# Nationalization or federalization of EMS



## JJR512 (Jan 22, 2009)

Would or could EMS be better if there was a national body that defined, refined, maintained, and enforced education standards, curricula, ambulance standards, and, possibly to some extent, some basic protocols or standing orders? The goal being that an EMT-B is an EMT-B no matter where he or she went to school. All EMT-Bs from any state or jurisdiction would get the same training and take the same test and be able to perform all the functions of an EMT-B in any state or jurisdiction and be able to work with other EMT-Bs from other jurisdictions just as easily as if they went to the same class together. Same thing for EMT-Ps, of course.

Now, here's the next part of my overall question. If you agree that there does need to be some kind of national body as mentioned, or even if you disagree a bit on the details and have some other ideas but still feel that, in principle, there needs to be a national body that oversees and unifies EMS, should this national body be an agency or bureau of some department of the US Federal Government, or can or should it be a private national association? If you choose that it should be a private national association, please describe how it would have the authority to enforce itself to all EMS agencies, both public and private, across the country.


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## akflightmedic (Jan 22, 2009)

There have been interesting discussions elsewhere on the net in regards to this.

Here is a snippet of a proposal from an ERDoc who is very proactive in EMS education, standards, etc.

How about this for a solution (of course this plan only applys to the US, sorry to all of our foreign friends). Start out by making a college like the rest of medicine has. Let's call it the American College of Prehospital Medicine (ACPM), similar to the American College of Emergency Physicians (ACEP). Initially, to gain any strength or legitimacy this college would have to fall under the auspicies of a stronger, more established organization such as ACEP. They will set the standards as to what it takes to become board certified. Let's establish the requirements as:
1. obtain a bachelors degree in prehospital medicine from an accredited college/university (not Joe's Online College).
2. pass a written and oral exam

The requirements for the bachelors degree would be established by ACPM/ACEP and would obviously encompass necessary courses but at the same time the student would be required to meet the college/university's general education requirements. Those who have been working in the field would be allowed to be grandfathered in by a process to be determined by ACPM/ACEP but would include the written and oral board exams. The grandfather clause would be closed at a predetermined point in time.

So, now we have a bunch of college educated, board certified paramedics running around. How do we get the ambulance companies to hire them? Seems simple enough. We have ACPM/ACEP lobby congress to change the billing/fee process (all that money that I donate to ACEP/EMPAC might as well go somewhere). Make it mandatory for full payment that a pt be cared for by a board certified paramedic. Those that are not will only recover, say, 25-33% of what the board certified medic would recover. Set the payment schedule up similar to what we have in the ER. There would be certain levels of billing depending on the severity of the pt. No company would want to collect up to 75% less so they would be forced to hire the board certified medics. With the small supply of board certified medics the salary would go up. Given the current economic climate in the US, congress would love to be able to cut costs.

Eventually as it aged, ACPM would become an independent entity in the American Board of Medical Specialities. I've only given the topic a little thought, but it might work. I'd love to hear some feedback.


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## VentMedic (Jan 22, 2009)

akflightmedic said:


> Here is a snippet of a proposal from an ERDoc who is very proactive in EMS education, standards, etc.


 
I wonder if he got the idea from the January 2009 newsletter for NAEMSP.

http://www.naemsp.org/documents/NAEMSPNewsJanuary09Final.pdf

Page 2, President's Corner.


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## Veneficus (Jan 22, 2009)

As much as I would like to see it, there would be an explosion of "state's rights" issues for federalized paramedics.


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## akflightmedic (Jan 22, 2009)

I don't know Vent. He posted that on Jan 13th on a diff site, you know the one.

Is he one in the same? It would be odd and out of character for him to poach and not credit the true source.


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## Dobby (Jan 22, 2009)

Im hoping that this might be of some assistance maby you have something similar in th U.S.A mabey this would give some ideas or helpful tips. 

Here in South Africa each and every person in the medical sector needs to be registered with  the Health Proffesions Council of South Africa (HPCSA), nursing staff have a different council. 

For further reference www.hpcsa.co.za


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## VentMedic (Jan 22, 2009)

akflightmedic said:


> I don't know Vent. He posted that on Jan 13th on a diff site, you know the one.
> 
> Is he one in the same? It would be odd and out of character for him to poach and not credit the true source.


 
This article was for a sub-specialty for doctors but the concepts could easily be applied to Paramedics.


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## WiFi_Cowgirl (Jan 22, 2009)

I think they should just leave it alone. I do sincerely believe that they could do worse. It is possible.. I also believe, that no matter how much it's debated. Nobody knows the correct answer to "fixing" EMS. From my view, how it affects me and the people I serve, it's perfect. Maybe bigger sirens.


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## BossyCow (Jan 22, 2009)

We can't even get the ER docs within our region to come to consensus on this, how are we going to set a national standard that meets all the needs of the different types of agencies? 

But, the feds have done such a great job with retirement, taxes, the environment and in regulating such industries as airlines, banking, securities.. what the hey... lets give 'em a shot at EMS!


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## TheMowingMonk (Jan 22, 2009)

Personally I think it is a great idea. I feel medic should at least have a bachelors, its one of the first steps towards getting better pay and more respect in the field. Plus it is closer to expanding the scope for medics since if a bachelors is required you are more likely to get competent care givers rather then these guys who barely pass through a medic program then mess up some point after starting and get some skill or drug taken away from other medics. It would be a long process to do, but I think it is something that eventually will be absolutely necessary for the growth and success of the field. But I think the first step really should be just standardizing everything, if not on a national level at least at the state level. I feel that this county to county thing does nothing but hurt care and make it harder for care givers to move to different spots even within their own state since standards can very greatly from county to county, especially in places like here in California.


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## lightsandsirens5 (Jan 22, 2009)

BossyCow said:


> We can't even get the ER docs within our region to come to consensus on this, how are we going to set a national standard that meets all the needs of the different types of agencies?
> 
> But, the feds have done such a great job with retirement, taxes, the environment and in regulating such industries as airlines, banking, securities.. what the hey... lets give 'em a shot at EMS!



I sincerely hope you are being sarcastic.:unsure:

I'm all for sticking with the county/state regulated method. The main reason being my county has one of the least resrtictive BLS protocols manual in the state of Washington. We can, in addition to O2, glucose, and activated charcoal, give ASA, Albuterol, and Epi (up to 2 Epi-Pens w/o pt perscription. More with Med Control.) Also, (I'm not sure if this is a state-wide thing or not) we give nine shocks to a pt with a shockable rythm. 

Those are just some of the things we do that can't be done in the rest of the state, the reason being, there is no ALS service in this county (not even protocols!), ILS might be 45 min-1 hr away, and there are a ton of radio/cell phone dead spaces in our area, meaning we can't contact med. control or dispatch.


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## lightsandsirens5 (Jan 22, 2009)

TheMowingMonk said:


> Personally I think it is a great idea. I feel medic should at least have a bachelors, its one of the first steps towards getting better pay and more respect in the field. Plus it is closer to expanding the scope for medics since if a bachelors is required you are more likely to get competent care givers rather then these guys who barely pass through a medic program then mess up some point after starting and get some skill or drug taken away from other medics. It would be a long process to do, but I think it is something that eventually will be absolutely necessary for the growth and success of the field. But I think the first step really should be just standardizing everything, if not on a national level at least at the state level. I feel that this county to county thing does nothing but hurt care and make it harder for care givers to move to different spots even within their own state since standards can very greatly from county to county, especially in places like here in California.



By medic do you mean paramedic, or EMT in general? Dosent a paramedic already need a bachelors?


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## NJN (Jan 22, 2009)

lightsandsirens5 said:


> By medic do you mean paramedic, or EMT in general? Dosent a paramedic already need a bachelors?



Nope, Not even an AAS.


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## JPINFV (Jan 22, 2009)

NJNewbie196 said:


> Nope, Not even an AAS.



Unless you live in Oregon. Heck, in Iowa you only need 280 hours to move from EMT-B to EMT-P.


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## VentMedic (Jan 22, 2009)

lightsandsirens5 said:


> I sincerely hope you are being sarcastic.:unsure:
> 
> I'm all for sticking with the county/state regulated method. The main reason being my county has one of the least resrtictive BLS protocols manual in the state of Washington. We can, in addition to O2, glucose, and activated charcoal, give ASA, Albuterol, and Epi (up to 2 Epi-Pens w/o pt perscription. More with Med Control.) Also, (I'm not sure if this is a state-wide thing or not) we give nine shocks to a pt with a shockable rythm.
> 
> Those are just some of the things we do that can't be done in the rest of the state, the reason being, there is no ALS service in this county (not even protocols!), ILS might be 45 min-1 hr away, and there are a ton of radio/cell phone dead spaces in our area, meaning we can't contact med. control or dispatch.


 
Here lies the problem. Some just count the number of skills they can do as a measure of their "professionalism".

Imagine where other professions would be if they had wasted as much time as EMS has just listing "skills". 



> Originally Posted by *lightsandsirens5*
> 
> 
> _By medic do you mean paramedic, or EMT in general? Dosent a paramedic already need a bachelors?_


 
Education/training for the Paramedic in the U.S. varies from as little as 500 hours (clock not credit hours) to a 2 year degree. At this time, only one state that I am familiar with requires the 2 year degree.

I could elaborate also on the difference between training and education but that got a thread locked recently. Some just don't want to see the difference or have their "feel good" school of training compared to one that offers a higher standard for learning and education to go with all that training. 

It is possible to have a national organization representing EMS, administering the tests and provide guidelines for each state to establish statutes with nationally recognized titles. Every other licensed profession has been able to do this regardless of where/who the healthcare professional works for. Even phlebotomists have now gone national and some states are liking what they see enough to require the same standards to be included in their own regulations.


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## BossyCow (Jan 22, 2009)

lightsandsirens5 said:


> I sincerely hope you are being sarcastic.:unsure:
> 
> I'm all for sticking with the county/state regulated method. The main reason being my county has one of the least resrtictive BLS protocols manual in the state of Washington. We can, in addition to O2, glucose, and activated charcoal, give ASA, Albuterol, and Epi (up to 2 Epi-Pens w/o pt perscription. More with Med Control.) Also, (I'm not sure if this is a state-wide thing or not) we give nine shocks to a pt with a shockable rythm.
> 
> Those are just some of the things we do that can't be done in the rest of the state, the reason being, there is no ALS service in this county (not even protocols!), ILS might be 45 min-1 hr away, and there are a ton of radio/cell phone dead spaces in our area, meaning we can't contact med. control or dispatch.



You and I are in the same state and apparently the same boat. The epi is state wide. Its the Kristine Kastner act and we not only can use Epi-pens but are required to carry them. 

Which county are you in? You can PM me with it if you aren't comfortable posting it to the forum.


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## lightsandsirens5 (Jan 22, 2009)

VentMedic said:


> Here lies the problem. Some just count the number of skills they can do as a measure of their "professionalism".
> 
> Imagine where other professions would be if they had wasted as much time as EMS has just listing "skills".



Well that is not exectly what I ment. I guess I thought we were discussing something else.


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## lightsandsirens5 (Jan 22, 2009)

BossyCow said:


> You and I are in the same state and apparently the same boat. The epi is state wide. Its the Kristine Kastner act and we not only can use Epi-pens but are required to carry them.
> 
> Which county are you in? You can PM me with it if you aren't comfortable posting it to the forum.



Wasn't the Kristine Kastner act enacted after that girl died because BLS couldn't give her Epi and no ALS was available?


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## jrm818 (Jan 22, 2009)

VentMedic said:


> Here lies the problem. Some just count the number of skills they can do as a measure of their "professionalism".
> 
> Imagine where other professions would be if they had wasted as much time as EMS has just listing "skills".



I'm all for increased education (the real, college-y kind) for paramedics in general, but I think in fairness L&S was pointing out that a national level regulation of EMS is rather one-size fits all approach for a very large country...and I think it's a fair point.

Extremely rural areas - it sounds like that's where he/she is - probably won't be well served by increasing the educational standards, and thus the expense, of paramedics, unless there is some way to improve access to ALS care in these areas.  The cruel paradox is that where good paramedics would be most useful, outlying areas with very long transport times, also have very low call volumes and tend to have very restricted revenue streams to support ALS as it exists now, never mind a more expensive version.  Urban areas with very short transports are much more likely to be able to provide 100% ALS coverage even now.

In these really rural areas many places would have no ALS.  In such places other more local solutions to providing EMS need to be considered, and national plans are generally not good at dealing with regional differences.

I can think of a few solutions to this - possibly some sort of telemedicine program where lesser educated/volunteer EMT's are allowed expanded scopes of care under the direct supervision of a hospital based EM physician, or possibly the integration of ALS as a two-tier fly car system where the medics are based in the hospital as a tech (although this may well operate at a loss...the hospital near my family in Mass (admittedly a land unto itself, EMS wise) looses about 200k a year providing ALS to the neighboring towns...I'm guessing that is why this isn't seen more).

That said, I do like the idea of a "college" of EMS to control standards for paramedics and to require a 4 year degree, but I think more needs to be done to address the problem that the places with some of the greatest need have the worst access.


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## lightsandsirens5 (Jan 22, 2009)

jrm818 said:


> I'm all for increased education (the real, college-y kind) for paramedics in general, but I think in fairness L&S was pointing out that a national level regulation of EMS is rather one-size fits all approach for a very large country...and I think it's a fair point.
> 
> Extremely rural areas - it sounds like that's where he/she is - probably won't be well served by increasing the educational standards, and thus the expense, of paramedics, unless there is some way to improve access to ALS care in these areas.  The cruel paradox is that where good paramedics would be most useful, outlying areas with very long transport times, also have very low call volumes and tend to have very restricted revenue streams to support ALS as it exists now, never mind a more expensive version.  Urban areas with very short transports are much more likely to be able to provide 100% ALS coverage even now.
> 
> ...



Darn. I need to work on my "speaking"! This is exactly what I was trying to say. 

National regulation would hit agencys with large areas of coverage, agencys in rural areas, and voulenteer agencys hardest. Taking into account that most agencys in rural areas do cover large areas and are voulenteer, they would be hit extra hard. That is the situation I am in and thus that is where my viewpoint is from.

So, is national regulation a good idea? In some cases, what could it hurt? But in other cases, it would be a very bad idea. So in the intrest of providing the best patient care possible to the people we serve, it is overall a bad idea to go national.


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## medic417 (Jan 22, 2009)

lightsandsirens5 said:


> Darn. I need to work on my "speaking"! This is exactly what I was trying to say.
> 
> National regulation would hit agencys with large areas of coverage, agencys in rural areas, and voulenteer agencys hardest. Taking into account that most agencys in rural areas do cover large areas and are voulenteer, they would be hit extra hard. That is the situation I am in and thus that is where my viewpoint is from.
> 
> So, is national regulation a good idea? In some cases, what could it hurt? But in other cases, it would be a very bad idea. So in the intrest of providing the best patient care possible to the people we serve, it is overall a bad idea to go national.



But with federal mandates would come federal funds.  Allowing all rural areas no more excuses for not staffing at an ALS level.


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## JPINFV (Jan 22, 2009)

Federal funding? Ever heard of an unfunded mandate?


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## VentMedic (Jan 22, 2009)

lightsandsirens5 said:


> Darn. I need to work on my "speaking"! This is exactly what I was trying to say.
> 
> National regulation would hit agencys with large areas of coverage, agencys in rural areas, and voulenteer agencys hardest. Taking into account that most agencys in rural areas do cover large areas and are voulenteer, they would be hit extra hard. That is the situation I am in and thus that is where my viewpoint is from.
> 
> So, is national regulation a good idea? In some cases, what could it hurt? But in other cases, it would be a very bad idea. So in the intrest of providing the best patient care possible to the people we serve, it is overall a bad idea to go national.


 
Do you have a hospital in your rural area?

Any healthcare professionals working at that hospital?

Doctors? Nurses? Medical Lab Technologists? Radiology Technologists? Physical Therapists? Respiratory Therapists? Speech Therapists? 

Maybe the highest level of care in the hospital should be the CNA if we use the same excuses EMS does. 

How about lawyers or accountants in your area?

Do you think any of these professionals were allowed to cry "but we are rural and shouldn't be required to be educated"? 

It is not unreasonable to provide some resemblance of good healthcare even in rural areas. Florida has managed to provide ALS to all of its 911 services.


