Was ist ein Krankenwagen?

[Veneficus]

For starters the town barber would assume the role of surgeon.

HAHAHAHAHHAHH!!! Good one!

While you laugh, in the absence of a physician and the reality that most people with life threatening injuries and illnesses will not survive or be seriously impaired, the idea of a "medicine man" or "common surgeon" who has specific training in less emergency and more outpatient type care may be worthy of serious consideration.

After all this is supposedly what NPs and PAs were designed for, but simply not the role they are filling in most cases.

The idea of stocking a bunch of epi, amio, and other code drugs and equipment clearly is an idea from people who have no idea what they are doing in an austere environment.

Allowing life threatening pneumonia, sepsis, tetanus, etc to develop and then try to BLS these people 2 hours to a paramedic not equipped or trained to handle it is a poor EMS system strategy.

As barbaric as it sounds, the ability to close a wound without knowing the different layers of skin, inflammatory mediators, or all of the "what if's" while handing out antibiotics like candy is going to be far more useful that a 2 hour ambulance ride on a backboard with a nasal cannula blowing oxygen up somebody's nose.

 

[Jambi]

I like mycroft's take on it...

I still think the paradigm of a federal or state service providing this makes more sense. People would be rotated in and out of backwaters where some of their skills would atrophy and in and out of inner city areas where their skills could be challenged more in other aspects. Maybe four years service like that, then earning higher rank/education get a more-permanent assignment...sort of like the military used to be. Heck, give them a GI Bill of sorts. And employ veterans preferentially.

I believe that EMS should be a public service just as fire and police are. This can be taken down two paths.

First would be a national model and integrating into the United States Public Health Service Commissioned Corps, though this would require an undergraduate degree however, and would also carry professional ramifications (positive).

Second would be a state sponsored program, but still within the public service model.

Third would be a more local approach at the city or county level, but still with a public service model.

A problem with this is that I do not think that the public service model, with benefits and pensions, is not necessarily a sustainable one. While this is more political than anything, it's worth mentioning as it will play a role in such a change.

There is also the issue with training and education. Of course what is and what's believed to be needed have been taken on ad nauseum, so there's no point in bringing that into play. However, there is the issue of attracting highly trained and educated persons to such areas, thus loan repayment programs or other incentives would be in order, or has Mycroft offered, set the system up on a rotating basis (Though I would ask CalFire employees if they like the rotation thing). The ability to attract, or not attract, such people (thinking Drs) to such areas is not a new one and continues to be an issue.


I see two things being needed is such areas. First, for most stuff, a freaking car ride to a facility would likely suffice. Thus, the need, as I see it, would be to have a provider that can reliably differentiate between the need for medical transport versus car ride. Furthermore, such a provider would be needed for those few situations where intervention is required prior or during transport. Therefore, a well educated, well trained, and experienced provider is needed in these areas. This can and should be augmented with tele-medicine.

I still like to model of Canadian providers for this, but the only way I see such a push taking hold would be to subsidize it through a federal program like the USPHSCC where such education and training is required for entry, and is incentivised via loan reimbursement.

Once we start getting too excited though, there comes a point where there may be preexisting professions that fill most of this gap like PAs and NPs, though an RN seems well-poised for such a spot with additional pre-hospital training.

Thoughts?

 

[Jambi]

Federal Service as I cited in the EMTB as first responder thread. USE those war-surplus supplies, medics and helos and humvees!

This federalization could occur through the USPHSCC, though paramedic would need to become commissionable along with RN, or as Vene has written, the paramedic vocation could be absorbed into nursing as a speciality/subspecialty.

This also makes me think of this: http://www.med.navy.mil/sites/nmotc/swmi/Pages/IDCBackground.aspx

Serves as the Medical Department Representative (MDR) aboard surface ships, with the units of the Fleet Marine Force, and at various isolated duty stations ashore independent of a medical officer. Performs patient care and associated shipboard administrative and logistical duties. Performs diagnostic procedures, advanced first aid, basic life support, nursing procedures, minor surgery, basic clinical laboratory procedures, and other routine and emergency health care. Conducts and direct preventive medicine and industrial health surveillance programs. Provides for health education to junior medical and all nonmedical personnel. Perform all patient care and medical management functions set forth in Chapter 9, Manual of the Medical Department. Administers the Radiation Health Program as necessary. Senior personnel assigned to shore and operational staffs provide medical assistance, training, and inspection services to operational forces and component units. Additionally, when assigned ashore, they serve primarily as nonphysician health care providers at fixed medical treatment facilities (MTFs).

http://usmilitary.about.com/library/milinfo/navynec/blhm8425.htm

 

[mycrofft]

Civil service

Surgeon General's office has structure and even neat uniforms.

