EMS 2.0: The Wet Blanket Post

It started in a response to Rogue Medic’s reply to an anonymous commenter, and my subsequent reply.

Happy Medic opined in his blog that EMS as we know it needs a reboot. EMS 2.0, he called it. Just a throwaway line, really, about how we need to re-think the way we’ve educated ourselves in the past, and how we will in the future.

Funny how those throwaway lines can ignite a firestorm. Since then, much of the EMS blogosphere has latched onto the concept, riffing on the ways we’re going to drag our profession kicking and screaming into the 21st century. We’re going to expand our scope of practice, broaden and deepen our education, and reinvent EMS into something its founders never envisioned.

We’re going to demand, and deserve, our rightful seat at the table with the grownups in health care, and we’re going to save lives and stamp out disease and pestilence, and who better to do it than us, right?

We’re paramedics, after all. We’re on the front lines of medicine.

[cue inspirational music here]

It would be more inspiring if it weren’t something I hadn’t seen a hundred times before. The reinvention of EMS is a meme that has been circling the various EMS internet forums and use groups ever since I first discovered the wonders of a modem back in 1995, and no doubt was hotly debated in hotel bars at every EMS conference for years before that.

It’s not a new subject.

It’s a meme with legs, however. It never quite dies, and I suppose that’s a good thing. The topic will be debated, grand ideas will be discussed, old medics will be called dinosaurs resistant to change and new medics will be ridiculed for their unrealistic idealism, volunteers will be lauded and bashed, fire service EMS will be lionized and demonized, and everyone will claim to have the answers…

… and then everyone will just drop it, because there are dialysis runs to be made, after all, and Homeless Hank needs his weekly ride to detox. We’re working too damned hard to endlessly debate these high-minded ideas.

And so the thread becomes dormant again, much like the varicella virus, lying in wait along the nerve roots of our collective psyche, biding its time until a new crop of medics can bring it to flower again, their infectious enthusiasm enough to weaken the defenses of the most jaded medics until –  BOOM! – it bursts forth in a rash of red, itchy Idealism Shingles.

And it always seems to be in a dermatome I can’t quite scratch.

Once upon a time, I was that idealistic new medic whose grand ideas were rudely extinguished by the wet blanket of reality, wielded by more experienced medics like TOTWTYTR. Some of our arguments back in the day were pretty damned fierce.

And now I find myself that older medic impelled to dash the hopes of a new generation of dreamers. On the other hand, I’m not quite jaded enough not to hope. I’m a paramedic, after all, a member of a profession still in its adolescence.

And like any adolescent, we are capable of boundless enthusiasm, hindered only by our astounding naivete. I suppose that naivete is of some use, however. Many of the greatest ideas of man came to fruition only because some genius was too damned stupid to know that what he proposed wasn’t possible.

But if we’re ever going to bring EMS 2.0 to fruition, we must first start with a little perspective. George Santayana once wrote, “Those who cannot remember the past are condemned to repeat it.”

Phrased another way, we have no idea where we’re going, unless we first know where we’ve been. Well, where we’ve been is a surprisingly short road. Napolean’s private surgeon may have invented the ambulance concept in 1792, but modern EMS as we know it stems from an innocuous government document written just 43 short years ago; “Accidental Death and Disability: The Neglected Disease of Modern Society.”

Forty three years.

That’s our entire institutional history, folks. I find it apropos that Happy Medic chose EMS 2.0 as the term for his concept. If EMS were software, we’d be a Beta release – full of promise, but still with plenty of bugs.

And much like software developers, many of our professional organizations like NAEMT do nothing to fix the problems, choosing instead to insist, “They’re not bugs, they’re features!”

Add many more features, and we’ll be the public safety version of Windows Vista: bloated and slow, prone to crashes, and a hog of system resources.

In the intervening 43 years since the EMS White Paper, our role has grown far beyond that of the BLS trauma technician envisioned in the original document. Along the way we’ve become the medical safety net for the entire health care system system.

