Seattle/King County Fire and EMS politics.

[Rialaigh]

It seems like this is what we should be doing everywhere in healthcare. For some reason there's a segment of the EMS population that seems to think that providing non-acute care is beneath them.

My issue is EMS has already become (not even in the transition stage, we have already transitioned) into a customer service taxi service. I would like to think that non-acute care IS beneath EMS. Because that was not what EMS was created for and utilizing EMS for non-acute care is not efficient.

For the price of an ambulance ride to the hospital for a non acute issue that could/should be dealt with by a family care physician you could

- Send a limo to the persons house to pick them up for a Dr. appt on monday and pay for the appt
- Send a Dr. to their house for a house call on Monday thereby eliminating the need to go to the hospital at all or even travel the Dr. office
- etc ..etc...etc..

I personally believe non-acute care is below ER physicians and nurses as well and people that show up with the complain of "tooth pain X 2 weeks" should be glanced at for 60 seconds by a PA or APNR in the triage room and told to follow up with their dentist or family practice doctor. If they don't have one then...tough luck until someone can fix the healthcare system to EFFICIENTLY provide these services to people who cannot pay for them. You cannot efficiently do that in the ER.

I personally would be okay with adding a hundred clinical hours to an EMT-B curriculum and then putting paramedics only on interfacility critical care transport tucks...

OR

Make paramedicine a 4 year degree that allows the medic to triage, treat, and hand off to BLS for transport to a community medicine center (urgent care) or the hospital, or write a refferal to a Dr.



However, as long as hospitals will run their own EMS in the same city it is a conflict of interest to allow people to AMA or discourage them from being transported to the ER. Business will dictate that everyone gets transported no matter what the reason because they can then bill for an ER visit too.

 

[Veneficus]

My issue is EMS has already become (not even in the transition stage, we have already transitioned) into a customer service taxi service. I would like to think that non-acute care IS beneath EMS. Because that was not what EMS was created for and utilizing EMS for non-acute care is not efficient.

You are right, it is not efficent.

I would not say it is beneath them nor would I say customer service driven is bad.

Afterall, medicine is patient driven. Is that not customer service?

If we only had EMSthat responded to life or death, we would only need basics. That cuts down on spots and salary. Does that work fr you?

For the price of an ambulance ride to the hospital for a non acute issue that could/should be dealt with by a family care physician you could

- Send a limo to the persons house to pick them up for a Dr. appt on monday and pay for the appt
- Send a Dr. to their house for a house call on Monday thereby eliminating the need to go to the hospital at all or even travel the Dr. office
- etc ..etc...etc..

True.

But who will pay for it? Nobody.

Because if somebody did pay for it, there would be no need to call EMS.

That is why the 75/yo lady with CHF goes into crisis and winds up with an ALS ambulance through the ER and into the ICU.

Because medicare won't pay the taxi cab ride to her doc for a lasix prescription refill that costs a few dollars.

There is also the big problem of primary care physician reimbursement and standard of care.

The former are not paid a livable wage as it is and many are going broke. Many (most)are forced to work in hospitals not only for job security, but also for all of the diagnostics that they would have to supply themselves. Like an x-ray, CT, or lab.

Customers (aka patients) will not wait 3 days for lab resuls when they could go to the ED and get them in 45 minutes.

Have a 55 y/o guy come to a PCP with a "really bad headache" guess where he is going? To the ED CT. Why pay the PCP middleman? Go direct, pay less.

You really want to see a farce: medical homes.

I personally believe non-acute care is below ER physicians and nurses as well and people that show up with the complain of "tooth pain X 2 weeks" should be glanced at for 60 seconds by a PA or APNR in the triage room and told to follow up with their dentist or family practice doctor. If they don't have one then...tough luck until someone can fix the healthcare system to EFFICIENTLY provide these services to people who cannot pay for them. You cannot efficiently do that in the ER..

I believe the ED physician is a complete waste. Replace them with IM who could help 99% of the patients in the ED better and have admitting capability.

Give all of acute care back to anesthesia, who are already in the hospital and deal with life and death patients daily. Oh and have the surgeon wander down when required. (which won't be often) Look at that, better care, cheaper, and eliminates the middleman.

I personally would be okay with adding a hundred clinical hours to an EMT-B curriculum and then putting paramedics only on interfacility critical care transport tucks....

again, in the name of efficency, have nurses run CCT and have basics do 911. More middleman loss.

OR

Make paramedicine a 4 year degree that allows the medic to triage, treat, and hand off to BLS for transport to a community medicine center (urgent care) or the hospital, or write a refferal to a Dr.

Exactly, and since the medics are doing it, there is still no need for EM.

However, as long as hospitals will run their own EMS in the same city it is a conflict of interest to allow people to AMA or discourage them from being transported to the ER. Business will dictate that everyone gets transported no matter what the reason because they can then bill for an ER visit too.

Misplaced fault.

Medical directors usually work in the ED. They bill those EMS patients. Also EMS in the US is paid for transport, which means, no transport, no money. At current some places bill for showing up, but with a large indigent population in a given area, that would be totally unsustainable.

 

[Rialaigh]

You are right, it is not efficent.

I would not say it is beneath them nor would I say customer service driven is bad.

Afterall, medicine is patient driven. Is that not customer service?

If we only had EMSthat responded to life or death, we would only need basics. That cuts down on spots and salary. Does that work fr you?



True.

But who will pay for it? Nobody.

Because if somebody did pay for it, there would be no need to call EMS.

That is why the 75/yo lady with CHF goes into crisis and winds up with an ALS ambulance through the ER and into the ICU.

Because medicare won't pay the taxi cab ride to her doc for a lasix prescription refill that costs a few dollars.

