This is an essay which I have wanted to write for quite sometime.  Many people in EMS who read this will be shocked at what I have to say.  But I also think that many will not be able to mount a credible argument refuting my thesis.  After fifteen years in the field, I have come to the realization that paramedics offer too much service at too great an expense to a public that could care less.  In other words, the services provided by modern EMS in the United States is an over inflated bubble, much like our economy, that is on the verge of collapse.

I used to be a regular guest on the EMS Garage.  There is one episode in particular in which I interrupted the current discussion to ask the following question: “Alright, now you guys all be serious for a minute.  I am talking to a few experienced service directors here, and I want you to answer this truthfully.  How many calls do you guys run each year where the outcome of the patient truly hinged on the fact that a paramedic was on scene performing ALS care as opposed to a simple BLS transport?  Come on, how many?”  There were quite a few knowing laughs to this question.  And if I remember correctly, someone joking said, “None.”  But the answer wasn’t really a joke.  No one really argued that the number wasn’t embarrassingly low.

The existential truth about my existence as a paramedic was painfully displayed to me yet again the other day.  I was performing my duties as the QA officer of a rural 911 service when I came across a run in which a paramedic responded to a patient whose blood sugar registered as ‘high’ on the glucometer.  The patient had some discomfort and diaphoresis which is to be expected, but was also alert and oriented.  The medic made this a BLS run and cleared up from the call to let the BLS crew transport alone.  This made me a bit concerned.  I looked up hyperglycemia in our protocol and found that we were supposed to start and IV, put the patient on the monitor, and give fluid boluses as appropriate to treat the condition on the way to the hospital.  I noticed that one of the EMT’s who made the run was currently on duty.  I spoke with her to ask how she felt about it.

“So, do you think the paramedic should have transported this patient?”  I asked.

“To be honest, no.  And to be even more honest, you are one of the only paramedics who works here who would ride in on that.  The patient was sweaty and uncomfortable, and she looked sick.  That’s all.  We put a cannula on her, fat lot of good that did, and drove her to the hospital.  The hospital wasn’t impressed with it either.  I think they would have set her in triage if it wasn’t for the fact that they had so many rooms open.  No excuse to make her wait really.”

“So you don’t feel as if the paramedic should have gone in on this?”

“Not at all.  I can talk nice to a person and take a blood pressure just as well as a paramedic can,” she said.

“Well, the protocol does say to start an IV…” I offered.

“And do what with it?” she asked, “Would that fix anything?”

“Well, it would dilute the sugar a bit.  But to be honest, the same amount of sugar would be inside the vasculature.  It would just be more diluted.”

“There you go.  She needs insulin right?  Do you have insulin?”

“No,” I admitted.

“Well the hospital does, and I gave her a ride there.  No worries.”

And I have to admit, she was right.  I never spoke to the paramedic about it.  I just let it go.

This is really the only job I have had where I am a paramedic in a separate chase car.  In fact, when I am working, I am the only paramedic available in the whole county.  So, the management staff doesn’t actually want me riding in on anything that could be safely handled by a BLS crew.  They want me available for other runs.  For instance, I used to make all abdominal pains an ALS affair.  But one of my bosses came to me and said, “Buckman, do you know that you are really the only person who does this?  BLS crews have been taking abdominal pains to the hospital for years.  What are you really doing?  You’re looking at a normal sinus rhythm on the monitor, and you are starting an IV and not running any fluid in the patient.  If the BLS crew takes the patient, then seeing that NSR on the monitor and not running fluids into the patient will just be delayed by about 20 or so minutes. There will be zero change in patient outcome.  Just drive back the station.”

And abdominal pain is not the only instance where I found I could drive back to the station.  Seizures fit the bill as well.  I was upset to find out that paramedics were making seizures BLS transports until one day it was put to me like this, “Would you accept a refusal from a seizure patient?”

“Sure I would,” I said, “I do all the time.  People who have epilepsy are just going to have seizures every now and again.  Their meds have to be adjusted.  Maybe something else has happened to throw the balance off.  But if they are careful not to drive and see their doctor, I really don’t mind.”

“Well, if you will leave them alone, then why in the hell wouldn’t you let an EMT take them?  I mean, status epileticus is one thing.  Maybe even a new onset seizure.  But a dude with epilepsy who just had one seizure and woke up confused…who cares?  That is a BLS call my friend.  And that’s about 95% of the seizure calls you get.  Just drive your happy ass back to the station and wait for the next one, big guy.”

