An advanced practice paramedic (APP) uses a portable intoximeter to test the alcohol level of an individual, which will help to determine whether this person needs treatment at an emergency department or if he can be directly admitted to a mental health crisis center. In the event of a large incident requiring "surge capacity," the APPs are available to respond and augment the conventional EMS workforce.
Photo credit: Photo by Mike Legeros
Photo credit: Photo by Mike Legeros
Helping a "frequent user" of EMS services to care for herself at home is good public policy and also reduces demand on the EMS system. Patients with real but urgent (not emergent) healthcare needs often have no place else to turn for assistance so they look to EMS to meet their needs.
Photo credit: Photo by Mike Legeros
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
Last, we haven’t heard the end of “healthcare reform.” While what ultimately is implemented may not be what was envisioned by our current leaders, America will neither tolerate nor be able to afford to continue down its current path. Nor will it tolerate a large number of our countrymen being without basic healthcare coverage. While we may disagree with a particular approach, many of us believe healthcare is one of the basic rights we all should enjoy.
There are, hidden in these changes, some threats to EMS as we know it today. There are also opportunities for EMS agencies and professionals to grow in scope and value to their communities.
Threats to EMS as We Know It
Things that don’t evolve become extinct. Animals, technologies, institutions and ideas all must progress with time. This also applies to EMS. And while the technologies and drugs available to us have changed over time, our fundamentals haven’t changed at all. Just as we did in the 1960s, we wait for a call, respond to the call, and transport the patient to the hospital. For this, we typically receive a sum allocated for transportation—if we don’t transport the patient, there is no payment, so transport we do. And since in most cases we are required by laws, regulations and payment rules to transport our patients only to hospitals, we do that—whether that’s the best place for them or not.
At the same time, economics are more challenging. The federal government continues to reduce payments made on behalf of Medicare and Medicaid beneficiaries, which in the case of EMS are already below the cost of providing services. Municipal and county governments are increasingly challenged to bridge the gap. More citizens with healthcare coverage are expected to result in greater demands on our EMS systems. However, since we currently lose money on almost every transport and get nothing for nontransport interventions, we can expect to be in worse financial shape if we try to grit our teeth and stay the same.
It is time for the EMS community to take the next step. If we don’t, someone else is going to step up and address the changes taking place around us. It might be existing professional groups such as nurses and physician assistants, or it might be a new brand of community health worker or emergency care practitioner10 such as are beginning to evolve in other countries. Or, it could be us—the EMS practitioners of today.
Instead of standing by while progress overtakes us, it is possible for EMS to step up and take a proactive approach to its communities and their healthcare needs. Without taking huge risks, EMS agencies, educators, advocates and individual providers can act to identify unmet needs and develop capacities to address them. Some of these we can address on our own. Others will require developing partnerships with other players whose missions lie between their patients’ needs and our ability to deliver services. For example:
Reducing the need for medically underserved citizens to call 9-1-1—This might be as simple as swinging by a particular residence, homeless shelter or other place to check blood sugars and recommend a sandwich or an apple prior to the next meal, or reminding someone we serve frequently to take their antiseizure medications. It is easier to fit this into our day than to handle the emergency call that will come later for the unconscious diabetic or the active seizure. Many of these patient encounters will not result in transports, and if they do, the reimbursement will likely be insufficient or nonexistent. Ask the medics working on your ambulances today to identify your community’s unique local needs.
Prevent people from calling 9-1-1 in the first place—Senior citizens suffer from a greater incidence of falls than other population groups. How about applying a little bit of learning from the fire service, and developing a prevention/inspection program that focuses on preventing residential falls? Not as a once-a-year special program, but as something EMS does every day, in between calls for service.
Save hospital ED time and space by getting patients to the right resources to meet their needs—Today, ambulance medics often transport people who are intoxicated or mentally ill to local emergency departments, where they get medically screened and occupy ED beds (frequently with special attendants) for lengthy periods while admission and transportation (at additional expense) are arranged. Field medics, working within properly designed and negotiated protocols and with a little bit of additional equipment, could perform and document these medical screenings and transport patients directly to the correct facilities, saving valuable ED time, eliminating duplicate transportation costs and saving the community a good bit of money.
Most medics have been involved with patients who don’t need the sophisticated services of a hospital emergency department, and whose needs could be met at an urgent care center, public health clinic or other, less-expensive resource. Yet every patient goes to the ED whether they need it or not. There has been research that shows medics do not do very well in determining whether patients need to go to hospitals—not surprising, since we are not given a single minute of training in this form of triage and decision-making.
