Peoria's Medical Mafia

[drjohn]

This is the first post on www.peoriasmedicalmafia.com.

Synopsis of Emergency Medical Services in Peoria

Peoria’s Medical Mafia documents thoughts regarding Emergency Medical Services (EMS) in Peoria, Illinois. There are approximately 65 posts on this web log, many of them regarding EMS.

Peoria has a population of 113,000. The Peoria Fire Department (PFD) is non transport and provides service at Basic-D level with basic medication. Several years ago the PFD purchased a very nice ambulance using the Foreign Fire Fund. The PFD applied to the Peoria Project Medical Director for permission to outfit this vehicle, their only ambulance, with various basic and advanced life support materials and equipment. This request was denied by the Project Medical Director. The PFD then sold this ambulance because it was not being used.

Peoria has an advanced life support company, Advanced Medical Transport (AMT), which transports patients and gives the only paramedic care in Peoria. It is considered a not-for- profit entity but grosses over 7 million dollars per year. AMT is supported by all three of Peoria’s hospitals. OSF-SFMC, the largest medical center in downstate Illinois, is considered the “resource hospital” for the Peoria Area EMS. All three medical centers have administrators that sit on the AMT Board of Directors. AMT suffered significant legal troubles several years ago when the federal government investigated it for Medicare fraud based on coding and charging. AMT was fined over 2 million dollars by the federal government.

The OSF-SFMC Emergency Department Director is also the Corporate Medical Director for AMT. He was the Project Medical Director for many years in the Peoria area and was salaried by both AMT and OSF-SFMC for his services. Numerous people in the area believe this arrangement constitutes conflict of interest. The PFD also believe that many obstacles have been created over the years to keep them at a basic non transport level so AMT can continue as the only paramedic and transport agency in Peoria.

I believe that Peorians have suffered and died in the pre hospital setting and continue to do so because of the paramedic/transport monopoly. Incredibly, the PFD has paramedics that cannot use their life saving abilities at the scene when they work as firefighters; however, when they “moonlight” for AMT, they are able to use their advanced life support skills.

Similar business arrangements as described above probably occur in other locations around the nation. But just because banks are robbed in many cities, does not mean it is right to rob banks in Peoria.

I hope this web site is informative. Some day Peoria will change for the better regarding EMS and pre hospital care. The system took a while to become this ill and it will take a while to recover.

John A. Carroll, MD
[email protected]

[medicmaster]

As I replied to your other post....

A couple of things here...

1. What exactly is the point of all of this?

2. Illinois' entire EMS system is f***ed beyond belief and is so full of bueracracy and red tape its a wonder that anyone in the state receives the care they deserve.

3. AMT from what I have heard has an excellent reputation as an advanced level provider. Aside from being a non-profit agency that "grosses over $7 million a year" (which there are non-profit hospitals that bring 100 times that amount in annually...it's all in how it is spent) and the fact that they had some trouble with CMS a few years ago, you offer nothing to state that they provide a low level of care. However, I do agree that they could stand to pay their staff a little more. (My fiancee considered doing a residency in EM at OSF, I looked into working for AMT...she has since decided on Family Practice instead.)

4. In my personal opinion, fire-based EMS (at the advanced transport level) is flawed. What evidence do you have to support the notion that PFD can provide better service.

Just my $0.02 anyways....

[F18Wub]

As I replied to your other post....

A couple of things here...

1. What exactly is the point of all of this?

2. Illinois' entire EMS system is f***ed beyond belief and is so full of bueracracy and red tape its a wonder that anyone in the state receives the care they deserve.

3. AMT from what I have heard has an excellent reputation as an advanced level provider. Aside from being a non-profit agency that "grosses over $7 million a year" (which there are non-profit hospitals that bring 100 times that amount in annually...it's all in how it is spent) and the fact that they had some trouble with CMS a few years ago, you offer nothing to state that they provide a low level of care. However, I do agree that they could stand to pay their staff a little more. (My fiancee considered doing a residency in EM at OSF, I looked into working for AMT...she has since decided on Family Practice instead.)

4. In my personal opinion, fire-based EMS (at the advanced transport level) is flawed. What evidence do you have to support the notion that PFD can provide better service.

Just my $0.02 anyways....

While I am not going to touch the "medical mafia", I am curious why you say that fire based EMS is flawed? My experience is just the opposite. I have worked at a private, a fire department that provided first response to the private, and fire based ems. The first response to the private's ALS was so filled with red tape and bias it was a joke, and I worked at the private at the time. I have full belief that Peoria can provide as good of level of care if not better than AMT, but that's all I am going to say about that.