And so, out of necessity I started looking at all the calls we run.  Will ALS really make a difference in patient outcome?  Is there ever something that we do that cannot wait 20 or 30 minutes until the BLS crew gets to the hospital?  It kind of became a game to see what really did merit an ALS run.  In fact, one of the lines that was drawn just out of shear stubbornness was stroke patients.  I can remember the conversation clearly.

“Even strokes are really a BLS run.”

“Oh, come on now,” I protested.

“Really?  Just what in the hell are you going to do?  How many strokes have you run in the last few years?  Did you give any medicine to any of them?  Did any of them have a dysrhythmia that needed to be treated?  Seizures are possible, but how many stroke patients actually have them?  So you basically just watch a normal sinus rhythm on the monitor, and start an IV so that you can shut it down and not run any fluid in the patient?  This is déjà vu man.  Why do you have to be there?”

In the end it was agreed that stroke patients are high risk, and the chance for ALS care to be needed is too great.  So we still make stroke patient’s ALS runs.  But again, it’s honesty time.  I had that discussion over two years ago.  I have taken many stroke patients to the hospital.  Not only that, but in my job as QA Coordinator I am aware of every case in which a stroke patient was taken to the hospital.  For over two years, none of them have needed anything other than a medic staring at a normal QRS and an IV that was shut down to TKO.  In other words…the medic wasn’t needed.

So, is there any need for ALS in the field at all?  I have identified three different kinds of runs which commonly occur and need ALS intervention.  I offer them here for your inspection: 

1. Breathing difficulties requiring breathing treatments.
2. Allergic reactions requiring multiple medications.
3. Hemodynamically unstable cardiac cases where electrical therapy is required for a conscious patient.  (Read: something an AED cannot do.)

This, as you might have noticed, is a very short list.  Something that is noticeably missing from this list is full arrests.  I omitted full arrests for a very good reason.  I have a dirty secret.  I have never successfully revived anyone who was in full arrest.  In fifteen years I have never done this.  Hardly anyone else ever does this either.  I have shocked unconscious v-tach back into a workable rhythm.  And I have delivered a few CPR’s to the hospital with a heart beat.  But none of them have left the hospital alive.  And so I have to conclude that no change in patient outcome would occur if these patient’s were taken in BLS.  And in fact, much of the ALS research supports this as well.  Early defibrillation saves lives.  That’s AEDs.  AED’s that are on the street, or with cops or fireman.  Perhaps in the hands of an early arriving EMT.  But upgrade that to a monitor held by a medic, and there is really no change in outcome.

I once had the great pleasure of interviewing Dr. Mickey Eisenberg with King County EMS which has an outrageous success rate with full arrests.  But do you know what that is attributed to?  Public policies regarding CPR and AED use.  A well trained EMS staff continues that care.  But it is not ALS care that revives people, it is the knowledge of the man on the street.  If memory serves, something like 70% of the citizenry is trained in CPR.  If someone goes down in Washington State, someone near you simply knows what to do until EMS arrives.  I would be very interested to see if adding or subtracting ALS care to that sort of scenario has any affect on outcome.  If I were to design such a study at this point my hypothesis would be that it does not.

Take a look at that list though.  Breathing treatments, for instance, are being given by EMT’s in many systems.  It is currently not allowed in my system, but this may change fairly soon.  Allergic reactions can sometimes be fairly involved calls.  In my system it is not uncommon to give SQ epi, and Benadryl.  Sometimes I will give fluid boluses if the patient needs it, but I cannot remember the last time in which I have had to do this.  Often times I find that the patient has given themselves a shot from an epi pen before my arrival.  EMTs in most services can administer a shot from an epi pen as well.  Benadryl is an over-the-counter medication for crying out loud.  Don’t tell me we can’t come up with a solution for that.

That leaves those hemodynamically unstable patients that need cardioversion.  Again, I find myself having to say that it is honestly time.  How many patients have I cardioverted in a way that was not possible with AED usage?  I know I have done this at least sometime in my career, but it was so many years ago I cannot recall specifics.  In the last 15 years this has probably occurred twice. 

