Restructuring EMS from the Ground Up

[firetender]

This came up for me while I was working out some ideas on the thread What is it a paramedic does? The responses to that thread were incredibly clear in pointing out OUR recognition of the reality of the job. There were few illusions there about what we do, and, additionally, there were some great models of systems that are breaking new ground in the expansion of the definition of Emergency Response.

Here, I want to get my thoughts a bit tighter.

Most systems of EMS, as they stand, are overburdened by people mis-using the services. Notice, I did not say "abuse". It is not the patient's fault, mostly because the way the US medical system has evolved it has taken the vast majority of medical care out of the reach and hands of the average citizen. Capitalism and its offspring, litigation, has played a very important role in affixing an inflated dollar sign to any medical intervention; therefore limiting access for the economically disadvantaged.

In the process patients have become a puzzle to be successfully solved, rather than a human being to be responded to. Studies show how separation and lack of human connection appears to be at the root of most emergency room visits. People go to great extremes to get compassion.

The culture of the paramedic and of emergency medicine denies these realities. This must be dealt with in order for EMS personnel to better do what they are actually called on to do.

The most readily available "faces" of the professional medical system are Ambulance personnel. They were originally conceived as primary response units for emergency situations but evolved into primary response units for what ails you.

The larger SYSTEM (US) continues to nudge more and more people into the Ambulance loop. That offers their first contact with medical professionals. But it does so WITHOUT providing back up to medics so they can be freed to provide real emergency services for people in real emergencies.

In reading these posts, and hearing how some of our compatriots in the British Empire are seeing things evolve there, I have to say I'm not all that convinced such systems as theirs will work in the US.

In terms of emergencies, I don't think we can wiggle out of sending the most qualified and specifically trained non-Physicians available -- just on liability factors alone. The "eyes and hands" of the doctor are indispensable on the scene. How long they tie themselves up on the scene, however, is something that must be controlled.

NO, I don't think an emergency paramedic should have to do the hand-holding or transporting of the non-emergent elderly, but someone should. It doesn't make sense to get paramedics involved in that. It would require three times as many ambulances available, each with highly trained medics as described in the NSW system or others as identified on the parent thread.

Flooding the streets with many more EMS personnel who are expected to attend to non-true emergencies also lowers each medic's exposure to emergencies, therefore reducing experience levels across the board.

The Emergency Paramedic should, however, be cross-trained well enough to quickly discern the next level of care, whether it be non-emergency transport, referral to another agency, 5150 hold, or whatever and then be able to get the next provider of care to the patient quickly while remaining available for the next call.

Based on these posts, now I'd offer a slightly different model with Two Levels:

Level One requires the equivalent of an Associate's Degree or better in Emergency Response. Training in handling physical emergencies would be to the EMT level, and beyond that would be extensive training in use of medical, psychiatric, social and community resources. The job would occasionally require transportation. The operative description would be post-stabilization referral and transport, with an emphasis on "movement" of the patient to the next appropriate level of patient care.

It would include a supervised Internship period, riding along for, say 100 hours with an experienced crew.

In reviewing the former posts, I came to the conclusion that a significant amount of the emergency work actually done is at an EMT level, but in areas that an EMT is not trained to handle; most of the posters told us of things they learned as paramedics.

Most of the work involves scenarios that most EMTs have to figure out on the fly; and in the process, feeling their lack of effectiveness or an inability to help.

(As an aside, I believe EMTs can learn how to respond to patients human-to-human without losing their effectiveness. If you re-define their role to INCLUDE providing the vital human link in the healing process, THEY will find they can be more effective AND fulfilled in their jobs.)

LEVEL TWO builds on that knowledge in the Bachelor's Degree in Emergency Response program, with Emergency training to the Paramedic level (above today's standards) and an expansion of the Associate's program to promote the ability to Triage patients more effectively.

The Level II Emergency Responder would primarily make the judgment call to call in Level I in the event that the call is not really an Emergency. If a true emergency, Level II should both treat AND transport.

This, then, also opens the door for the Bachelors in Emergency Response to REALLY provide a solid, medical knowledge for the medic, leading to the Master's level.

So much talk centers on the job description, led by paramedics, squeezing its way into professional status by imposing mandatory educational levels that -- since they are limited to the practice of first response emergency medicine -- do not really address the realities of the job.

Where the real work begins is in taking today's EMT level providers more seriously because it is within their realm that most of the action occurs. By taking the Entry level seriously, it sets the stage for the upper levels to be better appreciated and expanded as well.

Let's expand the profession from the ground up, rather than the top down. The EMTs of today should be trained to be able to effectively deal with the bulk of what their calls really are: non-emergency. Entry level would be upgraded to Associate's level which still makes the profession accessible.

Paramedics should be better trained, but used appropriately so they can render and be available to offer immediate advanced emergency medical care and transportation. Other than that, their job would be to mobilize a second tier of support services.

Our dispatchers could be easily trained (decision-tree style) to discern whether to send Level I or Level II as first responders. Any doubt, send Level II.

