# Columbus, Ohio debates ALS



## amberdt03 (Mar 25, 2009)

ok, so i'm pretty sure that they are wanting to get rid of ALS care all together, which is very stupid i think. unless i'm misunderstanding the article. 




http://www.jems.com/news_and_articles/news/09/ohio_debates_als.html


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## Epi-do (Mar 25, 2009)

What is that they say about the fire department?  Oh yeah, years of tradition, unimpeded by progress.  Leave it to a fire department to recommend taking EMS backwards instead of forward....


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## Sparky79 (Mar 25, 2009)

Epi-do said:


> What is that they say about the fire department?  Oh yeah, years of tradition, unimpeded by progress.  Leave it to a fire department to recommend taking EMS backwards instead of forward....



Actually, the fire department is trying to keep the medics. The people who are recommending the downgrade in service are a committee appointed by the mayor and city council to try and cut costs.


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## Veneficus (Mar 25, 2009)

Epi-do said:


> What is that they say about the fire department?  Oh yeah, years of tradition, unimpeded by progress.  Leave it to a fire department to recommend taking EMS backwards instead of forward....



I am curious as to what makes it a step back to take EMS away from a service that doesn't want it, and reduce the amount of medics not getting enough patient contact to maintain skills?

We are not talking about the boonies, you could probably take somebody to the hospital in columbus almost as fast as you could start an IV. 

additionally, many of us for years have said that EMS providers (fire or otherwise) must expand their role to public health or their services will not be economically sound. Some places like Wake Co. are embracing this, I expect to see this type of article many more times in the future.

Cost to benefit ratio is a reality of medicine. The days of sparing no expense are over.


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## triemal04 (Mar 25, 2009)

For :censored::censored::censored::censored:'s sake people...did any of you actually read the article?


> *A committee *charged with finding ways for Columbus to save money has recommended that the city return to a basic emergency medical system.





> The economic advisory committee, appointed by Mayor Michael B. Coleman and City Council President Michael C. Mentel, suggested comparing costs and benefits of the current system with basic life support





> Robert F. Howarth, *a lawyer *who led the committee.





> "A paramedic is vital in saving lives; there is a huge difference," said Battalion Chief Doug Smith, spokesman for the Columbus Division of Fire. "I think (Howarth) is wrong."





> Dr. David Keseg, the Fire Division's medical director, said the study did not take into account the benefits of drugs that paramedics administer. "This paper in and of itself is not a good defense of trying to promote" an all-basic emergency medical system, he said.


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## Epi-do (Mar 25, 2009)

Sparky79 said:


> Actually, the fire department is trying to keep the medics. The people who are recommending the downgrade in service are a committee appointed by the mayor and city council to try and cut costs.



My mistake.  I had a 5 year old whining at me because I wouldn't let him have his way while I was reading, and thought the committee came from the FD, not the mayor.



Veneficus said:


> I am curious as to what makes it a step back to take EMS away from a service that doesn't want it, and reduce the amount of medics not getting enough patient contact to maintain skills?



I could have misunderstood (Which is possible.  See above reference to 5yo.), but I was under the impression that the FD is providing EMS for the city, and not a seperate ambulance service, whether it be third service, hospital based, contract with a private, or what have you.  If EMS is solely falling upon the FD, removing ALS care from the FD effectively removes it from the patients that the FD is serving.  

I would love to see EMS completely seperated from the FD.  However, if the FD is the only way EMS is provided to a particular community, I would rather see them provide ALS care than for the community to have no ALS available at all.  That is what I was referring to when I made my comment about it being a step backwards.


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## Veneficus (Mar 25, 2009)

triemal04 said:


> For :censored::censored::censored::censored:'s sake people...did any of you actually read the article?



yes i did read the article, yes i do understand the fire department is trying to keep it. I am familiar with columbus and I am certain the only reason fire wants it is for revenue generation to buy big shiney trucks and fund positions, not to advance EMS practice. 

The drugs paramedics use to save lives? You can have basics give nitro, ASA, and epi pen. Doesn't really leave much life saving drugs.

Yes, lawyers, mayors, and even the public are going to be taking a closer look to where money is spent and what they are getting for it. It is long overdue. 

