Do we REALLY save lives?

[rescue1]

Wow, lotsa replies. Thanks guys, especially Vene and Melclin--that's the sorta stuff I was looking for.
Just as an aside, my first post was written at 2am, so if it came across a little disjointed, that's my bad. I also don't want people to get the idea that I think EMS is about nothing but life saving and danger and carrying orphans in respiratory arrest out of buildings. I think the ricky rescue live-saver culture is absurd, and I have to deal with it every single day, in the form of people swaggering around talking about how cool it will be able to intubate patients.

I think EMS has the potential to be more then the taxi service which is currently is in most areas of the US. I don't need to be convinced that community paramedicine and treat and release programs are part the future of EMS. So I guess anything with "lifesaving" in it was a poor choice of title. I should probably have said "How effective really is US EMS?"

As I said earlier, my impetus for posting this was a discussion at my volly squad where I was, as usual, discussing the various benefits of being a staffed, ALS equipped ambulance. Someone posed the question "Give me an example of someone who died because we took 10 minutes to get there with a BLS crew instead of 2 minutes with an ALS crew" (the hospital is right in town making transport times short, as an aside). I could only, off the top of my head, mutter something about witnessed cardiac arrest.
Now obviously, this is still in the mindset of EMS being a primarily lifesaving organization, but it had some validity to it. Why would a community pay more for this supposedly "better" paid service when the bumbling volunteers can still get similar outcomes? I mean, I knew US EMS had some issues, but that just seems absurd.

(Note, this is not a bash on volunteers, I'm sure there are quite a few good volunteer ambulances in America. I just don't deal with good ones on a regular basis)

really that's your argument? what if I told you all fires go out eventually (even if they end up running out of fuel), people who remain trapped in cars is just an example of darwinism, and I have never seen a cat's skeleton in a tree? doesn't that just blow three big holes in the justification of your existence as a firefighter?
ask your friend how often he has drew his gun in his career. now ask him how many times he has fired his gun in the line of duty. bet the first number isn't that big, and the second number is less than 3.

Well, first, the kitten thing was just a little sarcastic. That and saying that all fires go out eventually is like saying everyone dies eventually, so why have health care?

But all those points still stand. Fire and Police are public safety agencies who impact society is very measurable and noticeable ways. If you have no firefighters, a blaze could destroy lots of buildings and cause huge economic hardship. No police, and people run around stealing stuff. You can't possibly be arguing that police and fire are unnecessary services. It's more difficult to quantify the benefits of traditional American ambulance services.




(Disclaimer, all of the above was typed while buzzed out of my mind on energy drinks)

 

[Shishkabob]

The nice thing is, if you just figure that you're here to help people however you can, it relieve you of the constant burden of asking "is this really a proper use of 911?" Should the homeless guy really have called for an ambulance? Does it reveal some deficit in his personhood? Is it a good use of finite system resources?

I have no idea; determining that isn't my job, or at least isn't my job while I'm working the road. But will it make him any happier? Sure, it's warm and they have food there, that's probably why he called. Sounds good, let's go dude, what kind of music ya like?

Yet, the issue is the opportunity cost: Helping someone who doesn't need it is taking the resource away from someone what DOES need it. I'd rather help a diabetic who's unconscious with a BGL of 22 then taking granny to the hospital because her legs hurt for a week and she's tired of it, but refuses to do the logical thing and see a PCP, but rather get a big ambulance and ER bill that she won't pay, or expects medicare to pay in full.


If they are willingly abusing the system, they don't need access to the system. If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.



We will never solve the problem if we let people think what they do is ok or acceptable, or even correct. Nip the issue in the bud, tell them what they did is incorrect, mistaken, or just plain wrong, educated on how to fix, and ensure they follow it in the future.

 

[medic417]

Yet, the issue is the opportunity cost: Helping someone who doesn't need it is taking the resource away from someone what DOES need it. I'd rather help a diabetic who's unconscious with a BGL of 22 then taking granny to the hospital because her legs hurt for a week and she's tired of it, but refuses to do the logical thing and see a PCP, but rather get a big ambulance and ER bill that she won't pay, or expects medicare to pay in full.


