New Program Allows Paramedics to Treat and Refer Patients

We live in a medically underserved area with limited medical services, especially EMS and primary care. Many times the LMRFD ambulance is used for minor illness or injuries because someone simply doesn't have access to a vehicle. 

 Transporting patients whose illness or injury does not require ambulance transport to an emergency department puts our ambulance out of service for one to two hours. 

The Treat and Refer Program would give paramedics an opportunity to address non-emergency health needs and referral patients to a more appropriate level of care.

The Treat and Refer Program would better serve our community by allowing local non-emergency vehicles to transport patients that would otherwise take the LMRFD ambulance out of service leaving us with nothing. 

Today in Arizona we have the Treat and Refer Program for paramedics. This gives EMS providers an opportunity to assess patients and referral non-emergency to a more appropriate level of care (e.g. primary care doctor, urgent care or behavioral health office). 

The Treat and Refer Program would allow paramedics to respond and treat patients at home or refer patients to their primary care, urgent care, or crisis services.

Treat and Refer Questions and Answers 

Q: What is the Treat and Refer (T&R) program? A: A T&R interaction is defined as a healthcare event with an individual that has accessed 9-1-1 or a similar public emergency dispatch number, but whose illness or injury does not require ambulance transport to an emergency department based on the clinical information available at that time.

Q: Does the T&R program replace existing emergency services? A: No. Individuals who have an emergency and need transport to an emergency department will continue to receive those critical services. The T&R program is intended to give providers an opportunity to address non-emergent health needs through an assessment and referral to a more appropriate level of care (e.g. primary care doctor, urgent care or behavioral health office). The T&R program will provide better quality care and more opportunity for individuals to engage in their own health.

EMD 420 -Alternative Patient Destinations 

This course provides EMTs and Paramedics the background knowledge to understand and implement community paramedicine and treat and refer programs across a variety of EMS response models and communities. Upon completion of the course, students will meet Arizona requirements for those students with a certification as a paramedic to function as a Community Paramedic in a treat-and-refer program

Additional Training Required for Treat and Refer 

 More Info HERE

 

Rethinking EMS: Don’t Knock ‘Homeboy Transport’ an article from Emergency Physicians Monthly

In some cases, the fastest way to get someone to the emergency room is by POV or Private Owned Vehicle. 

 

Apple pie and motherhood. That’s how EMS systems have come to be viewed in this country. While in some locations this is a well-deserved perception, in many others, local EMS systems have become out of step with medical evidence.

 

As the Associate Director of Paramedic Training for Los Angeles County several decades ago, I remember the extensive classroom and practical training provided to the students. If I recall correctly, the total number of hours of education was about 1,800. You can envision the level of detail that was achieved given this extensive amount of time. 

In retrospect we covered a huge amount of material that was essentially irrelevant to field care. But the goal was to ensure a comprehensive level of training. The esprit de corps was high and being selected for the training was considered an honor.

 

 It was generally assumed that paramedic-level care was the gold-standard for EMS. The huge popularity of the TV show, “Emergency!” which focused on three imaginary LA County paramedics in the 70s, catalyzed the nation’s interest in developing paramedic programs.

 

Yet, since those early days there has been a growing body of evidence suggesting we need to challenge many of our assumptions about the best ways to provide prehospital care. 

From issues like the decreasing need for prehospital drug therapy (especially in the setting of a cardiac arrest) to evidence that little is gained by lights and sirens transport (and that it is associated with about 12,000 ambulance collisions annually in the U.S. and Canada) to the demonstrable overutilization of helicopter transport, the list of EMS practices that are worthy of scrutiny continues to grow.

But a much more fundamental question is arising. Perhaps less is more. Perhaps in some settings EMT-based rapid transport can result in better outcomes than ALS care. The next four papers challenge EMS agencies to look careful at the status quo.

1. BLS trumps ALS in some cases...

ALS transport and care were associated with decreased survival in patients with penetrating injuries and ISS scores below 30, and provided no significant benefit for patients with more severe injuries. It appears that speed of transport (ie, BLS care) is more important than the level of care provided.

