# The uncoupling of Fire and EMS



## Veneficus (Apr 30, 2011)

As people rally against tax raises, demand less government affiliation, and are even started to look at government salaries as overly generous, are we witnessing the forces come together that may end the merging of EMS and Fire?

I was reading this article:

http://www.emsworld.com/article/article.jsp?id=16918&siteSection=1

recalling this one:

http://www.ems1.com/jobs/articles/475988-ohio-committee-wants-paramedic-roles-reduced/

and one of my friends brought this to my attention:

http://www.fox8.com/news/wjw-layoffs-txt,0,1562158.story

Not to mention:

http://nationallawforum.com/2011/04...e-bargaining-rights-of-ohio-public-employees/


It seems logical to me that if cities are suggesting finding private EMS providers instead of municiple ones to reduce costs that the fire based EMS is not the economic panecea its proponents have always claimed it was.

It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?

Now most of us think what we do is valuable, even important, but it seems the general public no longer does.

So here are the questions:

What are the next likely steps in the progression? 

What is a tangible and economically demonstratable way to convince people to pay enough tax to support these programs since the chest pounding of being heroes seems to be losing its audiance?

Would new leadership from outside the established ranks be able to help?


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## mycrofft (Apr 30, 2011)

*Fire Departments will fight it*

EMS is what keeps enough people on thier rolls to fight fires and still treat employees as something other than mules, if they want.

The American public will in large part believe anyone who will guarantee them that if elected, "water will run downhill but never reach the bottom", and they will get rid of those who can't deliver that...then they will run up deficits since they won't raise funding sources (taxes, either raising them or collecting from heavy hitting contributors like oil companies).
Fire depts can fiond a way to still be part of EMS, even if it is just a refiguring of the organizational charts.


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## Veneficus (Apr 30, 2011)

mycrofft said:


> EMS is what keeps enough people on thier rolls to fight fires and still treat employees as something other than mules, if they want.
> 
> The American public will in large part believe anyone who will guarantee them that if elected, "water will run downhill but never reach the bottom", and they will get rid of those who can't deliver that...then they will run up deficits since they won't raise funding sources (taxes, either raising them or collecting from heavy hitting contributors like oil companies).
> Fire depts can fiond a way to still be part of EMS, even if it is just a refiguring of the organizational charts.



I have no doubt FDs will fight it, my question is can they succeed?

Certainly not using the arguments they have been up to this point I think.


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## Veneficus (Apr 30, 2011)

Maybe I should be more clear on what I am asking...

If you were the head of a mniciple agency that handles EMS, what is the plan in today's economic and political realities of not seeing your department outsourced or downsized to a skeleton crew?


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## abckidsmom (Apr 30, 2011)

Veneficus said:


> It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?
> 
> Now most of us think what we do is valuable, even important, but it seems the general public no longer does.



I see this a lot when dealing with child safety seat issues.  I think we have delivered safety to people for so long, and are capable of delivering more and more safety, but people are reaching the limit of discomfort they are willing to put up with to achieve baby steps forward in safety.

So what if a defibrillator arrives at 5 minutes instead of 8?  Only the AHA and EMS system admin can appreciate the difference.  

The general public really don't care...only people who have the education to see the difference.

I see this most often in counseling parents to rear face their toddlers in a car seat, or to leave their elementary age kid in a booster.  They just don't see the benefit being worth the inconvenience.  

I think it's the same with tax dollars.



> So here are the questions:
> 
> What are the next likely steps in the progression?
> 
> ...


 
I don't think it's going to work like that.  The chest pounding of being heroes combined with education of the people to be able to appreciate the difference in service levels.  The people have to actually care.

Sadly, our apathetic society is not willing to pay a high price for this.

Maybe we should show them the video of what fire and ems look like in Moscow and see if they'd like to swing more that way?


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## mycrofft (Apr 30, 2011)

*What would I do...*

If I were the sort who could do something, in an urban to close-suburban setting:
1. Make currency as a paramedic mandatory to train and work as a firefighter.
2. If possible, contract transport (including everything from picking them up off the floor to the hospital, except for technical extrication) to a private company.
3. Stop responding a firefighting crew and truck to every EMS call.
4. Contract out medical control, probably some company in Florida or Bermuda.
5. Downgrade response vehicles to something cheap small and economical to run since transport will no longer be done by FD.
6. Two man EMS crews.
7. Cap EMS responders' pay to parallel a fifth year firefighter's to encourage them to cross into firefighting and move newer hires in (lower pay, less accrued benefits).
8. Break the unions.
9. Two-tier response system; lots of Basic units, and a series of single ALS stationed in an area apportioned based upon population.
10. Have contract, either with emergency responder or with another company if cheaper, to take calls deemed non-emergent by responders.
11. Make each employee do _*fire response only *_for first year, then refresh and work EMS if they want, but subject to cross-manning pumpers etc. on demand.
12. Mandatory annual physical fitness test including lift, and a weigh-in.
13. Leave town before I was fragged by firefighters.


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## usalsfyre (Apr 30, 2011)

Mycroft, your still using the fire service

How about legislation to chuck the ISO(as useless an organization as NAEMT) out of the state, make the realization that modern buildings are meant to burn and poorly suited to interior attack and reduce fire service staffing levels to a more realistic point and stop using the fire service (expensive) to plug up gaps in EMS coverage.

