A BLS ambulance from an EMS service in a financially distressed rural area responds to a 48-year-old morbidly obese patient who collapsed in his third floor bedroom with congestive heart failure.
They’re forced to move the 350 lb. patient down the stairs by themselves because they lacked portable communications to request a fire assist in a timely manner, couldn’t afford a mechanical stair chair and were faced with a patient who was getting progressively worse.
By the time they get him down the stairs in the supine position, he’s drowning in his own fluids and lapses into respiratory arrest. Then, until they rendezvous with an ALS unit, the man is in cardiac arrest and can’t be saved.
At the hospital, the lead paramedic asks why the BLS crew moved the patient in the supine position and learned of their lack of financial resources, CPAP, stairchair and medical direction. They also explain they’ve been unable to find a physician to serve as their volunteer medical director and advocate for improvements in their rural system.
The hospital staff sends the patient to the morgue and writes “ALS unable to resuscitate” on his chart. The case is closed on their end, and no one will ever know the deficiencies in the rural system and work to improve their equipment and level of care.
I learned about this case while speaking at an EMS conference in a rural area. It was sad to hear that this unnecessary death was allowed to occur in 2011.
Two weeks later, while on a ride-along in a metropolitan system, we responded to an unconscious patient on the sidewalk in front of his home. He had a large hematoma on the right side of his skull and a blown right pupil.
There were no witnesses present, so we couldn’t zero in on whether he had had a heart attack or diabetic episode and struck his head when he collapsed to the pavement. Or maybe he had been assaulted, or had fallen and suffered a head injury or subdural hematoma. The ALS crew used a combined trauma and unconscious medical protocol and transported him to a trauma center.
At dinner later in the shift, the crew said, “We wish we could find out what that guy’s discharge diagnosis ends up being so we can determine whether we gave him the appropriate care.” It once again made me think how ridiculous it is that we could send people to the moon, use a smartphone GPS app to determine the location of restaurants within 10 feet, and yet we still can’t get disposition data on our patients.
In this month’s JEMS, you’ll see why I believe there’s light at the end of the long, dark EMS data and system improvement tunnel. First you’ll learn that the National Association of State EMS Officials (NASEMSO), in an epic effort, has compiled some of the most comprehensive and accurate data in EMS history (see “And the Survey Says,” p. 34). This data will help administrators and manufacturers identify equipment, staffing, medical oversight and EMS system needs and begin to correct them.
In “E-Linkage at Last” (p. 40), you’ll learn how a federal grant and regional initiative in the San Diego region is truly linking EMS and hospital systems together via a secure, 360° data exchange, which should serve as a technological template for other systems.
This, coupled with the much anticipated naming of a federal lead agency for EMS by the Obama administration, should significantly improve our ability to improve EMS.
EMS has suffered from the lack of one central lead agency since the Carter administration eliminated federal oversight and significantly reduced EMS funding. The return of federal EMS oversight will not only reinstitute a standard national game plan for EMS, but it will also provide equal opportunity for system improvement. Although funding has been offered via focused grants and terrorism initiates, the small and rural services have been all but forgotten by the federal government.
I worked under federal EMS visionary and bureaucratic bulldozer, David Boyd, MD, in the ’70s when he headed the powerful federal EMS initiative. I learned the power of the government purse. If he told you to get ambulances off CB radio frequencies and away from barroom dispatch, you accomplished it. And in addition to completing those specific objectives, we also had to obtain matching funds and documents of support from ambulance services, hospitals and government officials. No match, no radios. No trauma and burn center designations, no federal funds. It was a carrot and stick program that worked.
The NASEMSO data won’t answer all our questions; the feds will take a year or so to set up their new EMS shop and begin to cut through the fog of deficiencies that has obscured EMS, and only a few pioneering EMS systems and visionary hospitals will begin to electronically gather, combine and share patient data. But I believe 2012 will be an epic turning point in EMS. JEMS