For a huge demographic in the United States, we are their primary care providers.

Some of us may see that as the natural evolution of our profession; our role expanding in pace with our growing skills and knowledge base. And they might ask, as with EMS 2.0, where we go from here, and how far might we rise?

Then again, a military commander might define many of the responsibilities we’re thinking of shouldering as mission creep. We cannot be all things to all people, and to try ultimately only lessens our effectiveness for the people who really need us.

Happy Medic gives his vision of some of the technological advances we’ll see under EMS 2.0:

“…Hospital radio reports via instant message, electronic patient care reports downloaded wirelessly on arrival, care back in the hands of the caregivers, not the bureaucrats. Alternates to automatically defaulting to transport in an ALS ambulance to an ER.”

With the exception of that last item, most of those things are easily enough done, and to my mind they represent embracing emerging technology more than an entire system redesign.

More problematic is that last goal: Alternates to automatically defaulting to transport in an ALS ambulance to an ER.

Even board-certified emergency physicians wrestle with the decision to admit someone to the hospital or not, and sometimes they make the wrong decision despite their vastly superior education. I’ll put it bluntly: paramedics are not capable of making transport/no transport decisions. We do not have the education needed to be system gatekeepers.

I’m not saying some of us can’t do it. I may be capable of making those decisions, and being right far more often than not. So may Rogue Medic, or Happy Medic, or TOTWTYTR, or many of the top tier medics in every EMS system in this country.

But then, it’s not only those medics who will be making those decisions, is it? Until every medic – even the barely competent knuckle dragger who barely passed the certification exam on his sixth try – is capable of that level of thinking, triaging patients to places other than the Emergency Department is a pipe dream.

The Fire Critic hit upon several good points in his post on the subject:

At what point in advancing more in-depth treatments, on scene surgical protocols, more advanced medicine treatments, and all around increase in skills will the Paramedics be required to go to longer schooling? This longer term in schooling might mean that many decide to go the route of a PA, Nurse Practitioner, or MD.

Exactly. Right now, medics barely have the education necessary to master their current scope of practice, much less a greatly expanded one. There are some excellent paramedic education programs out there, but for the most part, the curricula, top to bottom, is woefully inadequate.

Implementation of the National EMS Education Standards will go a long way toward addressing that problem, but even then, there may well be a ceiling to EMS education. IS there a uniquely prehospital knowledge base that is broad and deep enough to encompass, say, Master’s Degree paramedics? Doctorates in paramedicine, perhaps?

Maybe so, but color me skeptical.

At what point will this increase in overall medical knowledge require higher paying salaries?

As Fire Critic pointed out, there are already providers trained at the level to which we aspire. They call themselves nurses and physician’s assistants, and neither of them are going to work for the chump change that they pay paramedics.

You will find no one in EMS that believes they are paid what they’re worth. And you know what? Every single one of them is right. There are many EMTs whose pay is not commensurate with their training and education. On the other hand, there are thousands more knuckleheads out there who are paid far more than they are worth.

Which brings me to my next point: Even if we do significantly raise the bar for EMS education, and the salaries follow, to enjoy any meaningful increase in pay, we are not only going to have to transform EMS, but the whole friggin’ health care reimbursement system.

That’s a pretty tall order for a fledgling profession still trying to decide whether it belongs in health care or public safety, and for whom  the majority of its practitioners provide their services for free.

Make no mistake; the current debate isn’t about health care reform, despite what the politicians on either side of the aisle will tell you. No, the debate is about health care payment reform. The sticking point isn’t one of access, or quality of care, it is who will pay for it all.

Whether we foot the bill through increased insurance premiums or higher taxes, either way we’re going to pay. Pick your poison.

The only sure bets for the future of health care, including EMS, is that 1) it will cost more to deliver, or 2) we will be paid less to deliver it.

And there’s a better than even chance both will happen.  Costs to insurers and taxpayers will skyrocket, and reimbursement for services will plummet.

So the question then becomes, if we are going to reboot the system, release EMS 2.0, how will we pay for it?

