Thread: EMS Issues in the Fire Service
03-24-2004, 10:56 AM #1
EMS Issues in the Fire Service
Snowshoe Mountain EMS
A tale of the rise and fall of an EMS system
This is a tale of a fragile EMS system that developed from nothing, reached its pinnacle as a premier EMS service which was emulated by many and that slide backward for reasons of economic savings and circumvention of regulations.
Not so long ago Snowshoe Mountainís EMS consisted of a ski patrol with limited first aid skills. It lacked in advanced medical and rescue skills and had little medical direction. Over the years Snowshoe Mountainís EMS developed into a hybrid system supplying Emergency Medical Services not only to a growing Ski Resort with 400,000 seasonal skier visits, it became a rural community rapid response team supplying EMS services to all in the surrounding area. This system grew from one Critical Care Paramedic providing around the clock coverage; to a staff of EMTís and medics under the auspices of the Fire Department. Physicians Assistants with emergency medical and trauma backgrounds were interwoven into this system and it continued to grow. As the call volume steadily increased, a seasonal (ski season) paid ambulance service assisted the fire department. The medics staffing this consisted mainly of flight medics and nurses. These providers were able to comfortably increase the skill level of the rural providers, offering PHTLS and Critical Care education. A Physicians Assistant with extensive trauma background (military) rounded off this team at its pinnacle. His oversight and guidance of his fellow PAís, Medics and EMTís made a notable difference in patient morbidity and mortality. This new system grew from people who had the foresight and the passion to make this the best possible EMS system for the community and the ever expanding Ski Resort. Over time this talented group of EMTís, Paramedics and Physicians Assistants have become widely known as a rural remote Trauma Team and is credited with saving countless lives in the most adverse conditions miles from any hospitals.
Understanding the need for enhanced medical coverage in the ever expanding Ski Resort and surrounding community, Snowshoe Ski Resorts to its credit agreed that change had to take place. The National Ski Patrollers who functioned alongside the EMTís were asked to increase their skill levels to bring uniformity and assist the fire department with the increasing call volume. Snowshoe Ski Resort promised a pay increase to those who completed the EMT curriculum. New employees of the Ski Patrol were preferentially chosen if they had EMT certification. This system was not without criticism as the older non-EMT ski patrollersí resisted change and the EMT requirements.
The argument was made that the National Ski Patrol Winter Emergency Care course mirrors the standard EMT curriculum. This is true however, the course is lacking in many of the important aspects of non-ski related care. To its credit the Snowshoe Ski Patrol was aware of this short coming realizing that the level of care provided by the National Ski Patrol was not up to State or Regional standards for ambulance or hospital personnel. Through the efforts of members of the Fire and Patrol divisions a bridge course was being developed. For many on both side of the house this became an issue and caused difficulties. An example of difficulty between the Ski Patrol and EMT departments was that off season classes for PHTLS, AED and CPR were poorly attended. Instead many elected to get their education in a one weekend Ski Patrol refresher course held annually in the fall. The problem with this one weekend course was that the emphasis for training revolved around skiing and basic ski related injuries. This annual and one weekend course is an open lecture refresher course and often was more of a social event than a learning experience. The difference between the Skier refresher course and that offered by the Fire Division is in the method and type of training as it relates to EMS patient care. Fire Department EMS training follows EMS continuing education guidelines and in conjunction with the Countyís EMS agencies, State standards for EMT recertification and in-house instructors at the advanced level.
Why were the talented P.A.-Cís and medics were driven off) You are asking yourself why were the talented P.A.-Cís and medics were driven off by management who refused to have the foresight to refine this system? The answer is simple. The State of West Virginias EMS system is based on regional protocol overseen by Medical Control Physicians who are never further away than a radio or phone call. A trust exists between the physicians and nurses and paramedics that these protocols will be adhered to. Basic daily tasks like contacting medical control, ambulance restocking, medication inspection and documentation were not being followed. Fire Department Medics began to complain to their supervisors that indiscretions were occurring at the Snowshoe Ski Patrol and Health Center. Sporadically at first, then weekly. Service delivery reports, medication errors and failure to follow protocols became more frequent. Administrators, alarmed at the increased complaints from the Fire and EMS Division regarding their ski patrollers and health center staff met with medical directors via phone and email. The Resorts administrators turned a deaf ear to the Medical Directors as profits in the ski patrol and health center were at an all time high. Many fire medics became quite concerned that their certifications were in jeopardy and declined participation in the program. The State Medical directors, Office of EMS and WVEMSTSN were apprised of the situational changes. As scrutiny came to bear on the ski patrol and Snowshoe so to it came to bear on the Fire and EMS Divisions. Fire and EMS continued with their daily documentation of improper activities. Snowshoe Senior Executives met secretly with State Officials regarding this and a blind eye was turned to Snowshoe. Exceptions to the rules became the norm. One State official (at a County EMS Board meeting) stated that Snowshoe is so used to having exceptions made that itís the norm for them and didnít matter. County EMS Board members were already well aware of the States position on tourism and what Snowshoe brought to the table. The Regional EMS Program Director soon too fell under his administratorís scrutiny for supporting the Fire and EMS departments. Snowshoe soon banned the Fire Chief and the EMS ambulance administrator from coming on the premises or volunteering as a ski patrollers unless it was for a medical call for which they had been dispatched. It soon removed the only other senior paramedic(who was associated with the fire department) from itís health center and replaced their expertise with non-EMTsí. With No P.A. in the off season the Resort guests care was being provided for by non-EMTís. The Fire Department paramedics continued to respond on calls (if the Resort felt like calling 911). Complaints were lodged with the Countyís Fire, EMS and 911 boards.
