EMT Shortage is hitting hard in CT

[Kavsuvb]

Looks like EMT shortage is hitting hard in the state of CT. Many Vol EMS depts are resorting to paid providers or hospital based providers.

 

[DesertMedic66]

Well that’s one way of transitioning from volleys to fully paid staff. Not saying that’s a bad thing…

 

[mgr22]

Nothing wrong with paid staff supplementing volunteers. It's worked in NY for years.

 

[DrParasite]

Looks like EMT shortage is hitting hard in the state of CT. Many Vol EMS depts are resorting to paid providers or hospital based providers.

NJ has been doing this for decades. It's not new, nor is it necessarily a bad thing.

Here is the thing: I am 100% supportive of volunteers in public safety, provided they are doing the job. Also, if you can provide an in hour crew 24/7, than you should. But at the end of the day, if they can't provide the service, the AHJ needs to do something to ensure that service is being provided.

There is another point: if you want a service to function at a certain level, you should expect to pay for it. Based on that article, the town doesn't pay anything for their volunteer EMS system, and the hospital is providing a 6 year no cost contract (where they are likely billing the residents), so you get what you pay for. If the town wanted a guaranteed response, they could allocate funds for an EMS service but they are choosing not to, and because it's not it's not a priority to them, so they instead of outsourcing it to the local hospital, who is either breaking even or running the service at a small loss, with the loss being made up by profits from other departments in the hospital.

 

[NomadicMedic]

It’s been going on in Connecticut for years too. Just because there’s a news story doesn’t mean it’s new.

 

[MrBrown]

I think this highlights one of the problems of leaving these sorts of things up the local municipality which can usually only raise money through property taxes or user fees suchlike. They are obviously under pressure to keep these taxes or fees down. That. to me, seems incompatible with the idea of ensuring local services run effectively. In New Zealand, Australia, the United Kingdom and some parts of Canada, the ambulance service s run at the state or province or regional level as part of the health system. That way, the local governments are not on the hook. The same here with the fire brigade, which is funded mainly by insurance levies and some central government funding but that is entirely non-contentious. I accept in the US there is no real public health provision so it makes it quite difficult to replicate such a model because there is no overarching public body responsible for providing healthcare. I am sure it could be done if it was really seen as a viable option.

Now in saying that, there will always be a need to some extent for volunteers. How far that should extend is debatable. I do not think "just get some people to do it for free" is the answer to solve the ills of insufficient money. I can happily say after decades of doing little, our fearless pols finally agreed to pump serious money to the ambulance service to largely replace the need for volunteers to double crew. Huzzah! There are also programmes where docs or other medicos and lawyers do some free work to help solve access block. Encouraging or forcing people to work for free is not the answer.

 

[DrParasite]

I think this highlights one of the problems of leaving these sorts of things up the local municipality which can usually only raise money through property taxes or user fees suchlike. They are obviously under pressure to keep these taxes or fees down. That. to me, seems incompatible with the idea of ensuring local services run effectively.

Why do you say that? shouldn't local services be funded at the local level? If I want an ambulance on every street corner, and am willing to pay for it, why shouldn't it get it? if the next town over doesn't want it, or are not willing to pay for it, they don't get it. you get what you pay for. And the further away you get from the local level, the worse many situations get. Don't get me wrong, I'm not against deionization, but I've seen the county and state screw things up royally, and the federal government is even worse.

In New Zealand, Australia, the United Kingdom and some parts of Canada, the ambulance service s run at the state or province or regional level as part of the health system. That way, the local governments are not on the hook. The same here with the fire brigade, which is funded mainly by insurance levies and some central government funding but that is entirely non-contentious.

You might not want to advocate too much about the UK's NHS system... unless you think a 1 hour wait for an ambulance with a pediatric head injury is acceptable...

and IDK much about Australia, but IIRC, the majority of the population is located on the east/south east coast right? so if I'm in northern Australia, and have a heart attack/get attacked by an animal/ get shot/etc. what's the response time going to be like? I'm assuming the majority of the calls are in the high population centers, so I pay national taxes, but the services are going to those big cities. As I mentioned beforehand, I know nothing about Australia, so that does include a lot of assumptions about the EMS system there.

