Nationalization or federalization of EMS

[TheMowingMonk]

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

 

[JJR512]

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.

 

[TheMowingMonk]

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

 

[lightsandsirens5]

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.

 

[akflightmedic]

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.

 

[TheMowingMonk]

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

 

[medic417]

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.

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.

 

[lightsandsirens5]

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!^_^

 

[medic417]

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!^_^

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

 

[lightsandsirens5]

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.

 

[BossyCow]

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.

 

[medic417]

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.

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.

 

[BossyCow]

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.

 

[medic417]

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.

 

[jrm818]

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.

 

[medic417]

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.

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

 

[jrm818]

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.

 

[JJR512]

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.

 

[ffemt8978]

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:

 

[JJR512]

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.