7 Myths About Fixing Our EMS Systems

Browsing through one of my favorite online forums I encountered Mikey, an EMS manager who asks the question, “Can we justify our current model of EMS?” Mikey has a list of issues with our current EMS model. He includes some statistics, some reasonable and others questionable. All of them point to the apparent failings of our current EMS model.

Mikey’s list includes the low volume of true medical emergencies, poor CPR outcomes and our inability to say we improve outcomes over private vehicle transport. I know, it’s all stuff you’ve heard before. Mikey poses the question, “Can we justify the expense of EMS?”

Then the real fun begins. The forum users begin suggesting what needs to happen to fix EMS. The suggestions include:

  • Creating national committees filled with street level providers to brainstorm and then dispense their wisdom for national adoption.
  • Better pay.
  • Improved education.
  • Community paramedics providing expanded models of care.
  • Higher standards of hiring.
  • Paramedic initiated refusal.
  • Government funded standards development.

Some of the ideas are great. There’s always plenty of insightful, well thought out input. But there are also a lot of EMS solution myths that rise to the surface when these discussions get rolling. Many of our ideas for how to fix all that ails us are shrouded in false beliefs and oversimplified analogies.

Here are six EMS fit-it myths that find their way into so many of our EMS rants. How many do you fall for?

1)      The myth of solution by committee.

In this delusion, we convince ourselves that even the most complex and pressing problems could be solved if only we just got the people closest to the issues to come together and talk. If that were to happen, we believe that the right solution would emerge from the dialogue and then we would ll agree and implement those solutions.

This idea is flawed on many fronts. First it places its faith on the myth of the single solution. (See below) It also disregards how difficult true dialogue becomes in these situations. Committees are notoriously awful at producing worthwhile solutions. The old axiom that a mule is a thoroughbred designed by committee is true.

When we elevate groups of individuals to the level of “problem solvers” we interject ego, turf wars, personality conflict, competing interests, inter agency politics and the interloping of millions of stakeholders all looking for a piece of the influence.

If you think problem solving within your organization is difficult, doing the same thing at the national level is monumental. (Literally…if it were to work, we would build a monument.)

2)      The Myth of the single solution.

This one is endemic to conversations about the woes of our EMS nation. It’s the belief that a single solution could be applied to EMS systems across America and they would work universally. Our EMS systems are unfathomably diverse. We have fire based EMS systems, private EMS industry, public service EMS delivery, hospital based EMS providers and combination systems.

Add to this the fact that we serve diverse populations from rural areas where EMS response can take hours (or longer) and call volumes are measured in calls per week to busy urban systems over-run with system abuse, overtaxed hospitals and annual declining budgets.

Don’t forget that over half of us are volunteers and most of us are under-trained and the idea that a single panacea idea or movement could solve the issue of modern EMS becomes extremely unlikely.

3)      The Myth that nothing is being done.

Here’s a shocker that most of the arm-chair EMS quarterbacks will have a hard time wrapping their brains around. Most every problem endemic to EMS in America and around the world is already being addressed and worked on by some organization or group of people.  And here’s the really sad thing. Most of them are begging for your support and you don’t even know they exist.

That’s right. While you’re angry about the lack of national representation of EMS, the NAEMT is working hard every day to fix that. (And you’re still not a member.) Movements like EMS on the Hill Day are taking place every year and you aren’t present. Upset about other jobs having strong national union representation? Check out NEMSA.

Worried about EMS education NREMT is fighting for a minimum national standard of EMS education as well with one of the most advanced testing processes available to anyone ever. (Even though you bash the test every time you take it.) And online education groups like CenterLearn and The EMS Web Summit are striving to bring real, cutting edge EMS education to your desktop.

Upset about system abuse? Agencies like West Eagle County EMS and Colorado Springs Fire are experimenting with community paramedic models to try to head off the call before it comes. Progressive EMS organizations are partnering with community service agencies to identify repeated 911 abusers to find more long term solutions to their ongoing problems. And that idea of a national committee? Groups like FRN-TV are working on creative ways to create that national dialogue you’re talking about. You should watch…and comment.