If I wasn't worried about reimbursement I'd work with the state to be allowed to run a front-loaded model putting a well trained single Paramedic or Intermediate in a response vehicles (cheap) and triage out those who don't require stretcher transport by ambulance (expensive). The response vehicles can then transport the non-emergent cases to the ED with minor treatment (anti-emetics, certain analgesia, ect). That way you can drastically increase the number of resources on the road while lowering overall cost. Of course, our medicolegal environment and reimbursement structure will never allow this...


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## rescue99 (Apr 30, 2011)

More than a decade ago, EMS folks were waging bets on just how long this whole fire based, advanced life support gig would last before evidence proved what a financial loss it is. Local bets gave it about 7 years. We figured about 7  years and cities everywhere would be seeking respite from the high cost of doubling the size of their fire departments. That's just about how long it's taken too. Communities have been saying, it's too costly, with no greater benefit for the past 3-4 years, and studies seem to support the opinion.


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## CAOX3 (Apr 30, 2011)

People place more importace on their possessions, houses and cars, their willing to pay for that, ie fire and police.  Lets face it the majority of our call volume is repeat customers.

People are not going to pay in the form of taxes in this economy something they might never use. 

EMS has a reckoning coming and it aint going to be pretty.


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## usalsfyre (Apr 30, 2011)

CAOX3 said:


> EMS has a reckoning coming and it aint going to be pretty.


Very true, and what some have been trying to make us see for a while. The scary part is it might be too late.


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## medicsb (Apr 30, 2011)

FD (or PD) first response has been shown to improve outcomes from cardiac arrest.  So, in my opinion both FDs or PDs SHOULD be included in an EMS system as it would be less costly than putting single EMTs in cars to do first response.  But, there is no need what-so-ever for ALS engines/ladders/etc. (no published data to support this costly practice).  Hell, you probably do not need more than one FF cross trained as an EMT, so you could probably just put FFs through a medical first responder course, which would save on initial training and con-ed; also, less training deserves less pay, which means more savings.  Have FF/EMT  be a promotion within FDs.  Only dispatch engines to for potential cardiac arrests (e.g. unconscious or not breathing).  

Also, recruit PD to transport any penetrating trauma in the back of the squad car if an ambulance isn't already on scene (best for urban, high density communities with a trauma center close by, such as Philadelphia, where this is done).   

I don't mind EMS being mixed with an FD so long as the name of the department acknowledges EMS (e.g. [town or city name] emergency services or [town or city] department of fire and EMS) and as long as the EMS side of the department is equally, if not strictly, over seen by physicians so as to ensure as much evidence-based practice as possible, including deployment practices and not just for medical & trauma care (fire chiefs and fire unions should not be dictating EMS response or levels of care). 

Ultimately, I don't see many FDs losing EMS.  Even if some lose transport, I'm sure that they'll continue with ALS engines or try to institute such a program.  And as soon as the economy turns around, they'll do everything they can to get it back.  Non-fire EMTs & paramedics NEED to organize (not necessarily unionize), so that they can advocate for themselves and turn EMS to its own true profession.

Oh, I guess I should include that there is probably very little patient benefit for the present-day paramedic skill set.  So, a tiered response system is, in my opinion, most ideal.  Those with the current paramedic skill set should be targeted to those who are most likely to benefit.  This could save money, depending on how it is implemented.  However, I do believe that the present day "EMT" skill set is too low.  So an AEMT/EMT-I level would probably be a good base level skill set (e.g. supraglottic airways, 12 lead acquisition, ASA, nebulized albuterol, CPAP, blood glucose assessment, SpO2...) for ambulances only to serve as a bridge to paramedic care.


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## Veneficus (Apr 30, 2011)

Rather than rehash who should be doing EMS or why, does anyone have any idea how to sell the public on funding EMS and not simply outsourcing it?


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## mycrofft (May 1, 2011)

*Find a scapegoat for high prices then tax them anyway.*

Bogeymen worked to get more and more money from taxpayers for Dept of Defense, big oil and big medicine subsidies, law enforcement, etc. (And the German National Socialist Party) . Name a culprit, and sic the public on them to assuage feelings of powerlessness; next, regretfully/temporarily/gradually ramp up taxes anyway, then blame your predecessors and successors for it.

"HMO's" proved that Americans will never be prevention oriented, just rescue oriented.

Social welfare programs like child protective services, the foster child system, and legal protection for victims of family abuse under restraining orders. etc., prove the American are like penguins on the ice...it's all fine, ignore the  screams from below and the shark fins circling the iceberg.

So get used to the status quo until it is stripped down out of its BS to the lower level of over-all care offered now but covered up by nearly everyone involved...followed by a vicious backlash and return to business as usual.


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## thegreypilgrim (May 1, 2011)

Veneficus said:


> It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?
> 
> Now most of us think what we do is valuable, even important, but it seems the general public no longer does.
> 
> ...



Here are my thoughts on the matter. Americans are sort of schizophrenic about taxes and social investment programs. We have a deep-seated suspicion and aversion toward taxes, but we demand quality public services. Just look at the current hysteria over Medicare and Rep. Paul Ryan's budget plan. Now (wonderfully ironic) the Republicans are being beat to hell in the town hall meetings because people don't want them messing around with Medicare/Medicaid. And, although Americans don't like taxes, polls show that most Americans want the top-earners to pay more taxes.

So, there's a desire to reduce costs without losing out on the quality of the service. Perhaps the best way to direct public opinion about this is to draw attention to this provision of the Medicare Ambulance Services policy:



> The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.



