After Rapid Growth, EMS Looks To Future With Less Federal Money
“Emergency medical service has become the mainstream of the American fire service,” says Jim Page, a former battalion fire chief and now executive director of the Advanced Coronary Treatment (ACT) Foundation. Page was speaking at the Born of Necessity EMS management seminar conducted in Cincinnati Oct. 21 through 23.
Consider that the EMS movement is little more than 10 years old. Advances in medical science around 1970 were offering greater hope for victims of various emergencies. But it became obvious that a weak link existed—the need for prompt and effective prehospital care. Fire departments were in the best position to help, and in more and more communities they have met the challenge.
Only six mobile intensive care units were in operation 10 years ago, according to Page. Now there are 3000.
“I’m not aware of any other public service,” Page said, “that has grown so significantly in that period of time.”
“We’ve had to prove ourselves,” Page added, speaking of the EMS introduction into the fire service and hospitals. But now the results are impressive. Page’s analysis of a recent ACT Foundation survey of 35,000 fire departments indicates that probably 78 percent, or just over 27,000 departments, are providing some level of EMS.
If each of those departments assisted only one patient per day—a very low factor to use, Page said—the number of contacts Americans have with EMS in a year would total almost 10 million.
Federal involvement was said to be instrumental in the growth. The United States Department of Transportation (DOT), for example, created training guidelines which caused ambulance attendants to evolve into emergency medical technicians, with improvements in both title and function. It was a major step. Now 500,000 persons are licensed and certified providers of some level of prehospital medical care, according to Page.
More recently, the Federal Emergency Management Agency (FEMA) and the United States Fire Administration (USFA) have assisted with advice, tiaining courses and other funding, including sponsoring the Born of Necessity series of seminars conducted by the ACT Foundation.
Page said the FEMA funding was relatively small on a federal level, but it had been used efficiently. For less than it costs to buy and operate a simple advanced life support vehicle for a year, the USFA can provide transportation, lodging, books and instructors to train 500 persons in EMS management.
Mike Fay, an EMS faculty member at the National Fire Academy in Emmitsburg, explained that there was an added bonus with the EMS management courses: It is now accredited and can earn credit toward a college degree.
Fay, the lead instructor, described how the course can be beneficial and indicated three types of programs lacking in good management which were likely to have future problems:
- Programs perhaps currently successful but without a plan for the future.
- Programs with a plan but which are too rooted in traditional ways and not keeping up with the state of the art.
- Programs at the current state of the art and perhaps with a plan but lacking flexibility and a spirit of innovation.
Everyone should be on the lookout for possible innovations, Fay said. The idea is to borrow successful ideas or equipment from another field and make them work to improve EMS.
An innovation suggested by Fay was the use of a low-cost microcomputer to help administer EMS programs. With the disk memory storage on his computer, he can store detailed information on 1000 ambulance run reports. Other uses are discussed in the EMS management course he teaches.
Future funding unknown
“We don’t know the extent of (future) federal assistance in EMS,” said Leo Schwartz, senior DOT official involved in EMS, “because Congress hasn’t decided on appropriations.”
He described how in 1970 Congress authorized money for certain emergency care improvement but subsequently failed to appropriate funds.
It is certain, however, that a number of federally funded EMS projects will cease. Indeed, a common theme in many of the speakers’ presentations was the new challenge to continue the good work with less federal financial assistance.
“Leadership must replace grantsmanship,” Schwartz said. He added that he was still optimistic about federal funding because the Office of Management and Budget has said EMS was “an appropriate federal function.”
State health departments will increasingly become the focal point for EMS development, according to Scott Swearengin, a paramedic who has been involved with the Ohio Department of Health. But as Washington transfers more of the funding responsibility to the states, competition for also limited local money will become more fierce.
“With these budget struggles,” Swearengin said, “it becomes easy to lock ourselves into the details of our daily operation and be blinded to the bottom line of our service: patient care.”
Part of the problem
He added that some fire chiefs are part of the problem rather than the solution. Some of the “old breed not tuned into EMS,” he said, seem satisfied if the medical apparatus is clean and parked straight. If, as he says, those chiefs hide behind a belief that the service is “first rate” and needs no improvement, then they feel justified in using available money elsewhere.
To avoid that blind spot, seek input from outside the fire department, Swearengin suggested. He directed a list of questions to EMS managers concerning medical directors, hospitals and EMTs:
Are you acquainted with the medical director and do you meet with him regularly? Does he play an active role? Do you have regular run reviews? Does he frequently ride with the apparatus to see problems firsthand?
