# Opinion on use of rapid response units



## jgaddis82 (Jan 4, 2012)

I realize that this has been discussed in some forms already, but I'm curious to know how medics feel about a statement that was made in my Emt-A class. It was said that within the next few years, medics will probably almost never be dispatched to a scene. That the Emt-A will have to call for a rapid response unit to get a medic when needed. The thought was that these RRU's would make for faster response of ALS to the scene and not tie up those providers when they weren't needed and could be used elsewhere.                                                   Is this a good idea in your opinion?


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## jgaddis82 (Jan 4, 2012)

I guess I should've said that I don't think this is such a good idea.


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## rmabrey (Jan 4, 2012)

I assume this was in reference to your area? Otherwise its a very broad statement. 

Sent from my Desire HD using Tapatalk


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## jgaddis82 (Jan 4, 2012)

Yes it was. But it is hypothetical at this point, so we could assume it as a scenario for any area.


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## akflightmedic (Jan 4, 2012)

jgaddis82 said:


> I realize that this has been discussed in some forms already, but I'm curious to know how medics feel about a statement that was made in my Emt-A class. It was said that within the next few years, medics will probably almost never be dispatched to a scene. That the Emt-A will have to call for a rapid response unit to get a medic when needed. The thought was that these RRU's would make for faster response of ALS to the scene and not tie up those providers when they weren't needed and could be used elsewhere.                                                   Is this a good idea in your opinion?



Horrible idea as the plan is backwards.

Everyone should get an ALS rapid response first, then if the medic determines the call is BLS, call them in for transport. They are the ones who can afford to wait for a ride...


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## Veneficus (Jan 4, 2012)

*Sorry*

Not going to work.

The future of EMS is a higher educated and trained provider responding to do prevention and treat and release. (As the rest of the civilized world has discovered)

The idea of using BLS or even ILS as a first response just adds extra cost to the system. Especially since the current standards of when to call ALS are so extreme I am not even sure why a tiered system exists.

The incidence of acute pathology is declining. Most of the patients today that actually fit into the category of emergency are people who have chronic problems with an acute exacerbation. 

As medical care progresses and people live longer, the goal must be to economically manage these people, not to waste countless dollars driving them to the hospital while paying and equipping an area's best providers to sit around and wait for 5-10% of the total call volume.


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## medicdan (Jan 4, 2012)

Why not use more sophisticated call triage-- and send at minimum an RRU (with highly trained medic) in a car to every call-- from there the medic can treat/release, treat/transport to clinic/urgent care, treat/call for ambulance transport, treat/ride with ambulance transport, etc. For a model, perhaps look at NHS in England, particularly the Northeast Ambulance service. Mark Glencourse has documented their design well online, particularly through his interactions with SF FF/Medic Justin Schorr (sp?). 

In this model, all patients get an ALS assessment (of sorts), but the medic has more flexibility-- and fewer (expensive) ambulances are required.


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## jgaddis82 (Jan 4, 2012)

I have to say that I agree with all 3 of you. These are exactly the kind of reactions we got in class. I don't think there is a right answer or a wrong answer here. As one solution would not work for some, but might for others. Either way, it makes for a great debate and gets some very interesting ideas floating about.


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## medicdan (Jan 4, 2012)

The focus needs to be on system design that matches needs, as determined by call volume, call acuity, hospital/clinic/urgent care resources, first responder resources, staff training, regulatory constraints, and ultimately, reimbursement and funding structures. No single system works everywhere-- as evidences by the thousands of different models of care domestically and internationally.


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## jgaddis82 (Jan 4, 2012)

In a situation where ALS does initial assessment and determines it can be handled as a BLS call, if the patient starts to go down then would there be an issue of abandonment?


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## EMT-Tony (Jan 4, 2012)

Where I work we have 2 crews of 3, the medic on the first out crew gets to use the paramedic response truck to every call, and I have to say it is cutting into the relarionships at the service.  Our service calls for a medic to be in the back on every call.  So we run into problems of medic on scene first( which usually only saves about 2 min average, cause the ambulance is always enroute in under 4 min) because even though the RRU has equitment medics rarley grab it, which turns the EMT's on the truck into baggage handlers.  Second it never gives BLS providers a chance to take lead or do a pt. assesment becasue medics dont like giving up lead where I work.  Lastley the RRU truck is a hastle because you more then likely you have to leave it on scene if a FR or law enforcement cant drive it to the hospital for you.  So this means before we can go back into service we have to drive back out to wherever the call was in the county and pick the stupid thing up.