It should be rather easy to stir up public exasperation with this when it is pointed out that the vast majority of ambulance transports are not necessary. It could then be argued that paramedics could be trained to treat people in their home and reimbursed for their clinical time when ambulance transport and ED work-up are not necessary.

Fire departments would oppose this, but it would put them in (for once in their history) a politically awkward position. Suddenly they would appear to be holding back progress, and with the public's growing awareness of the costs of their pension programs, this would be unwise. If they continue to oppose it, there's a good chance the public would finally tell them, "No". So, here's what would need to happen.

(1) Introduce legislation to restructure CMS policy on ambulance reimbursement to no longer require actual transport, but to encourage treatment in home and payment of paramedics for their clinical time.

(2) Simultaneously create legislation that links (1) to a newly proposed education standards scheme to be commissioned by the appropriate national body (I'm thinking CoAEMSP). Essentially, a legal framework which provides sizable federal grants to educational institutions to create curricula based on the proposed core principles. These training programs must consist of enough college credit hours to confer an Associate's degree (60-80 credits) or higher.

(3) Currently licensed providers can be grandfathered in, but this is unlikely to appease the FDs. Only time would tell exactly how much political capital they're willing to expend on this, but one of three outcomes will follow.

(3a) FDs successfully block the proposed changes. We'd be back to square one with this, but in 10-20 years when the system collapses it will be at the hands of the FDs and the public will have a historical record for this.

(3b) FDs accept changes. Cultural inconsistencies between FD (public safety) and EMS will likely erode FD participation in this (how many FFs can you see doing senior or infant wellness checks, helping substance abuse patients with their med compliance, etc.?). FD will eventually just _de facto_ no longer get involved with EMS as opposed to being removed from it _de jure_.

(3c) FDs fight changes and lose. Now we have to pursue one of two options. Either we privatize EMS or incorporate it into a publicly operated service. Americans tend to deify the private sector, so I would imagine this is what people would want. Efforts could be made to encourage state and local governments to pass legislation requiring EMS organizations operate on a non-profit basis or as a highly regulated utility in order to eliminate the scourge of profit-motivated services and the loss of quality associated with them. More ideally I'd like to see the case made for a tax-subsidized public service. Much like a nationalized single-payer health insurance system this would actually be much more cost-effective (King County, WA is able to fund KC MedicOne entirely with small levies attached to resident's property taxes). This would fund either municipal or statewide third service organizations which I think would be preferable to private NPOs, but politically would require much investment.


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## Shishkabob (May 1, 2011)

medicsb said:


> FD (or PD) first response has been shown to improve outcomes from cardiac arrest.



No, it hasn't.


Quicker access by trained personnel has.


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## usalsfyre (May 1, 2011)

thegreypilgrim, sounds great, and I would agree with it if I could trust more than 20% of paramedics I work with to make an appropriate triage decision. If we're grandfathering people in without additional education I see this plan being a failure, either providers will shun responsibility and continue to transport everything (likely considering that most providers look for every possible reason to pass the buck now) or you will see a lot of patients inappropriately triaged out with the expected results. Most likely I'd say you'd see lots of the former with just enough cases of the later to make spectacular headlines...


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## Veneficus (May 1, 2011)

thegreypilgrim said:


> Here are my thoughts on the matter (cut for brevity)



It sounds good until the property tax part.

As we see currently, property tax is a fickle friend. Because of major devaluations in property, municipalities and the services depending on it are getting decimated now.

I think it would be better to eliminate property tax entirely and go with an excise type of tax. That way more than just property owners will be paying for services. Everyone who spends money would.

However, the thing that really complicates that is people on fixed income like seniors. Since the amount they would spend in excise would create a sharp rise in their cost of living. Unlike property tax reductions for seniors, it is harder to create programs to shield people from excise.

In order to help this I decided to go with excise instead of VAT. That way you could at least exclude rises in utilities like electric, gas, and sewage. But I don't think food items would be easy to shield from it either, So there would be an associated increase in cost of that.

It would also help reduce costs to seniors who own their own homes, as well as eliminate one reason for raising rent on those that don't. (I am not fool enough to think rent would go down just because property tax is eliminated)


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## thegreypilgrim (May 1, 2011)

usalsfyre said:


> thegreypilgrim, sounds great, and I would agree with it if I could trust more than 20% of paramedics I work with to make an appropriate triage decision. If we're grandfathering people in without additional education I see this plan being a failure, either providers will shun responsibility and continue to transport everything (likely considering that most providers look for every possible reason to pass the buck now) or you will see a lot of patients inappropriately triaged out with the expected results. Most likely I'd say you'd see lots of the former with just enough cases of the later to make spectacular headlines...



This, admittedly, is a glaring problem. Unfortunately I don't see a real way around it. I suppose we could develop an abridged training program that's focused on primary care oriented issues for those being grandfathered in to attend, but I'm not all that confident in the effectiveness of something like this. There's really no other option that I can see, though.


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## thegreypilgrim (May 1, 2011)

Veneficus said:


> It sounds good until the property tax part.
> 
> As we see currently, property tax is a fickle friend. Because of major devaluations in property, municipalities and the services depending on it are getting decimated now.



Well, I'm not tied to any particular existing tax category to affix funding for public EMS. The property tax thing was just an example of what King County does.

Perhaps if we had a national sales tax or a carbon tax that might be possible. Or, just create a whole new "Ambulance Tax" that people pay for separately I don't particularly care.


