The Paramedic? Do we need them?

Replies to This Discussion

Permalink Reply by geoff.horning on May 6, 2012 at 11:16am

Timothy, I couldn't disagree more with this sentence.  Having been an elected official at the small city level, I can tell you without a doubt that our insurance was set at certain levels regardless of the number of vehicles we ran.  Regardless of the number of Fire Apparatus and Police vehicles we ran, the number of city cars and public works trucks that we placed on the road everyday.  This sounds like a combination of two things, "voodoo governing", and a bad example on our part.  If we are allowing drivers of emergency vehicles specifically in this context emergency medical vehicles to put the public in danger due to their disregard of the law (which we as a profession are) and they are driving like idiots (which they are), it should be changed, right now, immediately, today.  Every blue light thrown in the trash, every siren box yanked out and every driver held personally liable for accidents they cause.  Too many vehicles on the road causing excess liability is a argument I can shoot about a million holes in, a million different ways.  I thought we did some backwards things when I was a Councilman but I'd love to know what "idiot" got away with saying this in a public forum. 

And unfortunately, I'm familiar with the idiots driving our ambulances, no need to introduce me to them, or their pack of excuses as to why unsafe driving was somehow justified, or was in actuality "safe" because of their "skill level".  I've been fighting that fight for years, and half if not 3/4 of the offenders held a higher rank than I did...

Geoff

Timothy Gibson said:

One of the largest motivators to the PA system getting away from the ALS chase cars was liability. They viewed each responding vehicle as a liability to citizens. Now double that liability by adding a chase car. 

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Permalink Reply by Timothy Gibson on May 6, 2012 at 12:39pm

Geoff, I think you misunderstood my liability statement. I was not referring to the insurance, though with this response I will add those factors. My reference to liability was the risk of accidents increases with emergency response. Despite increased driver training and such the use of lights and sirens seems to make the general traveling public become more erratic. From the IAFC "Emergency response creates an increased risk to firefighters and to other users of the roadways. The increased risk must be balanced against the potential benefits of faster response in situations where lives and/or property are at risk. Emergency response shall be limited to situations where prompt response is likely to reduce the risk of death, serious injury or disability, or preventable damage to property." (http://www.iafc.org/files/downloads/VEHICLE_SAFETY/VehclSafety_IAFC...) Even the best drivers are susceptible to accidents caused by the other drivers actions and until we can read their minds we will fall victim to drivers that initially yield and then pull out in front of the responding apparatus. This makes us liable, 2. susceptible or exposed; subject (websters dictionary), to causing harm that could be avoided by limiting the number of responding apparatus or by limiting the use of emergency response. Studies have been produced and used that show these variables as not worth a risk based benefit. At one point NYC even considered removing lights and sirens from Fire and EMS apparatus based on their statistics showed only a 7 second benefit in response and a near 5 time higher accident probability compared to non emergent response. By putting 2 responding trucks on the road, they could deem it 10 times more likely that an accident would occur. While working for a DoD agency, we would send the first fire apparatus emergent, and all support apparatus would respond non emergent until the emergency was deemed actual and the risk versus benefit changed. So limiting response to one ambulance would reduce your liability of accident.

Since you mentioned the insurance, that too affects the cost of response. While the insurance does not cover one or 16 responding vehicles, you are charged based on the number of apparatus you maintain in a fleet. If you have an ambulance your rates are much lower than if you have 200. Since you are still maintaining a transport vehicle, you are only adding to you fleet rate by manning a second non transport capable vehicle for paramedic response. Putting the paramedic in the transporting truck bean counters would agree that they wouldn't need to maintain 2 vehicles insurance, maintenance or equipment. Under PA EMS vehicle licensure requirements, your BLS ambulance must maintain a set list of equipment. Adding an ALS responder, you are required to have many similar pieces of equipment plus the ALS equipment. So the municipality or agency is purchasing a lot of duplicate equipment which adds to the costs of operation. The savings of salaries of 5 paramedics on 5 transporting vehicles compared to 5 BLS and one ALS responder may not be an actual cost benefit with the costs associated with operating this system over time (this varies with state minimum staffing as some states require 2 paramedics for ALS while others permit one EMT and a Paramedic for ALS licensure). On top of that, if you believe the response liabilities are increased by multiple responding apparatus, then you could also understand the increase in insurance rates. Just like your personal car, if you have an accident, your rates increase. So using statistics, it is feasible to believe that your insurance costs are going to be greater as your rates increase from increased accident incidents.

