When I was a child, I was a slave. I knew this because I had to do all the work around the house, such as setting the table, picking up my room, taking out the trash and (gasp) occasionally even vacuuming. Now that I’m a grown-up (at least legally), I would kill to have life as easy. Perhaps that’s why, when my five-year-old son informs me that “Setting the table makes my head hurt. Silverware is dumb. The table is dumb,” I reply, “Yep, it probably is,” and chortle like a cruel, heartless tyrant. I’ve been there.
Paramedics and other emergency care providers are, if nothing else, grown-up children. We get to drive fast things with flashing red lights and lots of noisy sirens. We get to stick needles in lots of things and play interesting games with drugs and electricity. If we’re working on the fire side, we get to operate machines that cut metal and chew up cars, and we get to spray water and foam from big hoses and tanks. So it’s not surprising that any task that fails to meet our definition of fun is subject to instant ridicule. Drawing blood for serum alcohol determination or toxicological analysis at the request of our law enforcement brethren is one of those jobs we love to hate.
Concerns
Why is drawing blood so universally disliked? A few reasons come to mind. First and foremost, it’s not what we, as EMS providers, have chosen to do. While we go to many calls that aren’t life-threatening, at least we know we’re responding to a person who wants help. Our attitude toward the individual call may not be uniformly positive, but we understand that coming to the aid of a few bad apples is the price for being able to help those truly in need. Responding simply to draw blood in the absence of any other need for EMS rattles our cage, and the frustration is often coupled with the perception that if the police really want this done, they can make their own arrangements. Add these feelings to the fact that these calls usually occur at “inconvenient” times, when EMS crews are trying to relax and recharge, and the resentment builds.
There are also medicolegal concerns surrounding the drawing of blood for law enforcement use. We’ve all heard the apocryphal stories about paramedics being dragged into court and grilled unmercifully about the technique of the blood draw, whether an alcohol or iodine wipe was used and their recollections of the incident itself. If the paramedic’s lucky and the story is particularly good, the provider gets dragged into a lawsuit involving malicious prosecution, police brutality and medical malpractice (of course, it goes without saying that the testimony is required on a day off without pay).
From a public relations standpoint, one might think that having EMS involved in law enforcement activities is a disaster waiting to happen. The community might begin to think of EMS as an arm of the law, breeding mistrust and hostility toward EMS personnel. This perception might be especially prevalent in areas where the reputation of law enforcement already suffers under the cloud of racism, corruption, inefficiency and brutality. It’s easy to see how these attributes might be inadvertently assigned to EMS providers (“guilt by association”), making those in true need of prehospital care less willing to call for help.
(I need to take a moment here to mention that although there are undoubtedly some law enforcement officers who are truly out of place, the vast majority I’ve encountered are compassionate and conscientious folks who, relatively speaking, get paid even worse for the job they do than EMS personnel. They rightly deserve commendation, not condemnation.)
In all honesty, I’m not sure I share these concerns. I wouldn’t say that the law enforcement blood draw is necessarily part of the EMS mission, but I don’t think it’s an inherently bad policy; and I do believe that there are some real advantages to participating in this process. To explore this concept, we need to jump out of the clinical arena.
Benefits
“No man is an island,” wrote John Donne; this is true of any public service. EMS exists in a milieu of complementary and competing interests, all jockeying for space and attention. The trick is to ally yourself with the right people to get what you need to accomplish your mission. It’s an unfortunate fact that EMS remains the new kid on the public sector block; as such, it still depends on the goodwill and support of other public services, the local medical community and the public in order to thrive. Participating in law enforcement functions helps to build these bridges, not only with law enforcement, but also with community hospitals and other resources that would be called upon to serve as support in the absence of EMS participation.
There are certainly some practical benefits to participation in the law enforcement agency (LEA) blood-draw process. Personal relationships may develop between individual LEA officers and EMS crews. These relationships may prove invaluable when extra help is required on scene or when extraordinary circumstances demand creative, “off-the book” solutions. These positive interactions are likely to facilitate patient care and to break down barriers of perception and distance. The development of policies and procedures to streamline the blood-draw process promotes similar relationships and cooperation on the administrative level.