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## medic417 (Jan 22, 2009)

JPINFV said:


> Federal funding? Ever heard of an unfunded mandate?



No funding then we see the states revolt.  Wow who whould have ever thought EMS could affect so much?


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## ffemt8978 (Jan 22, 2009)

Can anyone tell me the last time the federal government got a program right the first time, without causing a bigger problem than they were trying to solve?


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## jrm818 (Jan 22, 2009)

"I'm from the government and I'm here to help"....

Ha!  they'd have to fund the mandate - Just like no child left behind, right?  Unless the USFG acutally takes over the ALS services, I doubt enough funds will come rolling in...and as someone mentioned, that's another whole can of worms.  Even if they took it over I doubt it would be fully funded...the feds dont' even pay fully through medicare now.

That said, if the government acutally took over EMS, what you say about funding care might be true.  However, I don't really know that I want some pencil-pusher in DC dictating the way care will be provided in North Dakota or Maine.  There is a good argument for local control of EMS based on community needs, though there is also a good argument for increased educational requirements.  

I wonder what sort of access the government would provide for outlying areas - in addition to having less money, rural areas places also have less people, and thus less congresspeople representing them and lobbying for them (and less money to put into campaigns in general...basically less political power).  I think its likely that major urban areas would get the vast majority of the EMS budget and pork barrel money, leaving rural areas holding the short end of the stick again.  

Similarly, I'm not comfortable with taking away the control of a local med. control physician.  I like the idea of national requirements of a BS, but if there were to be national protocols, I'd have a problem.  I think the physician who is "donating" his liscence to be used for EMS should retain ultimate control over the actions of his/her medics.

EDIT: 

States revolt - haha!  nice idea, unfortunately I think not.  more like news story for one day and then everyone forgets...


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## jrm818 (Jan 22, 2009)

VentMedic said:


> Do you have a hospital in your rural area?
> 
> Any healthcare professionals working at that hospital?
> 
> ...



They may have more than a CNA, but I know that many small rural community hospitals don't have, for example,  PT's, RT's, speech therapists, or any physicians beyond GP's (or fancy imaging technology to be operated by rad. techs).  Specialists are reserved for the big hospitals...sometimes multiple hours away.  Thus the push for increased telemedicine in these areas.

I don't know how rural Florida gets...but if you do manage 100% ALS coverage at outlying places - how?  who pays for it?  Is this a state funded thing, or through fire departments?


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## VentMedic (Jan 22, 2009)

jrm818 said:


> They may have more than a CNA, but I know that many small rural community hospitals don't have, for example, PT's, RT's, speech therapists, or any physicians beyond GP's (or fancy imaging technology to be operated by rad. techs). Specialists are reserved for the big hospitals...sometimes multiple hours away. Thus the push for increased telemedicine in these areas.
> 
> I don't know how rural Florida gets...but if you do manage 100% ALS coverage at outlying places - how? who pays for it? Is this a state funded thing, or through fire departments?


 
Florida is very rural in many areas. We got ALS through good tax base allocation and districts. We are also very much Fire Based EMS. 

Yes, even rural hospitals have at least 1 - 2 of each (RT, SP, PT and definitely radiology technologists and Dieticians). I would also hope they have RNs and not just CNAs or LVNs. There are a basic set of standards for staffing a hospital that must be met by state and Federal requirements or NO Medicare reimbursement. It is NOT an option.


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## mycrofft (Jan 22, 2009)

*I'm only skimming herer*

JRM818 I liked your post, particularly since I have agreed with it here and privately.

The EMT-A and EMT-P were federal creations but then the states stook off with them. The military reserves and Guard medics shold be used to furnish medical care for those without, it's the government's job to do the work other's won't but is required. Besides, it will give them invaluable experience. If the emergency departments don't shape up, they will _*need*_ nationalization.

My ignorant guess is that the cost for the set-up year might cost the same as two weeks' air ops over Iraq.


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## Flight-LP (Jan 22, 2009)

ffemt8978 said:


> Can anyone tell me the last time the federal government got a program right the first time, without causing a bigger problem than they were trying to solve?



TSA....... 



























(with just a hint of sarcasm!)


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## mycrofft (Jan 22, 2009)

*Roger that Flight.*

Wanna work for a year in South Dakota or Watts-Willowbrook?


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## lightsandsirens5 (Jan 22, 2009)

VentMedic said:


> Do you think any of these professionals were allowed to cry "but we are rural and shouldn't be required to be educated"?



That isn't what I ment. I'm saying that basics in rural areas are more educated than basics in more populated areas. And federal regulation would shut the door for rural countys to expand their scope of practice. 

Also, no offence, but Washington has alot more rural areas than Florida and the people in this state arent going to want to pay enough taxes to staff every agency with full time ALS crews. That just dosent work. Especally when you have very rural agencys that might get ten call outs a week.


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## jrm818 (Jan 22, 2009)

VentMedic said:


> Florida is very rural in many areas. We got ALS through good tax base allocation and districts. We are also very much Fire Based EMS.
> 
> Yes, even rural hospitals have at least 1 - 2 of each (RT, SP, PT and definitely radiology technologists and Dieticians). I would also hope they have RNs and not just CNAs or LVNs. There are a basic set of standards for staffing a hospital that must be met by state and Federal requirements or NO Medicare reimbursement. It is NOT an option.



I'll concede the point about RT's PT's and SP's... (till now) I was pretty sure they weren't required.  I tried looking quickly to get an idea of the requirements, but couldn't easily find them so I'll trust your greater experience and knowledge and presume they were.  (side note: wtf?  Why a speech pathologist?  not that I dare knock SP's...my mom is one, and spent many years being educated, but why a requirement for every hospital?)

That said, I am certain that many rural hospitals don't have much in the way of physician specialists, or imaging toys that exist at larger hospitals.  They may have a physical therapist...but try finding a neurologist or getting an MRI.  In the emergency care arena, the specialists are likely to be even more important than the staff you mentioned.  The hospital may have access to such specialists via some sort of telemedicine/consult arrangement, but may have none acutally on staff (warm body in the building).

I'm gathering from your response that the fire-based EMS has a large role in increasing the rural access.  I'm curious if you think that is a good model...given the attitude towards Fire/EMS on this site in general.


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## VentMedic (Jan 22, 2009)

lightsandsirens5 said:


> That isn't what I ment. *I'm saying that basics in rural areas are more educated than basics in more populated areas.*


 
Huh?

So those in the city with easy access to colleges are just a bunch of uneducated fools for providing ALS when we could be just EMT-Bs with a few more "skills"?




lightsandsirens5 said:


> And federal regulation would shut the door for rural countys to expand their scope of practice.


 
Explain..


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## lightsandsirens5 (Jan 22, 2009)

jrm818 said:


> That said, I am certain that many rural hospitals don't have much in the way of physician specialists, or imaging toys that exist at larger hospitals.  They may have a physical therapist...but try finding a neurologist or getting an MRI.  In the emergency care arena, the specialists are likely to be even more important than the staff you mentioned.  The hospital may have access to such specialists via some sort of telemedicine/consult arrangement, but may have none acutally on staff (warm body in the building).



At my hospital we have 1 MD on call and maybe 1-2 RTs, 1-2 RNs. The other people are just ER tecs. There is also a mobile MRI that might get delivered every three weeks for a few days. If not, the nearest MRI is a two hour transport time away. We take tons of pts to the city because 8 out of 10 days in the winter, the air ambulance service can't fly here.


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## lightsandsirens5 (Jan 22, 2009)

VentMedic said:


> Huh?
> 
> So those in the city with easy access to colleges are just a bunch of uneducated fools for providing ALS when we could be just EMT-Bs with a few more "skills"?




No no no....... I mean rural EMT-Bs have the oppurtunity to be more educated.

I dont want to get into an arguement and get banned here, but that is just my take.


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## Sasha (Jan 22, 2009)

lightsandsirens5 said:


> No no no....... I mean rural EMT-Bs have the oppurtunity to be more educated.



How?

10chars


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## VentMedic (Jan 22, 2009)

jrm818 said:


> I'll concede the point about RT's PT's and SP's... (till now) I was pretty sure they weren't required. I tried looking quickly to get an idea of the requirements, but couldn't easily find them so I'll trust your greater experience and knowledge and presume they were. (side note: wtf? Why a speech pathologist? not that I dare knock SP's...my mom is one, and spent many years being educated, but why a requirement for every hospital?)
> 
> That said, I am certain that many rural hospitals don't have much in the way of physician specialists, or imaging toys that exist at larger hospitals. They may have a physical therapist...but try finding a neurologist or getting an MRI. In the emergency care arena, the specialists are likely to be even more important than the staff you mentioned. The hospital may have access to such specialists via some sort of telemedicine/consult arrangement, but may have none acutally on staff (warm body in the building).
> 
> I'm gathering from your response that the fire-based EMS has a large role in increasing the rural access. I'm curious if you think that is a good model...given the attitude towards Fire/EMS on this site in general.


 
There are a couple of different levels for Speech and the edcuation goes to doctorate. The doctorate level practitioner may not be necessary. Why send a stroke patient 2 hours by ambulance to the city for a swallow study or therapy post intubation or CVA? Some hospitals may share one if they are with the same system but usually one hospital can work their tail off with inpatient and outpatient. 

If the hospital does X-Rays, they need a Radiology Technician or Technologist. Most hospitals, in the 21st century, have at least a basic CT Scanner which requires that RT to be certed in. 

If the hospital has ventilators, there should be at least one RRT in house or available on call. 

The Radiologists or Neurologists don't need to be onsite to read a scan or X-Ray. 

Pull up any small hospital website and look at the services they offer. Many little hospitals make their money by outpatient services which pay the bills. PT, OT, Respiratory, HBO, EKG/Cath, Pulmonary Lab, Sleep Lab, Speech... all good money makers...now.


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## TheMowingMonk (Jan 22, 2009)

This is getting off the topic of EMS standardization, I dont see why everyone jumps straight to need to federalize it, I think a good first step would just be standardising on the state level. Because places like california were you can travel an hour and pass through 3 counties all with drastically different protocals, just having a standard within the state that all counties followed i think would be a good step, then from there move towards federalization.


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## jrm818 (Jan 22, 2009)

TheMowingMonk said:


> This is getting off the topic of EMS standardization, I dont see why everyone jumps straight to need to federalize it, I think a good first step would just be standardising on the state level. Because places like california were you can travel an hour and pass through 3 counties all with drastically different protocals, just having a standard within the state that all counties followed i think would be a good step, then from there move towards federalization.



Problem: California
Solution: Cut em loose!  Let the state float left a few more miles.  ha...kidding...

Seriously though - some states have wide variations in their environments.  PA for instance has two big cities at either end...and a whole lot of nothing in the middle.  The protocols we use in the city with 10 -15 minute transport times probably don't fit the middle of the state with transport times measured in hours.

just as an example...insulin as mentioned in another thread.  Around here its no big deal for a hyperglycemic pt. to wait a few minutes to get to the hospital...preferable for the titration to be done there.  If we're an hour plus away, that cost/benefit analysis begins to shift in favor of insulin admin in the field.

America is too diverse for a one-size fits all approach.  national educational requirements...sure...as long as there's some way to preserve rural access.  National protocols?  No thanks.  

Of course the answer to me is: OK, national protocols with allowances for  regional variations

my answer: that's the staus quo, pretty much.  I think the lack of education is a far greater problem than different protocols, and the arena best suited by some sort of national standardization (I still favor private "college" type...rather than USFG regulation).  The government has no business diddling with medicine, imho.


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## TheMowingMonk (Jan 23, 2009)

I think a better way to do it would be a national minimum standard, mean some standard that everywhere would have to fulfil but with room for rural areas to expand on it as needed. Then everyone can have that minimum standard and then areas were expanded skills are needed they can be trained to handle them above the standard


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## JJR512 (Jan 23, 2009)

lightsandsirens5 said:


> That isn't what I ment. I'm saying that basics in rural areas are more educated than basics in more populated areas. And federal regulation would shut the door for rural countys to expand their scope of practice.



I understand what you are saying here. If I understand correctly, you are saying that because ALS coverage is more sparse in rural areas, Basics in rural areas get unique opportunities to learn and do a few more skills than Basics in metro areas to try to make up a bit for the lack of ALS. Then you are saying that federal regulation would take this away. But why do you assume that? Why not make the push for _all_ Basics to get those extra skills that your rural ones have? Along with better education standards to support the use of those skills, of course.

Or, as *TheMowingMonk* said in his reply right above this message, which was allow individual jurisdictions to _add_ to the minimum standard.

Personally, I would prefer to have a higher minimum standard that is followed by all, rather than a lower one for most but allowing some to expand on it. Why? First of all, in general, the more educated, the better. Secondly, if you have the lower standard but allow some to expand on it, *then it isn't really a standard.*

One of the benefits to standardization, and I'm surprised nobody else has brought this up yet, is that no matter where in the country you go, you'll know what to expect. For example, in the event of a major disaster or catastrophe, something that overwhelms the local emergency services. Help is needed from other agencies, maybe from neighboring states, maybe even from across the country. No matter where they came from, all EMT-Bs would have the same knowledge and skill-set. EMT-Bs from different ends of the country could work together as easily as if they went to the same classes together. Same deal for Paramedics.

Allowing some EMT-Bs to have an expanded knowledge and skill-set over and above the national standard might work _as long as these EMT-Bs are taught that these extra skills are special and can only be performed in their local jurisdictions and should be forgotten about in other places._

In general, I like the idea of the "college" and board certification. I'm not sure that a BS is required for EMT-P, though. The only EMT-P BS program in my area that I'm aware of (UMBC) does not actually go very much further, if at all, into the actual EMT-P skills and knowledge than other area AAS programs. It's almost entirely just additional general education. Unless I'm very much mistaken (which is possible). Now I will never argue against getting a better education. But I have known a lot of very good Paramedics, and only one of them had a BS, and she wasn't any better than the others. So my feeling on this point is that an AAS _might_ be acceptable. Perhaps some kind of expanded AAS, with more clinical time added, I don't know. I mean, you don't even need a BS to be an RN; an RN is an Associates-level degree (BSN being the four-year nursing degree).

But the exact details of what the education standards should be are more to the side of the point, which is more about whether there should be any national standard at all, and if so, should it be federal (government-based) or not.


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## TheMowingMonk (Jan 23, 2009)

I agree with JJR512 that there is no reason why All EMT-Bs should all be taught the same standards even if that means giving them expanded skill sets (given the training and education that goes with the kill sets is required as well) but everyone seems to be against the Idea unless you are in a rural area. I like what JJR512 is saying. and on the notes for Bacholers for Paramedic, I know around here when paramedics do the full bacholers programs, it starts as an AS in paramedicine and with some more classes they can get a BS in Public Health. but again it all varies from area to area which is why i think standardization would be awesome if it was possible


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## lightsandsirens5 (Jan 23, 2009)

Sasha said:


> How?
> 
> 10chars



Actually that is worded badl. I should have said that because ALS care is sparse to non-existant in many rural areas, and ILS may or may not be available (And if it is, it may take them up to 1 hr to arrive), basics have the oppurtunity to utilze skills not allowed in other areas. They ain't always mor edgeikated, they just have more learning oppurtunitys open to them as basics.


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## akflightmedic (Jan 23, 2009)

How do they have MORE learning opportunities when in actuality the likelihood that advanced skills would be necessary as rural areas are LESS populated, therefore less calls and certainly less opportunity of doing whatever advanced skill it is you are proposing?

Also, what oversight do they have if they do not have regular leadership/guidance from a higher educated level to ensure they are indeed doing it correctly or when needed?

The fact that they are rural is all the more reason to have an advanced level provider in the area. 

Anyways, someone once quoted to me and I do not know the originator of the exact quote, "Practice does NOT make perfect....PERFECT practice makes perfect".


I speak from experience, I am the last person you need to explain long transport times to and rural settings, having worked in remote Alaska for several years. When the closest band aid hospital was 45 minutes by airplane and the closest Level 1 and hospital with cardiac care abilities was over 3 hours by airplane, I think I know a thing or two about remote/responses. I have also witnessed first hand the damage that is done by expanding the scope of lower level providers who in their defense, do not know what they do not know.


