I have gotten a couple of concerned messages from colleagues over my EMS Bubble post.  They seem to be upset at my logic.  And to be honest, it was just a blog post.  It wasn’t a paper or a study.  So it wasn’t very polished.  But I would like to clarify a few things.

I will admit that I am on my way out of EMS.  And although it may look like it sometimes, I am not looking back in anger.  I realize that to swallow this you will have to avert your eyes from half of my blog posts.  But the reader should remember that this blog is a public exercise in catharsis.  It is meant to entertain as well as to inform.  However, since I am no longer married to this profession, I find myself looking at the EMS system with a certain objectivity and clarity that was not there before.  In other words, I no longer find the need to defend my own existence.  And this has changed my viewpoint dramatically.  I would like to think that in the past my own viewpoint on EMS was not clouded by self interest.  But I find it harder and harder to tell myself that these days.

I also realize that it is not fair to place an argument on the table, have some people disagree with it, and then back away saying it was just a blog post.  I would be in effect, turning myself into a straw man, only to watch my own argument blow away.  So, if you have the patience, I will attempt to tidy up the rough edges of this previous post.

I would like all of the paramedics who are reading this to clear your mind for a moment.  Step back and assess what you do for your patients that is up and above the capabilities of a BLS provider.  In other words, I want you to think about endotracheal intubation versus simple BVM use or even combitubes or King Airways.  If someone took intubation away from you tomorrow, and you were forced to use basic airway skills would there be any change in patient outcomes?  A lot of research suggests that there would be no change.  Some research suggest that things would get better.

I would like you to clear your mind and consider defibrillation.  If you were forced to use an AED for the next few months, would shocks still be delivered to your patients?  Would there be any change in outcome?  I realize that cardioversion would no longer be available to you.  But as I have said in my previous post, I have been working for 15 years and there is simply not much call for this.  And as I said, I think it is possible to build an AED that could automatically cardiovert someone with the permission of the provider.  But putting that aside, would the absence of your monitor really change the outcome of any of your patients?  They would still be shocked if they were in v-fib or pulseless v-tach.  They would still make it to the hospital where, lo and behold, there is an ECG machine waiting for them.  Would it really change the spread of that disease or the patient’s chance of walking out of the hospital?

Let’s say that for the next few months you stopped establishing IV access for prophylactic reasons.  In other words, unless you wished to actually give a fluid bolus, don’t start an IV.  Would anything change?  In my argument I made the point that I would like to see something like an EMT-Intermediate ruling the roads.  So fluid boluses would be possible for GI bleeds, dehydration, and trauma.  But as we all know, many times fluid boluses simply aren’t the answer.  Some studies suggest they make things worse.  If you stopped starting IV’s tomorrow, would the outcome of any of your patients be different?  Keep in mind that an IV would be started just a few minutes from now at the hospital you are currently driving towards.

Take just about anything you do and delay it by just a few minutes until you get to the hospital.  Does it change outcome?  Keep in mind that you have basic airway, epi pens, and other BLS things at your disposal.

What brought all this about?  I work for a service that was BLS until April Fools Day of 2007.  I was one of the first paramedics hired when the service officially went ALS on that date.  In order to go ALS, we needed to add staff.  Now instead of two people being on duty, we have three.  The paramedic rides in a separate vehicle fitted with ALS equipment.  ALS equipment was added to all the ambulances at great expense.  This equipment is maintained at great expense.  And in the end, we charge the patient quite a bit more for our services.

The odd thing that I have noticed is that all these EMT’s who were used to transporting everything BLS before paramedics were available could really care less whether or not a paramedic is there.  Here is the breakdown of services past and present:

BLS only run for the average medical patient:  Crew arrives, takes vital signs, applies oxygen, puts the patient on the cot, and drives them to the hospital.  The transport takes 20 or 30 minutes.  After arrival the ER staff will start a saline lock as needed and looks at the ECG.  Then they will do lab tests and make a diagnosis.

ALS intercept run for the average medical patient:  Crew arrives, takes vital signs, applies oxygen, puts the patient on the cot.  Now an IV is performed in the cab with an ECG.  The transport takes 20-30 minutes.  After arrival at the ER the staff takes another ECG, often times ignoring yours.  Then they remove all of your IV equipment attached to the catheter hub, and attach their own.  Then most times they just let the IV site sit there not being used…like you just did.  They will do lab tests and make a diagnosis.

