Bridge to Nowhere: Has your EMS System Evolved with the Times - Administration and Leadership - @

Bridge to Nowhere: Has your EMS System Evolved with the Times


Gary Ludwig, MS, EMT-P | From the December 2013 Issue | Tuesday, December 10, 2013

In the 1930s, the Japanese government, as a gift to Honduras, built the Choluteca Bridge in southern Honduras. This engineering marvel was constructed with the most modern technology available. It was built with tremendous strength and durability so it could survive the mightiest of earthquakes or hurricanes.

In 1998, Hurricane Mitch did a direct hit on Honduras and devastated the country. Most of the area received 75 inches of rain in four days, and the city was heavily damaged as a result. Choluteca was hit the hardest.

A total of 150 bridges were destroyed in Honduras, but the Choluteca Bridge survived. Upon closer inspection, however, it was discovered that the roads leading to either side of the bridge were wiped out and the river that once ran underneath, which normally was several hundred feet wide, had now been diverted and was running around the bridge. Essentially, the bridge had now become a stand-alone monument with no roads going to it and no river flowing underneath.

The Honduran government was in a quandary. Several solutions were offered, including diverting the river back under the bridge or extending the existing bridge over the river’s new course. Either way, it would take a lot of work to make the bridge useful again.

Our EMS systems are just like the Choluteca Bridge—they were built for a different place at a different time.

EMS systems of today are the exact same design we’ve had for over 40 years. Someone calls for an ambulance, an ambulance responds, someone is taken to a hospital.

The Patient Protection and Affordable Care Act (PPACA), which was approved by both Houses of the Congress, signed into law by President Obama and affirmed by the United States Supreme Court, is now the law of the land. Republicans continue to look for ways to stop the PPACA but the earliest possible time a Republican could be in the White House is 2017—a full three years after the law has been in effect. Even then, it’s doubtful a Republican president could stop the 2,700-page law and 14,000 pages of regulations unless both houses of Congress are also Republican.

The recent shutdown of the goverment showed Republicans aren’t conceding so easily—but equally holding strong are Democrats.

But just as the Choluteca Bridge was built for another purpose, EMS systems need to start thinking about reinventing themselves. The PPACA creates that new atmosphere for change. Some EMS services are starting to adapt to the change.

Large ambulance services like AMR see the writing on the wall and so do their investors. AMR has now been rolled into a new organization called Envision Healthcare. The company is positioning itself with three core business units: AMR and its ambulance operation, EmCare with its outsourced physician services, and Evolution Health with its ability to provide services by offering after-hospital care for patients with chronic medical conditions. Envision went public in August with an IPO that raised about $966 million. Shortly after, it began buying other businesses and rolled those into it’s EmCare and Evolution Health groups. AMR also announced the formation of a Community Paramedicine program that, according to its advertising, is “innovative to integrated out-of-hospital care.”

It certainly looks like AMR’s parent company is positioning itself to deliver other care under the PPACA that doesn’t necessarily mean taking the patient to the ED.

MedStar in Ft. Worth, Texas recently changed its name to MedStar Mobile Health to rebrand itself with the additional services it provides beyond taking 9-1-1 patients to the ED. MedStar now manages the care of hospice patients, chronically ill CHF patients, and the use of a nurse in the 9-1-1 center to manage the pathway of patients who don’t need an ambulance to take them to an ED.

The Green Bay (Wis.) Fire Department has partnered with Bellin Health in the “Hook and Ladder” program to provide home services to patients who’ve been discharged from the hospital with heart attacks, CHF and other heart surgeries. The goal is to keep them from being readmitted. While at the home, they also conduct safety inspections and hang smoke detectors.

The Mesa (Ariz.) Fire Department has also changed its name to Mesa Fire and Medical Department and has moved toward partnering with a local hospital to have a nurse practitioner and a firefighter/paramedic respond to a scene with the goal of treating and releasing patients. It’s also rolled out smaller vehicles called “transitional response vehicles” (TRVs) that will respond to low-acuity medical calls. Some TRVs carry mental health professionals with the goal of keeping psychiatric patients from being taken to an ED.

The future of healthcare is changing fast, and EMS systems can either watch the train leave the station or get on the train as it rolls down the track, transforming what has been our traditional EMS system. Unfortunately, some EMS systems will just remain a Choluteca Bridge. 

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Administration and Leadership

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Related Topics: Administration and Leadership, Leadership and Professionalism, trvs, progression, PPACA, mobile healthcare, evolve, emcare, Choluteca bridge, change, AMR, Jems Leadership Sector

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Gary Ludwig, MS, EMT-P

Gary Ludwig, MS, EMT-P, is a well-known author, lecturer and consultant who has successfully managed two large award-winning metropolitan fire-based EMS systems. He has 37 years of fire, rescue and EMS experience and has been a paramedic for over 35 years. He’s also past chair of the EMS section for the International Association of Fire Chiefs and has a master’s degree in management and business. He can be reached at


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