July 6, 2008

Mobile ERs a Model for Emergency Services

By Jennifer Upshaw, The Marin Independent Journal, Novato, Calif.

Jul. 6--Temperatures were hovering near the century mark last month and San Rafael resident Barbara Perinoni just wasn't feeling well. Her daughter called 911.

A cadre of firefighters lifted the dizzy and nauseated woman into a waiting ambulance.

Seated by her side on the way to the hospital, San Rafael firefighter-paramedic Mark Sedlack was monitoring her progress when she threw up all over him.

"That's not your fault," he said. "I'm sorry you're sick. I just happened to be in the line of fire.

"We'll blame it on Ryan's driving," he joked, referring to the paramedic at the wheel.

These days, Sedlack and dozens of other Marin firefighters trained as paramedics find themselves responding to far more medical cases than any other call

for service. The phenomenon is part of a nationwide trend in which the fire service has evolved into a kind of mobile emergency room.

In graying Marin, where one out of every three residents will be 65 or older by 2030, medical emergencies already account for most fire calls. Although call volume has remained steady over the years due to a stable population, authorities expect that to change as the population ages and the uninsured continue to seek treatment in hospitals.

Also expected to affect the system is Marin's shortage of primary-care physicians -- a factor expected to tax pre-hospital care as paramedics and hospital staff work on more complicated cases. Paramedic service also is expected to cost more as insurance companies curb

reimbursement for ambulance rides.

"The fire service has done a great job with fire prevention," said Marin County Battalion Chief Mike Giannini. "Years and years and years ago, we had a lot more fires and through our efforts we've reduced that number.

"We've evolved and found a niche in offering EMS care," he said. "We're there to mitigate your problem, whatever it is."

Fire-based system In Marin, paramedic service is carved into five zones serving Novato, San Rafael, West Marin, the Ross Valley and Southern Marin.

Marin's fire department-based emergency medical services means it is possible to send the highest-trained responders -- the paramedics -- to 911 calls from Sausalito to Novato. Those paramedics provide a continuum of care, treating the patient at the scene and transporting them to the hospital.

Such a system is considered a model, fire officials said. In most places, people are treated by fire department paramedics but ride to the hospital in a private ambulance.

"Calling 911 is, in some cases, the only access to the health-care system people believe they have and know will be effective," San Rafael Fire Chief Chris Gray said.

Nationally, the uptick in call volume is already being felt, said Fergus Laughridge, president of the Falls Church, Va.-based National Association of State EMS Officials. As a result, recruiting and retaining paramedics is a challenge, he said.

"You have what used to be the burnout rate of five to six years in metropolitan areas," he said. "The rate is now three years. Folks are saying, 'this is not for me.'"

A Marin County Health and Human Services advisory committee on emergency medical services is studying the effect the aging population will have on the system, county officials said.

"Their No. 1 priority is the issue of the aging on the EMS system," Dr. Bill Teufel, Marin County emergency medical services director.

"If you look at older people, we already know they consume health care at a pretty voracious rate," Teufel said. "They are big-time consumers of health care because they are older and they are sicker. They are also consumers of pre-hospital care.

"As we get older, you can expect more 911 calls -- they will be more complex, harder to handle," he said. "The elderly are much more challenging, much more complex. They are just going to be putting an increasing load on the system in Marin.

"Are we planning for this? I think so," Teufel said.

Last week, Novato Battalion Chief Ted Peterson, the fire district's emergency medical service director, returned from a California Ambulance Association convention in the Lake Tahoe area. The event featured a talk on baby boomers that predicted future demand on emergency medical services.

Call volume will increase, he said, but he believes Marin's system can handle it.

Sophisticated model Similar to the mutual aid system, fire department-based emergency medical services allows officials to cover each other's zones when needed, or reassign firefighter-paramedics who work on fire engines to staff reserve ambulances.

"It's a very sophisticated system and it's a model for fire-based EMS," Peterson said.

In addition to ambulance service, placing a paramedic on a fire engine helps bring advanced life support to the scene with haste, said Larkspur Fire Chief Bob Sinnott, executive officer of the Ross Valley Paramedic Authority.

"It's becoming the industry norm," he said. "It puts the paramedic there faster. It's not necessarily having the ambulance show up that's critical -- it's simply getting the paramedic there quickly."

Balance is key, county fire's Giannini said. Diluting the system with paramedics means individuals have less opportunity to gain experience, he said.

"It's important to not go overboard," he said. "I think Marin has done a good job of achieving that balance."

Fire officials agree that practicing prevention now can reduce the load later.

Medical call volume can go down thanks to factors such as improved medical care and greater in-home care, even for conditions that may actually be on the rise.

"For example, we are seeing fewer diabetic- and asthma-related 911 calls, even though the percentage of the population suffering from these conditions has, if anything, increased," Southern Marin Capt. Matt Muldoon said.

Enhanced public health that encourages people to assess whether they can treat themselves at home and fall prevention education for the elderly, among others, could ease the strain, Giannini said.

Just as they have gotten better at fighting fires, so too can they improve emergency medical services, he said.

"I see the fire service on the verge of taking that same approach to medical management of EMS issues," he said. "Right now we're focused on managing the event. What I think we should do is look at EMS from a proactive standpoint, and look at prevention to lessen our need to prevent people from going into the hospital in the first place."

Contact Jennifer Upshaw via e-mail at [email protected]


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