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## TheMowingMonk (Jan 23, 2009)

That is why u don't just expand the scope, the education and skills practice hasbto go with it for it to be successful


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## medic417 (Jan 23, 2009)

akflightmedic said:


> How do they have MORE learning opportunities when in actuality the likelihood that advanced skills would be necessary as rural areas are LESS populated, therefore less calls and certainly less opportunity of doing whatever advanced skill it is you are proposing?
> 
> Also, what oversight do they have if they do not have regular leadership/guidance from a higher educated level to ensure they are indeed doing it correctly or when needed?
> 
> ...




Yup what he said.  Blind un educated leading the blind uneducated get no where.  Get educated if you really care for your rural patients.  Like AK we have no one here to help so better be ALS or people die, some still die with ALS but not near as many as would if we stayed BLS because theres "no money for ALS".  There is always money for ALS you just have to learn how to work the system.


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## lightsandsirens5 (Jan 23, 2009)

> Yup what he said. Blind un educated leading the blind uneducated get no where. Get educated if you really care for your rural patients. Like AK we have no one here to help so better be ALS or people die, some still die with ALS but not near as many as would if we stayed BLS because theres "no money for ALS". There is always money for ALS you just have to learn how to work the system.



I take offence at this. A basic is not a blind un-educated person, neither is the SEI training them. Just because you aren't a semi-god like paramedic dosent mean you cannot save some persons life!

~~~~~~~~~

There may be money, but I see several problems.

1)Who is going to want to voulenteer multiple hundereds of hours of their time for a paramedic course and then take that education and voulenteer it? Take into account that most of your rural EMS is provided by farmers, auto mecanics and construction contractors.

2) Assuming money is available, what paramedic is going to want to work in an area where they might go 2full days with out a call?

3) A agency that only gets between 1500-1800 calls a year dosent have the pt contact volume to support the yearly requirements for ALS stuff like IVs and intubations.

The only practical way to provide any pre-hospital care to the people we serve is with BLS/ILS providers who have the oppurtuinty to add more "advanced" skills to their BLS training. Besides, a basic that is doing these things isn't "uneducated". The have taken the class and passed the practicals and writen test for that subject.

That is mearly my point of view and I'm not trying to force it on anybody.

I better stop arguing before I get banned!^_^


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## medic417 (Jan 23, 2009)

lightsandsirens5 said:


> There may be money, but I see several problems.
> 
> 1)Who is going to want to voulenteer multiple hundereds of hours of their time for a paramedic course and then take that education and voulenteer it? Take into account that most of your rural EMS is provided by farmers, auto mecanics and construction contractors.
> 
> ...



Who said volunteer?  I said there is money for ALS and by that I meant full time paid professional ALS.


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## lightsandsirens5 (Jan 23, 2009)

medic417 said:


> Who said volunteer?  I said there is money for ALS and by that I meant full time paid professional ALS.




Like I said:

2) Assuming money is available, what paramedic is going to want to work in an area where they might go 2full days with out a call?

3) A agency that only gets between 1500-1800 calls a year dosent have the pt contact volume to support the yearly requirements for ALS stuff like IVs and intubations.

I'm not dening that rural ALS is a bad idea, I'm just saying that in alot of areas it is impractical and the best altenitive is BLS/ILS with a few more skills.


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## BossyCow (Jan 23, 2009)

medic417 said:


> But with federal mandates would come federal funds.  Allowing all rural areas no more excuses for not staffing at an ALS level.



I'm sorry but do you also believe in the tooth fairy and the easter bunny? 

Federal Mandates come with invoices not checks. We can't rely on funding from a government with Trillion Dollar Deficits to bail us out. Besides, any federal funds I've seen go to the largest agency... ie: the state, county... and those funds are primarily slurped up by the agencies with higher population densities. We are the ugly stepchild and an independent agency, junior taxing district. Our only legal avenues for funds are taxes (limited by legislation) levies (failed them so far) and grant writing. Grants are notorious for excluding day to day operations fees. 

Our major hurdle is that our citizenry can't see paying for 3 full time medics (the minimum required to provide 24/7 coverage) to sit around the station 24/7 while answering less than twenty calls a month. Our state mandates a minimum wage for standby pay, so we can't pay them only for the calls they run without sacrificing our mandatory 24/7 coverage requirement.

We currently have ALS _WHEN AVAILABLE_ from an adjoining agency and they have recently cut staff and reduced their availability, which they can do as a private agency as long as their primary response area remains covered.

I'm getting really tired of the "You can do it if you try or prioritize" comments. This is not a matter of priorities, not a matter of lack of interest. This is a reality of an impoverished, rural, geographically isolated area. And I am not the only one. Most of the solutions are based on an urban area with a healthy tax base that merely requires reallocating funds already collected.I hear things like.. 'If people are willing to pay for water, garbage and sewer, they should pay for EMS'... yeah that works.. sell that to a tax base on private wells, with septic systems, who burn their garbage or haul it to the dump themselves.

I live in what can be classified as a third world country. I have residents without electricity. I get people who drive their sick or injured into the fire station or to the local general store where there's a phone. The average education level is 'some high school' but most of them do possess functional literacy, but just barely. Alcoholism and drug abuse is rampant. Preventative healthcare is a luxury item and probably 90% don't have any kind of insurance. 

Our 'downtown' consists of a general store, post office (in the general store), a laundromat, two churches and a school. We get .37 per thousand of assessed value of the county property taxes. Attempts to raise this have failed. 

So, lay off the sanctimonious "you can do it if you try" cheers. We are trying, and we do what we can with what we have to work with. I am not complacent, I am not settling for sub-par, I am working desparately, non stop and constantly to improve what we have. I have the marks of that brick wall permanently imprinted on my forehead. I have improved the standard of care so far and I will continue to do so. But those of you in cities and towns with industry, jobs have no idea what the reality of the rural areas truly is. Nationalization, standardization, will go to a common denominator and areas like mine will be left out.


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## medic417 (Jan 23, 2009)

BossyCow said:


> I'm sorry but do you also believe in the tooth fairy and the easter bunny?
> 
> Federal Mandates come with invoices not checks. We can't rely on funding from a government with Trillion Dollar Deficits to bail us out. Besides, any federal funds I've seen go to the largest agency... ie: the state, county... and those funds are primarily slurped up by the agencies with higher population densities. We are the ugly stepchild and an independent agency, junior taxing district. Our only legal avenues for funds are taxes (limited by legislation) levies (failed them so far) and grant writing. Grants are notorious for excluding day to day operations fees.
> 
> ...




Wow we could be living next door to each other.  Of course sounds like you are on the good side of the tracks.  Seriously My area is that bad as well, yet we found a way to be paid 24/7.  We have no industry.  Those that choose to work end up traveling at minimum an hour away to make minimum wage.  Many including myself drive over 200 miles one way to make income to survive, then I work part time here.  So your comment about those in citys/towns must have been directed at others.  

I am glad you are looking at improving and I commend you.  

Yes my comment about Feds running it was meant with a lot of sarcasm.


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## BossyCow (Jan 23, 2009)

medic417 said:


> Wow we could be living next door to each other.  Of course sounds like you are on the good side of the tracks.  Seriously My area is that bad as well, yet we found a way to be paid 24/7.  We have no industry.  Those that choose to work end up traveling at minimum an hour away to make minimum wage.  Many including myself drive over 200 miles one way to make income to survive, then I work part time here.  So your comment about those in citys/towns must have been directed at others.
> 
> I am glad you are looking at improving and I commend you.
> 
> Yes my comment about Feds running it was meant with a lot of sarcasm.



So where do the funds come from that pay you 24/7? Specifically? 
And the commute you describe to industry with family wage paying jobs would be a vast improvement to our situation. We have lost several timber and pulp mills and are slated to lose more.


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## medic417 (Jan 23, 2009)

BossyCow said:


> So where do the funds come from that pay you 24/7? Specifically?
> And the commute you describe to industry with family wage paying jobs would be a vast improvement to our situation. We have lost several timber and pulp mills and are slated to lose more.




First you bill for all calls whether transported or not. First we pursue insurance, medicaid, Medicare, etc.  We allow people to pay whatever they can afford each month, you would be surprised how much that adds up after a while.  

Second the citizens all voluntarily contribute an extra $5/mth. 

Third you use grants for any supplys.  While there are not grants for payroll there are grants for supplys and equipment.  That leaves the money budgeted for supplys available to be put back into payroll.

Much will have to ajusted in community/county budgets.  And I could go on and on.  Its there but I agree you will beat your head against a brick wall getting community leaders to give it up but eventually it will happen.  You already have most everything(ambulance, equipment, utilitys, etc) so all you are looking at extra is pay. Perhaps start off only paying 1 person then each year add 1 more etc, less shock to the budget makers that way.  

Now take it a different route.  Why can your vollunteer agency not go ALS?  You as volunteers would be out money for the education but monthly expenses really would not go up drastically for service.  Yes initially adding EKG etc would be an expense but you might be surprised at what some big city services are willing to give away to small towns for free or at low cost. 

 When I started in EMS as a volunteer we were ALS. We covered entire 2000+ square mile county that only had about 1800 people, almost all living below poverty line.  We always had at least one paramedic on the 1st ambulance and often one one the second one.  Many times we had two on each. (that service is now paying 2 people and about to add a 3rd paid member) 

Hope these few ideas gives you more to think about.  Always look outside the box.  Be creative.  I know you want the best for you patients based on the posts you bring here.  Hopefully a "jerk" like me may give you more ideas to keep feeding the desire to change things there.


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## jrm818 (Jan 23, 2009)

There's the issue of the cost effectiveness of providing full time ALS coverage, especially if the educational requirements of medics gets upped, in some rural areas.  It's great to talk about how ALS everywhere is good for EMS...but what is good for EMS and EMS providers is not necessarily good for the community as a whole.  In many places EMS may be a priority..sure.  But I can imagine (I dont know if BossyCow's or your community fit into this picture, but I'm sure someone's does) a community with little access to preventative or primary care medical care where the increased expense of providing 24/7 all EMT-P coverage would be a waste.  It's hard to put a price on someone's live, but in areas with very low call volumes, I'm willing to bet there are places the money would be better spent providing cheap/free primary care clinics or something like that (and by better spent I mean the money would do more to increase the health and well-being of the population, and maybe save more lives (although its near impossible to quantify lives saved by prevention) if it were put into preventative care rather than EMS).

Really, what percentage of EMS patients would have a truly worse outcome if they had delayed access to ALS care?  Yes, some certainly would, but from my experience the number isn't really all that high, and the difference in outcome isn't all that great - on average.  I don't know that much research has been done to quantify this, but I am certain that in a country this large, there are multiple areas where the true benefit of all time ALS is not nearly justified by the cost..even if that area is not yours.

The point of this is not "EMS doesn't matter," but that a community where this is the case would be ill suited by nationalized EMS, unless exceptions were made for such areas.

As many have said, the idea that the USFG would re-distribute funding to poor rural areas is a pipe dream.  If the Gov't took over EMS, the cities and towns with political power (e.g. money) would get the bulk of the budget.  I commend (I think, obviously dont' know much about the specifics) your area on what they have done, but that doesn't mean it could be done everywhre - and certinaly doesn't mean it _ought_ to be done everywhere.


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## medic417 (Jan 23, 2009)

jrm818 said:


> There's the issue of the cost effectiveness of providing full time ALS coverage, especially if the educational requirements of medics gets upped, in some rural areas.  It's great to talk about how ALS everywhere is good for EMS...but what is good for EMS and EMS providers is not necessarily good for the community as a whole.  In many places EMS may be a priority..sure.  But I can imagine (I dont know if BossyCow's or your community fit into this picture, but I'm sure someone's does) a community with little access to preventative or primary care medical care where the increased expense of providing 24/7 all EMT-P coverage would be a waste.  It's hard to put a price on someone's live, but in areas with very low call volumes, I'm willing to bet there are places the money would be better spent providing cheap/free primary care clinics or something like that (and by better spent I mean the money would do more to increase the health and well-being of the population, and maybe save more lives (although its near impossible to quantify lives saved by prevention) if it were put into preventative care rather than EMS).
> 
> Really, what percentage of EMS patients would have a truly worse outcome if they had delayed access to ALS care?  Yes, some certainly would, but from my experience the number isn't really all that high, and the difference in outcome isn't all that great - on average.  I don't know that much research has been done to quantify this, but I am certain that in a country this large, there are multiple areas where the true benefit of all time ALS is not nearly justified by the cost..even if that area is not yours.
> 
> ...



I hope its not my child that needed ALS and died because you feel money is more important.


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## jrm818 (Jan 23, 2009)

Actually the gist of my post is that there are other things that the money can be spent on that would better serve the healthcare needs of the community.   Try again.

I hope its not the mother of your daughter that received poor (or none) prenatal care resulting in the death of the mother and daughter, a birth defect of some form, etc.


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## JJR512 (Jan 24, 2009)

From reading some of the posts from today it seems to me that there is a bit of a crisis in the rural areas of the country. Some areas, like wherever * medic417* is, seem to have found a workable solution, at least for now. I'm sure that medic417 probably feels it could be better, though. Other areas are still struggling, like wherever *BossyCow* is. Some of medic417's community's solutions may work for BossyCow's community, some may not.

Couldn't a national EMS system possibly _help_ communities like BossyCow's? At the very least, couldn't a national system provide a networking mechanism so that the success stories can be used as teaching examples for the still-struggling communities? Sort of like what's happening here between medic417 and BossyCow but on a larger scale?

Nobody likes the prospect of higher taxes, but suppose this national system was federalized, giving it the ability to be funded through taxes. The total national cost of EMS can be calculated and put into the federal budget. Alternatively each state can fund their own agencies through state taxes.

Alternatively, funding can start with billing for EMS calls and payments from insurance companies, as *medic417* mentioned. Thus the tax could be smaller or possibly not needed. There are several counties in Maryland, though, that fund EMS (to be precise, the County Fire Department, which includes EMS) entirely through taxes; citizens are never charged for ambulance services or having their house fires put out. The MD State Police is the primary provider of helicopter medevac service and this is funded almost entirely through vehicle registration fees.

My feeling on the funding issue is that EMS is an essential service that is (or should be) available to all citizens, therefore, all citizens should pay for it. This would seem to be best accomplished through funding from income tax.

But ultimately, I believe that there _are_ ways a national system can help to solve the EMS problems of the small rural communities.


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## ffemt8978 (Jan 24, 2009)

JJR512 said:


> But ultimately, I believe that there _are_ ways a national system can help to solve the EMS problems of the small rural communities.



In the same way Medicare/Medicaid was meant to be a national system to help solve problems?:wacko:


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## JJR512 (Jan 24, 2009)

It also occurs to me to mention that a national system could have greater ability to identify the issues plaguing EMS now, such as abuse of EMS ("frequent fliers") and to design solutions to these problems and work to lessen or eliminate them. These problems are cost drains so eliminating them would lessen the cost of the EMS system as a whole, which however it is funded, would lessen the amount that needs to be paid for.


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## JJR512 (Jan 24, 2009)

ffemt8978 said:


> In the same way Medicare/Medicaid was meant to be a national system to help solve problems?:wacko:



I don't actually know very much about Medicare, so I can't really comment. It's my understanding that Medicare could use a bit of an overhaul itself.

Look, I'm not saying that a national EMS system with real and true authority (including the power of enforcement) needs to be a part of the government. I'm just not sure how a private association can get that level of power. What *akflightmedic* [post=118612]proposed earlier[/post] could/might work.


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## lightsandsirens5 (Jan 24, 2009)

JJR512 said:


> Nobody likes the prospect of higher taxes, but suppose this national system was federalized, giving it the ability to be funded through taxes. The total national cost of EMS can be calculated and put into the federal budget. Alternatively each state can fund their own agencies through state taxes.



What fed. budget? The one that is only a few tens of billions in the whole? 
*said with a hint of sarcasim*

Boy JJR512, you sure got some of us going with that thread starter!!!:wacko:

Yes, I can definately see how it would benifit in some ways, but I also see how it could hurt. So l am for keeping it, at least for the momet (sp?), state regulated. Maybe in the future we will have to go to a federal system. Who knows?


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## Summit (Jan 30, 2009)

I see this perpetual discussion continues. 

And we see people holler "NO! Someone might take my acts allowed away!" whenever something is proposed without stopping to think that *higher standards mean more skills DONE RIGHT - Better Care(tm)*. And of course the more education sends shivers down the spines of those who have their c-card and expect to do nothing but the bare minimum.



lightsandsirens5 said:


> A basic is not a blind un-educated person



Not uneducated, most are (way) UNDEReducated. And so are many medics when you think about it and compare to other countries.



akflightmedic said:


> There have been interesting discussions elsewhere on the net in regards to this.
> 
> Here is a snippet of a proposal from an ERDoc who is very proactive in EMS education, standards, etc.
> 
> ...



Very interesting proposal... I love it... but the IAFF & Private EMS vs ACEP/EMPAC lobby battle would be brutal.

As to worries about the one size fits all approach. From what I know about Canada, it can be made to work. After all, *with in depth education, you can teach to the extremes and then each agency can make its own protocols as necessary.
*
Similarly, the access to ALS in remote areas could be solved by the way I understand it is done in Canada, whereas working for the state one might serve rotations in rural areas. This idea is predicated on *society deciding that top level EMS is a NECESSITY rather than a luxury.*

It COULD be made to work. It would be a miracle though (I'm never optimistic about fed.gov involvement, but I see no other way here) or at least take a great deal of work and commitment to get the kinks worked out and there would be a period of adjustment.


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## lightsandsirens5 (Jan 31, 2009)

Summit said:


> Similarly, the access to ALS in remote areas could be solved by the way I understand it is done in Canada, whereas working for the state one might serve rotations in rural areas.



Say you lived in the city, are you going to be willling to leave your family behind to go work in a rural area for a week or more? 

Are you sure this is the way it is done in Canada?


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## BossyCow (Jan 31, 2009)

medic417 said:


> > First you bill for all calls whether transported or not. First we pursue insurance, medicaid, Medicare, etc.  We allow people to pay whatever they can afford each month, you would be surprised how much that adds up after a while.
> 
> 
> 
> ...


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## A140160 (Feb 1, 2009)

You know, at least to me, it seems that the primary issues in this thread have become garbled after long discussions.  Personally, I work for a company that gets approx. 350-400 calls/year.  We run 1 ambulance, and just about all of us are farmers.  However, ALS is provided between the 3 ambulance companies in the area by the closest city.  I don't know how far you are from a bigger city/town, but that may be one way to go.  The management section of EMS is not exactly my specialty, I just show up on scene in my truck and get to work, so I won't even pretend to know what's up about that.

The issue with standardizing EMS is seeming to be the area where everyone is at everyone's throats.

In my opinion, the quality of care provided by healthcare practitioners is something that should not, and can not be under appreciated or over stressed.  With a higher standard with which to train our EMS providers, our patients will receive better care.  However, national standardization of the protocols for us is _not_ in the best interest of the patient.  For urban settings, many EMS providers do not need to be able to do some things that many rural providers do (I mean no insult by this, as you will see in a moment).

Urban EMS tends to have ALS support just about whenever they need it, which, accompanied with a short transport time, means that the EMT does not need to be able to provide longer term care.

Rural EMS, such as my company, does not have ALS very often.  Because our only paramedic is shared by 2 other ambulance comapnies in the county, many times our BLS people hear "It's John Wayne time", and may have to provide treatment for long transports.  Because of this, rural EMS can make use of protocols that an urban setting can't, and all of our providers have training in their additional certifications.

The only possible solution that I have thought to this problem (while watching the Super Bowl and typing a reply!) is that if EMS did get national standardization, stipulations could easily be placed into the protocol allowing more advanced treatment to be provided by the BLS unit providing certain criteria were met.  To put it another way, the Good Samaritan law lets the practitioner be allowed to do something when they believe in good faith that it will benefit the patient.  In this way, the protocols could be written in such a way that if a longer transport was required, certian skills would then become available to the EMT.


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## JJR512 (Feb 2, 2009)

Just for clarification, I was not proposing that there be a national set of protocols to be followed universally by all.

In fact, I'd like to go out on a limb here and say that, for the most part, protocols might not be necessary at all.

What exactly are protocols? A protocol (in the EMS world) is an instruction that says, "If you have this, this, and this, then do that." Compare this to EMS education, which says, "If you have this, this, and this, then do that, and here's how you do it." The protocols that I'm familiar with (those for Maryland EMS providers) don't really tell me anything I shouldn't already know from EMT-B class, in terms of general patient care.

And this is something that doesn't have to just be a benefit of a nationalized, uniform EMS system, either. EMS classes are usually tailored to local protocols, so in any jurisdiction, the protocols could probably be mostly done away with, for the most part being replaced with a simple instruction: "Do what you've been taught." Of course, the benefit of a national unified system would be that all providers at the same level would be taught the same thing, so if you move, or go to help out at a disaster in another area, you'll be able to work seamlessly together with the other providers there because you'll all have been taught the exact same thing.

And please understand that this does not exclude the possibility of having certain skills taught and made available that are over and above the baseline standard of your level if the needs of your particular jurisdiction requires it. In those situations, there would probably need to be protocols describing when those special skills can or can't be used, with it always being made clear that those are special skills to be used in the local jurisdiction only.


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## Summit (Feb 2, 2009)

^

Like I said above, with indepth and high level education standardized across the country, you can educate providers to all types of treatment modalities, even to the extremes, then each agency can make its own protocols more restrictive if necessary.


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## BossyCow (Feb 2, 2009)

A140160 said:


> Personally, I work for a company that gets approx. 350-400 calls/year.  We run 1 ambulance, and just about all of us are farmers.  However, ALS is provided between the 3 ambulance companies in the area by the closest city.  I don't know how far you are from a bigger city/town, but that may be one way to go.


That is pretty much what we have here. But our ALS agencies have recently dropped service and limited their responding units. I was responding to the posts that say "Just get ALS, its easy if you try." which frankly I'm sick of hearing.



> The issue with standardizing EMS is seeming to be the area where everyone is at everyone's throats.



Yes it does. Because when you standardize, you have to pick one to fit all. 



> Rural EMS, such as my company, does not have ALS very often.  Because our only paramedic is shared by 2 other ambulance comapnies in the county, many times our BLS people hear "It's John Wayne time", and may have to provide treatment for long transports.  Because of this, rural EMS can make use of protocols that an urban setting can't, and all of our providers have training in their additional certifications.



Which according to some means all your farmer vollies need to man-up and go to paramedic school.



> The only possible solution that I have thought to this problem (while watching the Super Bowl and typing a reply!) is that if EMS did get national standardization, stipulations could easily be placed into the protocol allowing more advanced treatment to be provided by the BLS unit providing certain criteria were met.  To put it another way, the Good Samaritan law lets the practitioner be allowed to do something when they believe in good faith that it will benefit the patient.  In this way, the protocols could be written in such a way that if a longer transport was required, certian skills would then become available to the EMT.



We have that in place currently. Which is why the current system isn't totally unworkable. I will continue to be the voice for the out of the way rural volly district which so many seem to be set on eliminating. What is a problem in the busy urban district is sometimes the solution in the out of the way backcountry districts.


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## medic417 (Feb 2, 2009)

BossyCow said:


> [I'm sorry, but do you have any awareness at all about the rules regarding a government agency payroll? You cannot have two people doing the same work and pay one of them and not the other. There has to be a clear delineation of the differences between their jobs. For instance, you can have a volunteer staff who's job is to assist the paid staff, but the job descriptions need to delineate who's responsible for what with the paid staff taking precedence in both responsibility and liability.So you can't gradually add paid staff one at a time. A volunteer cannot be made to commit to being available for a specific period of time, and has to be able to not go on a call if life intervenes. Otherwise they are on-call personnel and have to be compensated by an hourly wage set by the state. In order to be an ALS agency you have to provide 24/7 coverage which means a minimum of 3 paid staff.
> 
> 
> 
> You have repeatedly tossed off how it can be done and how easy it is if I get creative .. but I'm beginning to think you really have very little understanding of the administrative side of the equation. Because   and it had all been done prior to your arrival at the agency.



Many services are Paid/Volly combinations nationwide.  What I have found in many places they initially start off with a paid administrator.  Then a paid assistant administrator.  You have created a distinction by having extra requirements such as remaining at the station while the volunteers still respond from home.  Plus the paid people do grant writing.  They file state reports.  They attend the meetings with various government entitys to get your voices heard.  You can create additional such as maintenance etc etc to have a distinction above the vollys.  Be creative.

I actually have a lot of administration experience.  Yes there may be variations in the laws.  You may need to petition your state to make a new ambulance license if it does not have it like what Texas has that is known as a BLS with MICU capable.  With that a service can staff with basics only but if they have a paramedic they can then operate ALS.  

I actually have found it takes very little extra time on the various small grants available for supplys and equipment.  Some of them only require a 1 page application.  

The other issues you mentioned may require you getting laws changed in your area and also changes to your charters.  

Comply with all rules, regulations, and laws and you will find you can use them to get what you need.


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## BossyCow (Feb 2, 2009)

medic417 said:


> Many services are Paid/Volly combinations nationwide.  What I have found in many places they initially start off with a paid administrator.  Then a paid assistant administrator.  You have created a distinction by having extra requirements such as remaining at the station while the volunteers still respond from home.  Plus the paid people do grant writing.  They file state reports.  They attend the meetings with various government entitys to get your voices heard.  You can create additional such as maintenance etc etc to have a distinction above the vollys.  Be creative.



What you folks aren't getting is that I'm being creative and working towards improvement. But we are not able to become ALS just because some urban posters here think we should. We do have a paid part time administrative assistant who does some filing etc. But she is primarily clerical. The meetings are attended by myself and the other chief officers of the department on our own time as vollies. We recently planned to go to a paid chief but the failure of our recent levy and the again reduced amount of both timber tax monies and property tax monies, forced us to re-evaluate. And that's what we need to remain BLS, not advance to a higher level of service



> I actually have a lot of administration experience.  Yes there may be variations in the laws.  You may need to petition your state to make a new ambulance license if it does not have it like what Texas has that is known as a BLS with MICU capable.  With that a service can staff with basics only but if they have a paramedic they can then operate ALS.



Our state allows something similar to that and if you read my post, I mentioned at one time we had vollie medics. But the response again, was directed at those insisting that my small rural district can and should become ALS. 



> I actually have found it takes very little extra time on the various small grants available for supplys and equipment.  Some of them only require a 1 page application.



That's true, and I write them. But, to imply that grants are going to be able to turn us into ALS overnight is unrealistic.



> The other issues you mentioned may require you getting laws changed in your area and also changes to your charters.
> 
> Comply with all rules, regulations, and laws and you will find you can use them to get what you need.



What I need is for others to understand that a lack of ALS is not a sign of lack of education, lack of dedication or so help me gawd, Creativity. Sometimes its just a factor of the geology and demographics. I'm spending all day on March 9th in my state capital trying to address some of these issues. On my own time btw. Not only not getting paid, but burning a vacation day from my day job to go.


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## VentMedic (Feb 2, 2009)

BossyCow said:


> What I need is for others to understand that a lack of ALS is not a sign of lack of education, lack of dedication or so help me gawd, Creativity. Sometimes its just a factor of the geology and demographics. I'm spending all day on March 9th in my state capital trying to address some of these issues. On my own time btw. Not only not getting paid, but burning a vacation day from my day job to go.


 
There are areas much more rural than yours that did see a need to become ALS with PATIENT care in mind. Parts of Alaska, rural Idaho and a 124 mile stretch of the Florida Keys are examples. While they do still have volunteer FDs on some islands in FL, controversial at best, they do have access to ALS care. Yes, there was a political battle that had to be fought but the need for appropriate EMS should be stressed when the nearest trauma/cardiac center is over an hour away by helicopter...after the helicopter reaches the scene.

If you do not have an ALS education to provide ALS care, then you are lacking in education. Multiple BLS certs are not enough education to provide for appropriate medical care in a rural region. The hours spent doing piece mill certs could have gotten one a Paramedic cert and a more solid foundation to build for advanced care. Once the foundation is poured, the rest gets a lot easier. 

This is one of our few volunteer ambulance services left in Florida and yes, they are ALS. 
http://klvac.com/

[FONT=Arial, Helvetica, sans-serif]*The mission of the Key Largo Volunteer Ambulance Corps. is to be recognized, trusted, and praised by our community for providing compassionate, professional, and progressive medical care at the best possible cost, by focusing on our long history of volunteerism and training. KLVAC responds to more than 1,400 ambulance calls a year with typically two ALS (Advanced Life Support) ambulances, staffed with a minimum of one paramedic and one EMT 24 hours a day, 7 days a week, 365 days a year. *[/FONT]​


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## Aidey (Feb 2, 2009)

I support a nationalization of EMS, but maybe not to the extent that some other people do. 

I think there needs to be one standard set of certifications/licenses for all 50 states. Period. If that means using the current NREMT levels, ok. Or a revised set of levels or something. But it needs to be standardized. 

Also, each level should have standard education across the board. Same number of hours for each level no matter what state you are in, same skills learned etc. 

All of this will be run and monitored by a national agency, preferably under Health and Human Services and not DOT. 

The agency in charge would set standards for equipment, and what needs to be on an ambulance for it to be considered a BLS, ILS or ALS ambulance. There would be a standard set of minimum protocols for BLS, ILS and ALS. There should also be something for first responder services who may not use ambulances.

Protocols could be expanded from those minimums, but could not drop below those minimums. If they did, the agency would loose their ambulance service certification for that level. To expand protocols certain criteria would need to be met, and it would have to be approved by the state EMS agency. (Which is pretty much how it works now when you expand your protocols). 

This will allow for one standard system that can be regulated (and understood) as a whole. It will also make it much easier for people who move to obtain reciprocity from state to state.


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## BossyCow (Feb 2, 2009)

VentMedic said:


> There are areas much more rural than yours that did see a need to become ALS with PATIENT care in mind. Parts of Alaska, rural Idaho and a 124 mile stretch of the Florida Keys are examples. While they do still have volunteer FDs on some islands in FL, controversial at best, they do have access to ALS care. Yes, there was a political battle that had to be fought but the need for appropriate EMS should be stressed when the nearest trauma/cardiac center is over an hour away by helicopter...after the helicopter reaches the scene.
> 
> If you do not have an ALS education to provide ALS care, then you are lacking in education. Multiple BLS certs are not enough education to provide for appropriate medical care in a rural region. The hours spent doing piece mill certs could have gotten one a Paramedic cert and a more solid foundation to build for advanced care. Once the foundation is poured, the rest gets a lot easier.
> 
> ...



Look at the tax base of the states you cite as examples. a lot higher than mine! I'm not against making our system ALS. I just chafe at the pedantic patronizing tone of those who talk about how easy it is. I've been fighting this fight for about 7 years now and the pat answers of "you can do it if you try" and 'You just have to be more creative' from those who have never walked in my shoes irritate me. I spend hours every week trying to keep an underfunded system alive because without it the citizens have nothing. Those sittiing in urban systems, who have never attended a legislative session or county board meeting or gone door to door to promote a levy only to watch it fail, have no right to judge, or to dictate to me what my system 'should' be.


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## medic417 (Feb 2, 2009)

VentMedic said:


> There are areas much more rural than yours that did see a need to become ALS with PATIENT care in mind. Parts of Alaska, rural Idaho and a 124 mile stretch of the Florida Keys are examples. While they do still have volunteer FDs on some islands in FL, controversial at best, they do have access to ALS care. Yes, there was a political battle that had to be fought but the need for appropriate EMS should be stressed when the nearest trauma/cardiac center is over an hour away by helicopter...after the helicopter reaches the scene.
> 
> If you do not have an ALS education to provide ALS care, then you are lacking in education. Multiple BLS certs are not enough education to provide for appropriate medical care in a rural region. The hours spent doing piece mill certs could have gotten one a Paramedic cert and a more solid foundation to build for advanced care. Once the foundation is poured, the rest gets a lot easier.
> 
> ...




You are right there is no excuse for remote areas not to have ALS.  Honestly you could argue they have greater need for it than do citys.  We may not have near the call volume of citys but when you spend a minimum of 90 minutes with every patient basics can basically only sit and hold a dieing persons hand.  But a medic might be able to convert that bad rythym and the person live. 

In this day and age Paramedic can even be attained with much of the class work by distance learning.


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## VentMedic (Feb 2, 2009)

BossyCow said:


> Look at the tax base of the states you cite as examples. a lot higher than mine! I'm not against making our system ALS. I just chafe at the pedantic patronizing tone of those who talk about how easy it is. I've been fighting this fight for about 7 years now and the pat answers of "you can do it if you try" and 'You just have to be more creative' from those who have never walked in my shoes irritate me. I spend hours every week trying to keep an underfunded system alive because without it the citizens have nothing. Those sittiing in urban systems, who have never attended a legislative session or county board meeting or gone door to door to promote a levy only to watch it fail, have no right to judge, or to dictate to me what my system 'should' be.


 