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## usalsfyre (May 1, 2011)

thegreypilgrim said:


> This, admittedly, is a glaring problem. Unfortunately I don't see a real way around it. I suppose we could develop an abridged training program that's focused on primary care oriented issues for those being grandfathered in to attend, but I'm not all that confident in the effectiveness of something like this. There's really no other option that I can see, though.



Have CoAMESP and NAEMSP create a program focused on primary care issues, appropriate triage, treat and release and referral outside of the ED. Ensure it includes didactic and clinical components. Then set a date that Medicare will no longer pay anything outside of BLS non-emergent rate unless it's documented a services medics have completed this curriculum. I don't know how to deal with the issue of BLS services, outside of eliminate them.


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## thegreypilgrim (May 1, 2011)

usalsfyre said:


> Have CoAMESP and NAEMSP create a program focused on primary care issues, appropriate triage, treat and release and referral outside of the ED. Ensure it includes didactic and clinical components. Then set a date that Medicare will no longer pay anything outside of BLS non-emergent rate unless it's documented a services medics have completed this curriculum. I don't know how to deal with the issue of BLS services, outside of eliminate them.



So, would this be a kind of "bridge program" for the currently licensed people to take?

I agree with you on BLS...there's really nothing to do with it. I'd say replace it with a wheelchair van type service for IFTs/hospital discharges. Unnecessary for out of hospital care. If someone is non-emergent they can either be left at home or call for a rapid response, single-staffed vehicle to take them to urgent care or some such.


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## usalsfyre (May 1, 2011)

Considering the IAFF is finding itself on shaky ground in a lot of places, running a smear campaign might not be in their best interest...

A bridge course is pretty much what I'm proposing. Granted the "bridge course" may be more extensive than some initial programs, but such is life.

As far as the the "Itwins" arguing against it? At some point they begin arguing against higher potential reimbursement, not to mention what a lot of their members want anyway (paramedic initiated refusal). The fire lobby is looking to have a hard row to hoe for the next few years. This might be the time to enlist them. More about being "community oriented", ect. I'd love to see EMS pulled completely out of the FD (and it's anti-intellectual, rigid rank structure environment) and placed in a realistic third service, but let's face it, it's not going to happen in some places. Better to focus on improving the FD's service.


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## thegreypilgrim (May 1, 2011)

*EMS Reform*

So, in this thread I outlined what I believe to be the necessary steps to reform American EMS into something worthy of an advanced, 21st century society.

I welcome your criticism/comments on that idea, but more importantly I ask the question of what steps should we take to even start something like this. Should we start by writing our local congressmen? Should we write the NAEMT (I don't believe this organization agrees with the sort of goals I outlined in the other thread)? The NAEMSP, ACEP, or CoAEMSP?

How should we pursue this?


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## thegreypilgrim (May 1, 2011)

usalsfyre said:


> Considering the IAFF is finding itself on shaky ground in a lot of places, running a smear campaign might not be in their best interest...
> 
> A bridge course is pretty much what I'm proposing. Granted the "bridge course" may be more extensive than some initial programs, but such is life.
> 
> As far as the the "Itwins" arguing against it? At some point they begin arguing against higher potential reimbursement, not to mention what a lot of their members want anyway (paramedic initiated refusal). The fire lobby is looking to have a hard row to hoe for the next few years. This might be the time to enlist them. More about being "community oriented", ect. I'd love to see EMS pulled completely out of the FD (and it's anti-intellectual, rigid rank structure environment) and placed in a realistic third service, but let's face it, it's not going to happen in some places. Better to focus on improving the FD's service.



Well, the best thing to do is put the ball in the FD's court. First extend them the opportunity to be a part of this (like yourself I'd prefer it if they didn't, and EMS just went out on it's own). If they reject it, then one of those 3 outcomes will follow. If not, then great. The only way it's not a victory is if they fight it and win which takes us back to where we are now, and in 10 or so years the system will collapse and their will be a historical record that it was at the FD's hands.

The next problem will be the Nursing lobby, but I think they'll be less of a challenge than the IAFF crowd.


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## RanchoEMT (May 1, 2011)

In some European EMS systems Doctor's are required to work a resident like period of time in the Pre-Hospital setting.  I think HEMS in America could incorporate this into local systems and possibly provide even higher level of care in the field...

On a Side Note: Osama Bin Laden is DEAD...(Sunday may 1, 2011)


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## medicRob (May 2, 2011)

RanchoEMT said:


> In some European EMS systems Doctor's are required to work a resident like period of time in the Pre-Hospital setting.  I think HEMS in America could incorporate this into local systems and possibly provide even higher level of care in the field...
> 
> On a Side Note: Osama Bin Laden is DEAD...(Sunday may 1, 2011)



Ride alongs with Nashville Fire is required as a residency rotation with Vandy. 

[YOUTUBE]http://www.youtube.com/watch?v=d1z7v7idoL0[/YOUTUBE]


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## RanchoEMT (May 2, 2011)

medicRob said:


> Ride alongs with Nashville Fire is required as a residency rotation with Vandy.



koO! I don't mean to hijack the original post.. i'll start another one in the ems section about Pre-hospital Advanced care, it seems like an interesting topic.

http://www.youtube.com/watch?v=UP9ODcwr7ck


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## systemet (May 2, 2011)

I think the problem is that people want a certain level of service when the call 911, or go to the ER, or family medicine clinic -- but they don't want to pay for it.  We're told that private enterprise is more efficient, and cheaper -- but this doesn't quite jive with the fact that the US health care system is the most expensive in the world per capita, yet fails to cover a large percentage of the population.  

