2-
I Know CPR, but I'm From Cleveland- Can I Help?
Using personnel from outside the service area
Q:
Someone wrote: "What does the "Guru" think of filling the "emptiness" of
daytime responders with personnel from outside the service area? How
should training issues be addressed and how should these personnel be managed?"
A:
As the term "outside the service area" is not defined, I will assume it means the immediate service area. I think this is a fairly easy
proposition, using the concept of a "visiting provider". Assume the individual
holds a verifiable license or certificate in the state- this provides some evidence that they are competent or, at the very
least, that they know about 70% +/- of the material on the test (states may
deny that issuance of a certification or license has anything to do with
verifying that a person knows what they are doing, leading to a whole other
discussion that we will not get into right now). So, step one is to get a
copy of their card. Most providers are affiliated with an agency (some states even
require this as a way to keep down the number of people who take EMS training). Then, of course, more and more
agencies have a medical director, also required by many states, that can verify that everyone who
practices in that agency is appropriately credentialed (you can stop laughing
now).
So, if everyone is really doing their job and upholding their responsibility to
protect the public interest, a provider could submit a copy of their state
card, and a letter from their agency to verify their affiliation and clinical practice privileges, and you should be
reasonably assured they are not a mass murderer (just think how well this would work if state
regulatory agencies were required to post provider status including disciplinary
activities where these data could be readily accessed). This pretty much
takes care of the "training" issue, though I think I would limit this status
to EMT level only- easier to oversee based solely on the fact that
the practice standard is better defined and less variable from area to area.
"Visiting provider" status should require nothing more than a provision in
the agency's by-laws or membership policy. Don't let some government agency, including
"The Office of EMS", tell you they have authority over who can be a member of your private organization- their
authority stops at who gets a ticket to play.
How to manage these people, these EMS interlopers? What are they doing that
needs managing- running hell bent all over your service area rescuing small
animals and doing CPR on unsuspecting citizens, grabbing headlines? Have a
single page of paper that spells out the rights and limits for visiting providers (it's called a job
description, and it is useful, even for people who are already "members" and probably don't have one).
Visitors should be willing to follow whatever basic organizational structure your,
agency has, presuming you have one- after all, they are now "members", and
"members" should be expected to play by some basic rules. In addition, while your
agency may not be the best organized in the world, you don't need to turn
your organization on its head because someone from out of town thinks they
can revitalize or revolutionize your agency during their semi annual fishing
trip. Most reasonable people just want to help out where they can, except
for those media mongers whose goal in life is to get their "15 minutes" every fifteen minutes. You should put a leash on those folks, but
thank them for their time.
Personally, I think this type of arrangement has great potential. Over time, providers around a state get to
know where help is both needed and wanted, and maybe they even visit you more often- after all, your
efforts are a sign of a "good community" where people "really care". The
big "management issue" is whether individual agencies, local "EMS Councils" and
more than a few state bureaucrats can get their overactive egos under control. Personally, I would rather be getting CPR from someone
from out of town than lying there dead as a stone waiting to see if any "local
talent" shows up to help.
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4- ADA and Ambulance
Accommodations
What is 'reasonable' or required
Q:
In the news I read that the Americans with Disabilities Act requires health professionals
to provide reasonable accommodation to people with disabilities to ensure that
they receive comparable care and services. And that includes, in many cases,
providing a lip or sign interpreter if the patient requests it. Some patients and families are pursuing the issue in court.
What exactly does the ambulance HAVE to have on board to meet ADA?
A:
Unlike a vast majority of "laws" passed by Congress, inevitably
followed by a ream of supporting "regulations" from our ABC agencies, ADA stands out as
being one of the least offensive and most practical approaches to dealing with people who are
"different" ever seen. This, of course, does not mean that everyone is in compliance. A few basic points: ADA
applies to organizations referred to as "Public Accommodations", or in simple
terms, organizations that serve the public (see how easy this is). An EMS agency
certainly falls into this definition. The basic requirement for compliance
is that an organization must provide "reasonable accommodations" for persons
with disabilities provided such accommodations do not present an "undue hardship". Sure, we can always sit around and argue over the
definition of "reasonable" and "undue", but try not to go left over this situation. For
the most part, ADA compliance is painfully akin to common sense.
So, now let us go to the question at hand. Is it possible to encounter a
person who is hearing impaired when responding to a medical emergency? Yes.