But the process is not as simple as “go” or “no go.” Does the patient need to go to the hospital by ambulance, or will some other modality that can be quickly arranged by EMS work? How about a taxi contract? Does the patient need to be seen right now, in the next 3 hours, the next 12 hours, the next 24 hours? Can their needs be met at a clinic or some other outpatient resource? Do we know where those are, and can we facilitate transportation and admission? I submit that it is possible to build a valid, evidence-based program and train EMS providers to properly assess, triage and direct patients who don’t need an $800 ride to a hospital in a $150,000 ambulance with two medics trained to provide advanced life support right this minute, when a $25 unaccompanied ride to another facility a few hours from now would appropriately meet their needs.
Preventing short-term readmission after hospital discharge—Agencies that pay for hospital services have begun to penalize hospitals financially when patients are discharged and then readmitted within a short time. While there are a multitude of reasons this might occur, some have to do with patients’ failure to understand or comply with hospital discharge instructions, or to promptly procure and take prescribed medications. EMS personnel, working as part of the healthcare continuum, could be notified of the needs of such patients, visit them at home shortly after discharge, review discharge instructions with them and their families, and make sure prescriptions have been obtained. Our experience and skills that allow us to interact effectively with people from all walks of life make medics an ideal resource for such interventions. And since hospitals will benefit economically from them, perhaps they will be able to fund some part of EMS’ involvement.
Working to improve the public health system—EMS providers have the knowledge and skill to augment public health resources in a variety of situations. Whether it’s establishing a remote treatment and holding area to handle victims of a mass foodborne illness or administering vaccinations to thousands of citizens as part of a pandemic illness prevention program, medics have the capacity to play a far larger role than sitting in a station or on a corner waiting for a pager to alarm.
Migrant worker healthcare—In some areas of the country, local economies depend on scores of migrant agricultural workers who move from place to place as the seasons change and various crops require harvesting. These are often low-wage communities whose members have little or no access to primary healthcare. Small problems (illnesses or injuries), unattended, become large problems, which then fall to EMS and local hospitals to solve. Can you visualize value being added by a cadre of EMS medics “riding the circuit” and tending to chronic and urgent healthcare needs of these workers?
Emergency healthcare and education in our schools—Years ago, every school had a nurse whose job it was to perform first aid, take temperatures and decide when students had to be sent home due to illness or injury. School nursing has taken on a whole new dimension now, with nurses managing care plans for ventilator-dependent and other seriously ill students who once upon a time did not attend public schools. In some communities, there are no school nurses, or one nurse is responsible for several schools and visits each one only occasionally. Our law enforcement colleagues have firmly established the benefit of having police officers assigned to schools. They work in school facilities, establishing rapport with students, staff and teachers. They assist in teaching subjects where they have expertise, such as drug abuse and prevention. They are able to respond to emergencies when necessary, both inside and outside of the school, with the full resources of their agency behind them. See any parallels for a school resource medic? In times when economics present the greatest challenge to school boards, a resource that can be shared and fulfill multiple useful roles might have great appeal.
Improving the Emergency Care System While Building Surge Capacity
Whether we’re talking about hospital beds or emergency ambulances, the first thought that comes to mind when surge capacity is discussed is the procurement of additional resources that can be pressed into service when there is a sudden uptick in demand. Yet no community is going to build extra hospital beds, buy extra ambulances or hire extra healthcare personnel to sit around and wait for a “big one” to occur. The way we’re going to handle surge needs is through redeployment of resources that serve nonemergent needs to handle emergent situations.
Most hospitals have the ability, within limits, to discharge patients early, cancel elective surgeries and make other operational changes to accommodate some level of surge. Law enforcement agencies can reassign staff to the street—detectives move back into uniform, school resource and traffic officers can be assigned to patrol areas of increased need. Fire services, often blessed with sufficient unstaffed reserve apparatus and with two-thirds or more of their workforces off duty at a time, can staff up and surge in the event of wildfire, earthquake or other major emergency.
In most communities, EMS agencies do not have this extra capacity. Peak-load staffing and tight economics (driven by transportation-based reimbursement and a crushing load of un- or underinsured patients) mean there are only enough ambulance vehicles and personnel to staff for the expected daily workload. Altering the standard of care (for example, not sending ambulances to particular categories of calls) comes with substantial concerns, both from community leaders and medical directors concerned about liability. But if EMS agencies embrace expanded roles, develop additional capacities and services, and provide additional training to their personnel, we too would have the ability to redirect medics employed in nonemergent roles to meet surge needs when required.