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Permalink Reply by Neil White on May 7, 2012 at 2:19pm

What measures are there for transient employees? Say in London you have X number of residents that you receive funding for, but in the daytime your service is covering probably twice as many as commuting workers surge into the city every morning and leave every night.

Emergency Care is free at the point of delivery....so anyone who needs Ambulance or ER treatment gets it to the point that they are in a stable condition. So we're looking at stabilisation of primary survey stuff....We do try to recover costs from non UK citizens but it proves difficult. 

One thing I do note is the difference in the expectations of the two nations. In the UK it seems more accepted to wait in an A&E for hours and the demand on EMS seems much lower. In my last US based system, customers (which I consider our Pts) believe that EMS is there to get them to the hospital faster, many expect an immediate bed upon arrival if they utilize EMS and my wife's hospital guarantees a 15 minute wait time for a pt to be seen

Our patients are stuck with the fact that there is no competition, in many areas there is only one general hospital covering 3 - 5 million people. With the next hospital up to an hour away, people live with the fact that they have to wait. I must admit the only benefit to come from Tony Blair was the 4 hour treatment target in A&E, before this, you could do a 12 hour shift bringing in your first patient of the day to see the previous day's first patient still sat in A&E. Now its 4 hours from walking through the door to being discharged or admitted. We too had the "I'll get seen quicker if I go by ambulance" types, this is born of our TV hospital shows, where the patient comes in by ambulance and there is a bed 15 nurses and 6 of the hospitals top doctors ready to treat them. All you can really do is minimise expectations, or leg it when the patient realises they sit in the waiting room like everyone else. 

Healthcare funding in the UK is a priority issue, though in my mind there are much savings to be made in administration than care. 1 Manager to every 4 employees at last count. 11 EMS agencies, 11 HR departments 11 stores departments 11 vehicle contracts, 11 IT departments, 11 call centres, Don't get me started on the cost of staplers!!!

If it was a free for all, wasteful and unnecessary tests would be ordered by inexperienced staff. Hence why there are certain protocols in the UK that drive even the most patient doctor mad....An ER Clinical Director having to wake up the Radiological Clinical Director at 2am to order a CT scan for example. 

Our biggest negative is drugs, cheep cheerful and where possible do without. Cancer being the biggest...we have the National Institute of Health and Clinical Excellence that looks at the cost versus reward of every treatment including EMS, Autopluse CPR machines fell foul of this process. 

Medicine has evolved, we're keeping people alive far longer than they should be, conditions which would have balanced the population 10, 20 years ago are now chronic conditions and life span is expanding into the hundreds. EMS has become less about ALS, Trauma and traditional ambulance care to managing two distinct groups of of people;

(1) Those incapable (normally due to lack of intelligence) to care for even the most simplest of health problems

(2) The acute exacerbation of Chronic and Elderly conditions. Management of poor social care systems that allow 94 year old dementia ridden patients to live in their own home and allow them only a 20 minute carer twice a day....

For some reason, we, as in the wider healthcare profession seem to either be reluctant to respond to this change in patient needs....and continue with the status quo because its what we know, some UK ambulance cover plans have remained unchanged for decades. 2 ambulances covering 100,000 plus people. You could say public outcry will change things, when something goes wrong and someone suffers but no, EMS trolls out the well rehearsed press release "it was an unusually busy day which caused unpredictable pressure on resources"

Will we change anything? I'm not so sure, hell we can't even agree over what a standard ambulance education should resemble..... 

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Permalink Reply by Ben Waller on May 7, 2012 at 10:01pm

Skip, that's a little different way to describe it but pretty close.

 

The "efficiency vs fairness" concept is a MPA foundation concept.  This is a pretty good basic description:

 

"Perhaps the primary objection to “efficiency” as a guiding principle of public

administration is that it seems so narrow. Being efficient suggests selecting one, or at most a

handful, of values at the core of public agencies. It connotes single-mindedly pursuing an

objective with little attention to external effects. Thus, Waldo (1952, 93-94) suggested that

economy and efficiency are about “getting things done,” with little attention to how they are

done. Yet how things are done—and, in particular, how people are treated as we get things done

—is of principal interest to many."   Grandy, Christopher, The “Efficient” Public Administrator:

Pareto and a Well-Rounded Approach to Public Administration, preprint for Public Administration Review

© 2008

 

The concept is one of those "simple, yet complex" issues.  That's why there are entire grad schools that teach it?  :-)

 

I don't think anyone really expects urban standards of cover, urban response times, or urban resource amounts in the rural areas, but it comes down to adequate coverage that probably is not as operationally or financially efficient as what can be achieved in urban areas.  When that coverage isn't adequate or nonexistant, then it's hard to argue that efficiency is either fair or effective for the rural people who need EMS coverage.

