# The 10 commandments of ems



## certguy (Feb 23, 2011)

With my son about to start EMT academy,I figured I'd share some dad wisdom;
THE 10 COMMAMDMENTS OF EMS
1.THOU SHALT CONSIDER THE SAFETY OF YOURSELF&YOUR CREW OF UTMOST IMPORTANCE.
2.THOU SHALT HOLD THE SAFETY OF ALL OTHERS SECONDARY.
3.THOU SHALT PROVIDE THE BEST CARE POSSIBLE.
4.THOU SHALT NOT PUT BILLING COMSIERATIONS OVER PT CARE.
5.THOU SHALT,TO THE EXTENT POSSIBLE,BE COURTEOUS,KIND&SYMPETHETIC TO PTS,FAMILY&THE PUBLIC.
6.THOU SHALT KEEP A PROFESSIONAL ATTITUDE&APPEARANCE AT ALL TIMES.
7.THOU SHALT KEEP A CLEAN,WELL STOCKED UNIT.
8.THOU SHALT KNOW YOUR RESPONSE AREA.
9,THOU SHALT WORK WELL WITH OTHER AGENCIES.
10.THOU SHALT,IF PERSONALLY AFFECTED BY A CALL,GET ASSISTANCE WHEN NEEDED.REMEMBER,YOU'RE JUST AS HUMAN AS YOUR PTS.


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## Veneficus (Feb 23, 2011)

certguy said:


> 4.THOU SHALT NOT PUT BILLING COMSIERATIONS OVER PT CARE.



But they are not seperable.


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## bstone (Feb 23, 2011)

Veneficus said:


> But they are not seperable.



Disgaree. If my PT doesn't have insurance and can't pay out of pocket that won't stop me from using every intervention possible.


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## firecoins (Feb 23, 2011)

1. Ambulate before Carry

2. Thou shall transfer patients to hospital closest to the facility that will serve my next meal.  

3. The amount of blood or vomit on your uniform is in inverse amount to the years you have in.  Pros get none on their uniform.  

4. Call for the lift assist anytime ABC is a problem. Heavy patients always seem to need to be carried down from small rooms on the top floor of walk up buildings.

5. Coffee is always in your drug box.  


I lost the other tablet.


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## Veneficus (Feb 23, 2011)

bstone said:


> Disgaree. If my PT doesn't have insurance and can't pay out of pocket that won't stop me from using every intervention possible.



And that won't stop collections, bankruptcy, nor elimination of familial assets from an estate on futile treatments. Actually it only hastens it. 

Tell me, what are the health and psycological implications that are affiliated of such, and how do they in anyway benefit the patient or relatives?

An EMS provider sticking their head in the sand to hide from issues they don't want to deal with is not patient advocacy. 

In the bigger picture, prescribing treatments that a patient cannot afford means they get no treatment. So the ability of a patient to assume such costs has a direct implication on what treatment can be offered.


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## bstone (Feb 23, 2011)

Veneficus said:


> And that won't stop collections, bankruptcy, nor elimination of familial assets from an estate on futile treatments. Actually it only hastens it.
> 
> Tell me, what are the health and psycological implications that are affiliated of such, and how do they in anyway benefit the patient or relatives?
> 
> ...



Are you suggesting that I take into consideration bills and balances when treating my patients?


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## Veneficus (Feb 23, 2011)

bstone said:


> Are you suggesting that I take into consideration bills and balances when treating my patients?



For certain.


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## bstone (Feb 23, 2011)

Veneficus said:


> For certain.



Absolutely, complete, 100% disagree. There is no way you will be able to convince me otherwise, so don't even try.


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## Veneficus (Feb 23, 2011)

bstone said:


> Absolutely, complete, 100% disagree. There is no way you will be able to convince me otherwise, so don't even try.



If you choose to cause harm to people in the name of "doing all you can," that is your decision.

But please consider if you are "doing all you can" for them or for you.


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## bstone (Feb 23, 2011)

Veneficus said:


> If you choose to cause harm to people in the name of "doing all you can," that is your decision.
> 
> But please consider if you are "doing all you can" for them or for you.





I think you have a seriously warped sense of morality if you place financial considerations over fully treating a patient. You're beginning to sound like an HMO exec.


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## Veneficus (Feb 23, 2011)

double post, disregard.


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## Veneficus (Feb 23, 2011)

bstone said:


> I think you have a seriously warped sense of morality if you place financial considerations over fully treating a patient.



Perhaps I do have a warped sense of morality, but certainly not for considering the costs when treating patients. I just realize my personal responsibility in the damage I caused by not taking cost into account.