It's also possible you will encounter a person who speaks only Urdu. Is it
"reasonable" to require all your staff to be fluent in modern sign language
communication so as to enable them to communicate about any and all aspects
of the care provided to an individual who is hearing impaired? Not. To be
fully literate in this form of communication takes time and practice. To
demand this level of proficiency would be an "undue burden", made
more so by the infrequent and short-term nature of such encounters. So what
do you "have to have" on board to be in compliance with ADA? Probably not much,
since it usually comes back to an argument about "reasonable", and this will
depend on setting to some degree. However, we can ask the question a different way. Is it reasonable for your staff to
understand that
1) there are people out there with hearing impairments
2) that when time permits it is appropriate to use a pad and paper to give and receive accurate
information
3) that people who can "read lips" must be able to see
the face of the person speaking to understand what is being said?
Sure, these seem like reasonable accommodations. Maybe your staff could become
familiar with a few selected signs that are important in the event of a major
health event- these could include pain, difficulty breathing, nausea, headache,
etc? You could even develop a brief policy/procedure/whatever
paper called "Working with the Hearing Impaired ". For those wound up about
ADA compliance for this patient population, couple these thoughts with a good
dose of political correctness, maybe a little news story about how sensitive
you are to the needs of "special members" of your community, and I think you're good to go. For those who adopt this strategy because
every member of your community deserves the best care you can offer, even if it
takes a little more effort on your part, thanks for the effort.
Web reference link:
Americans with Disabilities Act Document Center
http://janweb.icdi.wvu.edu/kinder/index.htm
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3- On Duty Without Pay
On premises policy without compensation?
Q:
The ambulance service I worked for made us do a 24 hour tour of duty (unless it was split up between workers, then it got really
crazy). On this shift, you clocked in at 8 am and out at midnight. During
the eight hours at nite, we were supposed to sleep, but could not leave the
facility. Also, our county does not have 911, or a dispatch center, so during the night, while we were clocked out, we also had to answer
the emergency phone. If it was a good call, we would get up, clock in and
go on the run. If it was a wrong number, or a bogus call, we were just
woke up from a good sleep. Sometimes they split the shift up, where someone works from 8 am
to 4 pm, and then the second worker comes in from 4 pm to 8 am the next am.
That would mean that the second person only actually got paid for 8 out of 16 hours. Sometimes, it is * am to 8 pm, and the second person
only gets 4 hours out of 12.
What do you think of this?
By the way, Paramedics are paid $10 per hour, Intermediates, $7
per hour, and Basics, $6 per hour. If you figure this up, a Paramedic actually only makes $6.66 per hour in a 24 hour shift, and Basics
make on $4 per hour in a 24 hour shift. Reason I say this is because medics cant leave the facilities to go home or the store, or be
with family when they clock out.
What are your thoughts?
A:
The US Department of Labor publishes a document called Ambulance Service
Establishments under FLSA (revised March 1977). In the absence of a major
change to these regulations that I am unaware of, the rules for 24-hour shifts and sleep time are
straightforward.
If you are on duty for a shift of less than 24 hours, you are working for all hours on duty. As
stated in the regulation, "sleeping" or being "engaged in other personal
activity" does not change your status. In fairness to the agency, you must
be prepared to respond and not wandering around as you please; "going
home or the store" or "being with family" can and is abused by staff and
can impact negatively on agency performance. The bottom-line, in at 16:00
hours, out at 08:00 the next day- you worked 16 hours. In at 20:00, out at
08:00 the next day- 12 hours worked. For persons who work a 24 hour shift
or longer, "sleep time" of up to 8 hours may be excluded as hours worked, if
the employer and the employee "agree" (if the policy existed and you accepted
it, that could be argued as an agreement). If the sleep time is interrupted
by a "call to duty", time on that call is classified as hours worked. If
you get less than 5 hours of sleep in 8 hours, all 8 hours are hours worked.
If the interruptions are "so frequent as to prevent reasonable periods of
sleep totaling five hours" then all 8 hours are hours worked. This last provision
always triggers an argument about the term "reasonable", such as the issue of answering the phone, but don't worry the government
or the courts will sort that if everyone can't agree. The big issue here
is hours worked, and from this, how many hours are due straight time and
overtime.
Your last question seems to raise the issue of minimum wage compliance. The
hourly rate could drop below the minimum set by law if, for example, you get
$40 for 12 hours worked (4 hours at $10 per hour, on a 12 hour
shift after taking out 8 hours "sleep time"). This issue goes away when one
complies with the FLSA guidelines for hours worked so discussing it just
muddies the water and doesn't serve any purpose.
Now, for your last question- what do I think? I think that if the sleep time provision is to be used, it
must be done within the limits provided by the regulations. The expressed
intent should be insuring adequate coverage, and protecting the financial
condition of the agency, as a change from this practice can be very expensive. From a
practical point of view, it can be a source of controversy (due at least in
part to the fact that there is a need to interpret certain provisions such
as what is reasonable). It requires a fair bit of paperwork and documentation to make sure everyone is on the up and up, and there
is always
some dispute about who was working when and for how long and why. However,
the good news is that it doesn't matter what I think.
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