Instead of trying to launch a movement, find where the movement is and join it. Champion the EMS champions who are already working hard to solve the problems of EMS.

4)      The myth of EMS ineffectiveness.

For folks who subscribe to the myth of ineffectiveness, EMS doesn’t do any good because so few of our interventions or actions are truly lifesaving.  It’s as if providing medical care that falls short of life-or-death interventions is beneath us.

By this same logic, urgent care clinics should close their doors. I mean really, how many of their interventions are lifesaving? If someone has a true emergency they have to call 911. They should feel so ineffective.

Of course, that’s ridiculous. They practice medicine. So do we. We listen, we question, we evaluate and then we give people advice. We also apply medical treatments and, yes, we take people to the hospital. We make a difference. We make a difference to the people we serve. If you need someone’s life to hang in the balance before you can feel like your work is important, you may want to switch jobs.

5)      The myth that only field EMS providers know the real answers to the problems.

This myth rears its ugly head with a rant that sounds something like this, “The problem with EMS is that the people implementing changes have been riding a desk for the last 20 years and don’t know a thing about real EMS. These jokers would be more likely to find Jesus in their morning toast than find a real solution to a real EMS problem.”

We’re convinced that real system solutions are only found behind the windshield of an ambulance. Anyone outside of direct patient contact is an idiot. Here’s the thing…I only hear this opinion from people who don’t spend any time with nationally recognized EMS leadership.

Sit in a room for a while with creative EMS managers and consultants like Chris Montera, Mike Taigman and Skip Kirkwood and your head will swim. You may find yourself overwhelmed with their creativity and the depth of their understanding of EMS operational challenges. (With all things truly considered.)

Let them give you an eye opening perspective of what EMS looks like from 30,000 feet in the air. Suddenly, your ground level, overly simplistic EMS solutions might seem a little naive.  If you spent less than 30 minutes trying to solve our nations EMS woes you may leave feeling a little foolish (or enlightened).

6)      The myth of instant results.

While the myth of instant results is present in every industry, it is particularly endemic to EMS. We don’t just want solutions; we want solutions that present themselves fast. We are results oriented people. If an idea works, then it should work now. If it hasn’t created results in six months scrap it and do something else.

Here’s the thing we so often forget. Today’s problems are the result of yesterday’s solutions. Emergency services are in-and-of-themselves solutions to yesterday’s problems. Fifty years ago, getting sick people to life saving interventions in a timely manner was a real problem. It isn’t much of a problem anymore. We created a system where anyone call a simple number and get bedside delivery of our most time-sensitive medical interventions. But the way we designed the system created a bunch of new problems today. Those problems are what we’re talking about now. Yesterday’s solution = todays new problem.

The better we design our solutions today, the fewer problems they will create for the next generation. But slow implementation solutions don’t win managers awards. Creative solutions that solve problems ten years from now aren’t that popular in an immediate gratification society.

We want sloppy, fast answers that show immediate results. With any luck, but the time the new problems emerge, we’ll be on to our next promotion and some other poor sap will have to solve the new problems we created.

7) The myth of the perfect solution.

We are also deeply intolerant of answers that only partially solve the problem we are trying to address. Even when the problem is death itself, we demand changes that produce dramatic results. If our cardiac arrest save rate is 4% before the implementation of continuous compressions CPR and it’s 7% after, we deem the intervention a failure.

Death happens to be a remarkably difficult process to reverse, and yet a 3% decrease in this troublesome disorder is apparently nothing worth celebrating. We are apparently in search of an intervention that will definitively reverse death. Nothing else will do.

It seems ridiculous, but this is how we measure positive change in emergency services. Unfortunately, this isn’t how positive change tends to happen. It happens slowly over many years, backed by the hard work of a whole bunch of really smart people.

