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Fraud

In response to Graybeard’s comment on my post about job prospects in the EMS field:

Yes, fraud is running rampant. In 2002, Medicare reimbursement for ambulances was less than $1 billion. In 2009, it had more than doubled, despite the fact that the amounts paid for each trip had not changed. I can tell you that the linked article’s claim that 80% of interfacility ambulance rides are fraudulent doesn’t surprise me one bit. I think that number is spot on.

The Feds are cracking down on this, but they are not even catching a fraction of the fraud. As the Affordable Care Act is implemented, it will only get worse.

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A warning to youngsters

People signing up for EMT and Paramedic schools are at an all time high. The economy is so bad, that people are trying to gain job skills to be employable. Employers are taking advantage of this, and things are getting tight. In the peninsula of Florida, there are a few choices for EMT or Paramedic jobs:

1- Fire Department. This is a decent job with good pay, but the hours are long. You go to EMT school, and then Fire school. This takes about 7 months to complete. You take a certifying exam for both, and then start looking for work. Paramedic takes an additional year. Starting pay is $10-12 an hour for a Firefighter-EMT with no experience. Paramedics get around $13-16 an hour. Firefighters work 48-56 hours a week on average, so take home starts near $30,000 a year for EMTs, and $40,000 for Paramedics. Pensions are nor what they once were, but they are still better than most other professions. The real downside is that the competition is fierce. Even a “stepping stone” department, where many new firefighters get a job, earn experience, and them move on has a lot of applicants. Departments with a job opening are getting 200-300 applicants for each position. For that reason, there are so many unemployed people with firefighter certifications, that the state has largely shut down funding for the training of new firefighters. Unless you have experience or are a minority, getting a job as a firefighter is a long shot.

2- Hospitals, Doctor’s offices, and clinics: These usually have decent hours, good working conditions, and pay varies widely. Hospitals pay well, and you usually work the Emergency Department in 3-12 hour shifts per week. Starting pay is usually $12 for EMTs and $16-$17 for Paramedics. Again, hard to come by, but not as hard as firefighter or theme park spots. You are restricted in what you can do by many places, so the work is not very exciting or challenging.

3- Theme parks: Even more difficult to get into than a firefighting spot, but the hours are great and flexible, and the starting pay is $14-16 an hour. Benefits are outstanding, if you can get a full time spot, but those are becoming as rare as unicorn sightings.

4- So you are then left with private ambulances. In this area, all these companies do is haul non-emergency medical patients between nursing homes, hospitals, and dialysis clinics. No 911 or emergency calls. In fact, in many counties, if the patient is emergent the ambulance is REQUIRED to pull over and wait for a 911 unit from the fire department to take over the patient. Starting pay is $9-10 for EMTs, and $13-14 for paramedics. Benefits are poor. Shifts are long, normally 12-14 hours each. You do not get a station to sit in on those times where you wait for your next call. You sit in the truck and wait. No reading, eating, sleeping, watching movies on your electronic devices, no texting, no phone use, and no drinking of anything except water. (Not even coffee) These jobs are easy to get, but turnover is high, and most people don’t stay for long, using this place to get experience and move on. A person that stays at one of these places for more than 2 years becomes unemployable anywhere else, because many employers assume that you are stuck there for a reason.

One manager at a private ambulance company told me that his crews were not allowed to eat during shift, because he doesn’t pay them to eat. Another told me that patient care is secondary to keeping the customer (nursing home, hospital, etc) happy, and that the patient was just cargo, and no one cares what cargo thinks. One of my former EMT students was told by an employer when he complained about working conditions, that for every EMT that was working there, there were 7 more looking for a job, and if he didn’t like it, he could be replaced tomorrow.

Compare that to other jobs in the area: Fast food pays $8.50-9 an hour, or about as much as an EMT, and without the exposure to diseases that comes with EMT. Paramedic jobs that started at $14 an hour ten years ago are starting at $13.23 now. In comparison, my son went to nursing school after only three years as a paramedic, and his pay is now $32 an hour. Nursing school is the same length as paramedic, but more than double the pay.