Defenders of private medicine will always suggest that this is a direct result of tort law in the US.  And perhaps it is, I don't know.  But I think there needs to be a fundamental change in how health care is delivered in the US.

The problem with low-tax neo-conservatism, is that you still end up paying.  You can have low taxes, but then you're not having universal health care.  You're not having free, state funded day care for 40 hours a week, you're not having free university education, you're not getting decent, free, eldercare, free busses or taxis for seniors, you're not getting 80% of your wage for 14 months of maternity/paternity leave.  

Maybe you don't need all of these - but you still end up paying for a lot of them.  If you have kids, maybe you're already saving for their university education.  Not necessary in a lot of places.  Maybe you're in a situation where one spouse is staying at home, because it's not worth the cost and difficulty of getting your kid to a private day care.  The family's losing income, and one spouse is losing potential career advancement.  Maybe you'd like to move out of EMS into another field -- one where potentially you can make more money and produce more tax dollars.  But the tuition cost is   a barrier.  Maybe you end up with a parent or grandparent living in your house, because there's no decent eldercare that's affordable.

Instead, American society gets cheap cars, cheap gas, lots of cheap consumer goods, big houses. [I should preface this with, I'm not American, but have lived for a long period of my life in Canada, which has many similar issues.]


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## systemet (May 2, 2011)

To the issue at hand:

EMS is currently delivered in most of North America as a municipal / county responsibility, funded by municipal/county taxes, and cost-recovery from billing the user or their healthcare insurance directly.

The only exceptions I'm aware of are in Canada; British Columbia Ambulance Service (BCAS)  (4.5 million people) is a single provincial public system; Alberta Health Services (3.8 million) is provincially-run system, integrated with healthcare, with a blending of publically operated services, and contracted private and fire-department services.  Nova Scotia (1 million) has contracted their entire ambulance system to a private contractor, EMC.  

These are obviously much smaller in terms of population than many US states.  So it's questionable whether this can be scaled up.

I think that there's a lot of redundancy in EMS.  Random city X has a full staff of paramedics and EMTs, has it's own medical direct, own protocols, own purchasing department, mapping, clinical education, quality improvement, supervision, possibly research departments.  Much of this is probably contracted or shared with the fire department, or a given city department.  But city X sits next to 3 suburban regions of reasonable population, and has a dozen rural counties within an hour.  There's a couple of separate flight programs in the area, and interfacility transfer is contracted out to a couple of different agencies.  

This is not an uncommon situation, right?  And what often happens, is someone calls 911 for a cardiac arrest, and the nearest ambulance isn't necessarily the city am.  It's an out-of-town crew doing a transfer, or an empty IFT truck going to the next patient.  But the city ambulance gets sent instead.  Similar things end up happening on the borders of the different response zones -- an eight year old kid has an anaphylaxis, right on the edge of one of the rural counties.  Perhaps the closest resource is actually a city unit on the edge of their response zone?  But they don't get sent because it's in county's jurisdiction.  Similar situations occur on a busy night in the city.  There's five ALS rigs doing nothing in the suburban region.  But the city's a million people and has 2 rigs available for calls.  Everything else is tied up.  The suburban department's not going to send their ALS rig into the city for coverage, because why should their taxpayer subsidise the city's service, right?

I mean, I realise that there are mutual aid agreements, and there are good dispatchers that recognise and compensate for some of these issues, but I think that they still occur way too often.

So I think we should centralise.  The state or province department of health should run the system.  There should be standard equipment, a single union, standard protocols.  Emergency medicine oversight for QI and protocol development, and research.  A single clin ed department, or perhaps two, north and south, if it's a large geographic area.  A single dispatch system.  Common radios, disaster plan, etc.  

Take EMS from being a municipal / country responsibility to a state / provincial responsibility.  Allow some subcontracting, but under certain conditions -- e.g. private company X can run ambulance, if they can bid a favourable price, but they have to use the state / provinicial contract for their employees, meet the state / provincial equipment standards, use the centralised dispatch.  Let the FDs be involved, but refuse to reimburse for ALS.  Remove fire department first response from any health care funding.  If they want to contract to run EMS, fine, but make their EMS resources dedicated, e.g. no dropping an ambulance to staff a pump.  Make sure the money doesn't move sideways into fire suppression.

Is this expensive?  Definitely in the short term there's going to be start up costs.  Labour costs should go up.  And you're shifting budget dollars from one budget to another.  This should result in a drop in municipal / county taxes and an increase in federal / state taxes.  

The public won't like this.  It will involve change.  The public hates change.  Interested parties will tell people that it's a matter of life and death, that bureaucrats are playing with healthcare (a la recent medicare debacle).  It may or may not be cheaper in the future, but it will probably result in a better level of care, and a professionalisation of EMS service.

It would take some political will.  EMS is not a big budget item.  Even in the context of a municipal budget, fire suppression or police services usually end up costing 5 - 10 times more, each.  In the health care budget it's a triviality.  But attempting to move responsibility for it means entering the debate about health care reform.


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## Meursault (May 2, 2011)

systemet said:


> So I think we should centralise.  The state or province department of health should run the system.  There should be standard equipment, a single union, standard protocols.  Emergency medicine oversight for QI and protocol development, and research.  A single clin ed department, or perhaps two, north and south, if it's a large geographic area.  A single dispatch system.  Common radios, disaster plan, etc.