When the first responder is a Level II unit (and yes, I agree, it would work best as a vital protection agency separate from Fire services) it sends the message USE IN EMERGENCY ONLY!

One way or another, the system of tomorrow is going to have to provide support for paramedics if it wants them to effectively handle real life-threatening emergencies. The best way they could be supported is to make sure they are well-trained to handle the bulk of their role, BEFORE they become paramedics.

 

[Veneficus]

I think that when restructuring systems, the first thing we need to look at is need.

1.We need somebody to drive people to various facilities. Dr. Appointments, dialysis, etc. (even though this could be reduced considerably with things like home dialysis)

2.We need somebody to respond to emergencies.

3.We need to do something with people whos primary reason for calling 911 is because they don’t have or know who else to call.

4.We need somebody to handle minor medical problems (like headaches, etc) without engaging the emergency system including the ED.

5.Now that we know what we need, we can work on who does it.
To address these in order.

1.We do not need an EMT to cart routine people around. EMT are not taught how to cart people around in school, so we must assume they are learning it on the job. That being the case, I stipulate we need ambulance drivers, not EMTs to do this. They could be paid accordingly, and the people paying should be billed accordingly. We need to stop this idea of “basic” life support being required or paid for.

In this need we must also address interfacility transports that do need a medical provider. There are many providers quite capable of filling this role, including nurses, PAs, RRTs, and advanced educated paramedics. These programs are usually well funded and well reimbursed, so if it is not broke, no need to fix it. I would suggest that it is the facilities (ether sending or receiving) that need t provide these teams and transport. Not 3rd parties.

2. Not every emergency requires a paramedic. Not all EMTs can handle all emergencies. However, the time sensitive ones like sudden cardiac arrest and major trauma, can be handled by EMTs. However, once the initial life saving is done, a more advanced provider is needed to maintain these patients. Sometimes the transport time is minimal, sometimes the transport time is long. Which providers you need and how many will not be a one size fits all solution.

3. People call 911 for a variety of reasons. Many do not have a medical emergency. So in order to meet this need 2 resources must be addressed. The first is resources need to exist. If you are going to set somebody up for a primary care visit, there has to be PCPs readily available. You can’t simply tell the person to call a PCP and expect that they will and inevitably when they don’t will be calling 911 again. The second thing you need is somebody to respond when these people call and direct them to or set them up with the proper resources. It may also help to have people follow up to make sure they are utilizing these resources. If you don’t make this a responsibility of EMS, you reduce the need for EMS but increase the need for other experts. Also over time, this situation may balance itself out and you will need less EMS responders, though in the beginning you will need more.

4. Not everyone with a headache needs a doctor. There are those who do. Unless the plan is to continue taking everyone who calls to the ED, somebody will have to handle minor complaints and afflictions. If you tell people with minor problems to see a doctor, if they can’t because of lack of resource or they get better in the meanwhile, all you end up doing is prolonging the problem or taking up spots on the PCP schedule by people who will be no call no shows. Clearly some people will slip through the cracks. But some level will have to be found “acceptable” for under triage.

5. Many changes will have to be enacted for this to come to pass in the US. It will have to be paid for, educated for, as well as be fluid enough to meet the needs of various communities. (urban, rural, etc) The real rub is that the wealthier the community the less need there is. So reality is the Haves (even the have very little) are going to be paying for the have nots.

As the population ages, those capable of producing become smaller than those consuming, as well as the narrowing of scope of knowledge in the average 1st world citizen, the physical amount of resources devoted to this will have to increase substantially. We can educate providers to the highest levels of mans’ collective knowledge, but if we do not meet the needs, we have no value.

Increasing education is the means to the end to solve dilemmas 2-4 in my opinion. Reducing education and funding solves # 1.

 

[MrBrown]

1. Patient Transfer Officers - basically a driver with two days of first aid

2. Paramedics / Intensive Care Paramedics

3. Telephone triage and advice

4. Extended Care Paramedics (sutures, some rx etc)

My utopian world would be one with a large number of Extended Care people out in 4WDs who can go to jobs instead of a traditional road ambulance but call them for stretcher transport if required. They would be able to provide Intensive Care backup when required at jobs.

This would reduce response times, get the right person to a patient and reduce overall cycle times by having more resources free and not tied to transporting people who did not need it.

If if it's appropriate eg broken arm you can get put in the car and transported rather than having to wait for a stretcher ambulance.

Phone triage and advice would be a big part of this system no longer would an EMD be a person with three or four weeks training in how to read questions off a computer. Or perhaps they would be but with the ability to screen calls and send non-urgent ones to a phone advice team of RNs who could do further assessment and recommend treatment. We have such a system but it is very poorly utilised.

All ambo's whether ECP or not would be have the ability to use a system simmilar to CARE in New South Wales which provides for alternate dispositions and referrals of patients with minor problems to other areas of community health. We also have a treat and not transport system for things like stable post hypos, post sz w/ known hx etc however I immagine this could be extended to things like chronic migranes or headache or backache with appropriate assessment and follow up plans in place.