Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic.

Every now and then, we get the latest news about some “groundbreaking” study involving EMS or even tangentially connected to EMS.  The older I’ve gotten (and hopefully a bit wiser as well), I’ve come to take most of these studies with a grain of salt.  I present to you a couple of reasons why.

First, most of these academic studies are done where the academic medical institutions are — typically big urban areas with ready access to full-service teaching hospitals. When you have a five minute transport time to a facility where every specialty of medicine is present and each attending physician goes by “Professor,” there is something to be said for rapid transport being treatment.  That goes even more so when your large urban EMS system is comprised, in part, of providers who have little interest in the clinical practice of medicine.

Next, most EMS research seems to have almost a fetishistic focus on resuscitation.  I’d surmise that the reasons are twofold.  First, the research outcomes are easy.  Unlike The Princess Bride, there’s no mostly dead.  It’s either dead or not dead.  It makes for easy endpoints in research.  Second, since American EMS was initially based on accidental trauma and out of hospital cardiac arrest, the resuscitation interest seems logical.

As such, we have ended up with some of the research questioning the value of paramedic-level providers.  And it’s true to an extent.  A BLS provider is perfectly capable of transporting a traumatic injury to a trauma center for the one intervention that matters — surgery.  And in the majority of cardiac arrests, BLS interventions of chest compressions and defibrillation are what matters.  And doubly so in both instances if you live in a large urban area with a plethora of hospitals.

But here’s what little of the research addresses.   Firstly, suburban areas, much less rural or frontier areas, where transport to definitive care is not measured in single digits.  In some rural and frontier areas of my home state, the highest level of medical care available in the county after normal business hours is a paramedic.  In these cases, there’s undoubtedly a benefit to providing the advanced level of care that a paramedic brings — but because there’s no “science” to definitively support this assertion, there’s skepticism at best about providing advanced level care. Additionally, some paramedic level interventions defy easy measurement.  Unlike the outcome of cardiac arrest – dead or not dead – it’s a bit more challenging to quantify and measure symptom relief. “Sir, earlier you described your ingrown toenail pain as 12 out of 10. Now that you’ve had some pain relief, what’s the pain level now?”  Meanwhile, the femur fracture patient says they are fine and don’t need pain management.   Similar measurement difficulties can occur with other medical crises such as respiratory distress and chest pain.   It’s hard to quantify subjective measurements.

What would go a long way toward providing meaningful EMS research for the rest of EMS would be to develop some research consortiums and studies that occur outside large urban medical care systems.  Factoring in the distance to transport to definitive care and removing the maniacal fascination with cardiac arrest resuscitation would be a huge step in providing meaningful data to EMS providers in suburban, rural, and frontier EMS systems.  One thing we know about EMS is that one system solution doesn’t fit all.  It’s time that our research agendas reflect that reality as well.

I’m getting up there in years.  Maybe not as old as some of my friends and mentors, but I’m getting there.  I don’t necessarily look back on the past as the “good ol’ days,” but I do recognize that things have changed — including medicine.  At the most fundamental level, our American system of healthcare, based largely on third party payment of insurance claims, has changed as well.

Years ago, if you got sick, you’d call your general practitioner and he’d make a house call.  As Medicare and Medicaid changed the reimbursement model (and private insurance adopted many of these standards), the house call became antiquated, so your doctor would meet you at their office, even after hours, to deal with an urgent matter.  As this model changed — and emergency medicine advanced — your doctor would meet you at the hospital ER.  Now, if you call your doctor after hours, you’re most likely to hear a recorded statement that says, “If this is an emergency, hang up and call 911 or go to the nearest emergency room.”

The result of this is that emergency rooms are crowded and EMS call volume continues to climb. The response from the emergency medicine world isn’t exactly inspiring.  Numerous individual EMS providers bemoan “911 abuse” for matters that aren’t “real emergencies.”  And now a noted emergency medicine physician-blogger has opined on “the go to the ER mentality of American medicine.”

Economics says that people are fundamentally rational. So, let’s take that approach.  If you have a medical problem and “do what you’re supposed to do,” you call your primary care physician.  With any luck, you’ll be able to get an appointment for an office visit in the next few days. If the matter is VERY simple and resolves quickly, you’re just out the copay for an office visit, assuming you have insurance.  If the matter is beyond the ability of what “evidence-based medicine guidelines” (AKA protocols for primary care medicine) allow for a primary care physician, you can expect multiple follow-up visits, referrals to specialists, and referrals out for lab work and imaging, all with their own separate copays and co-insurance.  Meanwhile, you’ve also lost time from work and your regular life as well because all of these visits have to happen between 8 AM and 5 PM on weekdays. Tell me how agreeing to “play by the rules” of American medicine is rational?

However, if you go to an emergency room, you’ll be seen by a physician trained in emergency medicine, which covers a wide spectrum of medical care.  You’ll also have access to lab studies, imaging, and, if warranted, consultation with specialists.  While the copay and coinsurance will be significantly higher, you are paying for access to a one-stop solution — and one that doesn’t require an appointment and is available 24/7. And if you call 911, you get a literal house call from a group of trained mid-level providers who show up with diagnostic equipment and medications that most primary care physicians don’t have in their offices — along with a ride to the above referenced emergency room where the majority of your medical needs can begin to be addressed.

Is emergency medicine, both in-hospital and prehospital, over utilized?  Absolutely?  What’s the solution?  I honestly don’t know.  I do know what doesn’t work — and that’s emergency medicine providers complaining about overutilization of emergency services.  In all likelihood, there’s probably no one solution. From the standpoint of business and economics, I’ve never known a successful business model based on telling people they don’t need your services and turning them away. Emergency medicine, both EMS and emergency departments, need to embrace their role as providers of unscheduled medicine to the masses.  Likewise, primary care, in order to remain relevant, needs to understand that not every patient’s needs can be scheduled two weeks from next Thursday and only during regular office hours. The problem is not an unequal or even inefficient model of healthcare delivery.  The problem is and remains a healthcare delivery system that is not meeting the schedule and demands of modern society.