Civil service is a way of providing vital services when private providers cannot or will not, due to lack of profit motive, excessive cost requiring amortization throughout a taxpayer base, cultural prejudice etc. The demonification of all civil service due to the excesses of some is a continuation of ignorant childishness and corruption plus private providers seeing a means to get into contracts they will lowball and otherwise milk to get more money for less product.

Control and regulation of care is a concern, but also, we need to ask the question just to get it out there: is care over-regulated in rural settings?

(sidebar signature: American corruption is abhorrent now not only in its prevalence, but in its lack of intelligence or ambition. If you are going to sell out, don't go cheap:glare:.)

 

[Jambi]

Civil service is a way of providing vital services when private providers cannot or will not, due to lack of profit motive, excessive cost requiring amortization throughout a taxpayer base, cultural prejudice etc. The demonification of all civil service due to the excesses of some is a continuation of ignorant childishness and corruption plus private providers seeing a means to get into contracts they will lowball and otherwise milk to get more money for less product.

Hence my belief that such a model is the only real solution. People will still react the same way they vote, on emotions and assumptions.

The more I think about it, the more I like the civil service/federal model. It would be a first step and could be used to move the vocation forward into a profession.

 

[Veneficus]

First would be a national model and integrating into the United States Public Health Service Commissioned Corps, though this would require an undergraduate degree however, and would also carry professional ramifications (positive).

I think this is probably the best idea I have ever heard. Both for getting rural providers and for advancing EMS as a profession. :beerchug:

Second would be a state sponsored program, but still within the public service model.

A good idea, but I think that forcing a state to fund it gets into the same political argument as regional services. "Why should wealthy places pay for poorer places."

Coupled with the anti-community mentality rampant in US society today, I see this being unfeasable.

Third would be a more local approach at the city or county level, but still with a public service model.

This does not work in urban areas now, I see no hope it would work in a rural area.

A problem with this is that I do not think that the public service model, with benefits and pensions, is not necessarily a sustainable one. While this is more political than anything, it's worth mentioning as it will play a role in such a change.

Current events demonstrate it is not.

However, there is the issue of attracting highly trained and educated persons to such areas, thus loan repayment programs or other incentives would be in order,

These loan repayment programs are not lucrative enough and do not work now.

I personally know a physician who accepted money from a farm organization in a contract such as this. Because of the residency requirement even for GPs in the US, he was forced to defer service until after residency.

When he finished, he discovered he could earn more working in a suburban hospital than his loan repayment would cover. So he just paid the money back.

The same problem exists for the National health service corps. I looked into doing this myself. Since they do not offer their own residency spots, you are still tasked with finding a residency own your own. Once you complete residency it is very obvious from a financial standpoint, uniformed service is a poor choice.

If uniformed service actually offered their own residency spots, there would be a line of doctors waiting to apply.

Furthermore, such a provider would be needed for those few situations where intervention is required prior or during transport. Therefore, a well educated, well trained, and experienced provider is needed in these areas. This can and should be augmented with tele-medicine.

I like the idea but I am unconvinced it could be done by any level outside of a physician. For those requiring advanced intervention over such a long period of time, Simple ALS equipment is not going to work. It will require the initiation of critical care therapies. Potentially even blood products.

There is extreme cost and logistical issues implicated with this. It would also be needed so little, I thin calling for airmed would be a much better option.

If airmed cannot fly, well...game over.

I still like to model of Canadian providers for this, but the only way I see such a push taking hold would be to subsidize it through a federal program like the USPHSCC where such education and training is required for entry, and is incentivised via loan reimbursement.

I do not think this can work with the established practices today. I think it would require basically a community care paramedic spot. With a bachelor's in some sort of health science.

