Was ist ein Krankenwagen?

[Veneficus]

For those of you just tuning in...

In the thread about the practicality of EMT basics as an emergency responder, there was a discussion about rural communities need of EMS.

Poster 11569150 added this to the discussion:

I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services. I would like to use covelo, ca as an example: it is an hour and a half drive to the nearest town from there let alone to the nearest hospital and als ambulance. The folks up there are mostly dope growers and natives. Handfuls of ambulance companies have looked at staffing that town but no one will touch it because its so secluded. They usually rely on air transport if the weather is nice other than that hour plus als rendezvous. Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place. Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely. Just saying something to think about.

While it was most likely the intention to point out the need of EMT basics in a rural population, I think unknowingly it raises a larger question of what the goals of rural EMS systems and even their components really are or need to be.

I am of the mind that minimally trained responders, basic first aid and MFRs are absolutely essential to rural communities. Particularly in communities similar to the one described here.

I am unconvinced that EMT-Bs in their current form are required or even useful in such situations. Infact, I am thinking that this type of community is so remote, that even in the continental US, it qualifies as a remote/austere environment better served by that type of care provider and system.

It is also my opinion that if such a community wants EMS, it is not going to be able to simply adopt a standard approach to suburban, urban and even most rural systems. Attempting such is a terrible misuse of valuable resources without benefit.

A little later in the thread I will talk about what I see as the best use of resources and system design, but for now, let me get to the thread title.

I think the German word for ambulance, Krankenwagen, is the most important part of the discussion. As I understand it translates roughly (I do not speak German) to "sick-car" more simply "sick-wagon" and a wagon in is defined by Merriam-Webster as:

a: a usually four-wheeled vehicle for transporting bulky commodities and drawn originally by animals

b: a lighter typically horse-drawn vehicle for transporting goods or passengers

I bolded the important parts.

The reason I bring this up is to support the point that an ambulance, while commonly understood to be a dedicated vehicle with sirens and lights, and a host of medical apparatus is not the only way to meet the functional definition.

I have transported a patient on a backboard, on a scoop stretcher, and on a canvas litter in a SUV (I believe a toyota, but I wasn't really paying attention to the make, it was small)

So really what the rural community needs is a vehicle capable of transporting a supine patient. I would further argue it doesn't even need to be a dedicated vehicle. It doesn't need lights or sirens. (not like they have a problem with traffic) It doesn't need a bunch of useless medical junk like onboard O2 and suction that was probably never turned on in the history of the vehicle, nor OB kits, back-up supplies, spine boards, vacuum splints, and all of that other BLS crap that causes driving a dialysis patient to and fro cost so much.

The sick remote rural resident needs a ride. In a wagon.

Now then...

I issue forth a challenge...

How would you set up an EMS system balancing effectiveness, level of care, and costs for such a community?

(I have already come up with a way, but I want to see what you think first.)

 

[NYMedic828]

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

 

[MexDefender]

So really what the rural community needs is a vehicle capable of transporting a supine patient. I would further argue it doesn't even need to be a dedicated vehicle. It doesn't need lights or sirens. (not like they have a problem with traffic) It doesn't need a bunch of useless medical junk like onboard O2 and suction that was probably never turned on in the history of the vehicle, nor OB kits, back-up supplies, spine boards, vacuum splints, and all of that other BLS crap that causes driving a dialysis patient to and fro cost so much.

If you do not work in a rural community or volunteered for one than you are more than speculating... making assumptions rural ambulances would not use such things.

but we do... part of the problem being is we have a higher transport time and scene time due to the overwhelming size of our jurisdiction which makes us use our ambulances even more so than a city ambo. I guess it depends on the location and what time of business runs the town economy and crime rate but I assure you what you just listed couldn't be further from the truth on usage.

 

[abckidsmom]

Maybe we should have the funeral home pick up the task. They already have a car that can transport a supine patient.

Even such a remote location will have law enforcement, and they will be using the same phone number as the people use for calling for an ambulance. Maybe the cops should do it?

 

[Veneficus]

If you do not work in a rural community or volunteered for one than you are more than speculating... making assumptions rural ambulances would not use such things.

but we do... part of the problem being is we have a higher transport time and scene time due to the overwhelming size of our jurisdiction which makes us use our ambulances even more so than a city ambo. I guess it depends on the location and what time of business runs the town economy and crime rate but I assure you what you just listed couldn't be further from the truth on usage.

I am not speculating on whether or not it is used. I know most of it will have no effect on outcome in a majority of cases, that doesn't matter if it is rural or down the street from the hospital.

 

[Ruamkatanyu]

Maybe pick up trucks with toppers could be used as bls ambulances in rural areas. In thailand most volunteer groups use them you can see some in my thai ambulances album.

