Can You Justify The Continuation Of The Current EMS Model(s) ?

[mikeymedic1984]

I know these stats are not near exact, but they are in the ballpark:

1. Less than 5% of EMS 911 calls are actual truly immediately life-threatening emergencies, meaning most could go to hospital by car and arrive alive.

2. The out of hospital cardiac arrest save rate to a quality stage of life afterwards is and has been less than 10% for the past 20 years.

3. Less than 1% of traumatic arrest patients survive.

4. I think you can say we CAN have an impact with AMI and Stroke, but is it our treatment or quick recognition and transport that improve patient care (we get the hospital teams moving faster, but we may actually delay arrival to the hospital versus being thrown in car), and if you do claim that, these patients are a small percentage of what we run.

5. Less than 10% of multi-system trauma patients have a spinal injury.

So with that being said, from a bean-counter or government official point of view, can you continue to justify all of the expense involved in your EMS system, for just a handful of patients ? Would the millions that are being spent, would it not be a wiser move to put the money in patient education and/or just staff twice as many one-man emergency taxi-cabs throughout the community, versus half as many traditional ambulances to transport patients.

Can you justify it with facts and statistics ? Sounds silly, but many EMS agencies are being looked at for takeover by privates or fire departments, so this is a serious question.

[Just Plain Ruff]

But all those who want to keep the status quo alive and well have to do is strut out those 5% life threatening emergency patients who benefitted from ems to a photoshoot, strut those 10% out of hospital code saves and those 1% trauma codes whose lives were saved. Strut those people out in front of the cameras and you have your poster children to keep the status quo alive and well.

Not trying to puncture your thunder but the above is one of the reason why we keep the status quo. And I just did Justify and validate the continuation of EMS As is or per say the status quo.

But I strongly urge you to bust through that glass ceiling and provide new improved reasons for making EMS Better.

We've been here on this forum for a very long time batting around this exact same question and the same concerns and although we talk about it long and hard, not many of us have gotten off our collective asses and done much about it which I put down for a root cause being that we are geographically diverse and cannot meet up and put our heads together.

So what do you suggest?

[mikeymedic1984]

I agree whole-heartedly Capt, I have always subscribed to the theory of eating the elephant one bite at a time, but the problem is that we typically take one look at the elephant, say it can't be done, and then walk away. It seems as though we are always waiting on someone else to start the process (AHA, DOT, Medicare, Pharmaceutical and Equipment companies).

So I guess the first question is what should EMS look like, without looking through our blinders of 30 years of the old way ? If we can envision the future, we can take steps to get there, but as long as we stay on the same road, nothing will change.

[Just Plain Ruff]

I have always been an advocate of taking those in the trenches, not those who have written books and those who have spent the last 20 years in management eating their way to a early heart attack and not setting their butts in the captains chair of a ambulance for the past 15 of those years but those who actually are seeing what goes on on a day after day basis.

Putting those people in a centralized location and saying, put your ideas together, give us the ideal system that you think EMS should look like.

Take 5 guys from a rural system, 5 guys from an urban system, 5 from a hems system, 5 from fire, 5 from private and 5 dispatchers, 5 supply people, 5 supervisors. You get an amalgamation of members from all over the country so you have a wealth of experience. Give em two weeks to come up with a framework as to what should be included in an EMS system. (it can also be GALS too) You can throw in 5 management people in order to provide the management perspective.

This two weeks needs to be funded not by the government nor by any entity that will have any say in how this EMS system will be funded or paid for in the future.

The people on the panel have to be paid for their time and travel, expenses and a small stipend equal to the shift work they missed out on.

Of course this isn't going to work in the end because Egos of the people involved later down the line will become huge and it will fall apart but the suggestions by this group will be implemented in pieces by forward thinking ambulance services in bits and pieces becuase of smarter people than the egos of those who will screw it up later on like I said.

But many of the suggestions will in the end be adopted into the national standards but it will be up to someone who has the backing of I don't know who to start the ball rolling to get the funding first, and then they have to put together the framework of an organization that can sponsor the group to make it a valid forum(national forum) and then you have to determine who you wish to invite(that's the hardest part ) Who are the movers and shakers in EMS that are working in the field and are not relegated to a desk. I'm not saying that those stuck behind a desk don't know the struggles of the field providers but many times they have blinders on in terms of field providers issues.