And yet, when new EMTs enter the field they find that people don’t always call 911 for appropriate reasons and more often than not, the people who die stay dead. In a few short years (or less) they are frustrated and angry. They write angry blogs dedicated to EMS rants and adopt the affect of the burned out old-timer. (Not realizing that we’ve seen this all before.)

There’s a much better way to go about all this.

If you’d like to work towards positive change in EMS, instead of adding one more angry rant to the pile, here are a few possibilities that would be far more productive.

A.)   Embrace the imperfection.  Life isn’t perfect. Neither is any job…anywhere. Life is about solving problems. When we’re done solving these problems, we get more. That’s the way it works.

B.)    Join the fight. You don’t need to start a movement. (There are already several.) You need to look into the long list of groups and organizations already working to advance the cause of improving EMS. They could all use your support.

C.)    Champion the people who are doing good work.  There are a bunch of them. EMS doesn’t need another rant. Rants are easy. Use your voice to talk about everything that’s right with EMS. If you can’t see it, you aren’t looking hard enough. When you do see it, help other people see it.

D.)   Be patient. Do the right things because they are the right things to do. If you don’t see immediate results, be patient. EMS isn’t going to change overnight, but it will change. It’s been slowly improving for the past 50 years and it will continue to improve. You could be a part of it.

E.)    Respect the folks who have invested their lifetimes working in EMS. Just because you don’t understand why they are moving in the direction they are moving doesn’t mean they are wrong. Ask them. You may learn something.

F.)    Keep your eyes open. The next brilliant idea is around the corner, but you’re going to miss it if you’re too caught up in your “everything sucks” mentality. People who explain what’s wrong are a dime a dozen. People who see what’s going to happen next and move in anticipation are rare and valuable. Be valuable.

Now it’s your turn: What other EMS solution myths do you encounter? What else can we do to be a part of a better solution? Leave a comment and let us know.

Comments

  1. Mike Grill says:

    Great thoughts Steve. I dig it.
    Community health approach is coming and progressive EMS org’s are inventing, evolving and partnering with community health agencies (hospitals, etc) to find their niche. For hospitals, outpatient service utilization is (has been) on the rise with a similar decrease of in-patient services. KEY QUESTION for EMS agencies, whether their fire based, private, third service, public utility model, etc., is “How can our agency partner with hospitals in order to better utilize our organizations current assets/resources?” Wellness and reducing readmissions has been the new mantra for hospitals nation-wide. And, we will only see this increase once the Supreme Court issues its ruling on health care reform next month. EMS agencies willing to evolve can play a key role by forming collaborative partnerships with local hospitals. This will not only benefit the hospital but the agency as well. North Las Vegas FD will be sending out pink slips to 50 of its firefighters very soon. Think what a powerful weapon a fire chief would have if she/he could demonstrate to their board or council that – by laying off these folks – they are crippling a relationship (and revenue stream) with their local hospital and interrupting a critical community health service line.

    Just my thoughts, I could be wrong – but don’t believe I am!

  2. Much of the dialog regarding the future of EMS is focused on Community Paramedicine or delivery of primary care by EMS. The IAFC EMS Conference in Las Vegas just had a major program about this. See: http://www.lifebot.us.com/community-paramedicine/ and http://www.mhn.us.com/events/

  3. Bob Baker says:

    Very insightful post Steve. There are so many ways to become involved in improving our service & our system… locally, regionally & nationally. Making positive change begins with a conscious effort to become involved in a positive way… while leaving our egos & penchant for parochialism behind.

  4. I’d like some evidence for points 1 and 2, please.

    And I second you on the conclusion. Having a birds eye perspective is what is needed. See the whole picture.

  5. for every montera/kirkwood/taigman there is, there are a thousand yahoos who are in positions to do lots of damage as well, so that myth, while a myth, isn’t without its merits.

  6. Skip Kirkwood says:

    This particular blog entry should be given widespread distribution. Steve’s points are – well, right on point!