There is a reason why the average EMT or paramedic spends less than 5 years in this job: injuries, poor working conditions, a lack of appreciation for hard work, and low pay all too frequently make the best and most talented leave. My advice to people that are thinking about a career in this field changed about two years ago: stay away.

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Duty

There is an interesting case in New York involving an EMT and a pregnant woman with asthma. The asthma patient had been seen earlier in the day by paramedics for her condition and had refused to be transported for evaluation. The EMT, who was working in dispatch for FDNY, was on a coffee break when the woman nearby began having an asthma attack. Bystanders, frantically looking for help, saw the dispatcher in uniform and asked her for help. The dispatcher called 911, but refused to get up and evaluate the patient. The women died.
FDNY Was sued by the dead woman’s family, and the EMT was charged with the crime of negligence. To protect itself from the lawsuit, the FDNY claimed that dispatchers on break do not have a duty to act, and asked that criminal charges against the EMT be dropped.
My personal feeling is that when you are on the clock and in uniform, you do your job, even if you are on a coffee break. This EMT should have tried to do something. Even without equipment, she could have performed CPR.
Off the clock, I agree that you don’t have a duty to act. Heck, I quit stopping at car accidents about ten years ago when a paramedic in Central Florida who stopped at a car accident was struck and killed by oncoming traffic, and the State of Florida refused to pay the widow his death benefits
because he was not on duty.
In this case, this EMT got lucky that her employer needed to avoid legal liability more than they wanted to prosecute her.

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Nice Try

There are many people who abuse 911 for various reasons. Some because they are whiney people with minor complaints that want to be seen now instead of in the morning, some because they want a free meal or to get high, some because they are simply stupid, and many because they are mentally ill.

There is a woman who falls into the latter category and is known throughout several states for faking seizures in order to get attention. This woman is well known by nearly every medic in the state of Florida who has more than a couple of years on the job. Chances are, if you are a paramedic in the state of Florida, you have or will run on this woman.

I have met paramedics all over Florida, Georgia, and even as far north as Maryland who have run on this woman. She has been seen on shows like Paramedics and Trauma: life in the ER. More than a few medics have given this woman Valium without realizing who she was. She is very good at faking.

So came the day that we ran on her at 2:30 in the A.M one early morning. Tired of running stupid calls, those of us who were there chipped in and paid her bus fare to Orlando, which was 20 miles away, put her on the bus, and patted ourselves on the back for ridding ourselves of the problem. (Come to think of it, this may explain why she has traveled so extensively.)

Two weeks later, I ran on her again. During the call, she handed me an envelope and told me that the Orlando firefighters had asked her to give it to me the next time she saw me. I opened the envelope, and in it was a note. It read simply:

Nice Try.

That, my readers, is a true story.

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There are incompetents everywhere

I work a second job at a large central Florida theme park. (There are only a few, you can guess which one.) During my last shift there, I was called to evaluate a man who was “having a seizure.” When I arrived, I found a 59 year old man who was sitting upright in a chair and only verbally responsive.  He has a history of cardiac, HTN, hyperlipidemia, and diabetes. A local hospital owned ambulance service was called. While waiting for them to arrive, we got the following vitals: HR 88, BP 92/54, RR 18, Temp 97.8, BGL 140. It was over 100 degrees in the park, and the patient’s skin was flushed. We initiated active cooling, and he was again responsive within ten minutes.

The unit arrived, and in walks the EMT. Alone. Then he began talking the patient into signing a refusal. The medic never even got out of the truck. They took no vitals and did not even put him on the monitor. I pitched a fit and threatened to call their supervisor. The medic came in, ran a strip and they collected their refusal and left. Here are my questions:

How does the medic know that this was not a seizure?
How does the medic know that this was not a cardiac problem?
Why did the medic send his EMT in to get a refusal without even evaluating the patient?
Why do some medics still insist that medics who work for EMS only agencies are automatically better than fire based medics? Is it possible that my position, that it doesn’t matter who signs the paychecks, it is what lies in the heart of the medic that counts, is the correct one?