Much of what you suggest already exists in the US; protocols are standardized at the state level and the post-9/11 emphasis on disaster planning has gone a long way to ensure interoperability. The existence of waivers, special projects, and service protocols reflects the awareness that not all services are staffed with equally competent providers, nor do they all need the same scope of practice.

The best reason your other suggestions haven't been implemented is that they involve infeasibly large areas. The coverage areas you envision would contain vastly different communities with differing EMS needs. Combined dispatch for large areas with high call volumes is also potentially inefficient and stressful. I agree that smaller communities might benefit from combining their EMS agencies, rather than relying on mutual aid, but that solution can't be applied indiscriminately to all areas.


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## systemet (May 2, 2011)

MrConspiracy said:


> Much of what you suggest already exists in the US; protocols are standardized at the state level and the post-9/11 emphasis on disaster planning has gone a long way to ensure interoperability. The existence of waivers, special projects, and service protocols reflects the awareness that not all services are staffed with equally competent providers, nor do they all need the same scope of practice.



Yeah, most of those suggestions were fairly peripheral to the main idea, of centralising EMS and seeing it as a healthcare function.

When I'd worked in EMS, we often had bizarre variations between different regions in the equipment, drugs, and protocols used.  

There are definite cost savings in reducing redundancies, for example, if you purchase ambulances for the entire state / province, the per unit cost goes down.

I'm also not sure that there is a real need for variations in protocols between different regions.  I accept that providers with long-distance transports, or transporting to less equipped facilities are going to need to have access to therapies that might not be useful if they're transporting 5 mins to a major trauma center.  I'm just not sure why one service with an hour long transport time needs to have different protocols from another service with hour long transport times.

If you centralise things, why not have one set of guidelines for transport time <20 mins, one set for more than 20 mins, and another set covering special situations for flight providers?



> The best reason your other suggestions haven't been implemented is that they involve infeasibly large areas. The coverage areas you envision would contain vastly different communities with differing EMS needs. Combined dispatch for large areas with high call volumes is also potentially inefficient and stressful. I agree that smaller communities might benefit from combining their EMS agencies, rather than relying on mutual aid, but that solution can't be applied indiscriminately to all areas.



I agree these are large areas.  I disagree as to whether it's feasible.  If we consider areas that are large in population, well this system pretty much already exists with the NHS in the UK.  If we look at areas that have a large geography, or remote regions, look at the geographic size of the Canadian provinces.

Why does a patient in community A need different treatment to community B?  How different are the needs of two communities?  Perhaps one area sees more highway trauma, and needs less continuing education in this area because they keep their skills up by constant use.  Perhaps another region sees more drug abuse -- but I can't see how the medicine becomes fundamentally different.

I don't see why dispatch amalgamation is inefficient.  It seems like it would be far more efficient.  The dispatcher has to do the EMD cards.  They can do that on a patient five blocks away or 500km away.  If you have enhanced 911, you can get caller location.  There's definitely issues with poorly-marked rural areas, and people who don't know their address or legal land description, or whatever.  But I don't think these necessitate the existence of small regional centers.  Take this model, and you can start doing better 911 service by throwing a nurse or physician on the end of the phone for callers with selected complaints to direct them to other resources than an ambulance.  

I guess it all rests on where the cost-benefit lies. 

A major advantage to centralising a system is that you can place resources where they're most needed, instead of in the communities that have the most tax dollars, or the most political impact.  If you have a small town 300km from anywhere, maybe it does need a dedicated ALS truck, and a couple of BLS rigs, just because it's a million miles from anywhere.  The system ends up being built to cover the call volume.  You can move resources around more efficiently, because you don't have to worry as much about politically created borders.

Granted, perhaps you're right and I'm wrong?  But I'm yet to be convinced that what I'm suggesting is impossible, impractical or undesirable.


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## Meursault (May 2, 2011)

systemet said:


> Why does a patient in community A need different treatment to community B? How different are the needs of two communities? Perhaps one area sees more highway trauma, and needs less continuing education in this area because they keep their skills up by constant use. Perhaps another region sees more drug abuse -- but I can't see how the medicine becomes fundamentally different.


The medicine isn't different, but as we both seem to recognize, the providers are. Until we can ensure that all providers are sufficiently competent with a given treatment/disposition option, we need to restrict its use. A functional continuing education system would go a long way towards making it possible to truly standardize protocols, but at their heart, specialized protocols are a recognition that some providers are better than others. That problem isn't going to be fixed by administrative reshuffling. 



systemet said:


> Take this model, and you can start doing better 911 service by throwing a nurse or physician on the end of the phone for callers with selected complaints to direct them to other resources than an ambulance.


This could just as easily be done by referral from local PSAPs. The barriers to non-emergency home care aren't geographic.



systemet said:


> A major advantage to centralising a system is that you can place resources where they're most needed, instead of in the communities that have the most tax dollars, or the most political impact.


You're absolutely right about cost-sharing being needed to fix the paradox of ALS availability.  That's an advantage of a central funding source, although I suspect political considerations would play, if anything, a larger role if budgeting was done at the state level. And here, I now realize, is my real objection to centralizing EMS at the state level: doing so necessitates more layers of decision-makers and administrators completely removed from care delivery and more attuned to regional and national politics. There have certainly been complaints about that occurring in NHS ambulance trusts.


