In December 2010, I attended a small brainstorming session at the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response. ASPR is the entity responsible for dealing with widespread public health emergencies—for assuring that community healthcare systems are ready and able to care for that which rarely happens, but would have dire consequences if it did. ASPR grants have provided many communities with preparedness funds for such things as hospital decontamination capabilities, personal protective equipment for EMS personnel, and a variety of training resources. It also manages the National Disaster Medical System (NDMS).1
The topic of the meeting, which was attended by leading emergency physicians, public health physicians, health economics and policy experts (and me), was, “How can we improve the emergency care system while at the same time improving surge capacity and our ability to deal with large public health emergencies?” The emergency care system was loosely defined to include EMS, primary care and emergency care—a far narrower definition than is usually applied at the federal level, but a bit broader than that used in the “field EMS bill” recently introduced in Congress.2
I found this meeting extremely stimulating. I have rehashed and replayed its discussions many times, discussed them with peers, and read a number of articles written by people who share all or part of the vision I’ve developed and embraced.
I think EMS in the United States is at a crossroads. The Institute of Medicine has identified this,3 although I’m not sure we’re talking about the same intersection. As a community, we are definitely polarized in our vision, and it doesn’t have anything to do with the colors of our trucks or whether our members also fight fires, enforce laws or wear hospital ID tags. Those differences have been and continue to be beaten to death, mostly without any grand meaning. The polarization I’ve observed exists across all those sectors. It is, in short, the way each of us answers the following question: Do we want EMS to be reactive or proactive? Simply put, reactive means we sit in our stations or on street corners and wait for someone to call us. Proactive means we get out and do things to improve the health of our community in between running emergency calls.
Today’s Reactive EMS Systems
Since the ambulances volantes operated by Napoleon’s surgeon general, Dominique-Jean Larrey,4,5 through the funeral home ambulances, tow-truck operator rescue services and up to most of today’s modern EMS systems, EMS has been a reactive service. Wait for a call for help, then respond and do the best we can for the person in distress with the knowledge, skills, abilities and tools available to us. There’s nothing particularly wrong with reactive EMS—we’ve saved a lot of lives, reduced significant suffering and helped millions of people along the way. What we may have missed is a number of things that impact us—things that happened not in the EMS industry, but in the world around us.
The care of chronic illness has improved greatly, so that people live longer. These people have healthcare needs beyond acute emergent care that can be addressed without necessarily involving transportation to hospitals.
Automotive engineering has reduced the incidence and severity of motor vehicle crashes. A crumpled vehicle no longer always correlates with a seriously injured person.
Research has shown that properly designed interventions can reduce traumatic injuries from falls, bicycle crashes, drowning and a host of other causes.6
Another dimension has been added to hospital economics: powerful economic incentives to keep people from returning to hospitals shortly after discharge.7–9