 2. Private Vehicle Transport Trumps EMS Transport

The authors acknowledge the methodologic limitations of their analysis, but note that these findings are consistent with a significant survival advantage of transport of GSW patients by private vehicle rather than EMS.

3. Cardiac Arrest better outcomes with BLS

In this large study, BLS care for prehospital cardiac arrest appeared to be associated with better outcomes than ALS care.

4. Endotracheal Intubation ETI vs Bag Valve Mask BVM

Rates of survival to hospital discharge were similar in the ETI and BVM groups (26% and 30%, respectively), as were rates of discharge with good neurologic outcome (20% and 23%).

Rethinking EMS: Don’t Knock ‘Homeboy Transport’

Truth is in some cases; patients have a better chance of survival with an EMT rather than a paramedic

Television and movies tell us that paramedics are the be all and do all of emergency medicine, and in some cases that's true. 

But in many cases the use of Basic Life Support, BLS skills like loading the patient and rapidly getting them to the definitive care of physicians have better survival rates than paramedics. 

Read the research links at bottom.

When I posted about using EMR's to respond to medical calls to give Dolan and Meadview a second ambulance, someone close to the fire district said, "Actually, there is less liability if nobody shows up than if somebody shows up and does something wrong". 

That is true.

It's also true that the more invasive procedures you do, the more chance for mistakes. So there's more chance that a paramedic will "do something wrong" because they do invasive procedures like endotracheal intubation or starting IV's. 

EMT's and EMR's use basic BLS skills like airway, breathing, and circulation. They secure an airway, give 02, support respirations, and rapidly transport the patient to the definitive care of a physician. 

My experience...

I was fortunate to take my paramedic training in Los Angeles during the 1984 Olympics. I trained as a Mobile Intensive Care Unit Paramedic at one of the first paramedic schools in the country, the Daniel Freeman Hospital Paramedic School. It was started by Dr. Walter Graf who's known today as one of the founding fathers of EMS.

We attended class 8 hours a day, 5 days a week for 8 weeks. Then 4 weeks rotating through various hospitals like Cedar Sinai, Martin Luther King, and the USC Medical Center. 

We didn't know it at the time, but we were training in the birthplace of emergency medicine as we know it today, the emergency department at the USC Medical Center's General Hospital. 

I spent time in C-Booth, and I really don't know how to describe C-Booth. It was a 10'x10' area with 4 beds, at least 2 always filled with someone who was about to die. It looked more like a MASH unit than today's emergency room.

An article by Intermountain Health Care described C-Booth this way, "the most critical, traumatic injured patients arrived in the trauma bay, called C-Booth, where “more people have died and more people have been saved than in any other square footage in the United States,” according to physician and director Dr. Ryan McGarry"

It was a teaching hospital; we were young paramedics, PA's, and physicians, it was an exciting place to learn, but one of the first things we learned was that mistakes happen, and patients die.

Back in Spokane

As part of my training, I spent 480 hours training with a Spokane Fire Department paramedic unit. On our first run, the first day of my training we got a shortness of breath call about two miles away at a bowling alley. 

A 40-year-old male who was bowling with his son was having an asthma attack. It only took us a few minutes; it was a straight shot down Division St from Station 10. 

He was in respiratory distress in the tripod position when we arrived using accessory muscles to breathe. 

I started an IV as another paramedic was assessing the patient. As he was assessing breath sounds the patient progressed into respiratory arrest. The paramedic intubated the patient using an endotracheal tube, I attached an ambu-bag to the ET tube bagged the patient as he auscultated each lung and saying he had breath sounds in both.

The patient quickly progressed into cardiac arrest as firefighters were bringing in equipment. I continued to bag the patient as firefighters started CPR. We loaded the patient and ran code to Sacred Heart Hospital a couple of miles away. 

One of the first things they do in the emergency room when you arrive with an intubated patient is do an x-ray to confirm the ET tube in the trachea and not the esophagus. As soon as they got the x-ray back, they called the code. 

The endotracheal tube had been placed in the patient's esophagus rather than the trachea and I had been bagging oxygen into his stomach rather than his lungs giving him no chance of survival.

The ER doc went out and told his family he was sorry that they did everything they could, but he had suffered a severe asthma attack.... 