Now, compare both types of runs.  What’s the difference?  Virtually nothing. The patient has to wait a bit longer for the ECG.  For chest pain patients, that extra couple of 12-leads we provide are useful.  You can often times see the changes progress.  But as we all know, 20% of all MI’s cause no ECG changes at all.  When we get to the hospital, they take their own ECG’s and perform blood work to confirm it.  Are we really to believe that the diagnosis of MI’s by ER’s would suddenly be crippled by not receiving the crews first ECG’s?  Of course not.  No more than it is for a patient who drives herself to the ER.  Right now I could pick a random person on the street and give him aspirin and nitro glycerin.  It would not hurt them in the slightest.  If I gave these to an EMT and told that provider to administer this to all chest pains (minus the few contraindications that exist) these patients would still get to the hospital, be diagnosed and treated.  Their symptoms would be alleviated and the benefits of platelet inhibition and vasodilation would still occur.  In other words, it would not change the outcome of the patient.

When our paramedic is busy, the EMT staff is completely unimpressed.  They simply take the patient to the hospital, and 99% of the time the same outcome happens to the patient.  Maybe 100% of the time.  When a paramedic is available, we do a few things 20-30 minutes sooner and charge the patient a lot more.

Is this worth it?

My hypothesis is that it is not.  I am not alone.  I hear a news report every so often about a town that thinks about “going BLS” where ALS existed before.  I would very much like to see some studies done in communities where this happened.  Was there a perceptible change in patient outcomes in the region?  How much money was saved?  Was there any difference in public perception of services?  When the tree fell in the forest and there was no one there to hear it, did anyone care?

To be honest I would like someone to prove me wrong.  Please keep in mind that I am by no means sure that I am right.  My observations lead me to suspicions that I would like to see confirmed with some studies.  And I can come up with several ways to do this right off the top of my head.  First, perform a study as I have described above.  Second, find a service like mine where BLS went ALS and see if there was any perceptible changes in outcome.  I can tell you right now that if you did this in my district the answer would be ‘no.’  Third, compare similar districts that are ALS and BLS.  Question the tax payers.  Do they notice a difference?  Question the hospital staff.  Look at outcomes.  Is anything different?

If there is a difference then I will be happy to hear about it, and I will be the first one to shake your hand.  The last fifteen years won’t have been a futile attempt at mental masturbation.

But if I am right…then millions…perhaps billions of dollars are being wasted with a new term I am going to whip out here: replication of services.  It is so expensive to do what we do.  It really is mind blowing.  I was once trying to explain it to a nurse when I worked in Dallas.  I told her the following: “Just think of our logistics nightmare.  I have been in a hospital when the cardiovascular departments (CVU, Open Heart, Telemetry) decided to upgrade their monitors.  They bought about four Lifepak 9’s (I’m dating myself here) and placed a 20 minute video in the break room for everyone to watch and sign off on at their leisure.  After everyone figured out how to use it, they put them on the carts and we were done.  Now, our ambulance service has over 40 units on the road.  In order to upgrade the entire service to LP10’s we had to purchase 50 monitors.  The bill was staggering.  Then we had to train people in four different counties in twelve different stations on rotating shifts.  The service contract alone is a freaking nightmare.  And our stuff doesn’t plug into the wall.  They need batteries!  So there is the expense of chargers at twelve stations and battery rotation and…you get the picture.  And get this…our income is tiny compared to yours, and we are lucky if half our patients pay us.”  Why did we spend that kind of money and jump through those hoops?  To take an ECG a little sooner than the hospital.  We spent the money to replicate a service that probably had no effect on patient outcome.

If you make that kind of expenditure, and that kind of commitment, there better be one hell of a return.  And I am afraid that I just don’t see it.

I would like to see the studies done.  And if my hypothesis is right, I would like to see all that money and effort funneled into something that would change outcome.  Off the top of my head…training the public to do CPR.  Don’t buy expensive monitors for every ambulance in your fleet.  Buy cheap AED’s and make them ubiquitous in your district.  I have seen the research on that.  I know early defibrillation works.  Don’t hire an army of paramedics.  Teach 70% of your population to do CPR and get the kind of resuscitation numbers that King County does.  Then have a moderately trained person pull up and continue that BLS CPR to the hospital.  I suspect that the bang for that buck would have more of an impact on the numbers.

Anyway, I’m sure this cleared up nothing.  I bet that my colleagues are just as disappointed by this argument as they first were.  However, I think it is a good exercise in these financially trying times to make sure we make the most of the fantastic amount of money we are spending.  Do not view your profession through the rose colored glasses of self justification.  Look at it for what it is, a ridiculously expensive system that continues to produce alarming studies about how little gain we make.

Feel free to keep sending me concerned emails and private messages.  The inbox is always open.