In the wake of the controversy with the Mayor of Toronto, Canada allegedly using crack-cocaine, I revisited a post from a few months back regarding the struggles of Toronto EMS, and the attempted takeover by the Toronto Fire Department, and it got me thinking about priorities. When it comes to delivering high quality pre-hospital care, we really need to take a closer look at what drives us to choose the systems and models for our community.
EMS is a diverse field, much more so than our brothers and sisters in the other branches of public safety. Largely, it is an a la carte industry. Choices about response structure, desired time, equipment, and protocols based on what decision makers feel is best for their community. Fire based. Third service. Private. With first response. Without. Two trucks. Twenty trucks. One paramedic and one EMT versus two paramedics. There are countless choices and configurations one could come up with, and countless community models to serve. All in all though, it all comes down to Frank Stroud’s old saying of “ambulance services can be fast, cheap, or efficient. Choose two out of the three.”
Once a decision is made about a system’s design, the community has to stick with it, at least for a little while, to see what is good and what is bad about it, and then decide what changes need to be made. Far too often changes are made based on snap judgments driven by one or two particular calls that usually require a high amount of attention. Instead, when making a change to their system design, especially when looking at who provides the care, the first question that should be asked should be “how will this improve patient care?”
I used to work a part time job in a small town outside of Springfield, Massachusetts for what was then the only third service municipal agency in the area. It was really a terrific system with experienced providers who did a great job. It had its share of short comings, but no system is the perfect system. When time came for the reevaluation of the town’s delivery method, there was a strong push to shift it over to the fire department. When the question was asked as to why it should be moved from a 3rd service to what was going to now be a career fire department instead of a volunteer one, the best answer that most could come up with was “that is how they do it in other towns around here.” Sure, there were financial reasons that the move was made, but ultimately the system was shifted to a leadership that had little to no experience in making decisions about providing ambulance care, which was going to be the bulk of their department’s work.
When Alameda County California made the change from AMR to Paramedics Plus as their ambulance provider, AMR outscored P+ in almost every category with ever bid reviewer. It was a near-unanimous decision that sticking with AMR would be the better choice when it came to providing care to the citizens of the county. Ultimately though the decision of who the bid was going to came down to financials and a lower sealed financial bid was submitted by Paramedics Plus.
Having to decide on an increased financial burden for the people of a community is a difficult thing to do. Far too often we opt for Frank Stroud’s “cheap, fast” model and leave out the “efficient” part of the equation. When it comes down to it, EMS is the out of sight, out of mind branch of public safety. Most of the people in the community we protect will never need or use us, and far too often just see us sitting in a parking lot on a street corner, grabbing a coffee at a corner store, or flying past them, lights and sirens-a-blazing on our way to help somebody else. We are a “we are there when you need us” industry. But ask anyone who has ever had a STEMI field diagnosed by a paramedic who gets them to the proper facility what they think of the paramedics and EMT’s and they’ll give you a different answer. As any family who has their mother, father, sister, or brother back after they were brought back to life from a sudden cardiac arrest how much their EMS system is worth, and they will tell you it’s priceless.
Ultimately what it comes down to is we need to get a keep our priorities straight. We need to do everything in our power to make sure that the patients are put first. It’s not about the providers; it’s not about the politicians. It needs to be about providing the highest level of pre-hospital care on every single run, regardless of the delivery method. Ultimately, when it comes time to reevaluate who runs the ambulance and how they run it, the first question that needs to be asked should be, “if we change, how will it benefit the patients?” Let the evidence drive the service. That is what really matters.