Do you solicit and accept input from hospital personnel? When was the last time? Or do you wait for a formal complaint? Have you implemented their ideas?
Can your EMTs provide input or criticisms without being labeled chronic complainers? Do you regularly ride with them to keep an awareness of their needs?
Getting along with your local private ambulance service is also important, according to Thom Dick, a paramedic with Hartson’s Ambulance Service in San Diego and associate editor of the EMS magazine, Jems. An ambulance company, he said, can help a fire department EMS program or hurt it.
Relations are improved if the department listens to suggestions and complaints. Say “thanks” if the ambulance crew or company has done something to warrant it. And, Dick continued, have joint training and continuing education classes occasionally—because the emergency situation is worked jointly.
If cooperation with the ambulance company doesn’t help and a working relationship is not salvageable, Dick suggested getting rid of the company. Look around at existing conditions, he said, because attitudes are reflected in the manner of dress, the maintenance of equipment and response times. But be sure to document bad experiences. Failure to do so, said Dick, makes the complaining fire department look bad instead.
Emergency medical dispatcher
Jeff Clawson, an EMT who became a doctor and then fire surgeon and medical adviser to the Salt Lake City Fire Department, introduced another party due for a more active role in the emergency medical services: the dispatcher.
Prehospital care begins when the phone call for help is answered, in Clawson’s view. The dispatcher can save lives, or he can be the weak link in the system. Training is the difference. Clawson added that it takes more than just EMT training to help the dispatcher to work blind, in effect.
To demonstrate, a tape was played of an actual emergency call from a distraught person reporting that a baby had just been pulled from a swimming pool and was not breathing. How long the baby had been under water was not known, but even the rapid response of the local fire apparatus may have been too late.
Fortunately, the call was received by the Phoenix Fire Department, a pioneer in dispatcher training for this type of emergency, according to Clawson. While emergency vehicles were on the way, the dispatcher calmed the caller enough so that she could understand and relay the necessary resuscitation instructions to another person on the scene.
Step by step the dispatcher described the procedures without letting the tension show in his voice, even when it seemed the caller was near hysteria. Is the fire department on the way, the woman asked several times with a shaky voice. Yes, she was told, and the instructions continued.
Then a different sound -a baby crying—was heard in the background. The baby was breathing again. And the listeners in the audience could breathe again, too.
Not all EMS responses are true emergencies, Clawson reminded. For example, a red-light-and-siren response to a “possible appendicitis” which saves one minute and 25 seconds is not warranted if the patient—subject to regular emergency room routine—is to undergo surgery more than three hours later. Similar examples were described.
“Yet today,” Clawson has written, “many systems still respond red-lightand-siren on every run. Think about the needless waste and increased danger that could be prevented if 50 percent of any city’s runs were nonemergency in response mode.” The 50 percent figure was the result of a study in Salt Lake City.
A priority dispatch system is made possible by asking certain key questions to assess the situation, providing prearrival instructions and by having predetermined response levels based on the level of consciousness and other determinants.
Clawson has developed a priority card system which guides a dispatcher through the key questions and directs various levels of responses. If adequate information is not available, full response is required. He said the priority response decisions should be medical ones planned or made by emergency physicians.
Free access to public
“The golden goose is dead,” declared Rich Adams, returning to the financial squeeze predicted for many programs as federal money dries up. Adams is editorial director for a Washington, D.C., television station and is a registered EMT. He told how the media can be used to reach the public, which can help retain funding if given a compelling reason.
The media should be considered, Adams, said, because an important message can get easy access at no cost, it is a highly effective device for influencing opinion and it has a strong political impact.
Competition plays a role here, too. The media cannot handle every message offered it, so EMS people will have to try harder.
“Get to know the players,” Adams said, and you will better be able to create a campaign that they will want to use. Include them when a disaster plan is being discussed or a drill is scheduled. Who knows, Adams wondered, perhaps a TV meteorologist may become useful in providing information about wind or weather that may affect a long-term hazardous materials incident.
In Adams’ Washington area, off-therecord meetings are scheduled with TV people and fire officials to air any problems and explain points of view. The effort maintains a spirit of cooperation.
Calling in the lawyers
For some situations, however, the conditions are such that public relations campaigns cannot help. Then it’s time to call in the lawyers.
Paramedics and EMTs are being sued these days—like other groups—more than ever before. So a mock trial was conducted to impress upon the audience the unpleasant reality that such an actual trial may involve. And it was indeed unpleasant to see what the lawyer can do after months of planning, to discredit the medical decisions that must be made within seconds in the field.
