n5iln

And this is a bad thing...how?

There are too many barriers to volunteer fire services going away. The first, and foremost, is the "free lunch" mentality of those receiving those volunteer fire services'...well...services. Let's look at the options here. Go to local-government-supported paid services? My department serves a 25-square-mile area, 85% of which is rural/agricultural in makeup, and the remainder is small-town. The landowners already scream like bane-sidhes whenever taxes go up for such trivialities as highway maintenance...what will they do with the substantial tax increase needed to fund a full-time fire department? How about a privately-owned pay-for-play fire service, one where the department gets paid by the property owner for services rendered? That's already being proven as a Very Bad Idea in several areas; my employer was one of the first companies to attempt that model, and they're fighting tooth and nail to divest themselves of those failed experiments. What's left? Nothing I can think of...except volunteer services. There's a reason something like 46% of the United States receives fire protection and suppression from volunteers.

That still leaves the question of what constitutes adequate communication, and whether the staff member on duty is or is not a care provider permitted under HIPAA to receive and review patient-care documentation by the ambulance crew. I learned this evening that the Operations Manager is going to be discussing the matter with the manager of the facility to determine what documentation will be necessary for the home to meet its reporting needs. My guess is that the home will have to develop its own form that the senior medic on the crew will sign indicating either "transported" or "evaluated/no transport". I'll know more when I go in for my next shift on Friday.

Herein lies the rub. A proprietor home is NOT a health-care facility. It's a group home operated by a third-party contractor who maintains the facility, makes the meals, does the laundry, keeps the lights, heat and cable on, and hands out meds. This one has a LPN on duty eight hours a day, five days a week, to inventory and count meds into residents' boxes for later distribution. Beyond that, there's a MSW in charge of the place, several staff members to see to the regular needs of the residents...and that's pretty much it. Of all of them, ONLY the LPN could be considered legally qualified AND have the "need to know" to review my PCR. And since we only transport OUT of the facility (evaluations and the like), that takes away the "need to know" unless either the ER doc or the patient's own doc decides to clue the LPN in on what happened in the ambulance or at the hospital...not likely; the LPN will most likely get a set of discharge instructions and an updated med sheet. In short, there is NO transfer of care from our crews to the proprietor home; it's only the other way around. So complying with HIPAA means they DON'T get a copy of my PCR, or, in this case, the refusal form...although they're more than welcome to review the patient instruction sheet that I provide a refusing patient.

There's a separate sheet we provide the patient that contains all that. It comes to us stapled to the refusal form, along with the HIPAA notice. We're sort of backwards in a lot of areas, but we've learned to be proactive with things that can land us in court...

You have the right of it in many, many cases. However, the regional Medical Director anticipated this very issue, and included a requirement in the regional protocols that mandates a PCR be completed for each and every dispatch, no matter the final disposition...transport, refusal or cancelled call. And in the case of a patient refusal, we are required to complete a primary survey, obtain at least one full set of vital signs, and complete an appropriate focused exam based on the original nature of the call and any complaint the patient presents. And all refusals are reviewed by the CQI committee. Additionally, it's a company policy that all refusals are cleared and logged by the duty supervisor prior to the crew departing the scene, unless remaining at the scene would cause further difficulties (as in the case of a domestic assault, in which case the police take over where we leave off). Based on this requirement, I consider a refusal form part of the medical documentation for the run, and therefore covered as privileged patient information under HIPAA.

How interesting that this thread should come up right now, considering a call I had early this morning. Scenario: Called to a proprietor home (not to be confused with a nursing home) for an evaluation of a resident that tripped and fell. We're told on arrival that this is a new requirement for the proprietor home; ANY resident who falls must be evaluated by qualified medical personnel, even if it's obvious that the only result will be a patient refusal. Patient is evaluated, all findings are within normal limits for the patient...not so much as a scrape or bruise. We complete the PCR and the required refusal form and obtain patient's signature on both indicating patient does not wish transport. Staff member then tells us they need a copy of the refusal form to document that patient was evaluated and refused transport. We refuse to provide a copy, indicating that the form falls under HIPAA as a medical document. Supervisor backs us when the staff member calls to complain. Something tells me this is going to mushroom in a hurry.