If this occurred in your town, County or State you would simply call your Medical Director, State representative or attorney, document the occurrences and work towards a solution. With international corporations overseeing the Snowshoe management, tourism dollars and local politicians in the mix, West Virginias EMS executives folded under the pressure letting down the very backbone it worked so hard to support. Rules were broken and daily exceptions made. As this years ski season unfolded we find the hybrid system replaced by non-EMTís, paper-medics and family practice P.A.ís.
This team is now without direction and functions by hands-off micro-management. Driven by a cash-up-front billing for all health related services, this machine is solely interested in the bottom line. Patient care and guest services takes a back seat to Visa and MasterCard. If you are a 911 patient, the Snowshoe EMS system will screen you for insurance/ability to pay and begin treatment. If you are indigent you will be turfed to the local fire department EMS or County resources. You see, this agency is a non-transporting EMS agency. With an overburdened County EMS system, the Snowshoe Agency refuses to get into the transport of the sick and injured. Snowshoe EMS boasts five paper-medics and 20 ďEMTísĒ. Let me explain this term: a paper-medic is credentialed but has never walked the walk, never intubated, mixed up a drip, decompressed a chest or even run a 12 lead. Few have ever run a code or defibrillated a patient. Their EMTís have never been on an ambulance, extricated an MVA patient, or rarely even suctioned a patient. Most hide behind their National Ski Patrol First Aid training as the gold standard. When their EMT expires, they simply choose not to renew because, in this system, the medical direction is now absent. While adequate for their job as patrollers, it falls short of the National standards set forth by the Registry and State qualifications. These EMTís are dispatched to 911 calls prior to the County ever knowing the calls exist (due to Snowshoe Mountainís proprietary 911 system). They portray themselves as EMTís to the lay public, practicing medicine without certification or licensure, determining treatment algorithms and choosing the facility where the patient is to be transported. This is all accomplished by circumventing medical control and protocols. These ďEMTísĒ are allowed to function above the paramedic level while under the auspices of the Snowshoe Health Center, often mixing drugs and administering medications under the watchful eye of a family practice P.A. ( who may not even be there). Why spend two years in a paramedic program after completing a one year EMT program when you can step into the clinic or someoneís home and impersonate an EMT?
No documentation is required for this patient intercept as the Snowshoe EMS fills out a proprietary form which is never seen by the States Trauma Registry or Offices of EMS.
So where do you get the real EMTís you need to fill the roster required by the State? One need to look no further than the local agencies whose lifeblood depends on volunteerism. Snowshoe EMS compensates these Medics and EMTís at a rate 30% higher than the State average. EMTís start at $9.60/hour, some even make $25.00/hour and Paper-medics begin at $12.60/ hour. Not a bad wage for never stepping into an ambulance at 3 AM. See, this agency stops providing care at 9 PM. They have an on-call person who decides patient outcome based upon their basic $12.00/hour, non-EMT skills. None of these on-call providers live in the community, so patient care is often delayed significantly while they get dressed and drive 15 minutes to interview the patient.
If this mind numbing emergency service agency appeals to you, put on your cowboy boots, hat and saddle up for a ride into Wild, Wild West Virginia.
Last edited by ShaversFork; 03-24-2004 at 09:40 PM.
03-24-2004, 12:36 PM #2
"Many medics became quite concerned that their certifications were in jeopardy and declined participation in the program." Am I to assume that you agree any providers worth their name & card would decline to participate because of shoddy management & actions of the unruly ones?