He never said he was sorry, but the paramedic had accidentally placed the breathing tube in his esophagus rather than his trachea. If it had been placed in his trachea and he received lifesaving oxygen, he may not have progressed into cardiac arrest. 

Talk about a learning experience for a paramedic trainee, did I help kill a guy. I always made sure I could see the vocal cords when doing intubations. 

Truth is in some cases, patients have a better chance of survival with an EMT rather than a paramedic, because EMTs use basic life support with rapid transportation to get the patient to the definitive care of a physician.

These are excerpts from EMS articles about survival rates when being transported by a paramedic vs EMT. The results may surprise you..

I love this article Rethinking EMS: Don’t Knock ‘Homeboy Transport’ because in Dolan many times we transport friends or family in private vehicles (POV) because of long response times. 

Article; BLS is more than basic, it’s fundamental to good care

Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis "In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS".

Article; Advanced ambulance care increases mortality

Patients suffering from trauma, heart attack or stroke have a better chance at survival if they are transported by a basic life support ambulance than by an advanced life support ambulance, according to a new study involving data from nearly 400,000 patients in non-rural counties nationwide. NOTE: Some will say this was done in non-rural areas but a nobody survives a cardiac arrest in Dolan Springs or Meadview. A paramedic and EMT alone cannot run an effective cardiac arrest and transport. It takes at least 4 people, someone needs to run the code, someone needs to drive, and you need at least two people to CPR. You can only do effective CPR for 10 minutes.

The study, published in the Oct. 13, 2015 issue of Annals of Internal Medicine, found that:

• For patients suffering from trauma, survival was 6.1 percentage points higher for those transported by a basic life support (BLS) ambulance than those who were transported by an advanced life support (ALS) ambulance. Patients with critical major trauma had a 12.5 percentage point greater chance of surviving for 90 days if transported by BLS.
• Patients with acute myocardial infarction (heart attack) were 5.9 percentage points more likely to survive for 90 days after their ambulance transport if they were transported in a BLS rather than ALS ambulance.
• Patients with stroke had a 4.3 percentage point greater chance of surviving for 90 days, when transported by a BLS ambulance.
• There was no survival difference between BLS and ALS ambulances for patients with respiratory failure.
• Greater use of BLS may also save money..

"But we found that basic life support patients were more likely to survive. They were also more likely to have better outcomes on measures such as neurological functioning."

LINKS USC Medical Center C-Booth

C-Booth Code Black

LA Times 1985 article, Tending to Broken Bodies : Heart of County-USC: the Emergency Room

 

What incentive do the people have to annex into the LMRFD?

What incentive do the people have to join the LMRFD? Nothing.

Be honest, would you voluntarily choose to increase your property tax by several hundred to several thousand dollars when you get the same services now at no cost? 

The LMRFD covers 144 square miles in the two communities of Dolan Springs and Meadview. It does not cover the 38 miles between the two communities, the hundreds of homes west of US93, in White Hills, or on US93 itself. 

We cannot continue to abandon the community paying for fire and EMS services to respond to areas that have been repeatedly told they have no service and have made no attempts to provide their own coverage.

I'm sorry but we need to reduce the area covered by the LMRFD Ambulance to the 144 square mile fire district. Currently the LMRFD CON, it's Certificate of Necessity covers 2200 square miles, that's 2056 miles outside of the 144 square mile fire district.  

Why should the LMRFD respond to your call leaving those who do support the fire district unprotected?   

We have no contractual liability to respond to fires outside the fire district. White Hills isn't in a fire district. We have no mutual aid agreement with White Hills because they have no mutual aid to offer. I'm not even aware of any volunteers from White Hills even though EMTs who work in Vegas live there. 

Residents in White Hills and West of US-93 must understand they are NOT in the Lake Mohave Ranchos Fire District or any fire district. They may believe they’re paying property tax to the district when they see “Fire District Assistance Tax” on their property tax bills. But this money typically just goes to reimburse departments that respond for rescue operations on state highways.

This is a map of the fire districts in our area. The big blue square is the area the LMRFD covers in Dolan Springs. The tiny blue dots above are scattered parcels and the larger blue area is the Meadview coverage area. 