The first two weeks is just the Brainstorming part. Part two is an additional 2 weeks of streamlining those ideas into top 10 ideas for each level of the ambulance service.

field services

supply

protocols

supervisor roles

management roles

equipment/ambulance

training

State EMS

national standards

Additional 1 week sessions would address each of the above but would pull in a task force for each of the points above consisting of a team of 3-5 people

I envision this to be a 1-2 year long process

I would be of course the project manager. My hourly rate is 150 per hour ha ha ha

Edited April 5, 2012 by Captain Kickass

[island emt]

I know these stats are not near exact, but they are in the ballpark:

1. Less than 5% of EMS 911 calls are actual truly immediately life-threatening emergencies, meaning most could go to hospital by car and arrive alive.

2. The out of hospital cardiac arrest save rate to a quality stage of life afterwards is and has been less than 10% for the past 20 years.

3. Less than 1% of traumatic arrest patients survive.

4. I think you can say we CAN have an impact with AMI and Stroke, but is it our treatment or quick recognition and transport that improve patient care (we get the hospital teams moving faster, but we may actually delay arrival to the hospital versus being thrown in car), and if you do claim that, these patients are a small percentage of what we run.

5. Less than 10% of multi-system trauma patients have a spinal injury.

So with that being said, from a bean-counter or government official point of view, can you continue to justify all of the expense involved in your EMS system, for just a handful of patients ? Would the millions that are being spent, would it not be a wiser move to put the money in patient education and/or just staff twice as many one-man emergency taxi-cabs throughout the community, versus half as many traditional ambulances to transport patients.

Can you justify it with facts and statistics ? Sounds silly, but many EMS agencies are being looked at for takeover by privates or fire departments, so this is a serious question.

#1 5% is probably close to accurate.

#2 I would guess it is even lower % to release with full neurological function intact.

#3 probably right.

#4. We as an industry have made large steps in improving recognition and treatment of heart attacks and getting them to appropriate cath lab care. Along with having more access to cardiac units in more hospitals. This is one area of great improvement over the past 10 years.

#5. probably even lower %. One of the big strides in this area is prehospital spinal clearance protocols. using an evidence based system to develop and institute a selective spinal immobilization protocol]. We have been using these for close to 15 years in our state and the studies prove that EMS has been almost as accurate as the ER docs with their access to X-Ray and CT scanning. Very few missed potential injuries not immobilized over thousands of pt's studied.

As far as justification of the cost: We need to be able to provide the level of service the taxpayers are willing to support financially.

Are there better ways some things could be done? Of course there are. There are many different models of delivering prehospital care and no one model will fit all locations. What works in a large urban area with access to a half dozen emergency rooms, will not work in rural areas due to the logistics of covering large areas of terrain and low populations with access to a single hospital, which might mean an hour + transport time.

Again it depends on what level of service the customers demand and are willing to pay for.

Some places want two Paramedics sitting in a truck on every other street corner and others have an expectation that when they call 911 an ambulance will get to them in a reasonable time and provide the care they need in a professional manner.

[HERBIE1]

This may be a bit of a rant and generalization, but here goes anyway...

We all know the stats- about how many of our calls are not genuine emergencies and how many of these folks COULD get themselves to a doctor on their own, but instead call 911. So the question becomes- WHY don't they?

Simple answer: Because they can.

Paring this down to a root issue, I think that those of us in EMS are fortunate that we as a society have become far too helpless and dependent- at least when compared to how our forefathers were. Most EMS systems are bursting at the seams and call volumes are though the roof. Yes, obviously many of these changes are positive and have made us a more "civilized" society, but I think they have also made us lazy. Essentially we have become so "civilized" that we have caused concepts like common sense and personal responsibility to be placed on the endangered species list. Do you think it ever occurred to folks a generation or so ago to rush to a hospital because their child had a sore throat, or because they had a couple episodes of diarrhea?

People have now accepted the fact that in many instances, we willingly cede power/control/authority to others on things that used to be considered the responsibility of the individual. Protection, livelyhoods, settling disputes- generally taken care of between parties with no governmental involvement. We've taken that responsibility away from folks. Same with health care. EMS has evolved because instead of folks being responsible for getting themselves or a family member to medical care, we arrive on the scene making lots of noise with our rigs, filled with fancy toys, to whisk someone to a hospital, while hopefully being able to alleviate some of their problems before we deposit them at the ER.

Yes, obviously sometimes we do make a difference, but as anyone who works in an ER can tell you, much of what we deal with is nonacute. As a result, expensive resources with highly trained people stand ready 24/7, when in many cases, the patients we/they see need no more care than what a primary care provider could give them.

