Amhet1

The patients that can pay, do. The ones that cant pay, are called frequent flyers.

There is a formula in Fitch, Prehospital Care Administration, 2nd ed, where you can graph subsidy to rate. In the calculation, you can show what the service would cost at $0 subsidy and how much subsidy you would need if your rate was $xxx.xx. If your municipal service is able to generate 70% of its operating revenue, then the govt entities must provide 30% subsidy for current operations. If the municipalities want to see a "profit", they will need to increase taxes, increase rates, or both. But as a govt agency, there should be no "profit". Ruff is right on the money about the actual revenue generated going to the general fund. In that scenario, your service is actually 100% supported by subsidy since your revenue generated doesnt actually go to you for operating the service. Scrolling back, I saw Woody's concerns about needing to hire 2 people to do the billing on 400 calls a year...... 1.09 runs per day..... either Woody is from NJ or some other liberal state or he meant 400 calls per day or month..... Whether its 1 or 10 calls per day, they should be able to handle it in-house. My other concern is comments that you should be getting 100% reimbursement on billable responses. What scares me it the over-simplification of the theory. There are multiple sources of revenue on some transports, but it only takes one indigent to break the 100% reimbursement rate. There may be a magic formula that will calculate the payor mix, reimbursement rate from Medicare, private insurors, Medicaid, etc, but the fact is that 70% recovery is a reasonable rate for self-billing services. To say that you should get an average of $400 a run 100% of the time fails to take into account ALL of the variables. Some services may only have a 2 mile transport whereas others may have 30 miles. There are services in BFE Colorado that may have to transfer patients 120 miles from a CAH to a Medical Center. As you may know from the Medicare reimbursement tables, part of that transport is billed at $9 a mile, some at $5. In the case of an MVC, some of that should be paid by auto insurance, over 65 and Medicare pays some of it, and if they also have private insurance. Was this a BLS-E, ALS-1.... I think you get the point. You also have to take into account the co-insurance, co-payments, and what to do with the outstanding balance after everyone has paid what they are going to. A service can charge whatever they want, be it $100 or $10,000... they wil be reimbursed whatever insurance says they will be reimbursed. One other point Id like to make is that each service is unique. I question 400 calls a year and a budget of $180,000, but I dont know the whole picture. The demographics of a community and the service supporting it has alot to do with costs and reimbursements and subsidy. If a community has set a standard of 8:59 or they want volunteer/part-time paid then those are the standards for the service and community. This becomes an issue not unlike a post about MBA's running EMS. I made the comment that there are specialties outside of EMS that we need to tap into to improve EMS. If I see numbers that dont pass the "smell test", I want someone with the knowledge to know why.

Thank ya'll for the compliments, but Im just a plain ole Basic with 30 years of experience. 7 years of volunteer back home, 3 years private and hospital based, 20 years Air Force and the last 5 running a stress computer. Being out of the field for the last 5 years has given me time to do some research and play with numbers. Its also given me time to see the forest and not just the trees (how bout that for a cliche?). Im leaving FL in a month or so for Denver. Right now Im kinda torn between finding another nice cushy Hospital job, an admin support job in EMS, or actually working in the field again. Id love to get a job crunchin numbers at Pridemark, but they use Zoll (the old Pinpoint) so they have enough software to crunch their own numbers.

All very good points, chbare. Some of the information I passed on may be somewhat dated as I haven't really looked into it in a few years. My comment about deflation before extubation was based on seeing significant pharyngeal trauma induced by it on one occasion. I agree that displacement may be an issue but I would be interested to see a comparative study between that and ET intubations in the field. I read recently that the Univ of Kansas is in the process of such a study. The results should prove interesting. I would like to comment on one point that you make tho. It is true that there is frequently some leakage around the mask, there is minimal chance of insufflation of the stomach. Recall that the tip of the mask sits at the esophageal os. The airway itself is open to room air so most (if not all) blowby from the mask will follow the path of least resistance, ie, passed back out the oropharynx. To support my point, I did find a study that compared the LMA (unknown model or type) to a simple face mask. This was published in the Canadian J Anes. Gas leak and gastric insufflation during controlled ventilation: face mask versus laryngeal mask airway. CONCLUSION: Ventilation was adequate in all patients using both techniques. Leak was pressure dependent and greater with LMA use. Most of the leak was vented to the atmosphere via the pharynx. Gastro-oesophageal insufflation was more frequent with ventilation using the face mask. LMA use with positive pressure ventilation would appear to be a better airway management method than the face mask. This was a randomized study using 20, 25, and 30cm of pressure on a group of 60 patients with 30 getting an LMA and 30 getting a mask under general anesthesia. Two other points I would like to make quickly. I am a proponent of the LMA because of its overall ease of use, the skill involved with placement is less than ET intubation thus making it preferable for smaller and more rural services, and less loss of technical competency when the skill is not performed frequently. Lastly, I would like to apologize to the original poster for heading off on my little tangents. I know you were looking for services that use the LMA and instead I go off and post about actually using them instead. ET will remain the gold standard for many years to come. There have been attempts to recreate the wheel with the EOA, EGTA, PTL (Pay the lawyer), CT, and the LMA. So far, the studies show the LMA coming closest to the ET in many respects.

