Quality Corner--Part 5: Patient Care Standards--A Quality Comparison

When it comes to the quality of patient care standards, EMS has a ways to go to catch up with the rest of medicine

Modern EMS began with a sense of sudden and belated urgency. The stage was set by the release of the National Academy of Sciences' 1966 report Accidental Death and Disability: The Neglected Disease of Modern Society, which claimed a soldier wounded in combat in Vietnam had a better chance of survival than a victim of a car crash on an American highway. A few visionaries in Los Angeles, Seattle, Pittsburgh and Columbus started the early prehospital advanced life support programs. Then in 1972 the television show Emergency! opened the floodgates, and people all over the country started asking, "Why shouldn't we have the benefit of prehospital ALS?"

At that time, no doctor or nurse in their right mind wanted to leave the familiar and secure environment of the hospital to crawl into overturned cars or administer care to victims of shootings and stabbings at uncontrolled (and many times still dangerous) scenes. Enter the firefighter and ambulance attendant, who were familiar and in many cases nutty enough to thrive on such intense challenges. And unlike doctors and nurses, they were "little fish"--i.e., not worth suing.

Forty years have since passed. Today physicians in many systems, many of whom started their careers as EMTs and paramedics, are more willing to actively participate in prehospital medicine. EMS has evolved and matured in other ways as well. But in the quality of patient care standards, the gap between many EMS systems and the rest of medicine remains cavernous.

It's an illogical disconnect. For all intents and purposes, paramedics practice physician-level medicine, albeit more limited and focused in scope. This is despite the fact that the typical paramedic, even as of this late date, receives between 9 and 24 months of training, compared to a physician's 8 years.

After medical school, physicians typically serve four years of internship and residency. This is where they practice what they learned under the watchful eye of senior physicians to ensure their practical application of medicine meets accepted standards. Most paramedics, by comparison, serve a preceptorship of between 3 and 6 months where they are mentored by a senior medic, after which they are turned loose on society. Back in the 1980s, I finished my nine months of medic school, completed a three-month preceptorship and then spent the next 20 years repetitiously doing what little I was trained to do.

In my first 20 years, I received exactly five letters of inquiry from my service's quality assurance committee. Twenty years, thousands of patients, and just five questions ever asked. I'd like to think I was that good. But, in retrospect, knowing what I know today, I am much more humble.

Given the meager amount of medical training I received, it's hard to imagine I didn't miss all kinds of things and make all kinds of mistakes along the way. But if no one ever catches your mistakes and points them out to you, how would you ever know? This is how many EMS systems throughout the country have operated for 40 years--and, in many systems, continue to operate today.

Short of manning all ambulances with doctors, it is not practical to expect the same care standards for medics as we do for physicians. But since the pathology, risks and stakes are the same for patients regardless of whether they're initially seen by a doc in the ER or a medic in the field, common sense dictates that quality review and improvement are critical to trying to close the gap as much as possible. It also makes sense that in EMS, index of suspicion and caution should be increased, not decreased from hospital standards.

EMS vs. Hospital Standards

A few years back, I arrived on the scene of a chest pain call. The patient was a 45-year-old male who presented conscious, oriented and in no apparent distress. His vital signs were unremarkable. His only past medical history was esophageal reflux. He described his discomfort as a burning sensation in his chest. He had just finished a spicy dish at a Mexican restaurant a couple of hours before, and there were no other associated complaints or symptoms, so I quickly determined it was a likely exacerbation of his GERD. I climbed up front and drove to the hospital and let my EMT ride with the patient. Who in EMS hasn't made such a clear-cut field diagnosis?

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