Yes, please, Jason if you're here, for the love of God please go see a doctor --
Step-dad is a firefighter; so many times they get to the scenes of accidents, and everything looks fine on the outside, patient feels completely fine so refuses ride to the hospital, but then 2-3 hours (sometimes even up to a day later) they end up far worse off and sometimes even dead from internal injuries that EMTs are not qualified to assess.
Ambulance rides are crazy expensive and insurance companies like to question if you actually needed one. If you don't need the EMT, just take Lyft to the ER.
It's such a surreal concept to me that having to be picked up by emergency services will cost you money. I feel so incredibly lucky to live in a country where healthcare is free.
I'd rather see the direct or marginal costs of the ambulance or paramedics billed to the user (so, if they expend saline, or bandages, or whatever, you pay for it), and the hourly wage and vehicle costs for the trip itself. That would price a routine EMT-B ambulance trip around $100 -- still enough that people who didn't need it would take a taxi or drive themselves to a doctor for a non-incapacitating problem, but cheap enough that it could be paid out of pocket.
The costs of keeping ambulances ready, training, etc. could be socialized somehow. I benefit by having 5-10 minute EMS response times even if I never use it for 70 years, so paying for that out of taxes or some other universal subscription fee to users makes sense, rather than putting all the costs on those unlucky enough to need it.
In some areas (those with municipal ambulance services), that's exactly what happens.
In my case, I volunteer with a combination career/volunteer fire/rescue/EMS agency. Our 'operating costs' are payed by taxes, but if you use the service, you get a bill ranging from ~$100 for a routine BLS transport to ~$500 for a 'significant' ALS call (lots of drugs and advanced interventions). We don't itemize, but we do adjust billing based on what was done.
My daughter had febrile seizures as an infant. The ride in the ambulance to the hospital was ~$1k, IIRC. I don't think that she was on any sort of IV or anything, but my wife was in the back (I rode up front). (This was in Portland, OR)
If you're prepared to socialise some of it, why not go the whole hog. Is there anyone who thinks that ambulances should e user pays? It simplifies things too, as a fair portion of accidents have a blameless victim, so the cost makes them a victim twice.
The problem is when it's totally socialized (like medicare), you end up with people abusing the service. If an ambulance ride costs you less than a taxi or even bus, and you're an asshole, you use an ambulance (in some places, provided by paramedics, so the direct costs are high -- in some places they also send a fire truck, so you end up with like 20 highly-trained guys and $500k of equipment) to go to a routine checkup. 3-5 times a week.
You could probably waive charging direct costs if you had some other way of deterring abuse, but they essentially always have to respond to 911 calls, so the only way I could think of doing so would be to arrest someone who misuses the service. A policy of informally losing the bill for legitimate calls might work, or doing the standard drug dealer "first one's free" strategy. But I don't think $100-500 for an ambulance would break most people, particularly with insurance; a charity could also cover the bills for some people.
No you don't, because there's no obligation for the ambulance officers to pick you up and take you. A taxi is in the business of taking anyone they can anywhere they can. An ambulance is not. The only time they'll offer you a ride is if they judge that you may need of it, so already qualified ambulance officers have deemed you a possible candidate requiring their services. Moreover, they've only got one destination - the hospital - and it's not as if many people want to go there willingly. It's not as if you can call up an ambulance to pick you up and take you down to the pub for the night. If the ambulance officers are qualified to recognise medical emergencies (they are - that's their job) then they're qualified to determine who requires ambulance transportation and can filter patients accordingly.
The problem with 'a charity covering the bill' is that you then need people to donate out of goodwill. That doesn't often happen.
There's already fines and punishment for abusing emergency support systems (e.g.: calling 000/911/your country's equivalent). Even if you abuse that, and even if you mislead the call centre operator to dispatch an ambulance to your house, they're not going to ferry you to your desired location unless your vitals show reason to consider it a possible requirement.
Ambulance services are free here, insofar as you pay for a small tax on every rates bill (said rates cover ambulance and waste management services) edit: Apparently not since 2003 - it's now simply just covered by the State. There's no out-of-pocket expense. I can guarantee you that we don't have ambulances running people not requiring their services around 24/7.
