RE: The Most Fundamental Problem with EMS

August 27, 2009

Ease up spelling police! LMAO!

Lee

From: texasems-l [mailto:texasems-l ] On

Behalf Of ExLngHrn@...

Sent: Thursday, August 27, 2009 1:27 PM

To: texasems-l

Subject: Re: Re: The Most Fundamental Problem with EMS

Renny --

If you proposed something like giving?carbon monoxide?to cardiac patients

instead of oxygen, and we said it didn't work, would you be upset at " total

opposition " ?

By the way, spell check.? :-)

-Wes

Re: The Most Fundamental Problem with EMS

You guys can't get rid of me that easy. Heck somebody has to be here to

drive peoples blood pressure up. LOL.

I understand disagreement but just am surprised to see total oposition

rather than ideas that could possibly make it work.

Renny Spencer

The Idealistic Paramedic

>

> Renny,

> Hey, buddy, you are starting to take it personally, don't do that. Just

> because someone disagrees with you, you don't want to take your toys and

go

> home, trust me. I am glad you stopped signing your posts " my worthless

> opinion " , because you obviously don't think your opinion is worthless.

Good. But

> this idealistic thing has got to go. There is absolutely not room in EMS

for

> that.

> (EASY, I am KIDDING) HA

> Chris

>

August 27, 2009

And where has your EMS experience been?? If I remember correctly, you work in

rural/frontier EMS, which has a very unique set of challenges.?? Urban,

inner-city EMS is an entirely different set of challenges.?? I think that where

is some of the hesitation comes from.

-Wes

Re: The Most Fundamental Problem with EMS

Henry,

LOL. I respect you guys with the experience and will keep throwing ideas out

here. In fact I will at some point post a denial guideline for you all to pick

apart for me. That may be a ways away though.

Wish I was young. I guess I'm EMS young as only 6 or 7 years experience, but age

wise i'm old.

Renny Spencer

The Idealistic Paramedic

> >

> > Wes for president. I agree 100%. If I remember only 10% of our calls are

true emergency. Where do you stop. Sorry mam your call is not a true emergency

and thus not worthy of my much inflated opinion of myself and super hero skills.

> >

> > Henry

> > Re: Re: The Most Fundamental Problem with EMS

> >

> > Renny,

> > I get what you are saying, and I am onboard, it just wont work. " But why do

> > we always presume that people will abuse if implemented " . It is because

> > they WILL.

> > I dont get it either, it would be so easy, but some people would rather be

> > back at the station getting paid to play x-box. There are several services

> > that I am aware of that are either considering or have already gone to a

> > system where 100% of denials MUST be approved by online medical control.

This

> > tells me that someone in the system screwed it up bad enough that the powers

> > that be took the option for denial completely out of the medics hands

because

> > of exactly what we are talking about. I was speaking to a guy that worked

> > for one of these services, and he said he just transported everyone because

> > it was too much trouble to try to get permission to deny. Everybody that

> > sneezes does not need an ambulance, and we should educate customers to what

we

> > really do, but, as long as we have (NOT ALL) some medics that can't

> > differentiate and a general public that frankly, (in my experience), doesn't

care

> > about getting educated on these issues and keeps calling, you are not going

to

> > change things, my friend.

> > **************A Good Credit Score is 700 or Above. See

yours in just

> > 2 easy steps!

> >

(http://pr.atwola.com/promoclk/100126575x1222846709x1201493018/aol?redir=http://\

www.freecreditreport.com/pm/default.aspx?sc=668072 &

> > hmpgID=115 & bcd=JulystepsfooterNO115)

> >

August 27, 2009

Sorry darn red neck spell check missed that one. You mean we shouldn't give

carbon monoxide. ;0 lol

> >

> > Renny,

> > Hey, buddy, you are starting to take it personally, don't do that. Just

> > because someone disagrees with you, you don't want to take your toys and go

> > home, trust me. I am glad you stopped signing your posts " my worthless

> > opinion " , because you obviously don't think your opinion is worthless. Good.

But

> > this idealistic thing has got to go. There is absolutely not room in EMS for

> > that.

> > (EASY, I am KIDDING) HA

> > Chris

> >

August 27, 2009

Wes,

I agree there are major differences. But a patient that needs something besides

an ambulance rural/urban needs that need met rather than just transported. I do

want the input of all areas as I try and design a guideline for denial.