 

[NYMedic828]

If you do not work in a rural community or volunteered for one than you are more than speculating... making assumptions rural ambulances would not use such things.

but we do... part of the problem being is we have a higher transport time and scene time due to the overwhelming size of our jurisdiction which makes us use our ambulances even more so than a city ambo. I guess it depends on the location and what time of business runs the town economy and crime rate but I assure you what you just listed couldn't be further from the truth on usage.

Ambulance usage of lights and sirens have not been proven to have any worthwhile improvements in outcome in 95% of places and are usually considered to be more dangerous in most cases than beneficial. They often only improve transport time by a couple of minutes at most over long distances.

In NYC if I can get by without lights and sirens then you don't need them out in the sticks. That is not speculation, that is a fact.

A big reason we still have them in my opinion is because when people call an ambulance they have this expectation that they immediately get blazing lights and sirens to the hospital. I annoy a lot of patients and family members when they ask me why we are waiting at red lights and I explain to them that there is no real emergency presenting itself here.

 

[abckidsmom]

My real opinion on this is that we should have different standards for EMS in different community types in the country. I like when the state requires all ambulances to have certain sets of equipment, though like you, I think the dialysis transport business should be excluded from the fully-stocked ambulance business.

An ambulance in the station, with BLS providers to grab it and respond when necessary is a perfectly viable option. These people are going to pick up a medic when they get in range of civilization, and as the medic who does the rendezvous I really want them to have a real ambulance, with maybe a real few sets of vitals and maybe some real airway management on the people with the altered mental statuses before I get there.

It might not make a huge difference in outcomes, but when you are scrambling to manage a BLS airway for a long ride, a nice suction set up, some adjuncts and a little education go a long way toward getting you to awesome.

It doesn't have to be fancy or all that awesome, but a van ambulance with some basic equipment and an EMT-B is an acheivable minimum standard in this country of 300 million people in 2012.

My dad, at the age of 17, in 1971 was thrown in the back of a pickup truck and driven to the hospital 1.5 hours away after a split-rim tire blew up in his face, destroying his forehead and leaving him with exposed brain. He was miminally responsive during the ride, and the trauma care in 1971 decided that they would harvest a rib and put it in there to replace the bone. He survived, and continues to, but his memory kind of sucks.

Rural EMS is not 100% necessary, but 90 miles from everybody's got an iphone, it's pretty selfish of the society not to do something about it.

 

[MexDefender]

Ambulance usage of lights and sirens have not been proven to have any worthwhile improvements in outcome in 95% of places and are usually considered to be more dangerous in most cases than beneficial. They often only improve transport time by a couple of minutes at most over long distances.

In NYC if I can get by without lights and sirens then you don't need them out in the sticks. That is not speculation, that is a fact.

A big reason we still have them in my opinion is because when people call an ambulance they have this expectation that they immediately get blazing lights and sirens to the hospital. I annoy a lot of patients and family members when they ask me why we are waiting at red lights and I explain to them that there is no real emergency presenting itself here.

I wasn't arguing the lights and sirens bit but the supplies and whether they have an affect on the outcome (life saving/prolonging) for the pt is the point, but many measures we learn are what others around me call "comfort measures" true or not, we still use them per protocols/judgement.

calls it bls crap but it has a use and is used in rural ambulance services. /only point.

 

[NYMedic828]

Rural EMS is not 100% necessary, but 90 miles from everybody's got an iphone, it's pretty selfish of the society not to do something about it.

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.

I wasn't arguing the lights and sirens bit but the supplies and whether they have an affect on the outcome (life saving/prolonging) for the pt is the point, but many measures we learn are what others around me call "comfort measures" true or not, we still use them per protocols/judgement.

calls it bls crap but it has a use and is used in rural ambulance services. /only point.

Blazing lights and sirens and increasing your driving speed often makes a patient less comfortable. A slow smooth ride is more relaxing and makes people feel like the world is not ending.

It has its use, but the risk vs reward is not weighted heavy enough on the reward end.

 

[abckidsmom]

Ambulance usage of lights and sirens have not been proven to have any worthwhile improvements in outcome in 95% of places and are usually considered to be more dangerous in most cases than beneficial. They often only improve transport time by a couple of minutes at most over long distances.

In NYC if I can get by without lights and sirens then you don't need them out in the sticks. That is not speculation, that is a fact.

A big reason we still have them in my opinion is because when people call an ambulance they have this expectation that they immediately get blazing lights and sirens to the hospital. I annoy a lot of patients and family members when they ask me why we are waiting at red lights and I explain to them that there is no real emergency presenting itself here.

You can keep the complaint monkey off your back by phrasing this with a little bit more kindness and gentleness. "We are already helping her, no need to increase all of our risk by driving lights and sirens to hurry her up to the hospital where they can do what we are already doing."