I can confirm this, works just fine in Germany and ambulances are free (i.e. covered by mandatory health insurance). And even if it would be abused - which I really can't imagine - I'd much prefer 100 idiots free riding to the hospital to one person dying because he can't afford the trip.
I was always told that here (Austria) if you call the ambulance but are not in actual danger you have to pay for it, and that it's very expensive.
But you can call an emergency physician if you're not sure if somethings wrong which is free in any case afaik. They will examine you and make a determination if you need to go the hospital.
My mother once called them because she was concentrating so hard on her heartbeat while trying to sleep that she started to panic because she thought it wasn't beating normally. The emergency physician examined her and deemed everything normal, made her calm down, and then just left. I was told if she had called the ambulance it would have cost a lot.
That's not true at all. If you call 911 (or someone calls for you), and you don't want to go to the hospital, you have to sign a form saying we offered to take you, but you are choosing not to go.
As rdl pointed out, the liability is just too high to refuse to take someone to the hospital.
When I lived in the UK, I called for an ambulance. The responder listened to my situation and told me I didn't sound high enough risk, so I got a taxi. I didn't get the sense this was unusual.
However, it wouldn't surprise me if the liability issues were very different in the UK.
Even in silly Poland (not to speak of Netherlands) abuse of ambulance service is treated very seriously. If the hospital makes the case that you made a call either as a prank or frivolously, you're in a world of trouble.
The argument isn't that they shouldn't get care, or even that they should have to pay for transport, but that they should be guided (using cost incentives, in the US market model) to use the most appropriate transport. ALS, BLS, mobility-but-not-EMS, or taxi). The problem is there are a lot of places in the US where "take an old person to see a doctor for a checkup" requires using BLS or even ALS ambulances, which is crazy, because ambulance would be covered but taxi would not be. It's better to just give these patients taxi vouchers, if you want the government paying for it, for $10-20, vs. a $100-500 direct-cost ambulance ride.
There's a separate argument about who should pay for what services, but "care should be delivered in the most cost-effective way to get the best patient outcomes" is independent of that.
The liability for refusing to transport a patient to ER who claims certain symptoms would be huge. Even doctors won't make that call in the US; there's no way an EMT or paramedic would.
And, if they're evaluating you on scene, even if they decide not to transport, they've already rolled the truck(s) to see you, which is probably much of the cost.
Some wilderness rescue services have an interesting take on it. If what you were doing was really stupid (like, hiking up and skiing a mountain in the middle of the night, during a storm), they bill you, but if you really just got screwed (fell and broke your leg), it's free.
I also think if you got "saved" by wilderness EMS, and were in a position to do so, you'd probably really want to donate money or other resources (time? promotion? something) to thank them.
A lot of patients need to go for visits with doctors at the hospital or in an associated complex. Many of those patients don't need special medical transport, or at the very least could go with BLS, but there are places where ALS gets used for everything and thus is very expensive. Medicare patients don't see this, but the reimbursement from Medicare to EMS is very small, too. If you have a substantial elderly or sick population, it can be a real problem.
If you talk to EMTs you'd find most calls are for elderly people with heartburn. Yes, some people abuse the system. Maybe offer one free ride a year or something.
In SF it seems to be a small population of seriously mentally ill, drug addicts (both OD and drug-seeking), those with ongoing conditions which they fail to manage properly, etc.
There probably should be a cheaper way to treat them than sending SF Fire over and over to the same addresses. And that way would probably be both more comfortable for the patients and lead to better long-term outcomes. Maybe more extended inpatient care for them (in a low-cost-per-day facility)?
These has got to be some sort of war-on-drugs or drug policy thing going on here. Why is this so bad where you are, while it isn't a massive problem where I am (New Zealand). Sure there are drug problems (Meth and alcohol are hitting headlines too often), but you rarely seen the sorts of scenes I saw on a brief visit to SF.
SF ends up with drug addicts/mentally ill from an area of maybe 30-50mm people, due to what are perceived (correctly) as more welcoming city services, culture, etc. Add to that the war on drugs and weird issues with medical care for the poor (medi-cal), lots of Vietnam era veterans, etc., and one of the most dysfunctional city/county governments I've ever seen. (Detroit and New Orleans are worse, but those cities are poor; SF is rich).
