Let’s Talk About Delivery

I wanted to follow up on my reply to Councilman John Bendel’s letter to the editor in the Asbury Park Press a little bit and talk about delivery and goals.  Realistically, regardless of what sort of department an EMT or paramedic works for, their goal should be the same.  We should be aiming to reduce morbidity and mortality of the conditions that we can directly impact and for those that we cannot have lasting impact on in the prehospital setting, we should aim to deliver them to a place where they can get treatment while doing everything that we can in our time with him to promote a favorable outcome in our limited time with the patient.

Too often, when debating about what delivery method works best, we get caught up in the weeds of the minor details that have a greater impact on the provider than the patient.  We worry about the training that we must do and the time that it takes, or the unproven theory that people serving their own community has a greater impact on patient outcome than the ability of the provider.  We get hung up on the importance of response times when they have less to do with patient outcome than care provided in most cases.

In Bendel’s letter, he touched on the fact that “MONOC can probably tell us how many lives were saved because a highly qualified EMT was on calls.  But no one can tell us how many lives were saved because a local squad got people to the hospital faster than MONOC would have.”  He’s probably right, but we need to ask ourselves why this is.  With a call volume that is often a fraction of what MONOC runs, why can’t volunteer squads better report their impact on patient outcomes?  I think that the answer to this is twofold.

First, most squads probably do not possess the outcome data that a company that MONOC has access to.  That is partially the fault of the system for not including volunteer services in this feedback loop, and partially on the squads for not seeking it out, and creating the infrastructure within their organization to acquire it.

Secondly, I don’t think that “fast delivery of a patient by a volunteer squad” has as much of an impact on patient outcome than Mr. Bendel thinks.  In cases where a patient is having an MI or CVA, time is a factor.  In cases where a higher level of intervention is required for respiratory patients who might require medication or treatments like CPAP, time becomes a factor when those higher levels of care are not available in the prehospital setting.  At the same time though, we know that earlier CPAP, for example, greatly reduces the need for intubation in the ED and reduces hospital stays overall.  In theory, patients might better benefit with a higher level of care earlier rather than a diesel bolus and heavy foot to get them to the hospital.

And then there are cases of cardiac arrest.  We know that earlier effective CPR and defibrillation benefit our patients.  Taking the time to move a patient to an ambulance and transporting them to the hospital does not.

But there I go again, getting down into the weeds.

Take the difference between BLS and ALS out of the picture for a second, and lets talk specifically about BLS, since paramedics in New Jersey are not supplied by volunteer squads.  Ultimately, what matters is a level of care needs to be delivered to our patients.  That level of care needs to be as similar as possible with each ambulance arriving at a scene.  If your community wants to invest in a fire based EMS service, and you are a firefighter who is also an EMT, you had better be able to deliver the same level and potential quality of assessment and care as someone who works for a private service.  If you are a volunteer EMT who works as an accountant by day, and rides the rig at night, you had better be ready to obtain the same amount of training as someone who collects a paycheck for a 40-hour work week as an EMT.

States and communities need to be the ones advocating for this level of equality for the people that they serve.  If economically one service works better for them by combining fire and EMS, or putting EMS under the police department, or contracting to an outside service, or going with a volunteer service, the quality of care provided by each of those needs to be measured and needs to be as similar as possible.

Failing to achieve an acceptable level of care just so that volunteer departments can stay “in business” only does a disservice to those who chose to live in that community.  They are the most important piece in this puzzle, not the provider.  We need to tailor our response to their needs and not our own.