"Fire and EMS continued with their daily documentation of improper activities." What did Fire & EMS do that was wrong? It sounds as though the Mountain's crew were the ones failing our respected medical profession.
"a paper-medic is credentialed but has never walked the walk, never intubated, mixed up a drip, decompressed a chest or even run a 12 lead. Few have ever run a code or defibrillated a patient." I have to think you have exaggerated this at least a little, if not excessively. I will agree wholeheartedly that there are providers out there with 30 minutes experience portrayed as 30 years.
So are you the only one that sees this current situation as a problem? What are you and others doing to bolster the Mountain EMS crew back to the higher status it once had? It's a case of proper management, getting rid of the bad apples & deadwood, and rekindling old flames with those banner employees of yesterday. It's not an easy task, but anything good is far from easy. Hope to hear of better relations there in the future.~Kevin
Of course, that's just my opinion. I could be wrong
03-24-2004, 03:18 PM #3
The Medics in the Fire Service are all "experienced providers". Over the years, the staff consisted of providers that wanted to provide exceptional patient care in exchange for free golf and skiing privledges and, of course, a paycheck. The patient population is a " Vacation Destination Resort". The Doctors lawyers and professionals bring their families here to relax and enjoy. We saw the need for paramedical teams that were experienced guest service providers as well as in the top of their profession. Our service is rated superior by the State and we are proud of the work our firefighters and medics do. What is occuring on a daily basis: our sister agency which is profit motivated, above the law and uninterested in expanding their horizon to include certification and licensure is refusing to follow state guidelines and protocols. They have the State EMS in their pocket due to the large amounts of Tourism dollars that are funneled throught our resort. The State EMS officials are in between a rock and a hard place because of the financial encumbrences that may be placed against them if they support our agency. We have been battling this for several years without success. Unlicensed ambulance transport vehicles, non-EMT's providing patient care, lack of protocols and medical direction occur daily. Documentation is there to prove this. County Comissioners are on our side but powerless against "the machine". If I brought their service to your back yard tomorrow and operated it like it is being done here it would be shut down immediately. The good old boy network and political favoritism is alive and well in my backyard. We just take it on the chin and keep on doing what we do best....providing the best possible care.
03-24-2004, 03:50 PM #4
For starters, who are "we" and "our sister agency" supposed to refer to in your situation? I may not be the only one confused about vague references here that don't seem to outline WHO is the big problem with this. I don't know you well yet & don't want to get off on the wrong foot, but I see a lot of writing without saying much. The general references going back & forth so quickly make it hard to follow.~Kevin
Of course, that's just my opinion. I could be wrong
03-24-2004, 09:34 PM #5
Ok so it seems a bit nebulous, we are the Fire Department, they are the Resort's Ski Patrol and associated Health Center (clinic).
We are bound by rules and regulations as set forth by State protocol. Our medics are National Registry, WV State Certified, CCEMT-P certified and have the usual designations of ACLS,PHTLS,PALS, etc. Their "providers" have National Ski Patrol Outdoor emergency care for their designation. Their Physicians Assistant is family practice- well away from ACLS,PALS, etc. The folks they send to your Hotel when you dial 911 are not EMT's(although they are portrayed as EMT's).
When we are called to a 911 call: they have been camping out on a patient for a half an hour or more. Enough time for them to run up a bill for IV's, exam, medication administration, etc. That is what get our goat. We have a < 4 minute response. Can they not wait for experienced providers to arrive, assess and treat enroute to a hospital an hour away? The best interest of the patient and family is not being served. We just came from a call where we had to restart the IV due to the catheter improperly placed and the fluid bag having an expiration of December 2003. It's documented, so what? Nothing will happen to them. The attending physicians are aware and appreciate our dilema, but have enough on their plate. They document as well. Our monthly QA's document so the State is aware. Big business is big business. In the era of Enron and Tyco mismanagement we are left feeling like Martha Stewart. It's OK for big business executives like CFO Mark Swartz of Tyco to loot the company for 12.5 million and his boss Dennis Kozlowski to scam $600 million. The little fish like Martha Steward get hammered hard for 40K in insider trading. My guys take a beating every time we ask for the madness to stop. No we are not like Martha, we play by the rules. With everyone eyeballing us we can't afford any bad press. Factoid: We have never had a complaint about our Fire or EMS since it's inception. Chalk that up to training, leadership and a great team of FF's,EMT's and medics. Yes I'm a bit sour because I am a Chief, serve on Fire and EMS boards and have been a medic since the eighties and my guys are getting dogged. Thanks for the ear Kevin...it's nice to vent after a long Monday- every day seems like Monday when dealing with these issues.
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