During times of a recession, it’s a wonder how any ambulance service can survive. With more and more people becoming unemployed, reimbursement for emergency services is at an all time low. This also means that less people are paying taxes to provide services like fire, police and EMS. Medicaid and Medicare programs have always had a history of cutting reimbursement during tough times. It’s now to the point where ambulance providers are only getting pennies on the dollar for what they bill.

All over the country, private ambulance services are going out of business or selling to larger providers. EMS jobs are not as abundant as they used to be. I happen to be fortunate as I work for a private ambulance service that remains financially stable right now. This of course has given me an opportunity to see what some people are willing to do get a job. We have paramedics not only moving from out of town, but out of state to work for us. It is unlike anything we have ever seen.

Now you would think that people working a secure EMS job would appreciate it, being that they can see whats going on around them. That isn’t exactly the case with everyone. I still hear attitude with crews when they are dispatched on a call for a skilled nursing facility or an inter-facility transfer. Sure, nobody enjoys those calls, but they are keeping services like us alive. While the 911 call for a stabbing is certainly exciting, it doesn’t pay the bills. As a matter of fact, 911 calls for the most part are a money loser.

If you are fortunate enough to be employed right now, remember that the calls you are running is the very thing keeping you in a job. When your employer cuts overtime, remember that it’s better than getting laid off. It’s far better to take a small hit now to ensure that you still have job in a year.

For those who are interested, I have another article I wrote a little while back about how a recession affects EMS.

I was teaching a CPR class a couple days ago to a group of EMT students. While I was explaining the 30 compressions to 2 breaths ratio, a student raised her hand and asked me if I actually count or even follow the AHA guidelines when working in the field. Believe it or not, this is the first time any student ever asked me that. I was honest and told the group that I do not always follow compression ratios. As a matter of fact, I probably never do. As you can imagine, the class was full of comments and questions after that answer.

Of course, I explained the science behind the AHA guidelines and why they recommend fast and hard compressions. The hard part was explaining why me and most of my coworkers don’t follow them. Being a paramedic, It’s easy to explain that my focus is around ALS interventions. Being that I have plenty of BLS providers on scene with me, I don’t typically have to worry about doing CPR. However there isn’t really a good excuse as to the large number of EMS providers that just “pump and blow”. It kind of makes me wonder how much of the Heart Associations studies actually included pre-hospital cases. More importantly, it makes me wonder if it really makes a difference.

….which brings me to my next point.

It seems like every time I teach a class, whether it be CPR or an EMT class, I always find myself having the “when you get into the field” talk. There seems to be this big separation of what you learn in the classroom and what you learn on the streets. I get that there are many things that experience teaches you that a textbook just cant. But why can’t our education be more realistic? It almost seems that we do everything BUT prepare our EMT and Paramedic students for real life scenarios.

We don’t tell people in CPR classes that bagging patients for any period of time usually leads to abdominal distention and regurgitation. Sure if you “properly ventilate”, that shouldn’t happen. But throw in the “bouncing ambulance” factor and the “2 people trying to do five things” factor and you got yourself a gurney caked with used hot dogs.

We don’t seem to tell our paramedic students that Mr. Homeless on 4th street only calls 911 complaining of chest pain because he knows you will give him Morphine, a bed and a hot meal. Is it that the people writing the books are so far disconnected from pre-hospital medicine? Or do we just think it’s too “politically incorrect” to tell our students that our patients lie to us?

All I’m trying to say is that we as EMS educators and providers need to put more emphasis on teaching our students the reality of working in this field. I would like to see us try and close this gap between classroom and field learning.

Anyone beg to differ?

Once upon a time lived a boy named Sue. He was well known as the bully around town. Sue was quite the perfectionist. It was understood that when you are in Sue’s territory you play by his rules. One wrong look and you better hold on to your lunch money for dear life, because Sue would have you roughed up and broke before you even knew what hit you.

On the other side of the neighborhood lived a boy named Doc. Now Doc was quite the opposite. He spent his days helping people with their various issues. A problem solver if you will. As a matter of fact, other kids were willing to pay Doc to help them with their problems. He was good at what he did and had a heart of gold. Unfortunately Doc wasn’t perfect. Sometimes he made mistakes, and that often made the other kids mad.