If they are willingly abusing the system, they don't need access to the system. If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.

This is why every Paramedic should have the ability to say no to people that do not need ambulances. Sadly though we all know there are people that just have the certification yet can't even safely transport much less decide no. So my theory is fire anyone to stupid to be able to learn to say no when appropriate.

 

[Brandon O]

As I said earlier, my impetus for posting this was a discussion at my volly squad where I was, as usual, discussing the various benefits of being a staffed, ALS equipped ambulance. Someone posed the question "Give me an example of someone who died because we took 10 minutes to get there with a BLS crew instead of 2 minutes with an ALS crew" (the hospital is right in town making transport times short, as an aside). I could only, off the top of my head, mutter something about witnessed cardiac arrest.

I think my response was a little too preachy to make the point I intended, which is: I feel much of the benefit of ALS, when used appropriately, is to relieve suffering. They can provide analgesia, anti-emetics, anxiolytics, sedatives; they can improve work of breathing; they can even, quite frankly, provide a better placebo effect and reassuring presence with all their interventions and blinkenlights. To me, that's big, which is why it annoys me when medics can't be arsed to push the morphine or zofran or otherwise put emphasis on palliative measures.

 

[Brandon O]

YWe will never solve the problem if we let people think what they do is ok or acceptable, or even correct. Nip the issue in the bud, tell them what they did is incorrect, mistaken, or just plain wrong, educated on how to fix, and ensure they follow it in the future.

If you mean this as a "how to fix EMS" solution, you may be right. But if you mean this as a recipe for "how to work in EMS as it exists today," I find it to be a fast road toward burnout. Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not. (And quite frankly, this will probably remain true even in an ideal world, because people will still call when they don't know whether something's an emergency -- that's why they called for a medical professional to advise them -- and in most cases, it won't be. But unless we want to start writing off large numbers of the population, that doesn't mean they were wrong to seek help, because it could have been.)

I also think that the sole perception of our emergency role attracts a far lower quality of provider than the alternative.

 

[Shishkabob]

Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not.

Trust me, having been in EMS for 3 years, I know my role isn't solely emergencies. However, my role SHOULD be solely legit medical complaints that either require, or could be helped by, my knowledge and expertise. Having the flu for 2 weeks, with no other complaints, , while a 'legit medical complaint', doesn't count. While leg pain could indicate an MI or PE, if you've had said leg pain for a week and nothing is different, you don't need an ambulance, you need to figure out why you didn't call for a taxi 5 days ago. Etc etc.

Just because we CAN help with an issue, doesn't mean they are using the right resources. Sure, FD CAN get a cat out of a tree, but would anyone argue that is correct usage of that resource, and that they should do it all the time, no questions asked, without trying to educate the people calling for it?


The issue isn't so much being called to a place when someone has a questions, it's them expecting a ride to the hospital, demanding said ride, even though they have no legal right to an ambulance, let alone a transport in one, or a transport in one to the destination they want.




You know one of the first questions I ask someone who calls for a minor complaint? "Why don't you take the medication you're prescribed for the issue you're calling for?" or "What made you wait so long to seek medical care?" Sure, it's had volunteer FFs complain about me making it seem like "Their complaints are not worthwhile", but I find it's the best way to try to educate someone, by understanding their thoughts behind their actions. Does it change how people act? Not as much as I want, but alas, it keeps me sane knowing I am trying to help people in the best way possible, which is guiding them away from thinking of the ambulance solely as a taxi and seeking the proper help, sooner, and much more affordably.

 

[Veneficus]

If you mean this as a "how to fix EMS" solution, you may be right. But if you mean this as a recipe for "how to work in EMS as it exists today," I find it to be a fast road toward burnout. Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not. (And quite frankly, this will probably remain true even in an ideal world, because people will still call when they don't know whether something's an emergency -- that's why they called for a medical professional to advise them -- and in most cases, it won't be. But unless we want to start writing off large numbers of the population, that doesn't mean they were wrong to seek help, because it could have been.)

I also think that the sole perception of our emergency role attracts a far lower quality of provider than the alternative.