It is a bit troubling when you realize attempting resuscitation and transport on an obviously dead kid to give them every opportunity results in the family going bankrupt, breaking up, and the surviving siblings having less opportunity.

Similarly when you start performing ALS procedures on patients "just incase" and turn the $300 bill into a $600+ bill because you couldn't tell when those "what ifs" were anything more than the remotest of possibilities.  

Or when you call that helicopter based on a mechanism that was based on the circumstances in 1965 and see somebody discharged home 30 minutes after getting to the hospital with a >$20,000 bill.

I say "you," but I am personally accountable for all 3 of those examples.



bstone said:


> You're beginning to sound like an HMO exec.



There is an old saying: "Amateurs talk tactics, experts talk logistics."

No need to convince you. Sooner or later you will have to come to terms with it too.


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## bstone (Feb 23, 2011)

We will have to agree to disagree. I simply will not fail to stop a massive bleed or treat chest pain because the vascular surgeon or cardiac cath might cost too much. If a patient has a DNR/DNI and/or similar orders then I of course respect them. But never, never will I cease treating a patient who can be saved just because of money. Life is worth a lot more than money.


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## Veneficus (Feb 23, 2011)

bstone said:


> We will have to agree to disagree. I simply will not fail to stop a massive bleed or treat chest pain because the vascular surgeon or cardiac cath might cost too much.



That is an easy example to come to terms with. It is seldom that black and white.




bstone said:


> never will I cease treating a patient who can be saved just because of money. Life is worth a lot more than money.



But how many are worth ruining to save one?

"Saving" a patient is a rather grey area. Let's look at an 86 year old male AML patient with >70% blasts with perhaps a few months to live. You could easily drain his life insurance and estate buying him chemo. You might prolong his life for a year. Maybe. You might also be leaving his widow to have to leave their life long home to move in with family or worse, a nursing facilty, with the money spent.

Like I said, you'll get to that point eventually, forwarned is forarmed.


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## bstone (Feb 23, 2011)

Veneficus said:


> That is an easy example to come to terms with. It is seldom that black and white.
> 
> 
> 
> ...



That 86 y/o PT has Medicare and the ambulance service is required to accept Medicare Assignment, so there will be no bankruptcy or massive bills.


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## Veneficus (Feb 23, 2011)

bstone said:


> That 86 y/o PT has Medicare and the ambulance service is required to accept Medicare Assignment, so there will be no bankruptcy or massive bills.



From the ambulance.

But hospitls and healthcare facilities often bill more than what medicare pays and what is not covered is passed on to the patient and by extension the estate.

Wonderful world isn't it?


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## bstone (Feb 23, 2011)

Veneficus said:


> From the ambulance.
> 
> But hospitls and healthcare facilities often bill more than what medicare pays and what is not covered is passed on to the patient and by extension the estate.
> 
> Wonderful world isn't it?



I don't think you understand how Medicare works. Medicare has modest deductibles and co-pays, just like any private insurance company. Once you meet those modest deductibles and co-pays you are not responsible for one penny more.

Most seniors also have what's called "Medicare Advantage" or, in some cases, a "Medicare Supplemental Policy". These plans, administrated by private insurance companies, cover above and beyond what Original Medicare covers. Medicare Part A (aka Hospital Insurance) along with a Medicare Advantage or Medicare Supplemental policy means that the person likely will receive *NO* hospitals bills. In the case of only having Original Medicare the bills are very modest as Medicare Part A covers hospitalizations.



> Medicare Deductible and Coinsurance Amounts for 2010:
> 
> Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132)
> Source: https://questions.medicare.gov/app/...icare-premiums-and-coinsurance-rates-for-2011



I know almost everything about Medicare. Something about a 30 page research project for a public health class on it.


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## Veneficus (Feb 23, 2011)

bstone said:


> I don't think you understand how Medicare works. Medicare has modest deductibles and co-pays, just like any private insurance company. Once you meet those modest deductibles and co-pays you are not responsible for one penny more.
> 
> Most seniors also have what's called "Medicare Advantage" or, in some cases, a "Medicare Supplemental Policy". These plans, administrated by private insurance companies, cover above and beyond what Original Medicare covers. Medicare Part A (aka Hospital Insurance) along with a Medicare Advantage or Medicare Supplemental policy means that the person likely will receive *NO* hospitals bills. In the case of only having Original Medicare the bills are very modest as Medicare Part A covers hospitalizations.
> 
> I know almost everything about Medicare. Something about a 30 page research project for a public health class on it.