Much of Meadview is not in the fire district pay no property tax yet we respond. Parcels just blocks away from the fire station are not in the fire district.

Meadview Area

Below is a map of the 2200 square mile area the LMRFD ambulance is required to cover. Why does it cover part of Coconino County? There are NO roads that even lead to that area without going through Kingman and Truxton many miles from Dolan Springs

 

Below the LMRFD 144 sm Fire District is in Blue and the 2200 sm LMFRD CON is in Red.  LMRFD's one ambulance covers an area larger than that covered by all other ambulances in the county combined. 

No other fire chief with such limited resources would send their ONLY ambulance 40 miles outside his fire district leaving taxpayers with nothing... 

The Taxpayers in the LMRFD Get NOTHING for their tax dollars. WHY do people outside the district get the same services?

In Arizona many fire districts operate on a subscription service charging $60 to $100+ a year. If you're not on the paid list, they don't respond.

So again be honest, would you voluntarily choose to increase your property tax by several hundred to several thousand dollars when you get the same services now at no cost? I didn't think so...

Yes an Emergency Medical Responders can Drive the LMRFD Ambulance Here's the LAW

The LMRFD could have a second ambulance using a paid or volunteer EMT and a volunteer EMR, Emergency Medical Responder. It costs $1500 to train an EMT and $250 to train an Emergency Medical Responder. 

The Emergency Medical Responder Law was passed by the Arizona Legislature because they understood without volunteers like Emergency Medical Responders on rural ambulances in medically underserved areas, people would die. 

Chief Bonnee has told me over and over that the LMRFD can't use EMRs. When I asked the medical director from KRMC, she said the LMRFD can use EMR's but there is some liability. 

I said, isn't it better if someone shows up? What's the liability if it takes two hours and someone dies, or nobody shows up at all? 

Rural Ambulance Transport

The law is pretty clear, EMR’s Emergency Medical Responders can drive the LMRFD ambulance and assist an EMT or paramedic as long as their primary responsibility is driving the ambulance.

I’m told over and over that we can’t use EMR’s on the ambulance that we have to have a paramedic and an EMT on the ambulance. Not True

 

Using volunteer EMR’s we could double our transport capability by reducing response times and improving patient care. 

 

ARS 36-2201 says "Ambulance Attendant" means any of the following:

A - An EMT, an advanced EMT, an EMT I-99 or a paramedic whose primary responsibility is the care of patients in an ambulance and who meets the standards and criteria adopted pursuant to section 36-2204.

 

B - An EMR emergency medical responder who is employed by an ambulance service operating under section 36-2202 and whose primary responsibility is the driving of an ambulance.

 

 

ARS 36-2202 - Duties of the director; qualifications of medical director

J. paragraph 5 of this section shall require that ambulance services serving a rural or wilderness certificate of necessity area with a population of less than ten thousand persons according to the most recent United States decennial census have at least one ambulance attendant as defined in section 36-2201, paragraph 6, subdivision A and one ambulance attendant as defined in section 36-2201, paragraph 6, subdivision B

 LAWS

36-2201 Definitions

In this chapter, unless the context otherwise requires:

5. "Ambulance" means any publicly or privately owned surface, water or air vehicle, including a helicopter, that contains a stretcher and necessary medical equipment and supplies pursuant to section 36-2202 and that is especially designed and constructed or modified and equipped to be used, maintained or operated primarily for the transportation of individuals who are sick, injured or wounded or who require medical monitoring or aid. Ambulance does not include a surface vehicle that is owned and operated by a private sole proprietor, partnership, private corporation or municipal corporation for the emergency transportation and in-transit care of its employees or a vehicle that is operated to accommodate an incapacitated person or person with a disability who does not require medical monitoring, care or treatment during transport and that is not advertised as having medical equipment and supplies or ambulance attendants.

6. "Ambulance attendant" means any of the following:

(a) An emergency medical technician, an advanced emergency medical technician, an emergency medical technician I-99 or a paramedic whose primary responsibility is the care of patients in an ambulance and who meets the standards and criteria adopted pursuant to section 36-2204.

