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Does the Public Have a Right to EMS? Part II

In our last discussion, I noted that access to EMS is not an "inherent "right" (at least from a constitutional sense). So if it's not a right, what is it? A legal requirement? A burden we've invented and taken upon ourselves? An economic experiment designed to manage loss of the human means of production?

We all have our own views of this question. For my part, I believe that EMS systems exist because human beings are inherently interested in the welfare of others. I'm less certain of the exact motivation for this interest. Some might say that the spark of God that exists within each of us leads us to this action. Others might contend that as we are all connected in a "Circle of Life" (my little boy and I have been watching The Lion King), we see our own suffering in the misfortunes of others, and we help them as we would like to be helped. Maybe it's simply our genetic heritage, our desire to insure that human DNA is propagated and endures. I'd like to think our behavior is not solely designed to preserve a few nitrogenous molecules, but stranger things happen.

No matter what drives us to do EMS, we can't escape the fact that in many ways, EMS service as we know it in the United States is a luxury. The argument is simply economic. We can enjoy the benefits of EMS systems because we have an unparalleled standard of living. Relative to other nations, we have a lot of extra cash that burns holes in our collective pockets. In a society obsessed with bells, whistles, gadgets, and labels, EMS is a natural fit. We invent the roles of paramedic and EMT. We give them lots of bright shiny vehicles to play with, lots of drugs and toys. I'm certainly not immune to this appeal. When recently asked why physicians even bother with EMS, my answer is that it's cool. Flashing lights, radio calls, enameled badges, live electricity, and fewer speeding tickets.

It's time we recognize that we're fortunate to even be able to debate the role of EMS, for in most places in the world this is a non-issue. Ambulance services often do not exist, and those that do are so overburdened and underequipped that they make our discussion simply laughable.

Why do we cling to this skewed perspective of our own importance? The answer came during one of the 9/11 remembrance shows a while back, during which an immigrant to our shores said that Americans have no idea what America means. People who are here simply don't know what they have.

There is a lot of truth to this statement. If you don't know what you have (or, conversely, what others lack), you emphasize the import of your luxuries and de-emphasize, or even ignore, the basics that got you there. In a sense, ignorance is indeed bliss. Not knowing the constraints on EMS elsewhere means your assumptions are never challenged.

I used to wonder how people who never ventured more than 50 miles from where they were born could ever lead a happy life. As I've grown older, I've recognized there are many components to happiness -- family, friends, a feeling of making your corner of the world a better place. But I've also recognized that the less you know about the outside world, the larger your own problems seem to be. The rest of the world fades and finally ceases to exist. The same is true of our perspective of EMS. The parochial nature of our public service systems means that we don't realize what we have, and what so many do not. Fortune has simply smiled upon us, and it's time to recognize that fact.

There are many in the United States who recognize the difficulty in starting emergency services in developing countries. To their credit, they are working closely with these nations to develop their capacities in prehospital care. But as I'm sure they would tell you, the one thing that never helps is to try to install a U.S.-style system. We share a wonderful myopia in the United States that we're the best in the world at everything, and everyone wants, or should want, to be like us (that's the bad American tourist figuring that if he screams loud enough, his English will get through that silly foreign skull). The same is true in EMS: We think everyone should be like us. They probably should, and they might want to, but in many cases they just can't. Donating a transport ventilator to a third world fire department means nothing if there's no effective way for citizens to activate an EMS system or if resources don't exist for rapid response to the scene.

Allow me to make an analogy to illustrate this point: You're the benevolent dictator of a banana republic. You have $10,000 to spend on health care. Assuming you're going to spend it on needed services, do you spend it on one Lifepak 12 or on 1,000 vaccinations against measles, one of the top killers of children in the developing world? The answer is obvious.

What does a developing nation do? It takes advantage of its cultural strengths to do what it can. In my experience, the citizens of developing nations share a wonderful spirit of volunteerism and a sense of community that has somehow vanished from the American scene. They seek opportunities to learn and to serve (I am continually amazed at the way people in disadvantaged countries carry notebooks with them at all times, eager to write down the next bit of information they encounter). In order to help EMS grow, we'll need to find the most cost-effective means to use the human resource.

Let me give you a real-life example. For a while, I worked with a group called Partners of the Americas to look at EMS in Colombia. In conjunction with the Cruz Roja Colombiana, I helped develop a potential project to train first responders. It was a logical way to go. I think that good airway management and first aid probably saves more lives in the field than anything else. Airway management can often be accomplished with first aid techniques, simple oral and nasal airways, and collapsible bags and masks. These skills fall within the province of the first responder. First responder status requires only a 40 hour training course, which fits a volunteer schedule. Putting these factors together, we concluded that most cost-effective way to enhance EMS care in the city of Bogota was to take the cadre of Cruz Roja volunteers and train them to the first responder level.

But remember this is Colombia. While Colombia has an enviable record of stability (it's the only country in South America that has not been under a military government since its independence), its economy suffers in comparison with ours. The Cruz Roja has its hands full with natural and civil disasters. There's no money for EMS development, and volunteers in a poor nation can't be expected to fund their own supplies. Even though first responder kits are inexpensive, there was no money to purchase them. No donations were forthcoming from supply companies, as there tend to be no donations where no market exists for proprietary products. So the project languishes in a file cabinet in my garage.

(Before we drop into our American myopia, feeling sorry for los Colombianos pobres, let me remind you that these are smart, professional people committed to their community. To think any less of them because of their limited resources is to adopt the worst of American attitudes.)

Once we begin to consider EMS as a luxury, our perspective on our internal quarrels seems to change. We find more impetus to base our profession on science, to back our claims of efficacy with data. We find that our spirit of community service rises, that we have more compassion for those in need. We use our good fortune to seek new opportunities to enhance our levels or service, and to help others rise to the challenge of providing prehospital care.

Let's resolve to improve the system, but let's never lose sight of where we are. For if the truth be told, we're just lucky to be here.


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