These islands are not heavily populated, nor are the incomes particularly high with many being retirees. Property value and income are disportionate and if you looked at the volunteer service link, a special district was created. Assistance is still needed from the state. 

You've been fighting a fight but what fight? You don't seem to be pro-Paramedic in many of your posts and still argue that your BLS service provides  good compassionate and professional care just like the big city ALS companies. 

If you were a Paramedic, do you not think you might be able to present some arguements more effectively from a different point of view? We have read all the EMT vs Paramedic arguements on the forums with each having their passionate stances for their title. Maybe it is time to lead by example and get your own Paramedic certificate if you are passionate about representing your service to provide a higher level of medical care.


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## Sasha (Feb 2, 2009)

medic417 said:


> You are right there is no excuse for remote areas not to have ALS.  Honestly you could argue they have greater need for it than do citys.  We may not have near the call volume of citys but when you spend a minimum of 90 minutes with every patient basics can basically only sit and hold a dieing persons hand.  But a medic might be able to convert that bad rythym and the person live.
> 
> In this day and age Paramedic can even be attained with much of the class work by distance learning.



By just putting a medic on a truck, you are not providing ALS. You still need the money to supply this Medic with all the equipment and drugs preform the ALS care. Which costs money that some places just don't have.

A medic on a BLS truck is really no more useful than a basic.


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## medic417 (Feb 2, 2009)

Sasha said:


> By just putting a medic on a truck, you are not providing ALS. You still need the money to supply this Medic with all the equipment and drugs preform the ALS care. Which costs money that some places just don't have.
> 
> A medic on a BLS truck is really no more useful than a basic.




Honestly most drugs that we as medics use are not expensive and have a good shelf life.  You said in another post you have most of the equipment from when you had paramedics.  So really other than the first month because of having to order all the drugs it would not add much expense.  

I know you want it, and I know your trying.  Hopefully our battles will either give you a new idea or at least help others that are new to the fight to improve rural EMS get ideas on how to start.  Never give up.


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## jrm818 (Feb 2, 2009)

VentMedic said:


> These islands are not heavily populated, nor are the incomes particularly high with many being retirees. Property value and income are disportionate and if you looked at the volunteer service link, a special district was created. Assistance is still needed from the state.
> 
> You've been fighting a fight but what fight? You don't seem to be pro-Paramedic in many of your posts and still argue that your BLS service provides  good compassionate and professional care just like the big city ALS companies.
> 
> If you were a Paramedic, do you not think you might be able to present some arguements more effectively from a different point of view? We have read all the EMT vs Paramedic arguements on the forums with each having their passionate stances for their title. Maybe it is time to lead by example and get your own Paramedic certificate if you are passionate about representing your service to provide a higher level of medical care.



I'm not even in this fight anymore but this struck me as kind of insulting.  How would you feel if someone told you to stop playing make-believe doctor and go get your MD, in the interest of best patient care blah blah.

What is this "pro-paramedic" nonsense?  The reality is that EMS is not the most important thing for most areas to spend their (often lacking) money on, and just because some places are willing to sacrifice for ALS does not mean they all are.  Is being "pro-paramedic" the same as being "anti-doctor," as in, you don't think everyone deserves to have an MD respond on the ambulance?  MD response is done in some places - the fact that paramedics even exists indicates that EMS as a whole is ready to sacrifice some educational and training requirements in the interest of cost effectiveness.  In some cases paramedic may not be the cost effective answer.  Heck, look at the call volume for your "rural" example - 1400/year!  Bossy has already said they run less than 20 calls a month.  Not quite a fair comparison.

With that volume, how on earth are these theoretical volunteer medics going to keep their skills up?  The only volunteer paramedics i've ever met or heard of have full time medic jobs somewhere else for that reason exactly.  It sounds like that is probably not an option in her area.


I think this little fight is the best argument against nationalized EMS.  People in one area decide that they know the best way to run things in areas they have no connection to besides hearing about them once or twice, and start issuing proclamations about how things should be done, based on thier own experience in a different area.  This country is so freaking big that the regional variations are beyond anything that can be well handled by a nationalized system.  Base level educational requirements perhaps...but certinaly not a central administration.

Bossy - it sounds like you are doing a phenomenal job given the resources available to you, and that you have more personal passion for good quality EMS than many of the 'pros" here.  How many brag about how they want nothing to do with EMS or providing even basic care when they are not at work being paid for it.  For you it sounds like this is more a calling than just a "job."

The personal jabs at bossy cow / bossy cow's system need to end.  I'm pretty surprised to see them aimed at her from this forum.


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## medic417 (Feb 2, 2009)

jrm818 said:


> With that volume, how on earth are these theoretical volunteer medics going to keep their skills up?  The only volunteer paramedics i've ever met or heard of have full time medic jobs somewhere else for that reason exactly.



Where I started in EMS we had a bunch of volly Paramedics.  They did not work elsewhere and we did fewer than 20 calls a month many times with multiple Paramedics on the ambulance.  They maintained skills and education by doing clinicals and attending classes though most of that required days away from home and paid work.  Yes now they are doing as I described slowly going paid.


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## VentMedic (Feb 2, 2009)

jrm818,

Anti-doctor? A doctor, or any other medical professional, can not use the same excuses made by some in EMS that "we live too far away" to get a higher education. 

How do you think other medical professionals keep up their skills and knowledge which may be more complex than the few hours required for even the Paramedic in some parts of the country? 

Why should the people in rural regions go without ALS care while EMS fights its "BLS vs ALS" battles? 

Maybe it is time the soft gloves come off in this profession for a dose of reality. The people in the UNITED STATES deserve to have quality medical care and that includes EMS. This goal is what started the profession in the 1960s and it is a shame that some have not even gotten to the level it started at in the 1960s.


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## jrm818 (Feb 2, 2009)

medic417 said:


> Where I started in EMS we had a bunch of volly Paramedics.  They did not work elsewhere and we did fewer than 20 calls a month many times with multiple Paramedics on the ambulance.  They maintained skills and education by doing clinicals and attending classes though most of that required days away from home and paid work.  Yes now they are doing as I described slowly going paid.



While I admire their dedication, I'd be uneasy with a medic treating me with that little clinical exposure, depending on how many clinical hours they did on thier own time.  That said, this is still specific to your region - there are any number of reasons this could be impossible somewhere else.


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## VentMedic (Feb 2, 2009)

jrm818 said:


> While I admire their dedication, I'd be uneasy with a medic treating me with that little clinical exposure, depending on how many clinical hours they did on thier own time. That said, this is still specific to your region - there are any number of reasons this could be impossible somewhere else.


 
What's with all the excuses for not providing quality medical care?

If we ran with your other thoughts of having only Paramedics on a truck instead of doctors is sacrificing care, having only EMT-Bs is definitely a sacrifice.

If that is your thought, having at least a Paramedic would be a benefit.


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## lightsandsirens5 (Feb 2, 2009)

medic417 said:


> You are right there is no excuse for remote areas not to have ALS.  Honestly you could argue they have greater need for it than do citys.



Maybe we do. But it is the age old "do more with less" thing! Look at the revenue that a city has. Now compare that to an area 30 times the size with one quarter the money! It is just as wrong for agencys that have the capability of ALS to force their way on agencys that don't have enough money, people or time as it is for us small rural guys and gals to force our way on the rest of you! EMS is *NOT* a one size fits all thing!



medic417 said:


> .....basics can basically only sit and hold a dieing persons hand.



This is not true and you know it. If you think it is, then God help you.



medic417 said:


> But a medic might be able to convert that bad rythym and the person live.



Who says a basic or intermediate can't? At my agency basically all we can't do is pace.




medic417 said:


> In this day and age Paramedic can even be attained with much of the class work by distance learning.



It still take the same amount of time and money that lots of people don't have.


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## Aidey (Feb 2, 2009)

I don't think nationalization has to mean "everyone, everywhere is ALS".


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## lightsandsirens5 (Feb 2, 2009)

^

AMEN!

ten char.


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## jrm818 (Feb 2, 2009)

VentMedic said:


> jrm818,
> 
> Anti-doctor? A doctor, or any other medical professional, can not use the same excuses made by some in EMS that "we live too far away" to get a higher education.
> 
> ...



I meant "anti-doctor" in that you don't think there should be doctors on ambulances, that paramedics are "good enough."  A MD is a higher education level than paramedic.  Are you suggesting that those who do not go from paramedic to MD/DO are "making excuses"?

As for the living too far away -that's because MD's are not volunteers.  Doctors do not go to school for many many years to give their service away for free - they could not sustain such a sytem.  Volunteers have to balance their other life functions with EMS, which prohibits long periods of time not working away from home.

In general I'd say that doctors keep their skills by seeing patients (in addition to classes, training, etc) for which they are compensated.  I doubt there are many (any) doctors who see less than 20 patients a month.  If there were such a doctor, I'd question if he was really needed, or if I wanted him treating me...

"why should people go without ALS?"  I'd say lack of money is a pretty good reason.  This rhetorical argument of "why not ALS" is infinitely regressive.  I can make the exact same argument with the exact same reasoning for having fully MD ambulance response...yet no one is calling for that.  MD ambulances in general aren't thought to be cost effective or feasible, and in some places paramedics may not be either.

Medical reality is that cost matters - a lot.  Availability of medical care is not free, and is not guaranteed in a lot of places.  Heck plenty of people can't get a Primary Care Physician, never mind good ALS emergency care.  I'd argue that the former is a lot more important overall.  Just because ALS is "better" than BLS does not mean it is an appropriate option for everywhere.

Heck in places where the medics may have borderline clinical exposure, i'd say ALS may be worse.  more treatment is not always better.


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## Sasha (Feb 2, 2009)

> But a medic might be able to convert that bad rythym and the person live.



In order to do that the medic must have the equipment capable of displaying the rhythm and defibbing, cardioverting, or pacing! The cheapest used lifepak 12 I found was in the 6,000 dollar range and it is only guarenteed for a year! Granted I didn't spend a lot of time looking, but man! That's a LOT of money for one month for an area that's living below the poverty line.


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## Aidey (Feb 2, 2009)

This conversation is moving too fast for me. 

I came from a service that felt that I-85 was the highest level of care they were required to provide, because after all, and IV is an ALS procedure. Anything beyond that was a bonus, even if it meant that cardiac patients were transported by someone who didn't even know how to turn the EKG monitor on. 

I was never confortable with it then, and I'm not comfortable with it anywhere else. There are more than 2 levels of EMS. People don't need to become paramedics, but there are other intermediate certifications they can obtain. 

While ALS may not be available everywhere, I don't like dressing up BLS to look like ALS. Be one or the other. If the people don't want to pay for ALS, fine, educate them on the consequences and be BLS. You can still work torwards becoming ALS, but don't do it 1/2 way.






P.S. I also want to add that this isn't about BossyCow's situation, but more generalized because I know there are other areas that have the same issues. (I come from one).


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## jrm818 (Feb 2, 2009)

VentMedic said:


> What's with all the excuses for not providing quality medical care?
> 
> If we ran with your other thoughts of having only Paramedics on a truck instead of doctors is sacrificing care, having only EMT-Bs is definitely a sacrifice.
> 
> If that is your thought, having at least a Paramedic would be a benefit.



missed this one in my last reply.  I don't think there need to be doctors on all ambulances, nor do I think all ambulances NEED paramedics.  Sure it's better, but sometimes you do sacrifice care for other priorities.  Yes ALS is probably generally better than BLS, but MD is better still.

The point is everyone here who is not an MD is working for a system which is "sacrificing" some degree of care in the interest of cost/availability of providers by employing paramedics instead of higher trained doctors.  How can you cast stones at a system in a different area who does the same sort of  cost/benefit analysis but finds that only EMT-basics are affordable/cost effective in their particular area.

so, more bluntly - what's your systems' excuse for not providing quality medical care by becoming a doctor?  I'm sure the answer is good, and I'm sure it resembles Bossy Cows systems reasons for not having paramedics.


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## BossyCow (Feb 2, 2009)

VentMedic said:


> These islands are not heavily populated, nor are the incomes particularly high with many being retirees. Property value and income are disportionate and if you looked at the volunteer service link, a special district was created. Assistance is still needed from the state.



We are a special district, which is much of our problem. The local citizenry is very heavily invested in their independence over the need for service. Our state only provides assistance in the form of fire education, timber tax and an under $2000 grant for 'misc. supplies' all other funding must come from our tax district alone. We are on a renewed attempt to pass a levy but each failed levy further depletes our budget. 



> You've been fighting a fight but what fight? You don't seem to be pro-Paramedic in many of your posts and still argue that your BLS service provides  good compassionate and professional care just like the big city ALS companies.



Yeah, I don't know where you got this. My husband is a paramedic and I'm extremely pro ALS. I've been tearing my hair out over the reduced ALS coverage from the agency I've been using for my ALS support. I have not said that my BLS is as good as ALS but have said we do what we can because we can't afford anything else. 



> If you were a Paramedic, do you not think you might be able to present some arguements more effectively from a different point of view? We have read all the EMT vs Paramedic arguements on the forums with each having their passionate stances for their title. Maybe it is time to lead by example and get your own Paramedic certificate if you are passionate about epresenting your service to provide a higher level of medical care



I have a day job for which I am very well paid. I am not going to leave that at 50+ years old and go to school for a career change that is not going to pay me what I make now. I have, however found scholarships and written grants to pay tuition for 3 different paramedic students. All three of them are currently working outside of my district.


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## lightsandsirens5 (Feb 2, 2009)

Sasha said:


> In order to do that the medic must have the equipment capable of displaying the rhythm and defibbing, cardioverting, or pacing! The cheapest used lifepak 12 I found was in the 6,000 dollar range and it is only guarenteed for a year! Granted I didn't spend a lot of time looking, but man! That's a LOT of money for one month for an area that's living below the poverty line.



Hey Sasha, are you fightin' for us now?

Gag! I didn't realize the 12 costed that much!!


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## VentMedic (Feb 2, 2009)

jrm818 said:


> I meant "anti-doctor" in that you don't think there should be doctors on ambulances, that paramedics are "good enough." A MD is a higher education level than paramedic. Are you suggesting that those who do not go from paramedic to MD/DO are "making excuses"?
> 
> As for the living too far away -that's because MD's are not volunteers. Doctors do not go to school for many many years to give their service away for free - they could not sustain such a sytem. Volunteers have to balance their other life functions with EMS, which prohibits long periods of time not working away from home.
> 
> ...


 
Your arguments for doctors vs Paramedics are not valid in that many services did (and do) HAVE physicians on the ambulances at one time but with proper education and training, Paramedics were allow to perform just as well. Physicians ARE STILL used on some transports if the patient warrants a higher level. They are also on the ambulances that provide EM residencies. 

We are talking about services that have not been ALS and some do not want to be ALS, not just because of money, but because of the additional responsibiliies of what a higher education and certification might bring in terms of liability and accountibility. 

The money thing should not be used as an excuse for not providing medical services. Poor people are just as entitled to medical care as the rich and can use that card to make a play for additional grants and adjustment in their state's tax distribution funding. 

So your arguement that because healthcare sucks in the U.S. in general, EMS should remain at a lower standard also? What about all the areas that have managed to provide quality EMS? Maybe they should lower their standards so those that make all the excuses will feel justified in their lower level of care?

BTW, most doctors and many other healthcare professionals do pay for their training and CEs out of their own pocket in addition to what their facilites provide.   The average professional from RNs to MDs will spend easily 300 hours of additional time on education and training each year.


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## Sasha (Feb 2, 2009)

lightsandsirens5 said:


> Hey Sasha, are you fightin' for us now?
> 
> Gag! I didn't realize the 12 costed that much!!



I would love to see the entire country as ALS. I think every patient deserves an ALS assesment, but if there's no money, there's no money. Calling someone uncreative or telling them they just have to try harder doesn't make it happen.


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## VentMedic (Feb 2, 2009)

jrm818 said:


> so, more bluntly - what's your systems' excuse for not providing quality medical care by becoming a doctor?


 
Again, doctors were common at one time on our 911 Fire Rescue ambulances. Doctors in their EM residency still ride on the ambulances. If we are transporting a patient, by flight or ground, that warrants a doctor, there will be a doctor on board.


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## VentMedic (Feb 2, 2009)

Sasha said:


> I would love to see the entire country as ALS. I think every patient deserves an ALS assesment, but if there's no money, there's no money. Calling someone uncreative or telling them they just have to try harder doesn't make it happen.


 
But, Florida, with all of its problems, was able to become all ALS for 911.


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## lightsandsirens5 (Feb 2, 2009)

VentMedic said:


> Again, doctors were common at one time on our 911 Fire Rescue ambulances. Doctors in their EM residency still ride on the ambulances. If we are transporting a patient, by flight or ground, that warrants a doctor, there will be a doctor on board.



And when we need ALS, we call up an air-med crew and they fly up and either take the pt or ride with us.


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## VentMedic (Feb 2, 2009)

lightsandsirens5 said:


> And when we need ALS, we call up an air-med crew and they fly up and either take the pt or *ride with us*.


 
Wow! Fly a helicopter to a scene and take it out of service for a ground transport? If you had a Paramedic already on board, you would save your district a lot of money by not putting the helicopter into flight and also endangering the crew with a patient that could go by ground.

This is probably the best argument I have heard so far on this thread as to why ALS is needed in some areas.


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## jrm818 (Feb 2, 2009)

VentMedic said:


> Your arguments for doctors vs Paramedics are not valid in that many services did (and do) HAVE physicians on the ambulances at one time but with proper education and training, Paramedics were allow to perform just as well.
> 
> *I'm pretty sure there are still treatments that MD's perform that Paramedics cannot.  The educational requirement aren't even close, and to suggest otherwise is laughable.  A more accurate statement would be "paramedics were able to provide care that was more cost effective and was a good enough analogue of MD care."  BLS is another iteration of that, simply at a lower level on the "sliding scale" of care.*
> 
> ...



10 characters, i guess my bold above doesn't count.  I'll be leaving this thread for a while now, back later tonight.

everyone carry on.


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## jrm818 (Feb 2, 2009)

VentMedic said:


> Wow! Fly a helicopter to a scene and take it out of service for a ground transport? If you had a Paramedic already on board, you would save your district a lot of money by not putting the helicopter into flight and also endangering the crew with a patient that could go by ground.
> 
> This is probably the best argument I have heard so far on this thread as to why ALS is needed in some areas.



OK i lied...after this I am leaving

that is not an argument for the "need" of ALS, but a benefit of ALS.  "need" would be proven by demonstrating that ALS care makes demonstrable positive changes in overall population health in a cost effective manner.  

E.G. if the money for ALS could also be spent increasing primary care access, and it was shown (as i bet it would be if this could ever be acutally quantified) that every dollar spent on PCP access has more of an effect on overal population health than every dollar spent on ALS, than I'd say ALS is not "needed" at all.


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## lightsandsirens5 (Feb 2, 2009)

VentMedic said:


> Wow! Fly a helicopter to a scene and take it out of service for a ground transport? If you had a Paramedic already on board, you would save your district a lot of money by not putting the helicopter into flight and also endangering the crew with a patient that could go by ground.
> 
> This is probably the best argument I have heard so far on this thread as to why ALS is needed in some areas.



OK, look. You want to fix EMS? Go ahead and try. I'd absolutly love ALS in rural areas. I just dont think it is always going to be feasible! What is next best? *Gasp!* BLS and ILS!!!!!!


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## VentMedic (Feb 2, 2009)

Why is it that some in EMS continue to argue against the advancement of medicine while other professions are continuously striving to find ways to improve healthcare in their professional areas and communities? 


jrm818,
You need to broaden you view about healthcare and learn how we do provide medical care to millions of people who are poor. EMS should not discriminate its 911 services based on the size of the patient's wallet. 

Luckily the Freedom House Ambulance service did not use your logic and saw the need for Paramedics over 40 years ago.


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## VentMedic (Feb 2, 2009)

jrm818 said:


> OK i lied...after this I am leaving
> 
> that is not an argument for the "need" of ALS, but a benefit of ALS. "need" would be proven by demonstrating that ALS care makes demonstrable positive changes in overall population health in a cost effective manner.
> 
> E.G. if the money for ALS could also be spent increasing primary care access, and it was shown (as i bet it would be if this could ever be acutally quantified) that every dollar spent on PCP access has more of an effect on overal population health than every dollar spent on ALS, than I'd say ALS is not "needed" at all.


 
So you justify flying a helicopter to a BLS truck just so they have a Paramedic to ride in the ambulance with them to the hospital?

Do you know how much the helicopter and what each flight costs?


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## Aidey (Feb 2, 2009)

VentMedic said:


> Why is it that some in EMS continue to argue against the advancement of medicine while other professions are continuously striving to find ways to improve healthcare in their professional areas and communities?



Because we, more than any other medical service in the US, are accountable directly to the tax payers. If the tax payers won't support it, we can't do it. We can't force them to fund ALS if they don't want to. It doesn't mean that people don't want to advance or make things better, but it creates a ceiling there that can be difficult to break through. 

Alternatively, we are also hampered by fire based EMS systems run by fire fighters who see EMS as the red-headed step child who is only good enough for the left overs.


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## lightsandsirens5 (Feb 2, 2009)

VentMedic said:


> You need to broaden you view about healthcare and learn how we do provide medical care to millions of people who are poor. EMS should not discriminate its 911 services based on the size of the patient's wallet.



Do you actually think this? Do you actually think that my service or any of the rest of us volly and or rural services really do this? :angry:

Does BLS/ILS not count as medical care in your book? I sincerely hope that this isn't the view of most of the rest of you that are in this discussion.


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## VentMedic (Feb 2, 2009)

lightsandsirens5 said:


> Do you actually think this? Do you actually think that my service or any of the rest of us volly and or rural services really do this? :angry:.


Did you bother to read what it was in context to?



lightsandsirens5 said:


> Does BLS/ILS not count as medical care in your book? I sincerely hope that this isn't the view of most of the rest of you that are in this discussion.


 
Again, as I have already pointed out, those who hold a title will argue that their title is the best. EMS has held on to its titles, all 50+ of them, and have continued to argue that their title is the best regardless of its limitations. If you, yourself, were to advance to a higher level, you might be able to do a whole lot more when it comes to providing care to the patient. At this time and for your level, you may not even know what all you don't know.


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## VentMedic (Feb 2, 2009)

Aidey said:


> Alternatively, we are also hampered by fire based EMS systems run by fire fighters who see EMS as the red-headed step child who is only good enough for the left overs.


 
So be it.  If the FD is the only option available to provide ALS care in a rural region, then they should.    You can not blame all EMS problems on Fire.   Many providing the arguments here are strictly ambulance and still do not want to advance their education to make their point of who can provide better care.


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## Sasha (Feb 2, 2009)

> Alternatively, we are also hampered by fire based EMS systems run by fire fighters who see EMS as the red-headed step child who is only good enough for the left overs.



Why do people want to blame all of EMS problems on EMS based fire service?


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## lightsandsirens5 (Feb 2, 2009)

VentMedic said:


> Again, as I have already pointed out, those who hold a title will argue that their title is the best. EMS has held on to its titles, all 50+ of them, and have continued to argue that their title is the best regardless of its limitations. If you, yourself, were to advance to a higher level, you might be able to do a whole lot more when it comes to providing care to the patient. At this time and for your level, you may not even know what all you don't know.



What does the 50+ thing mean? :unsure:

I am trying to advance, I'm taking an ILS class this spring.


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## VentMedic (Feb 2, 2009)

lightsandsirens5 said:


> What does the 50+ thing mean? :unsure:
> 
> I am trying to advance, I'm taking an ILS class this spring.


 
There are over 50 different EMS certifications/licenses in the U.S. with each state being "creative" for whatever purpose to do a piece mill patch work that has severely fragmented EMS. To further complicate matters, some states change titles and "skills" every couple of years so it is difficult to even know who is doing what or who is called what. This leads to confusion not only amongst the EMS providers but the public as well as the politicians who want to help but can't figure out all the different levels. 

http://en.wikipedia.org/wiki/Emergency_medical_responder_levels_by_U.S._state

Washington state has at least 6 or 7 different levels. 

This is by far more damaging than what Fire-EMS can be blamed for since many of the FDs do strive for their FFs to be Paramedics and provide ALS. Granted the way some FDs approach it is not always perceived to be the best, but the right general concept is there.

Don't stop at ILS. Go straight to Paramedic or whatever it is called in your state.


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## A140160 (Feb 2, 2009)

Anyone that knows me, (and I seriously doubt any of you know me  ) knows that I hate all this flowery talk my way around the other person crap, so I'm going to say it very clearly hear:  Please, stop playing my guns bigger than your gun with everyone!  There is no need for us to be picking at each other about what's better.  Sure, ALS can provide better care, but in reality, not everyone warrents an ALS response.  Mrs. Jane Doe doesn't need a paramedic to treat her because she stubbed her toe!  On the other hand, Mr. John Doe could definately benefit from an ALS response while having a huge MI!  This thread has gone from how we might be able to do something, to lets try to insult someone because their different from us.  You can't change incomes or demographics with words, and therefore you aren't going to be changing the range of ALS with bickering among each other as to who's better.


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## VentMedic (Feb 2, 2009)

A140160 said:


> Sure, ALS can provide better care, but in reality, not everyone warrents an ALS response.
> 
> _____________________________________
> You can't change incomes or demographics with words, and therefore you aren't going to be changing the range of ALS with bickering among each other as to who's better.


 
Regards of not every call is ALS, a community should have access to ALS without waiting for a helicopter to bring a Paramedic. This is about providing quality medical care which often gets confused with the terms EMS has dished like labels that belittle patient care. 

These arguments would never fly if a hospital was to decide it could be ran with only CNAs and LVNs instead of RNs. 

To change what happens iin an area, the providers themselves must change and grow as medicine changes. They must accept that the world is changing and people in the U.S. can ask for better care. If the providers themselves are giving the arguments against advancing the level of care, what message are they giving the people that do hold the tax dollars at both the private citizen and government levels? 
"We've done just fine without no big city ideas". Great attitude to keep your community hidden from all those scary things in the real world. 

I have been there and seen communities out in the middle of nowhere go from volunteer BLS to an all paid ALS. Some residents of those communities were as poor as they could be without living on the street and some were even homeless. Yet, their community had ALS and an improved chance for survival if they did have a medical emergency.

Enough with which patient should have ALS or BLS. They need MEDICAL CARE. You don't know what a patient needs until an assessment is done and then without the proper education, you still probably won't know. If you do assess something more is going on, what can you do to make a difference?

So, there are times when some EMS providers themselves are the reasons why EMS has not come together with the single goal of doing what is best for THE PATIENT. Everyone has their own agenda and set of excuses.


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## Veneficus (Feb 2, 2009)

Vent,

This goes to the can of worms of public safety vs. public health. (which implies medicine)As you know I am squarely in the public health/medicine camp. For a long time we have tried to show people our perspective and they will be dragged kicking and screaming, as examples look at what wake county just instituted or the advanced practice scope developing in Britain. The idea of BLS vs. ALS is a naïve argument perpetuated by those who do not understand anything more than what their skill testing sheets require.

This thread, which I have been following, but largely holding my tongue, is preposterous. Legally and practically nationalizing EMS is impossible. Could you imagine the US fire Service as a federal agency? It works here in Europe because states are divisions of a country, whereas in the US, the country is actually a federation of largely independent states.

Somehow from that the thread digressed to the ALS vs. BLS and what is affordable argument. That can only lead to the education argument. Then in classic predictable form, those who know the least about medicine have the most to say about how it should be done. 

Our current concept of an EMS safety net has not worked, is not working, and will not work in the future. A new safety net that includes primary care needs to be put into place in all communities. As there is not enough physicians to put on ambulances, there are not enough “mid level” providers to go around either. More detailed knowledge of medicine and autonomy (and commensurate responsibility for such) is the only realistic way forward for both economics and patient care. 

As for paying for it, I think our brethren down under have a solution workable in the US. There must be a state EMS agency. Just like there is state police, and a state fire marshal. Now I know that many states are economically challenged, but healthcare needs to be a higher priority than parks and recreation, transportation, and other expenditures. Unhealthy people cannot work, they cannot learn, they cannot travel, and they cannot overall contribute to making their community better. The US has more sociological consumers than producers. That is going to get worse before it gets better. The public, aka patients, are no longer served by an expensive taxi ride to the hospital, which is what skill based EMS is. It is no wonder in most places there is little public support for EMS. As it stands It is largely not worth paying for. 

Anyone who wants to help a patient needs to forget IVs and ET tubes, LMA, medications, etc and start learning biology, chemistry, anatomy, physio, patho phys, etc. There is a reason basic science is a prerequisite for every level of healthcare provider all over the world.  (except US EMS apparently) Medicine is not like working a saw or welding, you have to know how and why things work, not just what to do when you see sign X and symptom Y. >90% of all “emergencies” are not life threatening. Why do we spend so much time, money, and effort on less than 5-8% of what we do?

My antagonists will argue they are saving lives. But they don’t even realize how flawed that perspective is. But they do need the mental security of thinking they had a positive part to play greater than a ride.


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## lightsandsirens5 (Feb 2, 2009)

VentMedic said:


> There are over 50 different EMS certifications/licenses in the U.S. with each state being "creative" for whatever purpose to do a piece mill patch work that has severely fragmented EMS. To further complicate matters, some states change titles and "skills" every couple of years so it is difficult to even know who is doing what or who is called what. This leads to confusion not only amongst the EMS providers but the public as well as the politicians who want to help but can't figure out all the different levels.
> 
> http://en.wikipedia.org/wiki/Emergency_medical_responder_levels_by_U.S._state
> 
> ...




Ahhh...I get you. I have heard that my stste is doing away with Intravenous Therapy Technician, Airway Management Technician, and IV/Airway Technician to make things simpler. So, a leeettle step in the right direction?

Soooooo.......you say skip ILS? I was thinking of it, but I can get the class for free and I can't afford a medic course right now, so I may do it just for the heck of it. (Besides I can get college credits for taking the class.)


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## Ridryder911 (Feb 2, 2009)

Wow! I did not realize we had so many experts in EMS development! (satire) Amazing, so many immediate Systems Developers that do not know squat about establishing EMS Systems and what is required or payment structures. Then yet want to proclaim National EMS Standard (patient protocols) when they have *NO* correlation at all. National Standards of Treatment and Protocols would be disastrous! Until we have a standardization of education, thinking of such is asinine! Making statements such Medical Doctors or comparison of such demonstrates poor knowledge of EMS Systems. Especially considering the history of how EMS was developed, and the role of the providers as physician representatives. 

How many of these so called "hurting services" actually have a adequate coding and billing department? If  you offer services for free then quit whining and change it! Your potential patients deserve better! You don't even bill insurance companies? If not, its not just foolish its stupid! Sorry, services costs and it would be nice if things in life where free, but the old saying "what you pay for, is what you get". If its in your charter, change it! 

My service offers a full time with double Paramedic 24/7 in a poverty town of < 1000 people. They pay addtional $9.00 a month for EMS + also get a bill if used. The reason? They understand after such services in the past such as volunteer, then fly by night EMS services that do it cheaper but leave in the middle of the night, its much cheaper to have one in the long run. The run volume has increased due public talk of professional services, and with the public utility subsidy and payments, we break even and with small profit. So yes, it can be done! 

If it is a true frontier and rural area, then the those that live in that area need to recognize the risks of living in such. Alike I said, first responder is one thing but don't acclaim to be an EMS. Rendezvous with ALS either ground, flight can be a standard procedure.

Patient care and those that treat should *NEVER SHOULD BE COMPROMISED or CHANGED BECAUSE OF THE INADEQUACY TO MEET THE DEMANDS*! When one does this, they have not only failed the system but the patients as well. 

If you really want to have a real discussion, then study systems development, regionalizations, EMS Systems and Administrative practices. One should have knowledge of medical administration and full understanding of how the health care systems operate. 

R/r 911


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## Foxbat (Feb 2, 2009)

Veneficus said:


> Vent,
> Could you imagine the US fire Service as a federal agency? It works here in Europe because states are divisions of a country, whereas in the US, the country is actually a federation of largely independent states.


It does not have to be federal agency _de jure_. Federal government may, for example, offer more financial assistance to departments if they conform to certain standards; it can even "force" states to regulate their EMS just like it "forced" them to set drinking age at 21. But who has the political will to do that?


> As for paying for it, I think our brethren down under have a solution workable in the US. There must be a state EMS agency.


Yes. At least at state level. Maybe, in like 30 years there will be a new white paper showing how many preventable deaths occur from lack of ALS in poor communities and how much money it costs to the country. But even then then "goverment is the enemy" attitude may prevail. 