(b) An emergency medical responder who is employed by an ambulance service operating under section 36-2202 and whose primary responsibility is the driving of an ambulance.

8. "Basic life support" means the level of assessment and care identified in the scope of practice approved by the director for the emergency medical responder and emergency medical technician.

13. "Department" means the department of health services.

14. "Director" means the director of the department of health services.

15. "Emergency medical care technician" means an individual who has been certified by the department as an emergency medical technician, an advanced emergency medical technician, an emergency medical technician I-99 or a paramedic.

16. "Emergency medical responder" as an ambulance attendant means a person who has been trained in an emergency medical responder program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36-2205.

36-2201

17. "Emergency medical responder" as an ambulance attendant means a person who has been trained in an emergency medical responder  program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36-2205.

18. "Emergency medical services provider" means any governmental entity, quasi-governmental entity or corporation whether public or private that renders emergency medical services in this state.

23. "National certification organization" means a national organization that tests and certifies the ability of an emergency medical care technician and whose tests are based on national education standards.

Other Fire Districts use Emergency Medical Responders Why Can't the LMRFD?

 I don't understand the reluctance of Chief Bonnee to train and use EMR's Emergency Medical Responders in the LMRFD. Other fire districts like Yucca and the Heber-Overgaard Fire District in rural areas use EMR's, so why don't we?

I contacted Chief McCluskey of the Heber-Overgaard Fire District and asked how he uses EMR's in his fire district. 

When I told Chief McCluskey we had one ambulance and response times can be hours rather than minutes.

Chief McCluskey said "Our volunteer EMRs enable us to keep the higher trained firefighters and EMTs in the District for the 2nd call which happens pretty frequently" Just like here in Dolan Springs and Meadview

 

Thu, Oct 10, 3:11 PM
Chief McCluskey
Heber-Overgaard Fire District
chief@hofdaz.com

Jay,

Don’t let their short sidedness stop your pursuit. No an EMR is NOT and EMT. However when you want to keep, medically trained EMT’s in the district (when transporting patients to the hospital), EMR’s become VERY valuable.  If we respond with EMR’s, they are a 3^rd person. Currently our EMR’s either respond to the scene in an additional ambulance or wait at the station for the transporting crew to stop and change out drivers. This way the scene gets the higher level of care, but the transport driver meets the state requirements. 

Let the other districts know they can call us anytime to get information on what we do. 

Thanks.
Chief D. McCluskey
Office (928) 535-4346 Ext 106
Cell (928) 240-4149
Fire Chief / Paramedic
Heber-Overgaard Fire District

Jay Fleming <leapspeaker@gmail.com>	Thu, Oct 10, 11:00 PM (8 hours ago)
to chief

Sorry I'm old and forget things..... 2 Question 

Since the law allows for EMR's to assist and drive the ambulance in rural communities, and the state doesn't "certify" EMR's, do you know if the medical director can stop EMR's from driving?  

Your EMR's respond to the scene in an additional ambulance, then the EMT or paramedic takes the 2nd in ambulance and the EMR and the EMT or paramedic transport? 

Thanks again

Jay

 

William McCluskey	7:17 AM (6 minutes ago)
to me

1. I’d have to look up the statue regarding medical control/director, but he/she can only require what level of service is required for the care of the patient under their direction. The driver provides no care during the transport therefore doesn’t fall under the medical directors control. 

2. Our EMR’s volunteer for time periods during the week. When a call comes out the “Car #” comes up on the air and responds to the station. By the time they get to the station, the responding crew has arrived and the Captain directs the EMR to bring the second amb or wait at the station.  

a. If the EMR is directed to the scene, they always drive without lights and siren. Upon arrival the EMR then prepares for transport in either amb at the wishes of the captain. Then drives the medic to the hospital. We are 45-50 minutes from Summit, so it’s a 3 hour event from dispatch to back in the area. 

b. If the EMR is told to stay at the station, the call has likely occurred west of the station and the crew will simply stop by the station on their way to the hospital and switch out drivers. 

Correct. Our volunteer EMRs enable us to keep the higher trained firefighters and EMTs in the District for the 2nd call which happens pretty frequently. Of course we encourage and pay for the EMRs to become EMTs but some just don’t want to or have the time to go. 