Renny Spencer

The Idealistic Paramedic

>

> And where has your EMS experience been?? If I remember correctly, you work in

rural/frontier EMS, which has a very unique set of challenges.?? Urban,

inner-city EMS is an entirely different set of challenges.?? I think that where

is some of the hesitation comes from.

>

> -Wes

>

August 27, 2009

Dudley has pinpointed the problem. While I do appreciate Renny's position

and embrace it philosophically, what he's promoting is, in fact, a sort

of primary care done by EMS. Jane correctly identified three of the

components of a system that permits refusals, but there are other aspects as

well

which are simply not in place.

The Red River Project in New Mexico attempted to implement the sort of

practices that Renny's talking about, but it was a rather spectacular failure

because there is no way to fund it under present reimbursement schemes.

Further, the level of education and training available to paramedics did not

support it without significant further training.

Such a system would require a coordination of efforts among not only EMS

but social service agencies that does not widely exist. Tucson is attempting

to do some of that by using what they call " Alpha Trucks " to respond to

calls that are triaged as low priority and possibly in need of something other

than EMS treatment and transport. The Alpha Folks do work with the social

agencies and the system appears to be working to some degree. Phoenix

tried the same thing and disbanded it because its experience was that it did not

work.

If all medics in the system had Renny's dedication and values, such a

system might work; sadly, the kind of dedication, training, and judgment needed

to carry out primary care in the field is lacking in current paramedic

education, training and practice in most areas of the country.

I spent a year working offshore as a rig medic, in a job that is basically

primary care. During that time I first began to realize how little about

medicine I really knew, how incompetent I was at dealing with non-emergency

conditions, and how great a resource The Merck Manual, on's Principles

of Internal Medicine, and Tintinalli's Emergency Medicine, and a good

medical director with which I had instant communication are. I learned that

paramedics are well trained in a very narrow scope of practice and that when

outside that narrow scope things can get very sticky indeed. It was the

scariest thing I ever did.

When we begin to make determinations about who needs a ride to the hospital

and who does not, we are placing one foot on a sheet of ice and the other

on a banana peel. Even ER physicians make errors in diagnosis with the

compendium of resources available to them. Most medics do not know either how

to order labs or how to interpret them, if we had them available, and most

can't read an x-ray or a CT or MRI scan. I can't see myself telling a

patient with vague signs and symptoms that care is not needed without those

tools, assuming I were able to use them. Yet that's what medic-initiated

refusals invoke.

As for the notion that people are going to sue no matter what we do, I'll

say this: No, they're not. People sue when they are done wrong. They

sue when they're harmed by somebody else. They do not sue over nothing,

common myth to the contrary notwithstanding.

Few understand how expensive it is to file and maintain a lawsuit. It

takes many thousands of dollars worth of resources. Lawyers simply do not

file unwarranted suits based upon the whims of their clients. A close

analysis of cases that are filed reveal a level of so-called frivolous suits

that

is minuscule. We have all hear the Poster Cases that are batted around, but

when one looks at the bulk of cases that are filed, they exist because good

lawyers have determined that the four elements of negligence are present

and provable by a preponderance of the evidence to a jury.

Nevertheless, if we put ourselves into a position where we are sure to make

errors, then we can and should expect lawsuits. I can tell you that

lawsuits are no fun for anybody. To be sued is a wrenching experience even if

you're completely in the right. I had rather run 1000 codes than run one

malpractice suit. The stress is immense.

Of course, common sense says that not every injury requires EMT/Paramedic

treatment and transport. If I sprain my ankle, I'm going to drive myself to

the ER or the Doc-in-the-Box or have my neighbor do it and I won't call

EMS. But I have a car and a neighbor. Many folks who need care do not have

transportation, and so forth.

We are in a service business, and we should concentrate on service. It's

nice to think globally about helping the frequent flyer who forgot to get

her Lopressor refilled not to call us, but if she does call, she gets a trip

to the ER if she wants it in my service. On the street is not the place to

be counseling her about watching her prescriptions, lining up transportation

for the next time she needs it, et cetera. As Renny correctly recognizes,

taking care of the social needs may be the right thing to do,

but it's also the most time consuming much of the time. Where I differ

with him is here: The needs that he's targeted do need to be addressed, but

not at the point of contact after a 911 call. If a service wants to engage

in that sort of service, then I can surely see specialized crews following

up and attempting to ameliorate the situation, but I cannot see it happening

on the streets.