The real benefits lie in the big picture. As an EMS agency, you need a visible presence in your community. You never know when a photo op will appear, and isn’t it great to be seen helping the police who help us live in safety? You need the support of the well funded, traditional, “essential” public services (often heavily unionized, which translates into votes and political power). Don’t the police think better of us when they think we’re working with, or even for, them? You need the goodwill of the local hospitals in order to address more pressing issues, such as diversion strategies and receiving facility EMS crew turnaround times. Won’t this be easier if you relieve a little of their load first? And if the community, law enforcement, and hospitals consider you a team player, won’t your life be easier when the tough issues arise?
If the bottom line is the good of the community, and someone has to perform the function, EMS is a natural choice. You’re helping the police; you’re helping the hospitals; you’re helping punish the bad guys; and you’re thought of as part of the team. Teams stick together. To paraphrase Mr. Spock, the simple act of the LEA blood draw accrues so many advantages that the needs of the many outweigh the inconvenience to the few.
I’ve mentioned that most of my support for EMS participation in LEA blood draws reflects political concerns, but there are important practical considerations. The first is that from a legal standpoint, drawing blood on scene at an incident not only shortens the chain of evidence, but also provides a more accurate estimate of the true toxicologic status of the suspect at the time of the incident. The average person will metabolize 25 mg/dL of ethanol per hour, but the range of metabolic rates is from 15 to 45 mg/dL/hour. If a patient’s ethanol level drawn 20 minutes after a motor vehicle accident is 80 mg/dL, the true level at the time of the incident may range from 85 to 95 mg/dL. When the blood is drawn two hours later at the hospital and found to be 30 mg/dL, the true serum ethanol content at the time of the crash may range from 60 to 120 mg/dL. In a state where 80 mg/dL represents the legal level of intoxication, the difference represents two separate categories of criminal charges, with varying implications and consequences.
Finally, let’s recall that phlebotomy is not within the usual LEA scope of training. I would no more want a police officer to take my blood than I’d want an EMS crew to take me down if I got drunk and irate. Police officers are trained to disable you in the most humane manner possible. I’ve seen EMS crews exercise control with the butt end of a flashlight. Both are effective, but the first choice is clearly better.
Saying no
I’ve shared with you my thoughts that EMS blood draws for LEA purposes are not the boondoggle some make it out to be. But let’s say that for whatever reason, you really don’t want to be involved in the process. Is there a way to scientifically negotiate your way out of it?
The term “scientifically negotiate” means that you’ll have to fight this battle with evidence. Simply saying that EMS shouldn’t do this without just cause is spitting in the wind and will only heighten any interagency problems that already exist. Don’t expect the medicolegal argument to hold much weight because everyone has their own legal horror stories. I also wouldn’t try to attack this issue in terms of costs; your fixed costs (EMS vehicle and crew) are already in place, and your variable costs (blood tubes and needles, gas and oil to the scene) are likely to be relatively low in comparison to the costs incurred by other public service agencies.
The most effective way to fight this battle is to try to gauge the impact of LEA blood draws on patient care throughout the EMS system. The easiest way to do this would be to look at differences in response times when one or more units is taken out of service for an LEA function. For example, let’s take a two-vehicle EMS system that covers a county one mile wide and 10 miles long. Each unit sits in the middle of a five-mile swath of land (for those technocrats among us, one unit is at the 2.5 mile point and the other is at the 7.5 mile point along the county’s range), and all EMS units go 60 MPH. If one unit comes out of service for 20 minutes for a blood draw, that means that citizens at the opposite end of the county now have an EMS response time of 7.5 minutes vs. 2.5 minutes during that third of an hour. It’s fairly easy to justify that this is a clinically important difference (by the way, is anyone else having flashbacks to seventh grade word problems?). The calculations are much easier to do in EMS systems with fixed basing (units responding from permanent stations), but a data-driven system status model can provide similar information.
This is obviously a simplistic model, but it gives you an idea of how to begin to examine the issue. Once you’re able to determine the average response time change induced by an LEA blood draw, you estimate how many times this occurs each day, week or month to estimate the total impact on your system. Then it becomes a matter of balance. Are the changes in response times clinically significant? Do they occur frequently enough that the risk is more than theoretical? Are there other situations in your system that also produce changes in response times based on units coming out of service, but are accepted without question? It’s critical to review these because endorsing some “out of service” scenarios and not others may lead to perceptions of inconsistency. You’ll need to think ahead; if you’re not going to do the LEA blood draws, who will?
Good will vs. system impactThe ultimate question is to ask if there is more to be gained or lost in the long-term picture by picking this fight. That determination is yours alone. I’ve got to go set the table. You see, I have to do all the work around here.
