Solving the problem of rural EMS

[Eydawn]

I've been thinking a lot lately. Many of you know that I do search and rescue for my county... and as such, we often work with the smaller rural fire departments in our area. I know a lot of us have lamented the problem of volunteer EMS (whether or not it is attached at the hip to fire) as a major factor in holding back our profession in terms of respect and wages and so on and so forth.

I've come to the realization that we will probably never be able to completely eliminate volunteer EMS. Many of the rural areas are simply just too small to make it financially viable to go fully paid and to acquire the number of paramedics that it would take to staff shifts 24-7. That leaves us with a bunch of volunteer FF/EMT-B types in the areas where we could best use ALS level care, which is frustrating for many of them and a disservice to many of our rural communities.

Here's the idea I've been kicking around in my head. What if we changed the approach a little bit? What if we used physician extenders in these rural areas? The advantage to having an NP or PA respond on EMS calls is that they are better educated than paramedics and can do things that might be beneficial on a long transport (or in a situation where you know you can't get the patient out until the snow stops), and they can also operate with regard to certain procedures and pharmacology without a direct order from the MD they are working under. They can also easily take care of minor things, like sutures or prescribing antibiotics.

An NP or PA could staff a clinic during "normal" business hours, providing a closer source of medical care and potentially eliminating some issues that would have been an ambulance call with the status quo in many of these areas. Someone who wanted to provide care in this setting would have to enjoy clinic work, and would have to be affiliated with the closest hospital, rather than being a direct part of the FD; for ambulance runs, they could operate just like everyone else, carrying a pager and responding when available (aka: not currently caring for a patient in the clinic).

It seems to me that it would be far easier to convince people to pay for the salary of someone who would be serving the community to a much greater extent than just responding to "emergency" calls. From the sociological perspective, the FD would be able to retain its position and still be very useful, but not be solely responsible for medical care (which we can all see isn't working). I think a lot of FD's would be much more amenable to this arrangement than having a bunch of their folks (who don't want to be paramedics) forced to become medics, or have external medics integrated into the infrastructure. The NP/PA isn't as much of a "threat" since they're not there to completely change how everything is run and aren't interfering at all on the fire side.

So what do y'all think? Am I way out in left field? Could it be feasible? We'd have to set up educational programs specifically geared to give the NP/PA prehospital experience, and candidates coming out of those programs would have to have a significant interest in working in rural settings.

Let me know what you think.

Wendy

CO EMT-B

[crotchitymedic1986]

I applaud you for throwing your ideas out there, if more people acted like you did, instead of just throwing their hands up in the air, and saying we cant fix it, EMS would be alot better.

The problem with your premise, as I see it, is:

1. You have to have EMTs and medics to make it a licensed ambulance so you can get reimbursed.

2. You will have trouble getting PAs to work in the rural area. Most rural areas would love a PA to function as a PA , but they cant find them.

I would offer three different suggestions:

1. Start with a basic service with paramedic on call, and do the non-emergent transports in your area to supplement revenue. You could pay someone to work 8 hours and still be volunteer at night until you got your call volume up.

2. If you have a hospital, use them to fund it, and use the EMTs/Pmdcs to work in the ER when not on call. The hospital gets some hands to help them, which they would pay more to hire RN hands, and you get some financial backing to get your paid service up.

3. Create a multi-county paid department. If you are that rural, the county on either side of you probably cant afford a service either; so none of those counties might be able to afford 100% of the bill, but maybe they could afford to pay a 1/4, 1/3, 1/2 of the cost ?

[CBEMT]

I've come to the realization that we will probably never be able to completely eliminate volunteer EMS. Many of the rural areas are simply just too small to make it financially viable to go fully paid and to acquire the number of paramedics that it would take to staff shifts 24-7.

Hey, you can't say that around here. Don't you know there are people in rural areas who can't wait for the chance to pay higher taxers to afford two paramedics to sit on their asses 325 days a year, if only someone would ask them to?

[Eydawn]

Would you mind not cluttering, CB? Offer an actual response, or stay outta the pool!

Crotchity, to address your two points as to why my proposal won't work...

You have to have EMTs and medics to make it a licensed ambulance so you can get reimbursed.

You already have EMT's. The PA is not going to be riding in that ambulance by themselves... they're going to need partners, just like everyone else, and I'm sure there can be some changes in licensing rules to allow a PA or NP to meet that requirement. In the volly system, the PA is arriving on scene with members of the FD... someone's gotta drive, right? And most of them are EMT-B already...

You will have trouble getting PAs to work in the rural area. Most rural areas would love a PA to function as a PA , but they cant find them.

I think we can find PA/NP types that want to work rural systems, and who are interested in pre-hospital as well as clinic settings; the trick is setting up programs specifically to recruit those individuals and adequately prepare them for those roles. I think the interest is there, we just don't have the structure set up yet to bring both sides together.

Wendy

CO EMT-B

[spenac]

Not a bad idea young lady newly wed, honeymoon must have done you some good . Actually there have been programs attempted where a small town agreed to pay off student loans, etc to get doctors, PA's, NP's, etc to move to rural areas, but many never find anyone to fill the spot.

As to using them on an ambulance. Flight often has someone besides a Paramedic or emt, so rules could be adjusted if they do not already exist to allow this.

I do disagree that areas can not afford paid service but you can search my user name for my arguments rather than detracting from a good idea.