Yes, some folks simply do not have the ability to transport themselves to the hospital, but how many times has a family member (or 2, or 3...) told you they would drive to the ER on their own, as you give their 30 year old healthy relative a $1000 taxi ride for their tummy ache? Job security- the more helpless folks become, the busier we get, but the more broken the system becomes. We can preach proper use of emergency services all day long-speaking engagements, posters, PSA's, radio and TV ads, print ads, etc- but unless there is a downside for opting to remain helpless aka-abusing the system- nothing will change. As anyone with medical insurance knows, there are serious financial consequences for not following proper procedures when seeking care, yet the very folks who abuse the system have no such rules imposed on them. In fact, the government has passed laws that essentially protect their right to continue to abuse the system and punish a hospital/clinic/entity for refusing to provide them the services the seek. Think about our documentation- sure, it's a record of any care we provide, but more importantly it's to CYA from potential future litigation. Sadly, that has become the overarching concern for anyone in the health care field these days.

We've been through all this before but it bears repeating- we need to look beyond today and see what exactly we want EMS to become in their future. We need to realistically examine our priorities, strengths, and weaknesses. We'll see what changes are coming with Obamacare and how it affects EMS, but my guess is we will only get busier since the focus is still centered on the government taking responsibility from the hands of consumers. Based on those changes, we can then adjust how EMS will move forward, and in what capacity we will provide our services. I am, however, dead set against the concept of more governmental controls, mandates, regulations, and/or intervention in our lives- ESPECIALLY with health care, so most of the changes coming seem to go against the grain of what our ancestors stood for. For the life of me, I will never understand how someone can think an enormous, inefficient, corrupt, bloated entity like the government can do ANYTHING better than the private sector. We'll forget for a moment the notion that most things the government does these days should NOT be their responsibility anyway.

Have the services available for those who truly need them, but require folks to follow very specific guidelines- ie "have some skin in the game". Just like someone with an HMO who must get their PCP's approval before seeking care, everyone who has their care subsidized needs to jump through a few hoops as well. It certainly won't completely eliminate the problem of sky high health care costs but it is a good start, it will improve efficiency within the system, and it eases the burden on the rest of us who pay for that assistance with our tax dollars.

end rant

[zmedic]

Couple of thoughts:

1: Trauma cardiac arrests don't cost the system much. Most of these people aren't transported, the system isn't build for these people because even if they were shot in the head or hit by a bus physically in the operating room, most of them would still die.

2: Part of the issue with having a perfectly efficent system is fire departments. I have big problems with a huge fire truck showing up to all these calls, but I understand that you have to give fire departments something to do if you want to be able to call up 50 guys for those structure fires.

3: Sure I've run on plenty of people who should have had someone drive themselves to the hospital. But I also think about the cases where the patient isn't that serious, but the family is freaking out. I wouldn't want those people driving like crazy people through the street. Safer for us to show up and transport. Also you get the advantage of those people being brought in with their meds, directly to a bed. It's pretty disruptive to the ER when people are brought POV and people have to run outside with a stretcher or wheelchair to bring them in.

4. Is the only point of EMS to get the patient to the hospital alive? Or is it to safely transport people and make them feel better enroute? I'd say that it's less than 10% of my calls where I go "this is total crap, this person is using me as a taxi." There are a lot of things we do like give albuterol to asthmatics, pain control to fractures etc that may not save lives but make people feel better.

I don't think you have to go change the whole EMS system. You have to come up with a good system, backed by evidence, where the medics can show up, do an assessment, and say "this is crap, we're calling a taxi." Denver actually used to have something similar (not sure if they still do) where there was a drunk truck staffed by one EMT, who when the medics found someone who was just an intox they would call the X car and they would take all the drunks to the hospital.

[Chief1C]

Our ePCR can do graphs and such.. About 47% of our dispatched calls are life-threatening emergencies, based on chief complaint; while 43% are life-threatening based on "provider impression". About three years ago, we saw a sudden drop in "junk runs", or bullshit complaints. Perhaps because so many frequent fliers passed on? Who knows. But I'd say 3 in 5 calls are emergencies which could end a life, without intervention.

Folks really don't abuse it that much anymore, but yeah, some do; however call volume has definitely dropped as compared to say ten years ago.

[chbare]

It has been found that properly integrating EMS into the larger community of health care, patient care and outcomes can be improved. From what I understand, parts of North Carolina have been able to do this and greatly improve patient delivery to cath lab, appropriate facility utilisation and overall STEMI care.

http://firstrespondersnetwork.com/codestemi/videos/understanding-stemi-from-the-ground-up/

Unfortunately, to move beyond STEMI care, much of the drive will need to be on EMS as a profession. In this case, the drive appeared to be highly physician led.

[Arctickat]

Three Words:

Mobile Health Services.

Expand the role of EMS to MHS that enables the paramedic to provide treatments in the home and reduce needless trips to te ER.