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An Apple a Day

EMS certainly has its rewards. There is nothing better than seeing a 6-year-old child victim of smoke inhalation start to cough and gag after you have ventilated him for five minutes. There is nothing better than seeing the ST segments return to normal and the patient's skin color change from pale and dusky to pink when the fibrinolytic you administered breaks down the clot, that caused the patient's acute coronary syndrome. There is nothing more rewarding than handing a healthy baby you just delivered to her mother. Even though the mother doesn't speak English, her eyes convey her thoughts and gratitude well.

If you are in EMS long enough, you will experience emotions such as the ones described above. But in the overall scheme of things, EMS needs to change its focus. Our role will always be to help save the injured and infirm, but medical literature now is telling us we should concentrate on two additional things. First, we have to start intervening earlier in the various disease processes we are called upon to treat. It's far better to give the chest pain patient oxygen, aspirin, nitrates and morphine and moving him to an interventional lab than trying to resuscitate him after he has arrested.

Second, EMS must take a more active role in disease and injury prevention. It is on this point I would like to dwell. I would bet that even a minimal EMS injury and illness prevention plan would save more lives in a year than all of the emergency care provided. Several EMS systems have embraced the idea of injury and illness prevention. However, such systems are few and far between. Why? In the recent Institutes of Medicine report on the status of EMS in the United States, EMS was defined as having three equal components: health care, public safety and public health. (See Figure 1) Without a doubt, public health has been pretty much left out of the picture.

EMS needs to take a lead role in numerous prevention measures. These include, but are not limited to, such things as:

  • Drown proofing of young children (and pool safety inspections);
  • Bicycle safety (including helmets);
  • Car seat safety;
  • Pediatric immunizations;
  • Elderly and disadvantaged immunizations;
  • Home safety inspections;
  • AED selection and education;
  • Day care safety inspections;
  • Nursing home safety inspections;
  • Poisoning prevention;
  • Sports safety; and
  • Driver education programs.

There is a Chinese proverb that says, "The superior doctor prevents sickness; the mediocre doctor attends to impending sickness; the inferior doctor treats actual sickness." It is time EMS begins to embrace a culture of prevention with the same vigor we embrace emergency care.

This discussion reminds me of an old poem. A Fence or an Ambulance?, was written in 1895 by English poet Joseph Mailins. It was published in a 1913 issue of the Bulletin of the North Carolina Board of Health. It is as true today as it was over a century ago.


By Joseph Malins

'Twas a dangerous cliff, as they freely confessed,

Though to walk near its crest was so pleasant;

But over its terrible edge there had slipped

A duke, and full many a peasant.

The people said something would have to be done,

But their projects did not at all tally.

Some said "Put a fence 'round the edge of the cliff,"

Some, "An ambulance down in the valley."

The lament of the crowd was profound and was loud,

As their tears overflowed with their pity;

But the cry for the ambulance carried the day

As it spread through the neighboring city.

A collection was made, to accumulate aid,

And the dwellers in highway and alley

Gave dollars and cents - not to furnish a fence -

But an ambulance down in the valley.

"For the cliff is all right if you're careful," they said;

"And, if folks ever slip and are dropping,

It isn't the slipping that hurts them so much

As the shock down below - when they're stopping."

So for years (we have heard), as these mishaps occurred

Quick forth would the rescuers sally,

To pick up the victims who fell from the cliff,

With the ambulance down in the valley.

Said one, in a plea, "It's a marvel to me

That you'd give so much greater attention

To repairing results than to curing the cause;

You had much better aim at prevention.

For the mischief, of course, should be stopped at its source;

Come, neighbors and friends, let us rally.

It is far better sense to rely on a fence

Than an ambulance down in the valley."

"He is wrong in his head," the majority said,

"He would end all our earnest endeavor.

He's a man who would shirk this responsible work,

But we will support it forever.

Aren't we picking up all, jut as fast as they fall,

And giving them care liberally?

A superfluous fence is of no consequence

If the ambulance works in the valley."

But a sensible few, who are practical too,

Will not bear with such nonsense much longer;

They believe that prevention is better than cure,

And their party will soon be much stronger.

Encourage them then, with your purse, voice and pen,

And while other philanthropists dally,

They will scorn all pretense and put up a stout fence

On the cliff that hangs over the valley.

Better guide well the young, than reclaim them when old,

For the voice of true wisdom is calling,

"To rescue the fallen is good, but 'tis best

To prevent other people from falling."

Better close up the source of temptation and crime

Than deliver from dungeon or galley

Better put a strong fence 'round the top of the cliff

Than an ambulance down in the valley.


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