Single Agency or Multi Agency EMS coverage?

[46Young]

I'm wondering what other's opinions are regarding EMS coverage for a specific region, such as a county, city, etc.

I've worked in NYC where there's FDNY EMS along with numerous hospital based and private 911.

The pros were less of a 911 burden in regards to cost/staffing for the city. The competition in providers results in increased salaries, working conditions, etc for the hospitals and privates. Whatever FDNY gets, the hospitals need to do better. The non union hospitals enjoy many of the same benefits that union hospitals and FDNY get, less retirement, of course. You can work for several hospitals per diem if your primary employer controls OT. Some hospitals have seperate IFT divisions. You're dedicated to 911 or IFT depending on the shift. The 911 buses are great for sharpening skills, even if it runs in the red.

The cons are many. There's no uniform standard of care. The quality, training, education, QA/QI, equipment, background investigations, etc. can vary widely from employer to employer. The FDNY conditions bosses are powerless to give discipline to EMT's and medics from outside agencies, unless an overt pt care issue is observed. Even then, the hospital's medical director can clear you, not FDNY's. Pt steering is a problem. Some hospitals will txp insured pts to their hospital, and send the uninsured to a city hospital. Protocols are rather limited, and any deviation from the cookbook must pass through the mother-may-I system. Also, quite a few EMT's and medics leave FDNY EMS for the better paying hospitals.

I worked in South Carolina for a third service Agency, the sole 911 txp provider for tha county. Our protocols were a little more liberal, and our QA/QI was thorough and organized. There was one standard of care. The main drawback was that the working conditions, holdovers, and such were less than desireable. With no local cometition, it was their way or the highway.

My current employer, fire based, also has a solid QA/QI program, and we're encouraged to use the protocols as guidelines, and only need to call for a few things. We're good as long as we're following best practices. The only way we get different providers is via automatic aid from bordering counties. Vollies and career personnel alike are held to the same standard and are required to do the same monthly/quaterly training.

Edit: Another con to the NYC system: they have a cap on 16 consecutive hours of work plus late job. You can log off with one employer, and log on with another 15 minutes later, and the system doesn't catch that. I used to 16 and then 12 more with maybe a 2 hour gap, tops. You could work indefinitely if you choose to, if shift availability allows.

 

[DrParasite]

I prefer a single agency responsible for an entire governmental area. that might mean a single agency per town, county, or borough.

a single point of accountability. a single set of protocols. a single chain of command. everyone is equal in a particular coverage area.

the biggest issue I have with FDNY (and other systems like is) is there are different standards of care, depending on which ambulance shows up. Not only that, but with one agency is responsible for staffing, coverage, and providing the service. and FDNY rig is not equal to a st. vincents, or any other hospital based unit. the equipment should be the same, the training and educational requirements the same and the pay the same, when in NYC it's not. the hospitals are one of the big reasons why FDNY EMS pay is so low, because everyone is replaceable with a vollie rig (with is paid, just voluntarily participates in the system), and the city doesn't need to have enough units, because privates will pick up the slack.

the government should provide ALL EMS services. everything should be tax based, and you should get what you pay for. if there aren't enough units, than raise taxes to ensure proper staffing levels. One standard of care, one set of protocols for everyone. NYC's pay scale also means everyone is looking to leave FDNY once they get a full time position in a hospital (which usually requires per diem work while working FT and OT at FDNY). It's a bad cycle, and inefficient for the tax payers, plus they have not long term employees.

as a side note, I was under the impression that NYC was standing orders for everything, because you were so close to a hospital. I guess that is not the case, and i was misinformed by an upstate medic?

 

[jjesusfreak01]

In my county (I know I sound like that kid from the Magic School Bus), the county operates most of the units, but there are a handful of privately owned services that operate within the same command structure, same protocols, and same dispatch. One big happy family, but different internal (non patient care) protocols for the different agencies.

 

[46Young]

I prefer a single agency responsible for an entire governmental area. that might mean a single agency per town, county, or borough.

a single point of accountability. a single set of protocols. a single chain of command. everyone is equal in a particular coverage area.

the biggest issue I have with FDNY (and other systems like is) is there are different standards of care, depending on which ambulance shows up. Not only that, but with one agency is responsible for staffing, coverage, and providing the service. and FDNY rig is not equal to a st. vincents, or any other hospital based unit. the equipment should be the same, the training and educational requirements the same and the pay the same, when in NYC it's not. the hospitals are one of the big reasons why FDNY EMS pay is so low, because everyone is replaceable with a vollie rig (with is paid, just voluntarily participates in the system), and the city doesn't need to have enough units, because privates will pick up the slack.

the government should provide ALL EMS services. everything should be tax based, and you should get what you pay for. if there aren't enough units, than raise taxes to ensure proper staffing levels. One standard of care, one set of protocols for everyone. NYC's pay scale also means everyone is looking to leave FDNY once they get a full time position in a hospital (which usually requires per diem work while working FT and OT at FDNY). It's a bad cycle, and inefficient for the tax payers, plus they have not long term employees.

as a side note, I was under the impression that NYC was standing orders for everything, because you were so close to a hospital. I guess that is not the case, and i was misinformed by an upstate medic?

I agree with all of that. We had CPAP back in 2005, and others didn't. We carried valium and ativan, others had versed. My agency required that we call one of our supervisors for each and every refusal, to curb excess refusals. The supervisor would speak with the pt on the phone. This greatly extended onscene times, and was unnecessary. Almost none of us did recert via CME's. We mostly all did challenge refreshers, as it was more time friendly.

I remember New Year's Eve 2005-2006 the hospitals upstaffed with extra 911 units since FDNY EMS was rumored to be planning a slowdown that night. You can't strike, but you can certainly kill some time onscene with a stable pt, and spend an hour and a half doing BBP (decon) on your bus, I suppose.

I support the gov't providing all 911 services. what many fail to realize is that it's not so much about needing to raise taxes to support emergency services. What's infinitely more important is not supporting politicians that are against business, in particular small businesses. If you drive away your tax base, you'll need to cut services. If you support candidates that seek to create a business friendly environment, you'll have a healthy tax base, with more funding available for emergency services.

Regarding protocols, unless things have changed, we had standing orders, and then med control options. You would call for morphine after running the cx pain protocol, for example.