One day came and a kid named Pat had a problem that Doc just couldn’t solve. Pat became very upset as he paid Doc all of his lunch money and didn’t get what he wanted. Pat decided to track down Sue and see what he could do to help. Sue assured him that he would get his money back, as long as he got to keep half. Pat couldn’t resist the offer and decided to take him up on the deal. So Sue tracked down Doc, roughed him up and took all his money. As a matter of fact he took more money than Pat gave him to begin with. Pat ended up getting all of his money back and Sue kept the rest.

Now Doc eventually recovered and went back to his business of helping people. That is until one day Pat returned and requested his services again. Not really sure what to do, Doc agreed to help him. Once again Pat wasn’t very happy with the service he received. Pat once again called upon Sue to get him his money back. Only this time Doc called upon his friend Sharky to defend him in his time of need.

Sharky stood up to Sue and saved Doc from losing all of his money again. This continued until one day Sharky realized that he was providing a valuable service for Doc. A service this good was worth some form of reimbursement. After all, if Doc didn’t have Sharky to help, then he would lose all of his money every time Sue came around. Eventually it got to the point where it cost more money to have Sharky help, then to just give Sue what he wanted. This of course made for hard times with Doc.

More and more kids were getting the idea that they could just call Sue to get what they wanted out of Doc. Of course Doc couldn’t stand to lose all of his money as he had to have something to buy his lunch with. So Doc decided to ask for more money in exchange for solving peoples problems. As the cycle continued, many people couldn’t afford to pay Sue anymore and therefore would not seek his services. Even with the small number of kids that were actually paying Doc for his services, his high prices still provided for enough money to buy lunch.

Times were tough, but Doc managed to eat everyday. That is until the kids that didn’t have enough money to pay Doc called upon Sue to help them with their problems. Sue then told Doc that whether or not the kids had money, he was going to help them unless he wanted to get roughed up and robbed again. Unfortunately it got to the point where Doc was helping every kid in the neighborhood and only a couple kids were actually willing to pay him for his service.

Eventually Doc just couldn’t keep helping people. The constant fear of Sue coming around finally got the best of him. He had no choice but to quit trying to help people and find another way to earn his lunch money.

As I sit here reading through Happy Medic’s Blog, I came across a very interesting post regarding billing, and refusal of treatment. He made some very valid points when it comes to fraudulent practices seen amongst many EMS providers. For the purpose of this post I am going to focus on legal issues when it comes to having patients sign AMA (against medical advise).

The Scenario:

You arrive on scene of a 26 year old female complaining of abdominal pain that started 2 weeks ago. After you start your assessment, she asks you if the ambulance ride is really necessary. You respond by telling her that her vital signs are all stable and that she looks fine. You explain that abdominal pain that started 2 weeks ago is non-urgent and that she should seek care with her primary care physician as soon as she can.

She accepts your advise and decides against transport to the hospital. You then ask her to “sign here” to release you from any liability SHOULD anything happen after you leave. She signs the form, apologizes for calling you out and wishes you a good day.

Here’s the problem with this scenario. You just had her sign a form that states that she is “refusing treatment” against medical advise. Well your medical advise was to stay home and seek care from her physician at her convenience. I’m sorry but Larry H. Parker is going to eat you alive in the court room.

Just because you got someone to sign a piece of paper, doesn’t mean your legally off the hook. Someone signing out AMA must give you Informed Refusal in order for the form to actually be legal. Just like Informed Consent, the patient must verbalize that they truly understand the risks from REFUSING TREATMENT. Tossing them a piece of paper and saying “please sign this” isn’t going to meet that criteria.

As EMT’s and Paramedics, we should not be giving medical advise unless it is in the form of convincing a truly ill person to go to the hospital. The proper way to address the “do I need to go” issue is to explain that it is not your decision to make and that if they want to go to the hospital, you would be more than happy to take them. I’m not saying force everyone to go, because that will get you in trouble too. Just be very cautious when expressing your opinion on their condition. We are not physicians and we cannot truly rule out a life threatening illness.

