In the kitchen that is. Over at JEMS, Guy Haskell has an article about a patient with suicidal ideation who evidently requires no less than 10 fire, police and EMS employees to treat her. The article brings up an interesting question: How many providers do you REALLY need on scene?
Having gone from a system that had up to 6 medics on every medical call (and more on traumas) to a system that only has two from the ambulance (and many calls get no first responders), I’m not sure that there is an easy answer. Predictably, the comments section of article devolves into an argument for or against ALS fire/ALS first response/public vs. private EMS/whatever else we want to argue about. That’s unfortunate because I think Haskell raises a legitimate concern. Driving emergency vehicles is dangerous. Driving them with lights and sirens is more dangerous. And not just to us but to the public as a whole. Putting everyone at risk under the guise of “first doing no harm” is ridiculous. We owe it to ourselves and our public to find a better way.
Medical priority dispatching does go a long way towards reducing the number of vehicles running code around the city, but I don’t think it goes far enough. Why not have units (first response or transport, I don’t think it matters) treat and release more patients? Why not only call a transport unit if the patient actually NEEDS transport? What about alternate destinations by alternate means? Say, for instance, your patient has suicidal ideations but has not made an attempt and is cooperative? Couldn’t you use a single responder to take that patient directly to the psychiatric facility? The vehicle would, of course, have to have a screen and door handles removed and what not, but I don’t see a reason why that couldn’t work. Suddenly, Haskell’s patient has one, maybe two, personnel on scene rather than 10. Cost savings and improved safety, all in one package.
Obviously this is the ideal. Some areas are moving towards such a model, but there is a long way to go. What about you? What do your ideal system look like? Totally ignore tradition for a moment and forget the way things have always been done. Design the perfect medical response and share it with the rest of us.
Last week it was reported that a Central Valley, California man was arrested and charged with failing to comply with his tuberculosis treatment. To my knowledge, there aren’t many cases where Public Health can mandate care, but TB is certainly one of them. Interestingly the article stated that county officials had also charged a woman for knowingly giving syphilis to her partner and refusing treatment. The county concludes that legal action is an extension of medical care. A bold, but likely controversial statement. What do you think?
While you ponder the answer to that question, I’ll leave you with a quote from the article:
He failed to self-administer the drugs on one day, telling a nurse he had gone on an alcohol binge and taken methamphetamine and didn’t want to hurt his liver…
Yup, wouldn’t want that medication to harm your liver…
At my real job the other day, I was offered a chance to participate in a state-wide summit on community paramedicine. Our state ambulance leadership is interested in understanding how other community paramedic programs are operating and whether this model is appropriate for Michigan.
This got us talking around the office about what, exactly, a community paramedicine program is. Community paramedicine has been in the news lately as state after state (most recently Maine) looks at the usefulness of developing such a program. Issues with funding and reimbursement as well as educational standards not withstanding, let’s look at what a community paramedic was intended to be. According to communityparamedic.org:
The Community Healthcare and Emergency Cooperative (CHEC) formed in July 2007 to address critical health care shortages in rural and remote areas—specifically by developing a new community health provider model.
Now this is all well and good, but I work in a largely urban/suburban system. What if I want a community paramedic program? A search for the term “urban” on the CHEC site turns up:
Now the International Roundtable on Community Paramedicine site states:
While its focus is on rural and remote medicine, the lessons learned may prove beneficial to the better provision of urban health care.
And I couldn’t agree more. The goal of a community paramedic program seems to be providing care to fill a gap in a particular community. While many of the existing and proposed programs are focused on the rural environment, why can’t we do the same in urban systems? In fact, what if we’re already doing this in an urban system?
When I worked in Alameda County, my manager Mike Taigman developed a program to send EMTs and paramedics into the homes of chronic adult asthma patients to work on educating them in “asthma-proofing” their homes. The county offered a similar program for children, but nothing for adults. Find a need and fill it.
Here in Grand Rapids, crews are able to take indigent and intoxicated patients to a sobering center staffed by nurses and EMTs to reduce load on the local emergency rooms. The hospitals subsidize the cost of the program because it provides a direct benefit to the community. Find a need and fill it.
At the end of the day, the term “community paramedic” is more of a buzz word than anything else. With state legislators becoming involved we are at an increased risk of building a “one size fits none” program by blindly patterning it off of existing programs. Each community needs to define what they need from their EMS practitioners both for emergency and non-emergency care. If we rush into implementing community paramedicine before we establish a usefulness and a need, then all we will do is prove that a system which worked in rural Minnesota doesn’t work in metro New York City. We are so interested in changing what we do now that we haven’t looked carefully at what we ARE doing that takes us outside traditional 911 response.
What about your system? Do you function outside of the traditional EMS realm already? Are you considering a community paramedic program? Who is guiding that process? Let me know in the comments.
It’s interesting and a little bizarre to be writing this post from an airport. In the decade since September 11, 2001 much has changed in our national consciousness but nowhere is this more publically apparent than when going through airport security screening. I remember how annoyed and flustered my fellow passengers used to get when they had to take off their shoes and only bring 3oz of liquids as a carry on. Now, everyone has it down to a science. The adjustment is pretty impressive when compared to ten years ago.