> My antagonists will argue they are saving lives. But they don’t even realize how flawed that perspective is. But they do need the mental security of thinking they had a positive part to play greater than a ride.


You mean that if all patients will be transported by taxis with red lights on top with only driver up front, outcomes won't change?


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## Veneficus (Feb 2, 2009)

Foxbat said:


> You mean that if all patients will be transported by taxis with red lights on top with only driver up front, outcomes won't change?



I am suggesting that without proper education and a focus on knowledge rather than skills, EMS is nothing but a glorified taxi service.


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## Veneficus (Feb 2, 2009)

Ridryder911 said:


> If you really want to have a real discussion, then study systems development, regionalizations, EMS Systems and Administrative practices. One should have knowledge of medical administration and full understanding of how the health care systems operate.
> 
> R/r 911



I want to have a real discussion on it. 

We both agree that education is a must and that a national scope would be a disaster. 

I think the role of the EMS provider needs to and is evolving.

I am also very aware that in the next 10 years the current payment system of US healthcare is not going to be the same. Prehospital providers may want to start increasing their role so when renumeration is overhauled they have enough value to society to not only have a position but a livable wage as well.


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## ffemt8978 (Feb 2, 2009)

medic417 said:


> Second the citizens all voluntarily contribute an extra $5/mth.


So what makes you think they're going to contribute an extra $5/month if they won't approve a tax levy?



VentMedic said:


> This is one of our few volunteer ambulance services left in Florida and yes, they are ALS.
> http://klvac.com/
> 
> [FONT=Arial, Helvetica, sans-serif]*The mission of the Key Largo Volunteer Ambulance Corps. is to be recognized, trusted, and praised by our community for providing compassionate, professional, and progressive medical care at the best possible cost, by focusing on our long history of volunteerism and training. KLVAC responds to more than 1,400 ambulance calls a year with typically two ALS (Advanced Life Support) ambulances, staffed with a minimum of one paramedic and one EMT 24 hours a day, 7 days a week, 365 days a year. *[/FONT]​


Big difference between billing 1400 calls a year and 300 calls per year...


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## VentMedic (Feb 2, 2009)

ffemt8978 said:


> Big difference between billing 1400 calls a year and 300 calls per year...


 
But, if you used that same logic, all the medical professionals living in rural regions could say they can't provide good patient care because they don't see enough patients. Fortunately, other professionals know what education/skills they need to keep current and have enough ambition and/or professionlism to maintain them. They don't use their chosen place of residence as an excuse. The other healthcare professionals also acknowledged what their chosen profession consisted of and the education it required. They obtained their education and continued on with their career in their chosen place of residence. Many prefer to take their advanced education, knowledge and skills back to their home towns to provide the highest possible quality medical care for their facility/agency. 

A small town hospital can still excel in patient care even if it doesn't have the latest technology or world renowned surgeons. I also know many of the surgeons from these smaller hospitals come to the big city facilities to practice new skills/techniques to take back home. It just depends on how hard you want to work for your career or to be a quality healthcare provider.


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## ffemt8978 (Feb 2, 2009)

No, I didn't say anything about standard of care...I was referring strictly to the financial aspect.


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## jrm818 (Feb 2, 2009)

VentMedic said:


> Why is it that some in EMS continue to argue against the advancement of medicine while other professions are continuously striving to find ways to improve healthcare in their professional areas and communities?
> 
> 
> jrm818,
> ...



On an individual basis EMS does not and should restrict access based on ability to pay...provided we are talking about emergent conditions, just as hospital ED's do not.  That does not mean all medical care is equal, however.

What I meant to convey is that on a community level there are differences in access to all kinds of social services, including health care, based on the wealth of the community.  The only way for a poor community to achieve equal access to EMS as compared to more wealthy communites is to make a greater sacrifice themselves to provide, e.g. ALS service, or for the government to redistribute wealth from the rich to the poor.  I've never much gone for that socialism stuff, so the only possibility I'm happy with is the community finding some way to afford ALS.  If the community decides they have more important things to spend their money on (primary care comes to mind in the healthcare arena), than so be it.

The community I work in is pretty economically depressed.  One township has a levy analogous to a fire district that pays us,in the rest patients pay individually.  The ambulance company stays afloat only due to large call volumes due to high density populations, and a contract with the hospital.  If this were a rural setting I can't see the company being able to afford to provide 24/7 ALS without a significant contribution from the population.  That depends on the population being convinced that ALS is a cost-effective way to spend their healthcare dollars....and I'd have a hard time making that case.

Freedom house was surely a good thing for the city, and it's pathetic the way it ended, but isn't necessarily a good model for the rest of the country.  Most places don't have a Dr. Safer hanging out half a mile away to start such a thing...


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## VentMedic (Feb 2, 2009)

ffemt8978 said:


> No, I didn't say anything about standard of care...I was referring strictly to the financial aspect.


 
But, you also must consider their equipment and vehicles. In addition, they do maintain a small staff for operations. I also believe they started paying their Paramedics. Key Largo also has a FD which was included in the special tax district. It's all relative on the type of service you want to provide. And, if you notice, there are not that many volunteers pictured and a little older than some of the other volly squads. Not all of us on the mainland agree with volunteer services but this one is backed by a trauma district with access to the services in Miami.


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## VentMedic (Feb 2, 2009)

jrm818 said:


> What I meant to convey is that on a community level there are differences in access to all kinds of social services, including health care, based on the wealth of the community. The only way for a poor community to achieve equal access to EMS as compared to more wealthy communites is to make a greater sacrifice themselves to provide, e.g. ALS service, or for the government to redistribute wealth from the rich to the poor. .


 
No, I disagree. Florida is a state of the haves and have nots. Our tax structure within the state is set up for allowances of disproportionate tax bases.  Each service also charges.


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## jrm818 (Feb 2, 2009)

Veneficus said:


> Vent,
> 
> This goes to the can of worms of public safety vs. public health. (which implies medicine)As you know I am squarely in the public health/medicine camp. For a long time we have tried to show people our perspective and they will be dragged kicking and screaming, as examples look at what wake county just instituted or the advanced practice scope developing in Britain. The idea of BLS vs. ALS is a naïve argument perpetuated by those who do not understand anything more than what their skill testing sheets require.
> [...]
> ...



I get the feeling that this is directed at least to an extent in my general direction.  I hope not, because I basically agree with everything you said.  My arguments about the cost-effectiveness of ALS aren't to suggest that EMS could never become an critical part of a communities healthcare system (i.e. finally be "needed"), but that as ALS is run in most places, it is probably not as important as everyone thinks.  

I am attracted to the idea of utilizing EMS to provide not only emergency service, but also a degree of primary care type services.  I think such a system could be a cost-effective way to expand access to preventative primary care medicine in poorer locations while also providing a high level of emergency care for the (relatively few) who need it.  By contrast, I think for many such communities, the money needed to expand to ALS could probably be better spent.


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## Veneficus (Feb 2, 2009)

jrm818 said:


> I get the feeling that this is directed at least to an extent in my general direction.



Not all all, actually i was trying to point out to vent (whom I usually agree with) that the discussion was getting very predictable.


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## BossyCow (Feb 3, 2009)

VentMedic said:


> But, if you used that same logic, all the medical professionals living in rural regions could say they can't provide good patient care because they don't see enough patients. Fortunately, other professionals know what education/skills they need to keep current and have enough ambition and/or professionlism to maintain them. They don't use their chosen place of residence as an excuse.



Actually they do Vent.. which is why rural areas are losing doctors and closing clinics. OB/Gyn departments are closing and scaling back with any high risk pregnancy being turfed to a more urban area. A friend of mine spent the last month of her pregnancy living out of a suitcase in Seattle (3+ hours away) because she was not able to get the level care she needed at our local hospital. 

Our local hospital also had to close its psych wing because they were spending thousands recruiting the mandatory psychiatrist to manage the department and once their minimum required stay was over, they would open private practice and leave the department without the Med control required by the state to operate. Now our psych pts take a ride to Bremerton with no other option than a single room in the ER for mental health crises. 


> The other healthcare professionals also acknowledged what their chosen profession consisted of and the education it required. They obtained their education and continued on with their career in their chosen place of residence. Many prefer to take their advanced education, knowledge and skills back to their home towns to provide the highest possible quality medical care for their facility/agency.



And how long were they able to operate before giving up and closing their offices? I see it around here and in the community I lived in before this one. The cost of operating a clinic has become more than just the cost of the doc's and equipment. We had a bunch of doc's here who were on the verge of going out of business when a big HMO out of Seattle came and bought them out and ran a clinic.. they ran it for about 4 years and then closed the doors, leaving the docs scrambling to come up with a way to serve their patients. Currently they are working with the local hospital to provide the billing on a stop gap/ measure and the docs are bailing as soon as they find work elsewhere. 



> A small town hospital can still excel in patient care even if it doesn't have the latest technology or world renowned surgeons. I also know many of the surgeons from these smaller hospitals come to the big city facilities to practice new skills/techniques to take back home. It just depends on how hard you want to work for your career or to be a quality healthcare provider



But its a whole lot easier to take that time off when you are earning a doc's salary than if you are a volunteer or a basic making $12 an hour with a family to support. 


This is how I look at it Vent.. I see rural EMS as a bleeding pt. Yes the patient needs a trauma center. I would love to have one of those in my back yard as well. To follow your logic, I shouldn't teach first aid and have people learn how to stop bleeding, because the pt needs a trauma center. I shouldn't have EMT's to extricate the pt and meet with ALS because the pt needs a trauma center. I shouldn't have an ambulance here to transport the pt to my local hospital.. because its not a trauma center. 

Yes I wish every patient in my district could have ALS. I wish my district could provide the training to local young people so that they could provide that ALS to their own neighborhood and support a family with those wages. I wish that the local surrounding agencies who have ALS could afford to send me an ambulance with medics on board every time I call them. But they are also over stressed and understaffed and trying desperately to meet the needs of their underserved citizenry. The nearest adjoining ALS agency is currently serving their area with one of the worst EMT-Per capita ratings in the country and I'm supposed to ask them to give me a medic? They don't have enough medics to serve either the geographic area or the population base that they are legally bound to serve. 

But to go back to that bleeding patient analogy, I'm just trying to stop the bleeding, because if I don't, that patient is not going to make it to the trauma center. I'm trying to keep some semblance of care in my district. 

Now pardon me if I take some pride in what I do. I know I'm not a medic/rn/doc. I know I'm just a simple volunteer with a minimal amount of training. But if my neighbor is in trouble and I can put that minimal amount of training to work to help them get to the professionals that can fix what ails 'em, I'm going to do it and being me, I'm going to do it with as much time, effort, practice and study as I can afford to give it. 

By your theory, teaching layperson CPR should be avoided because there should be a medic within that first 3 minutes of arrest with a Defib unit. 

Now I don't know where you got the idea that I don't like ALS or dislike medics because I have the highest respect for both. There is nothing I like better than to see a medic with his/her 12 lead and drug box enter my ambulance when I have a critical pt in the back. I would cheerfully retire from EMS forever on the day that the public health community pulls its head out of its nether regions and gives my neighbors the same level of care that the urban areas receive. 

In the meantime, whether it irritates you or not.. I will continue to try to stop the bleeding.


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## JJR512 (Feb 3, 2009)

jrm818 said:


> I think this little fight is the best argument against nationalized EMS.  People in one area decide that they know the best way to run things in areas they have no connection to besides hearing about them once or twice, and start issuing proclamations about how things should be done, based on thier own experience in a different area.  This country is so freaking big that the regional variations are beyond anything that can be well handled by a nationalized system.  Base level educational requirements perhaps...but certinaly not a central administration.


I feel the exact opposite. I still believe that many of the problems the rural providers are complaining about can be solved with a national system. Unless I'm grossly misunderstanding her, BossyCow is not saying that her area doesn't need ALS or that BLS is just fine. She is not saying that they don't want it. What she is saying is that her area cannot afford it. This is because the way it is now, the funding for it would come from just her area, which apparently is a poor area. A system with a "central administration" would give all the districts access to a central supply of funding and mandate that all areas get at least the minimum standard of care. If it is decided that the minimum standard is access to ALS by 911 in all areas, then that's what they get.

Does the FCC regulate rural radio stations less than they do urban stations? Does the FBI not care about a serial killer if he lives in a remote area (hint: Unabomber)? Does the FAA suddenly stop caring about planes when they fly over remote rural areas? No. And don't tell ask me how will a national EMS system get paid for by the US Federal Government when its budget is so horribly broken, because it pays for all those services and hundreds more. They just created a whole new top-level department (Homeland Security), they can find a way to fit an EMS into the budget somewhere.

In this sense, although many people are scared of this word, EMS would become _socialized_.



lightsandsirens5 said:


> Hey Sasha, are you fightin' for us now?
> 
> Gag! I didn't realize the 12 costed that much!!


The owner of a private ambulance company I used to work for told me that the fully-loaded LP12s he ordered were $18,000 each. Not sure if they were new or used, though.



VentMedic said:


> There are over 50 different EMS certifications/licenses in the U.S. with each state being "creative" for whatever purpose to do a piece mill patch work that has severely fragmented EMS. To further complicate matters, some states change titles and "skills" every couple of years so it is difficult to even know who is doing what or who is called what. This leads to confusion not only amongst the EMS providers but the public as well as the politicians who want to help but can't figure out all the different levels.


And this is a prime example of why I have brought up the need for national standardization in the first place. Thank you!



Veneficus said:


> This thread, which I have been following, but largely holding my tongue, is preposterous. Legally and practically nationalizing EMS is impossible. Could you imagine the US fire Service as a federal agency? It works here in Europe because states are divisions of a country, whereas in the US, the country is actually a federation of largely independent states.


There are many federal agencies that operate across the country, in each of the independent states. In any event, please note that in my original question, I made it clear that it was not just about creating a _federal_ (i.e., governmental) agency, but alternatively some type of non-government national agency. As I have said more than once, I am not saying that this absolutely has to be part of the government.

Looking at the concept of a national agency, federal or not, it doesn't actually need to _run_ the individual departments. Individual departments can still be run by themselves, the county, or the state, as however they are now. The national agency _could_ be formed solely as a regulatory and oversight agency. In a sense, this would make it somewhat similar to the FCC. The EMS agency would create regulations, education standards, ambulance standards, equipment standards, etc. 



Ridryder911 said:


> Wow! I did not realize we had so many experts in EMS development! (satire) Amazing, so many immediate Systems Developers that do not know squat about establishing EMS Systems and what is required or payment structures. Then yet want to proclaim *National EMS Standard (patient protocols)* when they have *NO* correlation at all. National Standards of Treatment and Protocols would be disastrous! Until we have a standardization of education, thinking of such is asinine! Making statements such Medical Doctors or comparison of such demonstrates poor knowledge of EMS Systems. Especially considering the history of how EMS was developed, and the role of the providers as physician representatives.


I cannot quite tell if it is _me_ specifically that you are referring to mainly in what you said. I absolutely agree that creating a set of national protocols would be a disaster for exactly the same reason that you do, which is that people all over are taught different things. This problem is the core of what I'm talking about. Standardizing EMS education _must_ be the first priority.

I remember you have said in the past that you favor a less rigid set of protocols, you do not like the "cookie-cutter" approach that says "when you see sign x and symptom y perform skill z". In fact, I was actually thinking of you when I wrote my previous post about grossly reducing the protocol set. With the caveat that the education is standardized first, so that everybody at the same level is on the same page, do you agree with the concept of the protocols largely being replaced with "assess the patient, use your clinical judgement, determine what needs to be done and do it as you've been trained to do it" approach?


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## VentMedic (Feb 3, 2009)

BossyCow said:


> Actually they do Vent.. which is why rural areas are losing doctors and closing clinics. OB/Gyn departments are closing and scaling back with any high risk pregnancy being turfed to a more urban area. A friend of mine spent the last month of her pregnancy living out of a suitcase in Seattle (3+ hours away) because she was not able to get the level care she needed at our local hospital.
> 