Removing Barriers to Proactivity
None of these ideas are particularly difficult to implement. None are terribly easy, either. Each has one or more barriers that must be overcome. Some of these are external to EMS, but many are within our reach to influence.
The biggest external barrier is the perverse economic incentives that exist in the system today. Reimbursement needs to be provided for services that involve other actions besides transportation to a hospital. Otherwise, we will continue to buy ambulances (even when we could do a lot with less-costly vehicles) and transport patients to EDs when less costly, more efficient destinations are more appropriate. This lies within the sphere of our federal healthcare agencies: the Department of Health and Human Services and the Centers for Medicare and Medicaid Services. If they want EMS to do its part, they must move to remove the financial disincentive to it.
Another barrier is EMTALA, at least the way it is structured today. EMTALA requires hospital emergency departments, but nobody else, to accept and at least “screen” all who present for care. Practically speaking, it requires free treatment of those who cannot pay. As we move toward some form of healthcare coverage for everyone, a new EMTALA is needed—one that requires others, like urgent care centers, primary care centers and other first-tier healthcare providers—to accommodate all who present. If we want people cared for by less-expensive providers in less-expensive facilities, the law needs to open the doors to those facilities.
A third barrier is presented by restrictive state-level scope of practice laws and regulations. In many states, the scope of practice is defined by a board or committee that has little if any input from EMS. Often, these regulatory boards are made up of members of other health professions, including some that perceive EMS as competition for jobs and services. The EMS scope of practice is often the most minutely specified of any allied health profession’s, delineating not only a pharmacopeia and invasive procedures but other minutia of prehospital EMS delivery—seemingly designed for the least common denominator of our community. If our federal policy-makers want EMS to help improve the emergency care system while building surge capacity, then federal action or incentives toward more permissive scopes of practice are needed.
Last, we need seed money to prove the viability of the changes I have proposed. ASPR, DHS and others have provided fortunes in grant money to healthcare and public safety agencies to develop capacities that may never actually be used, or may only be used for rare, catastrophic events. It would be wise and timely to redirect some of those funds to incubate demonstration projects, expand projects already under way, and document the results of those projects in a manner that will withstand the scrutiny of peer review.
Barriers Within EMS
One view of today’s EMS system is that we are our own worst enemies—that we focus on distinctions between our subgroups and won’t even consider that the other guys might have something to offer. We don’t want to join forces because “we” are good and “they” are evil. In this behavior, we shamefully mimic our polarized, politicized elected officials, who make policy based not on what is good for the citizens they represent, but what is good for the political party that supports them. As we see every day, that is not a great way to solve complex problems.
Along with that we have some groups that don’t want to see EMS embrace new roles because it involves effort they don’t have time for—people who see EMS as an ancillary activity to their primary mission or role. In this group I see firefighters and fire chiefs who accept EMS only as a necessary evil they must endure, and now a viable way to maintain jobs for their workforce or union. I also see many volunteers who see any added training or service mandate as a bad thing and who, given the chance, will mobilize to oppose it. Note this is not all firefighters, fire chiefs or volunteers, but it is surely enough to keep the advance from moving smoothly.
The third barrier is our lack of in-depth education. We have evolved too far toward a “don’t teach me anything I don’t need to know to pass the test” mentality. Our education at all levels is mostly bare-bones, entry-level, test-oriented and an insufficient foundation on which to build a new generation of EMS services. We have eschewed and resisted in-depth education in areas that do not relate to the glamorous 5% of what we do, while we have little or no education about the needs of the many in our communities who could benefit from our services.
We need to move toward a solid academic foundation for EMS medics, with baccalaureate degree programs that include the basic sciences, clinical knowledge and skills, and in-depth study of community health, indigent care, injury prevention, the workings of the healthcare system, alcohol and substance abuse, and the like. And we have to stop whining that we don’t get paid enough to learn all that stuff. We get paid as well as many baccalaureate-educated allied health professionals, K–12 teachers, social workers, etc. We have to make the first step. If we wait for somebody to say, “OK, we’ll pay the medics more if they agree to get the education they need to do their jobs in the 21st century healthcare environment”…well, I won’t hold my breath. We must overhaul EMS education in this country as it is being overhauled, advanced and improved in Canada, the United Kingdom and Australia, if we are to move forward.