[MIKEYLIKESIT]

Sorry 'Master" but you are flawed. My department began ALS Transport service in 1973. Why? Because the privates couldnt do the job. That was 33 years ago. The Fire Department is still here. How many private ambulance services have come and gone, went belly up etc. since then?

[jaybird210]

Sorry 'Master" but you are flawed. My department began ALS Transport service in 1973. Why? Because the privates couldnt do the job. That was 33 years ago. The Fire Department is still here. How many private ambulance services have come and gone, went belly up etc. since then?

He is right on point #2, though.

[MIKEYLIKESIT]

Maybe at the IDPH Jay. But which state had a medical team in place and working in Louisiana within days of Katrina? Our system (South Cook) has been wonderful to me since I started paramedic school...20 years ago.

[medicmaster]

Mikey,

For one, Chicagoland is a whole different ballgame compared to the rest of Illinois...things seem to run much smoother there.

I will agree that there are fire based EMS systems that do a fantastic job. However, my point was not to break it down into fire based and privates. There are many county and muncipal based third services who do much better jobs than privates.

I agree that most privatised EMS systems do not do a good job at providing service (although there are some that do.) From what I know about AMT, they are a good private provider.

My point is though, and this is just my personal opinion, that the world of emergency services has come to be very specialized, and I think that fire protection would be better served by firefighters who train only to be top notch fire fighters without being bogged down by running a dozen EMS calls, and then fighting a structure fire at 3am. EMS would be better served by having highly trained paramedics who are focused on patient care.

I recently began working for a city where EMS and Fire are separate city departments. Although the stations are shared, and there is an excellent working relationship between our two agencies, we have separate department heads, and the medics are very high quality. The firefighters are also very high quality, and when we all need to play together, things go smoothly.

Our city is only one of three in the nation to have all three public safety agencies nationally accredited, and I can definately say that our EMS department is one of the highest respected systems in the state.

With that said, I'm not saying that I don't think that PFD can provide better service than AMT, I was simply making a point that this doctor presents no evidence to say that they can.

[drjohn]

Dear Medicmaster,

I appreciate your comments above.

When patients were brought into the ED my most important conversation was with the paramedics or EMT's that brought in the patient. How the patient looked at the scene and enroute was very important and my respect for Peoria's paramedics and all levels of prehospital level providers was and is great. They are not the problem.

As www.peoriasmedicalmafia.com documents, evidence in Peoria is lacking, or I would provide it for you. EMS everywhere needs to be transparent. The one statistic that we seem to know, as verified by a consulting firm several years ago, the PFD responded to life threatening emergencies two minutes faster than did AMT. Is that clinically important? Maybe, especially when chest pain and breathing problems are involved, according to the medical literature that looks at response times. When I spoke with the Peoria Area EMS office several years ago, I was told that there is no aggregate data to look at regarding clinical outcomes. I do not know if that is true, but the data is not "out there" to find easily. I tried IDPH also to obtain this data, and got nowhere.

My point is not to provide data, for reasons described above, that the PFD can provide better service than AMT, even though I think they could with the proper director and level of training. My point with the web log is to say that the first arriving best trained provider should be allowed to provide his or her services for the benefit of the patient. When PFD paramedics have to stand around and wait for AMT to arrive to give ALS, that seems wrong. I know there are alot of rules regarding how departments respond, but the situation in Peoria needs to be scrutinized carefully. When the patient needs an endotracheal tube, and the PFD firefighter cannot place one unless asked to do so by AMT, that seems to be problematic, doesn't it? What if AMT is not on scene to ask for help with the tube?

Not all conflict of interest is bad. If conflict of interest is acted upon in a negative way, that is not good. George Hevesy, MD is the ED Director at OSF and was the PMD for the Peoria area for many years. OSF is the main supporter of AMT. Hevesy was and is the Corporate Medical Director for AMT and paid by AMT for his services. He is also Director of Region 2 for IDPH. The general public doesn't understand what any of this means, but EMS providers do.

I have talked to municipal fire departments all over the United States. When they are designated to provide service at a certain lower level, many departments have options that allow some of their firefighters who are paramedics to function as paramedics even though the department is not "paramedic". Please advise me how this takes place. This seems to make sense. The PFD should be able to use this option, shouldn't it?

Thanks.