I do not mind paying some taxes so that anyone can get help when they need it. The thought 'Do I have enough money to call an ambulance?' should never be something someone should consider. If you need emergency services you should be able to call and get help.
But I do understand what you are saying, I just do not think of it as spending money as my taxes most likely would not change regardless, they would just be used for something else.
In the US right now "spending marginally less money" probably means "borrowing marginally less money", which would actually be good. I don't think taxes would be lowered in response to cost savings, but deficit borrowing might be.
I am not a crazy anti-healthcare nut as this comment will make me appear, but I think you mean "healthcare is paid for by others/collectively", since it isn't free to provide services, unless your doctors are working for no money.
There are 7 billion people on Earth right now. You are going to find some that don't know what the hell "breathing" means if you just try hard enough. Using this to pick apart at the word "everyone" is just as pedantic as picking at the specific definition of "free" in that question.
Even more, in most systems I know the amount paid for health insurance is fairly explicit. Where I live you actually get a bill from a non-state company (some things may be subsidized from other taxes, and if you can't afford it you also get a subsidy, though) so no, people don't think it's "really-really" free. It's "people with more money contribute more".
I'm afraid breathable air does cost you the energy required to operate the lungs. This energy is mostly generated from digesting organic matter such as vegetables and meat which can vary in price. Free cannot exist since we live in a universe with entropy. In other words in any given system some energy (cost) is lost.
I thought you explained it perfectly yourself, but sure. You were not addressing the original point about breathable air being free. Instead, you built a straw man, based on the presumed cost of /breathing/ it, which actually had nothing to do with the original point.
By the way, if you want to be as anal about the definition of "free" as to include totally peripheral expenses (as if a pencil costs you $100 for signing a check with it), you might as well get to the bottom of it and say that everything is free on the basis that no matter or energy is ever expended.
The quick response times our ambulances achieve are due to their being strategically placed around a city, manned and ready to go.
It works this way whether you're talking about a city-owned ambulance at the fire station or a privately-owned one idling in a parking lot somewhere. In either case, you (or your insurance, or your city, or your state...) are paying for a driver and at least one paramedic to sit around at the ready, not just for the quick trip.
I don't think that doesn't make any "economic logic", for lack of being able to remember the correct term.
If that were true - if the price was based on the cost - you would have small towns & rural areas where it would be so expensive, no one could use them, and cities where even though there were more ambulances, EMTs, etc, the cost would be spread so thin as to be barely noticeable
I don't believe the price is tied so directly to cost of service
It's hard to make out exactly what your point is but you're correct if you're trying to say that the price here is not simply about supply and demand. The costs of ambulances are subsidized in many ways (but they're never "free") and you're also dealing with people who generally don't have the ability to shop around. It's not a "market" item, really, on either side of the transaction.
Regarding rural areas and small towns: they often keep costs down by having crappy medical services in general, and slower response times specifically. It's not always that bad, though. If a town isn't sprawled out response times shouldn't suffer so much.
I don't want to push this next claim too far, as I only have "I have heard" to back it & no actual numbers or links, but...
I have heard on more than one occasion that the reason emergency services (ambulances, ER, etc) are so expensive is to recover the cost of all the uninsured users.
People can be refused at a clinic if they have no insurance, so they go to ER for everything, where in many places they cannot be turned away. Hospitals therefore have to bill YOUR insurance to recover these costs
You are assuming too much: my ambulance ride isn't expensive. I live in a municipality which provides its own ambulances. In a geographically dense suburb it's efficient, logical and cheap (relatively) for EMS services to piggyback off of fire services. There aren't enough free riders around for the system to fall over from the "uninsured." If you're around here, you've probably helped pay for it.
> Hospitals therefore have to bill YOUR insurance to recover these costs
You know who takes an even bigger hit? Uninsured but solvent patients. Insurance companies have greater bargaining power.
None of that has anything to do with the ambulance business.
When you consider all the costs involved, it's not so unreasonable. You've got the cost of the ambulance station, ambulance itself, equipment, maintenance, fuel, medical consumables, paramedics, technicians, etc.