We need to work, in a unified manner, toward removing both these internal and external barriers. Specifically:
Making omelets means breaking a few eggs—Yes, there are people heavily invested in the status quo. Some of them are bosses or owners. Proposing and working for change is going to annoy some of them. But building a good system for the future involves moving some cheese today! Our forefathers risked their lives and went to war over a three-pence tax on a pound of tea. Isn’t our professional future worth fighting for?
Yes, if you make someone powerful angry through your efforts to do the right thing, you might get fired. Stuff happens! Be prepared so that if you have to change jobs, you can do so without discomfort. Consider a little Dave Ramsey-style financial management. There are always organizations out there looking for good people, but you might have to move to find one. Be ready.
Join your professional associations, and support them with money, time and effort—Collective effort is the only way to influence public policy. Fewer than 5% of credentialed EMTs belong to the National Association of EMTs, and fewer than 2% of supervisors and managers belong to their professional associations. Of those who do, fewer than 1% are active members who contribute to their associations’ activities.
NEMPAC, the political action committee of the American College of Emergency Physicians, is this year the fourth-strongest physician PAC in the country. Their “Give a Shift!” campaign encourages members to donate the equivalent of one shift’s compensation each year to advancing the cause of emergency physicians. As a result, they have lots of money to influence public policy. Sure, docs make more than EMTs and medics. But imagine if every one of the 600,000 or so credentialed EMS folks out there in the U.S. gave one shift’s worth of compensation—maybe $100 or so. That would be $60 million worth of public influence. How much do we have now? Not much—the only EMS PAC I know of is the American Ambulance Association’s Ambu-Pac, which works very hard on…increasing Medicare reimbursement. Hmm.
Address public policy—We are deeply mired in the rut of transportation-based reimbursement, and we must get out of it. We need to begin to educate our communities, especially our elected officials and senior city and county management, that it is a good thing to expend local taxpayer dollars to support EMS. If you are a typical EMS provider in the U.S. today, you can get just enough money from transport revenue to barely provide adequate response to 9-1-1 calls, with nothing left over for innovative programs, public education, leadership development, specialized equipment, etc. Now, imagine your city or county council provided you with $5 per capita to augment what reimbursement brings. Would that do good things for your service? I know it does for mine! And there is no reason national and state organizations that pay for particular services (e.g., Medicare and Medicaid) couldn’t pay for these non-transportation services—if we had the means (lobbyists and other advocates) to have it written in to law.
Do some work in your free time—It might be nice to make a couple of extra bucks from a part-time job. But would there be benefit in doing something else, perhaps under the auspices of your employee association, to improve your community? Have you noticed at Christmas time the positive press our law enforcement colleagues get from “Shop With Cops”-type programs, or the visibility of the Marine Corps Reserve Toys for Tots program? We could do the same things with the same benefits. We all say we want EMS to have the professional respect and recognition it deserves—but you get what you earn, and you don’t earn visibility and respect by doing the minimum expected by your agency or community.
We are truly at a crossroads in the development of EMS. With a little bit of vision, a little bit of effort, a little bit of money and a lot of willingness, the EMS community can step up, fill some significant gaps in the community healthcare and safety net, and provide a bright future for itself and its members. If not…well, think of those dinosaurs.
1. Office of Preparedness and Emergency Operations. Public Health Emergency, www.phe.gov/about/opeo/Pages/default.aspx.
2. H.R. 6528, 111th Congress.
3. Institute of Medicine. Emergency Medical Services at the Crossroads, 2006.
4. Skandalakis PN, Lainas P, Zoras O, Skandalakis JE, Mirilas P. “To afford the wounded speedy assistance”: Dominique Jean Larrey and Napoleon. World J Surgery 30(8): 1,392–9, Aug 2006
5. Ortiz JM. The Revolutionary Flying Ambulance of Napoleon’s Surgeon, http://napoleonic-literature.com/Flying_Ambulance.htm.
6. Centers for Disease Control and Prevention. Success Stories in Injury Prevention and Control, www.cdc.gov/injury/SuccessStories/stories.html.
7. Plautz J. Penalties for High Readmission Rates. National Journal, http://nationaljournal.com/njonline/penalties-for-high-readmission-rates-20090721.
9. Hospitals Aim to Reduce the Number of Patients Readmitted After Discharge. www.washingtonpost.com/wp-dyn/content/article/2011/02/21/AR2011022102949.html.
Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, is chief of Wake County EMS in North Carolina and a member of EMS World’s editorial advisory board.