n5iln

Yes there is. People continue to want to do it for free.

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.

This type of home would also have a contractual agreement with the state that licenses it and must also abide by certain agreement of care for adequate supervision of care and appointed agents. The person calling you on behalf of the home and the patient then may become an agent of that facility as defined by your state's guidelines. In order for them to maintain their license to operate they must show that they have extended the offer of adequate medical assistance to a patient in a timely manner. This has been a huge legal issue and has resulted in the pulling of licenses from these facilities for failure to act or to provide adequate documentation when brought before their licensing board. I would not blame anyone for wanting to cover themselves if they were acting on behalf of the home and the patient. This again depends on the contractual agreement this home has with the state and various reimbursement agencies. An agent does not have to be a licensed medical person under most guidelines for these facilities. HIPAA also covers authorized agents in its regulations. Transfer of care does not necessarily mean leaving the facility. Your minimal contact with that patient may legally bind you for that moment of care. You will then, in good faith, leave that patient in care of themselves or another person. Was there adequate communication between all parties involved? The best way to assure this is by something in writing. Since you are the evaluating party and have accepted refusal by the patient it would then fall on you to ensure adequate communication has been provided.

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.

Nursing Home personnel also would like show that you did more then walk in, take a refusal and leave.

I did just see this issue discussed in a recent journal. This issue actually has very little to do with HIPAA, but rather it is more of a "transfer of care" issue between two healthcare providers. This is similar as to when you hand off a copy of your PCR to the ED. For the patient, new forms with specific information now show you have transferred the responsibility to patient that he/she was informed and he or S.O. can read about it again if he forgets what you said. You may also see an improvement in "transfer of care" for the patients (BLS routine) that are picked up at hospital to be transported to other facilities, ie nursing homes, dialysis, HBO etc.

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.

I believe you also have to provide a patient with the risks and benefits of refusing care. They need to be documented on the run ticket and a copy given to the patient.

I'm not sure what the legal ramifications of not providing these risks and benefits is but I would think if a patient signs a refusal you need to provide the risks and benefits.

Just my two cents.

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.

Personally I would like to see a universal system for every county where I live. ALL under one service and none of this 5 different services for one area. But they would have to be staffed with GOOD medics and not volunteers. They would have to be professional looking not show up on calls in shorts and tee shirts.

Lady

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

Discuss.

Not confused about the fact that her B/p would drop after taking NTG. It just sounded like that when it wore off, it actually made her hypertensive afterwards. The NTG would explain the low B/P the first time around, but what I'm really curious as to why she shot up in to the 150 range, and then lowered again by the time we got to the hospital, without more administration of NTG. Maybe she was just that anxious, but she was keeping it inside...no idea. Thanks again.

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.

None unless they have a court order.

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!).

Dude, don't play stupid. If this argument were about anything but your pet issue, you wouldn't even make such an absurd statement. Tick tock. Seconds count. Every minute your patient waits while volunteers at home decide whether or not they want to respond to a sick call while they're watching ER is a minute against their survival clock. Same thing with waiting for you to respond to the station to pick up the ambulance. And especially those daytime runs where nobody is available. Does this happen often in YOUR little squad? I don't know. Doesn't matter. As Rid has pointed out, this isn't about YOU. This is about a broader issue of volunteers in general. Focus.

Well then, like your friend RiderRob, you have yet to read the ten pages of the volunteer topic, or any of the other multiple topics here that have thoroughly addressed the subject. Do your homework and get back to us when you're educated.

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.

You're dodging the point. Nobody said anything about you being a bad provider. The point is simple if you read it. The reason your community doesn't have full-time professional medical personnel standing by in an ambulance 24/7 to respond to emergencies is because people like you will provide half that service for free. It is the reason people in your community die. And it is the reason that there are no actual EMS jobs for you or any other EMT or medic in your community. So yes, you are screwing your community.

However, yes, I will agree with 422 that it is mostly out of ignorance. And a lot of selfishness. Certainly not out of any altruistic sense of civic pride. Otherwise, all your community's trash would be collected by volunteers too.

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.

What the general consensus is, is that volunteer services aren't really necessary except for the most remote areas. Therefore, they are taking away paid full time jobs from ppl who invested 2 yrs of school (medic) because they want to give their services and education away for free and that's just crazy.

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.)

Hrm, the site must have been Slashdotted when I tried looking at it last night. But now that it's up, and I've read it...

