ALS Care in Urban vs Rural areas thoughts?

[steve_emt_68]

As a Paramedic serving a rural area of Nebraska and a member of the local BLS squad, I think we have figured out a system that works well for Nebraska. I am employed by the local Critical Access Hospital to provide interfacility transports. I also respond to 911 calls for Paramedic intercepts. We have found that our system works well. We provide ALS to our community when we are available.

The system works so well that we now cover six critical access hospitals with two stations and are looking at additional expansion at the request of outlying hospitals.

We also work the emergency room of our two primary hospitals when not responding to calls. This allows our medics to stay proficient in skills like IV starts, rhythm strips and intubations, We also are exposed to numerous prescription medications that help us when in the field assessing our patients. Working in the ER also helps us "prove ourselves to the physicians in the area and builds trust with them.

As in many rural areas, it is impractical to have a Paramedic on every truck, this system allows the communities to maintain their local volunteer squad while still receiving the benefits of ALS care and it allows the Critical Access Hospitals to have access to qualified interfacility transports without burdoning the local squads and pulling nurses from the hospital. This is truely a win win situation.

[JakeEMTP]

We provide ALS to our community when we are available.

" When we are available " doesn't sound like the best option, or very practical. I hope someone doesn't require ALS when you AREN'T available. Or maybe I misunderstood.

As in many rural areas, it is impractical to have a Paramedic on every truck

Ah, but if Paramedic was the standard, this wouldn't be an issue.

this system allows the communities to maintain their local volunteer squad

Which is detrimental to my profession

This is truely a win win situation.

For whom, exactly?

[toutdoors]

Dust, it is hard to argue some of your points, they are extremely valid. It is easy to see that you also seem to care deeply about EMS, and the standard of care that is out there.

I hope you don't interpret my posts to imply that volunteers should be used in place of full time career personnel, I would not support that idea myself, and I was a volunteer. Let's face it, the full time medic is going to see more calls than the volunteer, no doubt, and it is very likely that they will be afforded more and better continuing ed while on the job, during down time. All of these opportunities will result in a medic that has seen more patients and has a broader base of education and experience to draw upon. That is a pretty good package no doubt.

But I guess my question would be this: If the budget was so tight for small town USA, and they could not afford to support a paramedic, should we say "Well sucks to live there, you get hurt or sick you die before the medics can make that 20-30 mile trip"? Or would it be a little bit better, to have at least a BLS transport service with 6-12 dedicated EMT's that recognize their limitations, and want to at least try to help their neighbor as best they can with what is available to them? Such as a simple AED and Combitube or King LT airway for the really problematic pt's?

I appreciate and admire your zeal in wanting to promote ALS as the next best thing to an ER in home town USA. Because I believe it is just that, not quite an ER, but pretty dang close to it. I think that it is absolutely awesome that we have a prehospital program here in the US that allows a person to become trained and certified to the point that they can do many of the same things performed in an ER to stabilize a pt. ACLS is an excellent example of this.

Honestly though, is there no middle ground? As an EMT I understand my limited educational background,(the limits of that education are becoming more evident the further along I go in paramedic class) and my the limited amount of skills I can perform. I can only hope that other EMT's are also aware of their limitations, and that we are NOT a cheaper version of ALS, we are no version of it at all!!! The one thing I can not stand is to sit and listen to a BLS provider sit and brag about how much they can do for you. All you can do is dress an injury, basic splinting, some C-Spine immobilization, assess V/S, and blindly stick a small garden hose down someone's throat, and sometimes zap the crap out of some poor guy. Maybe get an IV, depending on scope of practice in some states. Now, all you EMT's I am not belittling us, (I may be in class for medic, but the card still reads EMT), what I am saying is very simply this: As an EMT, there are a FEW things I can do to help you survive (hopefully), until ALS arrives, or we get you to the ER, whichever occurs first. I am not a miracle worker, nor do I have a fingerprint from the hand of God in my back pocket, I am simply someone who has been trained to mitigate the few things that can take you out of this world real quick, like no airway, and no pulse. The rest of the stuff, well, hang in there bud, there is more help on the way. Sometimes just the presence of someone on scene to say, ok, we are going to do our best for you and we have more help on the way, is enough reassurance to calm a cardiac pt down for those extra few minutes needed for ALS arrival, or for that trauma pt to say, ok, I can make it through this, these guys will take care of me, and hey, more help is on the way, great. Then again there are those times when all the help on scene at the time of the incident will not help some poor sap out of their woes.

I don't know Dust, is there room for some middle ground with the understanding of how narrow that room may be? I mean seriously, is something better than nothing? I won't argue the fact that in a perfect world, there would be a medic on every ambulance in this country, but frankly, I do not see that happening.

