The perfect system.

[croaker260]

Well, this use to be the norm here, but as we have grown and the pool of local ER docs have grown, this is not always the case. Still, relationships with our docs is a thousand times better here than elsewhere.

We do have a full time education department, and two very involved doctors. Our FTO program has been mentioned in Best Practices in EMS journal.

I think most rural ALS agencies run a tiered system by default if not design...but not a targeted tiered system. In most rural areas , they likely cant afford, nor (asimportant) have a call volume to support a targeted and tiered system.

In rural systems, I think its important that, for a rural system to have paramedics, they must be able to support medics. Im not talkign about a certificate of need alone...wich is mainly to prevent competition in a fragile geographic marketplace, but the call volume and logistical and clinical support to support medics.

Those that cant should adopt the ILS rout instead. In reality, many ALS rural agencies, not all mind you, but many...are operating at about the latest EMT I level anyway.

I say this with my vision of a paramedic being a clinically sophisticated medic with advanced rescusitation skills and scope (i.e. RSI). Something most agencies of all types, rural, suburban, or urban, wont throw the rescources at to obtain or maintain...not cant...but wont.

[zippyRN]

a 'perfect' EMS system? let's see

the obvious aim is to deliver the right provider, in the right vehicle to the right patient in a timely fashion

it means having a Calltaking system which has greater sensitivity and specificity than AMPDS - or we have to accept the over triage that AMPDS provides. the perfect system would also have triage advisors in control who can upgrade or downgrade questionable calls - traige advisors would be pre hospital Health Professionals ( probably mainly Paramedics, Nurses and the advanced practice versions of same)

the perfect system would aim to get first responders to truly life thereatening calls in 4 or 5 minutes and those first responders would be dvanced first aiders with AED + medicla gasses or EMT-Bs

the perfect sytem would aim to deliver an Ambulance and a Paramedic or other prehospital Health Professional ( i.e. PHRN ., Advanced practice Paramedic/ PHRN or field physician) within a suitable time frame - the UK uses 14 / 19 minutes based oan an arbitrary 'urban ' or 'rural' standard ...

the perfect syem would have a number of types of ambulances ranging from ACA/ EMT-B transfer buses controlled by the Emergency control ( rather than PTS control) through middle tier vehicles, to Technician vehicles (QAT / PCP / EMT-i with fewer invasive intervnetions) and Technician and emt-I 99 / Paramedic vehicles... some of the paramedci ambulances i nthe service may no have wheels instead be helicopters

the perfect system would also be able to deliver care at the point of need where this is most appropriate and cost effective e.g. wound care for those who would require transport back home as well as to the ED

the perfect system would empower all it's health professional staff to make some direct referrals to speciality and to take patients to the most appropriate recieving hospital not the nearest one with a decent ED and allow advanced practice providers and field physicians freedom to organise direct admissions for the majority of patients who need admission and don't require resus room care.

the perfect system would support not transporting patients whose clinical condition does not warrant transport, ED attendance etc...

the perfect service would offer alternative transport methods after face to face assessment by the health professional provider - (hence the ACA/EMT-B transfer trucks mentioned earlier)

The perfect syem would be able to provide full critical care 'at the roadside' where it;s indicated e.g. MCI , entrapment RTC, other entrapment scenarios and be able to contribute meaningfully to technical rescue and USAR

[cosgrojo]

In rural systems, I think its important that, for a rural system to have paramedics, they must be able to support medics. Im not talkign about a certificate of need alone...wich is mainly to prevent competition in a fragile geographic marketplace, but the call volume and logistical and clinical support to support medics.

Those that cant should adopt the ILS rout instead. In reality, many ALS rural agencies, not all mind you, but many...are operating at about the latest EMT I level anyway.

I say this with my vision of a paramedic being a clinically sophisticated medic with advanced rescusitation skills and scope (i.e. RSI). Something most agencies of all types, rural, suburban, or urban, wont throw the rescources at to obtain or maintain...not cant...but wont.