If it did work the way it is, it would be working. Res ipsa loquitur

Once we start getting too excited though, there comes a point where there may be preexisting professions that fill most of this gap like PAs and NPs, though an RN seems well-poised for such a spot with additional pre-hospital training.

The reason these existing professions do not do it is because the lifestyle, pay, and benefits do not adequetely compensate for the effort involved.

The only large group of people who seem to find uniformed service desirable or beneficial are exmilitary. (which means they probably already have a retirement income, or have already had several military promotions that make their pay and benefits far better than entry level.)

If you look at the average starting salaries for many physician specialties outside of residency, assume a total principle and compounded interest of $600K (average as of late according to The New Physician Magazine) You could likely pay that off within 6 years post residency with money to spare and a really nice lifestyle.

I know a married couple of physicians, one an EM the other an OB/GYN. Using his salary as a post residency EM, they paid off both of their total loans in 4 years. Her salary was all keeps.

 

[hogwiley]

This point I strongly disagree with.

It is your choice and solely your choice to remain in a rural area and as such you accept the consequences of that choice.

This is the similar to how it is my responsibility to put food on the table for someone who chooses not to work and collects money from everyone else in society.

You want to live in a certain area, you accept the pros and cons of that decision.

Actually its not always a choice. People live where they were raised, have family, are familiar and comfortable with their surroundings, and because they dont have the money to move.

Even still, people in rural America do accept the "consequences" of where they live by and large. We do just fine without a taco bell and best buy on every corner, and accept the fact that if you have a serious medical emergency that needs immediate advanced medical attention, you are probably going to die. It actually happens all the time. You can probably find all kind of examples of people dying from an AMI out in the sticks who would have survived had they lived in an Urban area, if anyone cared to look.

Its the people in big citys that are crying to the media and calling lawyers because junior was out selling drugs and got shot and the ambulance took a whopping 18 minutes to get there.

 

[Jambi]

Actually its not always a choice. People live where they were raised, have family, are familiar and comfortable with their surroundings, and because they dont have the money to move.

There is always choice in both where a person lives, and what services they're willing to pay for.

there is a local community that voted to pay an increased tax to have an "enhanced" ambulance response time because they live in what's considered a rural area where a response time under 29 minutes and 59 seconds is considered acceptable.

Their desire for risk aversion was great enough to stimulate a lowered risk acceptance.

There is always a choice.

 

[mycrofft]

There is always choice in both where a person lives, and what services they're willing to pay for.

there is a local community that voted to pay an increased tax to have an "enhanced" ambulance response time because they live in what's considered a rural area where a response time under 29 minutes and 59 seconds is considered acceptable.

Their desire for risk aversion was great enough to stimulate a lowered risk acceptance.

There is always a choice.

There isn't always a choice to move at a given time, often because folks wait too long to leave an area with dwindling incomes and infrastructure. You don't make it on the edge by quitting, but their steadfastness causes them to wait too long to jump. They might beg money for a ticket out or a ride, but they lose everything.

On the other hand, it is a syndrome here (or was, before the real estate bubble popped) that retirees would move to the mountains then have to move back because it was too far to vital services, namely, medical.

 

[wildrivermedic]

Actually its not always a choice. People live where they were raised, have family, are familiar and comfortable with their surroundings, and because they dont have the money to move.

...especially in Native communities (Covelo, CA was originally cited) where the entrenchment is thousands of years deep, for better and worse.

IHS does provide physician care in most of these areas though the services vary. Where I live the clinic does not provide any care beyond basic family practice, and that only during business hours. Federal grants also fund Community Health Worker positions and other preventative/early detection programs. Emergency care and transport falls to us as a nonprofit volunteer crew.

There is a need for non-emergency transport, to keep us available instead of driving the toothache to town in the middle of the night. The answer is not to downgrade our ambulance to a medivan. These are our friends and neighbors we're caring for, and we make sure we have all the tools available (and know how to use 'em, too). My personal preference is for expanded and ongoing education for rural responders, leading to a cautiously expanded scope including those few things shown to make a difference in extended transport time.

 

[EpiEMS]

If you want to end the unnecessary use of a fully-stocked BLS ambulance for patients that don't need it, pull the funding. There's a better way to handle the "I don't have a car" problem, say, community-based funding for non-emergent transport to medical services. Have an ambulette service -- you can handle many patients that way without needing an ambulance.