreation
Benton Pets & Hobbies
Benton Schools & Education
Benton Social Services
Benton Travel & Tourism


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Exclusive: Mack Maine Confirms Omarion's Departure From Young Money
Wednesday, Aug 19, 2009 11:30PM
After rumors of R&B singer Omarion being dropped from Lil Wayne's stacked Young Money roster, which includes Drake and Bow Wow, SOHH reached out to the company's president, Mack Maine, to see if the gossip was true.
While keeping details limited, Maine said the label has cut business ties with the former B2K singer.
"Omarion is no longer with Young Money," he said via a written statement. "May God be with him and his future endeavors." (SOHH)
The singer reportedly signed with Weezy's record label in early June.
Drake hasn't finalized his highly-anticipated major label deal yet, but friend and collaborator Omarion, who appeared on Drake's popular So Far Gone mixtape, has found a label home. Omarion has signed to Lil Wayne's Young Money imprint, becoming Drake's labelmate. Speculation about the signing started when fellow singer, Tyrese, posted a Twitter message several days ago congratulating him on his new deal. Omarion took to his own Twitter page just yesterday (June 1) and confirmed that he is indeed signed to Young Money. (Billboard)
Young Money, which consists of Drake, Jae Millz, Nicki Minaj and more, recently made headlines after signing Bow Wow.
"To the naysayers, I hope that you give me the opportunity to earn your respect," Bow Wow wrote Tuesday (August 18) night in a blog entry about his record deal. "I know that over the years I've put many of my faults on display which I make no excuses for. I'm young and I've made mistakes and I will make more. No different than any other 22 year old, I still have some growing up to do...To anyone who's confused or says I don't belong in Cash Money. Let me remind you that I've been down with Baby, Slim, Wayne and the whole Cash Money family from the beginning. 10 years ago when we really were 'Lil' me and Wayne did a song for the Hardball movie soundtrack. Baby was influential in my third album. Last year, Wayne and I spent 2 months together in New Orleans filming Hurricane Season. So please don't be misinformed and think I'm just jumpin' on 'what's hot' or trying to ride others success. This has been my extended family for more than a decade." (Global Grind)
Maine reportedly took over as Young Money president earlier this year.
Young Money Entertainment aka Young Moola is an American hip-hop record label which was founded in 2003 by Lil Wayne. The distributing label is Universal Music Group and the label is an imprint of Cash Money Records. The president of Young Money is Mack Maine who took over from Cortez Bryant in 2009. (Lil Wayne HQ)
Check out Lil Wayne & Omarion's "I Get It In" collaboration below:


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Tony Romo went 25-for-35 passing for 321 yards and a touchdown in the Dallas Cowboys' loss to the Atlanta Falcons on Sunday night. Romo's lone touchdown came on a 21-yard pass to Kevin Ogletree in the fourth quarter.
Romo bounced back nicely from a four-interception performance in Week 8 against the New York Giants. He went over 300 yards passing for the fourth time in eight games played this season. Romo now has 10 touchdown passes to 13 interceptions on the year.
Fantasy Impact: Romo still hasn't had a truly great fantasy performance since the season opener, but fantasy owners have to be relieved to see the quarterback play a relatively mistake-free game for once. Of course, it still didn't get the Cowboys the win, but that's neither here nor there for fantasy purposes.
Romo has a potentially tricky matchup against the Philadelphia Eagles next week. He remains the same high-risk/high-reward fantasy option he has been since the beginning of the season. Start with caution.
For more fantasy info, head over to the SB Nation Fantasy War Room 4-8:30 p.m. ET Monday through Thursday and 8 a.m. to 1 p.m. ET on Sunday. Check out SB Nation's own Fantasy Football game, Pick 6!


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The NIU Huskies and Northwestern Wildcats will meet on the football field for the first time since 2005 when the teams play at Ryan Field on Sept. 6, 2014, officials from both universities announced Tuesday.
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An East Texas family is taking the Gregg County Jail to court after their loved one died in the jail's custody earlier this year.
51-year-old Bobby Madewell Junior died in the Gregg County Jail on March 21st. Medical examiners say he died of an apparent seizure.
Madewell's family filed a lawsuit against the jail on August 6th, in the Marshall Federal Court.
The lawsuit claims Madewell was not given the right medication while in custody.
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5* Shooting Guard Robert Hubbs Commits to Vols
HUGE get, and Coach Martin's second 5* in nine months. I was at practice on Saturday during his official visit, and he stood out at the "T" in Tennessee and bombed 40-foot three point shots. While I was watching, he went 4 of 6.