Well said,

I woukld just like to restate, the "emergency, life saving role" of EMS was initiated in a time when large amounts of people suffered acute events that could be acutely corrected.

If you think your job is "real emergencies" in this day, bad news, they are going to become less frequent, not more.

For those of us that started before mandatory seatbelt usage, when cars were tanks with wheels, and even car seats were unheard of, every car accident was an emergency. There was no such thing as "no patient" and the interventions that are directed towards class III and class IV shock we used regularly. (we didn't know they didn't work then as they don't work for what they are designed for now)

respiratory problems, diabetics, etc are all chronic problems. They are managed chronically with the occasional acute exaserbation. That is the way of the future every aspect of medicine is governed by it, not just EMS.

Death is no longer the enemy to be conquered, palliative and end of life care is back.

Trauma that 20 years ago would definitively get you an emergent laparotomy will not longer even be operated on.

Whether you are managing the chronic drug fiend, urban outdoorsman, or full code nursing home patient, the days of Johnny and Roy coming to the rescue are gone.

Even your Emergency STEMI alert is going to receive treatment based on their overall health.

Do you really think the 90 year old lady with a complicated history is going to the OR for a hip replacement?

Do you think the 65 year old chest pain call with decades of untreated hypertension, arteriosclerosis, and renal insufficency automatically qualifies for a CABG or intravascular stent?

How about after his previous 3 stents and CABG?

Really, you think the chronic poorly controlled diabetic is saved by your interventions? They just live to die another day, often being hacked apart a piece at a time.

Your CHF patient who can't breath today, won't be able to pee in a few years. Enter in the IFT dialysis derby. For at least 3 days a week of their life wasted and complicated with compartment syndromes from volume overload, unhealing wounds, cellulitis, neuro deficits, bleeding, clotting, etc.

Well, there still are the once in a blue moon anaphylaxis patients right?

Welcome to modern medical reality heroes.

"Your feeble skills are no match for the power of the dark side."

 

[titmouse]

that quote from "Bringing out the dead" was crazy .

 

[RocketMedic]

Sounds like you're a bit bitter,Veneficius

. Where are you in Europe?

 

[Veneficus]

Sounds like you're a bitter

It is not that I am bitter, I am realistic and very tired of hearing people put forth the same sad and outdated dogma.

The cutting edge of medicine is all molecular and biochemical.

From genetically engineered viral treatments to blood banks created with stem cells.

Many surgical techniques are approacing perfection, from off pump bypass to 20 minute cross clamp times on aortic repairs.

Despite the lag time from academic research to clinical acceptance, treatments and thinking not 20 years old are rapidly becomming obsolete.

Can you imagine how far behind EMS is still using treatment modalities from the 60s and 70s today?

There are political leaders in the US asking why they should pay for ALS, not just people on this forum.

I have been fortunate in my time from the fire service to medicine and everything in between I have done, to be around basically when things change from an old way to a new. It gives the benefit of knowing what was and what will be.

It is frustrating when people can't keep up. It is a flaw in homo sapien to desperately cling to a world they knew. But more important than mental security is not getting caught with your pants down when somebody asks you to justify why you are being paid. (the purpose of this thread)

I see trying to drag EMS into the future like trying to drag a person out of a burning building and having them resist you the entire way. The only difference is, instead of naturally selecting themselves out, they are going to take a whole industry with them.

Many industries over the years have found themselves obsolete, when that happens people find themselves unemployed or underemployed. While it doesn't affect the young people as hard, look at all the people in their 50s today who are out of work with skills no longer desired by employers who still need to work.

In another 10 years at the going rate, the people with 5-10 years in EMS today can realistically see themselves being paid worse or unemployed completely without marketable skills if they do not enact change. (the most logical being from emergency response as a primary function to emergency response as a colateral function as the predominant pathology changes)

Both the fire service and law enforcement figured out a long time ago proactive and preventive in the way to ensure a future. While I support it for EMS, it is not something I made up.

Given the avoidance of change in EMS during the past and the economic realities of today, change will have to be accelerated.

