What does it mean to be “successful” in EMS? Have you ever considered what a really “successful” service would look like? Does it have all the latest equipment and consistently ride on the cutting edge of “evidence-based” guidelines rather than blind protocols? Or is it one that has a growing fleet and is constantly looking to hire more staff to serve an ever-increasing demand? After all, in the business world, “growth” is often a proxy measure for being “good.” In that case, an increase in calls-for-service would indicate it is a more necessary and vital system? But, could the very fact that we are servicing every call be an indication that we are simply pampering the public and encouraging further abuse of the 9-1-1 system? A recent political article in the UK poses the question “How to make our ambulance service the best in the world” and it suggests that misuse of the system, along with outsourcing, is what is limiting its current success. Could it be that our hard-won popularity is the source of our biggest problem?
Maybe we could lay some blame on allowing the public to define their own idea of an emergency in the late 1960’s when 9-1-1 was first introduced. By placing EMS under the auspices of the National Highway Traffic Safety Administration in 1970, I think it is clear that the industry was thinking of emergencies as scooping patients off the interstate and carrying them to the hospital. But the MVC is no longer a primary source of calls. The fact that you are increasingly less likely to die in a car crash means that medics now spend more time in homes and businesses dealing with non-traumatic medical complaints. And we are dealing with so many calls that we spend an inordinate amount of time trying to teach the public when to call 9-1-1 and even look to penalize them for making the wrong call.
But schizophrenia is nothing new to EMS. Half of the emergency medical services in the US are delivered by fire-based services while the other half are commonly “third services” possibly hospital or even private ambulance-based services. Expectations in rural areas differ greatly from services available in urban centers. We tell people to call 9-1-1 when they need us, but complain that their definition of need is often different from our own. Then authorities start looking to fine users for calling EMS when it is officially deemed not to be an emergency. However, in some cases, even the accidental butt-dialing of 9-1-1 has led to criminal arrests.
If we look at what the fire service has accomplished in their primary field, we find that they have significantly reduced the need for their services by having decreased the number of structure fires. This is a great argument that a reduction in the number of calls may objectively represent more success. Interestingly though, while the number of calls is down, they have managed to grow the number of paid career-level firefighters. Dr. Harry Carter wrote an article earlier this year on success in the fire service, saying “a successful fire department is one which meets the needs of its community, both actual and perceived.” However, Carter also goes on to say that, “but you would be surprised at how many fire departments fail to satisfy their primary customer – the taxpayer.” While successful overall in reducing the need for responses, the cost of fire services has steadily risen. It is more likely the impact of building codes and fire prevention programs that has slowed the number of house fires rather than crediting aggressive firefighting tactics or increased staff. Similarly, to realize an actual drop in medical calls will not require more paramedics, but substantial changes in personal habits leading to healthier living.
But what can we do to improve EMS? The current trend toward Mobile Integrated Healthcare, or Community Paramedicine, show signs that these programs do actually preempt emergency medical calls but that redcution is accomplished by scheduling planned visits to “frequent EMS customers.” And places like Portland are looking to divert 911 callers from hospital trips to reduce workloads at hospitals. Until reimbursement for services can be untied from delivering patients to the Emergency Department of the local hospital, we will continue to have financial incentives that drive both costs and calls upward. It is this increasing utilization of finite services, however, that comes with a decreasing satisfaction with response times. The public does not want to be told about prioritization of calls, they expect service. Cities like Pittsburgh are happy just to keep response times nearly constant with increasing demand even while citizens are expecting more immediate service.
Perhaps our biggest failure is the success we feel in our own minds that we consistently deliver the necessary service for each call by our own personal, professional yardstick. The real measure of our success is in the hearts of our constituents – the taxpayer. What would happen if we focused less on controlling their use of our services and had the ability to respond more appropriately to all requests with appropriate staffing, equipment, finances, and destination options? The world may never know.