You're not only paying for the time you spend in the ambulance, but for the paramedics to be on standby, and for technicians to clean and prepare the ambulance for its next trip afterwards.
Wow. Maybe there are legal or labor expenses way over what we have in South American countries.
I've heard that a lot of medical expenses in the U.S. are due to the high amounts of litigation (I still can't believe the stories of healthcare costs in the United States).
There must be a difference in ambulance spec too. How do you compare this? Can I confirm that the earlier comment of yours meant $14,000USD? I can't read Spanish unfortunately. Thanks.
I grew up in a country (Canada) where healthcare was free, but you still paid for emergency services. The two are not the same, and there is a real benefit to discouraging the unnecessary use of ambulances.
> It's such a surreal concept to me that having to be picked up by emergency services will cost you money. I feel so incredibly lucky to live in a country where healthcare is free.
We have a (very good) public healthcare system here in Australia; but an ambulance will still cost you.
Not for people in Queensland. It used to be rolled in to our electricity bill at $24/quarter but that was abolished a while ago (apparently 2003). We're now just covered simply by living in Queensland for ambulance transport anywhere in Australia (that is, if I need an ambulance in Victoria, I am covered by the State) [1].
I'm in Vancouver. I got hit by a cab on New Year's and had to pay $80 for the ambulance. The cab's insurance is picking that up, despite the whole ordeal being my fault, so they're sending me a check for $110 then asking me for $1500 back. Go figure.
In my country, ambulances are free for only life-threatening cases, but most everyone pays for an Emergency service (ambulances and walk-in ER), which costs U$ 15/month.
FYI, where I am, people other than pensioners pay a small annual registration / insurance fee to the ambulance service to avoid large fees upon use of the service
Someone always makes this comment. It's unhelpful as the meaning of free is clear. It's the same kind of free as the bank bailout. It cost you nothing and a hell of a lot at the same time.
>picked up by emergency services will cost you money
It does cost you money. Europe plays a different game than the US but both are games. Thanks to Kennedy no one can be turned away from the ER for lack of insurance and bills are paid off later for cents on the dollar if you have no assets. If you have assets and no insurance too bad.
> Thanks to Kennedy no one can be turned away from the ER
Which is funny, since they're only required to "stabilize" you once you're there. I know a guy who was attacked, suffered head injuries, and couldn't remember who he was. He was patched up and discharged in that condition since he didn't have his insurance card on him (and, I assume, since a shirtless and beaten-looking guy with long hair is just assumed to be homeless).
I am quite certain that behavior isn't typical of the hospitals in our area, but I bet it's totally legal. And a valuable cost-saving measure! An MBA somewhere is surely proud.
Whatever next? So every injury type is specified? This is surreal. How is this cost effective? I thought socialised healthcare was bad as it was inefficient, yet someone writing up the injuries you're covered for doesn't seem very cost friendly.
Yes, every injury type is specified. You wouldn't believe what is defined in ICD-10. E.g. Stabbed while crocheting: Y93D1 (not to be confused with Activity, computer keyboarding: Y93C1), Hurt at the opera: Y92253. And then there's the famous V9027XA: Drowning and submersion due to falling or jumping from burning water-skis, initial encounter. I should emphasize that these are all real; I am not making this up.
Yup, and as others have mentioned ICD-10 is worse.
There are also CPT codes that specify the procedures and diagnostic techniques that doctors and other healthcare providers do.
Insurance is then a mapping from ICD codes to allowed CPT codes. Good luck getting that information from your insurance company, however. Once I had a claim denied because someone transposed two digits in an ICD-9 code, and the treatment obviously didn't make sense. The insurance company couldn't tell me what the codes were - just that it was not an approved treatment for the reported condition. That took a lot of painful debugging to resolve.
Oh, and CPT codes are copyrighted by the AMA [1]. If you want to use them you have to pay licensing fees. Too bad it's not usually a case of "want to use" but instead "must use." I'm not sure if ICD codes are copyrighted.
The cynic in me sees the insurance company trying to figure out if the part of the bolt that struck came from the cloud or the ground, and if the former, dismissing the claim as an 'act of god'...