RMMS orientation for Techs (read: anyone not hired to function as a Paramedic-in-charge; this includes Basics and Intermediates) spends a full day on documentation. I have to presume that paramedics get at least two days on documentation. And rightly so; the PCR may be seen by some as an evil of EMS, but it's most definitely a necessary evil. This call is going to cost an EMS service a crew, a bunch of money, and a serious PR hit, all because the crew didn't take the time to either completely document a bad call, or (hopefully this isn't the case) did document it fully, but didn't follow their protocols and then decided to try and talk their way out of it.

At the risk of sounding crass and obnoxious, I'm going to repeat what's already been said by several others. Two rules of EMS documentation: 1) If it ain't written down, it wasn't done. 2) If it IS written down, you better have done it! And don't think for a moment that nobody outside the crew will know if something was or wasn't done. Post-mortems reveal much.

I'll shut up now.

The 2nd class I attended in Basic class, the instructor stated and I quote, " If it isn't documented, you didn't do it".

The corollary to that, of course, is "If it's written down, you'd better have done it!" Fudging a PCR is a really good way to get your gluteus in a sling.

End mildly humorous sidenote...

Interesting read! From Jems.com............

http://www.jems.com/Columnists/emslaw/articles/85201/

And people wonder why Intubation is under such scrutiny currently!!!!!

Hrm, the site seems to be down...

If there was no one to volunteer to do the job of EMS, even the rural townships would figure out a way to get paid personnel to do the job. Rid hit on something that is the absolute lynch-pin of the matter. Supply and demand. When the demand for a product or service is high, supply is soon to follow. No, I repeat, No county, city, or township would forfeit their denizens safety because there wasn't enough coins in the coffers. If there were NO volunteers at all anywhere to do EMS or fire calls, do you think the Government would stand idly by and let the country slip into safety oblivion? I don't think so. New rules, new regulations, and yes, new money would be developed and appropriated as needed. There would be federal money coming out the wazoo if there was a revolt. We are talking about a country that spends trillions of dollars on frivolous programs and experimental ideas that never come to pass. If something as important as total lack of public safety knocked on the front door, the government would race to answer it.

Also, no one is saying that EMT's in rural quarters of the nation have to be paid like MD's. Pay commiserate with economic and regional standards would be fine. I just don't believe that something as important as pre-hospital emergencies should be an un-compensated vocation. Not because volunteers aren't good at it, but because this field "deserves" to be paid. I agree that donating your time to the community is a fantastic, and worthwhile thing. But why not get paid for this particular service, and volunteer for something else? Go paint over some graffitti, mentor a fatherless child, go listen to some war stories at the local nursing home, pick up litter on the weekends, get involved with your local legislation. There are plenty of other excellent things you can be doing with your time that SHOULD be volunteer. EMS should not.

I agree 100%. But I also know a bit more about economics than I like to think about. And while local governments would step up, would it be fast enough to fill the void? I can't see it happening, given the inherent inertia that any bureaucracy has. And in the interim, people die for lack of care. I can't accept that as an option.

As far as pay scales go...I'm not looking for an MD's pay. I'd be happy with pay somewhere on the same level as a typical staff secretary at a medium-sized corporation, or even as much as someone who changes tires at the local Goodyear store. Even a professional firefighter's salary -- entry-level. Something that demonstrates the level of responsibility I have as a member of the EMS system. But until the US healthcare system gets out of the hands of the insurance companies, that ain't gonna happen. So I have to accept that I'll never be paid what my services are truly worth (a common lament, I know), and still provide the best care I'm capable of...whether I'm in my paid rig or my volunteer rig. And yes, I do both. Happily, and with a professional attitude.

Just my two cents' worth...save up the change for a root beer or something...

My suggestion is run away from any EMS that has a 700 pg. manual.... Obviously, they don't believe you can think on your own.

You probably don't want to know how big the regional ALS protocol manual is, then... :?

Keep in mind that this manual was written to cover just about any eventuality that the corporation could think of, including MCIs, DRT deployments, and so on. As a lowly Tech, I probably use maybe 8-10 pages' worth during any given shift, and most of that are specifics on paperwork and communications.

The question remains, though...if what I have on hand is "way too much," and what EmtJim has on hand is "way too little," where's the middle ground -- what gets the job done without putting too much bureaucratic overload on the field medics?