Agreed, I see this all the time. Most departments is my area are volly squads that are lucky to have a paramedic but usually have some sort of intermediate semi-available. Luckily there is a local resource hospital that has it's own intercept service that can provide ALS when needed (with a really good group of competant medics). The problem is that is one truck that is responsible for somewhere around10-16 townships... a lot of area to cover with response times sometimes in the 30-40 minutes.

The burden for this service is so great that they are trying to go out of their way to help the local municipalities set up ALS guidelines and training for their people. It's a seemingly slow process, considering most municipalities don't want to foot the bill for these things.

[cosgrojo]

the perfect system would also be able to deliver care at the point of need where this is most appropriate and cost effective e.g. wound care for those who would require transport back home as well as to the ED

the perfect service would offer alternative transport methods after face to face assessment by the health professional provider - (hence the ACA/EMT-B transfer trucks mentioned earlier)

The perfect syem would be able to provide full critical care 'at the roadside' where it;s indicated e.g. MCI , entrapment RTC, other entrapment scenarios and be able to contribute meaningfully to technical rescue and USAR

Thank you for bringing something new the the conversation. Ground transport for non-emergent transfers is extremely important. I would also add that ALS transfer busses need to be staffed for patients being transferred to a higher level of care or to specialists (you may have mentioned that... and if you did, I apologize).

And the need for an available critical care unit is also a component of any "perfect" system.

Question: If you have a run of calls and all of your primary response units are occupied, do you call on an available transfer bus, or call on the mutual aid system? I ask because there is a private company in my area that prides itself on having ALS on every rig, and if a 911 call comes in and they have nobody but a BLS rig, they will call another company (or activate mutual aid) to do the call (even if the other service has no ALS). How do you feel about that? Is it cutting of your nose to spite your face... or is it building up a brand name?

[zippyRN]

Thank you for bringing something new the the conversation. Ground transport for non-emergent transfers is extremely important. I would also add that ALS transfer busses need to be staffed for patients being transferred to a higher level of care or to specialists (you may have mentioned that... and if you did, I apologize).

an escorted ALS transfer only needs and ambulance and an emergency driver if the escorts know what they are doing - some of our Neonatal and Paed ICU transfers i nthe Uk work on this basis of 'retrieval' where the team goes ahead with their kit in an RRV and prepares the patient for transfer while their dedicated transfer ambi follows on driver only

and unescorted ALS transfers would be done by paramedic ambulances as part of their general role it's a matter for the service planners whether they choose to dedicate vehicles or not there.

And the need for an available critical care unit is also a component of any "perfect" system.

Question: If you have a run of calls and all of your primary response units are occupied, do you call on an available transfer bus, or call on the mutual aid system? I ask because there is a private company in my area that prides itself on having ALS on every rig, and if a 911 call comes in and they have nobody but a BLS rig, they will call another company (or activate mutual aid) to do the call (even if the other service has no ALS). How do you feel about that? Is it cutting of your nose to spite your face... or is it building up a brand name?

depends - in the perfect system a propertion of the paramedics/ PHRNs and advance providers would be in RRVs so if you don't have a paramedic ambulance a transfer vehicle could come out and transport with the Healthprofessional crewing and the other crew mwmber of the transfer vehicle following in the rrv ...

[croaker260]

Question: If you have a run of calls and all of your primary response units are occupied, do you call on an available transfer bus, or call on the mutual aid system? I ask because there is a private company in my area that prides itself on having ALS on every rig, and if a 911 call comes in and they have nobody but a BLS rig, they will call another company (or activate mutual aid) to do the call (even if the other service has no ALS). How do you feel about that? Is it cutting of your nose to spite your face... or is it building up a brand name?

simple, in the event that there is not ALS unit timely available, the unit you call is the one who can get there the quickest, regardless of level or affiliation. Hopefully your availability of system BLS/ILS transport units would be such to take up the slack. Remember we are talking a LOT more BLS/ILS than ALS transport capability. I am thinking 3:1 as a conceptual starting point, but don't know anyone who has actually studied it.

In an urban system, even most ALS patients can survive BLS, not optimal...but there you have it, and in trauma may be better served by it.

QA and systems review should look at these events and make sure they are truly a fluke, and not a system weakness.

depends - in the perfect system a proportion of the paramedics/ PHRNs and advance providers would be in RRVs so if you don't have a paramedic ambulance a transfer vehicle could come out and transport with the Healthprofessional crewing and the other crew mwmber of the transfer vehicle following in the rrv ...