If you get struck by lightning, please call an ambulance...
There are _many_ people who call ambulances for things a taxi could handle just as well (often those people aren't worried about paying for it... medicaid will cover some small portion of the bill, and they'll ignore the rest), but a lightning strike isn't one of those things.
It's not so much that we're not qualified to assess them, it's just that no one has invented portable X-ray (or CT, or MR...) glasses yet (I'm looking at you, Google!).
Field portable x-ray (DR, even) and US is pretty widely available. Probably not something you'd put on even a normal ALS truck, but on expedition medicine or if you had to set up a facility in advance, were far from a permanent facility, etc. I've seen DR used for tb screening quite frequently (it avoids exposing the expensive radiologists to the field...); US for midwives for ob/gyn also makes a lot of sense, and I've seen those used with GSM or 3G backhaul of images to a radiologist.
Probably the best use would be to have x-ray capability in the truck to verify placement of endotracheal tubes. Shooting an adequate chest film is something you can learn in 5-10 minutes (although, licensure requirements...).
(I've seen fairly portable CT, but in the sense of "shipping container with 1-2 day setup"; there are of course the CT and MR imaging trucks too.)
Adequate in 5-10. I doubt this. I have trained students for 10ish years. I have seen what very experienced ED nurses (and consultants, anaesthetists etc) do with their 'diagnosis' from films, despite numerous courses and flash qualifications. This is without taking the film. Do it for years, see lots of things, make lots of mistake and then you'll get good.
Radiography students are generally competent for unsupervised chest radiography after about 6 months to a year. This is working 2 days a week, study for 3 days. You could probably produce a crap film but good enough to show ET tube in significantly less time, but a good operator has other ways to verify tube placement.
Portable x-ray in bigger towns provides a great service to rest homes, prisons etc and is fiddly and laborious. It's a niche market. The same (but less common) with mobile MRI. CT must be done somewhere in a mobile fashion, I haven't seen it.
It is easy to get a little twisted with terminology, but mobile x-ray generally means you push it around the hospital, portable meaning you carry it out the van, up the stairs, into the rest home (the 600kg mobile machine is not something you would carry easily).This terminology is widely abused though!
I meant "adequate for verifying chest tube placement", not " images which would actually be generally useful" (I saw plenty of skill differences among fully licensed rad techs, out of maybe ~50 military rad techs I observed, so I can appreciate the level of skill involved). (as for non-rads "reading"; it was pretty weird. Plenty of orthos were excellent, as expected, for the specific things they cared about, but there were a fair number of rad techs and GP doctors who got really good at some specific things. In working on PACS, I learned enough to be able to identify what was in the image, whether it was good, basic errors in shooting vs. later image corruption, etc., but beyond really obvious things like major fractures, it was really hard. The "look for violations of bilateral symmetry" cheat breaks down in a lot of cases where the body isn't symmetric :( But verifying ETT was one thing I could do pretty quickly. But even with trauma I think a lot of what the rad was for was to look for things like cancer or other less obvious issues, possibly pre-existing, even in trauma patients.
Mobile CT are kind of interesting; I've only ever seen a mobile head CT, and that was designed to be wheeled into the OR to use in the middle of surgery, rather than sending the patient down the hall to the full body CT. But this was almost exclusively at hospitals designed around trauma care in a healthy 18-45 year old patient population.
In most of the hospitals I saw, it was never "mobile vs. portable", but "the Philips" or "the GE" vs. "the MinXRay", and even those were essentially left on wheeled carts most of the time.
I have never really considered imaging without interpretation. Sorry! This must be a legal nightmare - I'm imagining a missed pneumothorax, fluid collection (Not always obvious when supine). That said, something is often better than nothing. Were you in the military? I assume this would be more trauma type work, which tends to be a bit easier for identifying badness. However the working conditions would be somewhat worse I imagine (I have been hospital/clinic based). I would have thought that the most useful type of imaging I the fields would be ultrasound for finding a decent vessel to jab or guiding some sort of drainage (chest fluid, ascites etc). What was most your work?