I wrote recently about celebrating my tenth year in EMS. If you do the math, you’ll realize that I had been an EMT for just about a month on September 11, 2001. I was in college at the time and I remember my roommate knocking on my door and waking me up to tell me that a plane had flown into the World Trade Center. As we watched on the news, reports came in of a second plane impacting the Twin Towers and another striking the Pentagon. We watched dumbstruck as the towers collapsed and mourned with the rest of the country the loss of the emergency workers and civilians who perished. Though I can’t be sure, I don’t recall ever questioning my decision to start a career in EMS. I never had the opportunity to help out at the World Trade Center site, though I know many who did and I am extremely grateful for all they sacrificed to be there.
I was watching The Daily Show the other night and Jon Stewart was interviewing Dr. Sanjay Gupta about his CNN special on the health effects of the dust inhaled by the emergency workers at Ground Zero. Stewart made an especially thought-provoking point about the current debate surrounding coverage of medical expenses for Ground Zero responders. For those who aren’t familiar with the back story, the government is providing medical care for rescuers with a variety of ailments which can be scientifically linked to the working conditions at the WTC site. The government recently decided that although elements present in the dust at Ground Zero are linked to cancer, the combination of those elements hasn’t been definitively linked to cancer so while they will provide coverage for a variety of respiratory and musculoskeletal issues, they won’t cover cancer in previous healthy individuals who worked on the pile. Apparently exposure to several cancer-causing elements at the same time doesn’t have a logical link to cancer. Go figure. Stewart said, and I’m paraphrasing, what’s the harm in accidentally treating a cancer in someone who volunteered to come back day after day to dig through smoldering rubble? Would it really be so bad to comp these first responders some health care even if we can’t definitively link their cancer to the dust at Ground Zero? I’d certainly be happy to have my tax dollars go towards that. But no one asked me.
Stewart made another point which made me realize that I’m probably getting old. He said that most of the members of his audience probably didn’t remember the attack or the aftermath around the county because they were too young. I guess that’s probably true. Those images, emotions and conversations are forever ingrained in my memory. Don’t think for a second that this is a bad thing. I remember the shock and the grief as we watched the events unfold, but I also remember the way the country united around this event and, for a while, actually stood together as a whole. With the recent rash of partisan nonsense in Washington and around the country, my hope is that everyone takes a moment to reflect not only on the loss we suffered on September 11th, but also how much stronger we became in the weeks and months afterwards. Remember how proud you felt to be an American and how united we felt. Remember the way it felt to see this picture in every magazine and newspaper and on every website imaginable.
My hope is that we won’t wait for another tragedy to put politics aside to work for a common good.
Where were you ten years ago today? Do you have vivid memories of the events or just glimpses? Let me know in the comments.
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.
So if I were asked to pick one buzzword most often thrown around in the EMS blog community I would have to land on “EMS 2.0″. But what is it? And more importantly, what does it mean to me?
WHAT IS THIS EMS 2.0 THING ALL ABOUT?
Thankfully Justin Schorr, of Happy Medic and Chronicles of EMS fame, has taken a moment to post the EMS 2.0 manifesto over at Chronicles of EMS. Now he doesn’t refer to it specifically as a manifesto, but that’s more or less what we’re talking about. In my opinion, the idea behind the EMS 2.0 movement is basically the thought that if we are given more leeway in treatment (and at the same time have higher expectation of ourselves and our peers) that patients can only benefit in the long run. What this means, unfortunately for some systems, is that management and medical directors are going to have to move outside of their comfort zone. Some folks are unwilling to do this. To that end, we, as a community need to push this type of agenda. There’s a link on the site to a PDF of the EMS 2.0 manifesto. Print it out, give it to your coworkers, students and management staff. Get involved with protocol committees and research groups. Learn all you can because when the time comes, we will need to stand together and show that we have the knowledge, skill and compassion to move away from a system which values us largely as glorified taxi drivers. It’s up to you folks!
DON’T GET LEFT BEHIND
One important point Justin raises is that not everyone has a place in the new EMS. You have to work for it. Now this is probably not a popular opinion, but that doesn’t make it any less true. It does however, jive pretty well with another post I read recently about psychomanipulation by bloggers of their audience. The basic premise is that a lot of blogs (in general, but definitely in EMS) pander to their audiences and only say things which are already popular. Doing so gets a lot of positive comments and makes the author feel good about how great they are, but does little to affect real change. What we should expect from authors, coworkers, management, the public and EMS agencies is the opposite. Honesty, and the tough conversations which result will do more to improve EMS as a service and a career than all the daisy and puppy dog posts in the world.
THE BOTTOM LINE
So basically the message is this: If you aren’t happy in EMS as things stand right now; get involved. If you like the idea of EMS 2.0 (realizing that is means something different for each system); do something about it. If you sit back and wait for EMS to improve around you, you’re going to get left behind. My part, and something that I see other EMS authors trending towards, is to have high expectations of my readership. The time has passed that paramedics are able to say “I don’t need to know that because I won’t use it”. The very real possibility is that you will need to use that knowledge in the future. Just because it wasn’t taught during medic school doesn’t mean it isn’t worthwhile. I hope that this and other blogs are places you can come to expand your knowledge base and become a better practitioner.
So get out there, learn all you can and take action. The future of EMS depends on all of us.