Apparently the "paramedic is a huge difference" statement didn't read the studies about ALS and BLS coming out of Ottawa.

What did you expect these people to say? "The lawyer is right! we've been wasting money all this time, sorry we messed up."


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## triemal04 (Mar 25, 2009)

Veneficus said:


> yes i did read the article, yes i do understand the fire department is trying to keep it. I am familiar with columbus and I am certain the only reason fire wants it is for revenue generation to buy big shiney trucks and fund positions, not to advance EMS practice.
> 
> The drugs paramedics use to save lives? You can have basics give nitro, ASA, and epi pen. Doesn't really leave much life saving drugs.
> 
> ...


Sorry, it was just the appearance of an automatic knee-jerk reaction from one person to immedietly blame the fire department when, turns out, they were wrong.  Bothers me sometimes.

Are you talking about the OPALS study?  Wasn't that flawed in some way?  Or only focused on a couple of conditions?  I honestly can't remember.

This case is a bit different it sounds like from others in that it's not giving control of the ambulance to someone who can do it cheaper (I'm guessing Columbus transports) but removing their ability to provide proper care.  If CFD is going to continue to transport, it'd be better to have them remain at the ALS level than revery to an expensive taxi.

Far as the drugs...you know better than that.  There's also the things that a paramedic will recognize that a basic won't, along with conditions that are treateable in the field, or reversable in the field (hypoglycemia, narcotic OD among others).


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## Veneficus (Mar 25, 2009)

triemal04 said:


> Sorry, it was just the appearance of an automatic knee-jerk reaction from one person to immedietly blame the fire department when, turns out, they were wrong.  Bothers me sometimes.



If FDs don't start stepping up to the plate and spending more effort with medicine and less with suppression this is going to continue to increase across the nation. If an FD wants to embrace a new role which EMS must become to remain economically viable, then I am all for it. But you as well as I know that The fire Service is reluctant in a majority of cases. Otherwise The model of King County wold be everywhere from FDNY to Columbus.



triemal04 said:


> Are you talking about the OPALS study?  Wasn't that flawed in some way?  Or only focused on a couple of conditions?  I honestly can't remember..



The major "flaw" is the level of education between canadian "basics" and american "basics." But having said that, there was a washing DC study showing the only statistical difference in bls vs als outcome was length of hospital stay. (which was shorter for ALS) However, the cost of the difference was not compared. So it is possible that money could be saved with an increased hospital stay over the daily operations of such a large ALS department. But at this point we do not know.



triemal04 said:


> This case is a bit different it sounds like from others in that it's not giving control of the ambulance to someone who can do it cheaper (I'm guessing Columbus transports) but removing their ability to provide proper care.  If CFD is going to continue to transport, it'd be better to have them remain at the ALS level than revery to an expensive taxi.



Undoubtably a private ALS service could come in and save the city money. A hospitl based service properly set up might also. (big IF on that though) But unless a realistic way to pay for ALS service is found, the current economic trend does not support business as usual. 



triemal04 said:


> Far as the drugs...you know better than that.  There's also the things that a paramedic will recognize that a basic won't, along with conditions that are treateable in the field, or reversable in the field (hypoglycemia, narcotic OD among others).



But Columbus acts like a glorified taxi service now with ALS. You are absolutely right, a medic can and should have better assessment skills, but they are not being used at this time. it is "you call we haul" Though last I heard they had a refusal of care in place, it was only after a response. So you are paying a lot of medics to drive around and hand out taxi vouchers. If you are dispatching a squad and an engine, you would probably save money driving the patient to the hospital just dispatching a squad. Especially with the fuel and maintenence of an engine.

As for reversable in the field, like I said, you could easily be well on the way to a hospital with a load and go mentality. If the transport times were longer I would agree, in this specific case, the response is the issue, not the transport. You could take a tanker full of narcan to an OD, but if they weren't breathing and it took you 6-12 minutes to get there, who cares? There are many places that could benefit from ALS care, but it is likely, that Columbus isn't one of those places. 

They could have made a much stronger case for the ALS FD, but they reverted to dogma. "We save countless lives." If that were true they could have dropped some concrete data to trump the report and the headline would have read something like "penny pinchng lawyer makes citizens less safe."