> Our local hospital also had to close its psych wing because they were spending thousands recruiting the mandatory psychiatrist to manage the department and once their minimum required stay was over, they would open private practice and leave the department without the Med control required by the state to operate. Now our psych pts take a ride to Bremerton with no other option than a single room in the ER for mental health crises.


 
What you are describing here is happening everywhere and not just in the rural services. Centralization of specialty services are in the big cities also. There is no need to have 10 high risk pregnancies units in 10 hospitals within 2 miles of each other. The same for a level 3 or 4 NICU. 

Many of these doctors would prefer to practice in the rural regions but some specialized service requirements are just not appropriate. 

High risk pregnancies need to be in a facility that can handle both the mother and the baby. They should not have to rely on a real fast ambulance trip cross country when something happens or the baby rely on a Level 3 or 4 neo team to fly in quick enough to save the child's life.

The same for psych services that are consolidating in to centralized locations. So far the only ones complaining are those that work on ambulances who hate "routine" psych transports. But, the overall cost savings are huge.

So this is nothing new as hospitals have been centralizing their resources for years.  

As far as the trauma center, you don't need one in youe backyard if you have a reliable system in place for your region to get people the appropriate level of care. But, that also should include highly trained and educated people to recognize when a higher level of care is needed immediately rather than a First Responder calling an EMT who then calls for an ALS truck who then call for whatever.


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## medic417 (Feb 3, 2009)

ffemt8978 said:


> So what makes you think they're going to contribute an extra $5/month if they won't approve a tax levy?



Tax is a cuss word.  You tell me your going to tax me and I rebel.  Funny though many people would actually pay less with the tax levy than they would a $5 month contribution.  We have actually had less than 5% not pay on a regular basis.  People look at it that they have an option.  Taxes are looked at as forced.  Plus once I approve a little tax whats to say that tax will not increase.  I have seen the extra amount in amounts from $3 to $10 a month in many communitys that are as impoverished as any areas in the USA.  You still bill for each call.  In my area standard is $100 plus mileage for us to show up.  Then you also bill for transport with rates for BLS or ALS plus mileage.


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## BossyCow (Feb 3, 2009)

VentMedic said:


> The same for psych services that are consolidating in to centralized locations. So far the only ones complaining are those that work on ambulances who hate "routine" psych transports. But, the overall cost savings are huge.



No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr. 


You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment. 

If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll. 




> Unless I'm grossly misunderstanding her, BossyCow is not saying that her area doesn't need ALS or that BLS is just fine.



This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally. 

I think Vent I'd have less of a reaction to your posts if you could just try to keep the condescension out of them. Not all of us without ALS or without medical degrees are uneducated, illliterate hicks in this for the adrenalin rush and the misplaced desire to be a hero. Some of us are dedicated community members trying as best we can to do what is possible, within a broken system to provide for our neighbors. Your repeated declaration of "Get your EMT-P" or get out of EMS is insulting, denigrating and shows a woeful ignorance of life in rural america. Your distant view of how other systems have done fine is merely anecdotal accounts of exceptions to the rules. Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again. 

Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.


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## Ridryder911 (Feb 3, 2009)

BossyCow said:


> No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr.
> 
> 
> You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment.
> ...



I can assure you if your hospital is dropping staff and going to extenders or associates it is on life support and will die. Might as well, write the DNR now. Such organizations as JCAHO, and major insurance providers will start reviewing and start denying payments. You proabably have already started seeing change in the name of supplies as that is also one of the first s/s of troubles. It is probably not that they cannot obtain the personnel but rather lack the funding to afford the "right" people. 

Unfortunately, I have seen this quite a bit and as a consultant have seen the ominous signs of death to the medical community. Too small to be able to afford and economically sustain, yet too far & too dangerous to be without. The later usually wins. Part of the risk of living in such areas. 

I am not criticizing invlovement in any volunteerism, or even BLS level. Rather I am again stating that their role is as first responder and should not confuse or give the impression that the community has a true EMS system. Many will never endorse or support; if they presume what they have is good enough. Alike hospitals and other healthcare facilities, regionalization has to occur to be able to sustain most communities EMS. This is where most Fire Services feathers begin to ruffle as well. Proctective feelings that they only want to provide for their "territory" or they have to "have our own" usually come into play. Although, there are Fire Districts, many of the cities and communities have their own and rather for it to stay that way. 

Well, not everyone gets what they want. 

The call volume(s) will increase. Even in the rural area, as the age of the baby boomer increases, as even small rural hospitals ED's have no more room. Change is imminent and that is one thing that is for certain, good or bad. 

R/r 911


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## VentMedic (Feb 3, 2009)

BossyCow said:


> No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr.


 
They would complain alot more with a dead or severely handicapped baby to care for.



BossyCow said:


> You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment.
> 
> If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll.
> 
> ...


 
No I did NOT contradict myself. Patients are taken to a hospital that better equiped to handle a high risk pregnancy and a neonate. It is a little more involved than just have a doctor who knows alittle bit about it but doesn't have the equipment or staff. It costs a small fortune to have a high risk unit/specialized surgical services as well as a NICU unit for maybe 3 - 8 babies per year that meet the criteria. And who would want to be in a hospital that has only LVNs caring for them with a high risk pregnancy or neonate? Please email me the names of these hospitals that are replacing RNs with CNAs and LVNs so I can put them on the AVOID LIKE THE PLAGUE list on the travelers or employment sites. There are still national mandates for staffing they must meet. Seriously, hospitals that cut care for their patients are just dangerous and should have their patients transferred to a better facility. 

Do you honestly think your hospital is going to build a level 3 NICU, specialized surgical suites and high risk unit if they don't want to hire RNs?

I am definitely not ignorant to rural life and have found the best way to conquer that stigma is to become better educated instead of using your "rural life as an excuse.

Again, I was the one who corrected someone for using the term uneducated as you continue to use when discussing rural life. I find that very insulting to those of us from the country side of life. Under educated is less insulting. 

PAs do NOT replace doctors. They are Physician extenders like NPs. They work under a physician's license, not independent practice. 

Psych patients: yes, they may have to endure a couple hours of discomfort. But, to be in a facility staffed only with CNAs and LVNs where they may have to be tied down for the duration, is much more cruel than being in a facility where they can have some freedom.

Please think of the patient. They are the ones getting the treatment, not the family members or the EMTs. They should be in a facility that has the best options. Those in the rural regions should at least be qualified enough to recognize this. 

When living in the islands, I always had a credit card handy with at least $10K on it so I or my loved ones could be flown to the most appropriate facility in a medical emergency if it was beyond the capabilities of the 30 bed hospital nearby. The drive to the mainland would be of no inconvenience if it was for more appropriate care like a cardiac cath. There is no need to sacrifice a life with the excuse "we're rural".


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## BossyCow (Feb 3, 2009)

> Ridryder911;121855]I can assure you if your hospital is dropping staff and going to extenders or associates it is on life support and will die. Might as well, write the DNR now. Such organizations as JCAHO, and major insurance providers will start reviewing and start denying payments. You proabably have already started seeing change in the name of supplies as that is also one of the first s/s of troubles. It is probably not that they cannot obtain the personnel but rather lack the funding to afford the "right" people.



Actually the hospital's basic services are still intact and stable. We are just redefining what that is. Good fiscal management has kept the infrastructure growing, the hospital's basic problems are the inability to compete salary wise with larger more urban areas. They have purchased some of the local clinics who have gone under and attempted to shore them up until they get back on their feet, but the economic reality of an area that is mostly uninsured retired people and a high public assistance population makes it a challenge for many of the doctors to stay in business.  But these are outside clinics, not the hospital itself.



> Unfortunately, I have seen this quite a bit and as a consultant have seen the ominous signs of death to the medical community. Too small to be able to afford and economically sustain, yet too far & too dangerous to be without. The later usually wins. Part of the risk of living in such areas.



That is the case here. Many of the higher income residents pay to go to Seattle or Bremerton for their healthcare. The lower income do without.



> I am not criticizing invlovement in any volunteerism, or even BLS level. Rather I am again stating that their role is as first responder and should not confuse or give the impression that the community has a true EMS system. Many will never endorse or support; if they presume what they have is good enough.


You have always been respectful and thoughtful in your understanding of the issues Rid and I respect your experience and your opinions. It's that flip, condescending attitude of "You'd have ALS if you just tried" B.S that really gets my blood boiling. I've spent way too much time and effort to try to change things to hear from someone with no inkling of what our region has been through telling me to 'get creative' and 'write grants'. That's like asking a multi-system trauma pt to 'buck up and quit bleeding'.



> Alike hospitals and other healthcare facilities, regionalization has to occur to be able to sustain most communities EMS. This is where most Fire Services feathers begin to ruffle as well. Proctective feelings that they only want to provide for their "territory" or they have to "have our own" usually come into play. Although, there are Fire Districts, many of the cities and communities have their own and rather for it to stay that way.



I think its more fear and panic than ego at work here. To eliminate what little we have and to turn our service over to a system that has repeatedly dropped its level of service in our area has people spooked. When you are the ugly red-headed stepchild of the state, the idea of trusting the state to provide for you doesn't have a good history on which to base that trust. 



> Well, not everyone gets what they want.



Well said!



> The call volume(s) will increase. Even in the rural area, as the age of the baby boomer increases, as even small rural hospitals ED's have no more room. Change is imminent and that is one thing that is for certain, good or bad.


R/r 911

Actually our call volume has decreased. It's gone from around 200 and some per year to just above 150. Some of this is changes in our recording but a lot of it has to do with the young kids moving to areas with more opportunities. I haven't seen the census stats but I won't be surprised to see a decrease. 

The larger more urban area where our hospital is located and where my husband works as a medic has seen a huge increase. They are currently running about 15-20 calls a shift with two medics and doing that on 24 hour shifts. With sick leave, vacation coverages and turnover in personnel, he's worked in the past week: 24hrs on friday, a 12 hr shift on Saturday, 24hrs on Sunday, and another 12 on Monday, he's got today, tomorrow and thursday to recuperate then he's back at it again. The 12's were overtime shifts to cover for guys on leave. Their floater position is currently on shift after the resignation of one of the medics and they are about to lose one more medic to another system that pays better. 

They at least have the option of billing for service which my system does not. And they are the agency that is supposed to fill in with ALS for me if the private ambulance company is unavailable due to an out of town transport. So this is my 'go to' system that's going to give me ALS???? I don't think so! Besides as a civil system, they cannot provide aid outside of their tax district without sending my agency a bill. I get the bill, but cannot bill my pt for the cost. This is how we went through a $1,000,000.00 reserve fund in the past 3 years.


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## Veneficus (Feb 3, 2009)

*Pandora's box*



BossyCow said:


> No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr. .



First let me say the ED is no place for a psych patient. But because of the hazard of an actual medical problem causing the altered mental status and the fact that psych facilities are not set up and cannot afford to do medical screenings, the ED is where the acute psych ends up.  This causes more problems. First it costs a fortune to run all the tests to rule out life threatening conditions, none of which can be ruled out by interview because of the alteration. Secondly, because nobody pays for psych care, (at least not anywhere near enough) the patient gets stuck in the ED until a facility decides it makes enough from the paying customers to offer a charity bed. If it is a state facility, it needs to wait for a bed to open. 

For the safety of all involved as well as the fact there is not enough resources in the ED to babysit psych pts and still perform the EDs primary function, patients must be restrained, both physically and chemically. Families need to get used to that idea. I have personally seen upwards of 11 psych patients lined up on walls in the ED and wait 48-72 hours for an available bed in a psych facility in urban areas. Meanwhile some JCAHO idiot is saying that is unacceptable and the hospital shouldn’t be paid. The only other option is to turf the people to the street, which is totally unrealistic. 





BossyCow said:


> If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll. .



 I am the standard bearer for socialized medicine. I even figured out a way to pay for it, but those living in rural areas will not see any appreciable difference from it. Socialized medicine will still be based on need. In small communities it is not reasonable to have every service available, so you will still be looking at long distances for service.



BossyCow said:


> This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally. .



You guys in rural America are stubborn; otherwise you would come to the city. There is safety in numbers. Many wanted isolation; they have received what they wished for. I am a charitable person, but I can think of no reason why urban Americans should pay for rural Americans who cannot support themselves and refuse to be relocated. My parents left Europe, giving up homes and land because there were no jobs at the time. Where they were going had a better future than what they left.  More people need to catch on to that. Think Global, not small town.

QUOTE=BossyCow;121833] Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again.[/QUOTE]

As for not having a doctor, I am lucky, my education will ultimately cost me $200,000 plus interest for the loans. I simply cannot work for less than I owe. If a community cannot afford a paramedic, they certainly cannot afford a doctor. Rural healthcare is lucky to have what it does. I am sorry to say it is about as much as can be realistically hoped for. Even if you have a PCP, the average PCP in the US has 2300 active patients and spends 8 minutes of face time each. They will probably not know anything about your family or remember anything about you until they pick up your chart next time you are in. They also spend between 1 and 2 hours of currently uncompensated paperwork time on a given day to get paid the meager amount medicare/medicade will give them. Some PCPs lose up to $40 per vaccination they give.



BossyCow said:


> Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.



Forgive my rudeness, but what you provide is basically a knowledgeable neighbor and a ride. It is a honorable service to your community as well as your fellow man. I would be very proud to do that myself and I agree that those in such a situation should be able to do more. Furthermore, lack of knowledge and ability may cause harm to the neighbor you are trying to help. I think you are doing your best in a situation in which there are no easy answers.


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## BossyCow (Feb 3, 2009)

Veneficus said:


> First let me say the ED is no place for a psych patient.



We have groups here working to set up some sort of acute medical health clinic that would at least be prepared for the special needs of the psych pt.





> I am the standard bearer for socialized medicine. I even figured out a way to pay for it, but those living in rural areas will not see any appreciable difference from it. Socialized medicine will still be based on need. In small communities it is not reasonable to have every service available, so you will still be looking at long distances for service.



As am I. I am not looking for a Mayo Clinic in my rural neighborhood. I just want people to quit yelling at me about how I should be doing more. 



> You guys in rural America are stubborn; otherwise you would come to the city.



Hell yeah! We do not as a rule complain about the lack of service, we know its the price we pay for the beautiful place where we live. I was making a point to those who state that ALS should be everywhere and I'm at fault for it not being here. I would love to have it, but its not a reality in my forseeable future.



> Rural healthcare is lucky to have what it does. I am sorry to say it is about as much as can be realistically hoped for.


 So you are saying that we cannot hope to have ALS? Hmmm radical notion.. but when I say it I'm accused of everything from ignorance to egomania to the overthrow of the future of EMS as a whole.



> Forgive my rudeness, but what you provide is basically a knowledgeable neighbor and a ride. It is a honorable service to your community as well as your fellow man. I would be very proud to do that myself and I agree that those in such a situation should be able to do more. Furthermore, lack _of knowledge and ability may cause harm to the neighbor you are trying to help. _I think you are doing your best in a situation in which there are no easy answers.




Harm? How can driving them to the hospital in a clean ambulance instead of the back of a pickup be more harmful? How can giving them the glorified first aid of BLS be worse than them dying on the floor of their home because they fell and fx a hip? You state above that my area is not going to get ALS and can't expect good healthcare, then you add at the bottom that by helping my neighbors get to the ALS agency and the ER is going to cause them harm... I give up.


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## Veneficus (Feb 3, 2009)

BossyCow said:


> You state above that my area is not going to get ALS and can't expect good healthcare, then you add at the bottom that by helping my neighbors get to the ALS agency and the ER is going to cause them harm... I give up.



Sorry, I was trying to state that providing certain treatments without advanced knowledge can be more dangerous than just doing what you are now. I could have said it a little better.


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## Ridryder911 (Feb 3, 2009)

I would like to hear from our team "down under" from what I understand, Australia offers ALS in even in the most remote and rural areas. 

R/r 911


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## Veneficus (Feb 3, 2009)

I understand that to be a state controlled agency that rotates duty stations. That would be great in the US. But so would the education they must have. I just don't see anywhere in the US opening their wallet to pay for it at the moment.


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