If you felt so strongly that the patient didn’t need to go, then why did you have them sign an AMA? Why not just leave them and call it good? There shouldn’t be a need to “cover your ass” if they really don’t need medical attention right?

If you want to play it safe, then don’t advise patients that their condition doesn’t require medical attention. That old lady with the stubbed toe just might have broken loose a clot from the DVT that you or her didn’t know she had (a stretch, I know). I’m not saying that you have to force everyone to go, but rather be careful of what you “advise” people before you have them sign a refusal of treatment. Lets try not to give the lawyers any more money than we have to.

Yes I’m bringing up the much feared “H” word…..but for a good reason!

I read various EMS-related blogs and Twitter posts every day. Most come with some pretty interesting stories about calls ran. Unfortunately, some are a little too detailed and have the potential to get some people in trouble. I know this because I speak from first hand experience.

Being guilty of sharing my calls for the day with the world, I have been known to give out a little too much information. On one occasion, my boss actually called me into his office because he received a complaint about a story I posted on my blog. Luckily it just amounted to me pulling the post off my blog and no real damage was done. However, had it have been pushed any further, I could have easily been fined thousands of dollars. My employer would have also been fined, which would have probably translated into me being unemployed.

Many EMS bloggers violate HIPPA and don’t even know it. There is a huge misconception that leaving out patient names protects us from privacy laws. The truth is, you have to pretty much leave out any details that could even remotely link the story to a patient. For example; if the patient can read your blog and identify the story as being their incident, then HIPPA has been violated.

So how do I HIPPA-Proof my blog?

The only way to make your blog 100% compliant is to just not reference calls without a patient’s permission. If you read my blog, you obviously know this is not how I practice. I do however, take several steps to minimize my risks.

First and foremost, NEVER use patient names, addresses, pictures, etc. Anything that directly links your story to the patient is just an attorneys payday waiting to happen. Making up fake names or not using names at all is an easy way around this.

We all like to brag about who we work for right? Well don’t do it. Don’t even mention what agency or company you work for. Doing so places yourself and your employer at risk. This goes for the entire blog, not just the story.

Don’t talk about where you work, or even where you live.  Be vague when discussing your location. Use terms like “Southern California” rather than “Los Angeles California”. This also applies to the entire blog.

Don’t get detailed when discussing call locations. Describing your scene as “Chili’s Restaurant on 4th street”, is a bad idea. Instead either make up a fake establishment or just don’t even mention any business names.

Blogging is like journalism, so aren’t I covered under the “freedom of the press?”

No, no and hell no.

Sure Geraldo Rivera can pretty much say anything he wants on TV and be covered under the constitution, but Geraldo isn’t a paramedic (thank god). We are healthcare providers and we sign HIPPA agreements when we go through school and start employment. As a matter of fact, posting protected information on the internet is about the worst way you can violate privacy laws.

Don’t get me wrong people, I love reading about how you intubated 2 people at the same time or successfully stuck an IV in someones earlobe. Just please be careful and protect yourself!

If anyone is interested, more HIPPA information can be found at http://www.hhs.gov/ocr/privacy.

Budget cuts, layoffs, and public criticism are all nightmares of nearly every public agency or department. In times of financial crisis and a near economic meltdown, public entities are getting desperate for an answer. The big question is, what happens when your government can’t afford to provide life saving services like EMS? The answer lies within the foundation of the American Dream. Private enterprise.

In a very large portion of the country, private business is already providing these life saving services at no cost to the tax payers. With so many cities and counties operating in the red, I’m left to wonder why more areas aren’t being serviced by private companies. By switching to a private or pay-per-service system, municipal governments can save a truck load of money. That is money that can be used to fund or improve critical services like law enforcement, roads or fire suppression.

There are certainly valid arguments, none of which are financial, that oppose such systems. Many people feel that emergency medical services is a responsibility of the government, and therefore should be operated by the government. Some more arguments against private EMS include:

• Stability

• Oversight

• Accountability

• Quality of care

I can certainly understand a fear that a private ambulance can “go under”, leaving an area with no coverage. However, during these tough times, there is hardly any stability with any branch of the government. Layoffs and budget cuts are forcing public agencies to decrease personnel and number of units available. The risk is equal on both sides of the fence. For every ambulance service that goes out of business or loses a contract, there are several financially sound companies waiting for opportunities to expand. If we trust privately run hospitals to service communities, then why can’t we trust private ambulance service?

