Nationalization or federalization of EMS

[ffemt8978]

No, I didn't say anything about standard of care...I was referring strictly to the financial aspect.

 

[jrm818]

Why is it that some in EMS continue to argue against the advancement of medicine while other professions are continuously striving to find ways to improve healthcare in their professional areas and communities?


jrm818,
You need to broaden you view about healthcare and learn how we do provide medical care to millions of people who are poor. EMS should not discriminate its 911 services based on the size of the patient's wallet.

Luckily the Freedom House Ambulance service did not use your logic and saw the need for Paramedics over 40 years ago.

On an individual basis EMS does not and should restrict access based on ability to pay...provided we are talking about emergent conditions, just as hospital ED's do not. That does not mean all medical care is equal, however.

What I meant to convey is that on a community level there are differences in access to all kinds of social services, including health care, based on the wealth of the community. The only way for a poor community to achieve equal access to EMS as compared to more wealthy communites is to make a greater sacrifice themselves to provide, e.g. ALS service, or for the government to redistribute wealth from the rich to the poor. I've never much gone for that socialism stuff, so the only possibility I'm happy with is the community finding some way to afford ALS. If the community decides they have more important things to spend their money on (primary care comes to mind in the healthcare arena), than so be it.

The community I work in is pretty economically depressed. One township has a levy analogous to a fire district that pays us,in the rest patients pay individually. The ambulance company stays afloat only due to large call volumes due to high density populations, and a contract with the hospital. If this were a rural setting I can't see the company being able to afford to provide 24/7 ALS without a significant contribution from the population. That depends on the population being convinced that ALS is a cost-effective way to spend their healthcare dollars....and I'd have a hard time making that case.

Freedom house was surely a good thing for the city, and it's pathetic the way it ended, but isn't necessarily a good model for the rest of the country. Most places don't have a Dr. Safer hanging out half a mile away to start such a thing...

 

[VentMedic]

No, I didn't say anything about standard of care...I was referring strictly to the financial aspect.

But, you also must consider their equipment and vehicles. In addition, they do maintain a small staff for operations. I also believe they started paying their Paramedics. Key Largo also has a FD which was included in the special tax district. It's all relative on the type of service you want to provide. And, if you notice, there are not that many volunteers pictured and a little older than some of the other volly squads. Not all of us on the mainland agree with volunteer services but this one is backed by a trauma district with access to the services in Miami.

 

[VentMedic]

What I meant to convey is that on a community level there are differences in access to all kinds of social services, including health care, based on the wealth of the community. The only way for a poor community to achieve equal access to EMS as compared to more wealthy communites is to make a greater sacrifice themselves to provide, e.g. ALS service, or for the government to redistribute wealth from the rich to the poor. .

No, I disagree. Florida is a state of the haves and have nots. Our tax structure within the state is set up for allowances of disproportionate tax bases. Each service also charges.

 

[jrm818]

Vent,

This goes to the can of worms of public safety vs. public health. (which implies medicine)As you know I am squarely in the public health/medicine camp. For a long time we have tried to show people our perspective and they will be dragged kicking and screaming, as examples look at what wake county just instituted or the advanced practice scope developing in Britain. The idea of BLS vs. ALS is a naïve argument perpetuated by those who do not understand anything more than what their skill testing sheets require.
[...]
Anyone who wants to help a patient needs to forget IVs and ET tubes, LMA, medications, etc and start learning biology, chemistry, anatomy, physio, patho phys, etc. There is a reason basic science is a prerequisite for every level of healthcare provider all over the world. (except US EMS apparently) Medicine is not like working a saw or welding, you have to know how and why things work, not just what to do when you see sign X and symptom Y. >90% of all “emergencies” are not life threatening. Why do we spend so much time, money, and effort on less than 5-8% of what we do?

My antagonists will argue they are saving lives. But they don’t even realize how flawed that perspective is. But they do need the mental security of thinking they had a positive part to play greater than a ride.

