All the comments here, on twitter and with our friend CK over at Life under the Lights have called our collective ideas to change how EMS is delivered EMS 2.0. Hospital radio reports via instant message, electronic patient care reports downloaded wirelessly on arrival, care back in the hands of the caregivers, not the bureauocrats. Alternates to automatically defaulting to transport in an ALS ambulance to an ER.

Ok, EMS 2.0 it is.

The movement is service based, focusing on what can be provided by EMS staff and giving those providers more access to services other than an ER in a hospital as the only option for patients.

EMS 2.0 combines advanced practice paramedic services as well as a number of options for transport, transfer and relocation.

This new service revolves around a seamless network of emergent, non-emergent, clinic and community resources working together, not each service struggling to deal with eachother’s overload.
Imagine an emergency room that only deals with emergencies. Imagine a clinic that only handles acute, non-emergent cases and a physicians office where people aren’t threatened by large co-pays and 40 day waits to get an appointment.
It won’t be reached in my service time, but if we’re going to get there, the foundation has to be built now.

We’ve figured out the patient care thing, let’s move ahead.

Multiple colleges and universities now offer Bachelor’s degrees in EMS and Paramedics are retiring from 30 and 40 years of patient care to teach others.

We have arrived as a profession, let’s start to act like it.

I have taken the steps to begin the process of changing the system where I am, are you? Would you rather find a shady place to ride out the rest of your career? If so, I only ask that you offer solutions or keep out of our way.

No longer will the excuses of “That won’t work” and “We tried that 15 years ago” be accepted.

I’ve submitted a test policy through my chain of command. A simple change to make a situation we encounter often easier to deal with. It does, however, include a simple change to put just a little more power in the hands for the folks doing the heavy lifting.
If they approve it, it will make our ability to provide medical care easier and serve as a launching point for the next 4 phases of the project.
If they reject it, their reasons will give me insight into how to better propose the other changes and I try again.

We can only change the world if we work together.

Here we go.

Life under the lights has taken up the EMS 2.0 cause as of late with another great post about how he would like to see EMS evolve in the future. Have a read and come back.

Fired up? Ready to do something about it? Good, because you’re a part of this.

As CKEMTP mentioned, there are a lot of things he and I disagree about, but I love this field and how seemingly opposites can agree on the fundamentals of their profession.

Profession. I can’t stress that enough. We are no longer a trade and need to stand up to those who try to treat us as such.

A community based model is a fantastic idea and can work. At my first paid position, we operated the ambulance out of the Community Health Office and had a list of folks we did home visits on each day. Every morning we went to 3-5 houses to visit folks at high risk. Diabetics, known asthmatics who were in poor health and similar situations. At the time I hated it. I was a Fireman “forced” to ride the bus. It was a few years later when I knew most of my clients before we arrived at the scene, knew their sugar ranges and just how much albuterol would make them better. It made me a better care giver.

That was around the time I began my Bachelor’s in EMS program. Half way through it I envisioned expanding the EMS system to include a clinic based element for rural and suburban areas. An ambulance can respond from a clinic and transport appropriate patients to the clinic for minor procedures or along to the proper hospital. On their downtime they assist in the urgent care clinic.
I incorporated a fire based model to respond from the clinic and the system made little sense with dualing command structures and confusion in supervisory authority.
The basic plan still sits in my little notebook I used to keep my ideas in back when I thought we could change things.

I re-read it after reading CK’s post.

EMS 2.0, for those of you not familiar, is a concept of changing the delivery and abilities of EMS to adapt to the changes in patient presentation and tools at our disposal. EMS 2.0 is named such because we need an overhaul and upgrade of the current system, not just a polishing and reshuffling of the same old ideas. Painting the ambulances red doesn’t make the men inside them part of the fire service, no matter how shiny it gets.

Talking to the Angry Captain about some personal and blog issues the other day I commented about needing to get “less political” in the coming months. Since my command staff is aware of this place (Hi, Chief) I do need to watch what I say, but when it comes to improving the way we do our business, it is my responsibility to be a patient advocate and get things moving in the right direction.

I don’t have a political axe to grind, represent any trade group or company, I’m just a practitioner seeking a better way of doing things. I’m currently in a fire based model that is undergoing a transition and can see a lot of room for change and improvement, but I am young in the business.

Let’s fight the good fight.

I was informed recently that I am not a health or human service but a sacred cow.

Did I gain weight?