I think the real problem is that some medics are unable to get a fire medic job for a variety of reasons (too fat, out of shape, can’t pass the test, whatever) and spend their time bashing the fire department. I do everything that an EMS only paramedic does, and I fight fires and perform rescues as well.

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Obama Care and the future of medicine

I was at Clincon yesterday, and one of the lectures was about trends in medicine. One of the topics was Obamacare. When Obamacare takes effect in eight months or so, some provisions will change the way that medicine is paid for in this country, and  not for the better.

The hospital will be paid a flat rate for a patient with a given problem, no matter how long the patient is in the hospital. For example, all patients who present to the hospital with congestive heart failure (CHF) will earn the hospital a set price, regardless of how many days that the patient stays in the hospital. This means that the hospital has an incentive to get you out of the hospital in a minimum amount of time, whether you are cured or not, and has the added incentive of diagnosing you with every ailment that they can think of, from halitosis to athlete’s foot.

To correct this problem, the geniuses in the government have devised a solution: If the patient must be admitted for the same condition within 6 months of discharge, the hospital gets nothing for the subsequent visits. So that CHF patient doesn’t follow his discharge instructions, and gets readmitted. The hospital eats it. It is only a matter of time before the hospitals are forced to find ways to keep frequent flyers away.

This is a real mess. I am not sure of everything that is coming, but I do know that it will create real problems in the health care field.

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Know your toolbox

A 69 year old male with an implantable defibrillator calls EMS because it shocked him. A medic who was on the call with me was assuming that the defibrillator was malfunctioning. That is usually not the case. In fact, I cannot think of a single time when an implantable defibrillator shocked a patient unnecessarily. This patient told me that he got lightheaded at about the same time as he was shocked, so I was running off the assumption that the patient had been in Ventricular Tachycardia, and the ICD shocked him. We put the patient on the monitor, and the patient was in a first degree AV block with frequent (15 per minute or so) PVCs.

The best treatment for PVCs is oxygen, so we started the patient on 4 liters, and obtained IV access. By this time, the patient was in ventricular trigeminy, and it wasn’t long before we started seeing couplets. Vitals: HR 88, BP 152/88, RR 18, SaO2 100%, EtCO2 34, and he weighs 193 pounds.  Of the five of us on scene, there were three medics, and the other two medics wanted to give him a cordarone drip.

I told them to give 100mg of lidocaine, and follow that with a maintenance drip of 2mg/ minute. The PVCs were almost completely resolved (less than 4 per minute) within 3 minutes, and we took our ride to the hospital.

When we returned to quarters, we had a discussion on the benefits of lidocaine versus cordarone, and turned it into a training session. I must admit that other medics may have different feelings on this, but here are the reasons why I prefer lidocaine over amiodarone for conscious patients:

1. Amiodarone causes too much hypotension for my comfort
2. Amiodarone frequently causes bradycardia
3. Amiodarone has a long half-life, so in the event that 1 or 2 occurs, the patient is going to be screwed for a long time
4. Although lidocaine toxicity is theoretically a worry, I have never seen it on any of my patients.

So that is why I go with lidocaine. Any other readers have different opinions? If so, why?

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Stupid humans

Yesterday at work, I was flagged down by a woman who wanted to report an alligator in the middle of the road. Not an unusual occurrence in alligator country, but not as common as it once was. At four or five feet, the alligator was not a large one, but there was a group of about 10 people who were stopped in the middle of the road, out of their cars trying to get pictures of the animal, some of them as close as 10-12 feet away.

The alligator was facing them, mouth open, and hissing at them. For those of you who do not recognize the behavior of an animal that feels threatened, this posture is alligator speak for “Leave me alone, or I will maul your ass with these huge teeth I’ve got here.” When an apex predator such as an alligator, or any animal, takes this sort of an aggressive posture, it behooves you to pay attention to the message and move away slowly without turning your back on it, lest you trigger a pursuit response from the predator. When the nice firefighter tells you to get in your car and leave before you get eaten, you should probably do so.