The people inhibiting it are dragging the field down and actively stopping it from becomming a proud profession with a future for its members.

While some will doubt my altruism from my manner, ask yourself:

What do I have to gain by ensuring there is a future for EMS and spending effort getting it there?

As far as I can tell, nothing at all.

I have benefited greatly from my time in the Fire and EMS services and I do hope to give a little back, as well as be one of the people who moved on who still look out for the people I came from.

Looking out for somebody other than yourself may not be popular in America now-a-days, but it was the ideal that dinosaurs like me lived by. Not only for our communities, but for our coworkers as well.

Where are you in Europe?

Katowice, Poland.

But it is fair to say I travel a lot. Including to the US to teach EMS and AHA classes for months at a time.

I have also been to a few other places as a medical provider on my breaks.

 

[Brandon O]

that quote from "Bringing out the dead" was crazy .

Great, great book for anyone in EMS. Pitch-perfect illustration of true burnout.

Movie's good too, and actually a very close adaptation. Check out both.

 

[Tigger]

If they are willingly abusing the system, they don't need access to the system. If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.

Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.

Even patients that make our job suck by forcing us to go to their crappy homes twice a week for a BS ride to hospital might still need an ambulance for a legit issue and if you scare them out of the system, they're not getting it and then we have done that patient a huge disservice. Some will say that that's what they deserve for calling wolf so many times, I guess I just think we can do better.

 

[EpiEMS]

Couldn't it be that the system, with all the third party payment problems, is the issue? If there's no payment, there's no way for incentives to align.

 

[titmouse]

I know its not gonna be Epic all the time, but I personally believe that its gonna make me a better person, and being able to assist people in my community that really require help is something that I am looking forward to.

 

[Shishkabob]

Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.

Probably didn't phrase it right: 2 points,

Point one: EMS, and transport from it, is not a right. You can demand a ride all you want, but it's not illegal to refuse it to you, hence why a few agencies can, and do, refuse transport.


Point two: You read my thread about the MedStar article. If someone is labelled a system abuser, they still get an APP to come and check them out. If it's legit, an ambulance is used to transport. If it's not legit, a medical director refusal takes place where the medical director refuses transport.

For system abusers who are still transported, they have home hospitals. They can ask / demand to go to any other hospital, but they can only be taken to the 'home' hospital.




If you're willingly abusing the system, there needs to be repercussions. If I call 911 every day for police for something that is not legit, I can expect to be arrested. If I call for a fire everyday that is actually just a candle, you can expect me to be arrested. Why is this different? Am I talking about arresting people? Not necessarily. But there needs to be something to dissuade the abuse... and monetary ones clearly aren't working since they refuse to pay the bills anyhow.

 

[Melclin]

Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.

Even patients that make our job suck by forcing us to go to their crappy homes twice a week for a BS ride to hospital might still need an ambulance for a legit issue and if you scare them out of the system, they're not getting it and then we have done that patient a huge disservice. Some will say that that's what they deserve for calling wolf so many times, I guess I just think we can do better.

We have means by which problem callers are dropped down the list of priority. If it turns out badly for them well then they should have read the boy who cried wolf. I must say though, that this is in a different sort of system. These people have access to all the healthcare they want. They just chose to call us repetitively because they're lonely or not coping with life. Thats sad, but whats sadder is that someone else could die while every ambulance in town is there patting them on the head and saying there there.

 

[Handsome Robb]

I can justify my existence as a firefighter--without the FD, city blocks would burn, people would remain trapped in cars and kittens trapped in trees. My friend can justify his existence as a cop--without police, life would be a little more exciting and dangerous for obvious reasons. But without EMS? People would have to...find someone to drive them to the hospital.

EMS exists for a reason. Not everyone has a ride to the hospital. Sure we don't save lives all the time, but I can show up on scene and make someone much more comfortable, care for them and make their family feel better on the way to the hospital. I can show up to a diabetic problem, start a line, give them dextrose, make them a sandwich in theory "saving their life" because you can't survive without glucose as well as taking a load off the local ER system because most don't want to go to the ER after we fix em up and make them food. That's what it's about not "saving lives". Why does everything have to be about saving lives and being a hero?

