Solving the problem of rural EMS

[Kiwiology]

I wouldn't say this problem is "unfixable" we could simply throw money at it and have a score of Advanced Paramedics (ALS) sitting out in Tumblweed Junction, Boondock City (pop. 204), Bayou Flats and the like. That wouldn't make good fiscal sense however or good medical sense when it comes to skill use and upkeep.

New Zealand has learnt the hard way that simple replication of the urban treat and transport model doesn't work out in the sticks. It depletes our rural resouces (on most rural stations here there is only one vehicle) and really doesn't provide optimal care for the patient; we more than likely transport rural patients to hospital (usually the regional trauma centre which is often an hour or more away) because we have no alternative.

Most of the patients picked up here in our region get transported to our local base hospital (level one trauma centre) which can be over an hour away each direction, add in time for PRF completion, restocking etc. Most times transport is because there is no alternative (especially at night or the weekend) which depletes resources (which believe me, are VERY scarce) out of the local communities which inturn impacts on the patient, the crew and our ability to respond to say chokings or a cardiac arrest because the only vehicle is an hour away dropping off a flu patient.

I really like the idea of intergration with the primary health sector, expanded scope of practice (with appropriate expanded education) and some out-of-the-box ideas for developing new ways of managing the rural sector. The "Paramedic Practioner" role has its greatest benefit I believe in the rural areas; patients can be treated and disposed of on the spot rather than transporting them an hour away to the hospital where they will sit in chairs for another couple hours and then need to find a way home.

Rural Victoria (Australia) and British Columbia (Canada, duh) are experimenthing with an idea simmilar to what Wendy suggested; place the Paramedic/Paramedic Practioner into the primary clinic setting; sort of like what an NP or PA does now. I'm sure that any rural GP or nurse would welcome the extra set of hands and it could rack up some CEUs while they're at it.

As for the provision of ALS out in the rural sector; this is a tricky one ... there is some very, very early talk here of developing the "hub" concept kind of like what the big airlines use to provide a network of Advanced Paramedics (ALS) who are mobile and can respond/intercept around a geographic area rather than being tied to a set station/vehicle. Kind of like the rapid response units in the urban setting.

New Zealand also uses a system that responds specially trained rural GPs and nurses to provide ALS care if it is required. The system is called PRIME (Primary Response in Medical Emergencies) and while I have not had personal experience with it (we have ALS On station here) I have heard both good and bad things about it. On the plus side it does provide higher level care than what the ambulance crew can but it also runs the risk of overworking already overworked rural practitioners (the scheme is currently voluntary).

[crotchitymedic1986]

Good points made by all, and I have to agree, I think you will be hard pressed to get a PA who will turn down urban money to work at rural Paramedic wages. Remember that if a PA wanted to make $30-40k per year, he/she could have attended far less school to do that.

I still do not believe that all of these communities can not afford an ambulance service, maybe they cant afford it in the traditional sense, but I imagine there is a way to fund it if you had to. Again, you do not have to start with 24 hour or even ALS coverage. Can this team serve a dual role of on-duty fire-fighter or police officer (to start) ? Can local business chip in on the cost ? Can you have fund-raisers or add a penney to the sales-tax ? Have you exhausted all grant funding possible ? Are you maximizing collections ? Have you thought about the outside the box ideas you could do (ie... Any Paramedic who moves to your county and volunteers for an 8-hour unpaid shift per week is exempt from homeowners taxes ---- or gets county health benefits, but no pay) ? And like I said, if you have a community that absolutely can not afford it, then I think placing the ambulance on the county-line between two counties that share the cost is the sensible alternative (supplemented by volunteer first-responders).

How many transports do you guys average in a month ? What are you charging for those transports ?

[Chief1C]

We have a problem? Maybe just to those who aren't rural it looks like we have a problem.

Not that we haven't tried. There's a lot of people who would rather die, than pay higher taxes..

[Arctickat]

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

Unfortunately, there are a couple of flaws here. First, some jurisdictions, like mine, do not have PAs. A simple change in the law could enable that, but the College of Physicians and Surgeons have to make the amendment, not the government. Secondly, we have paramedics filling vacant NP positions in the clinical setting. Where are we going to get NPs to work the EMS field when they can't even staff their own?

The Saskatchewan model dictates that an individual should be no more than 30 minutes from a ground ambulance base, thus multiple EMS services in a 30 mile radius from one another would be too many. Rather than have a multitude of volunteer services, only one is provided with government funding. A program which started over 40 years ago and has worked quite well to regulate the quality of practitioner, EMS services, and eliminate competition. Since half the population of the province lives in a rural setting in communities under 5000 people, this seems to be a pretty good model for providing EMS services, considering the longevity.

The fact that we are already working in the clinical setting shows a strong progression towards a Clinical Care paramedic or Paramedic Practitioner. The classic paramedic of the past has to adapt and evolve to the needs of today's health care. There is no reason a Paramedic couldn't be doing primary home care rather than a poorly trained aide who can hardly recognise a medical emergency. With patents being sent home from hospitals to recuperate there it's not a far stretch for the medics to make daily rounds within their zones to change dressings, conduct followup care, or do simple welfare checks. It's just not glamorous enough for those in EMS because they can't use their lights and sirens. A progressive EMS manager will make changes like these, the rest will be lost to attrition.