  7. Art Hsieh says:

    Excellent speaking points Steve. Help me tie some threads together – do we strive for national unity? Do we work for local solutions? Can we somehow figure out how to broker both ends of the change continuum? It’s really not that simple, as you point out. As an educator, I hope that my colleagues would instill some of foresight and moral fortitude in our future leaders. I know some do, but most do not. I hope that fewer “ol’ boys” exist and that the door is open for more bright, motivated future leaders to help steer the EMS ship into its future. I hope we can evolve past the “E” in our name and really embrace what most of us have been doing for decades – provide basic health care and help enroll patients into a highly fragmented healthcare system.

    I am hopeful. Thanks for popping some really monstrous EMS bubbles.

  8. “They practice medicine. So do we. We listen, we question, we evaluate and then we give people advice.”
    – Yes, we do. Unfortunately, it’s debatable as to whether or not we’re qualified to give it. This is one of the great paradoxes of an educational model built around “taking people to the hospital and making sure they don’t die en route” and what we’re actually expected to do when people call 9-1-1 because someone needs to be “checked out.”

  9. Mark Caplin says:

    How about starting with changing the educational requirement? Shouldn’t you have at least an Associates degree to be a paramedic?
    How about changing the funding stream? If you go to someone’s house, wake them up with D50W and make them eat a sandwich, shouldn’t EMS get paid for that. Does a guy with “back pain” who all he needs is Ibuprofen or Naproxen, ice and stretches really need to go to the ER at 0300? The problem is the “take ‘em all to the hospital” approach. No transport, no pay. I love Johnny and Roy, but the way teach paramedics is very much like it was back then. Stabilize and transport. Cookbook medicine. It was when I was in PA school that I realized the stuff I learned in Paramedic school and is still being taught (backboard anyone in a car wreck, splint it as it lies, heat stroke = no sweating) is wrong and probably dangerous. If only 17% of the stuff that EMS sees is a true emergency, shouldn’t Prehospital folks learn more about primary care? We tried this model 20 years ago in Alameda County. It was an uphill battle but we had all of the stake holders present and got their buy in. But nothing has changed.

  10. Excellent, insightful points, Steve.

  11. I’ve been out of the EMS realm a couple of years now, but the educational concerns are legitimate. Our standards ought to be high; EMTs have tremendous responsibility. Furthermore, much on the streets is based upon anecdotal experience and often there is a disconnect from what ought to be done based upon current literature. Additionally, there is a tendency to become myopic particularly with those whose educational foundation is perhaps less expansive than might be considered desirable. There is certainly more work to be done. Number 5 above could be expanded to include physicians and others outside the prehospital setting who often do not receive the respect that is their due. Medicine is complex, and a closed mind often misses the mark simply due to ignorance. There are many opportunities to learn something for those whose minds (and ears) are open to them.

  12. 2) The Myth of the single solution.

    What myth? The author obviously doesn’t get it, there is a single solution, and great systems across the country get it day in and day out.

    Everyone wants to turn around and say, ‘My system is different…’

    How?

    Do people in your town, city, county call a different number than 9-1-1 to get help?

    When you call 9-1-1, do you get pre-arrival instructions?

    Do you NOT send a BLS, AED equipped first responder to life-threatening assignments?

    Do you NOT do community education on how to access the 9-1-1 system, public CPR, first aid classes, injury prevention?

    Do you NOT have a community based violence reduction program?

    Do you NOT have a public access defibrillation program?

    Do you NOT have a tiered ALS/BLS based system designed on community NEEDS?

    Do you NOT have ALS units that can treat patients for cardiac, respiratory, and stroke emergencies?

    Do you NOT have a medical director who takes an active part in your system, helping with QI, writing protocols, education, and remediation?

    Do you NOT have a comprehensive quality assurance/quality improvement/quality management program?

    Do you NOT have GOALS, OBJECTIVES, and PERFORMANCE STANDARDS for your system, that everyone must meet?

