One of the final papers I had to write was for a class called “Studies in Contempoary EMS”. It was kind of a fun seminar class where we read research and debated. The last assigment was to answer questions about a fictional EMS agency that you were running. The questions are related to system structure, funding, staffing, protocols and research. I decided to write my paper as a letter to the program director, as if he had called looking for info.
Enjoy. (And yeah… it’s all fictional. I mean, Happyville? Really?)
May 26, 2010
Joe Blow
XXXXX Community College
1111 South XXth Street
XXXXX, WA 12345
Dear Joe,
Thanks so much for your phone call seeking information about the newly formed Happyville Emergency Medical Services Authority (HEMSA). As you may have read in the JEMS article that featured our service, Happyville is a mid sized community of approximately 45,000 people which had been served by a BLS level volunteer Fire/EMS agency for over 20 years. Through attrition, the volunteer agency suffered a decline in membership and there was little interest from the remaining members of upgrading the service to an ALS level. In 2008, an initiative was raised, proposing the creation of a municipal EMS authority, similar to other agencies that follow the Public Utility Model (PUM) of EMS delivery. In late 2009 the initiative was passed, the initial operating funds were earmarked for development of the system, the EMS assets of the fire department were transferred to the control of HEMSA and we began operations as the primary 911 response agency for Happyville and the areas surrounding the city in unincorporated Smirk County in January of this year.
Many people have contacted me about the funding and operations of HEMSA, asking why we decided on implementing a modified PUM, rather than simply placing the EMS services out to bid, as many of our neighboring communities have done. As a public utility model, we found that as a non profit agency, HEMSA, in conjunction with the municipality, was able to develop a professional work environment for our employees, develop stringent response time guarantees, implement a full ALS response to every 911 call without screening BLS vs. ALS, and we are more effectively able to fund the system through a combination of general fund allocations for capital improvements, nominal charges to city residents that appear on the utility bill and insurance reimbursement. As you well know, in these days of less than adequate reimbursement from Medicare and other insurance plans, it is difficult for an ambulance service to subsist on insurance reimbursement alone, yet HEMSA receives more than 70% of it’s operational funding from insurance reimbursement due to our utilization of a third party billing agency.
As a requirement of the Authority’s agreement with the City of Happyville and as a major point in our charter, HEMSA operates as a full ALS agency. That is, none of our units, with the exception of Non Emergency Transport (NET) units are BLS only. Our dedicated 911 units are currently staffed with a Paramedic and an EMT-Intermediate. While we believe dual paramedic units would be ideal in terms of patient care, at the present time it is simply not cost effective to staff our units with dual paramedics. However, our EMT-Is are encouraged to attend the Happyville Regional Community College paramedic education program and HEMSA will provide tuition assistance and a flexible schedule. If an employee of HEMSA completes the paramedic program and subsequently stays employed with HEMSA as a paramedic for 18 months, he or she will be granted full reimbursement for tuition. Joe, we’re a new program, but I feel that growing our own paramedics is a great way to build the team, and we currently have 4 of our intermediates in the medic program now, set to graduate in late June.
The question you asked about our protocols is an interesting one. As you may know, we have recruited an outstanding Medical Director, Dr. Mayhoosh Tyrotiside, who was instrumental in the development of the revised Paramedic protocols in Austin-Travis County Texas. Dr. Tyrotiside was involved in the initial hiring of our paramedics and considers the ability to apply critical thinking to pre-hospital medicine the most important trait of all when it comes to being a paramedic. Therefore, Dr. Tyrotiside developed protocols that are very liberal in terms of procedures, medications and on line control. As one example, our paramedics have done 36 hours of continuing education in the L&D unit at Happyville Regional and have been cleared to perform a field episiotomy if needed. In addition, we have very liberal pain control protocols with several options for analgesia including Morphine, Fentanyl, Dilaudid and Entonox. Joe, I can say without reservation that our paramedics are held to higher standards than most others in the state. Each HEMSA medic is required to spend one day per quarter in the OR with an anesthesiologist performing endotracheal intubation to demonstrate continued competency and once per year our medics will take part in a cadaver lab for practice of more invasive procedures. While our protocols are liberal, Dr. Tyrotiside believes in a strong QCI program and we conduct biweekly run review meetings where interesting or flagged cases are discussed and reviewed. These meeting are held as education, not discipline. Our paramedics feel that they are an important part of the patient care team and appreciate that fact that they are given significant leeway in treating patients, rather than forcing signs and symptoms into an algorithmic box.
As for EMS research, both Dr. Tyrotiside and I feel that research is an important part of what we do and the studies in which we take part, serve to help drive the future of EMS and medicine. At XXXXX in XXXXXXXX County, where I was employed before coming to HEMSA, we were involved in several research programs, including the hypothermia ICE study, RES-Q-POD ITD study and code/non code response time/outcome study. I encourage all of our paramedics to pursue research opportunities in areas that interest them. We assist with obtaining grants and provide administrative support. Research is not a condition of employment at HEMSA, but several of our medics are currently working on a retrospective study of fire based vs. PUM ALS response time and outcome, a study I’m curious to see. In addition, Dr. Tyrotiside and I are preparing to submit a proposal to the IRB for a pre-hospital study that examines the efficacy of Amiodrone vs Lidocaine in refractory VF. It should be some interesting work and our field staff is excited about the possibility of taking part in this project. I’ll be happy to share the details with you when we get the study approved.
Joe, I hope that answers your questions about HEMSA. We’re proud of what we’ve accomplished in the first few months of operation and we look forward to many years of continued excellence in patient care and serving the good people of Happyville and Smirk County. If I can answer any further questions about our operation, staffing, research commitment or protocols, please feel free to call my office or send an email. With luck, we’ll have an opportunity to connect in person at EMS Expo in Dallas this fall. I’ll be speaking on mid sized cities and the PUM model on Friday. Hope to see you there.
Sincerely,
ME
Executive Director of Operations
Happyville EMS Authority