Just glad my medic bends the rules, and doesnt fall into the whole RRU trip that the other medics do

just my 2cents


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## downunderwunda (Jan 4, 2012)

Two things come to mind here. Firstly no one should work on their own. This leads to the second point. EMT-B should not exist. 

Now to explain  Pre hospital medicine is a profession. We should be progressing to higher standards, providing the best care to all who call for an ambulance. The notion that a medic is s god ('the medic should decide if it is a BLS call or not') is self serving poppycock. We, as a profession need to improve our skills with international best practice & intensive care paramedics are not the be all & end all of pre hospital care & that attitude needs to be removed. 

No pre hospital clinician should work alone for both their protection & the protection of their patient. There are many influences daily on us that can cause us to not make the 'best' decision. A partner can help with that.


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## Remeber343 (Jan 4, 2012)

But then, paragod, who would we have carry our bags and do things we don't want to do?!


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## jgaddis82 (Jan 4, 2012)

Wow Tony. That's the first time I've heard anyone(seen) anyone speak of how RRU actually affect the operations of their system. Very interesting.


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## EMT-Tony (Jan 4, 2012)

Thanks jgadd, I seem to be the only one who brings it up at my service being one of the only ones that has worked at other services, I have talked tothe director and he has taken my point to heart, but its theowner that doesn't want it to change, the battle goes on I suppose


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## rescue1 (Jan 5, 2012)

downunderwunda said:


> Two things come to mind here. Firstly no one should work on their own. This leads to the second point. EMT-B should not exist.
> 
> Now to explain  Pre hospital medicine is a profession. We should be progressing to higher standards, providing the best care to all who call for an ambulance. The notion that a medic is s god ('the medic should decide if it is a BLS call or not') is self serving poppycock. We, as a profession need to improve our skills with international best practice & intensive care paramedics are not the be all & end all of pre hospital care & that attitude needs to be removed.
> 
> No pre hospital clinician should work alone for both their protection & the protection of their patient. There are many influences daily on us that can cause us to not make the 'best' decision. A partner can help with that.



Good luck dealing with the volunteers on that one, at least in the states. 

Not that I disagree with what you're saying, but it's unfortunately true.


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## mycrofft (Jan 5, 2012)

One of the Black Holes of EMTLIFE: the future of street EMS/prehospital EMS as a profession. As the discussion crosses the event horizon, it inexorably becomes a polarized exchange of ideas about where it is going, much as I imagine it went when the mice discussed being the cat.


 "No more EMT-B's" means you have robbed hundreds of thousands of rural and IFT patients a level of care above first-aid and jacked up the personnel cost of prehospital EMS (PHEMS) by maybe thirty percent, unless with the resultant influx of credential mill paramedics you force down the pay scale for PHEMS overall.

I worked in two tiered response systems in the late seventies-early eighties. If ALS is close and can respond very quickly and there are enough, then fine. If not, then no, but you have then to figure out how to actually do it.


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## Trevor (Jan 5, 2012)

Veneficus said:


> Not going to work.
> 
> The future of EMS is a higher educated and trained provider responding to do prevention and treat and release. (As the rest of the civilized world has discovered)
> 
> ...



Vene- Absolutely agree with you 100%, but I wonder if you have any research or articles that support that??


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## Veneficus (Jan 5, 2012)

*Res Ipsa Loquitor*



Trevor said:


> Vene- Absolutely agree with you 100%, but I wonder if you have any research or articles that support that??



I am sure there are some various articles around somewhere, most of what I said there is considered common knowledge in the medical circles I associate with.


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## rescue1 (Jan 5, 2012)

mycrofft said:


> "No more EMT-B's" means you have robbed hundreds of thousands of rural and IFT patients a level of care above first-aid and jacked up the personnel cost of prehospital EMS (PHEMS) by maybe thirty percent, unless with the resultant influx of credential mill paramedics you force down the pay scale for PHEMS overall.