    Do you NOT have an Integrated hospital system?

    I mean DUH, yes we have DIFFERENT SERVICE DELIVERY MODELS, volunteer, paid, fire, private, third service etc.

    But if YOU have all the things that I stated above, then you are one of the systems that is GOOD, and in reality YOU do have a SINGLE SOLUTION. You have the endemic components that are required to assure that you are providing great care.

    Otherwise you can PICK any service delivery model you want, if someone is showing up with a wheelbarrow and dragging you off to the hospital, than yes your care is going to be suboptimal.

    How many times are we going to miss this? It really doesn’t matter WHO is providing the service, the questions is HOW…and if they are active participants, in a responsive, dynamic system, the PATIENT is the one who benefits.

    The SINGLE SOLUTION is:

    1. Single access point for entry into the system (Dialing 9-1-1)

    2. Receiving pre-arrival instructions when you call

    3. Sending a BLS/AED equipped first responder to life-threatening assignments

    4. Providing community education on how to access the 9-1-1 system, public CPR, first aid classes, injury prevention

    5. Community involvement in reducing violence

    6. Full service public access defibrillation program

    7. Tiered ALS/BLS based system designed on community needs

    8. ALS units to treat cardiac, respiratory, and stroke emergencies

    9. Medical director who works on QI, writing protocols, education, and remediation

    10. Comprehensive quality assurance/quality improvement/quality management program

    11. Integrated hospital system

    12. GOALS, OBJECTIVES, and PERFORMANCE STANDARDS for your system

    We struggle with this all the time. Everytime I see someone without experience and education trying to make these decisions they make the wrong decisions and at the end of the day the person who suffers are the patients and the residents.

    Is there some ‘rarified’ substance in the air that makes a heart attack, a stroke, CHF, or status asthmaticus respond differently in your community?

    When a bullet leaves a gun and pierces a human body, when someone is ejected from a motor vehicle and lands on the pavement, does the bodies internal process’s react differently?

    So why is your system of response different or unique?

    Are the lessons of James, Kaplan, Torlich, and Rheinhardt, are they lost to us? Or are we so arrogant that we cannot see what we need, and are we not brave enough to do what we need to do to get there?

    Even if you have a different service delivery model (which is what I think the author is getting at here, but I also think he doesn’t understand the difference between what is a system and what is a service delivery model), so even if you have a different service delivery model is your expectation different for patient outcome?

    Do you say ‘Oh, I have a fire-based EMS system delivery model, so I guess the outcome for me if I get a heart attack is different than a hospital based service delivery model or third service?’

    Does anyone really EXPECT that because a system is paid versus volunteer that their outcome will be different?

    I am not talking about perception versus reality, I am talking about when a human being dialing 9-1-1, is the first words out their mouth ‘I live at 3000 37th Avenue and my mother is sick…send me the best 2 paramedics you have!’ OR is the expectation is that we are sending our best…that the system, from the 9-1-1 phone call, to the first responders, to the ambulance, the hospital, specialty referral center, etc, etc, etc, are all the very best we can provide…and if that is the expectation, if you are a government official either providing the service or regulating it, aren’t you obliged to deliver on that promise?

    Then don’t waste our time and tell me that your community is different, that you need to do things differently, and that your requirements are different…yes, you may have different demographics, and you may have more medical emergencies than trauma’s, BUT that means you need to pay additional attention to that subset of patients who do not see a lot of, but who are vulnerable to death and disability…and you need to develop additional competencies and training for your field personnel…but that does not give you a pass to not have a trauma center for your system…

    You see at the end of the day, successful systems are the SAME, the difference between good and bad is they are managed appropriately.

    Daniel R. Gerard, MS, RN, NREMT-P

  13. Steve Whitehead says:

    @Mike The community paramedic train has certainly left the station. I think most of these programs will live or die based on the support they receive from local hospitals. I watched a well designed program in Arvada die off because we couldn’t find support from the physicians to let their patients call us instead of coming back to the hospital. Services that can truly partner with their local hospitals will have a much better chance at survival.