I get the feeling that this is directed at least to an extent in my general direction. I hope not, because I basically agree with everything you said. My arguments about the cost-effectiveness of ALS aren't to suggest that EMS could never become an critical part of a communities healthcare system (i.e. finally be "needed"), but that as ALS is run in most places, it is probably not as important as everyone thinks.

I am attracted to the idea of utilizing EMS to provide not only emergency service, but also a degree of primary care type services. I think such a system could be a cost-effective way to expand access to preventative primary care medicine in poorer locations while also providing a high level of emergency care for the (relatively few) who need it. By contrast, I think for many such communities, the money needed to expand to ALS could probably be better spent.

 

[Veneficus]

I get the feeling that this is directed at least to an extent in my general direction.

Not all all, actually i was trying to point out to vent (whom I usually agree with) that the discussion was getting very predictable.

 

[BossyCow]

But, if you used that same logic, all the medical professionals living in rural regions could say they can't provide good patient care because they don't see enough patients. Fortunately, other professionals know what education/skills they need to keep current and have enough ambition and/or professionlism to maintain them. They don't use their chosen place of residence as an excuse.

Actually they do Vent.. which is why rural areas are losing doctors and closing clinics. OB/Gyn departments are closing and scaling back with any high risk pregnancy being turfed to a more urban area. A friend of mine spent the last month of her pregnancy living out of a suitcase in Seattle (3+ hours away) because she was not able to get the level care she needed at our local hospital.

Our local hospital also had to close its psych wing because they were spending thousands recruiting the mandatory psychiatrist to manage the department and once their minimum required stay was over, they would open private practice and leave the department without the Med control required by the state to operate. Now our psych pts take a ride to Bremerton with no other option than a single room in the ER for mental health crises.

The other healthcare professionals also acknowledged what their chosen profession consisted of and the education it required. They obtained their education and continued on with their career in their chosen place of residence. Many prefer to take their advanced education, knowledge and skills back to their home towns to provide the highest possible quality medical care for their facility/agency.

And how long were they able to operate before giving up and closing their offices? I see it around here and in the community I lived in before this one. The cost of operating a clinic has become more than just the cost of the doc's and equipment. We had a bunch of doc's here who were on the verge of going out of business when a big HMO out of Seattle came and bought them out and ran a clinic.. they ran it for about 4 years and then closed the doors, leaving the docs scrambling to come up with a way to serve their patients. Currently they are working with the local hospital to provide the billing on a stop gap/ measure and the docs are bailing as soon as they find work elsewhere.

A small town hospital can still excel in patient care even if it doesn't have the latest technology or world renowned surgeons. I also know many of the surgeons from these smaller hospitals come to the big city facilities to practice new skills/techniques to take back home. It just depends on how hard you want to work for your career or to be a quality healthcare provider

But its a whole lot easier to take that time off when you are earning a doc's salary than if you are a volunteer or a basic making $12 an hour with a family to support.


This is how I look at it Vent.. I see rural EMS as a bleeding pt. Yes the patient needs a trauma center. I would love to have one of those in my back yard as well. To follow your logic, I shouldn't teach first aid and have people learn how to stop bleeding, because the pt needs a trauma center. I shouldn't have EMT's to extricate the pt and meet with ALS because the pt needs a trauma center. I shouldn't have an ambulance here to transport the pt to my local hospital.. because its not a trauma center.

Yes I wish every patient in my district could have ALS. I wish my district could provide the training to local young people so that they could provide that ALS to their own neighborhood and support a family with those wages. I wish that the local surrounding agencies who have ALS could afford to send me an ambulance with medics on board every time I call them. But they are also over stressed and understaffed and trying desperately to meet the needs of their underserved citizenry. The nearest adjoining ALS agency is currently serving their area with one of the worst EMT-Per capita ratings in the country and I'm supposed to ask them to give me a medic? They don't have enough medics to serve either the geographic area or the population base that they are legally bound to serve.

But to go back to that bleeding patient analogy, I'm just trying to stop the bleeding, because if I don't, that patient is not going to make it to the trauma center. I'm trying to keep some semblance of care in my district.