I accept in the US there is no real public health provision so it makes it quite difficult to replicate such a model because there is no overarching public body responsible for providing healthcare. I am sure it could be done if it was really seen as a viable option.

That's not entirely true... but do you really want some government official in another state determining that you shouldn't have an ambulance that can provide a quick response during an emergency?

Now in saying that, there will always be a need to some extent for volunteers. How far that should extend is debatable. I do not think "just get some people to do it for free" is the answer to solve the ills of insufficient money. I can happily say after decades of doing little, our fearless pols finally agreed to pump serious money to the ambulance service to largely replace the need for volunteers to double crew. Huzzah! There are also programmes where docs or other medicos and lawyers do some free work to help solve access block. Encouraging or forcing people to work for free is not the answer.

I do agree, but as you so clearly stated "our fearless pols finally agreed to pump serious money to the ambulance service to largely replace the need for volunteers to double crew." In the US, too much of the country has received the service for free for decades, so now that agencies are looking to improve their services, better response times, and raise standards, the pols are saying "why should I have to pay for something that has always been done for free?"

 

[CCCSD]

Brown doesn’t comprehend the US systems.

 

[NomadicMedic]

Brown doesn’t comprehend the US systems.

He’s pathological liar and is best ignored.

 

[MrBrown]

@DrParasite I won't quote your entire post at length, but needless to say, and this is not a criticism, it shows a very American mindset that I find hard to understand, even after having spent significant amounts of time in the US. There is this entrenched fear or loathing or just downright hatred of the government that is not something I have seen elsewhere. For example, lets say one particular state wants to establish a statewide ambulance service run by the state Department of Health using a standard vehicle and equipment, all bought in bulk, and establish a network of stations and suchlike to ensure local response and fund it from the state health budget so the local towns or cities do not have to try to raise the money themselves. Great idea. But something like that in America is scoffed at and booed.

And to answer your specific question, yes, I see nothing wrong about waits of one to two hours or more for non-urgent ambulance dispatch. When my flatmate worked in Control (five or more years ago), I believe then non-urgent work could be held for up to two hours. That is not including the portion of work that was told you are not getting an ambulance. I remember just before I stopped having anything to do with the ambos (2014), they introduced nurse triage of low acuity work into the control room and demand dropped something like 15% overnight. The immediately comparable example I can think of is triage at the emergency department, so I looked up the lowest category for the Australiasan Triage Scale and category 5 patients (lowest acuity) are deemed safe to wait up two hours to see a doctor. As a different but somewhat related example, the Police Detention Legal Assistance scheme now no longer defaults to in-person attendance.

I think lack of volunteers is a shame. It is a clear sign of the changes in the modern world.

 

[DrParasite]

@DrParasite I won't quote your entire post at length, but needless to say, and this is not a criticism, it shows a very American mindset that I find hard to understand, even after having spent significant amounts of time in the US. There is this entrenched fear or loathing or just downright hatred of the government that is not something I have seen elsewhere.

It's likely cultural. the US is, historically, a partnership between the federal government and the states, with the 10th amendment to the US constitution explicitly saying any rights not explicitly assigned to the feds are the responsibility of the states.

For example, lets say one particular state wants to establish a statewide ambulance service run by the state Department of Health using a standard vehicle and equipment, all bought in bulk, and establish a network of stations and suchlike to ensure local response and fund it from the state health budget so the local towns or cities do not have to try to raise the money themselves. Great idea. But something like that in America is scoffed at and booed.

Because the larger you get, the more inefficient things tend to get, and the less voice smaller areas have in how things get done.

I was raised in Middlesex county NJ, a suburban county of 25 individual municipalities, over 322 square miles, with a population of 863,162 (all as per Wikipedia). In that county, I have at least 25 individual EMS organizations that provide 911 services, some paid, some volunteer, some a mix of the two. It's likely closer to 35 EMS orgs, with 3 or 4 towns having multiple EMS agencies that cover different parts of their town (it's has changed since I moved). So on any given day, I have ~35 BLS ambulances in each of the towns, with the larger towns and cites often staffing 2+ ambulances for their area. There are also 15 or so ALS flycars covering the entire county, and very little FD involvement in EMS.