Perhaps you might explain then how my mom who has both medicare and medicare advantage routinely receives $6000+ bills for her recent hospitalizations?

You might also consider not every country in the world is covered by US medicare. Some actually make you pay for what you get or you don't get it.

Don't like 86, try 36?


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## bstone (Feb 23, 2011)

Veneficus said:


> Perhaps you might explain then how my mom who has both medicare and medicare advantage routinely receives $6000+ bills for her recent hospitalizations?
> 
> You might also consider not every country in the world is covered by US medicare. Some actually make you pay for what you get or you don't get it.
> 
> Don't like 86, try 36?



Two answers-
1) She is receiving the EOB (Explanation of Benefits). It says that the hospital billed Medicare for $6000, but this is not what the hospital OR your mother pays. The numbers are strikingly high but they are never what is actually paid.

2) The treatment she received is not part of Medicare's covered treatment. It might be experimental, not FDA approved, herbal treatment, etc.

Look at the EOB. There are always several lines, including what the hospital billed Medicare, what Medicare paid, what they sent to the Medicare Advantage plan, etc. 

There simply is no way she got a $6000 bill from a hospital even if she only has Original Medicare. The 2011 deductible is only $1100ish.


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## truetiger (Feb 23, 2011)

I don't think he's asking you to withhold treatment, rather to see the bigger picture. You need to be aware of the consequences of your interventions.


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## bstone (Feb 23, 2011)

truetiger said:


> I don't think he's asking you to withhold treatment, rather to see the bigger picture. You need to be aware of the consequences of your interventions.



Consequences- patient lives or patient dies. Sans DNR, DNI, Advanced Orders, family request it doesn't really matter.


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## Veneficus (Feb 23, 2011)

bstone said:


> There simply is no way she got a $6000 bill from a hospital even if she only has Original Medicare. The 2011 deductible is only $1100ish.



The bills are not EOB, there are 2 one for roughly 6K and another for 5K from 2 different hospitalizations at the same facility.

I should hope dialysis, pain control, and cellulitis are covered.


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## truetiger (Feb 23, 2011)

It's not that black and white. There's always more than one way to solve a problem.


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## AndyK (Feb 23, 2011)

Excuse the lack of apprehension here as i'm not a US resident so have little experience of your healthcare system but am I right in thinking that a healthcare professional would knowingly withhold treatment for lack of means of payment from a patient?


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## Veneficus (Feb 23, 2011)

AndyK said:


> Excuse the lack of apprehension here as i'm not a US resident so have little experience of your healthcare system but am I right in thinking that a healthcare professional would knowingly withhold treatment for lack of means of payment from a patient?



It is not as simple as the patient not being able to pay. 

It is a question of whether or not performing the treatment ultimatley causes more harm than good from the financial ramifications.

Part of medical treatment is to inform the patient of all of their options. I think it is absolutely wrong not to discuss the potential costs of those treatments with them when making the decisions about what they want. Especially since there could be lasting consequences on others. 

I also think it is important not to throw every treatment possible at patients who are responsible for paying the bill for it when they place trust in a healthcare provider to do what is best for their presentation. 

Running every test on every patient is not good medicine. It is waste at the least and potentially incompetence. 

In the US, many patients are responsible for part or all of their bill. Some agencies are more aggresive than others in collecting.

It is only responsible to be aware that costs are a concern, should be addressed openly, and do play a significant factor in the lives of not only the patients but of the relatives as well.


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## jgmedic (Feb 23, 2011)

AndyK said:


> Excuse the lack of apprehension here as i'm not a US resident so have little experience of your healthcare system but am I right in thinking that a healthcare professional would knowingly withhold treatment for lack of means of payment from a patient?



No It's that we should take into consideration a pt's ability to pay if we are doing interventions "just to be sure". If it's a life or death situation, that's different. But things like prophylactic IV's, maybe not.


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## bstone (Feb 23, 2011)

AndyK said:


> Excuse the lack of apprehension here as i'm not a US resident so have little experience of your healthcare system but am I right in thinking that a healthcare professional would knowingly withhold treatment for lack of means of payment from a patient?



No, they should never take it into consideration.


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## AndyK (Feb 23, 2011)

ok guys, thanks for the replies... certainly an interesting concept and differs considerably to here. Ambulance & Paramedic services are generally free to anybody who needs it and interventions based purely on patient needs rather than wants.. I think that's what you are alluding to aswell JGMedic?

BStone.. I suspect you and I are of similar breed, Pro Utilitate Hominum and all that... it certainly raises an interesting question about prehospital ethics if immediate care interventions are based on social and economic considerations of an individual by some providers. 