Now pardon me if I take some pride in what I do. I know I'm not a medic/rn/doc. I know I'm just a simple volunteer with a minimal amount of training. But if my neighbor is in trouble and I can put that minimal amount of training to work to help them get to the professionals that can fix what ails 'em, I'm going to do it and being me, I'm going to do it with as much time, effort, practice and study as I can afford to give it.

By your theory, teaching layperson CPR should be avoided because there should be a medic within that first 3 minutes of arrest with a Defib unit.

Now I don't know where you got the idea that I don't like ALS or dislike medics because I have the highest respect for both. There is nothing I like better than to see a medic with his/her 12 lead and drug box enter my ambulance when I have a critical pt in the back. I would cheerfully retire from EMS forever on the day that the public health community pulls its head out of its nether regions and gives my neighbors the same level of care that the urban areas receive.

In the meantime, whether it irritates you or not.. I will continue to try to stop the bleeding.

 

[JJR512]

I think this little fight is the best argument against nationalized EMS. People in one area decide that they know the best way to run things in areas they have no connection to besides hearing about them once or twice, and start issuing proclamations about how things should be done, based on thier own experience in a different area. This country is so freaking big that the regional variations are beyond anything that can be well handled by a nationalized system. Base level educational requirements perhaps...but certinaly not a central administration.

I feel the exact opposite. I still believe that many of the problems the rural providers are complaining about can be solved with a national system. Unless I'm grossly misunderstanding her, BossyCow is not saying that her area doesn't need ALS or that BLS is just fine. She is not saying that they don't want it. What she is saying is that her area cannot afford it. This is because the way it is now, the funding for it would come from just her area, which apparently is a poor area. A system with a "central administration" would give all the districts access to a central supply of funding and mandate that all areas get at least the minimum standard of care. If it is decided that the minimum standard is access to ALS by 911 in all areas, then that's what they get.

Does the FCC regulate rural radio stations less than they do urban stations? Does the FBI not care about a serial killer if he lives in a remote area (hint: Unabomber)? Does the FAA suddenly stop caring about planes when they fly over remote rural areas? No. And don't tell ask me how will a national EMS system get paid for by the US Federal Government when its budget is so horribly broken, because it pays for all those services and hundreds more. They just created a whole new top-level department (Homeland Security), they can find a way to fit an EMS into the budget somewhere.

In this sense, although many people are scared of this word, EMS would become socialized.

Hey Sasha, are you fightin' for us now?

Gag! I didn't realize the 12 costed that much!!

The owner of a private ambulance company I used to work for told me that the fully-loaded LP12s he ordered were $18,000 each. Not sure if they were new or used, though.

There are over 50 different EMS certifications/licenses in the U.S. with each state being "creative" for whatever purpose to do a piece mill patch work that has severely fragmented EMS. To further complicate matters, some states change titles and "skills" every couple of years so it is difficult to even know who is doing what or who is called what. This leads to confusion not only amongst the EMS providers but the public as well as the politicians who want to help but can't figure out all the different levels.

And this is a prime example of why I have brought up the need for national standardization in the first place. Thank you!

This thread, which I have been following, but largely holding my tongue, is preposterous. Legally and practically nationalizing EMS is impossible. Could you imagine the US fire Service as a federal agency? It works here in Europe because states are divisions of a country, whereas in the US, the country is actually a federation of largely independent states.

There are many federal agencies that operate across the country, in each of the independent states. In any event, please note that in my original question, I made it clear that it was not just about creating a federal (i.e., governmental) agency, but alternatively some type of non-government national agency. As I have said more than once, I am not saying that this absolutely has to be part of the government.

Looking at the concept of a national agency, federal or not, it doesn't actually need to run the individual departments. Individual departments can still be run by themselves, the county, or the state, as however they are now. The national agency could be formed solely as a regulatory and oversight agency. In a sense, this would make it somewhat similar to the FCC. The EMS agency would create regulations, education standards, ambulance standards, equipment standards, etc.