There are likely differing views, and mine is only one. Service areas

differ widely in geographics, demographics, and needs. Not all solutions work

everywhere. That this topic is being debated civilly is good.

Bottom line: Always do what is in the patient's best interest and you'll

generally be fine. Remember the first tenet of the law: You have a DUTY

to your patient. Many seem unclear as to whom they owe their duty. Well,

it is not to the hospital, the nurse, the doctor, or the accountant. It

is to the patient. If we remind ourselves of that as we start to every

call, we'll do good care and stay out of trouble.

Gene Gandy, JD, LP, NREMT-P

Doctor of Illusionism, Grade II, in Residence

> Â

>

> Now someone else said we only get paid if transport. I ask why? We should

> be billing for all responses. If you go see the doctor and decide not to

> get treated you still get charged. So if you call we should charge.

>

> ABSOLUTELY!! ABSOLUTELY!! !!? But there is a HUGE difference between

> getting paid and charging people.? The majority of EMS reimbursement comes

> from insurance companies, Medicare and Medicaid.? Very few insurance c

> ompanies, and NO Medicare or Medicaid dollars are spent paying for EMS to do

> anything but load the patient up and transport.? (I know about BLS Emergency

> for DOS's...)? That is the crux of this.? Some places (google Wake County

> EMS) are doing some of the social services and primary care things you are

> talking about and are having some success...but no one but local tax payers

> are paying for it...and they are not going to fund a system like that for too

> long without

>

> We can bill and charge who ever we want for what ever we want...but if we

> want to seriously look at doing primary care we need tort reform issues

> addressed and we need structural change in how EMS is reimbursed.?

>

> Dudley

>

> Re: The Most Fundamental Problem with EMS

>

> I see where you are coming from. I agree there are some lazy people in our

> profession. Thats why I say if it were to work it would have to be tougher

> to deny than to transport. Maybe extra forms to fill out on top of the run

> report that must be sent to the supervisor and medical director for

> review. If someone abuses the denial process fire them. If that doesn't

motivate

> people to do it right they do not have any business in EMS.

>

> And I know some would say if it takes longer how does it benefit us. Well

> in the long run it will help stop certain calls. But more importantly it

> will actually get the patient in touch with whatever resource they need

> quicker. Perhaps we help them schedule with mental health, or learn about the

> medical transportation transportation program if they are just having trouble

> financially getting to the doctor.

>

> Now someone else said we only get paid if transport. I ask why? We should

> be billing for all responses. If you go see the doctor and decide not to

> get treated you still get charged. So if you call we should charge.

>

> Just more of my worthless rambling.

> Renny Spencer

> Paramedic

>

> --- In texasems-l@yahoogrotexasem, Clgrote126@., Clgrote

> >

> > Renny,

> > I get what you are saying, and I am onboard, it just wont work. " But why

> do

> > we always presume that people will abuse if implemented " we always presu

> > they WILL.

> > I dont get it either, it would be so easy, but some people would rather

> be

> > back at the station getting paid to play x-box. There are several

> services

> > that I am aware of that are either considering or have already gone to a

> > system where 100% of denials MUST be approved by online medical control.

> This

> > tells me that someone in the system screwed it up bad enough that the

> powers

> > that be took the option for denial completely out of the medics hands

> because

> > of exactly what we are talking about. I was speaking to a guy that

> worked

> > for one of these services, and he said he just transported everyone

> because

> > it was too much trouble to try to get permission to deny. Everybody that

> > sneezes does not need an ambulance, and we should educate customers to

> what we

> > really do, but, as long as we have (NOT ALL) some medics that can't

> > differentiate and a general public that frankly, (in my experience),

> doesn't care

> > about getting educated on these issues and keeps calling, you are not

> going to

> > change things, my friend.

> > **** A Good Credit Score is 700 or

> Above. See yours in

> > 2 easy steps!

> > (

>

http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\

r.ahttp://pr.atwolahttp://pr.atwolahttp://pr.atwo&

> hmpgID=115 & amp; bcd=Julamp;

> >

August 27, 2009

Renny,

Yes, I think that's the way to do it. Followup is where we can do some

good.