The argument about oversight, accountability and quality of care with private ambulance services is weak. In reality, there is more government oversight when it comes to contracted services then there is when the city or county runs their own service. Private ambulance services have to follow strict guidelines in order to maintain a contract. With no contract, the company can’t operate, which translates to no business. Contracts call for response time compliance, number of units available, quality assurance programs and complaint resolution. When fire or third-service based systems are in place, all the governing boards typically care about is amount of money they spend. Which, by the way is usually over the top.

Private business has to earn their money and manage it. If they don’t generate enough revenue, then they can’t operate. Sound familiar? If you are a working person supporting a family then it probably does. Government agencies don’t have to worry about generating income. They just spend the money and ask for more when they run out. It sounds harsh but it’s true. Next time you get behind on your car payment or mortgage, try asking your boss for more money and tell me how it goes.

In conclusion, I feel that private business is just as capable if not more capable of providing efficient and quality emergency medical care. As always, I welcome all questions and comments. You can e-mail me at sean@medicmadness.com or simply comment below.

Have a great week.

Hello readers. Today I am going to discuss the impact of a downward economy on EMS and the medical field in general. Until recently I actually believed that the medical field was immune to the economy. Like many others, I thought that since people can’t control when they get sick, that EMS and medical facilities would never suffer. That idea is absolutely wrong. Many things factor into financial hardships for medical facilities and EMS agencies during a recession. High unemployment rates and government cutbacks are just a couple examples.

Many American Citizens receive private health insurance as a benefit from their employers. When establishments are going out of business and people are frequently laid off, the number of insured patients significantly decreases. This can affect the medical field in general because people will not typically see a family physician for non life-threatening conditions, as they have no means to pay for it. While this may not affect the emergency call volume for EMS providers, it can certainly affect reimbursement. As it already stands, government provided insurance like Medicaid and Medicare already reimburse at an alarmingly low rate. In California, the average reimbursement rate is 14 percent. That means for every dollar that an ambulance service bills, they will only receive 14 cents. Even without a recession, this is still a huge obstacle for ambulance providers to overcome. With more and more people losing jobs, the amount of non-payers and government-assisted payers goes up.  Sounds bad enough right? It only gets worse.

When businesses collapse and people lose jobs, the government also suffers. People not working means people aren’t paying taxes. This equates to higher taxes and government cut backs. Medicaid and Medicare programs across the nation are tightening their belts, making reimbursement more difficult. Some states are even going as far as to delay payments. In addition to the decrease in cash flow, the state and federal government tend to place higher taxes on businesses, making daily operation even more difficult.

Despite all the doom and gloom that goes along with a recession, many agencies will prevail. Good financial planning, cutting overtime expenses and eliminating wasteful spending will be the key to success during these times of financial crisis.

As always, feel free to e-mail me with any comments or questions.

Good evening readers. Watching the news recently has left me wondering about the amount of resources that we dedicate to emergency response. A recent clip about a vehicle that drove through a glass door at an urgent in the Los Angeles area was nothing short of amazing. When the news story started, the live feed showed several emergency vehicles surrounding the building. 13 to be exact. By the time the story was done airing, I counted 19 emergency vehicles between fire and ambulances.

Being that 6 people were transported to the hospital, I can certainly understand the additional ambulances. However, I have a hard time making sense of nearly 20 response crews. I am not an expert in fire operations by any means, but I’m confident that this incident could have been handled with less resources. The image displayed on TV’s nation-wide showed some crews treating the victims, and at least 12 people standing around outside the building.

A good comparison to this incident would be the Mojave Air and Spaceport explosion in 2007. 4 critical patients who suffered from blast injuries were transported via air ambulance to a trauma center. 2 patients died at the scene. The total response included 3 fire engines, 3 air ambulances and 2 ground ambulances. The ground ambulances were canceled once the airships arrived on scene.

Obviously Mojave, CA does not have anywhere near the resources that Los Angeles does. However, the incident was run with an adequate number of personnel to ensure scene safety, proper patient care, and expedient transport.