Wow! I did not realize we had so many experts in EMS development! (satire) Amazing, so many immediate Systems Developers that do not know squat about establishing EMS Systems and what is required or payment structures. Then yet want to proclaim National EMS Standard (patient protocols) when they have NO correlation at all. National Standards of Treatment and Protocols would be disastrous! Until we have a standardization of education, thinking of such is asinine! Making statements such Medical Doctors or comparison of such demonstrates poor knowledge of EMS Systems. Especially considering the history of how EMS was developed, and the role of the providers as physician representatives.

I cannot quite tell if it is me specifically that you are referring to mainly in what you said. I absolutely agree that creating a set of national protocols would be a disaster for exactly the same reason that you do, which is that people all over are taught different things. This problem is the core of what I'm talking about. Standardizing EMS education must be the first priority.

I remember you have said in the past that you favor a less rigid set of protocols, you do not like the "cookie-cutter" approach that says "when you see sign x and symptom y perform skill z". In fact, I was actually thinking of you when I wrote my previous post about grossly reducing the protocol set. With the caveat that the education is standardized first, so that everybody at the same level is on the same page, do you agree with the concept of the protocols largely being replaced with "assess the patient, use your clinical judgement, determine what needs to be done and do it as you've been trained to do it" approach?

 

[VentMedic]

Actually they do Vent.. which is why rural areas are losing doctors and closing clinics. OB/Gyn departments are closing and scaling back with any high risk pregnancy being turfed to a more urban area. A friend of mine spent the last month of her pregnancy living out of a suitcase in Seattle (3+ hours away) because she was not able to get the level care she needed at our local hospital.

Our local hospital also had to close its psych wing because they were spending thousands recruiting the mandatory psychiatrist to manage the department and once their minimum required stay was over, they would open private practice and leave the department without the Med control required by the state to operate. Now our psych pts take a ride to Bremerton with no other option than a single room in the ER for mental health crises.

What you are describing here is happening everywhere and not just in the rural services. Centralization of specialty services are in the big cities also. There is no need to have 10 high risk pregnancies units in 10 hospitals within 2 miles of each other. The same for a level 3 or 4 NICU.

Many of these doctors would prefer to practice in the rural regions but some specialized service requirements are just not appropriate.

High risk pregnancies need to be in a facility that can handle both the mother and the baby. They should not have to rely on a real fast ambulance trip cross country when something happens or the baby rely on a Level 3 or 4 neo team to fly in quick enough to save the child's life.

The same for psych services that are consolidating in to centralized locations. So far the only ones complaining are those that work on ambulances who hate "routine" psych transports. But, the overall cost savings are huge.

So this is nothing new as hospitals have been centralizing their resources for years.

As far as the trauma center, you don't need one in youe backyard if you have a reliable system in place for your region to get people the appropriate level of care. But, that also should include highly trained and educated people to recognize when a higher level of care is needed immediately rather than a First Responder calling an EMT who then calls for an ALS truck who then call for whatever.

 

[medic417]

So what makes you think they're going to contribute an extra $5/month if they won't approve a tax levy?

Tax is a cuss word. You tell me your going to tax me and I rebel. Funny though many people would actually pay less with the tax levy than they would a $5 month contribution. We have actually had less than 5% not pay on a regular basis. People look at it that they have an option. Taxes are looked at as forced. Plus once I approve a little tax whats to say that tax will not increase. I have seen the extra amount in amounts from $3 to $10 a month in many communitys that are as impoverished as any areas in the USA. You still bill for each call. In my area standard is $100 plus mileage for us to show up. Then you also bill for transport with rates for BLS or ALS plus mileage.

 

[BossyCow]

The same for psych services that are consolidating in to centralized locations. So far the only ones complaining are those that work on ambulances who hate "routine" psych transports. But, the overall cost savings are huge.

No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr.


You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment.

If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll.

Unless I'm grossly misunderstanding her, BossyCow is not saying that her area doesn't need ALS or that BLS is just fine.

This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally.