It seems if you have the people interested in helping the community and district this way, it’s a Win-Win for the district and community.

My 2 cents 

Chief Dee McCluskey
Fire Chief/ Paramedic 
Heber-Overgaard Fire District
(928) 240-4149

 

The Intersection at US93 & Pierce Ferry Rd was Made More Dangerous by Setting Up a Secondary Crash Zone

Why is US93 Such a Dangerous Highway

The intersection at US93 and Pierce Ferry Rd was made far more dangerous by the recent upgrade. Like many locals ADOT must have thought people from other countries that drive on the left side of the road were stopping to cross northbound US93, then looking the wrong way and pulling out in front of northbound traffic. 

The upgraded turn lane comes off at an angle so southbound traffic turning onto Pierce Ferry Rd stops looking directly at northbound US93 traffic. The design had the unintended consequence of creating a new crash zone.

Before the upgrade southbound US93 traffic would use a “normal” turn lane where the driver moves into the turn lane and then makes a 90° turn and stops facing traffic on Pierce Ferry Rd. Like in the example below, two vehicles could cross US93 at the same time without crossing paths. One crossing northbound US93 and turning south into the speed up lane, and one crossing the northbound lanes of US93 and continuing on Pierce Ferry Rd

The upgrade changed the intersection so southbound US93 traffic comes off at an angle and stops looking at north bound traffic on US93. As you can see below this design sets up a new crash zone. Also the driver at the stop sign on Pierce Ferry Rd waiting to cross northbound traffic sees a warning sign that says “Traffic from the Left Does Not Stop”.

The problem is while the driver is looking for high speed traffic on US93 from the left, that Mustang sitting there hits you from the right. 

Doesn't ADOT have a computer that analyzes these changes? Didn't an ADOT traffic engineer see this additional crash point as a problem? Here’s the crash zone again… Who has the Right of Way? Usually, the vehicle on the right has right of way, but here?

Recently Rosie’s Café was remodeled and now we have the new TA Express, Pilot and Last Stop Travel Centers on US93. We’ve also seen an increase in the number of accidents because of the additional traffic entering and leaving these new travel centers.

 The TA Express has a slight curve going northbound making it difficult to see semi’s crossing US93 especially at night. 

We recently had a double fatality accident when a northbound car slid under a semi trailer.

Another problem is response time and resources. The Lake Mohave Ranchos Fire District only has one ambulance that covers 2200 square miles. including the first 50 miles of US93. That's an area larger than the state of Delaware. If the ambulance is busy transporting a patient from the Hoover Dam area it can take up to 3 hours for it to clear the hospital and respond to an accident on US93 and an additional hour to arrive at the emergency room.

Medical helicopters are used in the area, but fire or law enforcement needs to be on scene to land the helicopter and flight times can take 1-2 hours for helicopter transport Las Vegas.

Response times for DPS can take up to an hour to calls on US93.

The dangers of US93 are a combination of factors. The rural location, poor highway design, and availability of emergency medical services make for an extremely dangerous highway...

How to Keep Starlink Running Durning a Power Outage or Emergency

The internet is an essential means of communication today. The ability to get and share local news, events, and emergency information is vital in our small rural community. 

The ability to keep your Starlink dish and computers up and running during a power outage is essential. We all use Starlink for the internet and things like streaming videos, but most smartphones today have wifi calling allowing you to make calls even with no bars of your phone. Check if your phone supports wifi calling before you need it... 

First we need to know how much power does a Starlink dish use? The new square antenna uses 50-65 watts normally and up to 100 watts if heating the dish because of snow, something we rarely need here in Dolan. 

A small inverter can run your Starlink system, but it needs to be a pure sign wave inverter to prevent interference with your Starlink dish and computer equipment. Cost runs from $50 to $150 for 1500-watt inverter large enough to power your Starlink, computers and more.

Powering Your Inverter

You will need a 12 or 24 volt battery to run your inverter. A simple emergency system is to mount the inverter in your vehicle. This gives you emergency power on the road, add an extension cord and you can power your electronics in the house.