So, to all the paramedics now reading this, I would like to ask you something point blank.  Don’t fool yourself now.  Be honest.  How many times have you driven into the hospital staring at a normal sinus rhythm with a TKO IV and a cannula?  How many of those patients could have gone in BLS?  Forget that.  How many of those patients could have driven themselves in?  Alright.  Now that you have the scope of that in your head, ask yourself how many times have you made the difference.  I admit that I have done that a couple of times.  There have been a few times in my career where seconds mattered.  My skill or a procedure was what tipped the scales.  However, I would have to admit that this happens once a year or less.

In other words, all of my extra training, all of my extra equipment, all of my extra pay, my extra vehicle, and all of that added cost and liability go to tip the balance on about one patient a year.  Really.  Truly.

That’s depressing.

Okay, if you are still with me then try to imagine the enormous expense that is incurred when a service goes ALS.  How much money is paid in salary?  In insurance?  In benefits?  In different equipment and service contracts?  In initial education?  In continuing education and CEU’s?  In ACLS and PALS?  In medications which usually just get stored in a moving vehicle until they go out of date?  In QA and QI?  What is the cost nationally?

And ask yourself this…in the midst of a failing economy and a broken healthcare system…would that money be better spent somewhere else?  And that is the key.  Most of the times that I bring this up I hear the old standby, “Yes but if one patient is saved, then it’s all worth it, isn’t it?”  The answer is no.  Not in a failing economy.  Not with a broken healthcare system where so many people have no coverage.  If this much money is being spent on something that has so little return, I cannot in good conscience justify it.  Money doesn’t grow on trees for anyone but bankers being bailed out by the federal government.  The rest of us have to chose our battles and put our precious money where it will do the most good.  I ask again, “Would that money be spent better somewhere else?”

But before you answer that question, I urge you to do this.  Go out into your district today.  Maybe you will do this while you go to lunch.  While you wait in line for your food, find a random taxpayer in your district and ask them point blank, “Ma’am, do you know the difference between an emergency medical technician and a paramedic?  Do you know which of those people will show up of you dial 911?  Do you know if a fire truck or an ambulance or both will show up if you call 911?  Do you know the difference between an AED and a monitor/defibrillator?

They don’t know, and they could care less.  This should be made abundantly clear by the attitudes of the families you encounter.  Do they know who is going to show up?  Do their expectations match the level of service they receive?  Do expectations of service level vary wildly from patient to patient?  Have you ever run into emergency room staff that doesn’t even know what your capabilities are?  Is it because they are stupid, or because we simply never use our training enough for them to become familiar with it?  If we never do what we are trained to do, how is the public or the hospitals ever going to get used to it much less comfortable with it?  And why should they care?

Admittedly, we have done this to ourselves.  For some reason we have chosen to make EMS amazingly complicated and vary the level of service from region to region.  We have half a dozen certifications that all have varying scopes of practice as if to make absolutely sure that no one is certain of our capabilities.  We have fire based, hospital based, private, non-profit, and government based services.  We have BLS, ALS, tiered, and volunteer services to keep the public on their toes.

Finally, much of the care that we give has not been properly researched.  Some people look at this as a travesty, but I do not.  It was born out of necessity.  If you plan to start an entirely new section of healthcare where nothing existed before, are you going to wait until there is a study on every single thing that could possibly affect your profession?  Of course not, you would be paralyzed in your tracks.  You have to use some ingenuity and common sense to get the system off the ground and then keep an open mind to changes.  Where did backboards come from?  How else are you going to get them to the truck, levitation?  So we carried them on wood until we found out that it soaked up germs.  Then we found out that people might be moving and shifting their weight on the board.  Then we found out that immobilization might cause other problems.  And now we have a study that says just doing nothing may actually work better.  Who knew?  But this will undermine us.  No matter how necessary it was, it will eventually knock down our credibility.  Everything right down to oxygen is in question right now to the point where it might be better for the family to transport the patient in the back of a pickup truck.  I don’t know.  If our normal methods of splinting, boarding, bleeding control, trendelenburg, oxygenation, intubation, and everything else have been called into question…how can we be at all certain that ALS care helps at all?

The sad truth is that we can’t.