I'm due to meet with some folks at Tucson FD soon and talk about their

Alpha Truck program. Their dispatch system is sophisticated enough that they

can identify call similarities at an address and make some determinations

based on call histories. Their Alpha Trucks then go to work to set up

appointments, et cetera. They can also do some street and treat care. They

can

do this because they are totally tax supported and do not count on

reimbursement for their budget.

I hope to find out more about how they work in practice soon. I do hear

them calling for BLS and ALS ambulances from time to time, so I understand

also that many times they see that the patients need treatment and transport.

Stay tuned.

GG

> Â

> Gene,

>

> Thanks for a clear reason rather than just dismissing my ideas.

>

> So I gather based on your thoughts maybe I should look at in my future

> dream guidelines to maybe establish some sort of follow up with patients that

> the crews felt really needed something besides an ambulance. Then at that

> point make sure the patient was helped to find resources they really needed

> if they had not already gotten the help.

>

> I still think I can establish a guideline for saying no to transport but

> I'll play with it some more. Hopefully in a few weeks/months I can submit my

> idea here for all to honestly look it over make suggestions etc.

>

> Sadly even while making the guidelines I know because of money my ideas

> might never come together in reality but who knows maybe I can help start

> something new by stirring up everyones BP's.

>

> Renny Spencer

> The Idealistic Paramedic

>

> --- In texasems-l@yahoogrotexasem, wegandy1938@, wegandy1

> >

> > Dudley has pinpointed the problem. While I do appreciate Renny's

> position

> > and embrace it philosophically, what he's promoting is, in fact, a sort

> > of primary care done by EMS. Jane correctly identified three of the

> > components of a system that permits refusals, but there are other

> aspects as well

> > which are simply not in place.

> >

> > The Red River Project in New Mexico attempted to implement the sort of

> > practices that Renny's talking about, but it was a rather spectacular

> failure

> > because there is no way to fund it under present reimbursement schemes.

> > Further, the level of education and training available to paramedics did

> not

> > support it without significant further training.

> >

> > Such a system would require a coordination of efforts among not only EMS

> > but social service agencies that does not widely exist. Tucson is

> attempting

> > to do some of that by using what they call " Alpha Trucks " to respond to

> > calls that are triaged as low priority and possibly in need of something

> other

> > than EMS treatment and transport. The Alpha Folks do work with the

> social

> > agencies and the system appears to be working to some degree. Phoenix

> > tried the same thing and disbanded it because its experience was that it

> did not

> > work.

> >

> > If all medics in the system had Renny's dedication and values, such a

> > system might work; sadly, the kind of dedication, training, and judgment

> needed

> > to carry out primary care in the field is lacking in current paramedic

> > education, training and practice in most areas of the country.

> >

> > I spent a year working offshore as a rig medic, in a job that is

> basically

> > primary care. During that time I first began to realize how little about

> > medicine I really knew, how incompetent I was at dealing with

> non-emergency

> > conditions, and how great a resource The Merck Manual, on's

> Principles

> > of Internal Medicine, and Tintinalli's Emergency Medicine, and a good

> > medical director with which I had instant communication are. I learned

> that

> > paramedics are well trained in a very narrow scope of practice and that

> when

> > outside that narrow scope things can get very sticky indeed. It was the

> > scariest thing I ever did.

> >

> > When we begin to make determinations about who needs a ride to the

> hospital

> > and who does not, we are placing one foot on a sheet of ice and the

> other

> > on a banana peel. Even ER physicians make errors in diagnosis with the

> > compendium of resources available to them. Most medics do not know

> either how

> > to order labs or how to interpret them, if we had them available, and

> most

> > can't read an x-ray or a CT or MRI scan. I can't see myself telling a

> > patient with vague signs and symptoms that care is not needed without

> those

> > tools, assuming I were able to use them. Yet that's what medic-initiated

> > refusals invoke.

> >

> > As for the notion that people are going to sue no matter what we do,

> I'll

> > say this: No, they're not. People sue when they are done wrong. They

> > sue when they're harmed by somebody else. They do not sue over nothing,

> > common myth to the contrary notwithstanding.

> >

> > Few understand how expensive it is to file and maintain a lawsuit. It

> > takes many thousands of dollars worth of resources. Lawyers simply do

> not

> > file unwarranted suits based upon the whims of their clients. A close

> > analysis of cases that are filed reveal a level of so-called frivolous

> suits that

> > is minuscule. We have all hear the Poster Cases that are batted around,

> but

> > when one looks at the bulk of cases that are filed, they exist because

> good

> > lawyers have determined that the four elements of negligence are present

> > and provable by a preponderance of the evidence to a jury.