There is also the big problem of primary care physician reimbursement and standard of care.

The former are not paid a livable wage as it is and many are going broke. Many (most)are forced to work in hospitals not only for job security, but also for all of the diagnostics that they would have to supply themselves. Like an x-ray, CT, or lab.

Customers (aka patients) will not wait 3 days for lab resuls when they could go to the ED and get them in 45 minutes.

Have a 55 y/o guy come to a PCP with a "really bad headache" guess where he is going? To the ED CT. Why pay the PCP middleman? Go direct, pay less.

You really want to see a farce: medical homes.



I believe the ED physician is a complete waste. Replace them with IM who could help 99% of the patients in the ED better and have admitting capability.

Give all of acute care back to anesthesia, who are already in the hospital and deal with life and death patients daily. Oh and have the surgeon wander down when required. (which won't be often) Look at that, better care, cheaper, and eliminates the middleman.



again, in the name of efficency, have nurses run CCT and have basics do 911. More middleman loss.

OR



Exactly, and since the medics are doing it, there is still no need for EM.



Misplaced fault.

Medical directors usually work in the ED. They bill those EMS patients. Also EMS in the US is paid for transport, which means, no transport, no money. At current some places bill for showing up, but with a large indigent population in a given area, that would be totally unsustainable.

I agree, The only reason I said I would like to think it is "beneath" them is because we were designed to be a service that facilitated field care and transport to a facility while providing life saving interventions in the field. What it has become is what everything has become in the US (with few exceptions) and that is a business. So yes, it is completely customer service oriented now and the 75 year old grandma that is slightly dehydrated doesn't give a rats tail if you give her some fluids or not, she wants to be treated nicely, with respect, and given a ride to the ER.

My point with the efficiency of transport is that the government pays for it. So if they are willing to pay for the billions of dollars spent on needless transport can't we pay guys 10 bucks an hour, give them a cab or mini van, and have free healthcare transport for everyone in the US. Call the number, cabbie shoes up, present the cabbie with a paper copy of your appointment reminder and an ID, get a free ride there and back, same goes if you want a ride to the ER. Cut the ambulance out of all that completely, sure makes more sense. Allow an individual to use the service up to 10 times a month or something...

Family practice physician salaries is a joke...and a completely different discussion. Most PA's I know make more then the DR. they work under at a family practice.

I would be all for having a IM doc running the ER and having anesthesia do all emergent procedures (or the surgeon), stuff like intubation, central lines (when needed). Hell give intubation back to respiratory therapist please.. (another pet peeve of mine... and another discussion).

The only reason I said paramedics run CCT is because around here at least the nurse in a CCT ambulance makes about 20k more than a medic in a CCT ambulance and they can both be taught the same things for transport easily. Hell, just make it a CC-EMT and get rid of EMT-P

 

[Rialaigh]

Also, I apologize for the huge D-Rail...


Back to Seattle and King county. On the topic of so few paramedic trucks. I have no issue with that, make the 7 paramedic trucks supervisors who handle complains and maybe are available for prolonged extrications. When a basic truck transports the medic over that area is aware and if a few trucks in the same area are out on transport the medic can provide backup and run calls in their absence. Frankly I applaud King County for cutting costs in this area if it is something that the citizens do not want to pay for.

 

[Summit]

You are right, it is not efficent.

I would not say it is beneath them nor would I say customer service driven is bad.

Afterall, medicine is patient driven. Is that not customer service?

If we only had EMSthat responded to life or death, we would only need basics. That cuts down on spots and salary. Does that work fr you?



True.

But who will pay for it? Nobody.

Because if somebody did pay for it, there would be no need to call EMS.

That is why the 75/yo lady with CHF goes into crisis and winds up with an ALS ambulance through the ER and into the ICU.

Because medicare won't pay the taxi cab ride to her doc for a lasix prescription refill that costs a few dollars.

There is also the big problem of primary care physician reimbursement and standard of care.

The former are not paid a livable wage as it is and many are going broke. Many (most)are forced to work in hospitals not only for job security, but also for all of the diagnostics that they would have to supply themselves. Like an x-ray, CT, or lab.

Customers (aka patients) will not wait 3 days for lab resuls when they could go to the ED and get them in 45 minutes.

Have a 55 y/o guy come to a PCP with a "really bad headache" guess where he is going? To the ED CT. Why pay the PCP middleman? Go direct, pay less.

You really want to see a farce: medical homes.



I believe the ED physician is a complete waste. Replace them with IM who could help 99% of the patients in the ED better and have admitting capability.

Give all of acute care back to anesthesia, who are already in the hospital and deal with life and death patients daily. Oh and have the surgeon wander down when required. (which won't be often) Look at that, better care, cheaper, and eliminates the middleman.



again, in the name of efficency, have nurses run CCT and have basics do 911. More middleman loss.

OR



Exactly, and since the medics are doing it, there is still no need for EM.



Misplaced fault.

Medical directors usually work in the ED. They bill those EMS patients. Also EMS in the US is paid for transport, which means, no transport, no money. At current some places bill for showing up, but with a large indigent population in a given area, that would be totally unsustainable.

OK... read the whole thread... and this is my favorite post.

 

[RocketMedic]

Also, I apologize for the huge D-Rail...


Back to Seattle and King county. On the topic of so few paramedic trucks. I have no issue with that, make the 7 paramedic trucks supervisors who handle complains and maybe are available for prolonged extrications. When a basic truck transports the medic over that area is aware and if a few trucks in the same area are out on transport the medic can provide backup and run calls in their absence. Frankly I applaud King County for cutting costs in this area if it is something that the citizens do not want to pay for.

It's not a cost that they ever had a chance at paying, and most of the citizens don't know there's alternate options available. That cost cutting = unbalanced service.