Why? Simply put, money. It has been said time and time again. Another problem is the public's perception of what they are getting, I agree wholeheartedly with you on this too Dust. But what do you think the problem is? Is it that BLS providers brag about how good they are, or is it that people are content to live where they choose, and have to accept the fact that they do not have all the resources avaible to them if they had lived in a larger urban environment? I say that the best we can do is educate people, look at what has happened in regards to heart attacks, and strokes. People are being told that if you think something is wrong, call for help. What is the result, we are getting more and more people calling because they think they are having a serious medical problem, when it may actually be some indigestion or slight naseau. Do I consider that to be a burden to us? Absolutely not, better safe than sorry, besides I am getting paid to be here, so go ahead and use me, that is why I am here.

Now Dust there are some old firefighters on my department that still say they did not want to do EMS, they joined to fight fires, so you have allies on the fire side too. But seriously, I hate to see that two organizations that should work so closely together can have such issues as to who should do what. You kinda make it sound as though there are no good fire medics out there at times the way you get rolling. Could just be your intensity, or my misinterpretation too. But I enjoy reading your posts, you put alot of thought into them, and shed some good light on subjects.

Take it easy

[AZCEP]

Very interesting suggestions you make tout. Sounds like quite a bit of thought went into them. Bravo.

The difficulty with finding the "middle ground" you speak of is the lack of providers that are willing to gain the education before they are given the "skills" they are after. The current BLS curriculum is where the intermediate was ten years ago. The intermediate level has all but been replaced for most areas because it is obsolete thanks to the current BLS. A rather vicious circle, yes?

Allowing for lesser levels does not improve the situation. This is not an easy problem to solve, but it is one that is definitely needed. Some tough choices will have to be made, and some feelings will get hurt in the process.

[steve_emt_68]

JakeEMT,

Unfortunately having ALS on every call isn't going to happen overnight so therefore it is better that we provide ALS when available which right now is approximately 95% of the time. If we were in an all or nothing situation no one would get ALS. I believe that we really do have a win win situation. By working with the volunteer squads we have improved their level of care and instilled confidence in their skills so that when we aren't there they can do their best. The communities still get immediate response while waiting on ALS. The hospitals get more to work with by having ALS respond and having ALS there to transfer out their patients and our crews gain valuable experience by working in the hospital environment.

Apparently you have some great disrespect for the volunteers in your area, that is unfortunate. I too have worked with poor volunteer squads. I however became involved with the squads to improve patient care. I currently serve as the training director for my local squad, we actually work on EMS skills not just rehashing old war stories.

This country was built on the volunteer spirit and I have seen many a paid squads who just go thru the motions because it is their job and when the end of shift comes they care less. You truely will not find people more engaged in patient care then the volunteers of the local squad. Sure they lack experience, knowlege and skills but they never lack dedication. That is why the system that we have is a win win. The volunteers do their thing provide BLS care and do it right now and ALS arrives and takes over. WIN WIN.

[Dustdevil]

Nonsense. You win because you get to go only on calls you think are worthy of your attention, and the vollies win because they get to play with the siren with nothing more than a part-time hobby commitment and three weeks of monkey training. After all, were else can you have that kind of fun that cheaply?

But in absolutely no way whatsoever does your community win anything. Paramedic intercepts is the absolute worst of all possible ALS solutions, but especially in a rural system. In fact, it is just a hair's width from useless. Sure, medics love it, for the reason mentioned above. All the glory and none of the BS. Wonderful. But the people that do need ALS are getting it fifteen to thirty minutes (or more) later than they needed it, if they get it at all. Many, many times they will never get it at all because the low-training, low-experience volunteer basics that assess them lack the necessary education and experience to competently determine who needs ALS and who doesn't. No, having a checklist "protocol" for when to call does not equal competent assessment. And, as you darn well know, they call you out on plenty of people who did not need ALS intervention, as well as critically delaying transport of people who really did need ALS just because some checklist said to call you instead of get them to the hospital. Do they call you out on suspected MIs, strokes, or respiratory distress, or do they get them to the ER as soon as possible? I think I know the answer to that, and it's not a good one.

EVERY EMS patient needs ALS. I will say it again; EVERY EMS patient needs ALS, with no exceptions. Do they all need ALS intervention? Nope. Not even most of them. But there is absolutely NO way to know who needs what until they have received a competent assessment from an advanced educated provider. Assessment is the single most important ALS skill in our arsenal. And without it, ALS intervention is useless.

Don't mean to crap on your parade, because yeah, I know how cool it is to dump all the BS runs on the jolly vollies and save your energy for the sexy runs. Most of us wish we were in that position. But EMS isn't about us. It's about the community we serve. And quite obviously -- despite all the garbage we all spew about doing it because we just want to help people -- the vast majority of providers in this country (especially the vollies) do it simply because they get a thrill out of it. It's time to stop labelling a system as "working well for us", when in fact we like it only because we like the selfish benefits it gives us personally, without giving a moment's thought about the benefits it gives -- or denies -- the community.