That, for the sake of Veneficus, is not meant as provocation - merely a wish to understand the system out of interest as an outsider, I hope no offence is taken by ignorance on my part!


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## certguy (Feb 23, 2011)

I certainly didn't mean to start a firestorm here.The commandments are meant as hand me down wisdom from 1 generation of EMT to the next.The commandment in question came about from me having to report a facility our company cotracts to for elder abuse,putting me square in my manager's crosshairs over lost business. Sometimes you have to take a stand for your pts.


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## usalsfyre (Feb 23, 2011)

bstone said:


> No, they should never take it into consideration.



You are very, very naive in how medical care is paid for, and how you draw a salary. 

Suffice to say, there's a large segment of the population that's one EMS trip away from finical ruin. "But at least your alive" can be little comfort when staring down the barrel of the long-term consequences of this. I'm not advocating withholding care by any means. However it's important to understand the money aspect of our job isn't all rainbows and unicorns either.


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## lampnyter (Feb 23, 2011)

I wouldnt have a problem not treating because they couldnt afford. Ive never had to deal with it because my agency doesnt get any insurance info or anything.


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## bstone (Feb 23, 2011)

usalsfyre said:


> You are very, very naive in how medical care is paid for, and how you draw a salary.


Except for the part in which I wrote extensively about Medicare reimbursement. Care to amend your accusation?


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## usalsfyre (Feb 23, 2011)

bstone said:


> Except for the part in which I wrote extensively about Medicare reimbursement. Care to amend your accusation?



Just because you can read the CMS guide doesn't mean you understand the end user consequences for the un/underinsured when non-payment is the issue. CMS, as slimy as it is, is the CLEAN side of reimbursement.


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## bstone (Feb 23, 2011)

usalsfyre said:


> Just because you can read the CMS guide doesn't mean you understand the end user consequences of the un/underinsured and non-payment. CMS, as slimy as it is, is the CLEAN side of reimbursement.



Still not seeing you prove your accusation that I am "very, very naive" about reimbursement and salary. The same can be said for you as you haven't demonstrated any specific knowledge on this topic, while I have written rather extensively about it. Would you like a copy of my 30 page report for a graduate-level public health class I took?


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## certguy (Feb 23, 2011)

certguy said:


> With my son about to start EMT academy,I figured I'd share some dad wisdom;
> THE 10 COMMAMDMENTS OF EMS
> 1.THOU SHALT CONSIDER THE SAFETY OF YOURSELF&YOUR CREW OF UTMOST IMPORTANCE.
> 2.THOU SHALT HOLD THE SAFETY OF ALL OTHERS SECONDARY.
> ...


Sorry,I'm a lousy speller.That's supposed to be considerations.


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## usalsfyre (Feb 23, 2011)

bstone said:


> Still not seeing you prove your accusation that I am "very, very naive" about reimbursement and salary. The same can be said for you as you haven't demonstrated any specific knowledge on this topic, while I have written rather extensively about it. Would you like a copy of my 30 page report for a graduate-level public health class I took?



How about this. I'll retract my statement that you don't understand how salaries are derived. If you have the education you claim, it's likely you understand the mechanics if this better than I do. 

I will not, however, retract what I said about your understanding of reimbursement, collections and it's effect on the end user. How does transporting an indigent or nearly indigent patient for a relatively minor complaint that didn't require emergency care and leading to defaulting on the bill improve overall health status? Very likely this will cause the patient to hesitate in seeking care when it IS an emergent complaint. This is not to mention the health effects of increased stress levels, and the generally poor health of the economically disadvantaged anyway. 

Again, I'm not saying to withhold care, but not being honest with yourself or patients about the finical aspects of transport is like I said, very, very naive.


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## bstone (Feb 23, 2011)

usalsfyre said:


> How about this. I'll retract my statement that you don't understand how salaries are derived. If you have the education you claim, it's likely you understand the mechanics if this better than I do.


I appreciate that.




> I will not, however, retract what I said about your understanding of reimbursement, collections and it's effect on the end user. How does transporting a patient for a relatively minor complaint, thereby causing increased stress levels, possibly causing the patient to hesitate



I never said this is a good thing. I said cost should not be a consideration when treating a patient with severe and life-threatening injuries. The examples I gave were severe trauma and an MI in progress. That is certainly not minor. Right?


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## usalsfyre (Feb 23, 2011)

bstone said:


> I appreciate that.


