Wednesday, January 29, 2014
Editor’s Note: This is the fourth of a Six-Part Series on the future of Emergency Medical Services.
Today’s EMS is a reactive service…everywhere. In order to survive, it will need to become a proactive service.
It will need to identify unmet needs and develop capacities to address them, according to Skip Kirkwood, chief of Wake County EMS in North Carolina, in EMS World.
Some EMS can do on its own, says Kirkwood, but some will require developing partnerships.
For example, reducing the need for underserved citizens to call 911 in the first place. Kirkwood says “it might be as simple as swinging by a particular residence, homeless shelter or other place to check blood sugars and suggest an apple or sandwich, or reminding someone to take their antiseizure meds. It is easier to fit this in the day than answer the emergency call later for an unconscious diabetic or an active seizure.”
Or partnering with a group to teach seniors fall prevention measures before they break their hip? Perhaps fire services can aid the elderly in building a ramp or installing rails.
These should not, Kirkwood says, be one-a-year programs, but something EMS does every day between actual emergency calls.
Instead of transporting mentally ill or intoxicated patients to ERs, field medics, operating within specifically designed protocols, could perform and document these medical screenings and transport patients directly to the correct facilities saving valuable ER time and expense, duplicate transportation and considerable community money, suggests Kirkwood.
Every medic involved with patients knows that many do not need the sophisticated and expensive services of an emergency department. Many could have their needs met at an urgent care center, public health clinic or other less expensive resource, says Kirkwood. Yet many medics do not do very well in triaging patients, because “we are not given a single minute of training in this form of triage and decision-making,” says Kirkwood.
However, it is not just the “where” a patient needs to go but also the “how.”
Is an ambulance necessary? It is understood that not every patient has their own resources for transportation. However many do and still an ambulance is called.
What would the savings be if a municipality contracted with a taxi service? A less expensive medical transportation company?
Kirkwood submits that “it is possible to build a valid, evidence-based program and train EMS providers to properly assess, triage and direct patients who don’t need an $800 [or $483.89] ride to a hospital in a $150,000 ambulance with two medics trained to provide advanced life support right this minute, when a $25 unaccompanied ride to another facility a few hours from now [or even right away] would appropriately meet their needs.”
Another need is education. A DCEMS paramedic tells of a call where a mother had called 911 because her baby had a fever. When they arrived, they did not need to transport the infant to the emergency room. Instead, they spent a half hour teaching the new mother what to look for when her child had a fever and how she could initially treat it…most often successfully eliminating the need for an emergency room visit.
So there’s medical education and there’s attitude education.
According to another DCEMS medic, this generation and the one before it have grown up with 911 as the only response to a problem. The public needs to be reeducated as to alternative resources.
Emergency healthcare education in schools and a school resource medic, similar to law enforcement’s school resource officer could go a long way in changing the public perception and usage of 911 and EMS.
However, according to Kirkwood, the “biggest external barrier is the perverse economic incentives that exist today. Reimbursements need to be provided for other actions besides transportation to a hospital. This lies within the sphere of our federal healthcare agencies, the Department of Health and Human Services and the Centers for Medicare and Medicaid services. If they want EMS to do its part, they must remove the financial disincentive to it.”
But even without the monolithic resistance to federal change, more local change could take place helping EMS evolve and take a leading role in better, wiser and less costly health care, especially for its most underserved and needy citizens.
Some believe, Kirkwood continues, that EMS is its own worst enemy.
He claims, “we focus on distinctions between our subgroups and won’t even consider that the other guys might have something to offer. We shamefully mimic our polarized, politicized elected officials who make policy based not on what is good for the citizens they represent, but what is good for the political party that supports them.”
Also, a lack of in-depth education, says Kirkwood, “we have eschewed and resisted in-depth education in areas that do not relate to the glamorous 5 percent of what we do.”
“We have to move toward a solid academic foundation for EMS medics with baccalaureate degree programs that include the basic sciences, clinical knowledge and skills, and in-depth study of community health, indigent care, injury prevention, the workings of the health care system, alcohol and substance abuse and the like.
“And we have to stop whining that we don’t get paid enough to learn all that stuff.”