John Carroll, MD

[medicmaster]

As www.peoriasmedicalmafia.com documents, evidence in Peoria is lacking, or I would provide it for you. EMS everywhere needs to be transparent. The one statistic that we seem to know, as verified by a consulting firm several years ago, the PFD responded to life threatening emergencies two minutes faster than did AMT. Is that clinically important? Maybe, especially when chest pain and breathing problems are involved, according to the medical literature that looks at response times. When I spoke with the Peoria Area EMS office several years ago, I was told that there is no aggregate data to look at regarding clinical outcomes. I do not know if that is true, but the data is not "out there" to find easily. I tried IDPH also to obtain this data, and got nowhere.

My point is not to provide data, for reasons described above, that the PFD can provide better service than AMT, even though I think they could with the proper director and level of training. My point with the web log is to say that the first arriving best trained provider should be allowed to provide his or her services for the benefit of the patient. When PFD paramedics have to stand around and wait for AMT to arrive to give ALS, that seems wrong. I know there are alot of rules regarding how departments respond, but the situation in Peoria needs to be scrutinized carefully. When the patient needs an endotracheal tube, and the PFD firefighter cannot place one unless asked to do so by AMT, that seems to be problematic, doesn't it? What if AMT is not on scene to ask for help with the tube?

In a tiered system, such as the one that exists in Peoria, first response (in this case the FD) is supposed to arrive several minutes before the ambulance. Fire stations are (should) be built in areas that allow an engine company's response to a scene as quick as possible. In most cities where the ambulance is not housed at the fire stations (such as with many private or third service providers), they are placed to provide coverage wherever needed to an entire city based on volume, versus an engine company whose primary objective is rapid response within its first due district. If the ambulance routinely beats the engine company, or they routinely arrive at the same time, then tiered response is a waste of resources.

Those two extra minutes give the engine company the oppurtunity to initialize BLS maneuvers and perform a patient assessment to pass along to the EMS crew when they arrive.

As an example, the city I work in has four fire stations with a fifth under construction. Two of these stations are staffed 24/7 with career firefighters, the other two are staffed with paid on call firefighters. We staff three ambulances 24/7 at two of the unstaffed stations, and one of the staffed stations. Most of our runs do not require additional manpower, so the squads will respond to EMS assignments unassisted by the engine companies. Exceptions are calls to the firefighter staffed station's district which does not house an ambulance, in which case they do provide first response. Other exceptions are if the squad housed at the other staffed station is out on a call and another truck from another part of the city has to respond. Motor vehicle accidents and unconscious persons will also be an automatic engine company response. Additionally, the EMS crews can request an engine company's assistance if needed. All of the engines are BLS equipped.

Not all conflict of interest is bad. If conflict of interest is acted upon in a negative way, that is not good. George Hevesy, MD is the ED Director at OSF and was the PMD for the Peoria area for many years. OSF is the main supporter of AMT. Hevesy was and is the Corporate Medical Director for AMT and paid by AMT for his services. He is also Director of Region 2 for IDPH. The general public doesn't understand what any of this means, but EMS providers do.

I realize I may be making an assumption here, but from what I saw on your blog, it seems that you questioned this guy's motives and intents and he decided to kick you out of the ER to keep you quiet. While I will sympathize with you in that this clown does not sound like the type of person we need taking EMS and Emergency Medicine into the future, I can't help but wonder if this is because you have an axe to grind with the man. Again, I'm playing deveil's advocate and making an assumption, but it sounds like this physician is the problem, not the EMS system. In fact, to be completely honest, with St. Frances being a very respected EM residency program, it scares me to think about how many ERP's in the midwest will adopt this guy's attitude about things!

I have talked to municipal fire departments all over the United States. When they are designated to provide service at a certain lower level, many departments have options that allow some of their firefighters who are paramedics to function as paramedics even though the department is not "paramedic". Please advise me how this takes place. This seems to make sense. The PFD should be able to use this option, shouldn't it?

This is true...at least over here in Iowa what it requires is that the transport agency's medical director must approve them to function as an ALS provider in the transport agency's squad, with their equipment.

Having ALS first response is something I'm very undecided about. I began my career with an ALS volunteer first responder service, but due to our rural setting, ambulance response to the scene after we had arrived was often times 10-15 minutes. In those 10-15 minutes, we had most if not all of the ALS stabilizing treatment performed. However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.

By the way....this has turned into a great discussion!

[k3twpfire]

However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.

Please explain how initiating ALS procedures is more of a hinderance when the ALS ambulance is 2 - 3 minutes behind the engine than 10 - 15 minutes.

[F18Wub]

Having ALS first response is something I'm very undecided about. I began my career with an ALS volunteer first responder service, but due to our rural setting, ambulance response to the scene after we had arrived was often times 10-15 minutes. In those 10-15 minutes, we had most if not all of the ALS stabilizing treatment performed. However, in a system such as Peoria's, when there is only a few minutes difference, this can be more of a hinderance. It seems to be of greater benefit if an engine has one paramedic that can function as an ALS provider when the transport service has arrived and can assist the transport paramedic with the critical cases.