When your wrong your wrong. I do appolgize, I'm used to dealing with my coworkers who fail to understand that doing you paperwork correctly and transporting patients is directly tied to them getting paid.



bstone said:


> I never said this is a good thing. I said cost should not be a consideration when treating a patient with severe and life-threatening injuries. The examples I gave were severe trauma and an MI in progress. That is certainly not minor. Right?



Sorry, didn't finish my post, Tappatalk defeats me sometimes. 

Severe trauma and evolving MI are one thing. I don't think anyone will argue about transport. It's the minor complaints that keep people from seeking medical care for the MI I'm worried about.

As a side note this is why community paramedicine needs to evolve from where we're currently at. A $50 home visit with instructions for symptom management looks after the patient far more "holistically" than a $300-1000 transport and several thousand dollar ED bill.


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## bstone (Feb 23, 2011)

usalsfyre said:


> When your wrong your wrong. I do appolgize, I'm used to dealing with my coworkers who fail to understand that doing you paperwork correctly and transporting patients is directly tied to them getting paid.


I understand. All is forgiven.



> Sorry, didn't finish my post, Tappatalk defeats me sometimes.
> 
> Severe trauma and evolving MI are one thing. I don't think anyone will argue about transport. It's the minor complaints that keep people from seeking medical care for the MI I'm worried about.
> 
> As a side note this is why community paramedicine needs to evolve from where we're currently at. A $50 home visit with instructions for symptom management looks after the patient far more "holistically" than a $300-1000 transport and several thousand dollar ED bill.



I agree. We need to educate paramedics to a BS level and let them treat and release on scene, or make arrangements for primary care services, not ED services.


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## firetender (Feb 24, 2011)

*Just like the Ten Commandments ain't it?*

Come off the Mountain with a couple tabs of wisdom and what are the damn people doing? Arguing over whose Golden Calf is cooler!


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## Anjel (Feb 24, 2011)

firetender said:


> Come off the Mountain with a couple tabs of wisdom and what are the damn people doing? Arguing over whose Golden Calf is cooler!



^^^ HA! LOVE IT! SO TRUE. There's no telling which way these forums will go.


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## certguy (Feb 24, 2011)

firetender said:


> Come off the Mountain with a couple tabs of wisdom and what are the damn people doing? Arguing over whose Golden Calf is cooler!


Amen brother!! Let's get back to imparting some wisdom on the younger generation.


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## sir.shocksalot (Feb 24, 2011)

firetender said:


> Come off the Mountain with a couple tabs of wisdom and what are the damn people doing? Arguing over whose Golden Calf is cooler!



Ha! I enjoyed them, but to be fair you did lose one of the tablets. If you find the other one let us know and maybe we'd appreciate it more 

And Bstone, usalfyre and vene are not telling you to not treat patients in acutely life threatening situations. Simply consider the financial costs of not just your treatment, but their admission to the ER. The ambulance is relatively cheap, the hospital is not. When you have a pt that is only kind of sick, talking them into an ambulance ride instead of an urgent care visit or PCP visit may do more damage than good. Also understand that not every pt needs an ambulance ride to the hospital when they or family can give them a ride.

We aren't saying evaluate their insurance before transport, just consider their financial situation before you force massive bills on people that might not need it.


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## FrostbiteMedic (Feb 24, 2011)

usalsfyre said:


> You are very, very naive in how medical care is paid for, and how you draw a salary.
> 
> Suffice to say, there's a large segment of the population that's one EMS trip away from finical ruin. "But at least your alive" can be little comfort when staring down the barrel of the long-term consequences of this. I'm not advocating withholding care by any means. However it's important to understand the money aspect of our job isn't all rainbows and unicorns either.



Rarely do I chime in on these types of threads, but now I feel that I must. For the most part, I agree with bstone, however, I can see the points posed by both veni and usals. I also think it is important to remember the spirit of what was said by the OP. When we respond out to a scene, it is our responsibility to render the best _healthcare_ that we can, regardless if the person has a bank account or not. That does not mean that we perform ALS interventions on someone with a stubbed toe. This means that we provide the level of care necessary to stabilize the patients condition. Ergo, even if the patient is a _106_ y/o white male showing signs and symptoms of an acute MI, if I don't have a DNR or advanced directive in my hand, that patient is going to get _the same_ level of care that a _26_ y/o would in that situation. Is it financially feasible? It very well may not be, however, I am *not* empowered with the ability to withhold care from this patient because my efforts may or may not be futile and may or may not result in a bill to him/his family.  Just a thought....


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## Veneficus (Feb 24, 2011)

AndyK said:


> That, for the sake of Veneficus, is not meant as provocation - merely a wish to understand the system out of interest as an outsider, I hope no offence is taken by ignorance on my part!



no worries


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