Sorry rdl, I cant seem to reply to your comment below (comment to deep?), thats some great experience. There must be a few hairy stories from that period. What was your company's product name (No problem if you cant post this). Ive used Agfa, IntelliPacs, Kodak (didnt enjoy).
From 2008-2010 I worked for medweb (company and product, it's a small/private business, doesn't make imaging devices, just software and packaged PACS); it's an ActiveX based viewer, really low end but also a cutting edge idea back in 1997 or so when they invented it. They ended up making a super lightweight system with the PACS server on a laptop, too.
AGFA was probably my least unfavorite, although IIRC they were really expensive. (In Kanadahar, the Canadian Forces who ran the medical role 3 until 2010 were using a pirated version of the software; they kept re-installing a trial license and hacking the date to work!) Really none of them were amazing, although I did really like the high-megapixel Barco monitors.
I've talked to some people doing an interesting cloud-hosted PACS (although they're in private beta, I see them listed in various places, so I think they're public -- radiology.io, now clariso.com.)
The sector is ripe for a grand slam by a good, integrated system. Decent CD/DVD printers that don't cost $20k US (for the damn referrers that insist on some kind of physical product), decent Mac and PC compatibility. Software that talks to GE, Siemens, Philips, Toshiba hardware in a reasonable manner. The ability to edit bad data easily and have it update remote workstations properly. Be easily searchable (Let me set up customised searches PLEASE - last 3 days of imaging off the scanner right by me for example). There are so many pieces to the puzzle and all seem to actively break each other. It's a hell of a mess at the moment.
You should talk to the Clariso guys -- I think they're US focused but really smart. Talking DICOM to the various modalities isn't that big a deal (although they all have weird bugs, and DICOM is a disgusting protocol), but good support for those stupid Plasmon archivers would be useful, or just figuring out a good client support option for local-to-workstation DVD burners. As for interop, the big issue is usually HL7/HIS integration at hospitals (for DoD, it was AHLTA, and for the VA, Vista, and for everyone else, usually EPIC but sometimes Practice Fusion). I think even the worst PACS is usually better than most hospital HIS/EHR.
It was really funny when I was supporting an ActiveX-based system and every single one of the doctors had a Mac personally, and I used a Mac running VMware windows as my primary machine. I think the percentage of radiologists (or really, doctors in general) using Macs is >75%, but the hospital deployments are always Windows.
One good way for a new PACS or RIS to get started would be in training environments. Telerad is the other good way (sending CTs, and usually several studies, over a VSAT network with ~16/4M bandwidth for all of theater, was interesting -- especially since the goal was to always beat the patient to the facility to give surgical teams time to study the studies. Easy for the 8h ride to Landstuhl, hard for the <60 minute medevac helecopter from Jalalabad to Bagram.)
What surprised me is a lot of people wanted to at least be able to read reports (and usually look at images) on an iPad. Some rads even wanted to read on an iPhone screen (!!!) so they didn't have to get out of bed, although that was for things like sprained ankles and they'd read for real the next day. A Retina iPad is a pretty adequate device, though, honestly; it would be amazing to see what a Retina MacBook Pro 15 could do. (for everyone else, a radiology monitor is often $10-20k and approximately Retina resolution; there are some special FDA regulations about the screens for uniformity, but fundamentally they're 2-3x overpriced for what they are. A decent IPS LCD is perfectly adequate in many cases, particularly for CT/MR/US which are low resolution; mammography is the main area where really high quality screens matter (often black and white, 3-5MP). And the high quality screen really only matters for a radiologist; for every other doctor reviewing the images, a good quality normal monitor is perfectly adequate, as the rad writes a text report and marks up the images to identify anything important.)
I worked for a small PACS vendor (mainly IT support and network engineering, and satellite network stuff, but also training rads, techs, and other doctors on how to use the image viewer, report writer, etc.) which was used for dod and others in iraq/afghanistan/kuwait/etc, and spent 2 years in Afghanistan (enh), Kuwait (awesome), and Iraq (been there, done that, was kind of boring by 2010). Also by the federal bureau of prisons, and some cruise lines.