You have to admit, the statements by FD oficials were pretty weak.


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## triemal04 (Mar 25, 2009)

Veneficus said:


> If FDs don't start stepping up to the plate and spending more effort with medicine and less with suppression this is going to continue to increase across the nation. If an FD wants to embrace a new role which EMS must become to remain economically viable, then I am all for it. But you as well as I know that The fire Service is reluctant in a majority of cases. Otherwise The model of King County wold be everywhere from FDNY to Columbus.
> I don't disagree at all.  It was just the automatic reaction to blame the FD for decreasing the service level when that wasn't the case.
> 
> The major "flaw" is the level of education between canadian "basics" and american "basics." But having said that, there was a washing DC study showing the only statistical difference in bls vs als outcome was length of hospital stay. (which was shorter for ALS) However, the cost of the difference was not compared. So it is possible that money could be saved with an increased hospital stay over the daily operations of such a large ALS department. But at this point we do not know.
> ...


I'm all for saving money given the current economic situation (and to allow EMS to continue and to allow funds to be spent on improvements and further care), but cutting the level of service provided...can't get behind that.


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## Veneficus (Mar 25, 2009)

triemal04 said:


> I'm all for saving money given the current economic situation (and to allow EMS to continue and to allow funds to be spent on improvements and further care), but cutting the level of service provided...can't get behind that.



I don't know how to edit the quote, but I think we do have a lot of common ground on this.

I would say it does cost less to run 1 ambulance than keep 1 person overnight in a hospital. But if you are running 30 ALS units and keeping a low number of (say 5) "sick" patients a few extra days a month, the dollar amount might be closer.

As for a study in a better place than DC, I really agree with that, but there may be some reluctance on FDs to do that because what if it doesn't come out their way? I think the study would be best done by a public health agency which has medical knowledge and objective interest.

The FD was more than capable of making the response more efficent, clearly it has chosen not to do that. If I were the Chief, I would have done it and said "See I saved money and cared for the public by maintaining the same level of care." Could really have helped him out politically. 

I would rather have a medic respond to all calls. But my opinion certainly isn't objective. What if it didn't change outcome by having only BLS in that specific area? (I do not think it would work nationwide) Certainly not in areas with low amounts of hospital beds or long transport times.

What about a small number of medics and an increase in the use of EMT-Is? Cheaper than a medic to stick on every piece of apparatus, many "life saving" treatments could be started with a medic on the way to serious calls. (or available if it turned out to be) Would also improve the skill of the providers.

CFD is my back yard. They are "old school" fire. If they don't accept change, somebody like a lawyer or banker will force it on them. I am sure we agree that is not a good idea.

Look at the news ot of Philly this week. They changed shifts for medics, saved an estimated $800k/year and everyone got to keep their job and no companies merged or closed. The union has filed a grievance after providers went nuts. Maybe CFD needs to take a leaf out of that book?


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## reaper (Mar 25, 2009)

So, Because of economic set backs, it is ok to undo all the changes that have been fought for in the last twenty years?

Yeah, see this one coming out in a good way!


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## triemal04 (Mar 25, 2009)

Veneficus said:


> I don't know how to edit the quote, but I think we do have a lot of common ground on this.
> 
> I would say it does cost less to run 1 ambulance than keep 1 person overnight in a hospital. But if you are running 30 ALS units and keeping a low number of (say 5) "sick" patients a few extra days a month, the dollar amount might be closer.
> I don't know.  Even if you averaged out the costs nationwide (heh, good luck with that) it's still got to be cheaper to have an ALS ambulance used rather than use a hospital for an equal amount of time.  Even adding in the BS calls and extra costs associated with pre-hospital care, I think it'd still save money.  Though, unless it's a hospital based system, that arguement could be hard to make given that it's two different agencies (hospital and ambulance) that are involved.  I suppose the case could be made that it saves the public money and keeps more beds open.  That be interesting...if ALS care shortens a pt's hospital stay, how does that translate into bed availability?
> ...


10 characters


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## AJ Hidell (Mar 26, 2009)

Interestingly, no one else seems to have focused in on the same line that caught my attention.



Robert F. Howarth said:


> "If there's no positive result or effect ... and basic life support is cheaper, then in fact the Fire Division could reallocate those assets and use them elsewhere."