Edited July 14, 2009 by Arctickat

[Eydawn]

Ah hah! So we need to create a new health care provider. Basically what many of you are saying is don't pigeonhole into a PA or NP, but create a Paramedic Practitioner instead... so that they are already familiar with the environment, but then educated to the level of a physician extender and therefore much better suited for a hybrid clinic/pre-hospital role.

I think I need to eat breakfast, read over things, and come back and take another look.

More to come.

Wendy

CO EMT-B

[joesph]

So her is what is happening in Flathead county. All of the incorporated city's have 24-7 ALS predominantly fire based with fire/medics then as you move out farther into the small communities it is volunteer BLS ambulances with air medical or ground ALS rendezvous. To my knowledge they all bill for services and are still losing there butts. We started our ambu 13 months ago (we were a QRU prior to that)and did'nt see a dime till this month so it has been funded up till know and for the near future from fire budget and a pitiful amount from the county. The largest town in county has the deepest paramedic depth and due to budget crunches will be discontinuing services out of city limits soon. The air medical is only one air craft and starting cost is around $10000. WE average around 65 transports per yr of which 30% are ALS and transported by others and of the remainder we expect a average of 60% cost recovery. Our population base is predominantly below the poverty line. This is presented as a example of rural challenges i'm sure there are other examples.

[Ridryder 911]

Ah hah! So we need to create a new health care provider. Basically what many of you are saying is don't pigeonhole into a PA or NP, but create a Paramedic Practitioner instead... so that they are already familiar with the environment, but then educated to the level of a physician extender and therefore much better suited for a hybrid clinic/pre-hospital role.

I think I need to eat breakfast, read over things, and come back and take another look.

More to come.

Wendy

CO EMT-B

Actually, that is in the testing phase as we speak. Some states are having such levels. The NREMT is exploring that possibility as much further education will be required. As far as a NP some states allow the NP to practice within their own license without being under a physician license. Also you do understand that the general salary of a NP and or P.A. is between $75 -150/hr? That is a lot of Paramedic salaries. You might meet one that will be willing to help but to be responsible for that care at that level, I doubt it would be free. Realstically, not much more they could do. We have ACNP on some of our helicopters and perform the same roles & procedures as the Paramedic but the salary of couse is much different.

[ccmedoc]

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.

Wendy

CO EMT-B

Any health care provider in the field of EMS, certainly paramedics, should e affiliated with a hospital and not the fire service. The biggest faux pas in EMS was basing it with fire in the first place.

[kristo]

An interesting post, Eyedown.

It just so happens that what you described pretty much fits this little town where I'm working this summer. This town has about 900 people, counting the farms and small villages around, it's probably about 2000 on the whole. We have a small "hospital" (actually, about 36 nursing home beds and 4 for "acute"). This hospital is not equipped for anything else than general internal medicine. A small lab for basic blood tests, X-ray, no CT or anything like that. The hospital also runs a primary care clinic staffed by two physicians. They also tend to this "hospital" when needed.

Now, those two physicians take turns being on-call. That means the general public (or hospital staff) can call them outside office hours for advice or acute problems. Depending on the case, they will come in and see the patient or ask them to come in the morning. Often, they will come in the middle of the night to do sutures, etc.

EMS here is provided by paid staff. One of them is a full time employee of the hospital, as a handyman/EMT (EMT-I), he is in charge of EMS here. He has a group of EMTs, including himself, who take turns being available for calls, two at a time. They get a modest hourly wage for simply being in town and available for calls. If there's a call, the hourly wage goes up to standard overtime rate for four hours or the duration of the call, whichever is longer.

Now, here's the twist. Since we have no paramedics, only two EMT-I's, a few EMT-B's and a few that do not have formal EMS training, the on-call doctor is always notified when there's a call (112 (European version of 911) notifies him). The doctor will then decide if he goes with EMS or not. For most priority 1 or 2 calls, the doctor goes with the ambulance.

We have about 100 calls per year here. Since our hospital is not really equipped or staffed for severely ill patients, transfers will go to either a large-ish hospital 1,5 hours away or to the country's capital, Reykjavík, to a large hospital there (2,5 hours).

I've been here for a month, and this actually works pretty well. Most of the EMTs are very experienced. The doctors direct patient care, EMTs assist and depending on the individual EMT and how well the doctor trusts him, do direct patient care. Sometimes, doctors will decide not to join the ambulance when taking patients to the larger hospitals, after evaluating the patient. This will of course depend on the patient and how well the doctor trusts the EMTs on the transfer.

Edited July 15, 2009 by kristo

[kristo]

Just noticed, Eyedown was talking about physician extenders, not actual physicians. Anyway, we don't have any such midlevels, so this is close enough.