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## systemet (May 2, 2011)

MrConspiracy said:


> The medicine isn't different, but as we both seem to recognize, the providers are. Until we can ensure that all providers are sufficiently competent with a given treatment/disposition option, we need to restrict its use.



This can still be done under a state protocol system.  You can still have, for example an RSI training module, and only qualify certain paramedics for that skill.  With central oversight, and clinical education, you can then target areas that have poor intubation skills for more focused training.



> A functional continuing education system would go a long way towards making it possible to truly standardize protocols, but at their heart, specialized protocols are a recognition that some providers are better than others. That problem isn't going to be fixed by administrative reshuffling.



I agree that you can't take under-performers and suddenly make the problem go away by changing the management structure and funding structure of an organisation.  But you may be able to address some of the factors that create and sustain poor performance.

By having an organised state clinical education group, and some real QI, you can start identify poor-performers, or poor-performing regions, and dedicate some focused training to them.  Because, probably, many of the people that are underperforming are also working in areas that have historically lacked good con-ed programs.  I'm not saying this is always the case, but it's probably quite common.



> This could just as easily be done by referral from local PSAPs. The barriers to non-emergency home care aren't geographic.



Absolutely.  It might be easier to implement this if dispatch is centralised. 



> You're absolutely right about cost-sharing being needed to fix the paradox of ALS availability.  That's an advantage of a central funding source, although I suspect political considerations would play, if anything, a larger role if budgeting was done at the state level. And here, I now realize, is my real objection to centralizing EMS at the state level: doing so necessitates more layers of decision-makers and administrators completely removed from care delivery and more attuned to regional and national politics. There have certainly been complaints about that occurring in NHS ambulance trusts.



I can't speak to the complaints in the NHS.  

As I envision this, we remove some bureaucracy.  If we combine smaller response areas, we remove a lot of management.  A large city might need several dedicated supervisors on per shift, but a group of rural services might be able to easily share a single supervisor.  

Perhaps it wouldn't work like that.  Perhaps the reality is that bureaucracy exists to generate more bureaucrats, and that any change works to increase the number present.

It seems to me that one of the major challenges facing EMS in North America is the fragmented and disorganised patchwork of care delivery.  I think these suggestions would go a long way to fixing it.  I can't promise that fewer, larger services would make working conditions better, or fix all the ills of EMS -- but I think it's a step in the right direction.  As much as national coordination remains a huge issue, it seems like it would be easier with less players in the game.


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## Jon (May 6, 2011)

thegreypilgrim said:


> So, in this thread I outlined what I believe to be the necessary steps to reform American EMS into something worthy of an advanced, 21st century society.
> 
> I welcome your criticism/comments on that idea, but more importantly I ask the question of what steps should we take to even start something like this. Should we start by writing our local congressmen? Should we write the NAEMT (I don't believe this organization agrees with the sort of goals I outlined in the other thread)? The NAEMSP, ACEP, or CoAEMSP?
> 
> How should we pursue this?


Grey Pilgram,

I spent some time in Washington DC this week for NAEMT's 2nd annual EMS on the Hill event. http://www.naemt.org/advocacy/emsonthehillday/EMSontheHillDay.aspx

NAEMT had 3 talking points we were discussing with legislators and staff THIS TIME:

PSOB expansion to all EMS providers working for a non-profit, non-governmental agency (3rd service).

Medicare Benefit Extension/Expansion (6% Urban/Rural, 17% Super rural).