Now I moved to Wake County NC, which has a single county wide EMS agency. As per Wikipedia, Wake County is 857 sq miles, and has a population of 1.15 million people, scattered among 10 municipalities and a lot of unincorporated areas. They have 30 24hr ambulances, and 15 peak load trucks (as per their website), and they rely on the local FDs to stop the clock.

so among covering 860k people, every town has an in house EMS system (including the urban ones, suburban, and rural ones), there are 50 units covering 322 miles, while in wake county, 1.15 million people, over 857 sq miles, there are maybe 45?

If I'm in Middlesex county, and I call 911, an ambulance should come from somewhere in my town.... in Wake County, it could be coming from the other side of the county.

I've said before that the most efficient law enforcement system is mall security. small coverage area, staff who work in one location day in and day out, and know it like the back of their hand. the larger you go, the bigger the coverage area, the more you stretch your resources.

Do I agree with regionalized purchasing? absolutely. But I also know what works in area 1 might not work for area 2, and it definitely won't work for area 3. Not only that, but when you want to make improvements, everyone needs to agree, or the bigger areas end up making the decisions for the smaller ones.

Also, who makes the decision where the ambulance station is located? someone at the state level? so all of the small towns don't get stations, because they aren't big enough, or there isn't a big enough call volume? Are you sacrificing the small town residents to provide better care to those in the cities?

And to answer your specific question, yes, I see nothing wrong about waits of one to two hours or more for non-urgent ambulance dispatch. When my flatmate worked in Control (five or more years ago), I believe then non-urgent work could be held for up to two hours. That is not including the portion of work that was told you are not getting an ambulance. I remember just before I stopped having anything to do with the ambos (2014), they introduced nurse triage of low acuity work into the control room and demand dropped something like 15% overnight. The immediately comparable example I can think of is triage at the emergency department, so I looked up the lowest category for the Australiasan Triage Scale and category 5 patients (lowest acuity) are deemed safe to wait up two hours to see a doctor. As a different but somewhat related example, the Police Detention Legal Assistance scheme now no longer defaults to in-person attendance.

So you are ok with a 2 hour wait for a pediatric head injury? because that was the example provided in that link (feel free to read it yourself, it's that person's story, not mine). What if it was your kid?

Also, you seemed to skip this section:

and IDK much about Australia, but IIRC, the majority of the population is located on the east/south east coast right? so if I'm in northern Australia, and have a heart attack/get attacked by an animal/ get shot/etc. what's the response time going to be like? I'm assuming the majority of the calls are in the high population centers, so I pay national taxes, but the services are going to those big cities. As I mentioned beforehand, I know nothing about Australia, so that does include a lot of assumptions about the EMS system there.

Do you consider a heart attack to be non-emergent? or a shooting? a 2 hour wait might affect patient outcomes

 

[MrBrown]

I had a look at the article. The description is a scalp laceration about one inch in diameter that it seems got covered by a dressing and bandaged. That is not a time-critical medical emergency requiring immediate dispatch of an ambulance. It is a low acuity job that could likely be safely diverted to telephone advice and non-ambulance transport. If it was a simple wound that could be closed with steri-strips or something, then a walk-in clinic sees fine. If not, it would need to be a hospital emergency department.

Sorry, I did not mean to skip the other part. Yes, in Australia the majority of the population is located along the east and southeast coasts. There are other large centres not in these areas, for example Perth, Darwin, Adelaide, Canberra, inland Queensland. Obviously I don't know the specifics, but each state has the responsibility for providing adequate cover. The mechanics of how they do that in terms of what combination of rosters or crewing arrangements or suchlike I do not know but it is seen as a state-level responsibility and not something for each local community to have to deal with individually with whatever money they can cobble together. I think the practical reality is, however, regardless of whether some small town has only enough population and workload to support say, one ambulance, and that ambulance is busy, then I do not think it would matter whether that ambulance is provided by the state ambulance service or a local group, you cannot escape reality.