Volunteer: FF/EMT in small rural volunteer FD (call volume: around 120/year for the department) Paid: EMT in fairly active urban ALS system (average call volume: 55,000/year systemwide)

Better check your state laws first. In NY, for example, blue lights are specifically restricted to volunteer FFs. NFPA doesn't have a lot to say about how ambulances are lit, unless the ambulance in question is a FD rig. The KKK-A-1822 specs are what govern ambulance design in the US. Their specs just happen to parallel NFPA specs in many areas. Just my two cents' worth...save up the change for a root beer or something... That said, my duty rig has NO white showing to the front other than the headlights. It helps a great deal with preserving night vision, if nothing else.

The obvious question here: where is the money for that going to come from? Discuss.

I've seen rebound hypertension after NTG wears off...it can be that profound. It also doesn't seem to last very long, so I don't normally panic about it unless the patient is symptomatic. I'd be more worried about the BP going back down below 100mmHg systolic afterwards, especially with no more NTG on board. But if the patient's not symptomatic from the comparative hypotension, I won't worry very much about it either. The bottom line: look at the patient. All the machines spitting out all those numbers don't mean diddly without looking at the patient. Is their baseline BP in the high 90s or low 100s systolic? Often we have no way of knowing unless the patient tells us first, and they may not think it's something to pass on to us unless we start fussing about it. And if we start fussing about it, that just makes the patient anxious, and throws their vitals for a loop.

BZZZT... As I understand HIPAA, the patient has the right to view ANY part of his or her medical records at ANY time, which means they (under the letter of the law) can read your PCR even before the ED sees it. Now under the SPIRIT of the law, they need to go through the routine of requesting a copy of their records from the business office during regular business hours, just as they would with their records from a physician's office or hospital. And there's absolutely nothing in HIPAA that says they can make any changes whatsoever to those records (except to correct demographic information). It would take a small team of lawyers to work through the details, and I'm a medic, not a lawyer (thank Ghu!).

just for the record: I'm a paid, career EMT. And I both appreciate and value the dedication and commitment of the volunteer staff that serves the village where I live. That service is staffed by a combination of paid and volunteer personnel, and maintains a full duty roster 24/7/365+. For two ambulances. I know. I also volunteer for that service, 24 hours a month. Stubborn, irreducible facts tell me there is absolutely no loss of life due to delayed response in my community; in fact, the service I work for probably loses more to response delays than the service I volunteer for. Good sir, I'd be happy to continue discussing this topic either here or in the "Volunteer v. Professional" thread. However, your ad hominem stance here leads me to believe you are either unable or unwilling to provide hard, factual information to support your position. I therefore withdraw from both threads; I see no dishonor in walking away from a no-win situation.

Before I start, there will be a brief pause to pull on my turnouts. I expect I'm going to need them once I finish saying what I'm going to say. First...I feel like you're making a lot of these claims solely as flamebait. You say people die in our communities because we have volunteer EMS instead of paid. Documentation, please. Complete with citations. Prove what you claim. Second...I have yet to hear anyone, here or elsewhere, offer up any sort of realistic, viable means of funding paid EMS in areas that are currently served by volunteer corps, other than what I suggested (complete nationalization of the health care system). There's only so many tax dollars to go around. What will get cut to fund EMS? Fire? Most of those are volunteer around here too, for exactly the same reason: no tax base to hire a paid staff. Trash collection? Done by private companies. Highway maintenance? Already well beyond the breaking point. The almighty dollar dictates a great deal in these United States. In this case, it dictates who can and can't have paid emergency services. Simple, painful, stubborn, irreducible fact: economics always wins out over just about any other consideration. I'd be so happy to have someone prove me wrong, logically and factually. 'Nuff said...for now.

For the sake of { discussion || argument }, could someone please define "remote"? I don't consider myself as living in a "remote" area -- the closest Level II trauma center is only about 45 minutes away by ground, 15-20 by air -- but volunteer emergency services are all there are for us. (Sidenote...it's only a Level II center because they don't have neuro in house 24/7 right now, or so I'm told.)