[JakeEMTP]

Apparently you have some great disrespect for the volunteers in your area,

On the contrary, I have great respect for the volunteers that clean up the parks and the river banks. We are talking about people here that are sick or injured. Every patient deserves and requires a thorough assessment by a qualified provider, regardless if it is a true ALS call or not. Your community deserves it and quite frankly, should demand it.

You truely will not find people more engaged in patient care then the volunteers of the local squad. Sure they lack experience, knowlege and skills but they never lack dedication.

I beg to differ on your first sentence. They may be keen, however, patient care suffers due to your second sentence. Without education beyond advanced first aid, experience, knowledge and skills, how is it beneficial to the patient? After all, that's what we're really talking about here.

[akflightmedic]

Great posts guys, nice keeping it civil.

Tout...welcome and thank you for quality posts. Maybe try breaking up into paragraphs when you write these long ones...would make it easier for everyone to read and possibily find and understand your message more easily.

[toutdoors]

Yeah AK, my high school English teacher kept harping on me about that too, sorry.

I agree with alot of people in here, Dust, and Jake are obviously incredibly intent on ensuring, or pretty much demanding that a paramedic be available on every ambulance.

Dust, and Jake, I believe that most people here will agree with you that more ALS is needed, as I have stated, I won't argue that point one bit. The big question is simply this: How do we, as an EMS organization, get more ALS services to people?

Where do we start the lobby efforts, and or the educational advertisements? Do we start with our medical directors, and ask them to start putting the word out to more medical directors that they should scrap their BLS and go to ALS? I agree it would be a starting point. It may even help get more ALS services out there. Will it solve the problem? I doubt it. but then again, the trend could catch on with smaller services going to ALS, then who knows, it hits the right person in the right position to have dramatic impact on EMS, and all of a sudden, it becomes a standard of care. Hey, that would be nice, and I say this will all sincerity.

Dust, I see by your name you are from southern Cali. Nice place, was stationed there for most of my enlistment. I am familiar in a very vague way, as to how the Orange County area is as far as communities. So maybe when you and I talk about a community of 300 people, you may be thinking of 300 people who have the money to afford to live away from all the crazies. I think of that community as being 300 people, from maybe 75 or so households, who rely greatly on the local farming economy to support their business in town, which may be as simple as a small mechanic shop, a gas station with a few groceries, a bank, and post office. Now we cannot forget the feedmill, or farmer's elevator that will handle all the grain. These are your everyday hardworking bluecollar people who live in their community because that is where they work. These people understand that they have chosen to live in an area that may not even have a medical doctor living within 5 or 10 miles from their community. Do you honestly believe you are going to convince these people that they need to kick their EMT's out and pay an increase in property and or sales tax to have an ALS service available to them? I would believe that would be the way most of these services would be made available. These people have been bandaging themselves up and driving to the hospital or doctor office themselves for most of their lives. (Sometimes they should have stayed put and called 911 that is for sure, but hey, this is who they are).

As I have stated, these people know the advantages and disadvantages to living in their little corner of the world. They accept these realities. So the question now becomes this: Who is it that will be the one to tell these communities that they MUST have ALS? I am curious Dust and Jake, if it were up to you, and you could have the say in the matter; How would either of you go about getting ALS everywhere?

Not trying to call you out to the parking lot here, just curious as to how you think it should be done. I look forward to your reply. I am learning alot from you guys as to how others in the EMS world feel, think, and function. This is pretty good.

[steve_emt_68]

Perhaps the systems you are used to is much differen't than what we have in Nebraska. This system truely does work. In addition to simultaneous dispatch we have also trained the Volunteer squads to request us when needed. I am not sure how much use a Paramedic will be in a community of 300 who might run 10 calls a year. How sharp on his skills will he be? Honestly, in our system we see ALS dispatched simultaneously in 75% of all calls.

My point was that for communities that cannot afford fulltime ALS, Our system works. It is the best of both worlds. How do you fund a system that requires 3 or 4 fulltime ALS crews to ensure transport coverage for 6 hospitals that frequently has two trucks on 3.5 to 6 hour interfacility transports and provide ALS coverage to 2,500+ square miles?

The cost involved would be stagering not to mention response times that alone would kill patients. By having BLS squads in each community, care begins sooner with lifesaving interventions (including Advanced airway, IV access, neb tx, glucometer, etc).

I believe that there is a place for BLS volunteer squads especially in rural Nebraska. We don't live in an area where you can spit and hit a hospital, transports here can be 30 minutes or more. Head to western Nebraska and transports can exceed 1 hour. In the perfect world we would have better training, more ALS crews and fewer stupid people (lower call volumes) until then, I like our system and no I don't get to cherry pick my calls, I still go on nausea and vomiting and GI bleeds, I go when the pager goes off at 5am or 3pm, it doesn't matter. They call, I haul.