How many fires are there compared to EMS runs? "City blocks would burn?" Really? If something needs to change the fire service needs to be cut back and EMS needs more support, but that's just me.

 

[rescue1]

EMS exists for a reason. Not everyone has a ride to the hospital. Sure we don't save lives all the time, but I can show up on scene and make someone much more comfortable, care for them and make their family feel better on the way to the hospital. I can show up to a diabetic problem, start a line, give them dextrose, make them a sandwich in theory "saving their life" because you can't survive without glucose as well as taking a load off the local ER system because most don't want to go to the ER after we fix em up and make them food. That's what it's about not "saving lives". Why does everything have to be about saving lives and being a hero?

How many fires are there compared to EMS runs? "City blocks would burn?" Really? If something needs to change the fire service needs to be cut back and EMS needs more support, but that's just me.

This has nothing to do with being a hero...it's about the effectiveness of a well run professional EMS system compared with a poorly managed EMS system in the the current US system, in which EMS exists primarily as a vehicle to transport patients rapidly to a hospital.
How can I justify (mainly in my mind) how a professional, fast, well trained ALS service is significantly better then a volunteer squad with a slow response and minimal training, with chase ALS a ways away? Basically see my second post, where I explain my point a bit better.

I'm not a whacker wanna be who's upset that I can't save people every day like they do on Trauma, trust me.

Also, I'm not saying that fire threatens us on a hourly basis and could destroy cities at any second...I'm just saying there is a real and measurable consequence to not having fire protection.

 

[DrParasite]

Well, first, the kitten thing was just a little sarcastic. That and saying that all fires go out eventually is like saying everyone dies eventually, so why have health care?

But all those points still stand. Fire and Police are public safety agencies who impact society is very measurable and noticeable ways. If you have no firefighters, a blaze could destroy lots of buildings and cause huge economic hardship. No police, and people run around stealing stuff. You can't possibly be arguing that police and fire are unnecessary services. It's more difficult to quantify the benefits of traditional American ambulance services.

no its not. I shot all your points full of holes, you just refuse to realize them. and your not alone, the FD and PD unions are great fear mongers. don't fund the FD, and your house will burn down. don't fund the PD, and you will become the victim of a crime. that's the argument.

it's very easy to quantify ambulance service. if you don't have EMS, you have a greater chance of not recovering if you experience a medical emergency or a traumatic injury. the difference is, most people don't think they will ever need EMS. As such, they don't want to pay for EMS, because they don't want to pay for a service that they will never need.

the difference is, FD and PD don't have any confidentiality issues like EMS does. FD or PD delivers a baby, and it's news. EMS does, and it's not. FD saves someone with a defib, and they tell the media. if EMS does, they can't. if someone gets shot 12 times, the PD usually has a statement about what happened.... EMS rarely speaks to the press, and has the misguided notion that no news is good news. no one thinks they will ever need EMS, and few people (outside of those IN EMS) actually know what EMS does.

Few fires will burn city blocks, even in urban cities. you put the tower up, surround and drown, and the city block is saved. usually the loss is just a house, maybe an exposure if the delay is that great. but it isn't a city block unless there are other factors at play.

think of it this way: if EMS doesn't do anything, and should need to justify their existence, why have EMS calls nation wide steadily risen in numbers in the past 40 years? apparently someone keeps calling for EMS and more and more people are calling them.

 

[ffemt8978]

think of it this way: if EMS doesn't do anything, and should need to justify their existence, why have EMS calls nation wide steadily risen in numbers in the past 40 years? apparently someone keeps calling for EMS and more and more people are calling them.

For discussion purposes only:
Stating that EMS can justify its existence simply because more and more people call them is not taking into consideration the nimber of people that call EMS simply for a taxi ride to the ER because they use the on duty ER staff as their GP. Nor does it take into consideration the increase in IFT calls because nobody wants to take on the liabilty of taking granny to the nursing home or the doctors office.

Better systems than EMS can be implemented to address these issues, but EMS (like the FD and PD) is terratorial by nature and does not want to give up anything that can be used to justify its continuing existence.

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