While this is true for very rural areas, we also need to consider that EMS (and fire) costs will be dramatically rising over the next decade or so anyway, due to the slow decline of volunteers in fire/EMS and the need to replace them with paid providers. Why not use this as an opportunity to increase some of the standards of EMS, even if it's taking the EMT-B and jacking up the training hours (and therefore the pay, hopefully) to something more reasonable? 

Somehow the Commonwealth countries have managed to make PHEMS a degree course at minimum, make it a reasonable career choice, and still provide EMS all over the country. In Canada that includes some EMT-Bs in the most rural of areas, and that makes sense--if your first due has 500 people in it (in 500 sq. miles), I don't think you can (or should) afford a staffed ALS bus.

IFT is a different beast, and I really haven't been exposed to it enough to really discuss it, but I will say that making paramedics with a bachelors degree transport granny back and forth from her dialysis seems a little absurd.


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## mycrofft (Jan 5, 2012)

If the new baseline if paramedic, then IFT will fall to them sometimes. And it won't be a big deal.

So the ideal is have the first on scene an ALS qualified unit, then stabilize and either transport themselves, or delegate transport to a BLS unit?


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## Veneficus (Jan 5, 2012)

mycrofft said:


> So the ideal is have the first on scene an ALS qualified unit, then stabilize and either transport themselves, or delegate transport to a BLS unit?



I think that will only be feasable if there is a transport destination other than the ED.

Really the cost of BLS transport compared to an ED visit is basically chump change. 

It also begs the question, since right now ALS is reimbursed by transport, not by consultation and intervention, How do we pay for all of those high level providers exactly?


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## mycrofft (Jan 5, 2012)

ANSWER: $65 Tylenol


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## Trevor (Jan 5, 2012)

Vene- I would have thought it to be common knowledge as well... However my system is moving in a "new direction" that doesnt really support that... And to my suprise, most people in my system support the movement... Im trying to locate something objective that says, just what you just did.


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## mycrofft (Jan 5, 2012)

http://www.ncbi.nlm.nih.gov/pubmed/10634274


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## Veneficus (Jan 5, 2012)

*The emperor's new cloths*



Trevor said:


> Vene- I would have thought it to be common knowledge as well... However my system is moving in a "new direction" that doesnt really support that... And to my suprise, most people in my system support the movement... Im trying to locate something objective that says, just what you just did.



If they don't think so now, nothing you present is going to change their minds.

Pearls before swine.


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## Trevor (Jan 5, 2012)

true that...


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## downunderwunda (Jan 5, 2012)

mycrofft said:


> One of the Black Holes of EMTLIFE: the future of street EMS/prehospital EMS as a profession. As the discussion crosses the event horizon, it inexorably becomes a polarized exchange of ideas about where it is going, much as I imagine it went when the mice discussed being the cat.
> 
> 
> "No more EMT-B's" means you have robbed hundreds of thousands of rural and IFT patients a level of care above first-aid and jacked up the personnel cost of prehospital EMS (PHEMS) by maybe thirty percent, unless with the resultant influx of credential mill paramedics you force down the pay scale for PHEMS overall.
> ...



I am afraid I don't agree with the US system at all. Call me a communist I don't care. There are a number of things that I believe the government should own, operate & not try to profit from. 

Healthcare is one of them. People should not have to think about their pocket for calling an ambulance & getting assistance. 

With this in mind, & the state makes the right decision & seperated fire & ems, treating them as distinct seperate professions, smaller rural communities then benefit. In fact they are better off. 

There will always be a place for volunteers to work & be trained alongside paid officers. The mentality that we need to be chasing the almighty dollar needs to leave ems. Then we can progress as a profession.


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## EMT-Tony (Jan 5, 2012)

Well after employee reviews today and a medic meeting this morning, my service has made the decision to take our RRU out of service till a plan that fits the needs and apporval of all employees has been meet.  The point that really made it was saftey, two trucks blazing down the road as apposed to one, and also a medic or whoever is in the RRU responding alone and the dangers that 'could' follow.