> >

> > Nevertheless, if we put ourselves into a position where we are sure to

> make

> > errors, then we can and should expect lawsuits. I can tell you that

> > lawsuits are no fun for anybody. To be sued is a wrenching experience

> even if

> > you're completely in the right. I had rather run 1000 codes than run one

> > malpractice suit. The stress is immense.

> >

> > Of course, common sense says that not every injury requires

> EMT/Paramedic

> > treatment and transport. If I sprain my ankle, I'm going to drive myself

> to

> > the ER or the Doc-in-the-Box or have my neighbor do it and I won't call

> > EMS. But I have a car and a neighbor. Many folks who need care do not

> have

> > transportation, and so forth.

> >

> > We are in a service business, and we should concentrate on service. It's

> > nice to think globally about helping the frequent flyer who forgot to

> get

> > her Lopressor refilled not to call us, but if she does call, she gets a

> trip

> > to the ER if she wants it in my service. On the street is not the place

> to

> > be counseling her about watching her prescriptions, lining up

> transportation

> > for the next time she needs it, et cetera. As Renny correctly

> recognizes,

> > taking care of the social needs may be the right thing to do,

> > but it's also the most time consuming much of the time. Where I differ

> > with him is here: The needs that he's targeted do need to be addressed,

> but

> > not at the point of contact after a 911 call. If a service wants to

> engage

> > in that sort of service, then I can surely see specialized crews

> following

> > up and attempting to ameliorate the situation, but I cannot see it

> happening

> > on the streets.

> >

> > There are likely differing views, and mine is only one. Service areas

> > differ widely in geographics, demographics, and needs. Not all solutions

> work

> > everywhere. That this topic is being debated civilly is good.

> >

> > Bottom line: Always do what is in the patient's best interest and you'll

> > generally be fine. Remember the first tenet of the law: You have a DUTY

> > to your patient. Many seem unclear as to whom they owe their duty. Well,

> > it is not to the hospital, the nurse, the doctor, or the accountant. It

> > is to the patient. If we remind ourselves of that as we start to every

> > call, we'll do good care and stay out of trouble.

> >

> > Gene Gandy, JD, LP, NREMT-P

> > Doctor of Illusionism, Grade II, in Residence

> >

>

August 27, 2009

Gene,

Thanks for a clear reason rather than just dismissing my ideas.

So I gather based on your thoughts maybe I should look at in my future dream

guidelines to maybe establish some sort of follow up with patients that the

crews felt really needed something besides an ambulance. Then at that point

make sure the patient was helped to find resources they really needed if they

had not already gotten the help.

I still think I can establish a guideline for saying no to transport but I'll

play with it some more. Hopefully in a few weeks/months I can submit my idea

here for all to honestly look it over make suggestions etc.

Sadly even while making the guidelines I know because of money my ideas might

never come together in reality but who knows maybe I can help start something

new by stirring up everyones BP's.

Renny Spencer

The Idealistic Paramedic

>

> Dudley has pinpointed the problem. While I do appreciate Renny's position

> and embrace it philosophically, what he's promoting is, in fact, a sort

> of primary care done by EMS. Jane correctly identified three of the

> components of a system that permits refusals, but there are other aspects as

well

> which are simply not in place.

>

> The Red River Project in New Mexico attempted to implement the sort of

> practices that Renny's talking about, but it was a rather spectacular failure

> because there is no way to fund it under present reimbursement schemes.

> Further, the level of education and training available to paramedics did not

> support it without significant further training.

>

> Such a system would require a coordination of efforts among not only EMS

> but social service agencies that does not widely exist. Tucson is attempting

> to do some of that by using what they call " Alpha Trucks " to respond to

> calls that are triaged as low priority and possibly in need of something other

> than EMS treatment and transport. The Alpha Folks do work with the social

> agencies and the system appears to be working to some degree. Phoenix

> tried the same thing and disbanded it because its experience was that it did

not

> work.

>

> If all medics in the system had Renny's dedication and values, such a

> system might work; sadly, the kind of dedication, training, and judgment

needed

> to carry out primary care in the field is lacking in current paramedic

> education, training and practice in most areas of the country.