I think Vent I'd have less of a reaction to your posts if you could just try to keep the condescension out of them. Not all of us without ALS or without medical degrees are uneducated, illliterate hicks in this for the adrenalin rush and the misplaced desire to be a hero. Some of us are dedicated community members trying as best we can to do what is possible, within a broken system to provide for our neighbors. Your repeated declaration of "Get your EMT-P" or get out of EMS is insulting, denigrating and shows a woeful ignorance of life in rural america. Your distant view of how other systems have done fine is merely anecdotal accounts of exceptions to the rules. Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again.

Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.

 

[Ridryder911]

No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr.


You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment.

If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll.




This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally.

I think Vent I'd have less of a reaction to your posts if you could just try to keep the condescension out of them. Not all of us without ALS or without medical degrees are uneducated, illliterate hicks in this for the adrenalin rush and the misplaced desire to be a hero. Some of us are dedicated community members trying as best we can to do what is possible, within a broken system to provide for our neighbors. Your repeated declaration of "Get your EMT-P" or get out of EMS is insulting, denigrating and shows a woeful ignorance of life in rural america. Your distant view of how other systems have done fine is merely anecdotal accounts of exceptions to the rules. Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again.

Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.

I can assure you if your hospital is dropping staff and going to extenders or associates it is on life support and will die. Might as well, write the DNR now. Such organizations as JCAHO, and major insurance providers will start reviewing and start denying payments. You proabably have already started seeing change in the name of supplies as that is also one of the first s/s of troubles. It is probably not that they cannot obtain the personnel but rather lack the funding to afford the "right" people.

Unfortunately, I have seen this quite a bit and as a consultant have seen the ominous signs of death to the medical community. Too small to be able to afford and economically sustain, yet too far & too dangerous to be without. The later usually wins. Part of the risk of living in such areas.

I am not criticizing invlovement in any volunteerism, or even BLS level. Rather I am again stating that their role is as first responder and should not confuse or give the impression that the community has a true EMS system. Many will never endorse or support; if they presume what they have is good enough. Alike hospitals and other healthcare facilities, regionalization has to occur to be able to sustain most communities EMS. This is where most Fire Services feathers begin to ruffle as well. Proctective feelings that they only want to provide for their "territory" or they have to "have our own" usually come into play. Although, there are Fire Districts, many of the cities and communities have their own and rather for it to stay that way.

Well, not everyone gets what they want.

The call volume(s) will increase. Even in the rural area, as the age of the baby boomer increases, as even small rural hospitals ED's have no more room. Change is imminent and that is one thing that is for certain, good or bad.

R/r 911

 

[VentMedic]

No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr.

They would complain alot more with a dead or severely handicapped baby to care for.

You contradict yourself. You say that this is not happening in medicine, but only in EMS. So I cite several examples of how it is happening in other fields of medicine and you say its happening everywhere. "Centralization of services" as you call it is what caused me to lose my main ALS support agency, they are so busy doing ALS transports for the hospital that they don't have the staff to respond to my ALS emergency. Because the rural hospitals are sending patients away because they can't afford to train, staff and equip in all specialties. In my area that includes cardiac, echo lab, neurology, pediatrics, and probably more I can't pull out of the brain at the moment.

If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll.


This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally.

I think Vent I'd have less of a reaction to your posts if you could just try to keep the condescension out of them. Not all of us without ALS or without medical degrees are uneducated, illliterate hicks in this for the adrenalin rush and the misplaced desire to be a hero. Some of us are dedicated community members trying as best we can to do what is possible, within a broken system to provide for our neighbors. Your repeated declaration of "Get your EMT-P" or get out of EMS is insulting, denigrating and shows a woeful ignorance of life in rural america. Your distant view of how other systems have done fine is merely anecdotal accounts of exceptions to the rules. Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again.

Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.

No I did NOT contradict myself. Patients are taken to a hospital that better equiped to handle a high risk pregnancy and a neonate. It is a little more involved than just have a doctor who knows alittle bit about it but doesn't have the equipment or staff. It costs a small fortune to have a high risk unit/specialized surgical services as well as a NICU unit for maybe 3 - 8 babies per year that meet the criteria. And who would want to be in a hospital that has only LVNs caring for them with a high risk pregnancy or neonate? Please email me the names of these hospitals that are replacing RNs with CNAs and LVNs so I can put them on the AVOID LIKE THE PLAGUE list on the travelers or employment sites. There are still national mandates for staffing they must meet. Seriously, hospitals that cut care for their patients are just dangerous and should have their patients transferred to a better facility.