    @Roger. Thanks for the link.

    @Bob. Thanks chief. I’m glad you liked the piece.

    @Floback In your call for evidence I hear resistance to the idea. You aren’t sure if those points have merit. I’m OK with that. Systems are diverse and committees are fraught with complex politics that make their agendas difficulty to achieve. I don’t mean to say that it isn’t possible for national committees to do good work. It’s just more difficult than we often recognize.

  14. Steve Whitehead says:

    @Burned out – I know that there is a lot of bad leadership and management to be overcome in EMS. I’ve been very fortunate to spend a good deal of my career under outstanding leadership. Few have been as fortunate as I. But we don’t give our good leaders the credit they are due. Fortunately, with social media, their voices are getting louder.

    @Skip Thank you sir. I appreciate that.

  15. Steve Whitehead says:

    @Art I’m hopeful about the future as well. An evolution of our system is coming. Patience and hard work are a big part of the recipe. Many of our revolutionary leaders have already arrived. Yes we should unify around best practices and minimum standards of care. Stronger education requirements (for instance) should be a national issue. (Even though it may destroy some local / rural / volunteer organizations that need to fall away anyway) And local systems need to be able to select what rung on the ladder is next for them. The rungs may be the same, but the order certainly is not. We aren’t all in the same place. And we don’t all need the same things.

    @Tom You are so right. Were still educating individuals to perform a different job than we are asking them to do on the street. And we can’t keep shuffling the knowledge deck without changing the time requirements of the class. Our educational agenda is full. We need more time with the students to do this right.

  16. Steve Whitehead says:

    @Mark Yup. I think we’re all saying the same thing. Or, at least it is a common theme.

    @Steve Hey thanks Steve. And thanks for all the good work you do sir. Loved your class at Zoll Summit.

    @Jim Ditto. Exactly. Thanks for your comment.

  17. Steve Whitehead says:

    @Dan I hear where you’re coming from Dan. It sounds like you’re tired of hearing systems use the “We’re just different here.” excuse to go forward and do nothing. (Or do what they’ve always done.) I could see why that would be frustrating. But, with your work with NAEMT and in EMS consulting I would think you would be one of the first to recognize that you can’t apply a cookie-cutter solution to every EMS system in America. Even in you list that you offer as an example of how we are all the same, I found myself answering no to many of your questions. AEDs, violence programs, tiered systems, stroke programs? No Dan. Many systems don’t have those things. And some don’t need them. And a bunch can’t afford them.

    It would be nice to say everybody do all this stuff because it works, but everyone can’t. In the bay area, all that stuff might make sense. In Oakland, I’m sure every penny you invest in violence reduction programs is money well spent. In Scotsdale, AZ, where the violent crime rate is ridiculously low, it doesn’t make sense to invest limited time and money into that type of program. That isn’t their next step. A rural system with long response times and 2 calls per week may not need a community AED program or a tiered ALS/BLS system. They need the right resources on scene the first time and they need a training model that helps them maintain their skills in the face of low frequency of skill use.

    I also strongly disagree with the idea that every person who calls 911 should have similar expectations of their system. People choose where to live and that will always impact the care that they receive. If you live in rural Montana, you can’t expect to be 8 minutes from ALS and one hour from a trauma center if something bad happens to you. You made a choice to live away from those things. There are advantages and disadvantages to living far away from large urban centers. Every 911 caller can’t have the same expectations of their 911 system.

    I get the idea that best practices are out there and we should share them and use them. I get that there is a similar future that we are all moving toward and we want the same thing for our citizens. (Quality care.) But every community and EMS system (Not just response model, system.) needs to figure out what the right next step is for them. We aren’t all in the same place.

    Thanks for your comment. I appreciate the time and energy you spent on this contribution.

