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4/30/2014 12:01:00 AM
Providing for Emergency Medical Service: What is optimal for Emmet County?
EMS in the field
The following definitions of different levels of Emergency Medical Services "in the field" were provided by Tom Charlton, medical director of the region's Medical Control Authority.

Medical First Responder (MFR): In this area, MFR's are volunteers (often doubling as fire fighters) who have been trained in basic first aid, advanced CPR, resuscitation, etc. Medical First Responders cannot transport people to the hospital. Their role is to provide initial scene stabilization-- to stop the bleeding, push on the chest, deliver the baby-- and wait with a patient until an ambulance arrives.

Emergency Medical Technician (EMT) Basic: Generally the entry-level of Emergency Medical Services. EMT Basics have a little additional training (mostly non-invasive) and are able to transport a patient. EMT Basics can also administer some medicines.

EMT Specialist/Advanced EMT: There are very few of this level of EMT's nationwide. Known as "mini-paramedics" EMT Specialists can administer additional drugs, use heart monitors, and have more assessment abilities.

Paramedic: The backbone of life support in a community. They provide the most advanced diagnostics, assessments, medical administration. Essentially, paramedics provide a small scale Intensive Care Unit in the back of an ambulance.

How best to provide funding for ambulatory care in Emmet County has been a hot button issue for years, and that debate hit a new low recently when the county's Ambulance Advisory Committee issued a one-page funding plan that was almost immediately rejected by the board of directors for the area's non-profit ambulance service, Allied EMS. The plan was also heavily questioned by several municipalities and community organizations like HARBOR Inc.

In the end, Emmet County's Board of Commissioners decided to instead approve ballot language for the August primary election to ask voters for a renewal of 0.25 mills for ambulatory care, instead of an increase. The Commissioners are also planning to issue some $15 million in bonds, part of which would be designated for county EMS infrastructure - buildings and equipment.

"We need to start having a very real discussion in our community," said Tom Charlton, an Emergency Department physician who also serves as medical director for the region's Medical Control Authority (see related article). "I need to hear from people what response times they think are acceptable and what they are willing to pay."

Charlton, who serves as one of the Ambulance Advisory Committee's non-voting members, said in a recent interview with this newspaper that he has serious concerns about the future of Emergency Medical Services in Emmet County, if the trajectory of funding is not changed in the near future.

"We're already seeing cracks in the foundation," he said. "We can't just flip a switch and expect to have excellent EMS when it has been underfunded for so long. We're already at the point where we're playing catch-up."

Understanding the complexities of a healthy EMS system is difficult, even for a professional like Charlton.

"I have 15 years of experience and a huge amount of training, and I still don't understand all the intricacies involved. It's like running a hospital. It's crucial to have experts in each content area," he said.

That's why one of Charlton's goals as medical director is to change the perception of ambulance service as just the "lights and sirens" response.

"EMS is not just the trucks or the equipment or even the paramedics. We need people to manage the schedule, human resources, additional training. I'm a board certified Emergency Medicine physician and I need to read every single day to keep up to date with best practices. Continuing education plays a huge role in having a high level EMS."

Part of the funding crisis has nothing to do with Emmet County, Charlton said. The laws Michigan has in place regarding emergency services do not include a mandate for ambulatory care.

That means there is no law that requires the county to provide residents with ambulance services.

"It's frightening to think about living in a community without ambulatory care," Charlton said. "But it isn't illegal, and therefore, it isn't traditionally funded by many municipalities."

In bigger cities, ambulances do not need to rely on taxpayer subsidies, as they generate enough through billing 911 "runs" (only when a person is taken to the hospital) and "taxi" services (transporting patients from one medical facility to another).

"In an area like this, it doesn't take a rocket scientist to see we just don't have the run volume to break even," Charlton said. The other problem northern Michigan faces, he noted, is the unevenness of the seasons-- in the summer, run volumes spike, but it is next to impossible to maintain that level of staffing during the much quieter off season months.

"We want to make sure our year-round residents are always covered. And that requires a serious conversation about funding. We need to stop looking at EMS as individual areas and start operating as community members, as friends and family and neighbors who are willing to do what it takes to ensure everyone gets the coverage they need. We need to look at this as a system. This is the kind of thing that can either bring a community together, or drive it apart. I'd like to see us work together."

Charlton is the first to say Emmet County's EMS is under-subsidized, but he's also the first to stress "throwing money at a problem" won't fix it.

"We could have an ambulance on every corner, but how often do you think those paramedics would be intubating people or putting in a chest tube? Skills that don't get used can get rusty. The real question is how much is enough (and how much is too much)? The goal is to have enough resources, but not too many resources."

Having studied the county's system-- ambulatory care is covered by Allied EMS and Mackinaw City EMS-- Charlton said he has a clear idea of what optimal coverage might look like.

The current model has two Allied trucks and one Mackinaw City truck on at all times, with a back-up ready to go if needed. Charlton said where the trucks are positioned leaves a "donut hole" of poor coverage in the center of the county, where the population is more sparse.

"People there are already paying taxes for EMS, but aren't getting a lot for it. I'm sure if you were to ask folks in Cross Village or Pellston if they should have a truck stationed closer, they would say yes," he said.

Charlton added ideally, he would like to see substations somewhere north of Harbor Springs, somewhere south of Petoskey, and somewhere in that center "donut hole" where current response times are not acceptable (although, he added, that truck could also 'float' some, as the center of the county receives the least number of calls), plus a truck in Mackinaw City.

Current funding for Allied EMS has relied heavily on a handful of donors who have purchased new trucks and equipment. Charlton said that he is grateful to live in such a philanthropic place, but noted that type of donor-dependant operating mode is not a long-term, sustainable solution.

"Equipment like heart monitors run $45,000, and ambulances cost between $150,000 and $200,000. Our fleet, as a whole, is long in the tooth," he said. "It's time we start reinvesting in EMS as a community. We need the right resources for the right patients and we need to be able to get to them in the right amount of time."

To this end, Charlton added there are only a handful of times that an ambulance is needed within a few minutes: for uncontrolled bleeding or signs of impending (or already occurring) cardiac arrest, which is when a heart stops beating.

"Last year, we had 35 cardiac arrests (on EMS runs) and we were able to bring about 25-percent of people back, which is at or above the national average," Charlton said.

Having worked with many of the area's EMS personnel, Charlton knows first hand the level of dedication and service they provide.

"I am so impressed by how long they have hobbled along without adequate funding. I give a lot of credit to these guys, who have been running the system for so long, patching it up and making tough choices," he said. "They deserve better. It's morally unacceptable to not do something better than what we have now. There is rust on some of our trucks. Several have 250,000 miles on them and many have broke down on multiple occasions. You don't want to be in the back of an ambulance and have it break down."

It is time for the people of Emmet County to speak up, Charlton stressed. He suggested contacting county commissioners, township boards, city council members, and even him.

"We need to hear from as many people as possible. We need to know what folks want. We have a functional EMS, not a high performing EMS," Charlton said. "I want to see us change that."

Related Stories:
• Emergency medicine is a calling for Medical Control Authority director


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