The short answer is, I don’t know. And if anyone else tells you they know, they’re either liars, or running for public office.

But then, I repeat myself.

But since we’re dreaming big, and revolution is spurred by the dreamers too naive to know what is impossible, I’ll tell you what I think EMS 2.0 should be:

Less EMS.

There, I said it.

Perversely, EMS has been the victim of its own PR success. We’ve spent decades exhorting the public to call us, even for the most trivial of issues. Call 911, and Johnny and Roy showed up on your doorstep, and nobody they treated ever died.

Heartburn? Could be angina. Best call the paramedics.

Dizzy? Could be a stroke. Call the paramedics.

Witness an accident? Don’t move the victim. Call the professionals who know how to do it.

Drive yourself to the hospital? What if your heart stops while you’re driving? What if you black out? Best err on the side of caution and call the medics.

I don’t begrudge the non-emergent calls I do, even the most trivial ones, because we have conditioned several generations of Americans that they shouldn’t ever feel ill, or suffer pain, or be inconvenienced in any way, and that the wonders of medicine will cure all their ills, and that despite the fact that Grandma hasn’t spoken in seven years, or moved in three, send her to the hospital anyway, because maybe this time the Fluorescent Light Therapy she gets in the ER will magically make her whole again.

And until we can convince Joe Sixpack, Suzy Soccermom and Tyrone Rockslinger that no, they in fact don’t need to go to the ED for their viral syndrome, and that no, they don’t need narcotic painkillers when Tylenol will do, and that no, the ambulance isn’t free, even if they never receive a bill, and that yes, Walgreen’s has the same home pregnancy tests that the ER does, at a tenth of the price, and that Grandma is suffering, and there is nothing that medical science can do but prolong her pain…

… then not a damned thing will change about the delivery of EMS in the United States. We first have to change the public’s expectation of health care, and that’s a task that will take generations to accomplish, if ever.

What we need is an army of guys like Chopper:


If people took his advice to heart, every EMS system in this entire country could deliver top-notch care with 1/5 of their current personnel, trucks and equipment. ED overcrowding would be a thing of the past. Health care costs would plummet, and the cost savings would be enough to drastically increase reimbursement to primary care physicians, enough so that accepting Medicare or Medicaid patients would no longer be a money-losing proposition.

Poof, there goes the problem of access to primary care.

But the problem is, America isn’t going to harden the fuck up, at least not until future generations are raised to expect less than their parents are getting now.

So until that day comes, I believe EMS 2.0 is going to involve not giving the public what they want, but what they need.

That means more EMTs, and less paramedics. As noble as the sentiment may be, every EMS call does not deserve a paramedic. In point of fact, not every EMS call even deserves a response, but we’ll leave that can of worms unopened until we can totally overhaul our tort system.

Educate the EMTs better, and train and equip the paramedics as exquisitely as you want. Use a third service, tiered response system, with the vast majority of care delivered by an extensive cadre of EMTs. Keep only a few paramedics on duty at any one time, and develop an effective medical priority dispatch system (not the current one), that assures that paramedics only get sent to paramedic level responses. In one fell swoop, gone is the paramedic shortage, and gone is the EMT glut.

Your EMTs become medical care providers they were trained to be, instead of ambulance drivers and stretcher fetchers, and your paramedics avoid the rust-out that inevitably follows skill dilution. Medical directors, with a much smaller cadre of ALS providers to oversee, feel more comfortable with expanded skill sets. Heck, maybe they’ll even, you know, provide some medical direction to the medics’ initial education programs.

Make the EMT not the entry-level EMS provider, but the default EMS provider. If a community wants the luxury of paramedics, then let them subsidize it with their tax dollars.

EMS systems become smaller, and leaner, but demonstrably more efficient. There will still be paramedics, only they’ll be a much better educated, more elite class of provider than the current version. And their reduction in numbers, and the cost savings from training and equipping less of them, will allow higher salaries for the ones that remain.

That’s EMS 2.0 as I see it.

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