    A national movement to improve EMS delivery will have far more success if it offers improvement as a best-practices buffet and lets local EMS agencies decide on the right next step for their system/model/region. If we show up and say, “Do this because it works in Alemeda County.” we’re bound to meet strong resistance.

  18. Steve, you are missing the point. You may not necessarily need a violence program, but you definitely need an injury prevention program. I think I mentioned injury prevention in my 12 essential components, not necessarily violence prevention. Violence prevention is a part of injury prevention.

    You may NOT need a stroke program (although I would find that hard to believe), but you MUST have organized systems of care (trauma, stroke, cardiac) to deal with those patients in acute/critical incidents.

    “ In Scottsdale, AZ, where the violent crime rate is ridiculously low, it doesn’t make sense to invest limited time and money into that type of program”

    You don’t have domestic violence in Scottsdale? You don’t have suicides in Scottsdale? You don’t have an issue with bullying in Scottsdale? There is no sexual or other physical abuse of children that occurs in Scottsdale? Nothing? There is a reason they call these silent epidemics.
    Again my point was that you MUST have injury prevention programs, so even if you don’t have a lot of violence (in your estimation), you still have a need for senior injury prevention (falls, etc.), child injury prevention (bike helmets, etc.), etc.
    I will give you that in a rural system or frontier system would do better with an all ALS system, not because they see more critical patients, but only because it takes them too long to respond to the patients that they have. Yes in a rural and frontier system you need all ALS (paramedic or intermediate) providers. But now you will have to grapple with how to maintain competency in this low volume call areas. Weekly training/education schedules are key, and even in BUSY URBAN systems, with struggle with competency, but as I said in my last post, the key to success with any system at the end of the day, successful systems are the SAME, the difference between good and bad is they are managed appropriately.
    “I also strongly disagree with the idea that every person who calls 911 should have similar expectations of their system. People choose where to live and that will always impact the care that they receive. If you live in rural Montana, you can’t expect to be 8 minutes from ALS and one hour from a trauma center if something bad happens to you. You made a choice to live away from those things. “
    No you are wrong. Rand Corporation and the Reason Public Policy Institute both did comparative studies of 9-1-1 access and societal expectations concerning access to service, primarily focusing on police and fire. It is never a consideration by the average member of the public about whether they will get adequate service from police, fire, and EMS when they decide on a home location. In over 85% of respondents, they never gave 9-1-1 access a thought. They will actually agonize over schools, stores, etc., more so than what they will do in an emergency. They may have actually thought about locations of hospitals, BUT they never considered trauma centers, because a hospital is a hospital to the average member of the public.

    I get the idea that best practices are out there and we should share them and use them. I get that there is a similar future that we are all moving toward and we want the same thing for our citizens. (Quality care.) But every community and EMS system (Not just response model, system.) needs to figure out what the right next step is for them. We aren’t all in the same place.

    You are correct when you say everyone isn’t in the same place, but that just means that you need to figure out how to get the requisite pieces to make your system work. You do understand that the response model is a component of the system, and that model includes how and what you utilize for first responder and how and what you utilize for transport.
    I have to take exception with your comment “Do this because it works in Alameda County.” .
    I worked in systems in NY and NJ prior to coming to California, so my experience is not shaded (or perhaps more appropo ‘jaded’) by my experience with Alameda County. I was a professor of emergency medicine at George Washington University, I have set up EMS Systems in the United States, India, South America, and Hong Kong. I have also written book chapters on EMS operations and systems, one of which ‘Emergency Medical Services System Development: Lessons Learned from the United States of America for Developing Countries’ you may or may not be familiar with. I have served as an advisor to members of Congress, I have written numerous papers on system development and integration into the larger conglomerate of health care overall. I was also a system director for the EMS in the 20th largest EMS system in the United States.
    I say this because my experience is more than Alameda County. I feel I am coming with this a more global point of view, and since I have developed complex systems here and around the world I thing I have something to contribute. I don’t want anyone to agree with me, and I don’t lose sleep with those who don’t. I just feel bad for those who don’t understand.

