It’s Not EMS Abuse; It’s EMS Use

There’s a lot of talk about “EMS abuse” by EMS providers. I’d submit there’s a lot of EMS “use.” We’ve done a good job of telling people to call 911, but we’ve failed in telling them what an emergency is, what EMS is, and what EMS can do for them.

From the days of William Shatner and his overly dramatic voice, we were told to call Nine One One. The public has an idea, that we’ve promoted, that if you call, a group of well trained professionals will show up and fix any problem at any hour. Truth be told, that’s not too far off.  With the possible exception of 24 hour plumbing and some food delivery options, we are about the only people doing that who are actually available 24/7.  And unlike those others, we don’t expect payment at the time of service.

Until we have better alternatives, involving EMS, primary care, and the public safety net, we’re going to continue to have EMS “use.” How many of us have spent the time actually educating the public about who we are and what we do?

In addition to my EMS career, I’m also an attorney. I find it amazing how many educated people have virtually no idea of what EMS does or how it works, aside from help coming if you call 911. I regularly run into professionals in other fields, even including the medical field, who don’t know the difference between an EMT and a paramedic.  We’ve done a terrible job of promoting EMS and explaining who we are and what we do.  The idea of EMS “abuse” is a direct result of our success in telling the public to “call 911 for an emergency.”  And the rest of the medical community uses us to punt to.  Call a physician after hours and their recorded message is likely to say, “If you’re having an emergency, hang up and call 911.” The challenge is that EMS and the public most likely define “emergency” differently.

Back when I was in third grade in Austin, we had a week in school called “Be A Medic Week.”  We learned some basic first aid concepts, how to call 911, and got a tour of the ambulance.  (FYI, back in the early 1980s, some of the ambulances here were still low top vans.) We need to be doing the same sort of education with the public as a whole.

It’s time to show our ambulance to the public and introduce ourselves.  This is what EMS Week should be about — not seeing which ER is providing us with free pizza. (Besides, the good pizza was already eaten by day shift or the respiratory therapists.) Let’s do some actual community outreach, promote ourselves and our profession, and educate the public and even the other healthcare professionals. Who knows?   Maybe it might lead to some increased recognition, better understanding of who we are, and maybe even some increased confidence in EMS.  Maybe even some increased pay eventually.

Right now, there are too many people who think that ambulance driver, EMT, and paramedic are interchangeable terms.  What are you doing to fix that? Fix that and it’s quite likely that current EMS “use” will correct itself.  I’m tired of people being afraid or unwilling to call us for their actual emergencies because they didn’t think we could help.

Lets have that conversation with the public about who we are, what we do, what’s on the ambulance, and how we’re trained. People should know that their EMS system, particularly if it’s staffed at the paramedic level, is often capable of providing the same care as you’d initially receive in the emergency department, will get you to the right emergency department for your condition, and have the ability to consult with a physician if needed.  Texas regulations refer to a paramedic equipped and staffed ambulance as a “mobile intensive care unit.” That’s a very appropriate description for the two systems where I’m fortunate to work. We have the training, equipment, and medications to provide assessment and care that approaches emergency department and ICU care.  I’m even more fortunate to work with colleagues who recognize that it’s a privilege and public trust to be able to walk into your home or business to care for you or your loved ones.

It’s a conversation that’s long overdue and one that I’d be proud to have with any of you.

Seriously, if you have questions about EMS, ask one of us.  And if you even think you’re having an emergency, call us.

Stay In Your Lane

Years ago, my parents called the same plumber anytime they had a plumbing issue.  Norman the plumber knew all about plumbing. Norman didn’t claim to know anything about carpentry, electrical work, or appliance repair. Norman didn’t claim that with a few more hours of continuing education, an extra certificate class, and his expertise as a plumber that he could do the job of a general contractor perfectly well.  Sounds ridiculous that a plumber, without anything outside of his experience as a plumber, would claim that he’s perfectly capable of being a general contractor, doesn’t it?

Yet, my friends, that’s exactly what we’re doing in EMS on a daily basis. At least in the United States, EMS exists because of the 1966 “white paper” entitled “Accidental Death and Disability: The Neglected Disease of Modern Society.” As a result of this paper, the United States began to develop an EMS system and trauma centers to care for the most severely injured patients. Around this time, emergency medicine began to emerge as a separate, distinct specialty of medicine.  Wikipedia (don’t laugh, it’s becoming a more respected source of information) defines emergency medicine as “responsible for initiating resuscitation and stabilization, starting investigations and interventions to diagnose and treat illnesses in the acute phase, coordinating care with specialists, and determining disposition regarding patients’ need for hospital admission, observation, or discharge.”  The National Highway Traffic Safety Administration defines EMS as “dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves.”

So, in short, EMS exists to take care of the acutely sick and injured and get them to the right hospital.  As I’ve defined it before, EMTs and paramedics should excel at the delivery of out of hospital urgent and acute care.  Further, we should excel at getting the right patients to the right hospital. In other words, we should know better than to take a patient that might need an ICU bed to a rural critical access hospital.  Likewise, the patient who demands to go across town to the hospital where their primary care physician “has privileges” might be just as well suited to go to the closest appropriate facility as it’s virtually unlikely that the patient will be admitted by their primary care doctor.

I expect a good paramedic to be able to provide advanced cardiac care, assess a patient, provide pain management, manage an airway, and get the patient to the right destination safely, among other things.  I don’t expect a paramedic, even with an additional “certificate course,” to be competent too far afield from emergency and acute medicine. While it’s true that EMS providers are seemingly a logical choice for any form of out of hospital care, the truth is that our current education model and skill set leave us ill prepared to deal with sub-acute complaints or routinely chronic conditions. It’s the definition of the old axiom “stay in your lane” – mind your business and keep moving forward.

Otherwise, when we keep telling EMS providers that the future is in mobile integrated healthcare, but don’t provide EMS providers the formal education necessary to be doing nursing and home health care, we end up fouling up and losing sight of what we do best — care for urgent and acute patients.  In a purely “hypothetical” case, you might end up missing an obviously septic patient because you ignored what the patient’s family had to say and kept suggesting “social work and home health care” because the patient also had chronic health issues.

When it all comes down to it, EMS has a basic mission.  Getting a patient into the healthcare system, ideally no worse than we first encounter our patient.

Which brings me to my final point.  By the time that EMS has been called, patients and their family members are already stressed and potentially frightened. If you’ve added to their stress, fear, or anxiety, you’ve failed the patient and haven’t been a good advocate for EMS.

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