Of course, that is not the behavior of the people in my area. Instead, they want to argue with you about how they only want a picture, and how you can’t order them around. Hey, I am not going to argue with you, go ahead and get your pictures. Once you get bitten, though, don’t file a complaint against me when I laugh at you.

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Spinal Immobilization is not always what is best

This is another one of those EMS related posts. For those of you who are not in the medical field, I am sorry if this post makes your eyes glaze over a bit.

We have been taught to backboard every trauma patient. My protocols have us routinely backboarding patients who have been in car accidents, falls, penetrating trauma to the neck or torso, and a host of other accidents. Even when there is no sign of damage to the spine, we backboard. This is a result of the practice of defensive medicine. That is, we do this under the theory that we could be sued by the ambulance chasing “if I don’t get you a big payoff, I don’t collect a fee” lawyers that are always on the television during the day. The belief goes that if the patient needed to be immobilized and wasn’t, there is a chance we could lose, but throwing someone who isn’t really injured on a backboard doesn’t hurt the patient, so we cover our collective butts by doing it to everyone.

Studies are starting to show that immobilizing patients is not a benign treatment. In fact, this 2010 study of over 45,000 trauma patients shows that patients who are victims of penetrating trauma to the torso, but do not present with any specific neurological deficit, experience a higher mortality rate when immobilized than similar patients who are not immobilized. We need to cease backboarding everyone. We are killing people. The lawyers are killing people. This needs to stop.

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My rant

Yesterday, I was a witness to a homicide. I watched a doctor kill a patient. This was one of the worst performances that I have ever witnessed from a physician. Her ego, lack of medical skill, and lack of caring were all contributing factors in the death of this patient. Lots of medic stuff to follow. I will try to link to explanations where I can.

So we had a call for an unresponsive 91 year old female. I checked her radial pulse, and it was weak at 30 beats per minute. We put her on the monitor, and she was in a narrow complex bradycardic rhythm with no discernible P waves, so we began pacing her. That is exactly what the American Heart Association says is the appropriate for an unresponsive patient with bradycardia.

Her initial vitals: HR 70(paced), BP 87/63, RR:19, EtCO2 23 and square, SpO2 93%. There was a little expiratory wheezing, but her capnogram didn’t show any obstructive pattern, and the EtCO2 of 23 indicated that this was a cardiac output problem, not a hypoventilation or respiratory problem. We decided that her problem was decompensated cardiogenic shock. We started a Dopamine infusion at 7 mcg/kg/minute.

We arrived at the hospital 15 minutes later. Her vitals were now: HR70(paced), BP 133/108, RR 19, EtCO2 26 and square, SpO2 94% (on NRB at ten liters).  This was a significant improvement.

The Doctor’s first question, even before I was done with my turnover: “Is she a DNR?” When I said no, and that the family was in the waiting room, her reply was “I am going to talk to them about a DNR.” This doctor then removed the pacing pads, discontinued the dopamine, and ordered atropine. Whatever, you are the doctor, even if you are taking a treatment that is working and changing course.

Five minutes later, the patient’s HR was 36, and her BP was 39/23. What did the doctor do? She ordered an albuterol updraft.At this point, I went over and politely showed her the capnogram, and pointed out that the lack of an obstructive pattern indicated that the beta agonist would not work. That is where she came unglued. She told me that she was giving it for wheezes, and I responded by telling her that wheezes do not always mean bronchospasm.

Then she got personal. She told me, “When you go to doctor school, you come back and we will fucking have this conversation.” What followed was not my most shining moment.

I told her: “If I were you, I would go back to my doctor school and demand a refund, if what they taught you was to give an updraft to a patient in cardiogenic shock with adequate respiration, just because you heard some wheezes.”

The good news is that my department and the medical director are standing behind me on this one.