Before that I was doing satellite/wireless/etc. networking, and some of my customers were various SOF who had fairly badass medics (regular army SF 18D is probably better than a civilian paramedic, at least for trauma, and the "other" guys had people beyond that, including some actual MDs who were also shooters). I did "combat lifesaver" class and then spent a lot of my spare time hanging out with the SF or SOF medics (because they tended to be more interesting than the shooters). I got some of the rad techs to teach me the basics of how to get decent images from CR/DR/CT/US, since I was trying to figure out which problems were caused by technique, which were caused by emitters or tables, which were caused by plates or scanners, and which were caused by our system. I kind of want to do an EMT course when I have time here, although I'm not sure where I'd volunteer to keep the skills current after that.
Before all of this I actually lived out in Baghdad for most of 2004/2005 with ~zero medical care or really any professional support (2 Americans, 100+ Iraqis), so it was mostly "learn anything you might possibly need well enough to do it yourself", and "don't get shot").
There were also civil affairs/outreach efforts, and some charity efforts (rotary club) to bring medical care to civilian population, which was weird, since Kabul had a private hospital with a 64-slice CT (when DOD had 16 and 32), and there was a private 2 Tesla MR in Jalalabad.
Mostly I was in "role 3" facilities, which were essentially as good a level 2 trauma center and a little bit of additional facility in the US. Also went to "role 2" (which were essentially 5-10 doctors, plus nurses and techs, with a couple of trauma bays, and X-Ray and US but not usually CT, and some of the FSTs (who augmented role 2 with much better surgical capabilities). In general the equipment and staff were top-notch, and the only problems were physical facilities. CTs tended to be in shipping containers, and the Army CSHes were big tent farms (which sucked), while USN and USAF tended to build fairly decent hardstand buildings (not as good as Stanford, but better than most of the rural counties).
On the issue of imaging without interpretation -- it's kind of funny. One of the big DoD pushes was to go back and have a radiologist read and issue an official report for every image shot of a US patient from the start of operations (2001/2002), in ... 2009 or 2010. There is the benefit that US people can't sue the government for malpractice, and Iraqis/Afghans aren't really in a position to sue, either (arguably the only ones with standing would be enemy combatants held in US custody).
Those are fairly common uses of 'mobile' and 'portable' in general (the 'mobile' radio is attached to the truck, the 'portable' radio is on your hip).
As far as '5-10' goes... rdl wasn't talking about interpreting films, he was talking about shooting them (and then transmitting them to a doc somewhere for interpretation).
There are some interpretations that could be taught in minutes . Most importantly, the one rdl mentioned, "Does that radio-opaque wire stay straight in the trachea, or does it deviate?".
Edit: I'm not sure the comparison to ED nurses is apt. Paramedics and nurses do very different jobs.
Yeah, even shooting good x-ray films is hard (rather, you can probably learn the absolute basics of radiation exposure, etc fairly quickly, but there is enough art to it that a good tech does a much better job than a radiologist (usually) or a bad tech, just at very practical things like patient positioning. At least in my experience -- the other issue being the craziness of an entire trauma team plus potentially a patient's unit representative plus techs plus radiologist all in a small CT room, or in the case of enemy combatants, armed MPs plus sometimes "other" guys plus patient plus techs...
But ETT and a few other things are the low hanging fruit. And with teleradiology you can even skip the "verify you got a decent image" step, particularly intra-hospital or for small images, because the rad can look at it immediately and tell you if you should reshoot.
I'd almost bet you could take a zero-training nurse or paramedic and give him a telerad-enabled x-ray or CT and get acceptable results working interactively with a radiologist and/or real rad tech remotely. Ultrasound might be trickier, but I saw midwives (who couldn't read or write, although they were really smart otherwise) trained in 3 days. I've never actually seen an MR used in person (since metal fragments tend to not go well with them; they just magically appeared on the PACS from elsewhere), but I imagine the basics of operating the machine aren't too much more difficult than a CT.
This is what I do now, I used to do CT and X-ray. MRI and CT have very little in common. While the images, very broadly speaking, look similar, the background knowledge required is very different. And they have crap interfaces. Really bad one. I save the error messages that are funniest now. MRI scanners are unreliable, temperamental, hard to get consistent results from and require constant care to avoid screwing things up! MRI isn't very good with serious trauma - too slow. I do miss that work though.