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## mycrofft (Jan 5, 2012)

downwunda, I hear you.

I cite my four hour ER visit, had a portable chest xray, EKG, about 1/4 liter NS IV TKO, one metoprolal PO, and MI lab panel (Chem panel and cardiac enzymes). Had to post a $1,000 deposit at the door of the ER ("Say what?!") and paid $500 (credit card) after insurance. Once they sent the EKG to my cardiologist, he said "That's a baseline for him, send him home".

A government hospital would not have had the motivation to do all this, as I told them going in it was a C4-C5 impingement...which it was.

Anyway, tiered response is one way to do it, but it has to be adopted on a case by case basis. Easier to send ALS each time.


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## downunderwunda (Jan 5, 2012)

then let's upgrade everyone to an ALS standard. Simple. Ems is a profession. As professionals an emtb is a driver. In my service a trainee can do more. Let's give end due credit, autonomy & increase the skills base. Easy.


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## Tigger (Jan 5, 2012)

rescue1 said:


> IFT is a different beast, and I really haven't been exposed to it enough to really discuss it, but I will say that making paramedics with a bachelors degree transport granny back and forth from her dialysis seems a little absurd.



Sending a basic crew doesn't make much more sense. An EMT-B course teaches one precious little about the world of IFT.


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## rescue1 (Jan 5, 2012)

Up EMT-B to something more, then. If you increase training hours with a focus on medications and understanding chronic conditions, you can have an EMS provider tailored to IFT. CC IFT or IFT that requires ALS can be left to paramedics. 

That way you can have dialysis transports, nursing home transports, etc that are not an inefficient waste of money (which a fully staffed ALS rig would be, almost all the time), but still have a reasonably trained provider. Hopefully salaries would also increase.

Though I'm curious to see how IFT works in the Commonwealth countries, or any of the Western countries where EMS tends to operate at the ALS level.


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## jgaddis82 (Jan 5, 2012)

*Re Emt-B*

It isn't really a tough jump from Emt-B to Emt-A. I don't understand why anyone would stay put at a basic level. No intention of dogging anyone, just saying. You gain a lot more skills and the class isn't that long. Just as it makes no sense not to move up to paramedic eventualy.
Still think we need trained professionals at all levels. I simply think it keeps the system balanced.


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## Handsome Robb (Jan 5, 2012)

jgaddis82 said:


> It isn't really a tough jump from Emt-B to Emt-A. I don't understand why anyone would stay put at a basic level. No intention of dogging anyone, just saying. You gain a lot more skills and the class isn't that long. Just as it makes no sense not to move up to paramedic eventualy.
> Still think we need trained professionals at all levels. I simply think it keeps the system balanced.



Agreed. From what I have read it seems like there will be more background knowledge for AEMTs in the new curriculum. Even at the end of my didactic portion of medic school I still don't feel like I understand physiology as much as I would like to.


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## jgaddis82 (Jan 5, 2012)

*re: nvrob*

I'm just now in my second semester of Emt-A class. Looks like we are expected to have quite a few more skills than the I99. It's gonna be tough on the physiology for me as well, just a lot to learn in a 1 year course.


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## bw2529 (Jan 7, 2012)

jgaddis82 said:


> It isn't really a tough jump from Emt-B to Emt-A. I don't understand why anyone would stay put at a basic level. No intention of dogging anyone, just saying. You gain a lot more skills and the class isn't that long. Just as it makes no sense not to move up to paramedic eventualy.
> Still think we need trained professionals at all levels. I simply think it keeps the system balanced.



In the volunteer world, moving up to paramedic can be a very costly proposition, unless you also plan on doing it as a profession.


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## jgaddis82 (Jan 7, 2012)

Agreed. Thus the statement that we need all levels of training. If you did decide to go career, there are grants and student aide that make it much less costly.


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## Veneficus (Jan 7, 2012)

NVRob said:


> Agreed. From what I have read it seems like there will be more background knowledge for AEMTs in the new curriculum. Even at the end of my didactic portion of medic school I still don't feel like I understand physiology as much as I would like to.



_Guyton's Medical Physiology_ is an easy solution to that problem.


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