This is a succinct summary of a major influence on present day paramedic advanced life support in emergency medical services today. This video shows how Dr. Nagel’s belief in the Miami Fire Department led to introduction of CPR, ECG, defibrillation, and medication administration in EMS.
While these major advancements have saved a countless number of lives, continued growth of EMS has been sluggish. In fact, the entire system has become inefficient. What was created as a mechanism to preserve life through treatment and transport of those who are acutely sick or injured has become synonymous with an initial means of assessment and transportation for any medical problem. In the ideal economic state, this increased use of EMS may have been welcomed by many municipalities looking to fund public coffers with revenue from user fees. This short term thinking did not adequately account for the economic recession that would ensue. I believe that the Affordable Care Act will further increase system use, whether necessary or not, as many now believe that ambulance transport is a prerequisite for any medical issue that they are entitled to as an insured individual.
Now, in many areas, emergency systems face an increased demand to provide care without the fiscal ability to proportionately adjust the infrastructure required to maintain an acceptable level of service. This deficiency in resources, alone, increases response times to emergencies. Hospital overloading may result in extended offload times for patients. EMS crews are forced to wait with the patient until a bed becomes available. This, too, reduces response capabilities and adversely affects response time. While public education to entice community intervention is paramount to reduce morbidity and mortality, such activities are often not prioritized due to the absence of revenue generation.
So how do we learn from the past and embrace the present? Some progressive systems (and even states) have already figured out that paramedics are well suited to use their field assessment skills to determine if a patient is in need of emergency care or not. For decades, they have made that decision by choosing to activate the lights and siren during patient transport. If the patient is not having an emergency, why must the paramedics transport them in an emergency ambulance to the emergency room?
Fear of liability. Certainly, some situations could be overlooked given the limitations of field assessment equipment. While many paramedics carry diagnostic tools that mirror those used in the emergency room, certain equipment, such as an X-ray machine, may be needed. When this happens, a cost:benefit analysis should ensue. If properly splinted, would obtaining the X-ray an hour later change the patient outcome? Probably not…and it would free up an emergency ambulance for potential response to a true emergency. This, in itself, may reduce some liability. Suppose a child drowns in a pool and the nearest ambulance is busy with a non-emergency patient. The next closest ambulance is waiting for a bed at the hospital with another non-emergency patient. The delayed initiation of care waiting for another ambulance may result in brain injury. Litigation is certainly a possible outcome of this scenario and patient care was adversely affected. I’m sure that Dr. Nagel had a fear of liability when he pushed to have paramedics perform unheard of procedures, but the primary focus was patient care and he made the choice as a patient advocate. The proposed change in operations is no different.
Community intervention. The scenario presented above could have a more positive outcome if there is community intervention. We are fortunate, in some areas, to have emergency dispatchers that provide instructions on how to sustain life while awaiting arrival of paramedics. However, even if one has the knowledge and physical ability, activities such as compressions are laborious and effectiveness by one person only lasts about two minutes. Community paramedics is a viable alternative that is becoming a standard in EMS systems. A single paramedic in a fuel efficient vehicle that costs a fraction of what two professionals in an ambulance does to operate. In addition to being an financially appealing alternative to cover any gap where ambulance response is delayed, community paramedics can assume care on non-emergency calls and provide proactive public education. For example, they can assist the patient who needed an X-ray in finding transportation to an orthopedic facility for evaluation. This exponentially improves system productivity and care for this patient. An ambulance and emergency room bed are available and the patient ends up at a definitive care location that is best suited to assess and treat the injury. How about prevention? If the community paramedic found missing safety mechanisms around the pool during a proactive, complimentary, home safety inspection, the child may never have drowned. This, obvious, improves patient outcomes while improving productivity. Again, we look at Miami and the decision to pioneer a visionary system that made sense at that time. This is what makes sense now.
I did not discover the concept of community paramedics, but I certainly advocate it. Municipalities must recognize that, despite difficult economic times, a long term benefit will be recognized in terms of hard and soft cost savings associated with increased productivity and decreased liability. Push your local representatives to adopt such a system.
Below are some sites to find out more. As you will find, each system has individual needs, but this is a great way to improve system productivity and patient outcomes.