Expansion of 700 mhz spectrum to 20 mHz so we can build a true broadband network for public safety.
~~~~~~


So - those were the talking points this year. In several of our meetings, discussion went to re-evaluating Medicare to leverage EMS to allow us to expand our role and fill some of the gaps we currently see in the system.


NAEMT is a small organization, compared with unions like IAFF and even organizations like IAFC... That being said - it's like the NRA is to gun owners... You may not agree with EVERY position they take... but they are the only one making the effort to try to speak for us... so pay the money and JOIN. They are building an advocacy network right now to allow field providers to become more involved.


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## Breakers1 (Jun 14, 2011)

*Fire EMS*

I rode with a MAJOR fire/EMS doing observation and almost all were reallying good

However, 1 service was the scariest thing I ever did. Not from the patients or areas we did calls but from the lack of caring, empathy, skill, motivation, from the EMS crews.

I rode on 4 different ambulances in that city....all Firemen who want nothing to do with EMS.  Even the custom license plate on the car of the medic was embarassing to ems.... it was "I H8 EMS". He hated he had to do it 2 months out of the year.


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## terrible one (Jun 14, 2011)

Breakers1 said:


> Even the custom license plate on the car of the medic was embarassing to ems.... it was "I H8 EMS". He hated he had to do it 2 months out of the year.



I saw a license plate EMSH8R at my nremt-p recert class and at the beginning of the plate was the firefighter symbol. 

I don't understand, if you hate 70-80% of the calls you go one why do you want to work as a firefighter? Go work for the forest service or somewhere that doesn't do medical aids


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## JoshMM (Aug 3, 2011)

I know this thread is sort of dead, but I am new so my condolences . 

Where I work as a paid firefighter, we only respond to major medical calls where there is a true need to fill the reasonable gap for our county ambulance service to respond. 

Example: Tone goes out for my engine.  65 year old male, difficulty breathing.  We respond. I jump off and grab the AED, O2, and basic jump kit.  We assess the situation.  I will take his BP/Pulse. We make sure he is "stable" until the Ambulance with Paramedic arrives.  I usually walk outside when they pull up, tell them his vitals, explain the situation, and get out of the way.

While they are in there doing their thing, I usually pull the stretcher off for them, and help with patient packaging.  Once we get the patient loaded, we part ways.  

I personally am getting EMT-B because as an EMR/CPR I feel like I could do a better job during that gap between our response and the ambulance arriving. Where I live, we usually are able to respond in our specific station territory much faster than Metro. I just want to do the patient a service while we wait for the experts. 

IMO, it seems to make more sense having specifically trained medical professionals overseeing the medical calls and trained firefighters handling the technical rescues/structure fires/etc. I hope this post made sense. 

Josh


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## JJR512 (Aug 4, 2011)

Separating fire from EMS might work in larger cities, especially older ones that get fires (usually minor) fairly frequently.

But in smaller towns and municipalities where the non-EMS calls are few and far between, it might be more difficult to separate EMS from fire. Especially when cost-savings is the goal. In these areas, the fire department that remains after taking EMS out isn't going to be very busy, and then people will complain about all these firefighters sitting around most days doing nothing, and getting paid for it.


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## Martyn (Aug 8, 2011)

mycrofft said:


> If I were the sort who could do something, in an urban to close-suburban setting:
> 1. Make currency as a paramedic mandatory to train and work as a firefighter.
> 2. If possible, contract transport (including everything from picking them up off the floor to the hospital, except for technical extrication) to a private company.
> 3. Stop responding a firefighting crew and truck to every EMS call.
> ...


 

OK, popping open the can of worms, and remember I am British...I have trained as an EMT...WHAT PART OF I DO NOT WANT TO FIGHT FIRES DON'T YOU UNDERSTAND? I am only interested in helping ill/sick/injured people. In the UK you dial 999 (equivalent of 911) if you are sick and guess what? You get an ambulance. Dial 999 if you are on fire and gues what? You get a fire truck. Getting beaten/mugged/robbed or whatever dial 999 and you get the police. I have lived over here for 6 years and cannot get round the mentality of I am having a heart attack, I dialled 911 and what got sent? A DIRTY GREAT FRICKIN TURNTABLE FIRETRUCK. Keep EMS as EMS, fire as fire and law enforcement as law enforcement. The costs involved in doing that must be ridiculous compared to just turning out an ambulance. So they get there first. In my experience that is because they get toned out BEFORE EMS gets the tone. What they gonna do, tie the PT on the ladder and haul butt to ER to make the EMS look bad.

Rant over (for now) and my apologies to Mycrofft for picking on/quoting your post. I have tried to keep out of these sort of arguments but a 'them and us' mentality just frustrates me. Lets all work as a team...BUT KEEP TO OUR SPECIALITIES!!!


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## JJR512 (Aug 9, 2011)

Martyn said:


> OK, popping open the can of worms, and remember I am British...I have trained as an EMT...WHAT PART OF I DO NOT WANT TO FIGHT FIRES DON'T YOU UNDERSTAND? I am only interested in helping ill/sick/injured people. In the UK you dial 999 (equivalent of 911) if you are sick and guess what? You get an ambulance. Dial 999 if you are on fire and gues what? You get a fire truck. Getting beaten/mugged/robbed or whatever dial 999 and you get the police. I have lived over here for 6 years and cannot get round the mentality of I am having a heart attack, I dialled 911 and what got sent? A DIRTY GREAT FRICKIN TURNTABLE FIRETRUCK. Keep EMS as EMS, fire as fire and law enforcement as law enforcement. The costs involved in doing that must be ridiculous compared to just turning out an ambulance. So they get there first. In my experience that is because they get toned out BEFORE EMS gets the tone. What they gonna do, tie the PT on the ladder and haul butt to ER to make the EMS look bad.
> 
> Rant over (for now) and my apologies to Mycrofft for picking on/quoting your post. I have tried to keep out of these sort of arguments but a 'them and us' mentality just frustrates me. Lets all work as a team...BUT KEEP TO OUR SPECIALITIES!!!


 
I cannot speak for the jurisdiction where you live, but I can tell you about the one where I work (well, volunteer). My county has a combined EMS/Fire dept. All of the stations have ambulances and fire engines. Most of the stations are able to staff one ff/paramedic on the ambulance and one on the engine at any given time. Now, the ambulance is not always in the station. Sometimes it's actually out there somewhere serving a call, sometimes in our first-due area, sometimes in a neighboring one. When a person who lives in my stations first-due area calls 911 for an _ambulance_, and my station's ambulance is busy or far away, 911 will send the _fire engine_. Why? Not because they expect the engine crew to "tie the PT on the ladder and haul butt to ER to make the EMS look bad". No, the reason the fire engine gets sent _in addition to the next-closest available ambulance_ is because the engine will get there first, and will come with a ff/paramedic on board. Not just a paramedic but a BLS jump bag, an ALS jump bag, O2 and airway/respiratory management equipment, an LP 12, a spinal immobilization kit and a long board, etc. Of course 911 knows that the engine can't transport the patient but they also know that the ff/paramedic (along with the other firefighters, ALL of whom are at least EMT-B) can manage the situation until the transport unit from the farther station arrives.

So like I said, I can't speak for what's going on in your jurisdiction, but maybe you can look at mine and realize it isn't always a conspiracy to make EMS look bad. Maybe they sent you a fire engine because that was the closest unit with EMS-trained personnel on board, and maybe they thought it was better for you to get _something_ rather than wait longer for an actual ambulance.


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