Do you honestly think your hospital is going to build a level 3 NICU, specialized surgical suites and high risk unit if they don't want to hire RNs?

I am definitely not ignorant to rural life and have found the best way to conquer that stigma is to become better educated instead of using your "rural life as an excuse.

Again, I was the one who corrected someone for using the term uneducated as you continue to use when discussing rural life. I find that very insulting to those of us from the country side of life. Under educated is less insulting.

PAs do NOT replace doctors. They are Physician extenders like NPs. They work under a physician's license, not independent practice.

Psych patients: yes, they may have to endure a couple hours of discomfort. But, to be in a facility staffed only with CNAs and LVNs where they may have to be tied down for the duration, is much more cruel than being in a facility where they can have some freedom.

Please think of the patient. They are the ones getting the treatment, not the family members or the EMTs. They should be in a facility that has the best options. Those in the rural regions should at least be qualified enough to recognize this.

When living in the islands, I always had a credit card handy with at least $10K on it so I or my loved ones could be flown to the most appropriate facility in a medical emergency if it was beyond the capabilities of the 30 bed hospital nearby. The drive to the mainland would be of no inconvenience if it was for more appropriate care like a cardiac cath. There is no need to sacrifice a life with the excuse "we're rural".

 

[BossyCow]

Ridryder911;121855]I can assure you if your hospital is dropping staff and going to extenders or associates it is on life support and will die. Might as well, write the DNR now. Such organizations as JCAHO, and major insurance providers will start reviewing and start denying payments. You proabably have already started seeing change in the name of supplies as that is also one of the first s/s of troubles. It is probably not that they cannot obtain the personnel but rather lack the funding to afford the "right" people.

Actually the hospital's basic services are still intact and stable. We are just redefining what that is. Good fiscal management has kept the infrastructure growing, the hospital's basic problems are the inability to compete salary wise with larger more urban areas. They have purchased some of the local clinics who have gone under and attempted to shore them up until they get back on their feet, but the economic reality of an area that is mostly uninsured retired people and a high public assistance population makes it a challenge for many of the doctors to stay in business. But these are outside clinics, not the hospital itself.

Unfortunately, I have seen this quite a bit and as a consultant have seen the ominous signs of death to the medical community. Too small to be able to afford and economically sustain, yet too far & too dangerous to be without. The later usually wins. Part of the risk of living in such areas.

That is the case here. Many of the higher income residents pay to go to Seattle or Bremerton for their healthcare. The lower income do without.

I am not criticizing invlovement in any volunteerism, or even BLS level. Rather I am again stating that their role is as first responder and should not confuse or give the impression that the community has a true EMS system. Many will never endorse or support; if they presume what they have is good enough.

You have always been respectful and thoughtful in your understanding of the issues Rid and I respect your experience and your opinions. It's that flip, condescending attitude of "You'd have ALS if you just tried" B.S that really gets my blood boiling. I've spent way too much time and effort to try to change things to hear from someone with no inkling of what our region has been through telling me to 'get creative' and 'write grants'. That's like asking a multi-system trauma pt to 'buck up and quit bleeding'.

Alike hospitals and other healthcare facilities, regionalization has to occur to be able to sustain most communities EMS. This is where most Fire Services feathers begin to ruffle as well. Proctective feelings that they only want to provide for their "territory" or they have to "have our own" usually come into play. Although, there are Fire Districts, many of the cities and communities have their own and rather for it to stay that way.

I think its more fear and panic than ego at work here. To eliminate what little we have and to turn our service over to a system that has repeatedly dropped its level of service in our area has people spooked. When you are the ugly red-headed stepchild of the state, the idea of trusting the state to provide for you doesn't have a good history on which to base that trust.

