Is Santa Clara on the Right Path?
I had debated for a while whether to weigh in on the recent report by the Santa Clara County Grand Jury (PDF link) detailing what they see as failings of the fire-based EMS system. I struggled with this decision because the jurisdiction is local to me and I have a few friends who work for fire agencies in that area. Ultimately, however, I think that I have a few thoughts that I can contribute to the dialogue without alienating myself.
FIRST THINGS FIRST
First, I’m going to defer on any statements regarding the usefulness of fire-based EMS. Truth be told, I’ve never worked as a firefighter and haven’t been interested in joining the fire service in a long time. Chris Kaiser over at Life Under The Lights, however, has worked in both first response and transport EMS. He also has a very interesting post detailing his thoughts on fire-based EMS and I could not have stated the situation more clearly or objectively. Please give it a read.
Second, I’ve heard and read a great deal of pretty alarmist statements regarding this grand jury report. It’s been said that the grand jury is simply attacking public safety unions. It’s been said that the fire departments and their employees are intentionally endangering patients to prove a point. Relax folks, the sky isn’t falling. Statements like this make a conversation about the merits of this report impossible. Have these grand jury members worked for the fire department or private EMS? Probably not. Does that disqualify them from looking objectively at the data? Absolutely not. Might it be a benefit? Perhaps.
FOOD FOR THOUGHT
Now, to the point I think that needs to be made. The EMS system isn’t perfect. It never was and it never will be. We will always be changing it and tweaking it to provide better patient care. Because that’s what the EMS system is for right? Right? I think we can all agree that the current system is outdated. It’s based on an old response plan steeped in tradition. As the fire chief said at my friend’s academy graduation: ”The fire service is 200 years of tradition unencumbered by progress”. EMS is no better, just younger.
Why not take a fresh look? Why not redesign a system which is more efficient, cheaper, faster and better for patients? The chief interviewed for the San Jose Mercury News article stated that a private provider would have to hire more paramedics at an added cost to patients if they were to provide first response. This is only a valid statement if we substitute three or four private paramedics for public paramedics. There is no evidence to show that more paramedics equals better patient care. The grand jury report suggests taking a long, hard look at the status quo. Why couldn’t we provide better care with fewer paramedics? Is there any evidence (actual published data) to show that we can’t? We’re all in favor of evidence-based medicine in EMS, what about evidence-based response plans?
This brings me to my last point. What is our goal? Improved patient outcomes? Survival to discharge in cardiac arrest patients? Decreased morbidity and mortality from stroke, STEMI, trauma and sepsis? Then why don’t we design a system with these outcomes in mind? Sounds like EMS 2.0 to me! Why do our first responder and transport system status plans simply put as many paramedics on scene in as short a time as possible? Where is the evidence showing that this does anything to improve patient outcomes?
At the end of the day, I hope that the message of the grand jury report doesn’t get lost among the political posturing. That message is simple: why not focus on the patients? Why not set the status quo aside and build a system that actually improves outcomes? So you tell me; why not?
With reimbursement for treat-and-release and treat-and-refer looming at both the state and federal levels. This might actually be a reality. I, for one, don’t want to be left behind.