In the midst of the budget battles, somehow the “other side” has controlled hijacked the conversation, claiming they are above mandated cuts because they provide health and human services.

Health services. I’m pretty sure I qualify there.
Human services. Debatable on some calls for service, but technically yes, my patients are humans.

How did I become a sacred cow? Politics.

In what is becoming more and more common around the US, EMS professionals are being marginalized as other services are expanding, mainly those dealing with substance abuse and low income services. But where do these folks turn for help when released from the fancy detox and housing unit? After buying cheap booze that is…

EMS.

We gather them up and funnel them back into the system, all with a legally mandated smile on our tired faces. And I have it pretty good these days. A few years back some of our rigs ran the same person 2 or 3 times a day. We’d drop them off and they’d go right back into the streets.

A pioneering supervisor with a background in social work teamed up with the local homeless team, grabbed a surplus van from the yard and started making the rounds. They found regulars, got them off the streets and into rehab. Out of rehab and into housing. Out of housing and on their feet again. Or, which is becoming more common, a bus ticket back home.
The program was remarkably successful and I will expand on it when particulars are approved for posting here at HMHQ.

This program was recently cut due to budget concerns by the powers above the powers that be. Seems to me there is more profit in keeping some folks from getting better or out of town. There is a lot of soft money non-profit dollars floating around out there and how dare a small group of people make more of a difference in a year than a dozen municipal agencies and private companies could do in a decade?

Maybe I’m exaggerating, maybe not. We’ll never know why a successful money saving program was eliminated in favor of apathy. Here or anywhere, it all comes down to dollar signs.

Standing on a sidewalk earlier today I was told by a client, recently moved from 1200 miles away, that my salary could feed and house a dozen people and that my job was “eliminatable.”

“But then who would come and pick you up for free, take you to free detox, free housing, free food just so you can get drunk and do it again? Without us you freeze to death in the street.”

He had no answer, but no one passing out the budget money seems to understand that we are the first rung in the Health and Human Services matrix.

We’re that square near the top that says ‘Arrival into system.’

This will begin an occasional reminder that ALS is not simply BLS with extras. Advanced Life Support addresses elements an 8 week EMT class barely covers.

I am not an “EMT Hater,” I am not looking to pick a fight with the “Basic for lifers” out there who take their duties seriously. This is geared towards those who think ALS belongs on an ambulance only.

All good Paramedics must be accomplished EMTs. I know that. But on a call the other day, an EMT with clearly no understanding of the situation told me I was in the wrong for checking a blood sugar before a blood pressure. (Altered mental status with bounding radial pulse.) He told me later that I need to “…put that ALS shit aside. BLS before ALS saves lives.”

It took me a minute to see what he meant to say, that BLS is better than nothing and ALS without BLS is clearly silly, but the underlying current is anti-ALS. Mainly because the ALS units here run more than their BLS counterparts.

Advanced Life Support begins when the bells ring and I combine my education and the information coming from radio. From that I can rule in and rule out possible beneficial treatments to conditions I may find. This way I’m not flying in the dark when we arrive.

I learned this business from an instructor who stressed “why.” Your patient’s pulse is 50 and irregular. You can treat it right away or you can find out “why” it is that way and treat the cause, not the symptom. Sure your patient is hypotensive, but “why.” It is often the “why” that can steer ALS in one direction or the other.

BLS treats the what, ALS treats the why.

When I asked my co-worker why he thought a blood pressure was warranted right that moment, he replied that was what they do, he didn’t have to care why. He asked if I knew the blood pressure by magic just by checking a pulse. I smiled.

Some communities are ditching Advanced Life Support in favor of a less expensive, but less effective, Basic Life Support system.

If you have ALS, fight to keep it. If you’ve lost ALS first response in your area, remember that the only rhythm BLS can treat is V-fib. By then it’s too late.

Sometimes the obvious is difficult to comprehend.
Why can’t my system make common sense choices like this from Medic999:

“Its obvious that something is bothering her sufficiently to call 999, and in all likeliness, a further GP would just send her to the hospital anyway. I told her that I would run her up to the hospital myself, in the car, to get her checked out further. “

He can cancel the ambulance and transport appropriate patients in his car.

Am I the only one stateside thinking this is the right way to do it? A scaling system that can adapt to the changing call as it develops?
The American model is locked into a BLS before ALS mentality and it is hurting the system.

