Wednesday, February 5, 2014
Editor’s Note: This is the fifth of a Six-Part Series on the future of Emergency Medical Services.
The National Highway Traffic Safety Administration is the federal agency that oversees EMS in the United States. In 1996, the NHTSA and the Health Resources and Services Administration joined with leaders from the EMS community to create a strategic plan for building the next millennium’s EMS system.
Its vision was as follows:
Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.
And yet, in 2013, little seems to have changed. In a 96-page report, the “how to get there” noted “EMS must expand its public health role and develop ongoing relationships with community public health and social services resources.
“EMS must become involved in the business of community health monitoring.
“EMS systems must seek to become integrated with other health care providers….”
In Red River, New Mexico, a model of adapting EMS clinical care to meet the health care needs of a rural community has been successful but not without bumps in the road.
“The Red River Project addresses the rural concern of community access to primary care services and the preservation of quality local emergency medical services (EMS) through an expanded scope paramedic program. The project has reduced out-of-town transports by more than 50 percent, keeping the valued assets of EMS in the local area for life-saving emergency care.
“Through an expanded scope level of care provided by local volunteer paramedics, the project answers the calls of a community that was unable to support the primary-care services of a full-time physician and clinic. Paramedics underwent specialized training as Community Health Specialists and are allowed to make many of their own decisions, yet the project relies on protocols that lean toward physician involvement, in most instances.
“Through a collaborative process, the project fostered the critical buy-in of the medical community in this unique venture away from tradition and addresses rural issues of emergency medical and primary care access.”
The medical director over EMS in Dorchester County is Dr. Robert Graeves. It is under his medical license that DCEMS operates.
Additionally, Graeves, an emergency physician, has privileges with Colleton Medical Center and Beaufort Memorial Hospital. He spent more than seven years with Trident Medical Center.
He is the medical director of DCEMS, the assistant medical director of Berkeley County EMS and the medical director of Environmental Management for Nucor Steel in Berkeley County.
Graeves estimates that about a third of EMS use is “probably not what it should be used for.”
He is quick to point out though, that it is part of today’s culture. “We want it now, all of it.”
If you try and analyze the inappropriate use of EMS, he says, some might be simply, the patient doesn’t have a car and uses 911 as a ride system.
“Or they don’t have a doctor [primary physician], or they can’t pay for it [a doctor] even if they have Medicare or Medicaid which may not pay for transportation, there is no real bus service here and they can’t afford a taxi.
He goes further to say emergency rooms offer wonderful emergency care but “not such good health care.”
“Health care” being non-emergency care that doesn’t require 911/ambulance/ERs.
“Some people have no option,” he says. “The ER is the go-to place.”
Graeves says the lack of options might have to do with economic problems, transportation problems, psychiatric issues, criminal domestic violence, drugs/alcohol, limited education to understand options, and a reluctance to pay for the gas.
“Others perceive they will be seen faster if they go to the emergency room,” he adds. “Or, possibly, [they use 911] to validate to family that they are actually sick.”
Others, he continues, use the ER to get prescriptions filled. “Perhaps they owe their primary care doctor money and are embarrassed.”
But at the ER, they can only get a few day’s worth of meds.
“Abusers are often young people…it’s what they grew up with.”
“It is a very complex area [the use of 911/ERs],” he says. “There are extreme cases, like the woman who was recently arrested for all the 911 calls she made, but enough fall into a grey area…it is a strain on the system and costs money in higher taxes or higher charges.”
Further, he says, misuse of EMS puts real emergency patients at risk. “Thre is a risk of ambulance response delay, a risk of accidents to crew, patients and others.
“Our crews are trained to respond as rapidly as possible.”
Every call is responded to as a real emergency.
“We are seeing that people ‘learn the system’ and their complaints change,” Graeves elaborated. “What comes in as ‘chest pain’ was, really, three days ago a cough or muscle injury.”
However, in a real heart issue, it has been proven time and again that minutes matter.
“[Heart calls] are what we do extremely well, and when a crew is out on a call that is a taxi service, that creates a five-, 10- or 15-minute delay, that could equal someone’s life.”
DCEMS is set up so that it can cover each medic station if a crew is on a call. It also has a roaming ambulance – Medic 8 – that will go into the coverage area of another station if that station’s crew is out on an extended call. However, the “substitute” crew still has to travel the distance to get to the covered call. This can add minutes to the response. Minutes that could mean life or death to a patient.
“As our society becomes more advanced,” says Graeves, “we expect more and it highlights the problems we need to manage. EMS is vastly different [now] than when it began.”
“We’ve provided better access and awareness…such as symptoms of a heart attack or stroke, so we [the public] are sensitive to these but at the same time we have poor access to health care. It is expensive, prescriptions are expensive and people are intelligent enough to know they need to be evaluated so they call 911.”
Graeves is a realist.
“If you want to design EMS, he says, you would have three goals:
• High quality
• Fast service
• Low cost
However, you can only ever get two out of three…so which one are you willing to give up?
“We don’t want to sacrifice quality and rapid response…that means we pay for it,” he says.
“EMS could last forever if you are willing to pay for it. Costs will rise or quality will suffer.”