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Florida EMS Director Highlights Challenges of Rural EMS

Mayo — Lafayette County Emergency Medical Service Director Trevor Hicks recently expounded on emergency medical issues facing rural communities, something he says will most likely not improve much in the future.

“The biggest challenge we face in a rural community as far as providing emergency medical services is educating the public,” said Hicks. “We don’t make the rules locally. The rules are made elsewhere through the Department of Health and Human Services in Washington D.C. They’re passed along through the CMS division, which is the Center for Medicare/Medicaid Services. That dictates what we do.”

Hicks said they have local medical control through the county’s EMS Director/Physician Robert Spindell, but he doesn’t make the rules either.

“They (EMS Directors) write the protocols as far as medical treatment, which are appropriate for the American Medical Association and the American Heart Association, but the rules are dictated through the federal government,” said Hicks.

The rules change constantly, Hicks said, and the challenge is getting that news out to the general public in a timely manner. The rule changes are not just one-sheeters. They can often be over 100 pages long and deciphering them can be a challenge. With abrupt rule changes, all of a sudden a service isn’t covered that used to be covered and that’s when patients get upset, he added.

“They still have the option to go (by ambulance) and you have the duty to carry them, but you have to let them know up front that financially it’s going to cost the patient,” said Hicks.

Additionally, when CMS rules change, third party private insurance companies follow suit.

“One of my biggest goals, around here especially, is to try to prevent the patient from getting hit with a big ambulance bill they can’t afford,” said Hicks. “We cannot fabricate a chart to make it cover it. That’s just not going to happen.”

One federal guideline addresses where to transport patients during a medical emergency. For Lafayette County residents, depending on where they live, the closest hospital is either Live Oak or Perry and oftentimes patients get upset because they want to be taken to Gainesville for treatment.

“Occasionally, when a patient meets a medical determination that says those services are not available at that facility, and we can locate the resources to move that patient beyond that facility, there’s a chain of events that have to happen,” Hicks explained.

First they have to get approval that the patient meets warranted conditions for medical reasons or necessity that aren’t available at the local facility, and then resources have to be available, whether by ground or air, to get the patient where they need to go.

CMS, he said, will generally extend coverage for transportation to specialty resource centers, such as a stroke, trauma or cardiac alert centers, as long as there is proper documentation.

Florida Administrative Code has changed for trauma alert victims, Hicks said, and patients must be transported to the closest trauma center to the accident. The closest for Lafayette County are Shands UF in Gainesville and Tallahassee Memorial Hospital. This presents challenges because they have to rely on available resources to get the patient to the facility.

“If we don’t have the resources and weather’s an issue and we can’t fly them, then they have to go to the closest hospital, but they are immediately transferred,” he explained. “It’s a time and distance factor.”

Time from point A to point B, the patient’s final destination, is always a consideration, Hicks continued. Many patients, he said, get upset because their doctor and all of their medical treatment has been performed at a hospital in Gainesville, so being transported to Live Oak or Perry seems to be a waste of time.

“The law doesn’t take that into consideration,” said Hicks. “

Patient and physician preference is not allowable under those guidelines, he said. Plus, they simply don’t have the resources available to transport patients to Gainesville or elsewhere.

“It’s not just us,” said Hicks. “This is a nationwide thing. CMS is only going to cover the expenses to a certain distance and that’s it.”

Hicks recalled one time that his department transported a patient by ground directly to Gainesville. It was a newborn and at the time resources were available to transport the infant.

“That was a specialty resource hospital for that child’s needs,” he said.

Hicks said his department cannot leave the county uncovered for three hours while they travel back and forth to Gainesville.

“We operate one ambulance 24 hours a day,” he said.

Sometimes two medical emergencies happen at the same time and Hicks said in cases like that they rely on backup personnel who come from home to the station and utilize another ambulance to handle the second emergency.

“It’s been that way for 25 years,” he said.

Even though they have three ambulances, they only have one on duty at a time that is staffed 24 hours a day.

“Looking at the national average and the American Ambulance Association it’s recommended to have one truck per 10,000 residents,” said Hicks. “We’ve got one truck per 8,000 residents right now.”

Hicks said they are at a point where they want to expand their operation, but financially the funds are not available. The issue of expansion was briefly discussed at the Oct. 8 county commission meeting where Hicks presented the board with a tentative budget that would be required to add additional services and personnel. Those costs would most likely have to be absorbed by the local taxpayers and it would be a significant amount of money.

Hicks said rural EMS is held to the same high standards as any other EMS in the country, even though they don’t have the luxury of being logistically close to major hospitals and trauma centers.

“We have rural healthcare facilities and we have critical access hospitals that we can get to, but they’re not trauma centers and they don’t provide 24 hour operating rooms,” said Hicks. “There’s a limited service that can be provided to a trauma or stroke patient.”

Doctors Memorial Hospital in Perry, Hicks said, is an initial trauma receiving facility, the same as Shands Live Oak and meets the five necessary categories.

“It has a physician, it has an emergency room, it has lab, it has x-ray and Doctor’s Memorial does have a surgeon they can call in if he’s available, however, the majority of trauma patients don’t go to the O.R. there,” he said. “They’re direct transfers out to a trauma center.”

When rural facilities receive trauma patients they do what they can to stabilize them before they are transported to a trauma center, which entails following proper EMTALA and COBRA procedures and making phone calls to trauma centers.

“It’s a big delay,” said Hicks. “Ultimately, all rural counties are faced with it.”

Hicks said to address the problem his department entered into a collaborative agreement with Century Ambulance, whereby they would meet at a rendezvous point to transfer patients from one vehicle to the other so they would more quickly be on their way to a trauma, stroke or cardiac center. They also have an agreement with Dixie County to take patients if they have resources available. He said the time delay has been greatly reduced by utilizing these resources.

Hicks said he does not foresee any major changes to rural Florida healthcare, as far as a trauma center being opened up in this region and he attributes it to resources.

“You have to have a board certified critical care surgeon in the hospital around the clock,” he said. “You’re not going to find those critical care trauma surgeons that are going to live in rural areas and provide service in rural areas because they’re typically tied to an academic medical center where you have a residency program.”

All Level 1 trauma centers, Hicks said, are required to be academically connected. Level 2 centers don’t have to be academically connected, but they have to provide the same services. Going to a local hospital, however, is not always a bad thing, he added, because EMS doesn’t carry whole blood.

“If a patient needs blood we need to be at the closest hospital that has blood,” he said. “That’s usually the only thing that’s going to keep that patient alive is getting that whole blood going in their body and get them to the trauma center so that they can figure out where the bleed is coming from. Fortunately, both of our hospitals usually have plenty of blood on supply and they can start that blood and continue the transfer. Nothing obviously replaces blood other than blood.”

As for access to patients during a natural disaster such as when Tropical Storm Debby caused major road flooding, Hicks said they have an alert system in the dispatch center that tells them a road is closed. They also have a fully ALS equipped four-wheel drive backup emergency vehicle that can access many areas that are impassable by their fire/rescue trucks, which are designed for travel on paved or hardtop roads. Hicks said the weight of the emergency trucks would cause them to sink on muddy dirt roads.

“If it’s a boating issue, we have to get the Sheriff’s Department or someone else involved that has a boat,” said Hicks.

Choosing to live in an area with limited healthcare resources like hospitals and trauma centers is one big drawback of rural life, Hicks admitted. In Lafayette County, however, Hicks said EMS and the entire crew is the best it’s ever been.

“I know that because I’ve been here a long time,” he said. “The personnel who work here are extremely certified to be here.”



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