Always take the five seconds to introduce yourself......ask the medic how he/she would like if his mother were treated in that manner...you start touching and assessing without an introduction...not very professional.

Not to mention a potential legal landmine. Our society has become so litigous that acting the way your medic did is practically pleading for an assault-and-battery lawsuit. I don't know about anyone else, but I certainly don't make enough on an EMT's pay scale to chuck out a few thousand dollars because I didn't ask if I could examine someone. (And that's just the attorney fees!)

The extra five seconds it takes to introduce oneself and ask "Why did you call us today?" is more than just courtesy; it's a CYA requirement. And you can get a lot of information that way -- information necessary for the formulation of a clinical impression and subsequent intervention plan. And not to put too fine a point on it, but if those extra five seconds will kill the patient, there probably isn't a lot that could have been done for them prehospital anyway.

Just my two cents' worth...save up the change for a root beer or something...

I'm not sure I have the time or energy to transcribe a 700-page operations manual...

Perhaps if you were to specify a few of the areas you're looking to revise? And what the standards currently are? First rule: "if it ain't broke, don't fix it." Second rule: "if it don't work, throw it out and replace it with something that does."

Okay, eight pages into this discussion, and a few people have touched on this, but nobody's come out and said it.

Volunteer EMS exists as an outgrowth of volunteer fire service, which in turn exists as a holdover from the turn of the last century when most rural areas couldn't afford to pay for a full-time department. About two-thirds of all fire service in the US is still volunteer, for two reasons: 1) rural districts are still dirt-poor, so the concept of paying a full-time department is simply out of the question, because the tax base just isn't there to support it, and 2) some people in some places still consider it an honor to donate their time and efforts to community and civic service.

Volunteer EMS isn't going to go away, no matter how much some people might wish it otherwise. Why? Because of money, or the lack thereof. Some services offer subscriptions to help pay the ongoing costs of operation, others simply have a set fee schedule for all runs. Most still have monthly chicken barbecues, spaghetti dinners or the like to put money in their general operating funds. Yet when someone calls 911 to report the MVC at the corner of Walk and Don't Walk, they expect the short bus with all the funny lights to pull up and work some EMS magic in short order. And somehow, it keeps happening.

Here's the long and short of it. There is one, and exactly one, way to eliminate all volunteer EMS in the United States, and there's absolutely no way it's going to happen, at least not that I can see in my lifetime. "What way is that?", I hear someone in the far back of the room ask.

...wait for it...

...here it comes...

...elimination of volunteer EMS will require nationalization of all health-care services in the United States. That's the only way to pay for it. And there's no way the insurance industry will permit that to happen; they have too much at stake.

Exactly, thanks to the new laws, it's all a gray area. Our policy is to turf to the supervisor. Works pretty good for us.

Good policy. That's why the supervisors make the big bucks, right?

I looked up the written policy for my service (which I just got handed today), and found that we can give the cops info if the patient is a crime victim, including child or elder abuse or domestic violence. Or we can give the cops a physical description of the patient if they are trying to identify a suspect, material witness or missing person. Anything at all beyond those uses and they have to subpoena the PCR. In fact, here's a direct quote from the policy: "Do NOT give law enforcement any...information when the sole purpose of the requiest is to assist law enforcement with their investigation or to help build a case against a suspect."

Just my two cents' worth...save up the change for a root beer or something...

So it seems the reasons for not having a shield outweighs the reasons for having one. Maybe if we weren't allowed or weren't issued we wouldnt be having this problem. So why the HECK are they around EMS?! (I'm not arguing here, I'm merely wondering about the history of this.) Who get's to decide, and while we're on the topic why do firefighters have them?

I'll go at this one backwards. FFs (in paid departments, anyway) have shields because they are public safety officials; they're hired by, trained by, employed by and paid by municipalities, with very few exceptions (Scottsdale, AZ being one that leaps to mind). Some EMS operations issue shields to their personnel as a holdover from when they were still part of the fire service; others are still part of the fire service, so they also hand out shields.

Just as a sidenote of curiosity, I still have my original shield from 18 years ago. I haven't worn it in 14 years, and I'll never wear it again. It's a neat memento, but like I said elsewhere, around here it's more of a target than it is anything else. And some gangbangers would love to collect this one, since it's not issued anywhere around here (yet another reason not to wear it, I don't work for the service that issued it any more, and that service no longer exists anyway!).