Benchmarks set to reach BLS patients faster than ALS patients simply because more of your resources are BLS is just silly. Yes, I said silly. We should be striving to reach the ALS patients within 6 minutes or less and let the scratched fingers and sick evals wait a little longer. They waited all day to call anyway.

My system has these same benchmarks and they were set in place when a BLS system was augmented with a smaller than curent day ALS force.

But now the volume is catching up and demand for ALS resources by BLS units is overwhelming the system everyday.

What is the solution, though? Adding ambulances is just like parking tow trucks near a problem intersection and waiting for the accidents to happen. We know what is causing the increase in call volume, why not nip it in the bud, where it starts?

The “patient.”

Patient is defined by Webster’s as both a noun and an adjective. But today, the two couldn’t be more opposite.

As an adjective, patient means enduring difficult situations with an even temper; Capable of calmly awaiting an outcome or result; not hasty or impulsive.
That is most certainly not the modern clientel of EMS services. They call demanding a level of service they do not need or understand, only so they can seek attention from an advanced system, the hospital, which they may or may not need. And all of it has to happen right now, no question, no delay, let’s go.

But the noun, patient, means one who receives medical attention, care, or treatment. “Receives,” not requests, or identifies with, but “receives.”

Does that mean I have not made patient contact until they receive care? Is calling 911 legally, technically, recieving care? Yes, unfortunately.

Why can’t I rely on my training and ability to assess people for illness and/or injury and define them as something other than a patient? Could that cut down on our call volume?
Absolutely. Would it spark a tidal wave of legal questions? Most certainly.

So where does it leave the average American EMS professional? En route to the hospital, that’s where.

WAKE UP friends! Our systems are about to be swamped with baby boomers hitting retirement and expecting the level of service they had to maintain for 40 years. If you thought we’re busy now, just wait 10 years.

Reading Medic999’s stories and then reading mine, I keep seeing distinct differences in the level of care provided by the systems. Medic999 is able to cancel an ambulance and refer the patient directly to the appropriate service, based on his professional assessment. That’s what we’re already doing, except the hospitals hold the keys to the services our clients need. We just move them from A to B, sometimes intervening.

If appropriate, again based on a professional assessment, they just need a ride, Medic999 can put them in the car and take them, leaving the ambulance available for a more serious call.

It makes so much sense it hurts to think about it.

So what is standing in the way? Profit. I can’t refer patient #1 to the rehab unit at St Farthest because they have a different insurance, who needs to have a referral from the patient’s primary care, who isn’t at St Closest either, but in a completely different HMO. And I can’t refer patient #2 to their general practitioner because, surprise, they don’t have one. Their only access to medicine at all is me, as a ride to a doctor, who is legally required to listen to them, clogging up a bed in an EMERGENCY room.

There needs to be a complete re-thinking of the way EMS is delivered in the US if any of it is going to survive the rapid increase in volume that is coming.
We can’t keep adding ambulances, we need to look for other ways to address the issues we face.

Help. We need help. We need a solution that can deal with the expectations of our clients, while still providing a competent, professional service that meets the needs, not the desires, of that client.
The UK system isn’t the answer, it can’t be so long as insurance companies can restrict access to services. But what about the fast car model?
Wake County EMS is having success with a variation of the FRU with their Advanced Practice Paramedic role, a design that interets me a great deal.

But in the end it really comes down to liability and cost. 2 things a Paramedic and EMT in the field have no control over. Sure if I can tell someone who doesn’t need an ambulance to take the bus I can save money, but increase liability. We can take everyone who summons us, regardless of the reason, which eliminates liability, but increases cost.

Enough. The fire based model won’t last long if it relies on an ever shrinking fire system and can’t survive in the private sector with the increase in volume and decrease in benefits.

Enough. We are no longer a group of certificate wielding drivers, we are licensed professional Care Givers.

Enough. The EMS systems can’t be governed by organizations that refuse to adapt to the changing landscape that is the modern patient, or citizen with a medical complaint.

Enough. We need those ambulances to stay in service for when the call comes in, the rare call, where we can actually use our advanced skills to make a difference.

“I’m sorry,” I had to tell the woman lying on the floor of the grocery store after fainting, “We don’t have anymore anbulances to take you in right now.”
After not 10 minutes prior being forced to summon an ambulance for a man who skinned his finger, who demanded transport.

We’re better than that. Now let’s get out there and do somethign about it, before it’s too late.

Humbly submitted,
Your Happy Medic