The article featured on the July JEMS cover, “Rethinking Delivery Models: EMS Industry May Shift Delivery Methods,” by Jonathan D. Washko, BS-EMSA, NREMT-P, EMD, garnered a great deal of interest from readers. What is ‘the new normal’ of EMS, and how do you embrace it? Also, a JEMS Connect discussion thread about the use of lights and siren at night generated a conversation among Facebook fans regarding this hot topic. Do they do more damage than help?
I work in a dynamic system. Our response times would be faster, no doubt about it, but only if you have the correct number of units available to respond. Without a high level of responders, response times that should take less than six minutes end up taking 20 minutes.
Also consider the half-life of your employees. Sitting for 12 hours a day, four days a week in a cramped ambulance isn’t healthy. I’ve seen EMS providers as young as 25 taking blood thinners. Obesity is becoming a real issue, as well as the ability to pack healthy and efficient meals for lunch and dinner, which doesn’t help the dynamic systems cause.
In my opinion, dynamic systems increase response times by one or two minutes at most. And that system only works if the provider is staffed correctly. On the other hand, stations increase the time an employee can serve his or her community. The question is: Which is more important?
I believe that the trend is to cross-train and diversify. I’m a strong supporter of combo units (a mini pumper of sorts) staffed with two firefighters, a police officer and a paramedic personnel. When this has been tried, it has been very successful, but only when the system is designed from scratch. Politics and empires will control change in the traditional departments.
This will allow more units to be used and be capable of multitasking. It will end aerial ladder trucks responding to sick patient calls. It will deliver 250 gallons of water with a reel line that can handle most fires if they’re attacked quickly enough. And it will reduce the stagnant periods that so many paramedics normally experience. This means more pay for more skills, more units for quicker response times and more efficient use of resources.
I was so excited to see the front cover of the July issue of JEMS. I couldn’t wait to read the article. But I was disappointed to see it was more of an opinion piece that didn’t tell us anything new.
As far as response times go, they’re never fast enough. From the information I have, the main response time is initiating CPR within four minutes of arrest. Nobody has enough money or the technology to accomplish this through EMS alone. This is up to the bystander who calls in. As far as dynamic vs. static deployment goes, how many people reach the retirement age of 60 with 25–30 years running eight to 12 calls a day in a 12-hour period?
If a patient can be transported to a hospital within the same amount of time it takes to do the paperwork required for a refusal, obtain the two required blood pressures, call their doctor or go through an on-call nurse to set up the appropriate treatment plan, the private ambulance service will choose the transport. Even the public EMS will choose this because it’s quicker to get the unit out to handle the call volume of a dynamic system. You start taking more than an hour on a call and you don’t transport the patient, and you need more ambulances on the street to make response times, which costs more money. Will communities really invest in their call-takers and call reporting systems?
The catch is that if you don’t dispatch an ambulance right away and the call goes from a low-level to a high-level response, then you get dinged for not making the high-level response time because of the time it takes to go through the entire set of questions. If it takes four to six minutes to go through the whole questionnaire, then the ambulance is almost to the scene by the time the call-taker is finished (at least in the cities). You might as well keep sending ambulances.
Bob Farley, EMT-P
Author Jonathan D. Washko, BS-EMSA, NREMT-P, EMD, responds:
Sorry for your disappointment. Unfortunately, I’m only given so many words and so much space to express concepts and ideas that quite honestly could fill volumes.
You’re correct in your observation related to the initiation of CPR and the timeliness associated with starting effective chest compressions and survival. You are also correct that few can afford to provide a four-minute response time standard with first response or transport assets
You may note in my article I discussed the initiation of CPR by a variety of methods, the first being dispatch life-support (DLS). DLS is pre-arrival instructions given by trained emergency medical dispatchers following clinical algorithms that provide lay callers the instructions necessary to get care initiated before EMS arrives. In many communities that embrace this type of system, pre-arrival instructions save countless lives through the immediate (within a minute or so of 9-1-1 activation) initiation of lifesaving treatments. My point is that response times do count in survival and many EMS systems that have improved response times (although they may not have published their findings) have also seen correlated improvements in cardiac arrest return of spontaneous circulation (ROSC) rates.
The mechanism by which the response time improves may vary, for example, the use of dispatch life support or system status management or just adding more resources into the EMS system or a combination of these in order to yield improved clinical results. The point is that systems attempting to achieve this with traditional deployment methodologies are financially unsustainable for a variety of reasons.
To your next concern regarding human sustainability, I agree. Workloads must be balanced in order to provide not just long-term financial stability but also the stability of our teams. Unfortunately, dynamic deployment (like any other tool) can be used for good or bad. It’s how the tool was used that matters. I know many individuals in balanced high-performance EMS systems that have worked their entire careers in the field and love the work they do.
To your third point, regarding whether private entities will embrace the concepts associated with healthcare reform, my answer is that they’ll have no other choice. As I mentioned in the article, once the economic conditions change and population-based payments replace fee-for-service payment methodologies, a shift in how we have to deliver care will take place driven by market force innovation and the dollars available to provide care. As this shift occurs, our mission in EMS will also shift toward keeping patients out of the emergency department and placing them in the proper locus of care.
Next, you’re correct in your concerns related to the legal risks associated with triage and care referral systems versus treating and transporting everyone. It is evident that the U.S. healthcare system practices risk avoidance in pretty much everything it does; however, if we’re to overcome these obstacles, we must shift from risk avoidance to risk tolerance, and the government will have to help us accomplish this through reform or some other mechanism.
Finally, your point about performance-based contracting is spot on. Regulators will have to also evolve and create penalty and reward systems designed around new goals and objectives. We may also see a shift in the regulators moving from government-based ones toward payer-based or provider-based governance models as their bottom lines.
Lastly, this little known excerpt from Jack L. Stout addresses many of my critics and is one of the impetuses that drives me to do what I do every day:
“As EMS providers, we invite the public to literally trust us with their lives. We advise the public that, during a medical emergency, they should rely upon our organization, and not any other. We even suggest that it is safer to count on us than the resources of one’s own family and friends. We had better be right. Regardless of actual performance, EMS organizations do not differ significantly in their claimed goals and values. Public and private, nearly all claim dedication to patient care. Efficient or not, most claim an intent to give the community its money’s worth. And whether the money comes from user fees or local tax sources, the claim is the same.
Our moral obligation to pursue clinical and response time improvement is widely accepted. But our related obligation to pursue economic efficiency is poorly understood. Many believe these are separate issues. They are not. Economic efficiency is nothing more than the ability to convert dollars into service. If we could do better with the dollars we have available, but we don’t, the responsibility must be ours. In EMS, that responsibility is enormous—it is impossible to waste dollars without also wasting lives.”
Use of Lights & Siren
Lights for safety on scene ... but if it’s a residence, we will usually turn them off once we arrive and no sirens at night in town .... we live in a small rural community and traffic is generally not an issue.
This issue again ... Sigh. Sadly, we as a profession of caring, are stuck utilizing all emergency signaling devices to be recognized as an emergency operation. Litigation against our fellow professionals has consistently found us at fault when we try to be ‘reasonable’ to the public and run silent to aid a neighbor. Running silent draws the criticism that we don’t take the response seriously. Using the signaling devices wakes everyone up and gets us tagged as hooligans with no regard for the public. It is with a wince that I flip the switches and roll using the signaling devices as the lesser of the evils is not getting you and your department stuck in a lengthy and costly litigation should the untoward take place.
David M. Neptune
If the nature of the call merits an emergency response it gets one. An emergency response means lights AND sirens, not lights OR sirens. The time of day has nothing to do with it.