“We’re the fifth largest city, and I think we’re in the top five largest counties in the country”¦we’re a big place, and it’s great working for large organizations in that you have large budgets and lots of opportunity,” says David Moffitt, captain and paramedic in the Phoenix (AZ) Fire Department (PFD), in his first press interview. He continues, “The tough thing about working for large organizations is that they’re giant battleships that are not nimble like a cutter. [But] we’ve got good intelligence, and I guess on a certain level you would even say that there’s some good emotional intelligence about reading what’s going on in the community.”
At a January 2020 summit organized by the National Highway Traffic Safety Administration’s (NHTSA’s) Office of Emergency Medical Services (EMS), someone mentioned “islands of success.” Tremendous work happens daily across our fine nation (despite the political news that can drown out the good). Like the oodles of technology emanating from San Francisco’s Ventureland, a handful of “darling” mobile medicine agencies breach the “noise barrier,” and those may simply be the ones with the best public affairs team. This small (and biased) sample gets all the attention, but it might discover that limelight burns. In the crevices of awareness around them live broadly relevant successes that are known only locally. A mobile medicine essayist’s joy is underdogs worth highlighting. A journalist’s mission is to coax them into the world.
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After all, mobile medicine agencies are like Swiss army knives: variously equipped to tackle extractions, falls, heart failure, sobriety failure, and loneliness. COVID-19 challenged the industry’s patterns in a starkly different way than Ebola or even substance use disorders. Cities shut down, crime dropped, and patients stayed home. However, rather than requiring rapid mobilization, which is what one trains for in this business, life simply seemed to stop. Not innovation, however – it sped up, happening in real time. Like magic that belies the amount of work happening behind the scenes, bridges between departments manifested as if they had been there all along. Across them walked interdisciplinary and empathetic leaders like Moffitt.
They say luck is opportunity meeting preparation. If so, then the coronavirus pandemic may be serendipity. It catalyzed the emergence of liaisons who excel at forging and sustaining relationships with partners that might otherwise be “side-eyed” as competitors for resources. The strangeness and urgency of this moment made overlapping Venn diagrams unexpectedly good. Therefore, it is no accident that Moffitt has earned the trust of one of America’s largest fire departments. He is one of the industry’s deepest thinkers about the ethics of mobile medicine, possessed with an underappreciated skill. Despite, in his words, having “barely graduated high school,” he deftly dices complexities, ranging from mobile integrated health — such as the frequently overlooked role played by police — to multistakeholder logistics involving personal protective equipment and infectious disease control, into actionable chunks. Moffitt then steps away from the aperture. The smartest soldiers occasionally let brilliant ideas masquerade as someone else’s.
According to Moffitt, the PFD “[is] best known”¦for customer service, [responsible for] the concept of “˜Mrs. Smith,’ which is making our citizens-slash-patients a “˜customer;’ and the development of modern incident command systems for fires, special operations assignments, greater alarm medical, and all that kind of thing. Along the way”¦[our leadership] fostered an environment of free thinking.” He said, “We are very blessed to be in an environment of some really good exec staff. They don’t have all the answers, and that’s not necessarily what makes a great leader. I think that they are not threatened by people underneath them bringing ideas–it really, truly seems like now, more than ever in my career, is the free market of ideas.”
Having been detailed from PFD to the Maricopa County Incident Management Team (IMT) as a liaison, Moffitt explained that the methods and perspectives brought to the COVID-19 response have necessarily evolved, but the IMT’s purpose remains clear. Nationwide, agencies are balancing the disruption of extraordinary vigilance against the uncertain risk of standing down. As a “conservative Republican with libertarian tendencies,” he concedes that, “If you were to plot this on the chart, I’m pretty sure we were set to have thousands and thousands of deaths and overwhelmed emergency rooms, and that didn’t happen.” Decision making during a crisis is “less science and more alchemy about measuring and interpreting outcomes. Where on the chart–if you were plotting a line–”˜was the juice worth the squeeze?’ in terms of the economic impact vs.s lives saved.”
Such reflection has the department thoughtful about its future, opening the door to telemedicine and other nontraditional practices that align with the burgeoning ET3 [Emergency Triage, Treat and Transport] value-based care model. ET3, as a concept and model, predates COVID-19; it emerged from neither the Assistant Secretary for Preparedness and Response nor the NHTSA. Is that a sign that the Centers for Medicare and Medicaid Services–the beating heart of the business of health care–is ready to recognize the essentiality of mobile medicine?
Moffitt continued, “I go back four years ago to the [memory of] a gal in bunny slippers and a bathrobe. I didn’t know what it would be called at the time, but I recognized something was missing, and it sure as heck wasn’t just me. There were probably tens of thousands of paramedics and EMTs all across the country, if not the world, thinking the same–that we have to innovate. If we were just to operationally stand up the diversion-at-dispatch or the nurse triage console concept, which is beautiful and elegant and serves a purpose and has a certain amount of economic value because you’re not dispatching resources–which again goes”¦to the argument about “˜how do you value something that you never see?'”¦–there’s been a certain amount of hand-of-divinity in the coalescence of information. In the after-action of the COVID pandemic, we might look back and say this was the single-most driving factor to whatever it is.
“EMS has always been partitioned away from [the broader health care] conversation”¦ that’s the silver lining to this pandemic in that they realize how we’re more than just critical infrastructure; we’re actually partners. And if we’re partners”¦my bosses are excited about the direction that this leads the potential for the fire department [coming] out of the center of the ideology of reimbursement.”
Moffitt’s enthusiasm shined as he contemplated what our industry has learned or has a chance to learn from COVID-19. Would his answer change if the pandemic had, in fact, happened before the advent of ET3? “This COVID response, we would have hell-or-high-water, we would have created a response, we would have reached out to our government partners, and we would have come up with a plan. I’m confident we would have gotten through it.”
“The conversation [that] I was fortunate enough to have an audience with [our executive leadership] a few years ago and start pushing up these ideas. My excitement in the middle of all of this came from them talking amongst themselves and me hearing about it, saying, “˜Is this it? Is now the time that we push this?’ Because for us, part of it has been the altruism”¦it comes back to that central focus of pushing down the right path of care.”