[joesph]

Dawn I'm glad you have chose to come up with a fix rather then bitch. Thank you. Your Idea has merit but I have a few questions. What kinda wages would we need to recruit a doc? My guess is enough to pay a couple of paramedics. What if your doctor or medics spent there time between runs training and doing run reviews with the volunteer organizations you have? Also what about using funds that would be spent on a doc to augment volunteers wages so the could be trained up to a higher level and keep there skills up. I do recognize that this system would be defrauded if not monitored closely. As to the idea of sharing a ALS ambulance between agencies I think that would be great. BLS reinforced by ALS or maybe a ALS intercept with a rescue to jump on the BLS ambulance. I disagree with the notion that volunteers are the problem. I think the problem is broader including accountability, (I hate the response ' what do you expect from us we are volunteers'). Another problem is a constant rivallry between b's and medics thats just silly. And as far as vollies holding wages down, maybe so I don't see enough of the US to know the conditions everywhere but what I am sure of is that if the vollies were not there the bean counters would still find excuses to hold the wages down. Reeducating the public to the need of quality EMS whether paid or volly is the key then the bean counters would have to pay for it.

[Ridryder 911]

So let's see if I got this right. Your now going to pay an NP or a P.A. $150,000 base rate and how much a year to make EMS calls? Your assuming that they would want to give away their talent and time. Since the average PA or NP starting salary for most rural ER's and clinics are about that much .. without additional workload. Could be a nice way to run off your help.

Good idea but I believe impractical. You work all day, then to be expected to be on EMS call? Think about it, how much down time, what about the litigation issues for malpractice and again on top of the responsibility. As well, P.A. are not independently licensed as they too work under the license of a physician.

I've had P.A. 's and NP's run calls with me. Fun but they would be the first to inform you that they are out of their environment. Not that they can't help but a lot of stress trying to adjust.

[ccmedoc]

I agree with Rid for the most part, but I would have to say that you would stand a much better chance of getting the NP in the field than the PA. NP is closer to the EMS mold than the PA, who most likely has little medical experience past the PA training. NPs have to be a nurse previous, PA could have been an accountant..

I like the ideas of maybe having a rapid response to augment the volley contingent, if they(volleys) are the only way to go, and if the NP was cross trained in the ways of EMS.

One question though, and I may have missed this; if the NP or other is off on an EMS call, who covers them? You would have to have at least a pair of them. With the additional training and instructional duties you propose this may well cost more than the, how was it so eloquently phrased ,"...two paramedics to sit on their asses 325 days a year..."

What you gain in the additional scope and abilities of the NP (you see which way I lean), you may (will) lose on the fiscal side. This is where this dilemma is based, from what I can glean from the posts thus far.

Why not add the PHRN designation in the area, and pull the rapid response from a hospital or local clinic. This is most likely cheaper, and the duality is easier on the planning committee. Besides, a LOT of RNs are paramedics also..

I'm still not convinced the ALS coverage is beyond the fiscal abilities of most, if not all, rural areas. The question then becomes not if there is ALS coverage, but how much...

[Eydawn]

I'm not talking full time clinic hours here... I'm talking making the NP's salary worth the rural area's time by having them fulfill a dual role. I'm sure it could be finagled appropriately. Maybe it would be beneficial to be a rotating system- have three that work under the auspices of the hospital who rotate in and out of the clinic/EMS role on a bi-monthly basis...

I'm not talking taking NP's and PA's with no experience and chucking them in a rural clinic and expecting them to fulfill a role they're not prepared for... in a way, I think I'm envisioning creating a new dynamic position that people would be expressly educated for. That way, you bring two kinds of healthcare to rural areas where it was previously unavailable... I think it's very financially feasible as long as it's handled correctly.

I'm fully aware that NP's and PA's are not MD's and must work under one. Hence why I think any NP or PA in that role should be affiliated with the hospital, rather than the fire department. They still have more freedom than a paramedic and the education to go with it... and are still able to do more in a clinic setting than a paramedic ever could, even with really liberal protocols.

Who covers the NP? Well, there's usually only one paramedic on at a time in rural areas that have them... so the next patient suffers luck of the draw and gets screwed. Without a program like this, they *all* get screwed in terms of having ALS care available to them.

As a community health model, I think the NP idea has more merit than introducing paramedics... and it has the bonus of drawing in people who really WANT to be NP's instead of what will happen if ALS is externally mandated... you'll get a lot of resentful fire folk who didn't want to do it in the first place who turn into half-arsed medics.

Wendy

CO EMT-B

[rock_shoes]

I agree with Rid for the most part, but I would have to say that you would stand a much better chance of getting the NP in the field than the PA. NP is closer to the EMS mold than the PA, who most likely has little medical experience past the PA training. NPs have to be a nurse previous, PA could have been an accountant..

This isn't always the case. In Canada the few (and I mean very few at this point) PA's that we have come from the Canadian Armed Forces paramedic ranks. Long term I think the best solution is going to be the development of a Paramedic Practitioner program. In Canada obtaining Advanced Care Paramedic certification requires the equivalent of 3 years full-time university education (some provinces front load with longer Primary Care programs while others backload with longer Advanced Care programs). Add an additional 2 years of targeted education to create a paramedic practitioner program and a new rural gold standard will be born.

I'm still not convinced the ALS coverage is beyond the fiscal abilities of most, if not all, rural areas. The question then becomes not if there is ALS coverage, but how much...

You make an excellent point. Extensive transport times in austere environments requires the best of the best if you want to provide proper patient care.