Yes to you and RDL - I see the point. I do dispute the 5-10 minutes though, but the point was that it could be learnt relatively fast. I'd assume some sort of weight versus exposure factors chart would hold 80% of the knowledge and when combined with a set 180cm tube-film distance and a digital system (forgiving!), things would be learnt quite fast.
It is deceptive how hard it is to get a patient properly straight, and thereby prevent ET looking deviated.
You could probably combine a CCD/CMOS imager (i.e. cheap webcam) with an x-ray (and maybe mm-wave imager or something) to help with this. Something like an AED as applied to radiology, with safety interlocks.
It would definitely be possible to have very simple scans done by someone who was given a crash course training (knees, lumbar spines, brains). The problem is that the most complicated work always fails to advertise itself - I found a liver tumour yesterday while scanning a lumbar spine. It appeared on 1 image of the planning scan (a crap, low res image). The student was was present didn't see it and dismissed it as an artifact when I pointed it out, and she is a good student. I'm sure protocols could be made to avoid problems (send all imaging to the PACS, even the duds) like this however.
One advantage is that you have a very fixed environment in the back of an ambulance. The stretcher is going to be in exactly the same place every time (I'd assume you'd have some sort of 'slot' to drop the 'film' in on the underside of the stretcher), and there are all sorts of fixed reference points in the back of the truck.
Patient positioning is something that we're pretty good at to begin with (if you think it's a pain to get them lined up to shoot the ET... try lining them up to drop it in the first place...)
The bit where they are fighting you off is the bit I always watched with interest. The erect or supine images are sort of scripted in ones mind after a while. It's the semi erect child with ankylosing spondylitis or some such thing that cause distraction. I remember the situation like it was yesterday. It must have been 10 years ago. I never did manage to get a film where the poor guys knee caps didn't appear over the bases of his lungs on every attempt. We never did see his lung fields well.
I was being a bit flippant in my initial post. I'm aware of (and quite excited about) the increased use of imaging (and various other labs) in the field.
I expect in 5-10 years ultrasound will be quite common, and x-ray may not be too far behind (mostly for respiratory related stuff... tube confirmation, confirming pleural effusions, etc...)
What would be cool would be using telerad (and telemed in general) to let some combination of family-caregiver, EMT, Paramedic, NPs, and doctors do both initial and definitive care in the field; should be a lot lower cost, both because it's cheaper and because it's better (old/sick/etc. people not being transported and then exposed to a bunch of other sick people would be a big win.)
I think (or at least hope) this is the direction medicine is headed in...
In the early (Johnny and Roy) days, it was _all_ telemedicine (send the strip and start LR...). We slowly got away from that for a variety of reasons, and are just now heading back to it.
While I'm not a huge fan of 'mother may I' medicine, I think it's crazy not to leverage the major advances in communications technology to bring a much broader range of specialties into the back of an ambulance.
Some area are having a lot of success with Paramedic Practitioners. The idea being that the can a) handle 'routine' medical calls without a trip to the ER, and can b) make proactive welfare checks on known frequent fliers (brittle diabetics, etc), reducing the load on the EMS system in general. Obviously they're also available as advanced level providers when needed, but this gives them something to do (and bill for) in their downtime.
Even with x-ray available to paramedics, they don't get the type of training needed to understand what they are seeing on an x-ray and even then they wouldn't have the training to correct any issues or authority to prescribe treatment. The best they could do is get a radiogram and pass it on, but even then, they usually are not in the best position to dose out radiation, nor would their patients likely sit still, since the idea is to get them to a hospital or care provider ASAP.
Probably one of the most common users of portable (ok, maybe I should say mobile) xrays are large animal veterinarians. I've seen them used with horses. Generally there's power at barns (someplace nearby, at least), but I imagine a generator would work.
Step-dad is a firefighter; so many times they get to the scenes of accidents, and everything looks fine on the outside, patient feels completely fine so refuses ride to the hospital, but then 2-3 hours (sometimes even up to a day later) they end up far worse off and sometimes even dead from internal injuries that EMTs are not qualified to assess.