    You can say whatever you want honest and truly. If it is peer-researched and fact based (Rheinhardt, James, Torlich, et al) then what you are telling me then that it is a disciplined, principled, defendable, scientifically sound/evidence based approach to solving the problem.
    If it isn’t…ok. If you can justify NOT having injury prevention programs, or other components of the EMS SYSTEM because you know something that Boyd, James, Rheinhardt, or somebody else didn’t, ok show me the proof.

    An EMS System is a system that is an integrated comprehensive public safety and health care system model, that is part of a LARGER Emergency Health Services System. The EHS system is a subset of the public health system. It has all of the endemic components I listed. It is not a matter of opinion, Boyd, Cowley, et al have written and published all of this before.

    You mention the myth one solution. Please tell us what the ‘one solution’ myth is?
    There is a distinct difference between a system and service delivery model. A system has a set of specific detailed methods, procedures, and routines that has been established o carry out a specific activity, to perform a duty, or solve a problem. A system is an organized, purposeful structure. It is regarded as a whole structure (and not it’s individual components) They are interrelated and interdependent of one another. These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system in order to achieve the OVERARCHING goal of the system.

    A service delivery model is how you delivery the specific individual components of the system. 9-1-1 call receiving may be handled by the police, first responder may be handled by the fire department, and ambulance transport may be handled by a private provider, third service or hospital based service.

    You have only ONE SYSTEM. If you or someone else has failed to develop comprehensive performance based assessments, standards, and oversight and a means to assure primacy of care for your patients and all of the players who are delivering components of the system, THAT is where your problem lies. A ‘single solution’, you already have that. If your problem is with the players and the people who manage the system, because they can’t play nice, or they refuse to include all of the components, then that is where you and everyone else needs to focus your attention on.

    It isn’t a ‘cookie-cutter’ approach. This is what you need to have a successful system. Ok if you have a rural or frontier system, you need to modify it, but you still have to figure out how you will ensure competency for paramedics or more appropriately your Advanced EMT’s.
    If you have some peer-reviewed paper or other text that says an EMS System is something different, ok, let’s see it. There are a myriad of service delivery models, but you access the system the same way: dial 9-1-1. If you are hurt and need to go to the hospital you go there the same way, in an ambulance. The ambulance brings you to a place, the emergency department.

    Explain in clear and concise terms what YOU think a ‘single solution’ is, I am sincerely interested.

    Remember one thing: If you want to point to a ‘single solution’ my question is why??? If you have failed your system by neglecting to develop and implement successful performance standards and oversight of all the providers who are in participating already, how will it get better in the ‘single solution’? You will just continue to fail and your patients will just continue to receive poor care.

    Tell me and everyone else what the single solution is? Perhaps that is where I am failing here.

    I am not trying to be argumentative, I am just trying to drive the discussion.

  19. An error in my previous comment. I was an EMS director in the 20th Largest healthcare system in the United States, NOT the 20th largest EMS System.

  20. Jon Politis says:

    Great insights Steve !

  21. Leslie Webb says:

    On the surface I would say that Paramedics should have the ability to decide which people go to the ER and who don’t. Because the day is coming when the hospitals are not going to be able to help everyone. I have always worked in the rural setting “different animal”, My wife who is a paramedic as well works in atlanta. Some of the garbage that she has to transport is just a plain waste of time and resource.

    Now having said that I don’t think some of the scum I have worked with EVER needs that kind of power. So what, do we keep hauling every bs call to the er and clogging up the hospitals or do we find some new kind of system of triage and transport?

    Now I only comment on the way GA and AL do it, Maybe your system is already like that.

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  25. KMalkowski says:

    I am revisiting the EMS system after 50 years. ( Detroit EMS, Michigan EMS Plan.) Your thoughts and insights are inspiring anad provoking.

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