In times of financial hardship, businesses and goverment agencies around the nation are doing what they can to cut costs. In the response to the current budget crisis, Police officers, correctional officers, state employees and even some fire agenices in California are mandating 2 unpaid days off a week for all employees. Many government workers are getting their walking papers, leaving departments understaffed and over worked. Not wasting money on “over-responding” to these incidents is certainly a way that we can work to overcome these hard times.

As always, feel free to e-mail me with any questions or comments.

A popular topic often debated in political races and amongst health care providers is the need for nationalized medical coverage (socialized medicine). Various other countries like Canada, England and Australia utilize such services. A popular argument for nationalized health care is availability of insurance for all citizens regardless of their financial situation. On the surface, the idea sounds reasonable, but in a nation run by private enterprise it can cause more problems then it’s worth.

Insurance coverage provided by both the state and federal government has proven itself to be inadequate and bad for business. As it already stands government funded health insurance reimburses pennies on the dollar for both emergency and non-emergency medical care. Many hospitals, private doctors offices, and medical facilities are turning away these patients because of a significant lack of compensation.

EMS providers are in a bad position as they don’t have the option of turning away non-payers or government-funded payers. This leaves ambulance services and emergency departments relying on private insurance companies to make up for the significant losses caused by government-funded insurance. Switching to a nationalized health care plan would be sure to place most private providers out of business.

The loss of private EMS services would require state and local governments to pick up the slack and provide the service at the cost of the tax payers. This of course would significantly increase income and property taxes to pay for the insurance and the services provided in place of private medical operations.

Sure, having more government jobs could result in retirement plans and good benefits, but the amount of jobs available could rapidly decrease. Budget cuts and increasing cost of doing business would either result in raising taxes or cutting jobs. Once government bureaucracy comes into play, you can be assured that the number of ambulances on the streets will decline. Local police agencies are a prime example. It is hard to find a police department that claims to have adequate staffing or funding. Socialized medicine would leave EMS agencies in the exact same situation.

Our health care system in the United States is far from perfect. Abuse on the system, lawsuits and uninsured patients are constantly increasing the cost to provide medical care. Work needs to be done to resolve this issue, but not at the expense of the tax payers.

If you have any questions or comments, please feel free to e-mail me.

Good evening readers. Today I want to discuss a topic that has been in EMS journals and the news frequently. Lately it seems that EMS helicopters are being used way more than they should. This applies to both emergency and inter-facility transfer calls. I do feel that helicopters are a vital resource to EMS, however it is a tool that should be used wisely.

As part of my job as a field supervisor I investigate calls where a helicopter was used on a daily basis. This includes the patient outcome, reason for deployment, time savings, care rendered prior to airship arrival and risk factors. People often use mechanism of injury as a decision on whether or not air transport should be utilized. I completely disagree with this practice.

Determining the mechanism of injury is great for assessing injuries, but not so great for transport decisions. A physical assessment should be the number one tool used to determine the severity of injuries and whether or not a patient could benefit from air transport. The old “better safe then sorry” routine has got to stop. As paramedics and EMT’s, we are trained to detect life threatening injuries. Launching a helicopter because “they might have internal bleeding” is not an example of a good assessment. Sure if the patient presents with poor skin signs, a distended abdomen, bruising, tachycardia and severe pain after rolling his car 3 times, then launch the helicopter if it will save time. But don’t do it just because his car looks “really bad”.

Being a patient advocate is not purely a medical role. Some other emotional and financial factors play into the positive outcome for the patient. Your patient will likely have a negative opinion on you and the service that you provide when they receive a $15,000 bill that the insurance company just rejected for his air-ambulance ride when he only had a broken arm. Something like this can greatly impact a persons life in a very negative way. All of this can be avoided by performing a good thorough assessment before making the decision to transport by air.

Your decision to use an air-ambulance may not just affect your patient, but other patients as well. When you take a helicopter out of the system, you may be denying that resource to a critically injured person that can actually benefit from the time savings.

Helicopters are a great tool and can really make a difference when time matters. As EMS providers we have an obligation to make sure that our resources are used responsibly.

As always, questions and comments are always welcomed. Please feel free to e-mail me.