Where I work, ALS engines are the rule, rather than the exception. I really don't understand how having more ALS providers on scene, providing care can be a hinderance, especially in a situation like Peoria, where, if I recall correctly, single medic ambulances are commonplace. Granted, most calls are not of a critical nature, but when needed, the assistance is of great benefit to the patient. Think about the flow of a scene. BLS engine shows up, assess the patient, begins BLS intervention. Ambo shows up 2-3 minutes later, gets report from engine, then begins to assess the patient, because the usually won't trust the BLS providers impression. (Someone will disagree with me on that, but I have worked in that situation before and that's how it was, even when I was a medic, and they knew me.) Then begins to provide ALS care. That can be quite a bit of time. Now, look at the flip side, and this is how it works in the area I work now. ALS engine shows up. ALS providers begin assessment and intervention. Ambo shows up, gets report, assess for themselves, but care is already ongoing, and uninteruppted.

With that said, I'm not saying that I don't think that PFD can provide better service than AMT, I was simply making a point that this doctor presents no evidence to say that they can.

At face value, this guy is an ER Doc, meaning he sees first hand the level of care that is going on. So, if things were working properly,with the high level of care expected, I doubt we would be having this conversation. But, keep in mind, having worked in the area, a good of medics working at privates did so for one reason. To be hired at a FD. Granted, not all, but a good deal of them.

[medicmaster]

Please explain how initiating ALS procedures is more of a hinderance when the ALS ambulance is 2 - 3 minutes behind the engine than 10 - 15 minutes.

Because with few exceptions, ALS interventions generally are not performed in the first few minutes...those first few minutes are (should) be spent performing an initial exam and assessment of the current condition.

Go down to Florida where they routinely will have an ALS company respond along with an ambulance, those scenes are chaotic when there are anywhere from 6-10 paramedics on a scene. The only instance where that might be valuable is on a cardiac arrest. What percentage of Peoria's calls are arrests?

[medicmaster]

At face value, this guy is an ER Doc, meaning he sees first hand the level of care that is going on. So, if things were working properly,with the high level of care expected, I doubt we would be having this conversation. But, keep in mind, having worked in the area, a good of medics working at privates did so for one reason. To be hired at a FD. Granted, not all, but a good deal of them.

1. He may be an ER doc, but he does not mention anything about poor care that he has seen AMT give. He is primarily against the physician in charge and talks about OSF's monopoly on the EMS system in Peoria by having a conflict of interest and barring PFD from using a transport unit.

2. Yes, medics going to work at privates so they can get hired at a FD is something that happens all over the country. Who wouldn't want to end up in an FD job, the pay is generally better. The problem is that many of them who are good medics with the fire departments become ****poor medics with the fire department because it is not of interest to them anymore. i.e. they became medics to become firefighters. I certainly realize that not all of them do, but probably the majority. (not just at PFD, but any ALS fire based system).

[k3twpfire]

Because with few exceptions, ALS interventions generally are not performed in the first few minutes...those first few minutes are (should) be spent performing an initial exam and assessment of the current condition.

Suspected Cardiac Patient - In our system, ALS interventions are expected to begin within 2 minutes. Patient with substernal chest pain - exam, history, medications, allergies, BP, 4 Baby Aspirin all can be done in the first 2 minutes. Then IV, followed by Nitro, etc. etc.

Known/Suspected Diabetics - Take a Blood Sugar - its 34.. start IV, D50, etc. etc.

There are many situations where ALS can be done in the first 3 minutes.

[medicmaster]

Suspected Cardiac Patient - In our system, ALS interventions are expected to begin within 2 minutes. Patient with substernal chest pain - exam, history, medications, allergies, BP, 4 Baby Aspirin all can be done in the first 2 minutes. Then IV, followed by Nitro, etc. etc.

Known/Suspected Diabetics - Take a Blood Sugar - its 34.. start IV, D50, etc. etc.

There are many situations where ALS can be done in the first 3 minutes.

With ACS, it has become standard of care to perform a 12-Lead EKG. This should be done with the initial vitals prior to administration of any medications as NTG especially can cause ST segement abnormalities to change or disappear altogether. Again, two minutes is not going to make a difference.

With the diabetic patient, I doubt you could obtain a blood sugar, perform an assessment and establish an IV all in two minutes, and once again, that two minutes is not going to make a difference in patient outcome.

Cardiac Arrest is the only situation where immediate ALS is beneficial.