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.

I'm just saying that no matter how impoverished an area is in this country, it's 1,000 times richer than many places in the world who manage to have rudimentary EMS systems.

There's no excuse for the local government not providing *something* along those lines.

Blazing lights and sirens and increasing your driving speed often makes a patient less comfortable. A slow smooth ride is more relaxing and makes people feel like the world is not ending.

It has its use, but the risk vs reward is not weighted heavy enough on the reward end.

Here we completely agree.

 

[NYMedic828]

You can keep the complaint monkey off your back by phrasing this with a little bit more kindness and gentleness. "We are already helping her, no need to increase all of our risk by driving lights and sirens to hurry her up to the hospital where they can do what we are already doing."



I'm just saying that no matter how impoverished an area is in this country, it's 1,000 times richer than many places in the world who manage to have rudimentary EMS systems.

There's no excuse for the local government not providing *something* along those lines.




Here we completely agree.

Wouldn't it be nice if the government actually cared about getting involved in EMS? Then we could have EMS standardized and unified, actual governing EMS bodies and everyone would receive the same service. This I completely support but it will never happen because EMS is a profitable business. I suppose I contradicted myself a bit here but I only agree with it if the footwork for the entire system nationwide is federally controlled.



I don't blatantly tell them there is no emergency, I usually say something more along the lines of "they are in a stable state and the risk of using lights and sirens is not indicated unless their situation is life threatening"

 

[abckidsmom]

Wouldn't it be nice if the government actually cared about getting involved in EMS? Then we could have EMS standardized and unified, actual governing EMS bodies and everyone would receive the same service. This I completely support but it will never happen because EMS is a profitable business. I suppose I contradicted myself a bit here but I only agree with it if the footwork for the entire system nationwide is federally controlled.

I don't think we really want the standardized and unified, same across the board EMS...look how that's working for the schools. Different standards for different areas. Like the different between a university hospital's ER and the podunk community hospital ER. A minimum standard that's enough to get by on.

 

[NYMedic828]

I don't think we really want the standardized and unified, same across the board EMS...look how that's working for the schools. Different standards for different areas. Like the different between a university hospital's ER and the podunk community hospital ER. A minimum standard that's enough to get by on.

I'll accept that.

I wasn't specific enough in my reply. As far as standardization I mainly mean as to the scope of an EMT or paramedic. I shouldn't be able to perfrom an emergency tracheotomy in one area but not even intubate in another.

 

[abckidsmom]

I'll accept that.

I wasn't specific enough in my reply. As far as standardization I mainly mean as to the scope of an EMT or paramedic. I shouldn't be able to perfrom an emergency tracheotomy in one area but not even intubate in another.

Different levels if necessary. I would not be averse to seeing a standardized level a click or two up from the paramedic right now, but I want it to be the highly educated supermedic that we dream of here.

 

[Jambi]

This can be turned into a why vs why not argument, but I think a look at other countries that provide to rural/austere environments deserves a look.

How does Canada, Australia, Great Britain, and New Zealand achieve this?

I chose these countries because each has an educational model in place that would seem to serve the need with additional education for independent short-term community care needed in such environments.

abckidsmom mentions that with all this money, the government should ensure that such services are available. If so, then why not subsidize a spot for a physician in that area then, and preempt any need for an expensive EMS system?

 

[Veneficus]

moderating my own thread

Back on point...

How would you set the system up?

What kind of providers?

What kind of equipment?

What kind of transport?

What scope of practice?

Who and how is it paid for?

 

[mycrofft]

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

HAHAHAHAHHAHH!!! Good one!

 

[mycrofft]

History

Maybe we should have the funeral home pick up the task. They already have a car that can transport a supine patient.

That is exactly where we were prior to NHTSA creating EMT's.

such a remote location will have law enforcement, and they will be using the same phone number as the people use for calling for an ambulance. Maybe the cops should do it?

Some don't have law enforcement either. But it has been done.

 

[mycrofft]

Move hospitals/public health closer to rural areas and stop concentrating them in urban centers. I can only cite Nebraska from experience, but there are as many (maybe more) hospital beds in Omaha as there probably are in the rest of the state, or the (at least) surrounding two hundred mile diameter on the map. Little county and community hospitals were run out of business, and while not much, they could be the proverbial "port in a storm", as well as health care preventing or forestalling the health issues which result in that (long) ambulance ride.

I am so happy here not to have read the old chestnut "There's nothing they can do for my pt I can't do in the ambulance".h34r:

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

Vollies and individuals certified in first aid to EMT-B; EMS or fire depts may get paramedics and up if they train refresh and support them. MD's at hospitals and clinics and Telemed if necessary. Labs and diagnostics: I'm not expert enough but the basics can be in a clinic. How an EMSA would handle this I am at a loss to know.