 

[DrParasite]

I agree, it wasn't a time critical emergency... unless you were the parent. and the uneducated public don't know what is going on, at least not until a medical professional gets there and assesses the kid. and head wounds bleed a lot. we, as medical people know that, but the general public sees blood and panics.

I know it's very US centric, but I want my tax dollars to go to services that I use first. not the next town over, not the next state over, and not on the other side of the country. I am willing to pay higher taxes for better services, and if you don't want to pay those high taxes, no worries, but you can't expect grade A services with grade C funding. but that's why I am ok for paying for the services that I use.

 

[johnrsemt]

Hard to make the US the same across the country: the 2 counties that Dr. Parasite mentioned were great examples for the East Coast; and even most of the Midwest and South East.

But I work in the West: at my PT job I work in 1 of 3 EMS services in the county: 52,500 population in the county. County is 17,203 Square miles. (1/20 the size of the county in NC, with a population of 1/22): so the 3 EMS services are in towns on the east side, middle and west side of the county: East and West side we pretty much split the county. East side of the county has a hospital in their town Level III (small for those out of the US); the next closest hospital is 125 miles away (Level II-Moderate size and capable): closest Level I is 250 miles away in another state.
The town we are based in closest hospital is 110 miles away (East side of county) then across into the next state 125-135 miles away. And we can be 80 miles from town, then back to town to get to the freeway to then drive to 1 of the hospitals. So that makes it tougher still.

We are all short in the West too, except the major Metro areas, but they run mainly Fire based EMS

 

[HardKnocks]

I've worked in multiple jurisdictions and, like others here, have seen the gamut for EMS/Fire response times from <7min to over 1 hours for a one unit BLS response.

I currently enjoy working in Rural area for the challenge and it keeps my thinking-out-of the-box-skills tight.

I would like to see a Continuing Education Program where we take Career City EMS Providers that have spent the majority of their service in Metropolitan area and place then in a very rural environment, (or a tour with a foreign EMS detail), that has a very limited response and asset levels.
I've seen rural providers run circles around some City providers that are used to having every tool, trick and asset at hand, but when they're put in an opposite situation, due to disaster, catastrophe and/or shortage, they start burping at the wheel...lol

 

[johnrsemt]

I have said for my entire EMS career that all EMT's should spend at least 1 summer working at a Scout or Youth camp where the closest EMS is 30-45 minutes away. You will learn more about working EMS in a case like that than you do working in a city for your entire career. It has been over 20 years for me, and I can still decide if a patient needs sutures or not; saves patients a lot of money when they don't need to go to the hospital for a small laceration.
Every Medic need to spend time in a rural area. Where the closest hospital is 2 hours away, and the closest helicopter is 45 minutes away (when you can get one). Medics in Major Metro areas do not do well coming to areas like that...... we have areas that we can't even call Medical Control for help, because there is no radio or cell coverage for 30 miles or more. Where you might have a 6 hour ground transport with an Acute MI, due to a blizzard, and you can't get a helicopter, and when you call the ED for orders for more pain meds and more NTG the ED doctor almost cries when you tell him you are still probably 4 hours away.

 

[HardKnocks]

I have said for my entire EMS career that all EMT's should spend at least 1 summer working at a Scout or Youth camp where the closest EMS is 30-45 minutes away. You will learn more about working EMS in a case like that than you do working in a city for your entire career. It has been over 20 years for me, and I can still decide if a patient needs sutures or not; saves patients a lot of money when they don't need to go to the hospital for a small laceration.
Every Medic need to spend time in a rural area. Where the closest hospital is 2 hours away, and the closest helicopter is 45 minutes away (when you can get one). Medics in Major Metro areas do not do well coming to areas like that...... we have areas that we can't even call Medical Control for help, because there is no radio or cell coverage for 30 miles or more. Where you might have a 6 hour ground transport with an Acute MI, due to a blizzard, and you can't get a helicopter, and when you call the ED for orders for more pain meds and more NTG the ED doctor almost cries when you tell him you are still probably 4 hours away.

I totally agree