Well, not everyone gets what they want.

Well said!

The call volume(s) will increase. Even in the rural area, as the age of the baby boomer increases, as even small rural hospitals ED's have no more room. Change is imminent and that is one thing that is for certain, good or bad.

R/r 911

Actually our call volume has decreased. It's gone from around 200 and some per year to just above 150. Some of this is changes in our recording but a lot of it has to do with the young kids moving to areas with more opportunities. I haven't seen the census stats but I won't be surprised to see a decrease.

The larger more urban area where our hospital is located and where my husband works as a medic has seen a huge increase. They are currently running about 15-20 calls a shift with two medics and doing that on 24 hour shifts. With sick leave, vacation coverages and turnover in personnel, he's worked in the past week: 24hrs on friday, a 12 hr shift on Saturday, 24hrs on Sunday, and another 12 on Monday, he's got today, tomorrow and thursday to recuperate then he's back at it again. The 12's were overtime shifts to cover for guys on leave. Their floater position is currently on shift after the resignation of one of the medics and they are about to lose one more medic to another system that pays better.

They at least have the option of billing for service which my system does not. And they are the agency that is supposed to fill in with ALS for me if the private ambulance company is unavailable due to an out of town transport. So this is my 'go to' system that's going to give me ALS???? I don't think so! Besides as a civil system, they cannot provide aid outside of their tax district without sending my agency a bill. I get the bill, but cannot bill my pt for the cost. This is how we went through a $1,000,000.00 reserve fund in the past 3 years.

 

[Veneficus]

Pandora's box

No, the ambulances are not the ones complaining. The complaints are coming from the families of the patients. Who instead of getting their loved ones into a facility that can treat them and stabilize their meds they are being restrained and tossed into an ambulance for a 2 hour ride to the facility, after intake into the local ER where they are restrained sometimes for hours, while waiting for the one on-call medical health professional who has to come in and make an official determination of their need to be transported to a Behavioral Med Ctr. .

First let me say the ED is no place for a psych patient. But because of the hazard of an actual medical problem causing the altered mental status and the fact that psych facilities are not set up and cannot afford to do medical screenings, the ED is where the acute psych ends up. This causes more problems. First it costs a fortune to run all the tests to rule out life threatening conditions, none of which can be ruled out by interview because of the alteration. Secondly, because nobody pays for psych care, (at least not anywhere near enough) the patient gets stuck in the ED until a facility decides it makes enough from the paying customers to offer a charity bed. If it is a state facility, it needs to wait for a bed to open.

For the safety of all involved as well as the fact there is not enough resources in the ED to babysit psych pts and still perform the EDs primary function, patients must be restrained, both physically and chemically. Families need to get used to that idea. I have personally seen upwards of 11 psych patients lined up on walls in the ED and wait 48-72 hours for an available bed in a psych facility in urban areas. Meanwhile some JCAHO idiot is saying that is unacceptable and the hospital shouldn’t be paid. The only other option is to turf the people to the street, which is totally unrealistic.

If we want equal healthcare and same level of service for all the population regardless of cost or ability to pay, then we have to socialize the system. Making sure that the medic/population ratio is the same across the country based on safe levels, instead of dependent on the agencies ability to fund the payroll. .

I am the standard bearer for socialized medicine. I even figured out a way to pay for it, but those living in rural areas will not see any appreciable difference from it. Socialized medicine will still be based on need. In small communities it is not reasonable to have every service available, so you will still be looking at long distances for service.

This is what I have always said JJR512, but the talk still goes on again and again and again about how we all have to become ALS and those who don't are just stupid, ignorant, backwards or doggedly stubborn and determined to undermine the advancement of EMS globally. .

You guys in rural America are stubborn; otherwise you would come to the city. There is safety in numbers. Many wanted isolation; they have received what they wished for. I am a charitable person, but I can think of no reason why urban Americans should pay for rural Americans who cannot support themselves and refuse to be relocated. My parents left Europe, giving up homes and land because there were no jobs at the time. Where they were going had a better future than what they left. More people need to catch on to that. Think Global, not small town.