I can actually go one better! When the '72 broke down, we got to borrow a 1967 Oldsmobile wagon conversion. One gumball light and the biggest damn siren Ive ever seen in my life!

The LMA is not nearly as popular here as it is in Europe. They really made the jump from the OR to EMS in the UK (if I remember correctly). It is true that thee is slightly less airway control with an LMA vs ET, but the simple fact is that you can drop an NG past the LMA prior to inflation and the problem is solved. The other big factor to consider is airway maintenance. Statistics available show FAR too many misplaced/displaced/bad ET placements. The LMA has less chance of being misplaced or displaced, and minimal risk of regurg if it needs to be replaced. The LMA is also completely functional with EtCO2 monitoring. It also meets all AHA guidelines for tube placement (with the obvious exception of passing the cords). The cost argument is not a valid one. A cursory look at the web shows the cost being equal to ET tubes. The LMA does not need 2 handles and 5 blades or stylet. So the over cost of use is less with the LMA. This is one of those cases where EMS is slow to move something to proven to be better and more beneficial. (I know, personal opinion). Look how long it took before we got some logical guidelines on backboarding. The one other caution with the LMA is making sure your ER staff knows its an LMA..... Its really painful on the patient to remove it without deflating first.

I was born as a child in small podunk community in S MI and started my previous life as a volunteer on a 1972 Pontiac high top. That was the only ambulance for about 100 sq mi. In 1982, the service actually got enough money to match the amount the governments were willing to match and they bought a used 1980 type II. It seems that if my hometown can "upgrade" on a shoestring, there should be little difficulty to find a vehicle for Podunk KY to "upgrade".....

Thanks bro. I realize I got a lil verbose, and headed off on a few tangents, but I think I got my point across. The hardest part was trying to NOT point fingers at any certain organizations.... =)

Do we send floor nurses out on trauma calls? Do we make our medics rebuild engines on our helicopters? Then why do we take experienced field people and promote them to run our services without the necessary education? What do we know about budgets and balance sheets? There are things that we can gain knowledge in but there is no way to develop true expertise. You see it nursing and many other fields every day. Yes a nurse is a nurse, but there are many specialties they may go into to include advanced practitioners and management. The difference is that they will go back to school to learn the skills necessary for the job. These are all steps in a nursing career ladder. You typically wont see a nurse become a CFO because its a different career ladder. What does this have to do with EMS, you say? Where is the career ladder in EMS? Our basic career ladder is Basic, Intermediate, Advanced (in some places), and Paramedic. There are lateral moves from Paramedic to Flight Medic, etc, and possibly upward to supervision and management type positions. There are many schools that provide a general "supervisor" class or classes, but very few formal educational opportunities to a BS or MS level that are specific to EMS. There are experts in other fields that would be a major asset to EMS in general and individual departments more specifically. Its easier to train a willing MBA to be an EMT to develop a "feel" for the job than to expect a paramedic to leave field to learn management. This is just one of many problems that face EMS in the US today. There is too much fragmentation and too many groups trying to work towards their own political goal. The USFA has its idea of what EMS should be and not be. NAEMSE knows what and how they want to teach. NEMSMA is working on a variety of programs to improve and enhance EMS. NHTSA is probably working on the most important step in EMS development since EMS "became EMS" with the NEMSIS project. I could go on and on, but the bottom line is that WE have to decide what we want EMS to be. WE need to decide the education standards. WE need to push for Bachelors and Masters programs to develop tomorrows leaders. For 30 years, we have had practices handed down from managers to supervisors to field personnel and through trial and error we have quality programs, treatment and dispatching protocols, training standards, and core competencies. Some of these things were handed to us and some we developed thru our own need. And some has been forced upon us. One of the best examples is the "8:59" standard for ALS. The AHA had one line in some report back in the '80s and everyone with a political agenda jumped on that as being the gold standard. It has never been a standard and will never be a standard. The standard is what the community decides is the standard. I guess the bottom line is that there is a place for many things in EMS that we dont take advantage of. Skill sets outside of EMS will be an asset to EMS if we use them and develop them correctly. But we must also develop programs within EMS that will be an asset to us. (Looking back, it looks like just said about the same thing Mike did, but far more verbosely and a bit more personal opinion)

As a young, excitable EMT back in the late 70's, we were transporting a cardiac arrest into the hospital..... I was radioing in and described the patient as being cyanotic and having diaphoretic fingernails...... Thats a mistake ya only make once. I have no idea why I still remember that call. The other call that still stands out is a response for a possible traumatic amputation... We arrive about the same time as PD. A guy comes running towards us with an armful of shop rags.... The guy says to me "Heres the arm, what do you want met o do with it?" Without missing a beat I look at him and say "Give it to that police officer over there".... Another one the staff wouldnt ever let me forget!

Im a retired AF medic and IDMT. Spent my last assignment in AFSOC with the opportunity to see the beautiful Ali Al Saleem back in '98. I got to do a promotion and reenlistment in the back of a H53 in Iraqi airspace =) I did miss out on the Dunker since I was at the Med Group. The OSM guys got to enjoy it tho <rolls eyes> I used to have all the certifications and alphabet soup.... Now Im just a plain ole FL EMT gettin ready to head for Denver