Apparently this lawyer slept through math class.  If we "reallocate those assets" elsewhere, who is going to operate the BLS ambulances?  What assets is this guy going to "reallocate" that will make the slightest difference?  And if that is his plan, why not do the obvious, which is to "reallocate" the entire system out of the fire department, and lay off a lot of suddenly useless firemen?  They could even "reallocate" all those apparatus that are first-responding on all those EMS runs too, further freeing up assets to save more money.  There's just a lot of ways to "reallocate" assets, saving a lot of money, without sacrificing medical sophistication.  In fact, they could save money and still increase medical sophistication if they had a clue.

How willing do you think this lawyer would be to entertain the NAEMT's recommendations for "reallocating" the lawyers of America to cut legal costs in the country?


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## Veneficus (Mar 26, 2009)

reaper said:


> So, Because of economic set backs, it is ok to undo all the changes that have been fought for in the last twenty years?
> 
> Yeah, see this one coming out in a good way!



Do you think that the idea to flood cities with paramedics as an advancement?

How about sending engine and ladder trucks with medics to calls?

Medic mills exist for strategies like this.


I think this might be a good opportunity for the people involved with prehospital care to start effecting some long overdue changes.


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## reaper (Mar 26, 2009)

Veneficus said:


> Do you think that the idea to flood cities with paramedics as an advancement?
> 
> How about sending engine and ladder trucks with medics to calls?
> 
> ...




No, I don't agree with any of it.

The committee is talking about doing away with all ALS providers. So, I would take a city flooded with medics, over a city with none!

We have fought over the years to get advanced providers in all areas. Setting a system back 30 years, is not going to solve anything. No, they do not need 5 medics on scene. But, they also do not need 5 basics on scene either. If they are trying to cut costs, then go with a basic/medic truck. I would take that over nothing!


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## Veneficus (Mar 26, 2009)

reaper said:


> No, I don't agree with any of it.
> 
> The committee is talking about doing away with all ALS providers. So, I would take a city flooded with medics, over a city with none!
> 
> We have fought over the years to get advanced providers in all areas. Setting a system back 30 years, is not going to solve anything. No, they do not need 5 medics on scene. But, they also do not need 5 basics on scene either. If they are trying to cut costs, then go with a basic/medic truck. I would take that over nothing!



Starting over might be the only way to fix the system. If the FD goes back to BLS only, I have no doubt a private may step up and offer to supplement ALS service billing patients. 

I don't want to get into a detailed discussion on the effectiveness or usefulness of the fire service, but I will say thier delivery model and strategies are outdated and extremely wasteful. 

For those same 30 years we have been talking about the problems in EMS, we have not made measurable progress in fixing them. We talk about EMS as a stand alone service, complain endlessly on how fire as a whole does not do EMS well. The truth is the industry may be powerless to effect real change. An authority that has power of the purse may be the only way to make a change. There exists a possibility that since Columbus was one of the first to have fire/ems, that FD EMS might start falling like dominos if it went away. 

I just don't see an ALS vacuum, I see a chance to finally make some forward progress. I keep saying how the role of EMS must change, how we cannot offer false measurements like response time or "saving lives." Our value to society has come into question. It can be defended with education, fiscal responsibility, and value to our patients. If not, we find our services no longer required, just like every other industry.


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## Shishkabob (Mar 26, 2009)

Fort Worth has a BLS with some ALS fire, while all ambulances are from a private company that runs B/M on trucks.

City gets extremely subsidized ALS rigs, and has atleast 2 medics on a shift at any one time in each house.

I fail to see how that's a bad thing.


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## AJ Hidell (Mar 27, 2009)

Veneficus said:


> There exists a possibility that since Columbus was one of the first to have fire/ems, that FD EMS might start falling like dominos if it went away.


Wow!  That is the most intelligent and visionary post made here in my time here!  :beerchug:



Linuss said:


> Fort Worth has a BLS with some ALS fire, while all ambulances are from a private company that runs *B/M on trucks*.


Black males?  Bowel movements?  :unsure:

Regardless, MedStar is not a private company.  There are more than two medics on a shift at any given time.  And they do not have "houses".


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