 

Thus, my previous comment about it being difficult to draw the line in the bigger, more regionalized services.

Skip Kirkwood said:

OK, Ben, I see your point now.  This goes to the discussion of "fair" versus "equal" that often come up in the employee relations context.  I always smile when employees say that they just want to be treated "fair and equal."  Of course, the two are not the same.  It is probably not feasible from a cost perspective to provide equal levels of EMS in all communities.  Whether that is fair or not is beyond me.  When I lived rural, I knew that I was on my own with regard to personal safety issues, and I equipped accordingly.  But that's probably another thread....

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Permalink Reply by Skip Kirkwood on May 8, 2012 at 1:34pm

Ben, in a roundabout way, you hit on one of my pet peeves - when people say that government should be "run like a business."

 

They know not what they ask!

 

Customers get to choose their businesses.  Residents or citizens do not.  Same with "pay" or "not pay" for a particular service.  Businesses strive for efficiency - governments probably should not - or hard to serve populations get disenfranchsed.

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Permalink Reply by dr-exmedic on May 8, 2012 at 8:12pm

Skip Kirkwood said:





Customers get to choose their businesses.  Residents or citizens do not.  Same with "pay" or "not pay" for a particular service.  Businesses strive for efficiency - governments probably should not - or hard to serve populations get disenfranchsed.





It really depends on your idea of a gov't striving for "efficiency." I don't think that expecting the gov't to pay an executive assistant the same they'd make in a business (rather than 50% more if you count benefits), or expecting the gov't to fire incompetent people, or maybe cut back on services when all of us are losing our jobs, is really all that big an ask.  I assume you've heard of the "rubber rooms" that the NYC school district uses to house all the teachers that can't be trusted to educate kids, but can't be fired? (Granted, they got rid of them...after a *lot* of publicity...but there is still plenty of fat at .gov that wouldn't last at .com, and doesn't help my limited tax dollars serve underserved populations one bit.)

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Permalink Reply by Skip Kirkwood on May 9, 2012 at 7:20am

There's more to it than some of the bizarre examples you can conjure up in some very odd places - I know of a city where there is an "engine company" (minus and engine) where they put all the firefighters that the other firefighters deem unsafe, but who can't be fired because of city politics.  Those aside...just to wierd.....

At .com, you need look no further than family owned businesses large and small to see the same stuff - junior, who is drunk most of the time, still gets a lot of money for services as VP of Community Relations, etc.

If governments strived for efficiency, you would not see what we consider to be basic government services in many communities, particularly those less densely populated.  Education and libraries, and parks would not be free - providing services for no cost is the height of inefficiency.  An efficient library system would go out of business and leave the books to Amazon.com.

My point is - government is government and business is business.  "Good" of either may share some practices (fiscal controls, honesty, etc.) but they are not the same.  We should be able to have both good business and good government.

Someone (a founding father, I think) once said "The people get exactly the quality of government that they deserve."  Oh, so true!  If we wanted better government at the national, state, or local level, we would have it - we would know where the problems are, and we would elect people who agreed to solve those problems.  Yet the American citizens re-hire their incompetents every year - look at the ratio of incumbents who win elections, versus challengers.  We hate our government, but we are too disengaged and too lazy to change it.  And God forbid that a change might cut back on something that WE like - we'd rather have the whole thing crash and burn than make a change to something to which we think we are "entitled."  Look at all the rich retired folks who oppose changes to Medicare......

What more is to be said?

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Permalink Reply by dr-exmedic on May 12, 2012 at 11:32am

Skip Kirkwood said:





At .com, you need look no further than family owned businesses large and small to see the same stuff - junior, who is drunk most of the time, still gets a lot of money for services as VP of Community Relations, etc.





Oh, there's waste at private companies to be sure. But it's a lot easier to punish waste at private companies, since waste affects the price they can offer you, and me buying the cheaper product at Amazon.com rather than Nepotism.com benefits me, whereas waste at the city of Pittsburgh costs me, and punishing that waste involves a cost to me (i.e. moving, or time & money involved in political activism).

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