The plaintiffs counsel, portrayed by Dallas attorney Jack Ayers, knew every weakness in the defense and bored in relentlessly. He had the special knowledge because he is also a paramedic who has been to medical school. He has taught Dallas Fire Department paramedics and regularly rides with them. Fortunately, his harsh treatment of the paramedic in this case was only for educational purposes.
The trial’s messages were the constant need for good patient care, complete written records of every run (trials may be delayed for years), the importance of good appearance along with clear and consise testimony at a trial, and a reminder that the plaintiff (the person who started the suit) has the burden of proof.
Ayers demonstrated how a plaintiffs lawyer can impugn a witness with an outrageous or offhand comment, which is likely to be stricken from the record. Nevertheless, the jury remembers. One exchange went like this:
Lawyer: Was the patient on a backboard at this time?
Defendant: Yes sir.
Lawyer: He was on a backboard, you took his helmet off, you hyperextended his neck, you inserted an endotracheal tube into his throat, is that right?
Defendant: Yes sir.
Lawyer: Obviously you were in a pretty big hurry because you destroyed his ability to speak when you did that, didn’t you?
(The question was stricken.)
Lawyer: Well, let me ask you this. You’ve read the physician’s report . . . you’ve heard the testimony. You know this young man can never speak again because his vocal cords were damaged. Do you think the good fairy did that to him?
The question was withdrawn, but the jury had at least temporarily forgotten the trauma of the automobile accident. And they certainly did not believe the good fairy was responsible for the vocal cord injury, so it must have been the paramedic, right? Yet the above testimony did not actually indicate that.
In any event, the message was that good training helps keep EMS personnel out of the courtroom.
Skill vs. knowledge attrition
The role of continuing education was covered by Barry Briese, executive director of the Florida chapter of the American College of Emergency Physicians. He described a study which shows that the attrition of knowledge over a three-year period is not as significant as skill attrition over the same time. Therefore, continuing education should be skill-oriented.
Briese recommended extrication and life support contests. They stimulate interest, provide motivation, allow integration of skills and are a tangible reward for excellence. Otherwise, he said, reward or recognition is too rare for EMS personnel.
Dr. Michael Copass also believes in the importance of positive feedback to paramedics. And as Seattle paramedic training officer, he not only expresses appreciation for an overall good performance, but also reports back to paramedics with patient follow-up information. If the paramedic recognized and properly treated a critical condition, yet the patient died due to other reasons, Copass passes along a “well done.”
Copass maintains that a consultation atmosphere, as among associates, does not reinforce excellent treatment as well as a medical control officer can. After all, reminds Copass, the medical control officer is accountable for medical matters, not the fire chief.
Seattle had one of the First paramedic programs, even before any law allowed fire personnel to take advanced medical actions. Physicians rode in the emergency apparatus and gradually transferred more care to paramedics.
Medical control was defined by Copass as a “willingness to let another individual practice on my license.” It is a heavy responsibility, and that is one reason he provides so much reinforcement for good work.
Some fire department EMS programs will deny the need for a medical control officer, according to Copass. Others have called that a “heads in the sand” attitude providing no strict assurance of quality patient care.
A “heroic doctor” who believed in fire department EMS involvement in the early days was described by Phoenix Fire Chief Alan Brunacini as playing a critical role during the growth of EMS there.
Brunacini called the first days “frontier times,” when the individuals involved were excited by the new idea of emergency medical service.
The “revolution” followed when the heroic doctor helped overcome some obstacles. Against hospital administrators, the fire department was the underdog. Some of the revolutionary leaders didn’t survive with the program, but the struggle went on.
The following period was called the “civil war,” as emerging paramedics had turf battles with some fire fighters. Words like prima donna were tossed around. The program continued to improve.
Pressures on the paramedics led to the “burnout stage.” The system violated the unity 6f command, Brunacini explained. Paramedics got orders from the chief, fire officers, head of EMS, doctors and hospital management. Actually, he said, there has been very little attrition from burnout in Phoenix, even after 10 years.
“We told our people they could not get burnout, but they could get tired from time to time.” In that way, management could recognize the pressures and provide assistance without accepting a scapegoat.
As new technology came along, it had to be evaluated and managed. Brunacini called this the “helicopter stage,” because it combined so much of that new technology.
The current stage is “hard management.” It’s time for refining management and technique. Brunacini described the need to simplify and shorten, making things basic for clear understanding.
Emphasis in performance
In Phoenix, the emphasis is on performance. During a slide presentation narrated by Brunacini, which featured response to a letter-bomb explosion with injuries, he commented on an aide shown wearing beads around his neck: “We have free spirits in Phoenix. But what we measure is performance, not looks or attitudes.”