>

> I spent a year working offshore as a rig medic, in a job that is basically

> primary care. During that time I first began to realize how little about

> medicine I really knew, how incompetent I was at dealing with non-emergency

> conditions, and how great a resource The Merck Manual, on's Principles

> of Internal Medicine, and Tintinalli's Emergency Medicine, and a good

> medical director with which I had instant communication are. I learned that

> paramedics are well trained in a very narrow scope of practice and that when

> outside that narrow scope things can get very sticky indeed. It was the

> scariest thing I ever did.

>

> When we begin to make determinations about who needs a ride to the hospital

> and who does not, we are placing one foot on a sheet of ice and the other

> on a banana peel. Even ER physicians make errors in diagnosis with the

> compendium of resources available to them. Most medics do not know either

how

> to order labs or how to interpret them, if we had them available, and most

> can't read an x-ray or a CT or MRI scan. I can't see myself telling a

> patient with vague signs and symptoms that care is not needed without those

> tools, assuming I were able to use them. Yet that's what medic-initiated

> refusals invoke.

>

> As for the notion that people are going to sue no matter what we do, I'll

> say this: No, they're not. People sue when they are done wrong. They

> sue when they're harmed by somebody else. They do not sue over nothing,

> common myth to the contrary notwithstanding.

>

> Few understand how expensive it is to file and maintain a lawsuit. It

> takes many thousands of dollars worth of resources. Lawyers simply do not

> file unwarranted suits based upon the whims of their clients. A close

> analysis of cases that are filed reveal a level of so-called frivolous suits

that

> is minuscule. We have all hear the Poster Cases that are batted around, but

> when one looks at the bulk of cases that are filed, they exist because good

> lawyers have determined that the four elements of negligence are present

> and provable by a preponderance of the evidence to a jury.

>

> Nevertheless, if we put ourselves into a position where we are sure to make

> errors, then we can and should expect lawsuits. I can tell you that

> lawsuits are no fun for anybody. To be sued is a wrenching experience even

if

> you're completely in the right. I had rather run 1000 codes than run one

> malpractice suit. The stress is immense.

>

> Of course, common sense says that not every injury requires EMT/Paramedic

> treatment and transport. If I sprain my ankle, I'm going to drive myself to

> the ER or the Doc-in-the-Box or have my neighbor do it and I won't call

> EMS. But I have a car and a neighbor. Many folks who need care do not have

> transportation, and so forth.

>

> We are in a service business, and we should concentrate on service. It's

> nice to think globally about helping the frequent flyer who forgot to get

> her Lopressor refilled not to call us, but if she does call, she gets a trip

> to the ER if she wants it in my service. On the street is not the place to

> be counseling her about watching her prescriptions, lining up transportation

> for the next time she needs it, et cetera. As Renny correctly recognizes,

> taking care of the social needs may be the right thing to do,

> but it's also the most time consuming much of the time. Where I differ

> with him is here: The needs that he's targeted do need to be addressed, but

> not at the point of contact after a 911 call. If a service wants to engage

> in that sort of service, then I can surely see specialized crews following

> up and attempting to ameliorate the situation, but I cannot see it happening

> on the streets.

>

> There are likely differing views, and mine is only one. Service areas

> differ widely in geographics, demographics, and needs. Not all solutions

work

> everywhere. That this topic is being debated civilly is good.

>

> Bottom line: Always do what is in the patient's best interest and you'll

> generally be fine. Remember the first tenet of the law: You have a DUTY

> to your patient. Many seem unclear as to whom they owe their duty. Well,

> it is not to the hospital, the nurse, the doctor, or the accountant. It

> is to the patient. If we remind ourselves of that as we start to every

> call, we'll do good care and stay out of trouble.

>

> Gene Gandy, JD, LP, NREMT-P

> Doctor of Illusionism, Grade II, in Residence

>

August 27, 2009

Renny you are starting to sound too much like ME. I am SOOOO proud!!!! LOL

Jane Dinsmore

To: texasems-l

From: spenair@...

Date: Fri, 28 Aug 2009 03:04:17 +0000

Subject: Re: The Most Fundamental Problem with EMS

Gene,

Thanks for a clear reason rather than just dismissing my ideas.

So I gather based on your thoughts maybe I should look at in my future dream

guidelines to maybe establish some sort of follow up with patients that the

crews felt really needed something besides an ambulance. Then at that point make

sure the patient was helped to find resources they really needed if they had not

already gotten the help.