QUOTE=BossyCow;121833] Rural healthcare is suffering and EMS along with it. We are dropping a staff of RNs and replacing them with PCAs, CNA, NAs, LPN overseen by one RN. We are losing doctors to a phsycians service staffed with PAs who know nothing of our families, our history and may not have ever seen us before or will ever see us again.[/QUOTE]

As for not having a doctor, I am lucky, my education will ultimately cost me $200,000 plus interest for the loans. I simply cannot work for less than I owe. If a community cannot afford a paramedic, they certainly cannot afford a doctor. Rural healthcare is lucky to have what it does. I am sorry to say it is about as much as can be realistically hoped for. Even if you have a PCP, the average PCP in the US has 2300 active patients and spends 8 minutes of face time each. They will probably not know anything about your family or remember anything about you until they pick up your chart next time you are in. They also spend between 1 and 2 hours of currently uncompensated paperwork time on a given day to get paid the meager amount medicare/medicade will give them. Some PCPs lose up to $40 per vaccination they give.

Your assertion that the progress in Healthcare globally is the model EMS should follow is ludicrous. We will go from one form of broken to another.

Forgive my rudeness, but what you provide is basically a knowledgeable neighbor and a ride. It is a honorable service to your community as well as your fellow man. I would be very proud to do that myself and I agree that those in such a situation should be able to do more. Furthermore, lack of knowledge and ability may cause harm to the neighbor you are trying to help. I think you are doing your best in a situation in which there are no easy answers.

 

[BossyCow]

First let me say the ED is no place for a psych patient.

We have groups here working to set up some sort of acute medical health clinic that would at least be prepared for the special needs of the psych pt.

I am the standard bearer for socialized medicine. I even figured out a way to pay for it, but those living in rural areas will not see any appreciable difference from it. Socialized medicine will still be based on need. In small communities it is not reasonable to have every service available, so you will still be looking at long distances for service.

As am I. I am not looking for a Mayo Clinic in my rural neighborhood. I just want people to quit yelling at me about how I should be doing more.

You guys in rural America are stubborn; otherwise you would come to the city.

Hell yeah! We do not as a rule complain about the lack of service, we know its the price we pay for the beautiful place where we live. I was making a point to those who state that ALS should be everywhere and I'm at fault for it not being here. I would love to have it, but its not a reality in my forseeable future.

Rural healthcare is lucky to have what it does. I am sorry to say it is about as much as can be realistically hoped for.

So you are saying that we cannot hope to have ALS? Hmmm radical notion.. but when I say it I'm accused of everything from ignorance to egomania to the overthrow of the future of EMS as a whole.

Forgive my rudeness, but what you provide is basically a knowledgeable neighbor and a ride. It is a honorable service to your community as well as your fellow man. I would be very proud to do that myself and I agree that those in such a situation should be able to do more. Furthermore, lack of knowledge and ability may cause harm to the neighbor you are trying to help. I think you are doing your best in a situation in which there are no easy answers.

Harm? How can driving them to the hospital in a clean ambulance instead of the back of a pickup be more harmful? How can giving them the glorified first aid of BLS be worse than them dying on the floor of their home because they fell and fx a hip? You state above that my area is not going to get ALS and can't expect good healthcare, then you add at the bottom that by helping my neighbors get to the ALS agency and the ER is going to cause them harm... I give up.

 

[Veneficus]

You state above that my area is not going to get ALS and can't expect good healthcare, then you add at the bottom that by helping my neighbors get to the ALS agency and the ER is going to cause them harm... I give up.

Sorry, I was trying to state that providing certain treatments without advanced knowledge can be more dangerous than just doing what you are now. I could have said it a little better.

 

[Ridryder911]

I would like to hear from our team "down under" from what I understand, Australia offers ALS in even in the most remote and rural areas.

R/r 911

 

[Veneficus]

I understand that to be a state controlled agency that rotates duty stations. That would be great in the US. But so would the education they must have. I just don't see anywhere in the US opening their wallet to pay for it at the moment.