So how do we fix this?  Time and time again I have found out that there is one thing that I do in the field that does actually help the patient.  Time and time again I have been complimented on my tenacity in one certain circumstance.  And this is something you would never expect.  It’s not sexy.  It is not dramatic.  It’s not even fun.  But simply taking the patient to the right hospital makes a world of difference.

Yes, I am serious.  When I am the paramedic on scene evaluating a patient, the thing I do that actually does matter is a good patient assessment followed up by transport (whether I go or not) to the right hospital.  Paramedics may be vastly over trained as far as capabilities and procedures.  But if I have learned anything about BLS care, it is that EMT’s are woefully under trained in assessment, and the capabilities of their local resources.  I can’t tell you how many times I have gotten on scene and said something like, “Whoa, change of plan.  This guy is having a stroke and the place you want to take him doesn’t even have a CT tech at night.  Let’s go over to hospital X and alert the stroke team there.”

Now, when I transported that patient, all I did was hold someone’s hand while I looked at a normal sinus rhythm and a saline lock that I didn’t push anything through.  But getting that patient to the right hospital in a timely manner made all the difference in the world.  Sadly, many paramedics can’t even do this right.  I can’t tell you how many times I have seen a supposed higher trained person put a non-rebreather on that patient, (Beneficial?  Not really.) watch the monitor, (It’s something to do, but the patient isn’t having a heart attack so who cares?  It’s a really expensive pulse counting machine at that point.  Oh, wait.  I have a pulse ox.)  and start a saline lock that nothing will be pushed through.  But where do they go?  The wrong hospital!  A small window of opportunity for reversal is ruined, and now the patient has a permanent deficit.

How do we fix this?  What I am about to say only comes from experience.  It would have to be studied and hammered out over the next ten years.  But if someone asked me to try and solve the problem, and to propose a new model to be studied, here is what I would propose:

Scrap all the certifications and consolidate them into one.  This one certification would look something like an EMT-Intermediate.  But this would be an over simplification.  This new certification would be short on procedures except for the basics.  Most of the drugs, advanced airway, and the monitor would be removed from the truck.  IV’s would stay, but the obscene focus on getting an IV would be removed.  I would call for AED’s that were capable of more.  Perhaps the cardioversion of live subjects who were unconscious, but had convertible rhythms.  But most of all, this new certification would be well trained in assessment and the capabilities of the modern healthcare system.

Scenarios in the classes for this kind of responder would end with statements like this, “Can anyone tell me where Timmy went wrong with this call?  That’s right, he transported to the wrong hospital.  This mother was under 27 weeks gestation and as we all know, Hospital X does not have the proper L&D department or a NICU for this kind of patient.  Upon arrival, that ER staff would have freaked out and called yet another ambulance service to transport the patient.  So basically, Timmy caused an added ER visit, and added transport, the bills that go with that, and endangered the fetus.  Now, what have we learned from this?”

I envision a public service campaign.  A thirty second spot running all over the country would have a script like, “Little Johnny died because he was taken to a hospital that could not handle trauma.  Suzie’s unborn baby died because she insisted on being taken to a hospital that doesn’t even have a pediatric ICU.  Mr. Smith died of an undiagnosed stroke because his family took him to a hospital that didn’t even have a CT scanner.  If you are having an emergency and you call 911, stop…and listen.  What they tell you may save your life.  Let them take you to the hospital that can care for you best, even if it is not your preference.  It may save your life.”

I would be very curious for someone to start a pilot system in a metropolitan area with a system like this and see what happened to patient outcomes versus expense.  I think this coupled with a public awareness campaign and a lay person CPR training model like King County’s would render cost effective improvements in patient outcome that were palpable.  That is my hypothesis, and sadly I don’t think anyone would ever study it.  And if I did propose it, I would eliminate my own position and I would be stripping myself of responsibility and lowering my own salary.  Who in their right mind would do that?

What we currently have is a bubble.  A bubble of expectation.  A bubble of scope of practice.  A bubble of expenditures.  A bubble of ego.  All over inflated.  All ready to pop.

As long as we continue to have infantile arguments about intubation and other scope of practice issues, we are going to be missing the obvious.  And we as a profession are nailing up our own coffins.  I would give up intubation tomorrow if all future EMS classes promised to spend that time on patient assessment and resource allocation.  Putting away the blade and using a BVM would cause zero change in outcome.  Taking the patient to the right hospital just might save our profession as well as someone’s life.

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