In a tiered and targeted system, the need of RRVs would be minimal in suburban and urban settings, unless they were command vehicles.

Since no one has , IMHO , figured out a way of consistently delivering a QUALITY system of ALS to rural communities, short of Air medical response to BLS served areas (which is not very cost effective or safe in most communities), the possible excpetion being RRV's type response systems.

I really do think that RRVs (or what ever you want to call them) shows real promise for rural areas, providing they belong to an agency that has the clinical and political motivation to support them clinically, but not much more than sending an ambulance out with the same crew. The one advantage is an RRV may be more cost effective on a case by case basis, depending on who is paying.

Bottom line is there is NO EASY WAY TO PROVIDE CONSISTENTLY SYSTEM WIDE ALS CARE TO RURAL COMMUNITIES. I say again, many rural residents would receive better care by well trained ILS service than a poorly trained under utilized ALS service. Any system design for rural communities needs to take the challenges of providing ALS care to a sparse population with lower call volumes in effect.

Can it be don? probably...but in most cases is too much work for the stake holders.

[TechMedic05]

Question: If you have a run of calls and all of your primary response units are occupied, do you call on an available transfer bus, or call on the mutual aid system? I ask because there is a private company in my area that prides itself on having ALS on every rig, and if a 911 call comes in and they have nobody but a BLS rig, they will call another company (or activate mutual aid) to do the call (even if the other service has no ALS). How do you feel about that? Is it cutting of your nose to spite your face... or is it building up a brand name?

Cosgrojo - I'm not trying to be entirely pessimistic here, but if it's the company I -think- it is, then, my suggestion would just be that it either a - Doesn't trust it's BLS emplpoyees, or b - doesn't want to lose a BLS truck for the short time it takes to do a local transfer, etc.

Just my thoughts.

[zippyRN]

<snip>

In a tiered and targeted system, the need of RRVs would be minimal in suburban and urban settings, unless they were command vehicles.

unless your chosen method of delivering the health professional to the call was the RRV to assess, triage and then hand off to an approrpaite transport unit ...

i know ALS RRV has a bad reputation in parts of the US - particularly the NJ system

Since no one has , IMHO , figured out a way of consistently delivering a QUALITY system of ALS to rural communities, short of Air medical response to BLS served areas (which is not very cost effective or safe in most communities), the possible excpetion being RRV's type response systems.

I really do think that RRVs (or what ever you want to call them) shows real promise for rural areas, providing they belong to an agency that has the clinical and political motivation to support them clinically, but not much more than sending an ambulance out with the same crew. The one advantage is an RRV may be more cost effective on a case by case basis, depending on who is paying.

Bottom line is there is NO EASY WAY TO PROVIDE CONSISTENTLY SYSTEM WIDE ALS CARE TO RURAL COMMUNITIES. I say again, many rural residents would receive better care by well trained ILS service than a poorly trained under utilized ALS service. Any system design for rural communities needs to take the challenges of providing ALS care to a sparse population with lower call volumes in effect.

Can it be don? probably...but in most cases is too much work for the stake holders.

economies of scale and appropriate management of the service

if you look at the UK and Aus you have big ( hundreds of units , thousands of staff) services run by / as a part of the Health System

the old county services in the UK were considered 'too small' yet many were 10 times the size of some US services

[Timmy]

That ALS can administer better pain relief to kids under 14 with out having MICA in attendance! Methoxy don’t cut it sometimes. Other than that I’m happy.

[cosgrojo]

Cosgrojo - I'm not trying to be entirely pessimistic here, but if it's the company I -think- it is, then, my suggestion would just be that it either a - Doesn't trust it's BLS emplpoyees, or b - doesn't want to lose a BLS truck for the short time it takes to do a local transfer, etc.

Just my thoughts.

No arguement here... but I think that maybe the overriding issue is that they promise ALS on every responding rig, and they don't want to appear as if they are not giving what their promise is. Regardless of what the outcome is. Just think it may be a tad dangerous for the patients.

BTW... where you been man?