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The Big-Picture Thinker


Even as a teenager, Dia Gainor was fascinated with EMS. Her first job, working in a county EMS office, allowed her to personally experience the challenges and excitement of the industry. Most importantly, she got to see what was necessary for an EMS system to work successfully. She learned that everyone had to contribute individually and as a group, much like performers in an exquisite, choreographed dance.

“I realized that systems are patients, too, with their own chief complaints and levels of consciousness,” Gainor says. “And thanks to some people who had faith in me when I was young, I was appointed to the Pennsylvania Turnpike Ambulance Task Force.” The opportunity allowed her to see EMS on a larger scale. “A newly certified paramedic at 19 years old, I suddenly saw the big picture at the state level and said, ‘this is what I want to do,’” she says.

Now, 27 years later, after dedicating 18 years of her career as the Idaho Department of Health and Welfare. In this role, she not only sees the big picture; on most days, she’s responsible for it. 

Crafting Important Messages
Perhaps one of Gainor’s most encompassing, big-picture challenges has been her role as National EMS Advisory Council (NEMSAC) chair. It was in this role that she led the draft and approval process of a position statement that “an accountable and sustained community level emergency medical care system is essential and must be assured in the debate and implementation of health-care reform.”

Another document, EMS Makes a Difference: Improved clinical outcomes and downstream healthcare savings was finalized in December and includes 10 guiding principles that underscore why health-care reform must ensure the stability and performance of a viable, funded EMS system. It notes that any health-care reform bill should include permanent funding for the National EMS Information System, EMS research, EMS readiness and surge capacity.

Gainor admits expectations were high for the Advisory Council from the start. “Our members, individually and collectively, did not want to be a bunch of bench-sitters,” she says. “We wanted to do something that would make an impact on EMS systems at large, but more importantly, on those parties that don’t yet know how to spell EMS.”

In early exercises to develop the position statement, the committee identified 88 distinct issues in EMS that warranted attention at a national level, with the fundamental and weightiest issues centering squarely on the economics of EMS.

“How do you begin to assert the importance of EMS if you can’t defend the difference that it makes?” Gainor asks. Answering that question was at the root of the committee’s challenge and the resulting paper.

“The references are three-quarters of the value of the document, because there wasn’t a place where you could turn and find all of those references,” Gainor says. She insisted that every committee that contributed to the document use a business case problem-and-statement model when writing and include as many references as possible.

“That’s what makes this document so ground breaking,” Gainor says. “I am personally not aware of any place or time where this breadth and depth of proof of the impact of EMS was captured in a single document.”

NEMSAC documents are at ems.gov.

Laying the Groundwork
The education begins immediately in the Executive Summary with the statement: “In the context of health care reform, the capabilities and potential of EMS and their impact on health care costs remain largely unrecognized.” 

“We don’t have the kinds of research initiatives, the types of studies, the demonstration projects, and the think tanks that the rest of health care seems to enjoy,” Gainor says. “As a result, we don’t have a large body of knowledge, let alone substantial peer-reviewed-journal-caliber research to hang our hat on.”

But Gainor is also quick to point out that EMS is still a relatively young industry with much to learn—and contribute. “I don’t think we should fault ourselves for where we are, but we can’t shrug and say, ‘I guess that’s the way it is in this business.’ We simply can’t accept status quo today as acceptable,” she says.

The Advisory Council also found another challenge facing EMS: the adoption of national guidelines and protocols developed through a rigorous examination of the scientific evidence and systematic guideline process.

“EMS stands to learn from industry and engineering more than it does from health care and hospitals,” Gainor says. “[When we’re] performing an important task, ‘winging it’ or doing it because that’s the way we’ve always done it, is not the way to be safe or effective. We have very little structured, demonstrated, proven decisions that guide what we do and how we do it.” 

The Advisory Council would also like to see an expanded role for EMS, one that’s more integrated with preventive services and acute care while also promoting overall community health.

“You have to start with the admittedly overused reference to EMS being at the intersection of public health, public safety, and emergency medicine; our foot in three worlds and our home in none,” she says. “That, in and of itself, is the root cause of the problem.”

This diversity—the variation of personnel, the kinds of organizations that EMS finds itself based in (hospital, fire, county, etc.) and the varying levels of EMS sophistication—certainly add a measure of texture to the industry. They also help create confusion. 

“Pretty soon you have to use a calculus formula to come up with the number of variations of EMS agency types and configuration challenges,” Gainor says. “We don’t even recognize each other in our own industry because of that diversity. That breeds the sense of homelessness that the statement is alluding to.”

Standardizing Care
As far as standards are concerned, Gainor points to the industries that already enjoy consistent state and federal standards and regulations, such as K–12 education, the interstate highway system, agriculture and transportation.

“These all match up with the names of federal agencies that have the regulatory authority to set some things in place, because they are too important to drop below a set standard from location to location,” she says. “We feel good that the FAA exists and ensures that the way planes take off and land happens in a very precise way, no matter what state or city or county you are landing in.” She would like to see some of the same standardization in EMS.

Gainor highlights the transport of patients as a specific example. “Why in all the modes of transport, such as freight, commercial trucking and transit, are [regulations] so clearly dictated, monitored, and accounted for, but not in the transport of patients? Where did that disconnect start?” she asks. “Why is a load of cattle rolling down the interstate highway safer than the patient in the back of an ambulance? How do you explain that we don’t have a comparable level of assurance for the safety of the driver, the crew and the patient that we do for other cargo?”

She also points to the invisibility that EMS sometimes feels in the overall health-care picture. Many people around the world have been impacted by EMS, by having a paramedic save either their life or the life of a friend or neighbor. Gainor acknowledges that most people understand that EMTs and paramedics save lives, but she would like the awareness to go deeper.

“It is often the case that Joe Citizen believes that,” she says. “We have to get to the point where the health-care industry at large knows that. It has to be imbued in everything. That’s the gap that we’ve got to bridge.”

Gainor hopes the position statement will resonate with many in the health-care industry, including policy makers on Capitol Hill who are currently wrestling with health-care reform.

“Before you tamper with something as fragile as health care, you better make sure that the safety net is intact, because that’s EMS,” she says. “My fear is that it will all fall on deaf ears in the absence of a unified voice for EMS.”

Gainor also hopes the statement will spawn additional research on the impact of EMS.

“I hope that essentially it will speak to every level of participant in the EMS system in a voice they recognize for the piece they can contribute,” she says. She includes EMTs, paramedics, administrators, national associations, research organizations and universities in this call, “because it touches every one of us,” she says.

And the end of the day, as Gainor looks squarely at the big picture, she’s more optimistic than pessimistic because of the kinds of positive changes that she sees being made in EMS. “We’re not going backward,” she says. “I think it’s more a case of growing pains than a stall mode, and I have to be hopeful because we are in motion.” 


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